bluuebunny/crossref_metadata_2025 huggingface dataset:
Reflexões sobre as origens das desigualdades de gênero: a teoria da valência diferencial dos sexos de Françoise Héritier
Authors: Veronique Jourda Kovaleski Nadia , De Souza Batista Tortato Cintia
Published: November 2019

O objetivo desse estudo é de interrogar-se sobre a origem das desigualdades entre os homens e as mulheres. De fato, nas sociedades atuais as disparidades entre homens e mulheres são grandes. A antropóloga e etnóloga Françoise Héritier, feminista e humanista, especialista das populações africanas e particularmente dos sistemas da aliança e das ligações familiares, estudou as relações entre homens e mulheres nos primórdios da humanidade e emitiu a teoria da valência diferencial dos sexos. Nossa analise apoia-se nessa teoria para explicar as desigualdades entre os sexos. Trata-se de um estudo bibliográfico. Chega-se à conclusão que não é o sexo, mas a fecundidade das mulheres que representou a grande diferença entre os homens e as mulheres e que a opressão das mulheres provém justamente da apropriação desse privilégio pelos homens.
A new petrophilous tiger beetle from the Trans-Pecos region of Texas and revised key to the genus Amblycheila (Coleoptera, Carabidae, Cicindelinae)
Authors: Duran Daniel P. , Roman Stephen J.
Published: November 2019

A new rock-dwelling (petrophilous) tiger beetle, Amblycheila katzi Duran & Roman, sp. nov. is described from calcareous canyons and steep hillsides in the Trans-Pecos region of western Texas. It is distinguished from all other Amblycheila based on multiple morphological characters, biogeography, and ecology. A revised key to the genus Amblycheila is provided.
Hiding in plain sight: an evolutionary approach to the South American Zika outbreak and its future consequences
Authors: Apari Péter , Bajer Katalin , Brooks Daniel R. , Molnar Orsolya
Published: November 2019

Emerging Infectious Diseases (EID) pose a world-wide health and socio-economic threat. Accelerating climate change and globalization are exposing unforeseen ways that pathogens cope with their surroundings. The 2015 Zika virus (ZIKV) outbreak was an example of expansion into previously inaccessible fitness spaces, causing a sudden epidemic. Recent studies indicating the subsequent decrease in symptomatic cases means the virus is in remission, currently poses little threat, and therefore can be ignored. We present an evolutionary scenario derived from the Stockholm Paradigm, of oscillating phases of expansion and isolation, accompanied by changes in transmission, persistence, virulence, and pathology. Chief among these is the likelihood that asymptomatic strains are constantly transmitted sexually. This suggests that the currently quiescent virus retains capacities to reemerge abruptly and spread rapidly in an arena of changing opportunity.
Les épreuves corporelles des bouchers et des bouchères
Authors: Zinn Isabelle
Published: November 2019

Cet article aborde les épreuves corporelles des professionnel·le·s de la branche carnée en Suisse d’un point de vue du genre et analyse les places assignées aux femmes et aux hommes dans ce secteur. La posture de l’auteure est de ne pas imposer de lecture genre a priori à son terrain, mais sa propre expérience d’ethnographe-femme dans ce milieu masculin a mis en évidence la mobilisation récurrente de la catégorie de sexe comme variable explicative, en particulier de la définition du « bon boucher ». Grâce à des vignettes ethnographiques tirées de notes de terrain, l’auteure montre ainsi comment un lien direct est établi entre une catégorie de sexe et une activité de travail, jugée soit « masculine » (l’abattage et le dépeçage de la viande), soit « féminine » (activités liées à la commercialisation de la viande). Les conditions de la production des corps au travail ne sont donc pas les mêmes pour les bouchers et les bouchères. Cette différenciation s’inscrit dans les réformes récentes de la branche (ouverture de nouvelles filières, en particulier de commercialisation) qui à la fois attirent un nouveau public, notamment féminin, et créent une reconfiguration de la ségrégation au sein de la profession.
Quantitative Research on Contribution Degree of Vibration Affecting Factors of Vehicle Suspension System Based on Robustness Analysis
Authors: Xiong Jianqiang , Yuan Le
Published: November 2019

Suspension system is the key component affecting vehicle ride comfort and finding out the main factors affecting suspension system vibration is the precondition of controlling suspension system vibration and improving vehicle comfort. Based on the principle of robustness analysis, the robustness analysis process of suspension system vibration influencing factors is constructed, in order to solve the problem, the three levels of front suspension stiffness, front suspension damping, rear suspension stiffness and rear suspension damping are selected, the experiment design scheme is adopted, power Spectrum of Class A road is used as input excitation source for suspension system simulation, the weighted acceleration root mean square simulation experiment of suspension system vibration under the influence of multiple factors is carried out.
Moth-Flame Optimization Algorithm Based Load Flow Analysis of Ill-Conditioned Power Systems
Authors: Mukherjee Suvabrata , Roy Provas Kumar
Published: November 2019

