Heart & Lung - The Journal of Critical Care - Articles in Press

Swine influenza (H1N1) and acute appendicitis - Corrected Proof

Burke A. Cunha, Francisco M. Pherez, Nicole Durie — 2010-07-16

Background: During the swine influenza (H1N1) pandemic that began in 2009, many hospitalized adults had gastrointestinal symptoms. The most common symptoms associated with swine influenza (H1N1) were nausea, vomiting, or diarrhea. In the experience of the authors, swine influenza was not complicated by abdominal pain. There are a wide variety of infectious and non-infectious disorders that may present with a pain in the right lower quadrant, mimicking appendicitis, ie, pseudoappendicitis. Influenza predisposes to some types of bacterial infection, eg, influenza pneumonia may be complicated by simultaneous Staphylococcus aureus community-acquired pneumonia or subsequent community-acquired pneumonia due to Haemophilus influenzae or Streptococcus pneumoniae. It remains unclear if there is direct involvement of the appendix, ie, pseudoappendicitis as occurs with measles or if influenza itself somehow predisposes to increased frequency/severity of bacterial appendicitis. German clinicians first noted an increased incidence of acute appendicitis in children/young adults with influenza. The American and British cases of influenza and acute appendicitis compared to age-matched controls with more severe and of delayed onset/complicated by appendicial perforation/abscess. These reports noted an increased incidence/severity of acute appendicitis during influenza.Methods and results: A 15-year-old girl presented to the hospital with an influenza-like illness and right lower quadrant abdominal pain. Acute appendicitis was diagnosed by a computed tomography scan and the patient underwent emergency appendectomy. Subsequently, it was noted that she did not have leukocytosis and, in fact, had borderline leukopenia. Her differential white blood cell count also revealed relative lymphopenia. Neither leukopenia nor relative lymphopenia are features of acute bacterial appendicitis. These two findings in the setting of an influenza-like illness indicate the underlying presence of influenza. Post-operatively, respiratory secretion samples were sent for swine influenza (H1N1) testing. Both her respiratory florescent antibody (FA viral panel) was positive for influenza A, as was her RT-PCR for swine influenza (H1N1). The authors believe that this is the first case of swine influenza (H1N1) and acute bacterial appendicitis. Direct involvement of the appendix by swine influenza (H1N1) virus could not be demonstrated.Conclusions: The authors conclude that during the swine influenza (H1N1) pandemic clinicians should be alert to the possibility of an increased incidence/severity of acute bacterial appendicitis in patients with swine influenza (H1N1) infection.

An unusual conduction - Corrected Proof

George Nikolić — 2010-07-15

The patient was an 89-year-old woman with a history of hypertension and strokes. Her medication consisted of aspirin and dipyridamole. The cardiovascular examination was unremarkable. A routine 12-lead electrocardiogram was obtained on the patient's admission to the rehabilitation ward ().

Characteristics of patients receiving vasopressors - Corrected Proof

2010-07-15

Background: Patients receiving intensive care frequently need pharmacologic support of their blood pressure because of shock. In some patients, shock is so severe that extremely high doses of vasopressors are needed to elevate their blood pressure.Objective: We sought to ascertain the maximal dose of vasopressors administered to patients, and to describe the population of patients receiving vasopressors in one intensive care unit.Methods: All adult patients admitted in 2001 to a 10-bed surgical unit in a university hospital, and receiving a vasopressor agent for 1 hour or more, underwent recordings of their demographic data, diagnoses upon admission, Acute Physiological and Chronic Health Evaluation (APACHE) II scores, vasopressors (including type, initial dose, dose increases, and maximal dose), number of days administered, complications, and mortality.Results: Of 689 patients whose charts were reviewed, 72 received vasopressors. The mean age was 65 ± 21.4 years, and 66% were male. The mean APACHE II scores were 24 ± 6.2. The administration of .5 μg/kg/minute of norepinephrine or epinephrine resulted in 96% sensitivity and a specificity of 76% for the likelihood of mortality. Using Kaplan-Meyer curves, those patients receiving less than .5 μg/kg/minute demonstrated an 80% 6-year survival. All 17 patients receiving more than 3.8 μg/kg/minute of norepinephrine, and all 5 patients receiving more than 9.6 μg/kg/minute of epinephrine, died. The length of time during which patients received less than their maximal dose of vasopressors had no influence on survival (P = .4). The elderly (aged ≥75 years) and the young (aged <75 years) had the same intensive care unit survival rates when receiving vasopressors.Conclusion: In this study, little likelihood of intensive care unit survival was evident when patients received more than .5 μg/kg/minute of norepinephrine or epinephrine.

