bluuebunny/crossref_metadata_2025 huggingface dataset:
Pilot study: validating staff nurses' observations of sleep and wake states among critically ill patients, using polysomnography
Authors: Edwards GB , Schuring LM
Published: November 2019

BACKGROUND: Effective management of sleep pattern disturbance begins with accurate assessment of the patient's sleep and wake states. OBJECTIVE: The purpose of this study was to validate staff nurses' observations of sleep and wake states among critically ill adult patients, using polysomnography. SAMPLE AND SETTING: The sample consisted of 21 adult patients with multisystem diagnoses in a 10-bed medical intensive care unit in a 540-bed acute care teaching hospital. METHOD: Each staff nurse caregiver observed a single patient for the entire data collection period of 4 hours, with a total of 15 nurses participating in the study. A total of 340 observations were made, with the possibility of 17 observations per patient. Nursing observations were made every 15 minutes on each patient and compared to the actual patient state as measured by polysomnography. RESULTS: Nurses' assessments were correct 81.9% of the time. CONCLUSIONS: There is some basis for using staff nurses as observers of sleep and wake states. Increased credence can be placed on nursing assessments and diagnosis of sleep pattern disturbance, resulting in more timely and effective management of the problem.
Withdrawal of mechanical ventilation: ethical principles and guidelines for terminal weaning
Authors: Daly BJ , Newlon B , Montenegro HD , Langdon T
Published: November 2019

BACKGROUND: Discontinuation of mechanical ventilation because of the recognition of futility of continued treatment or because of patient or family request is an increasingly frequent occurrence in critical care. Although there is broad consensus about the patient's right to refuse life support, little has been written about the actual procedure of withdrawing mechanical ventilation. OBJECTIVE: The purposes of this article are: (1) to review ethical arguments supporting the view that it may be morally permissible to withdraw mechanical ventilation from patients who are neither terminally ill nor imminently dying and (2) to provide guidelines for the procedure of ventilator withdrawal. METHOD: Ethical principles supporting the position that ventilator withdrawal under these conditions can be morally justified and principles suggesting that ventilator withdrawal is morally objectionable are evaluated. Factors contributing to clinicians' ambivalence about this issue and guidelines for planning and implementing treatment withdrawal are discussed.
Organ donation: comparison of nurses' participation in two states
Authors: Adams EF , Just G , De Young S , Temmler L
Published: November 2019

BACKGROUND: The number of organs available for transplantation in the United States is insufficient, and the donor rate in New Jersey is particularly low. OBJECTIVES: To explore reasons nurses do or do not refer organ donors and to identify factors that contribute to differences in referral rates in New Jersey and Pennsylvania. METHODS: Registered nurses (N = 976) in 57 nongovernmental acute care hospitals, primarily in emergency departments and intensive care units, completed a questionnaire that focused on their knowledge and participation in the organ procurement process. RESULTS: Two-thirds of the subjects said they had participated in organ procurement. Pennsylvania nurses had a significantly higher involvement rate than New Jersey nurses. Pennsylvania nurses were also slightly more knowledgeable about the process. A higher proportion of nurses in both states who attended continuing education programs participated. CONCLUSIONS: Nurses need more inservice education regarding policies and procedures for organ donation.
The impact of routine chest radiography on ICU management decisions: an observational study
Authors: Marik PE , Janower ML
Published: November 2019

OBJECTIVE: To document the impact of routine daily chest radiographs on treatment decisions in a medical ICU. METHODS: The study sample consisted of 200 consecutive patients in an 11-bed medical ICU of a university-affiliated teaching hospital. During the study period, each patient's current and previous chest radiographs were reviewed in the ICU during morning rounds. A computerized digital video display system was used. Changes in therapy made as a consequence of this review were recorded. RESULTS: A total of 471 chest radiographs were reviewed. The patients' mean score on the Acute Physiology and Chronic Health Evaluation II (APACHE II) was 14.6 +/- 2.5, and the mean length of stay in the ICU was 3.6 days +/- 2.1 days (range, 11-24 days). A change in therapy was made on the basis of information obtained from review of the chest radiograph in 174 instances (37% of radiographs). The most frequent therapeutic interventions were use of a loop diuretic to treat pulmonary edema (26%), repositioning of an endotracheal tube (24%), and diagnostic studies to determine the cause of a new pulmonary infiltrate (16%). At least one change in therapy was made for 91 (66%) of the 138 intubated patients but for only 14 (23%) of the 62 nonintubated patients; this difference was significant. Differences among diagnostic groups were largely a reflection of the number of patients who were intubated. CONCLUSION: Routine daily chest radiographs may be justified in critically ill patients in a medical ICU because for a large proportion of these patients management decisions are made on the basis of information obtained from the chest radiograph. This observation may be applicable only to ICUs that have a high turnover of patients who are in the unit for a short time.
Stress during mechanical ventilation: benefit of having concrete objective information before cardiac surgery
Authors: Kim H , Garvin BJ , Moser DK
Published: November 2019