Using a novel bio-inspired optimization algorithm based on the navigation strategy of moths in a universe called transverse orientation, called the Moth-Flame Optimization Algorithm (MFOA), has been applied to solve the load flow problem for power systems under critical conditions. This mechanism is highly effective for traversing covering expanded radius in straight direction. As a matter of fact, moths follow a deadly spiral path as they get confused by artificial lights. For the tuning of parameters, both exploration and exploitation processes play an important role. MFOA is exercised for load flow analysis of small, medium, and large ill-conditioned power systems. The three different standard ill-conditioned cases considered in order to verify the robustness of the algorithm are IEEE 14-bus, IEEE 30-bus and IEEE 57-bus test systems. The results obtained by the application of MFOA shows that the algorithm is able to provide better results than the results obtained by the application of a biogeography inspired optimization algorithm, namely biogeography-based optimization (BBO) and a nature-inspired optimization algorithm, namely the whale optimization algorithm (WOA). This approves the superiority of the proposed algorithm. Simulation and numerical results demonstrate that the MFO is a potent alternative approach for load flow analysis under both normal and critical conditions in practical power systems especially in case of failure of conventional methods, thereby proving the robustness of the method. To the best of the authors' awareness, it is the first report on application of MFOA load flow analysis.
Perceived Benefits of Loyalty Programs and Relationship Quality
Authors: Corbishley Karen Margaret , Mason Roger B. , Meintjes Corne
Published: November 2019

The aim of this article is to investigate perceived loyalty program benefits inherent in loyalty programs and how they might affect relationship quality, specifically in the South African FMCG sector. A quantitative study was undertaken where loyalty program members were approached via a national database. Hypotheses were individually tested by means of regression analysis. All three forms of perceived benefits exhibited positive relationships with each of the relationship quality constructs. Retailers that are considering which benefits to include in a loyalty program would find the results instructive. This article also adds to the international body of research in the field of relationship marketing, customer loyalty and retail loyalty programs. This study reiterates the importance of loyalty program design and the potential for attitudinal change towards the retailer.
Effect of Employee Empathy on Service Loyalty Through the Development of Trust in and Satisfaction With Service Employee During Service Interactions
Authors: Bahadur Waseem
Published: November 2019

This study examines the indirect effect of employee empathy on service loyalty through the intervening effect of trust in and satisfaction with service employees during service interactions. Data was obtained through a self-administered questionnaire from university students. 410 useable responses were used to perform data analysis. Confirmatory factor analysis, structural equation modeling, and bootstrapping for indirect effects were conducted to test the hypotheses. The results show a significant impact of employee empathy on trust in service employee and satisfaction with service employee during customer-employee interactions. Also, satisfaction with a service employee showed a significant effect on service loyalty during service interactions. The study enhances the understanding of empathy within banking services during interactions between service employee and customer. It also provides insights for service managers and frontline service employees on how empathy develops customer's trust and satisfaction with a service employee.
Understanding Research Online Purchase Offline (ROPO) Behaviour of Indian Consumers
Authors: Khandelwal Utkal , Yadav Seemant Kumar , Kumar Yogesh
Published: November 2019

E-commerce business is increasing at a huge speed in India but still bigger cake is in the hand of offline retailers. Because of the easy accessibility of internet, a unique kind of consumer behaviour has been seen where the consumer searches products and information through internet and then purchases offline. This article accesses the factors why consumers research online and purchase offline. The objective of this study is measuring attitude towards ROPO behaviour. For this, a survey method has been used and data was collected online and offline. The principal component factor analysis technique is used in order to investigate the common factors that might explain underlying reasons for ROPO behaviour. It was found that factors affecting ROPO behaviour are product knowledge and information, online shopping infrastructure, quick possession, risk reduction, and shopping experience among Indian consumers. The findings of this study provide important insights for the e-commerce platforms which have spent money trying to be competitive and do not get the expected conversion.
An Assessment of the Impact that Service Quality and Customer Satisfaction Possess on Customer Loyalty in Internet Banking
Authors: Iqbal Tahir
Published: November 2019

The purpose of this study was to explore the effect of service quality (SQ) and customer satisfaction (CS) on consumer loyalty (CL) in internet banking in the case of the KSA. The basis of this study was set upon the e-SERVQUAL model and its dimensions: include efficacy, consistency, privacy, fulfilment, and website design. The study was aimed to recognize the elements influencing service quality (SQ) along with the concept and significance of SQ in online banking in particular. The study was based on the quantitative research design and the participants for this study were the bank customers who are using internet services. The sample size of this study was kept to 150 participants. A close-ended 5 point Likert scale questionnaire was formulated in order to assess the phenomenon of the research. In addition, the SPSS software along with Smart PLS was utilized to examine the data collected from 150 customers of the banks. The SEM and correlation test were applied for assessing the association between SQ and CL along with CS and CL. The findings of this study indicated that there is a significant positive impact of service quality and customer satisfaction on the customer loyalty of internet banking users in KSA. Hence, the banking industry of KSA has been recommended to pay specific heed to all the dimensions of e-SQ and customer satisfaction.
The Evaluation of Computer Algebra Systems Using Fuzzy Multi-Criteria Decision-Making Models
Authors: Huseyinov Ilham , Tabak Feride Savaroglu
Published: November 2019