Caregiving burden and quality of life of pneumoconiosis caregivers in Hong Kong - Corrected Proof

2010-07-15

Objective: Silicosis is the most common type of pneumoconiosis in Hong Kong. This study explored the clinical correlates of the caregiving burden and quality of life (QOL) among pneumoconiosis caregivers in Hong Kong.Methods: The study sample included 112 patients with pneumoconiosis and their caregivers. Caregiving burden was measured using the Caregiving Burden Scale (CBS), and caregivers' QOL was assessed using the physical and mental components (PCS and MCS, respectively) of the Medical Outcomes Short Form-36. Pearson's correlation coefficient and Spearman's ρ were calculated to examine the relationship between CBS, PCS, and MCS scores and caregivers' and patients' sociodemographic variables. Stepwise regression analyses were performed to determine the independent correlates of CBS, PCS, and MCS scores.Results: Caregiving burden was correlated with certain patient characteristics (duration of disease, severity of dyspnea, exercise tolerance, depressive symptoms, daily functioning, and community living skills) and with caregivers' variables (depressive symptoms and availability of family support). Regression analysis showed that patients' daily functioning (β = −.345), caregivers' depressive symptoms (β = .509), and the availability of family support (β = .240) were independent correlates of caregiving burden, explaining 45% of the variance. The independent correlates of PCS included patients' severity of coexisting diseases (β = −.179) and caregivers' depressive symptoms (β = −.521). Both patients' (β = −.155) and caregivers' (β = −.633) depressive symptoms and patients' severity of dyspnea (β = −.183) were independent correlates of the MCS.Conclusion: Caring for pneumoconiosis patients entails a significant caregiving burden for caregivers, and adversely affects their QOL. Caregivers' depressive symptoms are related to both their caregiving burden and QOL.

Two aberrancies for the price of one - Corrected Proof

George Nikolić — 2010-07-15

The patient was a 29-year-old woman with unexplained persistent vomiting and mild (3.4 mEq/L) hypokalemia. Except for a regularly irregular pulse, there were no other abnormalities. A 12-lead electrocardiogram was obtained ().

Accuracy and precision of buccal pulse oximetry - Corrected Proof

2010-07-05

Objective: We sought to describe the accuracy and precision of buccal pulse oximetry (SbpO2) compared with arterial oxygen saturation (SaO2) and pulse oximetry (SpO2) in healthy adults at normoxemia and under 3 induced hypoxemic conditions.Methods: In this prospective, correlational study, SbpO2, SaO2, and SpO2 values were recorded at normoxemia and at three hypoxemic conditions (SpO2=90%, 80%, and 70%) for 53healthy, nonsmoking adults who were without cardiac or pulmonary disease, baseline hypoxemia, peripheral edema, dyshemoglobinemia, and fever. Bland-Altman analyses were used to assess agreement and precision between SbpO2 and SaO2 measures and between SbpO2 and SpO2 measures. Data were adjusted to account for a lag time between buccal and finger sites.Results: When comparing SbpO2 and SaO2 values, mean differences of –1.8%, .3%, 2.4%, and 2.6% were evident at the normoxemia, 90%, 80%, and 70% levels, respectively. When comparing SbpO2 and SpO2 values, the mean differences were –1.4%, .1%, 3.3%, and 4.7% at the normoxemia, 90%, 80%, and 70% levels, respectively. The SbpO2 and SaO2 values met a priori precision criteria (1.6%; 95% confidence limit, –4.9% to 1.3%) at normoxemia. The SbpO2 and SpO2 values met precision criteria at normoxemia (1.5%; 95% confidence limit, –4.4% to 1.5%) and 90% (1.9%; 95% confidence limit, –3.6% to 3.8%) conditions, but exceeded precision criteria at the other tested conditions. On average, SpO2 lagged 21 seconds behind SbpO2.Conclusion: Buccal oximetry is an inaccurate and imprecise method of assessing SpO2 when oxygen saturation is <90%. The divergence between SbpO2 and both SaO2 or SpO2 values increased as hypoxemia worsened. The buccal method overestimated oxygen saturation in proportion to the degree of hypoxemia. Such overestimates may lead nurses to conclude falsely that a patient's arterial oxygen saturation is acceptable when further assessment or intervention is warranted.