BACKGROUND: Negative emotional reactions and difficulty in communicating are common in patients receiving mechanical ventilation and may adversely affect recovery from cardiac surgery. OBJECTIVE: To determine the effect of providing concrete objective information about emotional stress and difficulty in communicating related to mechanical ventilation to Korean cardiac surgery patients. METHODS: A quasi-experimental 2-group design was used. The 22 subjects in the control group received the usual information; the 21 in the experimental group received concrete objective information in addition to the usual information. State anxiety, negative affect, use of sedative and analgesic medications, and difficulty communicating were compared between the 2 groups after surgery. RESULTS: Patients who received concrete objective information experienced less anxiety and negative mood during mechanical ventilation, less difficulty in communicating, and a shorter intubation time than did patients in the control group. The 2 groups did not differ in the amount of sedative or analgesic medication used per hour during mechanical ventilation. CONCLUSIONS: Nursing interventions that include concrete objective information help cardiac patients cope with the stresses associated with surgery and mechanical ventilation.
Interrater reliability of 2 sedation scales in a medical intensive care unit: a preliminary report
Authors: Hogg LH , Bobek MB , Mion LC , Legere BM , Banjac S , VanKerkhove K , Arroliga AC
Published: November 2019

BACKGROUND: Critical care nurses must assess the effectiveness of sedatives and analgesic agents in order to titrate doses. OBJECTIVES: To measure the interrater reliability of 2 sedation scales used to assess patients in medical intensive care units. METHODS: The interrater reliabilities of the Motor Activity Assessment Scale and the Luer sedation scale were compared prospectively in 31 patients receiving mechanical ventilation in an 18-bed medical intensive care unit of a tertiary care institution. Three registered nurses, 1 clinical pharmacist, and 1 physician simultaneously and independently followed a standardized procedure to rate each patient by using the 2 scales. Scales were randomly ordered to counteract ordering effect. Analysis of variance with post hoc Duncan multiple range tests was used to detect bias; a correlation coefficient matrix was used to examine degree of association among raters; and the intraclass correlation coefficient was measured to control for multiple raters. RESULTS: No significant bias was detected with either scale. The Motor Activity Assessment Scale had less variation (Pearson r = 0.75-0.92) than did the Luer scale (Pearson r = 0.37-0.94) and had a stronger intraclass correlation coefficient (0.81 vs 0.79). CONCLUSIONS: The Motor Activity Assessment Scale showed the highest consistency among raters.
Heart Period Variability of Intubated Very-Low-Birth-Weight Infants During Incubator Care and Maternal Holding
Authors: Smith Sandra Lee
Published: November 2019

• Background Heart rate has been used to measure infants’ physiological stability during skin-to-skin holding. Variability in heart period (interbeat interval), a more sensitive measure of autonomic nervous system tone, has not.

• Objective To describe heart period variability in intubated very-low-birth-weight infants during incubator care and during maternal skin-to-skin holding.

• Design/Methods An experimental, interrupted time series, crossover design was used; infants served as their own controls. Infants were randomly assigned to treatment order: 2 hours of intermittent skin-to-skin holding for 2 consecutive days followed by 2 days of incubator care or vice versa. The analog signal representing heart period was sampled and quantized at 5 Hz via a dedicated computer system in multiple 300-second epochs each day.

• Results Fourteen infants with similar characteristics completed the protocol. The mean interbeat interval was 332 ms during skin-to-skin care and 368 ms during incubator care. Power within the low-and high-frequency regions of heart period was not significantly different between skin-to-skin holding and incubator care. Mean low-frequency power was 124.6 ms2 during skin-to-skin holding and ranged from 51.9 ms2 to 71.4 ms2 during all periods of incubator care. Mean high-frequency power was similar during skin-to-skin holding and incubator care (8.8 ms2 and 6.1 ms2). Infants of 32 to 34 weeks’ corrected gestational age had increased power in the low- and high-frequency regions.

• Conclusions Heart period variability did not improve during skin-to-skin holding. Gestationally older infants had increased power in the low- and high-frequency regions, suggesting a maturing autonomic nervous system.
Pathophysiology and Management of Abdominal Compartment Syndrome
Authors: Walker Jeffrey , Criddle Laura M.
Published: November 2019

Abdominal compartment syndrome is a potentially lethal condition caused by any event that produces intra-abdominal hypertension; the most common cause is blunt abdominal trauma. Increasing intra-abdominal pressure causes progressive hypoperfusion and ischemia of the intestines and other peritoneal and retroperitoneal structures. Pathophysiological effects include release of cytokines, formation of oxygen free radicals, and decreased cellular production of adenosine triphosphate. These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome. The consequences of abdominal compartment syndrome are profound and affect many vital body systems. Hemodynamic, respiratory, renal, and neurological abnormalities are hallmarks of abdominal compartment syndrome. Medical management consists of urgent decompressive laparotomy. Nursing care involves vigilant monitoring for early detection, including serial measurements of intra-abdominal pressure.
Incidence, Timing, Symptoms, and Risk Factors for Atrial Fibrillation After Cardiac Surgery
Authors: Funk Marjorie , Richards Sally B. , Desjardins Jill , Bebon Christy , Wilcox Heather
Published: November 2019

• Background Atrial fibrillation is the most common complication after cardiac surgery and a major cause of morbidity and increased cost of care.