The main purpose of this study is to present a systematic methodology based on fuzzy Multi-Criteria Decision-Making (FMCDM) models to help users evaluate computer algebra systems (CAS). CAS is a software package for the manipulation of mathematical formulas. The suggested methodology is user-centred which involves users' subjective evaluation judgments. User judgments are represented by means of fuzzy linguistic modelling techniques. An evaluation criteria framework based on the concept of the usefulness of CAS is developed. Next, two FMCDM models – fuzzy Analytical Hierarchy Process (FAHP) and fuzzy Technique for Order Preference by Similarity to Ideal Solution (FTOPSIS) are proposed for the evaluation procedure. The FAHP is applied to determine the relative importance weights of qualitative evaluation criteria; the FTOPSIS is applied to rank the CAS alternatives. The illustrated case study demonstrates the applicability and effectiveness of the proposed methodology.
Automatic Correction of Free Format MCQ Tests
Authors: Habeek Muaaz , Dridi Charaf Eddine , Badeche Mohamed
Published: November 2019

Although the technology for the automatic grading of multiple-choice exams exists, it is neither efficient nor as automatic as it claims to be. All proposed methods have a predefined answer sheet format that looks like a crosswords table or a chessboard. Because of this format, all questions must have the same number of choices. Such an answer sheet is not clear, and candidates taking the exam can and will accidentally mark the wrong cell in the table. Most of them assume that there is only one possible answer for every question. This article proposes an algorithm that does not require any special format, works with all scanning resolutions and is actually fast.
Dynamic Management of Resources in Cloud Computing
Authors: Tiwari Pradeep Kumar , Joshi Sandeep
Published: November 2019

It has already been proven that VMs are over-utilized in the initial stages and are underutilized in the later stages. Due to the random utilization of the CPU, resources are sometimes heavily loaded whereas other resources are idle. Load imbalance causes service level agreement (SLA) violations resulting in poor quality of service (QoS) aided by the imperfect management of resources. An effective load balancing mechanism helps to achieve balanced utilization, which maximizes the throughput, availability, and reliability and reduces the response and migration time. The proposed algorithm can effectively minimize the response and the migration time and maximize reliability, and throughput. This research also helps to understand the load balancing policies and analysis of other research works.
Future of critical care
Authors: Rudy EB , Grenvik A
Published: November 2019

Critical care, as a specialty in both nursing and medicine, is well recognized and the number of people requiring hospitalization for critical illnesses continues to increase. The purpose of this paper is to examine the future and the changes that lie ahead in critical care. New and expanding roles for nurses are projected along with a continued refinement and expansion of the critical care medicine subspecialty for physicians. A variety of changes in critical care are anticipated that reflect our increasing abilities in biotechnology, basic and clinical research, and data management. These changes are viewed for their obvious impact on cost, ethical controversies, and patient care and outcome.
Mycobacterium tuberculosis in persons infected with the human immunodeficiency virus
Authors: MCJr Co
Published: November 2019

BACKGROUND: After decades of decreasing incidence, the number of new tuberculosis cases started to rise again in the mid-1980s and continues to be a major public health problem in the United States. The incidence of tuberculosis and drug-resistant tuberculosis is increasing among persons infected with human immunodeficiency virus. OBJECTIVE: To review the epidemiology, pathogenesis, clinical presentation, diagnosis, drug therapy, patients' nonadherence to prescribed treatment, and nursing issues related to the care of persons dually infected with tuberculosis and human immunodeficiency virus. METHODS: Fifty references addressing important issues in tuberculosis and human immunodeficiency virus were identified by searching the Medline data base and bibliographies of relevant articles. DISCUSSION: Tuberculosis is a communicable infectious disease caused by Mycobacterium tuberculosis. It is curable and preventable but generally fatal if undiagnosed and untreated. People with human immunodeficiency virus infection are at higher risk for reactivation of latent tuberculosis infection and for developing life-threatening tuberculosis. Specific nursing interventions are formulated to guide practice when caring for HIV-infected persons with tuberculosis. Future nursing research needs are suggested. CONCLUSIONS: An understanding of the complexity of the care involved will enhance the clinical management of tuberculosis in human immunodeficiency virus-infected patients and lead to a decline in the appearance of new drug-resistant tuberculosis strains.
Effects of three methods of femoral site immobilization on bleeding and comfort after coronary angiogram
Authors: Hogan-Miller E , Rustad D , Sendelbach S , Goldenberg I
Published: November 2019

