literature review of stress management

Stress Management Interventions for Nurses: Critical Literature Review

Affiliation.

• 1 Mayo Clinic.
• PMID: 31014156
• DOI: 10.1177/0898010119842693

Background: The nursing literature contains numerous studies on stress management interventions for nurses, but their overall levels of evidence remain unclear. Holistic nurses use best-available evidence to guide practice with self-care interventions. Ongoing discovery of knowledge, dissemination of research findings, and evidence-based practice are the foundation of specialized practice in holistic nursing. This literature review aimed to identify the current level of evidence for stress management interventions for nurses. Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor. Various stress management interventions for nurses have been investigated, most of which are aimed at treatment of the individual versus the environment. Contemporary studies only moderately meet the identified standards of research design. Issues identified include lack of randomized controlled trials, little use of common measurement instruments across studies, and paucity of investigations regarding organizational strategies to reduce nurses' stress. Conclusion: Future research is indicated to include well-designed randomized controlled trials, standardized measurement tools, and more emphasis on interventions aimed at the environment.

Keywords: burnout; nurse; resilience; stress management; systematic review.

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• Nurses / psychology*
• Nurses / statistics & numerical data
• Stress, Psychological / psychology
• Stress, Psychological / therapy*

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A Literature Review of Stress Management

Lewis, Anthony , Thomas, Brychan C and Williams, K (2011) A Literature Review of Stress Management. International Journal of Professional Management, 5 (3). pp. 1-7.

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• Published: 07 May 2024

The impact of nurse’s sense of calling, organizational commitment, job stress, and nursing work environment on patient safety management activities in comprehensive nursing care service units during the covid-19 pandemic

• YeJi Lee   ORCID: orcid.org/0000-0001-8180-4091 1 &
• Won Ju Hwang   ORCID: orcid.org/0000-0002-0498-6183 1 , 2  

BMC Nursing volume  23 , Article number:  311 ( 2024 ) Cite this article

49 Accesses

Metrics details

As the number of COVID-19 patients rises, there has been a notable increase in the workload for nurses. However, medium-sized hospitals lacked standardized protocols or consistent approaches to address the specific working conditions of nurses. Furthermore, concerns about patient care have heightened as the issue of nursing shortages coincides with the expansion of the comprehensive nursing care services project.

This study aimed to investigate the factors that influence patient safety management activities, such as calling, organizational commitment, job stress, and nursing work environment, among comprehensive nursing care service unit nurses during the COVID-19 pandemic.

A conceptual framework based on the Job Demand-Resource model and literature review of patient safety management activities was used to develop structured questionnaires that were distributed to 206 participants working in 7 comprehensive nursing care service units of small and medium-sized hospitals with at least 300 beds in the S and K provinces. Data analysis was conducted using descriptive statistics, chi-squared tests, t-tests, ANOVA, and hierarchical regression with the SPSS/WIN 23.0 program.

The results showed that calling (β =.383, p<.001) and job stress (β= -.187, p =.029) significantly influenced patient safety nursing activities in comprehensive care service ward nurses. The explanatory power of the model was 26.0% (F= 6.098, p <.001).

Conclusions

Our findings suggest that comprehensive care service ward nurses' career, income, COVID-19 patient nursing anxiety, calling, and job stress were important factors that influence patient safety nursing activities. Therefore, it was essential to develop calling education programs and improve the nursing work system and establish a fair compensation system during the pandemic situation.

Peer Review reports

Introduction

In February 2021, the COVID-19 vaccine was introduced in South Korea, and vaccination was carried out starting with healthcare professionals and then vulnerable populations. Despite the increasing vaccination rates, the number of new COVID-19 cases continued to rise, with over 1,000 new cases per day since July 2021, leading the government to declare a "fourth wave" of the pandemic [ 1 ]. During the early stages of the COVID-19 outbreak, there was confusion in hospitals regarding the screening and admission process for COVID-19 patients, which led to the revision of the Infection Management Medical Law, resulting in nurses strictly adhering to respiratory infection control, standard precautions, and the use of personal protective equipment to focus on patient safety [ 2 ]. However, as the COVID-19 situation has continued long-term, studies have suggested a reevaluation of the "heroic" image of nurses under social pressure.

Comprehensive nursing care services aim to provide high-quality nursing care, with improvements in patient safety such as prevention of falls, pressure ulcers, medication administration, and infection control emphasized in medical institution evaluations. However, the expansion of comprehensive nursing care service units coincided with the COVID-19 situation, resulting in an increased workload for nurses in these wards. Therefore, due to the close relationship between the increased direct nursing activities and patient safety nursing activities in existing comprehensive nursing care service units, and the increased sense of responsibility for patient safety nursing activities due to the COVID-19 situation, it is necessary to explore methods to improve the quality of patient safety nursing activities by nurses in these wards.

Sense of calling is a mindset that goes beyond religious meaning and involves finding fulfillment in one's work and making socially significant contributions, recognizing the value of giving meaning to one's work and contributing to society [ 3 ]. Those who possess a sense of calling not only find satisfaction in their work, but also gain the strength to persevere through various obstacles [ 4 ]. Following the COVID-19 situation, the media has shown interest in nurses who care for patients with a sense of calling, but there has been a lack of diverse activities and accurate behavior descriptions of nurses [ 5 ]. However, the professional ethics of nurses who worked at COVID-19 screening clinics to prevent the spread of infectious diseases during crisis situations was a sense of calling [ 6 ], which can be seen as the driving force behind patient safety nursing activities.

Organizational commitment refers to an individual's willingness to work for and remain a member of the organization to which they belong and is an important variable that promotes efficient task performance among members, ultimately enhancing the organization's performance and quality of nursing services [ 7 ]. Particularly during outbreaks of novel infectious diseases, securing personnel and fostering close cooperation among medical personnel are essential to respond effectively [ 8 ]. Therefore, identifying factors that contribute to patient safety nursing activities, such as organizational commitment, is not only important for clinical nurses, but also necessary for the expansion and development of comprehensive nursing care services in small and medium-sized hospitals.

Implementation of comprehensive nursing care services has been reported to increase patient satisfaction and hospital reutilization rates compared to general hospital wards [ 9 ]. However, it also leads to an increase in job stress for nurses due to demands from patients who expect nursing services beyond their scope of work [ 10 ]. Additionally, it results in increased documentation for tasks like skin care, medication management, and more, adding to job stress [ 11 ] comprehensive nursing care services wards have nurses who constantly enter and leave patient rooms depending on their demands, as there is no primary caregiver staying with the patients. Given the easy transmission of COVID-19 through close contact, comprehensive nursing care service unit nurses are stressed by the risk of exposure to infection sources [ 12 ]. Therefore, nurses in comprehensive nursing care services wards are facing a double burden of existing workload and new expectations and responsibilities related to COVID-19 prevention measures.

The nursing work environment encompasses various aspects, including physical, relational, and managerial characteristics that enable nurses to provide professional care [ 13 ]. When comparing small and large hospitals operating comprehensive nursing care service units, small hospitals face difficulties in securing nursing staff due to lower salaries and poor working conditions, leading to a concentration of nursing personnel in large hospitals [ 14 ]. Thus, there is an increasing demand for safe and secure nursing services from hospital customers [ 15 ], while small hospitals' nursing staff shortages can lead to difficulties in providing quality nursing services.

Likewise, the COVID-19 pandemic broke out during the expansion of the comprehensive nursing care service project in small and medium-sized hospitals and nurses were working with sense of calling in this chaotic nursing environment. However, because there were no approved work guidelines and protocol for nurses, nursers had to bear work stress, so they left the field and threatened patient safety. Therefore, this study attempted to identify the relationships between nurses' sense of calling, organizational commitment, job stress, and nursing work environment, and the factors influencing patient safety nursing activities among nurses in small hospitals' comprehensive nursing care service units. The conceptual framework of this study was grounded in the Job Demand Resource (JD-R) Model proposed by Bakker and Demerouti [ 16 ], upon which the following research model was constructed (Fig.   1 ).

Research model applying the job demands-resources model

The purpose of this study was to identify the factors affecting patient safety nursing activities in the context of COVID-19 by investigating the relationship between the sense of calling, organizational commitment, job stress, and nursing work environment of nurses in small and medium-sized hospitals' comprehensive nursing care service units. To achieve this, the study aimed to examine the general characteristics, level of sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities of nurses in comprehensive nursing care service units. Based on these findings, the study aimed to provide information on the relationship between sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities, as well as the factors influencing this relationship.

Study design

The present study was a descriptive survey research designed to investigate the level of general characteristics, sense of calling, organizational commitment, job stress, and nursing work environment of nurses working in small and medium-sized hospital nursing care service units, and to identify their impact on patient safety nursing activities. Prior to the start of the study, approval was obtained from the Institutional Review Board (IRB) of K University under the reference number (KHSIRB-21-583).

Participants

The participants of this study were from seven small to medium-sized hospitals in the S and G metropolitan areas, each with a comprehensive nursing care service unit consisting of more than 100 beds and less than 300 beds. One of the hospitals was a specialized spinal joint hospital, while the other six were general hospitals. Since the COVID-19 outbreak, three hospitals have been operating COVID-19 residential treatment centers and dispatching nurses, two hospitals have been operating COVID-19 inpatient wards, and two hospitals have been monitoring COVID-19 patients who are under home quarantine. Newly employed nurses with less than one year of clinical experience were excluded as they were in a period of adjusting to the hospital organization, which could lead to decreased organizational commitment, based on previous studies [ 17 ]. The sample size of the participants was calculated using G*power 3.1, and the study targeted a total of 206 participants, considering a dropout rate, with 183 participants required for a regression analysis to explain the study's power with an effect size of 0.15, 18 independent variables, a significance level of 0.05, and a test power of 0.9. Sixteen questionnaires with unreliable responses were excluded, resulting in 190 questionnaires being used for analysis.

Sampling method

This study gathered data from February 24, 2022, to March 3, 2022, at seven small and medium-sized hospitals with nursing and nursing integrated service wards, each having 100 to 300beds. These hospitals have situated in S City and the Gyeongin region. The target demographic for the data collection was nurses, and an online survey was employed for this purpose. Owing to COVID-19 quarantine protocols, external visitors had not allowed at the hospitals. Therefore, the study's objectives and details were communicated to the nursing department over the phone, and explicit permission to collect data was obtained. The researcher provided the online link to the nursing department, and through the unit manager, the department distributed an online link to the structured mobile questionnaire to those who willingly agreed to participate in the study. The research subject's consent ensures that personal information was kept confidential during their participation in the research, granting them the right to refuse involvement even after the research has started. The research results were kept anonymous and will be exclusively utilized for research purposes. These findings were intended for both statistical purposes and potential publication. The process begins with a research consent form explaining that the survey can be conducted, and only those who have confirmed their consent online before the survey were directed to the survey participation. To deter fictitious participation in the web-based survey process, participants were required to respond to all items during the survey, and each question was configured to allow only one response to prevent multiple submissions. In cases where additional clarification was necessary, participants had the option to receive explanations over the phone. As compensation for the time taken due to participation in this study, a gift (online beverage voucher) was provided. Prior to delivering the gift, phone numbers collected before sending it were checked for duplicate participation, and phone numbers collected after the confirmation of sending the gift were discarded.