• Objectives To examine the incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery.

• Methods A total of 302 patients were continuously monitored for atrial fibrillation with standard hardwire and telemetry devices during hospitalization after coronary artery bypass graft and/or valve surgery and with wearable cardiac event recorders for 2 weeks after discharge from the hospital. After discharge, patients recorded and transmitted their rhythm by telephone daily and whenever they had symptoms suggestive of atrial fibrillation.

• Results Of the 302 patients, 127 (42%) had atrial fibrillation; 41 had it after discharge, and for 10 it was their first episode. The first episode occurred at a mean of 2.9 days after surgery (SD, 3.1; range, day of surgery to 21 days after surgery). Although palpitations was the most common symptom (17%), most episodes of atrial fibrillation (69%) were not associated with symptoms. Independent predictors of atrial fibrillation were age 65 years or greater, history of intermittent atrial fibrillation, atrial pacing, male sex, white race, and not having hyperlipidemia. Independent predictors of atrial fibrillation after discharge from the hospital were having atrial fibrillation while hospitalized, valve surgery, and pulmonary hypertension.

• Conclusions Atrial fibrillation is common after cardiac surgery and often occurs after discharge from the hospital and without accompanying symptoms. Outpatient monitoring may be warranted in patients with characteristics that place them at increased risk for atrial fibrillation.
Readiness for Behavioral Changes in Patients With Heart Failure
Authors: Sneed Nancee V. , Paul Sara C.
Published: November 2019

• Background Successful self-care in heart failure often requires lifestyle changes such as avoiding sodium, excess fluid intake, alcohol, and tobacco; exercising regularly; and losing weight. The Transtheoretical Model, a framework for making behavioral changes, proposes that change requires a series of stages.

• Objectives To identify the stage of readiness for change in 6 lifestyle behaviors important in heart failure and to determine differences in signs and symptoms of heart failure, self-reported knowledge of the disease, and self-reported behavior between patients who have taken action and patients who have not.

• Method A mail survey of 250 patients with heart failure.

• Results Most respondents reported consistent avoidance of tobacco (90.6%), alcohol (87.9%), sodium (81%), and excess fluid (72.6%) and regular participation in exercise (67.1%) and trying to lose weight (64.7%). Yet only 38.7% had a regular exercise program, and 94.2% had eaten high-sodium foods in the preceding 24 hours. Knowledge of heart failure was low (mean score, 67.4%) and did not differ by stage of change. Only 30.4% of the respondents were at their desired weight, and most overweight subjects had been trying to lose weight for more than 6 months.

• Conclusions Although respondents thought they were consistently adhering to recommended guidelines for changes in lifestyle, actual reported behaviors did not always support this evaluation. Use of the stage of change tool to assess stage of readiness to make lifestyle changes may not work well in patients with heart failure, perhaps because of the number and complexity of the changes needed.
Arginine Immunonutrition in Critically Ill Patients: A Clinical Dilemma
Authors: Stechmiller Joyce K. , Childress Beverly , Porter Tricia
Published: November 2019

Commercial enteral nutritional formulas for enhancement of the immune system are widely used in critical care. Immunonutrition with arginine can enhance inflammatory and immunologic responses in animal models and in humans. Although clinical improvements in surgical patients have been reported, benefits in critically ill patients with systemic inflammatory response syndrome, sepsis, or organ failure are less clear. Recent meta-analyses on the use of immunonutrition with arginine in critically ill and surgical patients revealed methodological weaknesses in most published studies. Specifically, a meta-analysis indicated that critically ill patients with preexisting severe sepsis may have an increased mortality rate when fed an immunonutritional enteral formula that contains arginine. These findings brought about confusion and controversy over the use of immunonutritional formulas in subsets of critically ill patients. A review of the literature on the function of arginine, its effect on the immune system, its roles in immunonutrition and in the clinical outcomes of critically ill patients, and the implications for nursing practice indicated that the benefits of immunonutrition with arginine in critically ill patients are unproven and warrant further study. Until more information is available, nutritional support should focus primarily on preventing nutritional deficiencies rather than on immunomodulation.
Pain Assessment and Management in Critically Ill Intubated Patients: a Retrospective Study
Authors: Gélinas Céline , Fortier Martine , Viens Chantal , Fillion Lise , Puntillo Kathleen
Published: November 2019

• Background Little research has been done on pain assessment in critical care, especially in patients who cannot communicate verbally.

• Objectives To describe (1) pain indicators used by nurses and physicians for pain assessment, (2) pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and (3) pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are intubated.