Cardiobacterium hominis endocarditis presenting as acute embolic stroke: A case report and review of the literature - Corrected Proof

Teera Chentanez, Thana Khawcharoenporn, Nalurporn Chokrungvaranon, James Joyner — 2010-07-05

We report on a case of endocarditis attributable to Cardiobacterium hominis in a 31-year-old man who presented with acute-onset, left-sided hemiparesthesia. Magnetic resonance imaging of the brain showed acute infarctions in 2 areas of the right cerebral cortex, and a transesophageal echocardiogram revealed vegetation in a previously unrecognized bicuspid aortic valve. The patient completed a 6-week course of ceftriaxone and aspirin, with resolution of the vegetation and neurological complications. Our literature review of C. hominis endocarditis suggests that aortic-valve involvement is associated with high stroke and valve-surgery rates. Favorable outcomes and treatment success are evident with either penicillin or ceftriaxone, in combination with (if indicated) valve surgery in patients with neurological complications.

Readmission to intensive care: A qualitative analysis of nurses' perceptions and experiences - Corrected Proof

Malcolm Elliott, Patrick Crookes, Linda Worrall-Carter, Karen Page — 2010-07-05

Objective: The purpose of this study was to identify and describe the experiences and perceptions of nurses regarding the factors that contribute to the readmission of patients to intensive care.Methods: Twenty-one nurses participated in the study. Unstructured interviews were conducted to ascertain participants' perceptions and experiences. Interview transcripts were analyzed using a constant comparison method to identify major conceptual categories.Results: Five main themes were identified that contributed to the readmission of patients to intensive care: premature discharge from intensive care, delayed medical care at the ward level, heavy nursing workloads, lack of adequately qualified staff, and clinically “challenging” patients who demanded a different skill set from the nurses.Conclusion: Discharging patients early from the intensive care unit when they are clinically unstable creates issues around workload and significantly challenges ward staff. It also increases the likelihood of patients being readmitted to the intensive care unit. Hospital managers need to look at ways of increasing the knowledge and skills of ward staff or identify more appropriate environments for managing these acutely ill patients.

Heart Failure Exercise And Training Camp: Effects of a multicomponent exercise training intervention in patients with heart failure - Corrected Proof

Bunny Pozehl, Kathleen Duncan, Melody Hertzog, Joseph F. Norman — 2010-07-05

Background: This study tested the effects of a multicomponent exercise training intervention called “Heart Failure Exercise And Training Camp” (HEART CAMP). The intervention was theoretically derived from Bandura's social cognitive theory.Methods: An experimental repeated-measures design was used. Participants were randomized to the HEART CAMP intervention group (n = 22) or the attention control group (n = 20). Participants were compared on self-efficacy for exercise, symptoms, physical function, and quality of life over 12 weeks.Results: The intervention group had a 31% increase in cardiac exercise self-efficacy and significantly fewer symptoms compared with the attention control group. Quality of life increased significantly in both groups.Conclusion: A theory-based intervention improved self-efficacy for exercise and symptoms in patients with heart failure.

Oral care and bacteremia risk in mechanically ventilated adults - Corrected Proof

Deborah J. Jones, Cindy L. Munro, Mary Jo Grap, Todd Kitten, Michael Edmond — 2010-07-05

Objective: Transient bacteremia occurs in healthy populations from toothbrushing. With the high incidence of bacteremia in the intensive care unit and toothbrushing as an oral care method, this study examined the incidence and clinical significance of transient bacteremia from toothbrushing in mechanically ventilated adults.Methods: Prospective pre- and post-test with all subjects (N = 30) receiving a toothbrushing intervention twice per day (up to 48 hours). The planned microbial analysis used DNA typing to identify organisms from oral and blood cultures collected immediately before, 1 minute, and 30 minutes after the interventions.Results: Seventeen percent of subjects had oral cultures that were positive for selected pathogens before the first toothbrushing intervention. None of the subjects had evidence of transient bacteremia by positive quantitative blood cultures before or after the toothbrushing interventions. Patient characteristics were not statistically significant predictors for systemic inflammatory response syndrome, length of hospital stay, or length of intubation.Conclusion: The toothbrushing intervention did not induce transient bacteremia in this patient population.