BACKGROUND: Postangiogram femoral site care varies by institution and practitioner. The literature is unclear about which intervention provides the best hemostasis and patient comfort. OBJECTIVE: To investigate which method of femoral site immobilization results in less bleeding and more comfort after coronary angiography. METHODS: Three hundred inpatients and outpatients undergoing coronary angiography in a large, metropolitan, tertiary care facility were assigned randomly to three types of femoral site immobilization. A three-group experimental design was used in this intervention study. Patients were on bedrest and received one of the following interventions to the affected (site of puncture) leg for 6 hours: group 1 had a sandbag applied to the femoral site, group 2 had a sheet over the affected leg and tucked under the mattress, and group 3 had verbal instruction to keep the leg straight and still. An ordinal level hemostasis scale was developed, with descriptors based on the extent of intervention necessary, ranging from 1 = none to 5 = surgical. A 17-item, Likert-type scale was used. RESULTS: The verbal instruction group experienced significantly more bleeding than the sandbag group. There was no difference in bleeding or comfort between the sandbag and sheet-tuck groups. CONCLUSIONS: Our results indicated that sheet-tuck immobilization of the affected leg provides the same degree of hemostasis to the femoral site after coronary angiography as the sandbag.
Antitachycardia pacing: an overview
Authors: Horwood L , VanRiper S , Davidson T
Published: November 2019

Ventricular tachycardia is the most common life-threatening tachyarrhythmia seen in patients with structural heart disease. In the past 10 years, many thousands of lives have been saved by the addition of the implantable cardioverter-defibrillator to the armamentarium of treatment options. Yet, despite the success of these devices in the prevention of sudden cardiac death, many patients felt that the psychological cost was too high. Loss or restriction of some of the most basic activities such as driving and working and not knowing when they would receive the life-saving but painful shock took a toll on patients' perceptions of the quality of their lives. When antitachycardia pacing was demonstrated to provide about half of these patients a life-saving, yet comfortable, means of controlling episodes of ventricular tachycardia, physicians and patients were eager to try it. None of the many ways to provide antitachycardia pacing has proved overwhelmingly more effective than the others. This paper describes and illustrates each type of antitachycardia pacing and demonstrates their programmed parameters. Several clinical case illustrations are included.
Preoperative ICU tours: are they helpful?
Authors: Lynn-McHale D , Corsetti A , Brady-Avis E , Shaffer R , McGrory J , Rothenberger C
Published: November 2019

BACKGROUND: Although preoperative education decreases the anxiety of patients and family members, the usefulness of a preoperative tour of the ICU has not been studied. In this study, the effect of an ICU tour on the anxiety levels of patients (n = 92) and family members (n = 91) before and after cardiac surgery was examined. METHODS: Using a pretest-posttest quasi-experimental design, patients and family members were assigned to a control group, which received preoperative teaching only (patients, n = 48; family members, n = 48), or to an experimental group, which received preoperative teaching with an ICU tour (patients, n = 44; family members, n = 43). Patients and family members completed two measures of anxiety, the State Trait Anxiety Inventory and a visual analog scale, before and after the intervention. After their first postoperative visit, family members completed the measures again. Repeated measures analysis of variance was used to compare anxiety levels after the intervention. In addition, patients completed the Patient Perception of the ICU Tour Questionnaire after transfer from the ICU. RESULTS: Although patients and family members had a decrease in anxiety after cardia surgery teaching, the decrease was not due to an ICU tour. However, the majority of patients who toured the ICU perceived the tour as beneficial and recommended a tour for future patients. CONCLUSIONS: ICU tours are included in many cardiac surgery educational programs. The majority of patients in this study perceived a benefit or a future benefit from an ICU tour, even though the tour did not significantly reduce the anxiety of the patients or family members.
The effect of turning and backrub on mixed venous oxygen saturation in critically ill patients
Authors: Lewis P , Nichols E , Mackey G , Fadol A , Sloane L , Villagomez E , Liehr P
Published: November 2019