• Methods Medical files from 2 specialized healthcare centers in Quebec City, Quebec, were reviewed. A data collection instrument based on Melzack’s theory was developed from existing tools. Pain-related indicators were clustered into nonobservable/subjective (patients’ self-reports of pain) and observable/objective (physiological and behavioral) categories.

• Results A total of 183 pain episodes in 52 patients who received mechanical ventilation were analyzed. Observable indicators were recorded 97% of the time. Patients’ self-reports of pain were recorded only 29% of the time, a practice contradictory to recommendations for pain assessment. Pharmacological interventions were used more often (89% of the time) than nonpharmacological interventions (<25%) for managing pain. Almost 40% of the time, pain was not reassessed after an intervention. For reassessments, observable indicators were recorded 66% of the time; patients self-reports were recorded only 8% of the time.

• Conclusions Pain documentation in medical files is incomplete or inadequate. The lack of a pain assessment tool may contribute to this situation. Research is still needed in the development of tools to enhance pain assessment in critically ill intubated patients.
Illness Representation After Acute Myocardial Infarction: Impact On In-Hospital Recovery
Authors: Cherrington Candace C. , Moser Debra K. , Lennie Terry A. , Kennedy Carol W.
Published: November 2019

• Background Despite significant progress in the treatment of coronary artery disease, myocardial infarction is still the leading cause of death in the United States. As suggested by Leventhal’s Self-Regulation Model of Illness, the continued high morbidity and mortality may be due to a failure to address the role of psychosocial factors such as illness representation, depression, and anxiety in recovery.

• Objective To determine the relationship between illness representation of myocardial infarction and the occurrence of in-hospital complications and if anxiety and depression mediate this relationship.

• Method A prospective correlational design was used to measure illness representation, depression, and anxiety 24 to 48 hours after admission for myocardial infarction in 49 patients and the frequency of complications during the acute event. Logistic regression was used to determine the likelihood of experiencing a complication.

• Results When demographic and clinical variables were controlled for, the more negative the representation of illness, the greater were the odds of experiencing a complication (χ2 = 16.9, df = 6, P=.01). The odds of experiencing a complication increased 5.1% for each 1 unit increase in the score on the Illness Preparation Questionnaire (B = 0.05, Wald = 4.442, Exp(B) = 1.051, 95% CI = 1.003–1.1010). Neither anxiety (χ2 = 3.0, df = 1, P = .09) nor depression (χ2 = 2.5, df = 1, P = .11) were significant predictors of the occurrence of complications.

• Conclusion In these patients, illness representation was predictive of the likelihood of experiencing a complication. Thus, illness representation appears to be an important psychosocial factor in acute recovery from myocardial infarction.
Relationship of Age and Sex to Health-Related Quality of Life in Patients With Heart Failure
Authors: Hou Nan , Chui Michelle A. , Eckert George J. , Oldridge Neil B. , Murray Michael D. , Bennett Susan J.
Published: November 2019

• Background Although health-related quality of life is diminished among patients with chronic heart failure, few investigators have examined interactions of age and sex with health-related quality of life longitudinally.

• Objectives To examine differences in health-related quality of life among 4 groups of patients with heart failure on the basis of age (<65 years and >65 years) and sex and to evaluate relationships of age and sex to changes in health-related quality of life during 6 months.

• Methods Patients from 2 outpatient clinics in an urban county hospital were interviewed at baseline and 26 weeks later. Health-related quality of life was measured by using the Minnesota Living With Heart Failure Questionnaire and the Chronic Heart Failure Questionnaire.

• Results A total of 165 patients (52% women; mean age, 57.6 years) completed interviews at baseline and 26 weeks later. At baseline, patients younger than 65 years had poorer health-related quality of life scores on total scales and some subscales than did older patients. Women had poorer scores than did men on some scales, particularly the emotional subscales. At 26 weeks, patients younger than 65 had poorer total health-related quality of life on 1 scale than did patients 65 and older, and women had poorer scores than did men on 1 total scale. With demographic and clinical factors controlled for, women younger than 65 had improvements in health-related quality of life on some scales.

• Conclusions Women younger than 65 years had relatively poorer initial health-related quality of life that improved after 26 weeks.
Outcomes Associated With Enteral Tube Feedings in a Medical Intensive Care Unit
Authors: Elpern Ellen H. , Stutz Luminita , Peterson Sarah , Gurka David P. , Skipper Annalynn
Published: November 2019

• Background Underfeeding of patients reliant on enteral tube feedings most likely is due primarily to interruptions in the infusions. Strategies to improve energy intake require an understanding of such interruptions and associated outcomes.

• Objectives To compare daily energy intake with goal energy intake; to ascertain frequency, duration, and reasons for interruptions in feedings; and to determine occurrences of feeding intolerance.

• Methods A prospective, descriptive study of a convenience sample of patients admitted during a 3-month period to a medical intensive care unit. Patients were included who were expected to receive continuous enteral tube feedings for at least 48 hours. Patients were studied until discontinuation of feedings, discharge from the unit, or death.