Demographic and work characteristics

Nurse’s Demographic and work characteristics were obtained by survey. Demographic and work variables included in the study were participants’ age, education level, work experience, income, increased workload after COVID-19, COVID-19 patient nursing anxiety, patient safety education experience, and institutional evaluation.

Patient Safety Nursing Activities

Patient safety nursing activities were measured using the tool developed by Park [ 18 ]. The tool consists of 24 items categorized into six domains: patient identification (4 items), communication among healthcare providers (5 items), high-risk medication management (2 items), accurate surgery and procedure verification (3 items), infection prevention (7 items), and fall prevention (3 items). Each item was rated on a 5-point Likert scale ranging from "never" (1) to "always" (5), with higher scores indicating higher levels of patient safety management activities. The tool demonstrated good reliability with a Cronbach's α of .87.

Sense of Calling

The Multidimensional Measure of Calling (MCM) developed by Hagmaier and Abele [ 19 ] was used to measure calling, which was adapted to Korean by Ha et al.[ 20 ]. The Korean version of the tool consists of 9 items, categorized into three dimensions: job-person fit and environmental fit (3 items), meaning and value pursuit (3 items), and transcendent summons (3 items). Each item was rated on a 6-point Likert scale ranging from "not at all" (1) to "very much" (6). The tool demonstrated good reliability with a Cronbach's α of .88.

Organizational Commitment

The measurement tool for organizational commitment used in this study was a three-factor organizational commitment scale that was validated for Koreans by Lee et al. [ 21 ], based on the organizational commitment tool developed by Meyer and Allen [ 22 ]. The scale consists of three sub-factors: affective, continuance, and normative commitment, and each item was measured on a 7-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (7). The reliability of the scale was confirmed with a Cronbach's α of .93.

The measurement tool for job stress used in this study was the Effort-Reward Imbalance (ERI) tool developed by Siegrist et al. [ 23 ]. The translation was confirmed by two bilingual experts who evaluated its linguistic and cultural suitability. Job stress was assessed by the validated Korean version of the original ERI questionnaire containing 23 items [ 23 , 24 ]. The reported internal consistency for the Korean version was satisfactory with 0.71 for effort and 0.86 for reward [ 24 ]. The effort and reward domains each have five items measured on a 5-point Likert scale, with the minimum score for effort being 6 and the maximum score being 30, while the minimum score for reward was 11 and the maximum score was 55. To analyze job stress, the ratio of the sum of effort items to the sum of reward items was calculated. As the number of items for effort and reward domains was different (6 and 11, respectively), the total score for the reward domain was multiplied by 6/11 = 0.545 to make the maximum score 1. A ratio of 1 indicates a balance between effort and reward, while a ratio less than 1 suggests that rewards were greater than the subjective effort, indicating no job stress, and a ratio greater than 1 indicates that rewards were lower than the subjective effort, indicating job stress.

Over commitment refers to excessive dedication to excessive work demands, with higher scores indicating more commitment due to excessive control demands. The scale for over commitment was measured on a 4-point Likert scale ranging from 6 to 24, with higher scores indicating greater commitment due to excessive control demands. The reliability of the scale was Cronbach's α of .71.

Nursing Work Environment

The nursing work environment was measured using the Korean version of the nursing work environment scale developed by Lake[ 25 ] and validated by Cho et al.[ 26 ] This scale consists of 29 items, organized into five sub-domains: patient surveillance (4 items), interprofessional communication (5 items), high-risk medication management (2 items), accurate procedure verification (3 items), infection prevention (7 items), and fall prevention (3 items). Each item was rated on a 4-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (4), with higher scores indicating more positive perceptions of the nursing work environment by the nurses. The reliability coefficient was Cronbach's α of .93.

Data collection

From February to March 2022, an online survey was conducted targeting nurses working in seven small to medium-sized hospitals in S city and the Gyeongin area that operate comprehensive nursing care service units with 100 to 300 beds. One of the seven institutions was a specialized hospital for spinal joint care, and the others were general hospitals with more than seven essential treatment departments. All medical institutions were private hospitals, and the operation of comprehensive nursing care service units began in 2017. After the COVID-19 outbreak, three of the institutions operated hospital beds for COVID-19 infected patients, and the rest were engaged in running care centers, dispatching personnel to COVID-19 dedicated hospitals, and monitoring COVID-19 high-risk individuals in self-quarantine. As per the COVID-19 prevention guidelines, external visitors were prohibited from entering the hospital, so the researchers explained the purpose and content of the study to the nursing staff over the phone and received permission for data collection. The researchers provided an online link to the nursing staff, who then provided a structured mobile survey link (Google) to the voluntary participants via the nursing staff. Participants received a compensation of a reasonable reward (online beverage voucher) for their participation in the study.

Statistical analysis

This study used SPSS Statistics 23.0 as the analytical tool for research problem and hypothesis testing. General characteristics of subjects were analyzed using descriptive statistics such as frequency, percentage, and mean. The level of significance of nursing job stress was analyzed by chi-squared test, and the means and standard deviations of sense of calling, organizational commitment, nursing job stress, nursing work environment, and patient safety nursing activities were calculated using descriptive statistics. Differences in patient safety nursing activities according to general characteristics were analyzed using t-tests and ANOVA, and post hoc tests were conducted using Scheffé test. Pearson's correlation coefficient was used to analyze the relationships between sense of calling, organizational commitment, nursing job stress, nursing work environment, and patient safety nursing activities. Finally, the hierarchical regression analysis was used to examine the effects of sense of calling, organizational commitment, nursing job stress, and nursing work environment on patient safety nursing activities.

Differences in patient safety nursing activities according to the general characteristics of study participants

The demographic characteristics of the participants are presented in Table 1 . Regarding the differences in patient safety nursing activities according to general characteristics, significant differences were found in the comprehensive nursing care service unit work experience (F=5.426, p <.001), income (F=3.805, p =.011), anxiety related to caring COVID-19 patients (F=2.795, p =.028), and institution evaluation experience (t=2.325, p =.021). In terms of the comprehensive nursing care service unit work experience (F=5.426, p <.001), those with less than 2 years of experience had higher patient safety nursing activity scores than those with 3-4 years of experience. Regarding income (F=3.805, p =.011), those with a monthly income of 351 million won or more had a higher patient safety nursing activity score, and a post-hoc test showed a significant difference between the income groups of 250 million won, 251-300 million won, 301-350 million won, and 351 million won or more. Anxiety related to nursing COVID-19 patients (F=2.795, p =.028) showed higher scores for those who reported "yes" (110.18±9.98 points), but there was no significant difference in the post-hoc test. Institution evaluation experience (t=2.325, p =.021) was associated with higher patient safety nursing activity among those who reported having evaluation experience. Educational level, work experience, position, increased workload after COVID-19, patient safety incident experience, and patient safety education experience within the past year were not significant (Table 1 ).

Degrees of sense of calling, organizational commitment, job stress, work environment, patient safety management activities

The overall average score of the participants' sense of calling, based on the nine questions, was 4.35 ± 0.85, with the highest average score in the area of the meaning and pursuit of work at 4.53 ± 0.91. The overall average score of the participants' organizational commitment, based on 18 questions, was 3.57 ± 1.17, with the highest average score in the normative sub-factor area at 3.63 ± 1.13. The participants' job stress was measured by 17 questions, with sub-factor areas of effort (3.58 ± 0.68), reward (1.74 ± 0.31), and the ratio of effort to reward ranging from a minimum of 0.51 to a maximum of 2.67, with an overall average score of 1.17 ± 0.35, which was higher than 1. Over commitment was measured by six questions, with an average score of 2.57 ± 0.60. The average score for the nursing work environment was 2.27 ± 0.46, with the highest average score in the area of collaboration between nurses and doctors at 2.44 ± 0.63, and the lowest average score in the areas of nursing manager's ability, leadership, and support for nurses at 2.14 ± 0.62. The average score for the participants' patient safety nursing activities was 4.77 ± 0.42, with the highest score in the area of fall prevention at 4.66 ± 0.46, and the lowest score in the area of high-risk medication management at 4.01 ± 0.76 (Table 2 ).

Association with job stress among study participants

In addition, a cross-analysis was conducted to identify variables associated with job stress among study participants. The analysis results showed that there was an association between age group and increased workload after the COVID-19 outbreak, with χ2 =9.089, p =.011. This suggests that there was a correlation between job stress and age group. The highest frequency of job stress was reported among individuals in their 20s, with 38.3% (49 individuals) reporting job stress. There was also an association between job stress and increased workload after the COVID-19 outbreak, with χ2 =7.523, p =.006. Job stress was reported as "yes" by 90.6% (116 individuals) of participants who experienced increased workload after the COVID-19 outbreak, which was the highest frequency reported (Table 3 ).

The correlation between nurses’ sense of calling, organizational commitment, job stress, nursing work environment, and patient safety management activities

The correlation between nurses' general characteristics, sense of calling, organizational commitment, job stress, working environment, and patient safety management activities were examined. Patient safety management activities showed a static correlation with sense of calling (r=.04), organizational commitment (r=.16), and working environment (r=.20). This means that higher sense of calling, organizational commitment, and better working environment led to higher levels of patient safety management activities. There was a significant negative correlation between job stress and patient safety nursing activities (r=-.19), indicating that higher job stress leads to lower patient safety nursing activities (Table 4 )

Factors in patient safety management activities

Factors affecting patient safety nursing activities of the participants were found in Table 5 . To identify the factors influencing patient safety nursing activities of the study participants, with patient safety nursing activities as the dependent variable, independent variables such as comprehensive nursing care service unit experience, income, COVID-19 nursing anxiety, institutional evaluation experience, sense of calling, organizational commitment, job stress, and nursing work environment were selected from the general characteristics with significant differences in patient safety nursing activities. Before conducting the regression analysis, multicollinearity diagnosis was performed, and the VIF (Variance Inflation Factor) ranged from 1.064 to 2.579, all of which were less than 10, and the tolerance limits ranged from .39 to .94, all of which were between 0.1 and 1.0, indicating that there was no problem of multicollinearity in the data. The Durbin-Watson test result was 1.961, indicating that there was no multicollinearity and that the residual distribution satisfied the normality assumption. In the results of residual analysis, all assumptions of linearity, normality of errors, and homoscedasticity were satisfied. There were no outliers.

In Model 1, since most demographic variables among the general characteristics have a relationship with social phenomena, age and education were used as control variables to minimize bias in the regression coefficient estimates. When comprehensive nursing care service unit experience and income, which showed statistically significant differences in the difference analysis, were entered, the regression model was statistically significant (F=5.243, p <.001). In Model 2, when COVID-19 nursing anxiety and patient safety-related characteristics were additionally included, the regression model was statistically significant (F=4.874, p <.001), and comprehensive nursing care service unit experience (β=-.235, p =.002), income (β=.224, p =.003), COVID-19 nursing anxiety (β=-.182, p =.01), and institutional evaluation experience (β=.182, p =.008) were significant influencing factors, and the explanatory power of the model increased by 17.7%.