OBJECTIVE: To examine the effect of a change in body position (right or left lateral) and timing of backrub (immediate or delayed) on mixed venous oxygen saturation in surgical ICU patients. METHODS: A repeated-measures design was used to study 57 critically ill men. Mixed venous oxygen saturation was recorded at 1-minute intervals for 5 minutes in each of three periods: baseline, after turning, and after backrub. Subjects were randomly assigned to body position and timing of backrub. Subjects in the immediate-backrub group were turned and given a 1-minute backrub. Mixed venous oxygen saturation was measured at 1-minute intervals for 5 minutes at two points: after the backrub and then with the patient lying on his side. For subjects in the delayed-backrub group, saturation was measured at 1-minute intervals for 5 minutes at two different points: after the subject was turned to his side and after the backrub. RESULTS: Both position and timing of backrub had significant effects on mixed venous oxygen saturation across conditions over time. Subjects positioned on their left side had a significantly greater decrease in saturation when the backrub was started. At the end of the backrub, saturation was significantly lower in subjects lying on their left side than in subjects lying on their right side. The pattern of change differed according to the timing of the backrub, and return to baseline levels of saturation after intervention differed according to body position. CONCLUSIONS: Two consecutive interventions (change in body position and backrub) cause a greater decrease in mixed venous oxygen saturation than the two interventions separated by a 5-minute equilibration period. Turning to the left side decreases oxygen saturation more than turning to the ride side does. Oxygen saturation returns to clinically acceptable ranges within 5 minutes of an intervention. In patients with stable hemodynamic conditions, the standard practice of turning the patient and immediately giving a backrub is recommended. However, it is prudent to closely monitor individual patterns of mixed venous oxygen saturation, particularly in patients with unstable hemodynamic conditions.
Therapeutic paralysis of critically ill trauma patients: perceptions of patients and their family members
Authors: Johnson KL , Cheung RB , Johnson SB , Roberts M , Niblett J , Manson D
Published: November 2019

BACKGROUND: Neuromuscular blocking agents are used in critically ill patients to induce therapeutic paralysis. These drugs leave patients fully immobile but conscious. Analgesics and sedatives are concomitantly administered with the paralytic agents. Little is known about what patients remember when they receive these combinations of drugs. Even less is known about the experiences and needs of the patients' family members during the patients' paralysis. OBJECTIVES: To obtain recollections of therapeutic paralysis in critically ill adult trauma patients and to determine the psychological, emotional, and educational needs of the patients' family members during the time the patients were paralyzed. METHODS: A qualitative phenomenological approach was used to investigate the "lived" experience of therapeutic paralysis of 11 pairs of subjects. Each pair consisted of one critically ill adult trauma patient and one member of the patient's family. RESULTS: The patients recalled their experience of therapeutic paralysis with vagueness, as if they had been dreaming. Few recalled pain or painful procedures. Patients remembered having nurses and family members provide emotional support and encouragement. Family members understood the rationale for use of the drugs. They remembered being encouraged to touch and talk with patients. The subjects suggested providing additional education about events that occur when paralysis is being reversed. CONCLUSIONS: Two confounding variables may have affected these findings: a liberalized visiting policy and use of effective pain and sedation protocols. Healthcare professionals and patients' family members should monitor bedside conversations and use touch and words of encouragement to support patients during therapeutic paralysis.
State of the science on parental stress and family functioning in pediatric intensive care units
Authors: Board R , Ryan-Wenger N
Published: November 2019

BACKGROUND: Critical illness of a child is stressful for parents and may affect family functioning. Most research on hospitalization in pediatric intensive care units has focused on the immediate responses of parents to the experience. OBJECTIVE: To critically review literature about pediatric intensive care units and to link those studies to a theoretical framework: McCubbin and McCubbin's resiliency model of family stress, adjustment, and adaptation. An updated synthesis of the literature is essential to prevent unnecessary duplication of research. METHODS: Guidelines presented by Ryan-Wenger were used to critique the scientific credibility and integrity of 38 research reports found by searching MEDLINE, the Cumulative Index to Nursing and Allied Health, and reference lists. The critique was organized according to the components of the research process, and then study results were reviewed according to the variables of the resiliency model. RESULTS: Most publications focused on variables in the adjustment phase, including stressors, resources, perceptions of stressors, and outcomes for patients' families. Obvious gaps in knowledge were related to families' vulnerability, type, and problem-solving and coping strategies. Many of the studies were biased toward white persons and toward mothers. CONCLUSIONS: Further research is warranted on (1) families of various ethnic backgrounds; (2) fathers and their low participation rates; (3) mother and father comparisons; (4) replication of interventional research with larger and more diverse samples; (5) exploratory and prospective, longitudinal research; and (6) research with children in pediatric intensive care units.
Delays in thrombolytic therapy for acute myocardial infarction: association with mode of transportation to the hospital, age, sex, and race
Authors: Davis LL , Evans JJ , Strickland JD , Shaw LK , Wagner GS
Published: November 2019