• Results Thirty-nine patients were studied for 276 feeding days. Patients received a mean of 64% of goal energy intake. Mean length of interruptions in feeding was 5.23 hours per patient per day. Interruptions for performance of tests and procedures accounted for 35.7% of the total cessation in feeding time. Next most time-consuming interruptions occurred with changes in body position (15%), unstable clinical conditions (13.5%), high gastric residual volume (11.5%), and nausea and vomiting (9.2%). Patients had diarrhea 105 (38%) of 276 feeding days. Gastric residual volumes exceeded 150 mL on 28 measurements in 11 patients. Five patients experienced episodes of nausea and vomiting. Four patients experienced an episode of feeding aspiration.

• Conclusions Precautionary interruptions in enteral feedings to decrease presumed risk of aspiration occurred frequently and resulted in underfeeding. Episodes of vomiting and of aspiration were uncommon.
Strategies for Behavior Change in Patients With Heart Failure
Authors: Paul Sara , Sneed Nancee V.
Published: November 2019

Appropriate management of chronic heart failure and its signs and symptoms requires a considerable amount of participation by patients. Behavioral changes that prevent or minimize signs and symptoms and disease progression are just as important as the medications prescribed to treat the heart failure. The most difficult lifestyle changes include smoking cessation, weight loss, and restriction of dietary sodium. The Transtheoretical Model is a framework for assessing and addressing the concept of readiness for behavior change, which occurs in a 6-step process. The model consists of 3 dimensions: the stages of change, the processes of change on which interventions are based, and the action criteria for actual behavior. The stages of change are discussed, and interventions are presented to assist patients with heart failure in progressing through those stages toward maintenance of changed lifestyle behaviors. Methods for measuring the level of readiness for change of patients with heart failure are also presented, because correct staging is required before appropriate interventions matched to a patient’s stage can be delivered.
Documentation on Withdrawal of Life Support in Adult Patients in the Intensive Care Unit
Authors: Kirchhoff Karin T. , Anumandla Prashanth Reddy , Foth Kristine Therese , Lues Shea Nicole , Gilbertson-White Stephanie Ho
Published: November 2019

• Background Patients’ charts have been a source of data for retrospective studies of the quality of end-of-life care. In the intensive care unit, most patients die after withdrawal of life support. Chart reviews of this process could be used not only to assess the quality of documentation but also to provide information for quality improvement and research.

• Objective To assess the documentation of end-of-life care of patients and their families by care providers in the intensive care unit.

• Method Charts of 50 adult patients who died in the intensive care unit at a large midwestern hospital after initiation of withdrawal of life support (primarily mechanical ventilation) were reviewed. A form developed for the study was used for data collection.

• Results The initiation of the decision making for withdrawal was documented in all 50 charts. Sixteen charts (32%) had no information on advance directives. Eight charts (16%) had no documentation on resuscitation status. About two thirds of the charts documented nurses’ participation during the withdrawal process; only one tenth documented physicians’ participation. A total of 13 charts (26%) had no information on the time of initiation of the withdrawal process, and 11 (22%) had no documentation of medications administered for withdrawal. Thirty-seven charts (74%) had information on whether the patient was or was not extubated during withdrawal.

• Conclusion Comprehensive documentation of end-of-life care is lacking.
Randomized Trial of an Intensive Care Unit–Based Early Discharge Planning Intervention for Critically Ill Elderly Patients
Authors: Kleinpell Ruth M.
Published: November 2019

• Background Few investigators have targeted elderly patients and monitored outcomes of care in studies on discharge planning interventions after critical illness.

• Objectives To pilot test an intensive care unit–based nursing screening intervention to assist in determining the discharge needs and outcomes of critically ill elderly patients.

• Method A randomized clinical trial with in-hospital and mailed questionnaires was used. Patients 65 years and older who were hospitalized in 1 of 2 intensive care units at 2 midwestern university-affiliated medical centers were recruited for the study. Control patients (n = 53) received usual discharge planning; experimental patients (n = 47) were screened in the intensive care unit by using the Discharge Planning Questionnaire. Both groups were assessed for readiness for discharge when discharged from the hospital and were followed up 2 weeks later with a survey completed at home.

• Results One hundred patients 65 to 90 years old (mean 73, SD 5.78) completed the study. Sixty-six percent were men. The 2 groups did not differ with regard to age, race, sex, severity of illness, lengths of stay in the intensive care unit or hospital, education level, or income. Patients in the experimental group were more ready than patients in the control group for discharge (P = .06). Patients in the experimental group were also more likely to report they had adequate information, had less concern about managing their care at home, knew their medicines, and knew danger signals indicating potential complications.