In Model 3, when sense of calling, organizational commitment, job stress, and nursing work environment were additionally included, the regression model was statistically significant (F=6.098, p <.001), and the comprehensive nursing care service unit experience (β=.209, p =.004), income (β=.241, p =.001), COVID-19 nursing anxiety (β=-.134, p =.048), sense of calling (β=.383, p <.001), and job stress (β=-.187, p =.029) were significant influencing factors, and the explanatory power was 30% (R 2 =.30, adjusted R 2 =.26, p <.001).

This study aims to investigate the sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities of nurses working in the comprehensive nursing care service units during the COVID-19 pandemic, and to identify factors influencing patient safety nursing activities, to provide basic data for improving patient safety nursing activities of nurses in comprehensive nursing care service units. This paper focuses on discussing the major results of the study. It was found that nurses in comprehensive nursing care service units during the prolonged COVID-19 situation had increased workload and job stress, which was related to the pandemic situation, and the overworked state of the frontline nurses underscores the need for social support systems for them, even if it is necessary for patient safety, as suggested in a previous study. The average score for patient safety nursing activities was 4.77, which supports the results of previous studies, but there have been no studies on the comprehensive nursing care service units using the same measure. The high average score for patient safety nursing activities found in this study and previous studies can be interpreted as indicating that there was greater emphasis on patient safety and that nurses in comprehensive nursing care service units are actively practicing patient safety in the context of the COVID-19 pandemic.

The subcategories of patient safety nursing activities were rated highest in falls prevention (4.77 ± 0.42), followed by infection prevention (4.66 ± 0.46), and the lowest was high-risk medication management (4.01 ± 0.76). This is consistent with previous studies that showed a high level of falls and infection prevention activities among nurses in comprehensive nursing care service units [ 27 ]. As the use of comprehensive nursing care service units increases with age, with the elderly over 65 years old and over 70 years old being at high risk for falls, and with orthopedics, neurosurgery, and internal medicine being the main departments in hospitals operating comprehensive nursing care service units, which mainly admit patients with reduced mobility [ 28 ], it is important for nurses to actively engage in fall prevention activities in order to prevent falls in hospitalized patients who may not have a primary caregiver. Therefore, it is necessary to provide education on fall prevention knowledge for nurses in comprehensive nursing care service units, develop fall prevention programs that consider ward characteristics, and improve the atmosphere by holding nurses responsible in case of fall accidents.

The next highest subcategory of patient safety nursing activities was infection control, which was rated highly because of the strong transmission of COVID-19 infection, resulting in the strengthening of infection control guidelines in medical institutions and emphasis on infection control by medical staff. Nurses in comprehensive nursing care service units are aware of the importance of infection control for the prevention of COVID-19 infection and perform thorough infection control activities, especially because of the characteristics of the ward that require close contact with hospitalized patients. They also closely monitor any small changes in patients while actively sharing information on infection control guidelines with medical staff, patients, and primary caregivers. Therefore, in the context of COVID-19, an environment for discussing changes in infection control guidelines while performing infection control activities, including hand hygiene, should be created, and collaboration is essential to prevent infection control activities from becoming a source of work-related stress. Patient safety nursing activities are an important indicator in the operation of comprehensive nursing care service units, and insufficient support and personnel shortage, as well as improving the organizational atmosphere related to safety reporting, should be addressed to improve the practical abilities of nurses.

Differences in patient safety nursing activities based on general characteristics showed statistically significant differences in comprehensive nursing care service unit work experience, income, COVID-19 nursing anxiety, and institutional evaluation experience. Regarding comprehensive nursing care service unit work experience, the average score for patient safety nursing activities was higher for those with less than one year of experience and one to two years of experience. This is contrary to a study suggesting that patient safety nursing activities improve with increasing experience due to greater clinical experience and responsibility. However, there is a need for repeated studies as a previous study conducted on nurses in university hospitals and small hospitals showed that those with less than one year of work experience had higher awareness of patient safety culture than those with more experience.

In this study, 36% of nurses working in the comprehensive nursing care service unit had less than three years of experience. This finding reflects the ongoing expansion of the comprehensive nursing service system. It was noted that relatively inexperienced nurses performed patient safety nursing activities while conducting regular patient rounds.

As for income, the results of this study differed from a previous study, which showed that nurses with income levels below 2 million won had higher patient safety nursing activity scores than those with income levels between 2.01 and 2.5 million won. On the other hand, it could also be due to the different characteristics of working hours in the comprehensive nursing care service unit, as there are nurses who work in three shifts, day or night shift in the same unit, which results in different allowances and salaries. Regarding COVID-19 anxiety, a group of nurses who did not experience anxiety symptoms when thinking about COVID-19 patients performed better patient safety nursing activities, indicating that job insecurity has a negative impact on safe behavior. In addition, a study conducted during the COVID-19 pandemic showed that nurses' anxiety about COVID-19 had negative effects on physical activity.

As for institutional evaluation experience, since the certification evaluation system for medical institutions emphasizes the importance of patient safety, nurses with institutional evaluation experience have increased knowledge and attitudes about patient safety and are making efforts to comply with institutional patient safety regulations to prepare for evaluations. Therefore, in order to enhance patient safety management activities of nurses in small and medium-sized hospitals' comprehensive nursing care service units, it is necessary to establish patient safety departments and standardize guidelines and expand the scope of certification evaluations within small and medium-sized hospitals, as the number of safety management departments in these hospitals is relatively low compared to larger medical institutions.

There was a positive correlation between patient safety nursing activities, sense of calling, organizational commitment, and nursing work environment among the study participants, while job stress showed a negative correlation. Emotional organizational commitment influences safe behavior and is supported by research that shows a correlation between emotional r [ 29 , 30 ]. To secure nursing personnel for patient safety, it is necessary to establish a fair compensation system for existing nurses and prevent the loss of personnel, creating a cooperative atmosphere among hospital members.

Factors influencing patient safety among nurses in comprehensive nursing care service units were analyzed using hierarchical multiple regression analysis. According to Model 3, the significant influencing factors were the length of experience in comprehensive nursing care service, income, anxiety on COVID-19, institutional evaluation experience, sense of calling and job stress. However, considering the high turnover rate among nurses with 3 to 5 years of experience in comprehensive nursing care service units [ 31 ], it is necessary to establish an appropriate compensation and welfare system for experienced nurses to enhance their patient safety performance. To reduce COVID-19 anxiety among nurses, hospital-level programs to develop and implement anxiety reduction strategies, such as psychological therapy, should be considered [ 32 ].

While sense of calling has been identified as the most significant variable in patient safety in the nursing field, there are limitations to discussing the influence of sense of calling and patient safety nursing activities due to the scarcity of previous studies that have applied research from other fields [ 33 ]. However, examining similar studies shows that nurses perform their duties to the best of their ability for the sake of patients during disasters, and in the case of the COVID-19, it is inferred that they exhibit a higher sense of professional responsibility for patient safety. Sense of calling is an important factor in nursing workforce management, as it enhances the organizational competitiveness of nurses and serves as a catalyst for achieving organizational performance [ 34 , 35 ]. Nursing is a profession where a sense of calling is more important than any other profession, and because of the high employment rate for nurses, practical motivations outweigh sociocultural aspects such as volunteering and sacrifice. Therefore, it is necessary to reflect educational curricula on sense of calling, which involves doing socially meaningful work from undergraduate education, and mentoring programsfor nurses [ 36 , 37 ].

The job stress investigated in this study refers to effort-reward imbalance (ERI), which is characterized by an imbalance between the effort invested and the rewards received within an organization. This situation creates an atmosphere where members are not fully appreciated, promotion prospects are poor, and job positions and income levels are inadequate for their education and career levels. In small- and medium-sized hospitals, opportunities to enhance expertise are limited, and there are insufficient opportunities for capacity development [ 38 ]. Inappropriate treatment and compensation can lead to job stress among nurses; therefore, career management systems for nurses in small- and medium-sized hospitals should be implemented, and opportunities for skills development should be provided. There is a correlation between job stress and increased workload before and after the COVID-19 outbreak. Due to the recent spread of COVID-19 infection, nurses have been required to make additional efforts in tasks such as working at screening clinics, managing treatment centers, and monitoring home care patients, in addition to their regular duties [ 39 ]. Therefore, it is necessary to examine whether there are discrepancies in salary due to COVID-19-related work between medical institutions and whether nurses are under excessive pressure from social pressure.

Additionally, a study [ 40 ] targeting nurses in the comprehensive nursing care service units reported that some nurses tried to hide infection exposure due to reprimands. This indicates a lack of protective measures for nurses in handling exposure to infections that may occur while caring for COVID-19 patients. Inappropriate treatment is a factor that hinders infection prevention nursing intervention related to patient safety; therefore, it is necessary to improve the organizational culture to prevent individual mistakes when reporting safety concerns.

In contrast, organizational commitment, and nursing work environment, which were found to have significant correlations in previous studies [ 41 ] as factors influencing patient safety nursing activities, did not emerge as significant factors in this study. Regarding organizational commitment, a regression analysis was conducted again with the inclusion of the highly correlated emotional organizational commitment sub-factor, but the results remained non-significant. In previous studies, the proportion of organizational commitment among those over 30 years old was 39% and 34.2%, respectively, but in this study, those in their 20s accounted for the highest percentage at 44.2%, indicating different results. Therefore, further research is needed to investigate the factors influencing organizational commitment and patient safety management behavior. As for the nursing work environment, the lack of patient safety manuals and the subjectivity of the tool measurement concept suggest the need for repeated studies using direct variables.

Nursing implications

This study aimed to measure the sense of calling and identify factors affecting patient safety activities among comprehensive nursing care service unit nurses during the COVID-19 pandemic and contribute to developing basic data that can be used in developing safety nursing activity indicators. Additionally, as a strategy to enhance patient safety nursing activities among comprehensive nursing care service unit nurses, it is suggested that a mentoring relationship should be developed and applied to increase their sense of calling and to reduce job stress.

Moreover, an intervention study should be conducted to examine whether the imbalance between the efforts and rewards of comprehensive nursing care service unit nurses affects patient safety nursing activities. To improve patient safety nursing activities among comprehensive nursing care service unit nurses, it is recommended to establish a reward system for nurses, measure excessive effort related to intertwined nursing duties, and verify the effects of reducing job stress through medical institution support systems.

Limitations

First, the study was limited in scope to nurses working in integrated nursing and care service wards in small and medium-sized hospitals in Seoul and some areas of the Gyeongin region with at least one year of clinical experience, and the survey was conducted online during a period when the number of COVID-19 confirmed cases was increasing. Therefore, caution is needed in generalizing the results even within the selected sample of nurses who responded faithfully to the online survey. Secondly, the instruments used in this study were created before the COVID-19 situation, so there may be differences in content from the sense of mission, organizational commitment, job stress, and nursing work environment of nurses in integrated nursing and care service wards during the current situation. Finally, since the infection control measures for COVID-19 vary by institution among nurses working in integrated nursing and care service, there may be differences in the COVID-19 nursing experiences of the subjects.