BACKGROUND: Although increased myocardial salvage and reduced mortality are associated with timely thrombolytic therapy for acute myocardial infarction, some patients still experience delays in treatment. OBJECTIVES: To examine treatment times in patients with acute myocardial infarction treated with thrombolytic therapy and to determine whether delays in treatment are associated with mode of transportation to the hospital, age, sex, or race. METHODS: Medical records of 176 patients with acute myocardial infarction treated with thrombolytic therapy at a community hospital were reviewed and analyzed retrospectively. RESULTS: Median times for the interval between arrival at the hospital and acquisition of a diagnostic electrocardiogram (door-to-electrocardiography time) and the interval between arrival and start of thrombolytic therapy (door-to-drug time) were 6 minutes and 34 minutes, respectively. However, 76.1% of the patients met the recommendation of the American College of Cardiology/American Heart Association of door-to-electrocardiography time of 10 minutes, and 47.2% met the recommendation of door-to-drug time of 30 minutes or less. Door-to-drug times did not differ significantly according to race or mode of transportation to the hospital. Door-to-electrocardiography and electrocardiography-to-drug times were significantly longer for older patients than for younger patients (P = .005 and P < .001, respectively), and electrocardiography-to-drug times were significantly longer for females than for males (P = .01). CONCLUSIONS: With increased emphasis on recognition and rapid treatment of patients with acute myocardial infarction at highest risk for delays in treatment, that is, women and the elderly, benefits of thrombolytic therapy might be maximized.
Endotracheal Suctioning With or Without Instillation of Isotonic Sodium Chloride Solution in Critically Ill Children
Authors: Ridling Debra A. , Martin Lynn D. , Bratton Susan L.
Published: November 2019

• Background Instillation of isotonic sodium chloride solution for endotracheal tube suctioning is controversial. Research has focused on the effect of such instillation in adults; no studies in children have been published.

• Objectives (1) To describe differences in oxygen saturation depending on whether or not isotonic sodium chloride solution is instilled during suctioning and (2) to describe the rates of occlusion of endotracheal tubes and nosocomial pneumonia.

• Methods A convenience sample of 24 critically ill patients were enrolled before having suctioning and after informed consent had been given. Ages ranged from 10 weeks to 14 years. Patients were randomized to 1 of 2 groups. In group 1, subjects received between 0.5 and 2.0 mL of isotonic sodium chloride solution, depending on their age, once per suctioning episode. In group 2, subjects received no such solution. A total of 104 suctioning episodes were analyzed. Oxygen saturation was recorded at predetermined intervals before and for 10 minutes after suctioning. Occlusion of endotracheal tubes and rates of nosocomial pneumonia also were compared.

• Results Patients who had isotonic sodium chloride solution instilled experienced significantly greater oxygen desaturation 1 and 2 minutes after suctioning than did patients who did not. No occlusions of endotracheal tubes and no cases of nosocomial pneumonia occurred in either group.

• Conclusions Results of this study support a growing body of evidence that instillation of isotonic sodium chloride solution during endotracheal tube suctioning may not be beneficial and actually may be harmful.
Family Presence During Cardiopulmonary Resuscitation and Invasive Procedures: Practices of Critical Care and Emergency Nurses
Authors: MacLean Susan L. , Guzzetta Cathie E. , White Cheri , Fontaine Dorrie , Eichhorn Dezra J. , Meyers Theresa A. , Désy Pierre
Published: November 2019

• Background Increasingly, patients’ families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence.

• Objective To identify the policies, preferences, and practices of critical care and emergency nurses for having patients’ families present during resuscitation and invasive procedures.

• Methods A 30-item survey was mailed to a random sample of 1500 members of the American Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association.

• Results Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedure) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures).

• Conclusions Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.
Administration of Sedatives and Level of Sedation: Comparative Evaluation via the Sedation-Agitation Scale and the Bispectral Index
Authors: de Wit Marjolein , Epstein Scott K.
Published: November 2019

• Objectives To compare levels of sedation in patients receiving continuous intravenous infusions of sedative/hypnotic or narcotic agents with levels in patients not receiving infusions and to compare subjective (Sedation-Agitation Scale) and objective (Bispectral Index) evaluations of sedation.

• Methods Patients receiving mechanical ventilation in a medical intensive care unit were evaluated prospectively. Level of sedation was assessed with the Sedation-Agitation Scale (range 1–7, unarousable to dangerous agitation) and the Bispectral Index (range 0–100, flat line to awake waveform) recorded before and after stimulation. Patients were classified as receiving continuous infusions if an infusion had been administered within 24 hours preceding assessment.

• Results Nineteen patients were evaluated on 80 occasions. Scores on the Sedation-Agitation Scale ranged from 1 to 5 (mean 2.6 and median 2) and correlated highly with values for the Bispectral Index (R2 = 0.48 before and 0.44 after stimulation, P < .001). Patients receiving continuous infusions were more deeply sedated than were patients receiving boluses or no medication (mean [SD] scores, Sedation-Agitation Scale: 2.1 [1.2] vs 3.3 [1.0], P < .001; Bispectral Index before stimulation: 63 [24] vs 86 [13], P < .001). Patients receiving continuous infusions were more likely to have a score of 2 or less on the Sedation-Agitation Scale (32/44 vs 8/35, P < .001).