• Conclusion Intensive care unit–based early discharge planning can affect elderly patients’ preparation for discharge.
Role of Diastole in Left Ventricular Function, I: Biochemical and Biomechanical Events
Authors: Villars Penelope S. , Hamlin Shannan K. , Shaw Andrew D. , Kanusky Joseph T.
Published: November 2019

Left ventricular diastolic function plays an important role in cardiac physiology. Lusitropy, the ability of the cardiac myocytes to relax, is affected by both biochemical events within the myocyte and biomechanical events in the left ventricle. β-Adrenergic stimulation alters diastole by enhancing the phosphorylation of phospholamban, a substrate within the myocyte that increases the uptake of calcium ions into the sarcoplasmic reticulum, increasing the rate of relaxation. Troponin I, a regulatory protein involved in the coupling of excitation to contraction, is vital to maintaining the diastolic state; depletion of troponin I can produce diastolic dysfunction. Other biochemical events, such as defects in the voltage-sensitive release mechanism or in inositol triphosphate calcium release channels, have also been implicated in altering diastolic tone. Extracellular collagen determines myocardial stiffness; impaired glucose tolerance can induce an increase in collagen cross-linking and lead to higher end-diastolic pressures. The passive properties of the left ventricle are most accurately measured during the diastasis and atrial contraction phases of diastole. These phases of the cardiac cycle are the least affected by volume status, afterload, inherent viscoelasticity, and the inotropic state of the myocardium. Diastolic abnormalities can be conceptualized by using pressure-volume loops that illustrate myocardial work and both diastolic and systolic pressure-volume relationships. The pressure-volume model is an educational tool that can be used to demonstrate isolated changes in preload, afterload, inotropy, and lusitropy and their interaction.
Attitudes of Critically Ill Filipino Patients and Their Families Toward Advance Directives
Authors: McAdam Jennifer L. , Stotts Nancy A. , Padilla Geraldine , Puntillo Kathleen
Published: November 2019

• Background Advance directives are important but often underused tools in critical care. Healthcare professionals’ understanding of how culture influences attitudes toward advance directives can improve knowledge and completion of these documents.

• Objective To understand the attitudes of critically ill Filipino American patients and their families toward advance directives.

• Methods A descriptive, correlational, cross-sectional study with a convenience sample of 22 Filipino American patients and 22 Filipino American family members at a West Coast medical center. All patients were admitted for cardiac surgery or cardiac interventions. Participants were interviewed with the Advance Directive Attitude Survey and A Short Acculturation Scale for Filipino Americans.

• Results Family members’ scores were significantly more positive than patients’ scores on the attitude survey (P = .01). Family members were more American acculturated than were patients (P = .001). Family members with more education had more positive attitudes toward advance directives (P = .02). Only 2 patients (and no family members) had completed an advance directive before the study. Only 27.3% of family members had prior knowledge of advance directives.

• Conclusion Overall attitudes toward advance directives were positive; however, the completion rate and knowledge of advance directives were low. Participants may have been saying what they thought the researcher wanted to hear in order to avoid disagreement. Such behavior could partly explain the positive attitudes of the Filipino Americans toward advance directives. Further research is warranted to understand how to increase completion rates for advance directives among Filipino Americans.
Nurses’ Communication of Prognosis and Implications for Hospice Referral: A Study of Nurses Caring for Terminally Ill Hospitalized Patients
Authors: Schulman-Green Dena , McCorkle Ruth , Cherlin Emily , Johnson-Hurzeler R. , Bradley Elizabeth H.
Published: November 2019

• Background Although nurses are ideally situated to facilitate communication about prognosis and hospice referral among patients, patients’ family members, and hospital staff, nurses do not always assume this task.

• Objective To identify common obstacles to nurses’ discussions of prognosis and referral to hospice care with terminally ill patients in the hospital setting.

• Methods Data from a previous study were analyzed. In that study, a total of 174 experienced staff nurses working full-time in hospital practice areas where terminally ill patients routinely receive care at 6 randomly selected community hospitals in Connecticut participated. Each nurse completed a self-administered, cross-sectional survey. In this study, the open-ended responses of the nurses were examined by using content analysis and descriptive analysis.

• Results The most common obstacles were unwillingness of a patient or the patient’s family to accept the prognosis and/or hospice, sudden death or noncommunicative status of the patient, belief of physicians’ hesitance, nurses’ discomfort, and nurses’ desire to maintain hope among patients and patients’ families.

• Conclusions The reasons for noncommunication of prognosis and referral to hospice care by nurses are complex. Because limited discussion between clinicians and patients about prognosis and treatment options can reduce the likelihood of referral to hospice care, improved communication skills may result in more referrals and a smoother transition to hospice.
Factors Associated With Prolonged Prehospital Delay of African Americans With Acute Myocardial Infarction
Authors: Banks Angela D. , Dracup Kathleen
Published: November 2019

• Background Delays in seeking treatment for signs and symptoms of acute myocardial infarction are longer for African Americans than for whites.

• Objective To determine factors associated with prolonged delay and the extent to which perceived racism influences prehospital delay in African Americans with acute myocardial infarction.

• MethodsSixty-one African Americans with acute myocardial infarction were interviewed within 1 month of hospital admission. Delay times were calculated on the basis of the interviews. Independent t tests and χ2 tests were used to determine factors associated with prolonged delays.