This descriptive survey aimed to gather fundamental information about the factors that affect patient safety nursing activities among nurses in comprehensive nursing care service units, including sense of calling, organizational commitment, job stress, and nursing work environment. The study focused on identifying the factors that contribute to patient safety nursing activities among nurses in comprehensive nursing care service units during the COVID-19 pandemic. The study employed the job demands-resources model as a conceptual framework. Among the general characteristics, factors such as work experience in comprehensive nursing care service unit, income, anxiety levels in caring for COVID-19 patients, sense of calling, and job stress were identified as influencing patient safety management activities. Higher levels of education, income, and sense of calling were associated with increased engagement in patient safety management activities. Conversely, lower experience in comprehensive nursing care service unit, lower anxiety levels in caring for COVID-19 patients, and reduced job stress were also linked to higher levels of patient safety nursing activities. To enhance patient safety management activities, it is necessary to develop a sense of calling education program, improve nursing work systems tailored to the demands of the COVID-19 situation, and establish a fair compensation system.

Implications for future research and practice

First, future research could explore innovative approaches that can strengthen nurses' sense of calling, through mentorship and institutional recognition. Second, a mediation study should be conducted to determine if there is an imbalance between the efforts and rewards of nurses in comprehensive nursing care service units that affects patient safety nursing services. Additionally, by quantifying the extent of excessive effort and its implications for patient safety, measuring excessive effort in interconnected nursing tasks requires the development of reliable metrics and tools that accurately capture the workload and stressors experienced by nurses in comprehensive care settings. Third, further research should be conducted with a broader range of participants from various medical institutions as the study only included nurses working in small and medium-sized hospitals in some regions. Finally, subsequent research should be conducted to identify new variables related to patient safety management activities that may have an impact beyond the sense of calling and job stress among nurses in comprehensive nursing care service units.

Availability of data and materials

The data that support the findings of this study are available from the authors Korea, upon reasonable request.

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This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT Future Planning (No. RS-2023-00245180) and by Korea Health Industry Development Institute (grant number: HI18C1317). The funding agencies had no role in the study design; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

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Lee, Y., Hwang, W.J. The impact of nurse’s sense of calling, organizational commitment, job stress, and nursing work environment on patient safety management activities in comprehensive nursing care service units during the covid-19 pandemic. BMC Nurs 23 , 311 (2024). https://doi.org/10.1186/s12912-024-01929-6

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Pharmacotherapy in Stress Urinary Incontinence; A Literature Review

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• Seyed Sajjad Tabei 1 ,
• Wesley Baas 1 &
• Ayman Mahdy 1 , 2  

Purpose of Review

Stress urinary incontinence (SUI) is a commonly observed condition in females, as well as in males who have undergone prostatectomy. Despite the significant progress made in surgical techniques, pharmacotherapy has not yielded substantial outcomes within the clinical domain. This review aims to present a comprehensive overview of the existing pharmacotherapy options for stress urinary incontinence (SUI) and the emerging therapeutic targets in this field.

Recent Findings

One meta-analysis demonstrated that α-adrenergic medications are more efficacious in improving rather than curing SUI symptoms. One trial showed reduced pad weight gain with PSD-503, a locally administered α-adrenergic receptor agonist. New data show that duloxetine’s risk outweighs its benefits. One small-scale trial was found to support the use of locally administered estriol in improving subjective outcomes. Emerging targets include serotonin 5HT 2C agonists, selective inhibitors of norepinephrine uptake, and myostatin inhibitors.

Only one of the evaluated drugs, duloxetine, has been approved by some countries. Currently, trials are evaluating novel targets. Systemic adverse effects such as gastrointestinal upset with duloxetine and orthostatic hypotension with α -adrenoceptor agonists have hampered the efficacy of drugs used to treat SUI in women and men.

Avoid common mistakes on your manuscript.

Introduction

Stress urinary incontinence (SUI) is a debilitating urological disorder defined as the involuntary leakage of urine upon activities that may increase the intra-abdominal pressure, such as exertion, sneezing, or coughing [ 1 ]. Various anatomical and physiological factors result in this condition, but the common endpoint of all etiologies is the inability of normal urinary control mechanisms to overcome the previously tolerated urinary pressure load. In these cases, there is often an interplay of various factors, which ultimately present as SUI. Non-modifiable determinants such as female sex and Caucasian race and modifiable factors such as smoking, obesity, and chronic constipation have all been shown to influence the progression to clinical presentation. Importantly, pregnancy, normal vaginal delivery, and past history of pelvic procedures such as hysterectomy have been shown to promote SUI in women [ 2 ]. Also, pelvic organ prolapse (POP), which can occur commonly after menopause or delivery, highly correlates with the concurrent presence of SUI, and in some cases, POP repair results in the unmasking of the urethral deficit and subsequent presentation with SUI [ 3 ]. A 12-year survey between 2005 and 2016 including more than 15,000 women in the US revealed that more than half of the respondents had experienced a form of incontinence. Moreover, around 1 in 4 respondents reported having a stress-only UI [ 4 ]. SUI significantly affects patients both in psychosocial and financial terms. Data evaluation in 2011 indicated that SUI management expenditures in the US were in excess of $12 billion per year [ 5 ].

Men, on the other hand, are prone to developing SUI often due to iatrogenic causes such as prostatectomy [ 6 ].

Although surgical methodology has progressed and conservative measures like pelvic exercises have been developed to treat SUI, the evidence-based clinical applicability of pharmacotherapy for SUI appears to be limited. This review looks to explore the current pharmacological arsenal in treating SUI and emerging experimental targets.

Literature Description

Α-adrenoceptor agonists (α-ar agonists).

Human studies have shown that three different subtypes of α-AR are expressed on the urethra, with α 1A -AR being the most common in both sexes. There have been attempts to address SUI by targeting these receptors. However, the abundance of these receptors in other organs has hindered its efficacy as an established therapeutic option for treating SUI [ 7 , 8 ]. Animal models had previously shown smooth muscle contractile changes in the urethra after stimulation of these receptors by noradrenaline (NA) [ 9 ].

In a 2011 study by Robinson et al., an experimental drug named PSD503 (phenylephrine 20% weight/weight) was proposed as a vaginal topical gel for treating SUI in women. In the phase II clinical trial, a total of 14 women were evaluated over a span of 20 months. Data indicated that treatment with this compound resulted in reduced pad weight gain compared to placebo (median weight reduction %: PSD503- 54.33%, placebo- 38%) [ 10 ]. Despite favorable outcomes, poor patient recruitment and follow-up were considered limiting factors in this study [ 11 ].

By implementing new data synthesis techniques, a network meta-analysis of pharmacologic and non-pharmacologic UI treatments was conducted in 2019. The analysis was stratified based on symptom resolution or improvement, and the quality of the outcomes was reported as “standard of evidence” (SoE) in accordance with the Agency for Healthcare Research and Quality’s recommendations. Two separate studies encompassing a combined sample size of 736 patients were examined to assess and compare the rates of “cure” among patients with stress urinary incontinence (SUI) who received treatment with α-agonists vs. those who did not receive any intervention. The results revealed a moderate SoE in favor of α-agonists when they were used to achieve “cure” in these patients (OR:1.22; 95% CI: 0.47–3.03). The results were more convincing when the efficacy was evaluated for symptomatic “improvement” in SUI patients. The improvement data analysis comprised seven studies with 5035 cases (OR:2.28; 95% CI: 1.60–3.30). This cure/treatment analysis revealed that α-agonists may be useful if symptom relief rather than complete resolution is the goal of treatment [ 12 ] Fig. 1 .

Voluntary and involuntary control of the urethra. The inhibitory role of the central control mechanisms has been outlined—illustration created in Biorender.com

β-Adrenoceptor Agonists and Antagonists

From a pharmacological standpoint, β-AR antagonists can potentially offset the relaxation effects of the endogenous NA stimulation and further enhance the α-AR urethral response of contracting the internal urethral sphincter. Drugs such as sotalol and propranolol have been studied in the past but have shown no meaningful response in the treatment of SUI [ 8 ]. The 5th edition of Walters & Karram Urogynecology and Reconstructive Pelvic Surgery textbook has outlined propranolol 10 mg b.i.d. to 40 mg t.i.d. daily as dosages that may help improve SUI symptoms [ 13 ]. However, no trials over the last 5 years have confirmed such a statement.

On the other hand, β-AR agonists such as clenbuterol have also been studied in the context of SUI treatment. Rabbit models suggested that selective β 2 -AR agonism, such as clenbuterol, propagated the external urethral contractile force [ 14 ]. There has been a lack of new human studies on this drug class over the recent years.

Antidepressants

An increase in norepinephrine levels can potentially ameliorate the contractile response through central nervous system mechanisms in the Onuf’s nucleus [ 15 ]. Serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) are two drug classes that have been extensively researched due to their shared properties [ 8 , 16 ]. Kornholt et al. published a study in 2019 looking into the changes in urethral opening pressure caused by imipramine (TCA). The effects of a single dose of imipramine 50 mg and placebo on 16 healthy women with BMIs in the normal range were investigated using a randomized, double-blind, placebo-controlled cross-over design. A 6.5 cmH2O rise in urethral pressure at rest and a 7.9 cmH2O increase in the squeeze condition were seen compared to the placebo. The observed increase in urethral opening pressure did not reach statistical significance (p-value: 0.07 at rest, p-value: 0.06 under squeeze condition). Despite the limited sample size, the researchers reached the conclusion that the administration of imipramine is not recommended for cases of stress urinary incontinence (SUI) [ 17 ].

Duloxetine (SNRI) has also been extensively studied in the setting of off-label use for SUI and has been approved by the European Union. Human studies have shown using pressure reflectometry methods that duloxetine is superior to midodrine and placebo in increasing urethral tone [ 18 ]. The physiological pathway through which duloxetine exerts its effect may be through maintaining NE and 5HT levels in the CNS and Onuf’s nucleus. In addition, recent evidence suggests that maintaining serotonin levels plays a role in increasing urethral opening pressure via the 5HT2C pathway, which could explain the success of duloxetine and SNRIs in treating SUI [ 19 ]. In a Cochrane review on SNRIs and their role in SUI that was last revised in 2008, Mariappan et al. concluded that duloxetine should be considered as an effective means of treatment [ 20 ]. However, there has not been any update in this regard over the last 5 years.

Duloxetine is one of the few drugs that has been studied in the context of post-prostatectomy SUI. Research was undertaken involving a cohort of males who had undergone prostatectomy. The study sample consisted of 94 patients who were subjected to a treatment regimen involving the administration of duloxetine at a dosage of 30 mg once weekly immediately following the surgical procedure, followed by subsequent dosages of 60 mg once weekly. Review after a month of treatment showed that patient satisfaction was achieved in a third of patients, but the remainder discontinued the drug due to dissatisfaction or side effects. Around 15% of patients had experienced nausea, fatigue, light-headedness or dry mouth [ 21 ].

Despite clinical efficacy, side effects with duloxetine appear to be a concerning issue. A review of 6395 SUI patients treated with duloxetine revealed that adverse events occurred in 22.1% of patients and were resolved upon cessation of treatment. Common events included nausea, vomiting, constipation, and dry mouth [ 22 ].