• Conclusion Objective and subjective assessments of sedation are highly correlated. Use of continuous infusions is associated with deeper levels of sedation, and patients receiving continuous infusions are more likely to be oversedated. Sedation therapy should be guided by subjective or objective assessment.
Pattern and Predictors of Early Rejection After Lung Transplantation
Authors: DeVito Dabbs Annette , Hoffman Leslie A. , Iacono Aldo T. , Wells Chris L. , Grgurich Wayne , Zullo Thomas G. , McCurry Kenneth R. , Dauber James H.
Published: November 2019

• Background Most lung transplant recipients experience improvement in their underlying pulmonary condition but are faced with the threat of allograft rejection, the primary determinant of long-term survival. Several studies examined predictors of rejection, but few focused on the early period after transplantation.

• Objectives To describe the pattern and predictors of early rejection during the first year after transplantation to guide the development of interventions to facilitate earlier detection and treatment of rejection.

• Methods Data for donor, recipient, and posttransplant variables were retrieved retrospectively for 250 recipients of single or double lung transplants.

• Results Most recipients (85%) had at least 1 episode of acute rejection; 33% had a single episode; 23% had recurrent rejection; 3% had persistent rejection; 13% had refractory rejection; and 14% had clinicopathological evidence of chronic rejection. Serious rejection (refractory acute rejection or chronic rejection) developed in 27% of recipients. Compared with other recipients, recipients who had serious rejection had more episodes of acute rejection (P = .004), and the first acute episodes occurred sooner after transplantation (P = .01) and were of a higher grade (P = .002).

• Conclusions Recipients who experienced higher grades for their first episode of acute rejection (P=.03) and higher cumulative rejection scores (P = .004) were significantly more likely than other recipients to have serious rejection during the first year after transplantation.
Skin Care Intervention for Patients Having Cardiac Surgery
Authors: Pokorny Marie E. , Koldjeski Dixie , Swanson Melvin
Published: November 2019

• Background Pressure ulcers are a major problem after cardiovascular surgery, occurring in 9.2% to 38% of patients.

• Objectives To determine the effectiveness of a skin care intervention program in preventing development of ulcers or progression from one stage to another and to determine the extent to which selected risk factors were associated with development and progression of pressure ulcers.

• Methods A simple interrupted time series design was used. The protocol involved interrelated assessment, staging, and type of intervention provided. The Braden Scale was used to determine risk for skin breakdown.

• Results Of the 351 patients in the study, 327 (93%) maintained skin integrity and 24 (7%) had skin breakdown. Breakdown by stages was as follows: stage 1, 62% (n = 15); stage 2, 29% (n = 7); stage 3, 4% (n = 1); and stage 4, 4% (n = 1). Age, sex (female), and heart failure were statistically significant risk factors for breakdown (P = <.001, .02, and .02, respectively). The mean scores on the Braden Scale of the breakdown group differed significantly from those of the skin integrity group from days 2 through 5 after surgery (P = .01). Seventeen (71%) of the breakdowns occurred during the first 4 days after surgery.

• Conclusions Skin assessments and nursing interventions should be increased on the day of surgery and the first to fifth postoperative days, including multiple assessments and skin care focused on maintaining skin integrity.
New-Generation Pulse Oximetry in the Care of Critically Ill Patients
Authors: Giuliano Karen K. , Higgins Thomas L.
Published: November 2019

• Objective To review the published, peer-reviewed studies to date on use of the new-generation pulse oximeters, which are manufactured with algorithms to filter out patients’ body motions, and describe the application of new-generation pulse oximetry in clinical practice in critical care.

• Methods MEDLINE was used to locate appropriate articles on pulse oximetry for the years 1995 to 2003. Each article was examined for scientific merit, content, and applicability to clinical practice.

• Results A total of 17 relevant articles on the clinical performance of the new-generation pulse oximeters were reviewed, and the data were organized into a table.

• Conclusions The combination of studies done in both clinical and laboratory settings did not provide any strong and convincing evidence that the performance of any single new-generation device was superior to that of any other new-generation device. However, the clinical performance of all the new-generation pulse oximetry devices was better than that of earlier devices.
Time Out! Is Timepiece Variability a Factor in Critical Care?
Authors: Ferguson Elizabeth A. , Bayer Carey Roth , Fronzeo Susan , Tuckerman Cheryl , Hutchins Larissa , Roberts Kathryn , Verger Judy , Nadkarni Vinay , Lin Richard
Published: November 2019

• Background Accurate documentation of time is essential in critical care for treatments, interventions, research, and medicolegal and quality improvement activities.

• Objectives To assess use of timepieces in critical care and to determine practical methods for improving their accuracy.