• Results Median delay was 4.25 hours and did not differ significantly between women and men (4.42 vs 3.50 hours). Most patients (69%) experienced their initial signs and symptoms at home, often witnessed by family members or friends (70%). Delay was longer for insured patients than for uninsured patients (4.45 vs 0.50 hours). Single, widowed, or divorced patients had longer delay times than did married patients (5.33 vs 2.50 hours), and patients with diabetes delayed longer than did those without diabetes (7.29 vs 3.50 hours). Perceived racism did not differ significantly between patients who delayed seeking treatment and those who did not.

• Conclusions Median delay times were substantially longer than the recommended time of less than 1 hour, reducing the benefit from reperfusion therapies. Education and counseling of patients and their families should be a major strategy in optimizing patients’ outcomes and decreasing the time to definitive treatment.
Ingestion of cold fluids: related to onset of arrhythmias?
Authors: Haughey BP
Published: November 2019

Although the results of this study provide too limited a database for establishing definitive guidelines for practice, they underscore the need for critical care nurses to focus observations on patients' responses to iced fluid restriction. It is important to determine whether and to what extent limiting ingestion of iced fluids induces patient stress, a factor that alone can create physiologic conditions conductive to the occurrence of arrhythmias. Further, in view of the importance of maintaining fluid balance in cardiac patients, it would also be of interest to learn whether iced fluid restriction significantly alters fluid intake. Observations that derive from clinical practice, such as those described above, can stimulate and guide future research designed to evaluate more extensively the efficacy of this coronary precaution.
Discharging ICU ventilator-dependent patients to home healthcare
Authors: Haynes N , Raine SF , Rushing P
Published: November 2019

Patients who are ventilator dependent have few alternatives to continued hospitalization. Within our institution and community, intensive care unit (ICU) bed occupancy and lack of skilled nursing facilities forced us to look for other ways to meet their healthcare needs. The only placement alternative to continued hospitalization for some patients appeared to be home care, because it was available and cost-effective. The possibility of using home care for the ventilator-dependent patient was a new concept for many of the staff, and generated a moderate degree of anxiety among them. Overcoming the anxiety and developing and implementing the discharge plan became our goals. The goals were achieved when the patient was effectively and safely discharged from the ICU to his home.
Shock, a clinical syndrome: an update. Part 3. Therapeutic management
Authors: Rice V
Published: November 2019

Supportive measures attempt to improve oxygen delivery to body cells. A patent airway, adequate ventilation, and supplemental oxygen are important prerequisites. Once oxygen is delivered to the alveolar/capillary interface, it must diffuse into the blood and be carried by adequate numbers of red blood cells. Hemoglobin in the red blood cells must bind with oxygen to carry it to the tissues; yet, the hemoglobin must release the oxygen to the cells in the peripheral capillaries. Cells must be able to use oxygen to produce energy and restore normal cellular function. Restoration of cellular function is a complex sequence that cannot be achieved with a single therapeutic intervention. The supportive management of the shock patient requires many different drugs and therapies to maintain tissue perfusion and to restore normal cellular function.
Epicardial pacing after cardiac surgery
Authors: Lynn-McHale DJ , Riggs KL , Thurman L
Published: November 2019

This article focuses on the use of epicardial wires, the different types of pacing therapy, troubleshooting pacemaker problems, as well as the nursing management of the patient receiving epicardial pacing therapy.
Oxygen transport in the blood
Authors: Carpenter KD
Published: November 2019

Knowledge of how oxygen is dissolved in the blood, transmitted through the bloodstream, and factors that affect oxygen delivery to body cells, is essential to the nursing management of the critically ill patient whose inherent physiologic mechanisms have been compromised by life-threatening illness. This article begins with a simplified review of respiration, progresses through a discussion of oxygen tension in the blood and hemoglobin transport of oxygen, and ends with a discussion of factors that affect the oxyhemoglobin dissociation curve.
Automated external defibrillators: an update of additions to the ACLS algorithms
Authors: Barbiere CC , Liberatore K
Published: November 2019

Instruction in the use of the automated external defibrillator is now a mandatory component of ACLS certification. Here's a review of changes to the ACLS algorithm.
Platelets Modulate IFN-γ Production against Candida albicans in Peripheral Blood Mononuclear Cells via Prostaglandins
Authors: Dewi Intan M. W. , Aleva Floor E. , Kullaya Vesla I. , Garishah Fadel M. , de Mast Quirijn , van der Ven André J. A. M. , van de Veerdonk Frank L.
Published: November 2019