Long-term implications of a single home-based educational intervention in patients with heart failure - Corrected Proof

2010-07-05

Objective: The objective of the study was to evaluate the effectiveness of a single home-based educational intervention for patients admitted with heart failure.Methods: There were 106 patients: 42 in the intervention group and 64 in the control group. Patients were randomly assigned to receive an intervention by nursing staff 1 week after discharge. Primary end points were readmissions, emergency department visits, deaths, costs, and quality of life.Results: During the 24-month follow-up, there were fewer mean emergency department visits in the intervention group than in the control group (.68 vs 2.00; P = .000), fewer unplanned readmissions (.68 vs 1.71; P = .000), and lower costs (€671.56 = $974.63 = GBP598.42 per person vs €2,154.24 = $3,126.01 = GBP1,919.64; P = .001). There was a trend toward fewer out-of-hospital deaths (14 [46.6%] vs 31 [55.3%]; P = .45) and improvement in quality of life.Conclusion: Patients with heart failure who receive a home-based educational intervention experience fewer emergency department visits and unplanned readmissions with lower healthcare costs.

Predictors of quality of life in heart-transplant recipients in Taiwan - Corrected Proof

Heng-Hsin Tung, Hwei-Ling Chen, Jeng Wei, Shiow-Luan Tsay — 2010-06-02

Objective: This correlational study sought to identify the predictors of quality of life in heart-transplant recipients in Taiwan.Methods: One hundred and fifty-three patients were recruited through purposive sampling. Data were collected using 6 questionnaires: (1) a demographic questionnaire, (2) the Transplant Symptom Frequency and Symptom Distress Scale, (3) the Self-Efficacy of Exercise Scale, (4) a compliance questionnaire, (5) the Beck Depression Inventory, Short Form 13, and (6) the Medical Outcomes Short Form 36-Health Survey. Data were analyzed using SPSS, version 17.0 software (SPSS, Inc., Chicago, IL). Data analysis included percentages, means, standard deviations, correlation coefficients, and forward regressions.Results: Depression was an independent, and the strongest, predictor of quality of life. Self-perceived health status and self-perceived family support also predicted quality of life. Symptom distress level predicted the physical aspect of quality of life.Conclusions: Based on this understanding, an interdisciplinary team can initiate a needs assessment for these heart-transplant recipients, and develop an intervention to meet their needs.

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft - Corrected Proof

2010-05-31

Objective: This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders.Methods: This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist.Results: The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms.Conclusions: The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

Value of the PaO2:FiO2 ratio and Rapid Shallow Breathing Index in predicting successful extubation in hypoxemic respiratory failure - Corrected Proof

Marc Y. El Khoury, Ralph J. Panos, Jun Ying, Khalid F. Almoosa — 2010-05-31

Purpose: We sought to determine the predictive value of the PaO2:FiO2 ratio (PFR), both independently and in combination with the standard Rapid Shallow Breathing Index (RSBI), for successful extubations in patients with primary hypoxemic respiratory failure (HRF).Materials and Methods: A retrospective chart review of 154 patients with HRF requiring mechanical ventilation for ≥24 hours was performed. The primary outcome was reintubation within 48 hours.Results: 142 (92%) patients were successfully extubated. Pre-extubation PFR and RSBI values among reintubated and successfully extubated patients were similar. The areas under the curve of the receiver operating characteristic curves using RSBI and PFR were .5 and .62, respectively. A PFR < 200 or RSBI ≥ 70 when the PFR was ≥200 indicated a higher risk of reintubation, with .7 sensitivity and .56 specificity (area under the curve, .69), using a classification and regression tree model.Conclusions: Neither the PFR independently nor the PFR in combination with the RSBI in a classification and regression tree model accurately predicted successful extubation in patients with HRF.