Hormones and Hormone Modulators

In a prospective observational study by West et al. in 2023, the effects of a 12-week course of vaginal estriol cream 0.5 mg on SUI in postmenopausal females were measured. Forty-six postmenopausal women with pure SUI or stress-predominant mixed urine incontinence (MUI) who were not receiving additional incontinence therapy were included in the study. The primary endpoint was evaluating the vaginal pH levels and changes in the “Urogenital Distress Inventory-6 (UDI-6) stress domain scores”. The findings demonstrated significant improvement UDI-6 (dropping from a median of 83.3 to 33.3, p  ≤ 0.001). Furthermore, vaginal pH levels notably reduced (from a median of 5.1 to 4.9, p  ≤ 0.001) following the 12-week treatment. However, there was no mention of how the pH and urinary symptoms correlated with each other following estrogen therapy [ 23 ].

Enobosarm, alternatively referred to as Ostarine or MK-2866, is an experimental pharmaceutical compound categorized as a selective androgen receptor modulator. Its primary purpose is to activate androgen receptors in muscle and bone tissues. In a Phase 2 clinical study, researchers explored enobosarm for treating SUI in postmenopausal females. For 12 weeks, postmenopausal women with SUI received 3 mg of enobosarm orally. Stress incontinence episodes per day were measured using a 3-day voiding diary. All 17 subjects completing the 12-week treatment reported at least a 50% decrease in daily stress leaks. The average number of stress leaks experienced per day fell by 83% after 12 weeks, with a mean baseline of 5.08 leaks per day reducing to 0.88 leaks per day. This improvement was durable during the 40-week follow-up. Some patients even achieved a negative bladder stress test (BST) at 12 weeks, signifying significant improvement. Quality of life also improved, evident from the QOL instruments. The median female sexual function index (FSFI) score, measuring sexual function, notably increased. The MESA stress score, assessing stress and anxiety, significantly decreased. The administered treatment demonstrated a high level of tolerability, as no significant side events were seen, affirming its safety profile [ 24 ]. However, it was later reported in 2018 that the “ASTRID (Assessing Enobosarm for Stress Urinary Incontinence Disorder)” Trial was called off by its sponsor due to unconvincing results [ 25 ].

Testosterone possesses the capacity to elicit anabolic effects on the musculature of the pelvic floor. Kim et al. analyzed information from the 2012 “NHANES (National Health and Nutrition Examination Survey)” dataset, encompassing more than 2,300 women. The results suggested that women with lower levels of serum testosterone had a greater likelihood of experiencing stress and mixed urinary incontinence [ 26 ]. A 2018 clinical investigation (ClinicalTrials.gov Identifier: NCT03116087) examined testosterone therapy in postmenopausal women with SUI and low testosterone [ 27 ]. However, there have been no results published yet.

In a non-randomized clinical trial, Gažová and colleagues investigated the potential of CEL complex, an herbal compound, in managing SUI among female participants. The study findings demonstrated significant reductions in incidences of stress urinary incontinence (SUI) and improved alleviation of symptoms. These effects were attributed to the proposed mechanism of action of the herbal ingredient, which is believed to augment natural testosterone levels and influence the sphincteric muscles [ 28 ].

Experimental Targets; TAS-303, Muscle Growth Promoters & 5HT 2C Agonists

One of the recent developments in experimental therapeutics for SUI includes the development of TAS-303. This drug is a selective inhibitor of norepinephrine (NE) uptake with minimal central nervous system activity. In 2018, Mizutani et al. reported that in-vitro studies of this drug on murine models showed promising results by increasing the urethral closing pressure and leak point pressures in vaginal distension (VD) rats with superior efficacy than duloxetine. The VD rats were used to simulate the dysfunctional urethra following vaginal delivery. To assess the cardiovascular side effects, heart rate and blood pressure were monitored in dogs treated with TAS-303 which showed no statistically significant change [ 29 ].

Following the success in animal models, Yono et al. published the phase I clinical trial results of TAS-303 in 2020. A total of 16 women (treatment n: 8; placebo n: 8 patients) were enrolled in this randomized, double-blinded, cross-over trial. Each patient received 18 mg TAS-303 orally and was evaluated for MUCP after 6 h. There appeared to be an increase in the MUCP in the treatment group (3.473 ± 12.154 cmH2O) and the placebo group ( 2.615 ± 9.794 cmH2O ). However, the comparison of both groups was insignificant (p-value = 0.80). Additional analysis also demonstrated that there was no difference regarding drug contractile effect between the proximal, middle, and distal urethra [ 30 ].

The preliminary findings from the phase II clinical trial of TAS-303 were given in 2022 by Takahashi et al. (ClinicalTrials.gov Identifier: NCT04512053). The objective of this study was to evaluate the effectiveness of TAS-303 at a dosage of 18 mg once daily over 12 weeks. The medication group comprised 110 female participants, while the trial’s placebo arm included 111 female participants. Japanese women older than 20 and positive 1-hour pad tests over the prior three months were deemed eligible to enter this study. Moreover, if the individuals met the mentioned criteria and presented with a mean stress urinary incontinency episode frequency (SUIEF) per 24 h of ≥ 1 in the weekly bladder diary, they were considered suitable to enter the treatment phase. Following a 12-week period, it was observed that the medication group experienced a decrease of 57.50% in the average daily SUIEF, whereas the placebo group displayed a reduction of 47.35%. Statistical analysis of the collected data revealed a significant difference between the two groups (p-value = 0.047). The presentation did not provide specific details regarding the side effects; however, it was indicated that both groups experienced them at comparable rates. Compared to the placebo arm, the TAS-303 group showed greater improvement in subjective criteria [ 31 ].

Efforts have been recently made to evaluate experimental myostatin inhibitors for treating SUI in murine models. One example is the activin type II receptor blocker Bimagrumab, which promotes muscle growth by blocking the myostatin pathway [ 32 ]. Yang et al. conducted a study wherein rats were administered bimagrumab, and the resulting outcomes were compared to those observed with other muscle growth promoters, namely clenbuterol and a derivative of 5-hydroxybenzothiazolone (5-HOB). After two weeks, those treated with bimagrumab showed a higher leak point pressure than rats that had undergone treatment with clenbuterol or 5-HOB. This success was also confirmed when the tissues were histologically evaluated, which were in favor of muscle repair. However, significant overall weight gain was a limiting factor in this study [ 33 ].

Another experimental class of drugs that have recently been studied are the 5-HT 2C receptor agonists. This class of drugs has shown the potential to increase the leak pressure point in vitro and in animal models. A study in 2018 showed that vaginally distended rats treated with Lorcaserin (Belviq ® ), a 5-HT 2c agonist which at that time was FDA approved for treating obesity, showed significantly higher leak point pressures than controls. They concluded that this drug promoted urinary control via its effect on the pelvic muscles and external urethral sphincter control [ 34 ]. The FDA withdrew its approval of Lorcaserin in 2020 after studies showed significant cancer occurrence with this drug and disproportionate risks to benefits [ 35 ]. Another study also confirmed the effect on the urethra by treating animal models with ASP-2205 fumarate, a selective 5-HT 2C agonist [ 36 ]. TAK-233, also known as OP-233, has a much higher selectivity for human 5-HT 2c receptors and has shown improvement in animal urethral closure, suggesting applicability in cases of SUI. The phase I trial (Clinical trials ID: NCT02113020) was undertaken in 2014; however, there are no published results in this regard. It was announced in 2016 that Takeda and Frazier had partnered to develop this breakthrough drug [ 37 , 38 ].

The accepted management options for SUI are dictated by the current understanding of the pathophysiology of this condition. Similarly, the bulk of research contribution over the last five years has been focused on surgical correction of this disorder rather than exploring pharmacotherapy options for SUI. However, the culmination of years of research on pharmacotherapy options has had a minimal impact in the clinical setting. The revised edition of the guideline on the management of female stress urinary incontinence (SUI) issued by the American Urological Association (AUA) in 2023 does not include any reference to medication as a conservative treatment option [ 39 ]. However, the European Association of Urology is more detailed on non-surgical options for women with SUI [ 40 ]. Their stance regarding hormonal options echoes the findings from a Cochrane review published by Cody et al. in 2012. It was concluded in this study that systemic estrogen therapy or combined estrogen/progesterone may worsen incontinence outcomes. On the other hand, limited use of locally delivered estrogen proved beneficial for overall incontinence outcomes (RR 0.74, 95% CI 0.64 to 0.86) [ 41 ]. The European guidelines also note that duloxetine may be used as a form of treatment for SUI. This is in contrast to the US, where duloxetine’s usage in these circumstances has not been approved by the FDA [ 42 ].

Multiple reasons could be attributed to the lack of widespread success of therapeutic regimens in SUI in the clinical setting. In the case of α-adrenergic medications, the Cochrane review by Alhasso et al. was critical in determining the overall inefficacy of such medications [ 43 ]. The abundance of such receptors on numerous organs, especially the cardiovascular system, is a matter of concern. Life-threatening adverse effects such as hemorrhagic stroke and cardiac arrhythmia have limited the success of this drug class [ 26 ]. Advances in developing tissue-specific drugs may prove beneficial in the future in diminishing such side effects. Re-evaluating data using novel data synthesis methods, such as the study done by Balk et al. in 2019, may ultimately provide a final answer to whether current available adrenergic medications could be used for SUI. By focusing the endpoints of pharmacotherapy on symptomatic improvement rather than cure, we may observe more favorable outcomes regarding adrenergic medications [ 12 ].

It is essential to underscore the significance of neurological pathways in treating SUI. This fact could be reiterated by observing the relative success of duloxetine and other antidepressants [ 21 , 44 ]. Interestingly, studies on female athletes have shown that those experiencing SUI during practice report fewer incontinence episodes during competition. This could imply the protective effects of neurological mechanisms and heightened catecholamine levels in preserving continence [ 45 ]. It would be intriguing to observe whether the recent reassessments of duloxetine, indicating a potential for risks outweighing benefits in the context of stress urinary incontinence (SUI) treatment, might prompt modifications to the existing European guidelines [ 46 ]. A thorough review of the pharmacological pathways of the mentioned drugs has been described by Michel et al. [ 8 ].

An area of pharmacotherapy that is understudied in SUI patients is the role of novel weight loss medications such as Ozempic and Wegovy (semaglutide). Recent studies have shed light on the correlation between BMI, weight, and waist circumference on the occurrence of SUI [ 47 ]. It would be interesting to see if weight loss medications result in any meaningful increase in long-term outcomes.

The currently available literature on pharmacotherapy options for SUI is rather limited in comparison with novel surgical techniques. The effectiveness and safety of different medication classes for the treatment of SUI have been assessed in numerous trials. The US regulatory authorities have not approved any medication class; whereas some areas such as Europe have approved the use of duloxetine. New target-specific drugs with less systemic side effects may pave the way for the approval of medications. Further research is also necessary to evaluate the role of pharmacotherapy in men in addition to women due to different lower urinary tract characteristics.

Data Availability

No datasets were generated or analysed during the current study.