• Methods Providers were surveyed to identify timepieces used during routine and emergency care. Times displayed on standard unit and personal timepieces were compared with coordinated universal time. Four models of atomic clocks were assessed for drift for 6 weeks and for resynchronization for 1 week. Bedside monitors were manually synchronized to coordinated universal time and were assessed for drift.

• Results Survey response was 78% (149/190). Nurses (n = 93), physicians (n = 32), and respiratory therapists (n = 24) use wall clocks (50%) and personal timepieces (46%) most frequently during emergencies. The difference from coordinated universal time was a median of −4 minutes (range, −5 minutes to +2 min) for wall clocks, −2.5 minutes (−90 minutes to −1 minute) for monitors, and 0 minutes (−22 minutes to +12 minutes) for personal timepieces. Kruskal-Wallis testing indicated significant variations for all classes of timepieces (P<.001) and for personal timepieces grouped by discipline (P=.02). Atomic clocks were accurate to 30 seconds of coordinated universal time for 6 weeks when manually set but could not be synchronized by radiofrequency signal. Drift of bedside monitors was 1 minute.

• Conclusions Timepieces used in critical care are highly variable and inaccurate. Manually synchronizing timepieces to coordinated universal time improved accuracy for several weeks, but the feasibility of synchronizing all timepieces is undetermined.
Outcomes of Care Managed by an Acute Care Nurse Practitioner/Attending Physician Team in a Subacute Medical Intensive Care Unit
Authors: Hoffman Leslie A. , Tasota Frederick J. , Zullo Thomas G. , Scharfenberg Carmella , Donahoe Michael P.
Published: November 2019

• Background Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff.

• Objective To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows.

• Methods During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes.

• Results Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02).

• Conclusions In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.
Nutritional Adequacy in Patients Receiving Mechanical Ventilation Who Are Fed Enterally
Authors: O’Leary-Kelley Colleen M. , Puntillo Kathleen A. , Barr Juliana , Stotts Nancy , Douglas Marilyn K.
Published: November 2019

• Background Inadequate nutritional intake in critically ill patients can lead to complications resulting in increased mortality and healthcare costs. Several factors limit adequate nutritional intake in intensive care unit patients given enteral feedings.

• Objective To examine the adequacy of enteral nutritional intake and the factors that affect its delivery in patients receiving mechanical ventilation.

• Methods A prospective, descriptive design was used to study 60 patients receiving enteral feedings at target or goal rate. Energy requirements were determined for the entire sample by using the Harris-Benedict equation; energy requirements for a subset of 25 patients were also determined by using indirect calorimetry. Energy received via enteral feeding and reason and duration of interruptions in feedings were recorded for 3 consecutive days.

• Results Mean estimated energy requirements (8996 kJ, SD 1326 kJ) and mean energy intake received (5899 kJ, SD 3058 kJ) differed significantly (95% CI 3297-3787; P < .001). A total of 41 patients (68.3%) received less than 90% of their required energy intake, 18 (30.0%) received within ±10%, and 1 (1.7%) received more than 110%. Episodes of diarrhea, emesis, large residual volumes, feeding tube replacements, and interruptions for procedures accounted for 70% of the variance in energy received (P<.001). Procedural interruptions alone accounted for 45% of the total variance. Estimated energy requirements determined via indirect calorimetry and mean energy received did not differ.

• Conclusions Most critically ill patients receiving mechanical ventilation who are fed enterally do not receive their energy requirements, primarily because of frequent interruptions in enteral feedings.
Moral Distress of Staff Nurses in a Medical Intensive Care Unit
Authors: Elpern Ellen H. , Covert Barbara , Kleinpell Ruth
Published: November 2019

• Background Moral distress is caused by situations in which the ethically appropriate course of action is known but cannot be taken. Moral distress is thought to be a serious problem among nurses, particularly those who practice in critical care. It has been associated with job dissatisfaction and loss of nurses from the workplace and the profession.

• Objectives To assess the level of moral distress of nurses in a medical intensive care unit, identify situations that result in high levels of moral distress, explore implications of moral distress, and evaluate associations among moral distress and individual characteristics of nurses.

• Methods A descriptive, questionnaire study was used. A total of 28 nurses working in a medical intensive care unit anonymously completed a 38-item moral distress scale and described implications of experiences of moral distress.

• Results Nurses reported a moderate level of moral distress overall. Highest levels of distress were associated with the provision of aggressive care to patients not expected to benefit from that care. Moral distress was significantly correlated with years of nursing experience. Nurses reported that moral distress adversely affected job satisfaction, retention, psychological and physical well-being, self-image, and spirituality. Experience of moral distress also influenced attitudes toward advance directives and participation in blood donation and organ donation.

• Conclusions Critical care nurses commonly encounter situations that are associated with high levels of moral distress. Experiences of moral distress have implications that extend well beyond job satisfaction and retention. Strategies to mitigate moral distress should be developed and tested.