Rurality and event-free survival in patients with heart failure - Corrected Proof

2010-05-31

Background: Evidence of health disparities between urban and rural populations usually favors urban dwellers. The impact of rurality on heart failure (HF) outcomes is unknown.Objective: We compared event-free survival between HF patients living in urban and rural areas.Methods: In this longitudinal study, 136 patients with HF (male, 70%; age, mean ± SD 61 ± 11 years; New York Heart Association class III/IV, 60%) were enrolled. Patients' emergency department visits for HF exacerbation and rehospitalization during follow-up were identified. Rural status was determined by rural-urban commuting area code. Survival analysis was used to determine the effect of rurality on outcomes while controlling for relevant demographic, clinical, and psychosocial variables.Results: Rural patients (64%) had longer event-free survival than urban patients (P = .015). Rurality (P = .04) predicted event-free survival after controlling for age, marital status, New York Heart Association class, medications, adherence to medications, depressive symptoms, and social support.Conclusions: Rural patients were less likely than their urban counterparts to experience an event. Further research is needed to identify protective factors that may be unique to rural settings.

Recurrent, severe, and rapidly reversible apical ballooning syndrome in status asthmaticus - Corrected Proof

Stephen L. Rennyson, Jeremy M. Parker, John D. Symanski, Laszlo Littmann — 2010-05-31

Apical ballooning syndrome, or Tako-tsubo cardiomyopathy, is a peculiar form of transient left-ventricular dysfunction originally described as triggered by emotional stress. Subsequent reports indicated that physical stressors can also induce this clinical syndrome. We describe for the first time, to the best of our knowledge, a case of recurrent, severe, and quickly reversible apical ballooning syndrome provoked by the use of high-dose inhaled β-adrenergic agonists in status asthmaticus.

Patient knowledge of and adherence to oral anticoagulation therapy after mechanical heart-valve replacement for congenital or acquired valve defects - Corrected Proof

Sara Van Damme, Kristien Van Deyk, Werner Budts, Peter Verhamme, Philip Moons — 2010-05-31

Objective: This study sought to determine (1) the level of knowledge that mechanical heart-valve patients (because of congenital heart disease or acquired heart-valve defects) have about oral anticoagulation therapy; and (2) to what extent these patients adhere to this therapy.Methods: This descriptive, cross-sectional study included 57 patients. Knowledge was measured using the Knowledge of Oral Anticoagulation Tool. Adherence was assessed with a visual analogue scale and the Swiss HIV Cohort Study Adherence Questionnaire.Results: Patients poorly understood symptoms relevant to over-anticoagulation and the effects of alcohol and vitamins on oral anticoagulants. The knowledge level of patients with congenital heart disease and acquired heart-valve defects did not differ significantly. Three-quarters of patients claimed to be 100% adherent to oral anticoagulant therapy.Conclusion: Most patients lack knowledge about oral anticoagulants, and one fourth of patients do not fully adhere to therapy.

Poor use of cardiac rehabilitation among older adults: A self-regulatory model for tailored interventions - Corrected Proof

Carrie N. Keib, Nancy R. Reynolds, Karen L. Ahijevych — 2010-05-31

Background: A greater number of older adults now live with coronary heart disease (CHD). This poses a significant public health problem, because older adults are at high risk for CHD-related mortality and morbidity. Overwhelming data support the benefits of cardiac rehabilitation for secondary prevention, yet only a small portion of eligible older adults receive it.Methods and Results: Whereas many studies examined factors that affect the use of cardiac rehabilitation among older adults, few interventions aimed to improve their cardiac rehabilitation participation rates. A substantial body of evidence indicates that an individual's illness perceptions play a pivotal role in health behavior, and may be a promising target for intervention. Drawing from the theoretic and empiric findings of others, a self-regulatory model is proposed that explicates how CHD perceptions of older adults may influence participation in cardiac rehabilitation.Conclusion: The model may provide a useful guide for the development of effective interventions tailored to older adults.

Use of octreotide in the treatment of chylopericardium - Corrected Proof

Eszter Szabados, Kalman Toth, Emese Mezosi — 2010-05-31

Chylopericardium involves the pericardial effusion of chyle, which can be a primary (idiopathic) or secondary condition to injury or obstruction of the thoracic duct. We present a case of isolated chylopericardium that appeared after coronary artery bypass grafting in a 46-year-old woman. After failure of the usual conservative therapy for chylopericardium, ie, pericardial drainage and a low-fat, medium-chain triglyceride diet, her treatment was completed with octreotide, a long-acting somatostatin analog. Octreotide was used subcutaneously at a 3 × 100 μg daily dose for 2 weeks. The production of pericardial fluid decreased gradually, and had normalized by the end of treatment. No side effects were evident during therapy.