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Tabei, S.S., Baas, W. & Mahdy, A. Pharmacotherapy in Stress Urinary Incontinence; A Literature Review. Curr Urol Rep (2024). https://doi.org/10.1007/s11934-024-01205-9

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Extensor tendon rupture and preoperative mri confirmations of suture anchor prolapse: a case report and literature review

• Ahmad Alhaskawi 1   na1 ,
• Haiying Zhou 1   na1 ,
• Yanzhao Dong 1 ,
• Sohaib Hasan Abdullah Ezzi 2 ,
• Xiaodi Zou 3 ,
• Zhou Weijie 4 ,
• Fangyu Yi 5 ,
• Sahar Ahmed Abdalbary 6 &

BMC Musculoskeletal Disorders volume  25 , Article number:  355 ( 2024 ) Cite this article

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Metrics details

While suture anchors are widely used in medical procedures for their advantages, they can sometimes lead to complications, including anchor prolapse. This article presents a unique case of suture anchor prolapse at the base of the distal phalanx of the little finger after extensor tendon rupture reconstruction surgery.

Case presentation

A 35-year-old male, underwent extensor tendon rupture reconstruction using a non-absorbable suture anchor. After seven years the patient visited our outpatients complaining of stiffness, pain, and protrusion at the surgical site. Initial X-ray imaging suggested suggesting either a fracture of the distal phalanx or tendon adhesion but lacked a definitive diagnosis. Subsequent magnetic resonance imaging (MRI) revealed bone connectivity between the middle and distal phalanges with irregular signal shadow and unclear boundaries while maintaining a regular finger shape. MRI proved superior in diagnosing prolapsed suture anchors, marking the first reported case of its kind. Surgical intervention confirmed MRI findings.

Conclusions

Suture anchor complications, such as prolapse, are a concern in medical practice. This case underscores the significance of MRI for accurate diagnosis and the importance of tailored surgical management in addressing this uncommon complication.

Peer Review reports

Introduction

Mallet finger, a condition resulting from trauma to the fingertip, presents as a drooping distal joint due to damage to the extensor tendon. Non-surgical options, such as splinting to maintain joint position, physical therapy for rehabilitation, and the RICE protocol for symptom management are often effective in mild cases. For severe tendon damage or fractures, surgical interventions like Open Reduction and Internal Fixation (ORIF), tendon repair, or joint fusion may be necessary [ 1 ]. Advanced techniques, including extensor tendon suture anchor fixation to the base of the distal phalanx, are used in severe cases. This procedure achieves precision by securing the damaged extensor tendon to the bone with suture anchors, promoting optimal healing, and restoring the proper alignment of the distal joint [ 2 , 3 ]. However, complications may arise in cases of unsuccessful treatment or delayed intervention. Persistent extensor tendon insufficiency can lead to conditions such as DIP (distal interphalangeal) joint flexion contracture, characterized by an inability to fully extend the affected joint. Additionally, swan-neck deformity, marked by hyperextension of the proximal interphalangeal (PIP) joint and flexion of the DIP joint, can occur [ 4 , 5 , 6 ]. Postoperative care involves immobilization followed by a tailored rehabilitation program to restore functionality. Early diagnosis and an individualized approach to treatment are essential for optimal recovery in mallet finger cases [ 1 , 7 , 8 ]. The suture anchor is a specialized medical implant used in orthopedic surgeries to attach soft tissues, such as tendons and ligaments, to bone [ 9 ]. However, the use of suture anchors may result in several potential complications. For instance, an inflammatory response may occur, leading to osteolysis after surgery. Studies have documented significant bony defects in the distal phalanx at the suture anchor insertion site, as seen on X-rays in some cases. Additionally, this inflammatory reaction can cause adhesion of the flexor digitorum profundus (FDP) tendon to the distal phalanx. It is crucial to be aware of these possible complications when considering the use of suture anchors and to carefully monitor patients postoperatively for any signs of adverse reactions [ 10 , 11 , 12 , 13 , 14 ].

This article reports a case where an MRI eventually detected suture anchor prolapse. Despite conducting a physical examination and obtaining X-ray images, the initial assessment was misleading and suggested either a mallet finger or tendon adhesion.

A 35-year-old male patient previously undergone extensor tendon rupture reconstruction surgery on his right little finger at another hospital. During the procedure, a suture anchor was placed at the base of the distal phalanx. Seven years post-surgery, the patient visited our department, complaining of pain, and stiffness in his finger. Notably, he reported no post-surgical trauma. Physical examination showed an inability to achieve full dorsal extension, but there was no disturbance of circulation or swelling. Mild redness and signs of infection were observed, along with a noticeable protrusion at the surgical site. An X-ray was performed, revealing an anomaly at the base of the distal phalanx of the little finger, raising suspicions of either a distal phalanx fracture or tendon adhesion (Fig.  1 ).

X-ray of the right hand presenting a malunion fracture block at the middle and distal phalanges of the right little finger

Following further investigation, an MRI was performed, revealing abnormal alterations in both the middle and distal phalanges of the right little finger. These changes were characterized by compromised bone connectivity, irregular areas of patchy high signal shadows (notably with lipid suppression), and indistinct boundaries. Notably, the bone morphology of the other right fingers appeared normal, displaying no discernible abnormal signals. Additionally, the joint surfaces were smooth, with no abnormalities detected in the surrounding soft tissues (Fig.  2 a, c). Therefore, the patient underwent surgery, where a significant amount of scar tissue around the inserted suture anchor. Following the removal of the scar tissue, it was discovered that the tail of the anchor was located in the center of the extensor tendon, close to the subcutaneous area, and protruding. Attempts to clamp the anchor directly through the tail were unsuccessful. After the base is enlarged with an electric drill, the anchor was completely removed. The bone defect was reinforced by artificial bone grafting and re-repair of the extensor tendon was performed (Fig.  3 ). Our patient was diagnosed with anchor prolapse, which was clearly visible on magnetic resonance MRI.

Comparing between MRI before and after the surgery. (a, c) preoperative images, show a foreign body, which did not rupture the extensor tendon, and a poor bone connectivity of the middle and distal phalanges, with patchy (lipid suppression) high signal shadow and unclear boundary at distal phalanx of the little finger(narrows). (b, d) postoperative images, present no foreign body shadow

Suture anchor prolapse at the base of distal phalanges of the right little finger, which could be misdiagnosed as an osteophyte or tendon adhesion

A finger-cap fixation was applied for one month, accompanied by the administration of oral antibiotics. The stitches were subsequently removed two weeks post-surgery. Functional exercises began after two weeks. At one month follow-up, the flexion and extension function of the distal segment showed improvement compared to its pre-operative state, and the nearly full range of motion was observed at the second-month follow-up (Fig.  2 b, d, and Fig.  4 ).

Second month after removing the prolapsed suture anchor, noticeable improvement of the movement of the right little finger

Suture anchors represent a pivotal advancement in modern surgical techniques, particularly in the field of orthopedic and sports medicine. Their primary function is to enable the secure attachment of soft tissues, such as ligaments and tendons, to bone, a task that traditional suturing methods may not adequately accomplish. These anchors, typically composed of metal or biocompatible polymers, are meticulously designed for insertion into the bone, providing a robust and reliable anchorage point for sutures. This technology is especially beneficial in areas subjected to high stress and movement, such as shoulder, hand, and knee joints, where it ensures a stable and enduring tissue-to-bone healing process. The utilization of suture anchors has been instrumental in reducing recovery time, minimizing postoperative complications, and enhancing the overall success rates of orthopedic surgeries. Their versatility and effectiveness in various surgical contexts underscore their significance in contemporary medical practice [ 15 , 16 ].

A key factor in the successful use of suture anchors is the selection of the appropriate anchor. This choice involves considering the size and material of the anchor, which may vary from metallic to bioabsorbable, depending on the patient’s condition and the specific surgical requirements. Moreover, the insertion technique is paramount [ 17 ]. The insertion process involves loading the suture into the anchor implant, placing it into a pre-drilled bone hole, and then applying tension by pulling on the free suture ends. This is followed by securing the suture end to suture cleats for stabilization, as described by Kevi Es Neison and Joodan Ei Foof [ 18 ]. According to Johnstone and Karuppiah [ 19 ], a proper technique involves using a guide wire or pilot hole for precise placement and ensuring that the anchor is inserted at an optimal angle to maximize pull-out strength. Additionally, it is vital to avoid overtightening the anchor, as this can lead to bone damage or anchor loosening [ 19 ]. To facilitate easier insertion of suture anchors, surgeons may employ various techniques. Proper drilling, using the correct drill bit size and depth, is crucial. Depth gauges can aid in achieving the correct depth and prevent drilling too deep or shallow. Enhanced visualization techniques, such as arthroscopic or imaging methods, are also recommended for precise placement, especially in less accessible surgical areas. Additionally, the use of ergonomic instruments designed for anchor insertion can improve the surgeon’s control and accuracy during the procedure [ 17 , 20 , 21 ]. However, the use of suture anchors is not without its disadvantages. The risk of prolapse or migration of the anchor remains a concern, particularly if the placement technique is not precise. There is also a potential risk of infection, a common issue with any surgical implant. Cost is another factor, as suture anchors tend to be more expensive than traditional suturing methods. Lastly, the effectiveness of suture anchors relies heavily on the surgeon’s expertise and experience, indicating a significant learning curve for optimal use [ 22 , 23 ].

Suture anchor prolapse, where the anchor dislodges or moves from its initially intended position, can occur for several reasons, and understanding these factors is crucial for preventing such complications. One of the primary reasons for suture anchor prolapse is poor bone quality. In patients with osteoporosis or other conditions that weaken the bone, the anchor may not secure properly, leading to a higher risk of prolapse. This issue is particularly significant in elderly patients or those suffering from diseases that affect bone density. Additionally, the use of an anchor that is too small or not suitable for the specific bone density can also lead to inadequate fixation strength, increasing the likelihood of prolapse. It’s essential to select an anchor size and type that is compatible with the patient’s bone quality and the specific requirements of the surgical procedure [ 24 , 25 ]. In addition, incorrect placement of the suture anchor is another significant factor contributing to prolapse. If the anchor is not placed at the correct depth or angle, it may not hold securely in the bone. Placement that is too superficial or in an area of the bone with less density can compromise the anchor’s stability. Furthermore, overloading the anchor by applying excessive tension to the suture or using it in a high-stress area without adequate support can lead to the failure of the anchor. Surgeons must ensure that the anchor is placed correctly and that the suture is tensioned appropriately to prevent such issues [ 22 , 24 ]. Suboptimal surgical techniques can also lead to anchor prolapse. Inadequate preparation of the anchor site, such as not pre-drilling a hole to the appropriate size or not cleaning the hole of debris before anchor insertion, can affect the anchor’s grip in the bone. Precision in surgical technique and thorough site preparation are therefore essential [ 26 , 27 ]. Furthermore, Patient factors play a significant role as well. Activities that place excessive stress on the area soon after surgery or non-compliance with postoperative restrictions can contribute to anchor prolapse. Additionally, conditions that affect healing, such as diabetes or smoking, may also increase the risk [ 22 , 28 , 29 ]. Suture anchor prolapse can often result in a range of symptoms, such as pain, stiffness, and mass projection at the prolapsed site, which can be similar to other conditions such as distal phalanx fracture and tendon adhesion. X-ray imaging of anchor prolapse typically reveals an avulsion fragment at the insertion site of the common extensor tendon on the distal phalanx at the distal interphalangeal joint, which may resemble a mallet finger type of distal phalanx fracture or tendon adhesion [ 16 ]. Distal phalanx fractures are frequently encountered in both emergency departments and outpatient clinics. Mallet finger deformities typically result from an avulsion injury to the terminal tendon of the distal phalanx, which leads to the detachment of a bone fragment from the insertion of the terminal tendon [ 30 ]. X-ray imaging typically reveals an avulsion fragment at the base of the common extensor tendon, indicating a mallet finger injury. Notably, a high proportion of mallet finger injuries present as isolated tendon injuries without associated avulsion fractures [ 31 ]. In addition, tendon adhesion, characterized by the adhesion of tendons to surrounding tissues and the loss of range of movement, can be diagnosed at the distal phalanx of the little finger by X-ray imaging and during the physical examination [ 32 , 33 , 34 , 35 ]. Tendon adhesion is a reported complication in up to 20% of patients with tendon injuries [ 32 , 33 , 34 , 35 ].