Platelets are known to have immunomodulatory properties. They modulate immune responses of leukocytes against various pathogens, including fungi. Candida albicans can cause systemic infection in immunocompromised individuals that is associated with a high mortality and morbidity. In the current study, we explored the role of platelets in antifungal host defense against C. albicans. PBMCs were stimulated with heat-killed (HK) C. albicans in the presence or absence of isolated washed platelets. Cytokines were quantified from culture supernatants by ELISA. Inhibition of platelet receptors and cytokine pathways were used to elucidate the mechanisms involved in platelet–leukocyte interaction. In the presence of platelets, PBMCs produced less IFN-γ upon stimulation with HK C. albicans. This effect was dependent on the direct contact between platelets and leukocytes but was independent of the platelet GPIb and P-selectin receptors. The attenuation of IFN-γ was not a direct effect on T cells but was dependent on the presence of APC and T cells. Platelets did not modulate the Th-1–polarizing cytokines IL-12 and IL-18. The addition of PG (PGE2) further diminished IFN-γ levels in PBMCs, and supplementation of cells with nonsteroidal anti-inflammatory drugs was able to restore the level of IFN-γ. Overall, we show that modulation of the Th1 response against C. albicans by platelets is dependent on PGs.
Congenital spinal canal stenosis with ossification of the ligamentum flavum in an achondroplastic patient: A case report and literature review
Authors: Kachonkittisak Kritsadakorn , Kunakornsawat Sombat , Pluemvitayaporn Tinnakorn , Piyaskulkaew Chaiwat , Pruttikul Pritsanai , Kittithamvongs Piyabuth
Published: November 2019

Achondroplasia has an effect on intracartilaginous ossification during the development of the spine resulting in a narrow spinal canal. This abnormal anatomy could make an achondroplastic patient tend to have spinal canal stenosis. We reported a case of congenital spinal canal stenosis with achondroplasia combined with ossified ligamentum flavum (OLF) at the thoracolumbar and lumbar spine, which was treated by decompressive surgery. We reported a 52-year-old Thai male with achondroplasia presented with progressive myelopathy and neurogenic claudication due to spinal canal stenosis. Spinal canal stenosis was observed at T10/11 and L1–L5 and OLF at T10/11 through L5 varying in size. Laminectomy and removal of the OLF were performed at T11 and L1–L5. The patient's neurological symptom improved after the surgery. He could walk with a walker at the time of 6-month follow-up postoperatively. In this report, we describe a rare case of achondroplasia with OLF presenting with progressive myelopathy and claudication symptoms from multiple levels of spinal canal stenosis. Laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and function.
Combi Brake System (CBS) Design and Tuning on an Electric Two Wheeler for Cornering Maneuver
Authors: Soni Lokesh , Domala Dhanraj , Venkateswaran Shivaram
Published: November 2019

To reduce the number of traffic accidents, most of the governments have mandated to include Combi Brake System (CBS) or Anti-lock Braking System (ABS) in two wheelers. While most of the homologation requirements for CBS can be fulfilled by straight line motion, CBS behavior is crucial while cornering for safety aspects. When vehicle is in cornering motion, the lateral forces generated at the tire decreases the effective longitudinal force available, which implies lesser braking force at tire.

This paper represents a design methodology for tuning CBS for various critical scenarios mainly during cornering maneuver. A detailed study has been made at various combination of vehicle lean angle, vehicle speed and friction coefficient of road (μ) in straight line and cornering maneuver to effectively decide on front to rear brake force distribution to avoid either of the tires’ lock-up. A co-simulation is done with BikeSim and Simulink softwares, where vehicle model is developed in BikeSim and CBS control algorithm in Simulink. Both the models are correlated against real test data.
Henry Moore in America
Authors: Rose Pauline
Published: November 2019

Although a quintessentially English sculptor, Henry Moore experienced outstanding success in the United States. A man much admired and revered, he was the natural choice for corporate and civil commissions, with many seeing ownership of his work as an expression of rank and aspiring wealth. The fact that the United States contains the greatest number of his sculptures, as opposed to his home country, cannot simply be attributed to superior spending power. Based on original sources, and containing many previously unpublished images, Pauline Rose's book explores the reasons for Moore's fame in America, and the construction of his American persona. An autonomous, creative genius was a seductive and popular idea for the Americans, a perception encouraged by the photographs, films and writings of him in the press. The impact of Moore's presence was likely even stronger precisely because he did not fulfil the expected traits of either the modern artist or the modern celebrity.

Rose's work focuses on contextual factors surrounding Moore's reception: political and economic imperatives within the United Kingdom and the transatlantic Special Relationship between the United Kingdom and America. Exploring the ways in which Moore was presented to an American audience via text and imagery and the influential network of his supporters which spanned the two countries, this insightful book examines a range of sculptural commissions in key American cities. His popularity is likely to be related to the ambitions of politicians and businessmen alike who perceived Moore's monumental sculptures as expressions of citizenship and humanity, particularly against the backdrop of the Cold War. This text is a valuable and innovative addition to studies on Moore. It will be indispensable to all those interested in twentieth century art history and cultural studies, Anglo-American relations, and the vibrant relationship between text and image.
This is Not Art
Authors: Jelinek Alana
Published: November 2019

Art is not political action. Art is not education. Art does not exist to make the world a better place. Art disrupts and resists the status quo and if it fails in this prime objective it only serves to deaden a disenfranchised society further.