Gender-specific characteristics of individuals with depressive symptoms and coronary heart disease - Corrected Proof

2010-05-31

Objective: In individuals with depressive symptoms and coronary heart disease (CHD), little is known about gender-specific characteristics that may inform treatments and outcomes. This study sought to identify characteristics that distinguish men from women with both conditions.Methods: By cross-sectional design, 1951 adults with CHD and elevated depressive symptoms completed questionnaires to measure anxiety, hostility, perceived control, and knowledge, attitudes, and beliefs about CHD. Gender differences were evaluated by multivariable logistic regression.Results: Women were more likely to be single (odds ratio [OR] 3.61, P < .001), to be unemployed (OR 2.52, P < .001), to be poorly educated (OR 2.52, P < .001), to be anxious (OR 1.14, P < .01), and to perceive lower control over health (OR 1.34, P < .01) than men.Conclusion: Women with CHD and depressive symptoms have fewer resources, greater anxiety, and lower perceived control than men. In women, targeting modifiable factors, such as anxiety and perceived control, is warranted.

Health promotion behaviors in women with chest pain - Corrected Proof

Joanne L. Thanavaro, Samer Thanavaro, Timothy Delicath — 2010-05-26

Objective: We sought to determine health promotion behavior (HPB) in women with chest pain (CP), and to explore the best predictors of HPB.Methods: The sample included 39 women without previous coronary heart disease (CHD), between ages 30 and 65 years, who were admitted with low-risk or intermediate-risk CP. The Health Promotion Lifestyle Profile II, the CHD Knowledge Tool for Women, and the Benefits and Barriers Scales were used to measure HPB, CHD knowledge, benefits, and barriers to risk modification for the study.Results: Women had low HPB scores ( = 127.3 ± 23.5). The best predictors for HPB (adjusted R2 = .44) included educational level (β = .34, P = .010), hyperlipidemia (β = −.25, P = .05), benefits (β = .33, P = .017), and barriers to risk modification (β = −.41, P = .004).Conclusions: Women do not practice HPB regularly. Women with less education, hyperlipidemia, lower perceived benefits, or higher perceived barriers to risk modification are less likely to practice HPB. Barriers exert the strongest influence on HPB.

Helium:oxygen versus air:oxygen noninvasive positive-pressure ventilation in patients exposed to sulfur mustard - Corrected Proof

2010-05-26

Exposure to sulfur mustard (SM) causes a variety of respiratory symptoms, such as chronic bronchitis and constrictive bronchiolitis. This study assessed the effectiveness of noninvasive positive-pressure ventilation, adjunct with 79:21 helium:oxygen instead of 79:21 air:oxygen, in 24 patients with a previous exposure to SM presenting with acute respiratory failure. Both air:oxygen and helium:oxygen significantly decreased systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse rate, respiratory rate, dyspnea, and increased oxygen saturation (P values: .007, .029, .002, <.001, <.001, <.001, and .002 for air:oxygen, respectively, and <.001, .020, .001, <.001, <.001, <.001, and .002, for helium:oxygen, respectively). Moreover, helium:oxygen more potently improved systolic pressure, mean arterial pressure, pulse rate, respiratory rate, and dyspnea (P values: .012, .048, <.001, <.001, and .012, respectively). The results of our study support the benefit of using helium:oxygen adjunct with noninvasive positive-pressure ventilation in patients exposed to SM with acute respiratory decompensation.

Physiological and anatomical bases for sex differences in pain and nausea as presenting symptoms of acute coronary syndromes - Corrected Proof

Cynthia Arslanian-Engoren, Milo Engoren — 2010-05-24

Acute coronary syndromes (ACS) are common in both men and women. Studies show that women have longer times before diagnosis and treatment in the Emergency Department and worse outcomes than men, which may be related to the differing symptom presentations of men and women. Men are more likely to have chest pain, whereas women are more likely to have dyspnea or nausea. However, women tend to be older and more likely to have diabetes mellitus, hypertension, and peripheral neuropathies. Men and women also exhibit differences in the neural receptors and pathways involved in pain and noxious-stimuli perception. Moreover, men and women may have subtle differences in the locations and sites of their atherosclerotic lesions, all of which may affect symptom presentation. The purposes of this review are to present: (1) the physiology of two common symptoms associated with ACS, ie, pain and nausea; (2) how these symptoms differ between men and women; and (3) how different comorbidities may affect the presentation of these symptoms.