Therefore, our case presented the benefit of MRI in diagnosing and locating the suture anchor prolapse at the distal phalanx of the little finger after, which had been misdiagnosed by X-ray imaging. The MRI scan revealed unusual changes in both the middle and distal phalanges of the right little finger. These changes were characterized by compromised bone connectivity, irregular areas of patchy high signal shadows (notably with lipid suppression), and indistinct boundaries, conclusively confirmed the presence of suture anchor prolapse. The MRI finding was confirmed through surgical intervention. In contrast, conditions such as mallet finger and tendon adhesion are typically diagnosed through clinical examination, ultrasound, and X-ray imaging.

This article presents a case in which the eventual identification of suture anchor prolapse was made through MRI, revealing a discrepancy from the initial assessment. Despite a thorough physical examination and the acquisition of X-ray images, the initial evaluation was misleading, pointing towards potential diagnoses such as a mallet finger or tendon adhesion. An inaccurate diagnosis may result in delayed or inappropriate treatment, underscoring the importance of careful consideration of radiological findings. Therefore, MRI has proven to be an invaluable diagnostic tool for detecting prolapsed suture anchors.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Magnetic resonance imaging

Open Reduction and Internal Fixation

(distal interphalangeal)

Proximal interphalangeal joint

Flexor digitorum profundus

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Acknowledgements

Thanks to Fatima and Maling for their support and encouragement.

The study was funded by Zhejiang Provincial Natural Science Foundation of China (LS21H060001). The funding body had no role in the design of the study; in collection, analysis, and interpretation of data; and in drafting the manuscript.

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Ahmad Alhaskawi and Haiying Zhou contributed equally to this work.

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Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, P. R. China

Ahmad Alhaskawi, Haiying Zhou, Yanzhao Dong & Hui Lu

Department of Orthopedics of the Third Xiangya Hospital, Central South University, Tongzipo Rd, Changsha, Hunan, 410083, China

Sohaib Hasan Abdullah Ezzi

The Second Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Province, 310003, Hangzhou, P. R. China

Department of Orthopaedics, Joint Service Assurance Force 903 Hospital, Airport Road, Shangcheng District, Hangzhou City, Zhejiang Province, 310053, P.R. China

Zhou Weijie

The First School of Clinical Medicine, Zhejiang Chinese Medical University, #548 Binwen Road, Hangzhou, Zhejiang Province, 310053, P.R. China

Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, Nahda University in Beni Suef, Beni Suef, Egypt

Sahar Ahmed Abdalbary

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HL, Sahar, XZ, and ZW designed the study, performed data collection and supervission; Ahmad, Yanzhao, Haiying, Sohaib, and FY wrote and drafted the manuscript. The authors have read and approved the final manuscript.

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Alhaskawi, A., Zhou, H., Dong, Y. et al. Extensor tendon rupture and preoperative mri confirmations of suture anchor prolapse: a case report and literature review. BMC Musculoskelet Disord 25 , 355 (2024). https://doi.org/10.1186/s12891-024-07476-0

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Case report article, old woman with sheehan's syndrome suffered severe hyponatremia following percutaneous coronary intervention: a case report and review of literature.

• 1 School of Clinical Medicine, Shandong Second Medical University, Weifang, Shandong, China
• 2 Cardiology Department and Experimental Animal Center, Liaocheng People’s Hospital of Shandong University and Liaocheng Hospital Affiliated to Shandong First Medical University, Liaocheng, Shandong, China
• 3 Department of Central Laboratory, Liaocheng People’s Hospital, Liaocheng, Shandong, China
• 4 Department of Cardiology, Shandong Corps Hospital of Chinese People’s Armed Police Forces, Jinan, China

Glucocorticoid deficiency can lead to hypoglycemia, hypotension, and electrolyte disorders. Acute glucocorticoid deficiency under stress is very dangerous. Here, we present a case study of an elderly patient diagnosed with Sheehan's syndrome, manifesting secondary adrenal insufficiency and secondary hypothyroidism, managed with daily prednisone and levothyroxine therapy. She was admitted to our hospital due to acute non-ST segment elevation myocardial infarction. The patient developed nausea and limb twitching post-percutaneous coronary intervention, with subsequent diagnosis of hyponatremia. Despite initial intravenous sodium supplementation failed to rectify the condition, and consciousness disturbances ensued. However, administration of 50 mg hydrocortisone alongside 6.25 mg sodium chloride rapidly ameliorated symptoms and elevated blood sodium levels. Glucocorticoid deficiency emerged as the primary etiology of hyponatremia in this context, exacerbated by procedural stress during percutaneous coronary intervention. Contrast agent contributed to blood sodium dilution. Consequently, glucocorticoid supplementation emerges as imperative, emphasizing the necessity of stress-dose administration of glucocorticoid before the procedure. Consideration of shorter intervention durations and reduced contrast agent dosages may mitigate severe hyponatremia risks. Moreover, it is crucial for this patient to receive interdisciplinary endocrinologist management. In addition, Sheehan's syndrome may pose a risk for coronary atherosclerotic disease.

Introduction

In developed countries, studies have revealed varying prevalence rates of Sheehan's syndrome (SHS) among women, ranging from 0.0051% ( 1 ) to 3.1% ( 2 ). There were also studies showing that the prevalence of SHS ranged from 1% to 2% among women who experienced hypotension due to blood loss of 1–2 L ( 3 , 4 ). Contrastingly, in undeveloped nations, the prevalence varies from 3.1% to 27.6% ( 5 – 7 ). The diagnostic journey for SHS patients spans a considerable duration of 7–19 years from symptom onset to definitive diagnosis ( 8 ). Sheehan's syndrome arises from ischemic necrosis of the anterior pituitary gland triggered by postpartum hemorrhage ( 8 ), leading to pituitary hormone dysfunction, including insufficient secretion of growth hormone, thyroid stimulating hormone, gonadotropin, prolactin, and adrenocorticotropin (ACTH) ( 7 , 9 ). Predominant symptoms are associated with dysfunction of the gonads, thyroid, and adrenal cortex due to insufficient secretion of gonadotropins, thyroid stimulating hormones, and ACTH, respectively. The latter is the most prominent and sometimes life-threatening. Supplementing various deficient hormones is the primary treatment for SHS.

Glucocorticoids, pivotal adrenal cortex hormones, play crucial roles in regulating glucose metabolism, blood pressure, and electrolyte balance. Deficiency in glucocorticoids can lead to hypoglycemia, hypotension, and electrolyte disturbances. Lifetime glucocorticoid replacement therapy stands as a cornerstone in managing SHS patients. Fluctuations in neuroendocrine system activity necessitate adjustments in glucocorticoid supplementation, while metabolic disruptions from other etiologies also dictate dosage alterations. Inadequate comprehension of these dynamics among healthcare professionals may impact the prognosis of SHS patients and predispose them to risks. Surgical treatments, including interventional procedures, represent significant stressors in medical care. Failure to administer preoperative stress doses of glucocorticoids to SHS patients can engender serious consequences. To our knowledge, this article represents the first documented case of severe hyponatremia in an SHS patient following percutaneous coronary intervention (PCI).

Case presentation

A 70-year-old female patient presented with paroxysmal exertional chest tightness persisting for one month, alleviated by a few minutes of rest. Forty years ago, the patient suffered from postpartum hemorrhage, without blood transfusion, subsequently developing lactation failure and amenorrhea. Five years later, she was diagnosed with SHS at the Affiliated Hospital of Shandong University. Management included 5 mg of prednisone acetate in the morning for secondary adrenal insufficiency, and 50 ug of levothyroxine for secondary hypothyroidism. Apart from medication adherence, the patient lacked awareness regarding adrenal insufficiency. The patient had a decade-long history of hypertension, controlled with 5 mg of telmisartan and 5 mg of amlodipine daily. This patient had a weight of 46 kl, a height of 1.57 m, and a BMI of 18.66 kg/m 2 . Upon hospital admission, her vital signs were stable with a blood pressure of 122/58 mmHg, and a heart rate of 65 beats per minute. Physical examination revealed no pulmonary rales, cardiac murmurs, lower limb edema. Laboratory finding indicated elevated blood troponin I (0.5487 ng/ml, 0–0.0175 ng/ml), normal blood sodium (141.5 mmol/L, 137 mmol/L–147 mmol/L), and elevated fasting total cholesterol (6.28 mmol/L, 3 mmol/L–5.7 mmol/L). Thyroid function tests revealed low level of free thyroxine (FT4) (6.77 pmol/L, 7.98 pmol/L–16.02 pmol/L), with normal levels of free triiodothyronine (FT3) and thyroid stimulating hormone. Electrocardiogram indicated sinus bradycardia. We diagnosed the patient with acute non-ST segment elevation myocardial infarction (NSTEMI) and performed percutaneous coronary angiography (CAG) and intravascular ultrasound (IVUS) examination. We found that the stenosis degree was 40%, 80%, and 60%, 98%, and almost completely occluded, respectively, in the left main trunk (LM), the proximal and middle segments of the left anterior descending branch (LAD), the proximal segments of the left circumflex branch (LCX), and the middle segment of the right coronary artery (RCA) ( Figures 1A–C ). The minimum lumen area at the distal stenosis of the LM was 4.51 mm 2 ( Figure 1E ), the plaque load at the most severe stenosis of the proximal LAD was 80%, with a minimum lumen area of 2.88 mm 2 ( Figure 1F ). Due to the patient's refusal to undergo coronary artery bypass grafting, two stents were inserted in the middle segment of the RCA ( Figure 1D ). The intervention lasted for 2 h, including coronary angiography, bilateral intravascular ultrasound examination, patient involvement in treatment decision-making based on examination results, and subsequent coronary intervention treatment, utilizing 130 ml of iodixanol. The patient did not experience any chest discomfort, but was nervous and had a blood pressure rise to 190/100 mmHg, managed with sublingual nifedipine tablets and intravenous isosorbide nitrate. Following percutaneous intervention (PCI), the patient experienced a sequence of symptoms from the 12th to the 50th h, including nausea and loss of appetite, profuse sweating, mild limb twitching, and drowsiness in sequence ( Table 1 ). Limb twitching persisited for 18 h from the 38th to the 56th h post-PCI. On the 24th h post-PCI, the patient was diagnosed with hyponatremia ( Table 1 ), and 2%−3% sodium chloride was intermittently administered intravenously. Despite increased sodium chloride supplementation, symptoms persisted until administration of hydrocortisone, leading to symptom resolution and rapid improvement in blood sodium levels ( Table 1 ). By the 62nd h post-PCI, symptoms of hyponatremia completely resolved, with blood sodium level increasing from 114.2 mmol/L to 132 mmol/L ( Table 1 ). At the 86th h post-PCI, blood sodium level returned to normal. After 40 h, blood tests revealed low levels of cortisol (2.76 ug/dl, 6.7ug/dl–22.6 ug/dl), ACTH (4.26 pg/ml, 10.1 pg/ml–57.6 pg/ml), FT3 (3.41 pmol/L, 3.53 pmol/L−7.37 pmol/L), and FT4 (7.12 pmol/L, 7.98 pmol/L–16.02 pmol/L). Following discharge, the patient continued oral medication with 2.5 mg prednisone acetate and 50 ug levothyroxine sodium daily, as well as dual antiplatelet drugs, statins, and antihypertensive agents. During the next nine-month follow-up period, the patient did not experience ischemic symptoms or hyponatremia.

Figure 1 . Coronary angiography ( A – D ) and intravascular ultrasound examination ( E and F ) in an elderly patient with Sheehan's syndrome. ( A ) The stenosis degree is 40%, 80%, and 60%, respectively, at the end of the left main trunk, the proximal and middle segments of the left anterior descending branch. ( B ) The stenosis degree is 98% at the proximal segments of the left circumflex branch. ( C ) The stenosis degree is almost completely occluded at the middle segment of the right coronary artery. ( D ) Two stents are inserted in the middle segment of the RCA. ( E ) The minimum lumen area at the distal stenosis of the left main trunk is 4.51 mm 2 . ( F ) The plaque load at the most severe stenosis of the proximal left anterior descending branch is 80%, and the minimum lumen area is 2.88 mm 2 .

Table 1 . Timeline of changes in symptoms, blood sodium titers, and hyponatremia treatment in this patient at 12, 24, 38, 50, 56, 62 and 86 h after percutaneous intervention. normal titer blood sodium reference value: 137 mmol/L to 147 mmol/L.

SHS and hyponatremia

Sheehan's syndrome is characterized by insufficient secretion of ACTH due to pituitary necrosis, resulting in decreased synthesis and secretion of adrenocortical hormones, particularly glucocorticoids. Glucocorticoids play a vital role in regulating sodium and water excretion and maintaining electrolyte balance in the body. Insufficient glucocorticoid levels lead to diminished renal free water clearance, causing water retention and dilutional hyponatremia, resulting in reduced plasma osmolality. Furthermore, despite low osmolality, there is inappropriate secretion of antidiuretic hormone (vasopressin) due to the absence of cortisol's tonic inhibition ( 10 ).

Clinical presentation and management

In this case, the patient had a medical history of a SHS diagnosis, presenting with secondary adrenal insufficiency and secondary thyrotrophin deficiency necessitating hormone replacement therapy. Secondary adrenal insufficiency arises from pituitary impairment, causing decreased production of ACTH and subsequent reduction in adrenal stimulation, leading to decreased cortisol production. Glucocorticoid deficiency emerged as the primary mechanism of hyponatremia in this patient. During the 2-h of coronary diagnosis and treatment, the patient was anxious, had high blood pressure, and was in a severe stress state, which required additional cortisol to cope with. The specific amount could be evaluated by a specialist doctor. However, due to secondary adrenal insufficiency, the patient could not suddenly increase the secretion of glucocorticoids to copy with the stress. Additionally, glucocorticoids were not pre increased before the procedure. Therefore, the patient was at risk of acute and severe adrenal cortical hormone deficiency, leading to excessive sodium loss, water retention, and subsequent hyponatremia.

Treatment response

Despite intravenous supplementation of 24.05 g sodium chloride within 26 h, hyponatremia persisted, accompanied limb twitching and drowsiness, indicating an exacerbation of hyponatremia and the formation of hypotonic brain edema. Administration of 50 mg hydrocortisone effectively relieved excessive sodium excretion and water retention. Even with 6.25 g sodium chloride treatment, the patient's symptoms almost disappeared after 6 h, and blood sodium increased from 114.2 mmol/L to 132 mmol/L after 12 h. The subsequent increase in blood sodium levels highlights the importance of glucocorticoid replacement therapy in managing hyponatremia secondary to SHS.

Management considerations

The case underscores the importance of preoperative stress dose glucocorticoid therapy in SHS patients undergoing procedures such as PCI. However, we were unaware the importance. Additionally, awareness of the potential for contrast agents to induce dilutional hyponatremia and stress response caused by PCI is crucial. Lack of endocrinologist consultation before the procedure and inadequate patient education regarding adrenal insufficiency contributed to the suboptimal management of this patient. Inappropriately administered sublingual nifedipine treatment, intended to manage transient hypertension, not only increased the risk of acute cardiovascular and cerebrovascular disease, but also increased the risks of further activating the sympathetic nervous ( 11 ) and exacerbating stress. Therefore, the interdisciplinary management involving endocrinologists is crucial for optimizing the treatment for patients with complex endocrine disorders like SHS, facilitating appropriate examinations, treatment and health education to prevent adrenal crisis and improve long-term outcomes ( 12 , 13 ).

Prolonged limb twitching and sodium correction

Unlike the transient symptoms of epilepsy, the patient experienced persistent limb twitching for up to 18 h, possibly due to prolonged lower blood sodium levels. This prolonged imbalance could have led to sustained electrical instability in brain cells, resulting in repetitive abnormal electro-discharge and impaired brain function, posing significant risks to the patient. However, our approach to correcting hyponatremia may not have followed optimal guidelines. Our method of correcting hyponatremia may not have followed the best guidelines. The target value for increasing serum sodium was not set to not exceed 8–10 mmol/L/24 h ( 14 ). Our treatment rapidly increased the patient's blood sodium from 114 mmol/L to 132 mmol/L in 12 h, and then continued to supplement with hypertonic sodium chloride. Within 26 h after identifying hyponatremia, 24.05 g of sodium chloride was administered intravenously. These treatments are unreasonable, and the overly rapid correction of hyponatremia may be a risk factor for osmotic demyelination syndrome. Proper management should aim to increase blood sodium concentration gradually, with close monitoring to prevent such complications.

Other proposed mechanisms of hyponatremia

Contrast agents have been implicated in inducing hyponatremia, particularly in women ( 15 – 18 ). Following administration, the contrast agents elevate the osmotic pressure of extracellular fluid, leading to passive water transfer of intracellular to extracellular compartments and resultant diluted hyponatremia ( 15 , 16 ). Sweating caused by sympathetic nerve stimulation and sweating caused by adverse reactions to iodixanol injection may also contribute to sodium loss.

Role of hypothyroidism

The patient's thyroid hormone levels were low before and after the procedure, indicating the presence of secondary hypothyroidism. Hypothyroidism may have contributed to hyponatremia mainly through the reduced ability to excretal free water, caused by higher levels of ADH. The elevation in ADH levels is largely due to the decrease in cardiac output that stimulates the carotid sinus baroreceptors, prompting the release of ADH. In addition, hypothyroidism can promote hyaluronic acid deposition in extravascular tissues, leading to increased water retention and reduced blood volume. This not only reduces glomerular filtration, but also increases the secretion of antidiuretic hormone, thereby increasing the risk of diluted hyponatremia ( 19 – 22 ). Therefore, optimizing levothyroxine therapy to restore normal thyroid hormone levels may help mitigate the risk of hyponatremia in such cases.

SHS and coronary artery disease

Previous studies have indicated a higher mortality rate in patients with pituitary dysfunction, primarily attributed to cardiovascular diseases ( 23 – 25 ). Due to chronic inflammation, dyslipidemia, and abdominal obesity, patients with SHS tend to develop coronary artery disease (CAD) ( 26 ). This NSTEMI patient suffered from severe coronary atherosclerosis, with traditional risk factors including hypertension and hypercholesterolemia. Long-term oral administration of glucocorticoids may be associated with hypertension and hyperlipidemia in such patients ( 27 , 28 ). In addition, hypothyroidism, which is common in SHS, can also contribute to hyperlipidemia ( 29 ).

Although severe hyponatremia following PCI in SHS patients is not extensively reported, there are cases of female patients exhibiting life-threatening adrenal dysfunction post-PCI ( 30 , 31 ). The lowest blood sodium level in these cases is 122 mmol/L, and there is no hypoglycemia. Glucocorticoids have good therapeutic effects. The difference is that these patients exhibit significant hypotension, shock, and even Takotsubo syndrome ( 30 , 31 ).

Conclusions

The deficiency of glucocorticoids caused by secondary adrenal insufficiency is the primary mechanism for severe hyponatremia in this patient with SHS. The stress induced by PCI exacerbates glucocorticoid deficiency. The contrast agent further contributes to dilutional hyponatremia. The preoperative stress dose of glucocorticoid is crucial to avoid this complication. Glucocorticoids were crucial in correcting severe hyponatremia in this SHS patient with secondary adrenal insufficiency. Shortening the duration of PCI and minimizing the dosage of contrast agents may be beneficial for preventing severe hyponatremia. Meanwhile, it is also crucial for this SHS patient to receive interdisciplinary management involving endocrinologists before and after the procedure. Additionally, SHS may serve as a potential risk factor for CAD.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Ethics Committee of Liaocheng People's Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

JG: Data curation, Writing – review & editing. YW: Data curation, Formal Analysis, Investigation, Writing – original draft, Writing – review & editing, Software, Methodology, Project administration, Supervision. AZ: Writing – review & editing. HP: Writing – review & editing, Data curation. FW: Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article.

The work was supported by Shandong Province Traditional Chinese Medicine Science and Technology Development Plan Project (No. 20190906).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

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Keywords: Sheehan’s syndrome, percutaneous coronary intervention, severe hyponatremia, glucocorticoid deficiency, stress, contrast agent, coronary atherosclerotic disease

Citation: Gao J, Wang Y, Zhang A, Pang H and Wang F (2024) Old woman with Sheehan's syndrome suffered severe hyponatremia following percutaneous coronary intervention: a case report and review of literature. Front. Cardiovasc. Med. 11:1353392. doi: 10.3389/fcvm.2024.1353392

Received: 15 December 2023; Accepted: 17 April 2024; Published: 29 April 2024.

Reviewed by:

© 2024 Gao, Wang, Zhang, Pang and Wang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Yuehai Wang [email protected]

† These authors have contributed equally to this work

This article is part of the Research Topic

Case Reports in General Cardiovascular Medicine: 2023