Depression, disability, and quality of life after off-pump coronary artery bypass grafting: A prospective 9-month follow-up study - Corrected Proof

2010-05-21

Background: Several studies have looked at the effects on mood and quality of life (QOL) among patients who underwent on-pump coronary artery bypass grafting (CABG), but few have reported on off-pump CABG (OPCABG).Methods: We recruited 50 patients undergoing OPCABG. The day before CABG, patients were interviewed using 4 questionnaires: the Beck Depression Index (BDI), Beck Anxiety Index (BAI), Sheehan Disability Scale (SDS), and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). The process was repeated at 1, 3, 6, and 9 months.Results: One month postoperatively, patients showed increased levels of depression (Δ 1.67 in the mean BDI score, P < .05) and disability (Δ 5.28 in the mean SDS score, P < .001) and decreases levels of anxiety (Δ 3.7 in the mean BAI score, P < .001) and QOL compared with baseline. When compared with the first month, at 9 months patients were significantly less depressed (Δ 3.58 in the mean BDI score, P < .001), were less disabled (Δ 5.34 in the mean SDS score, P < .001), and had better QOL (Δ 3.82 in the mean Q-LES-Q score, P = .014). At 9 months, 44% had some degree of depression and 48% had low QOL.Conclusion: Despite that all scores returned to or below baseline at 9 months, a high percentage of patients still had depressive symptoms and overall poor quality of life (QOL). BDI scores at baseline are good predictors of QOL at all measured intervals. This should make physicians more prudent in diagnosing and observing these patients.

A rare case of Epstein-Barr virus-induced dilated cardiomyopathy - Corrected Proof

Halil Mutlu, Manzoor Alam, Ozlem Fidan Ozbilgin — 2010-05-17

Although half of dilated cardiomyopathy (DCM) cases have unknown causes, the remaining causes of DCM are extensive. In some cases, DCM starts with myocarditis, which is basically an inflammation of the heart muscle. Myocarditis can present in a variety of ways, from asymptomatic to cardiogenic shock. Myocarditis is associated with a wide range of infections, most commonly viral, bacterial, and parasitic. The main mechanism seems to be immune-mediated damage to the myocardium, which leads to a global or local ventricular dysfunction and DCM. Epstein-Barr virus is a rare cause of myocarditis. We could locate only 15 cases (9 adults and 6 children) reported in the medical literature in English. We report an adult patient who presented with signs and symptoms of heart failure most likely secondary to myocarditis caused by Epstein-Barr virus infection. The diagnosis was made by viral serology and a multidisciplinary approach.

Psychosocial predictors of change in quality of life in patients after coronary interventions - Corrected Proof

2010-05-14

Objective: Health-related quality of life (HRQOL) after coronary interventions (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty) usually improves in patients, but not in all patients. Some patients actually show a significant decline in HRQOL. Our aim was to explore the potential of psychologic well-being (anxiety, depression), vital exhaustion, Type D personality, and socioeconomic position as predictors of HRQOL in patients with coronary disease.Methods: A total of 106 patients scheduled for coronary angiography were interviewed before (baseline) and 12 to 24 months after coronary angiography. Socioeconomic status was evaluated by education. The General Health Questionnaire 28 was used for measuring psychologic well-being (anxiety, depression), the Maastricht interview was used for measuring vital exhaustion, and the Type D questionnaire was used for measuring personality. HRQOL was assessed using the Short Form-36 (physical and mental components) questionnaire. Functional status was assessed with a combination of New York Heart Association and Canadian Cardiovascular Society classifications. Linear regressions were used to analyze data.Results: A change in physical HRQOL was predicted by baseline psychologic well-being (β = −.39; 95% confidence interval [CI], −1.00 to −.16) and baseline HRQOL (β = −.61; 95% CI, −.83 to −.34). A change in mental HRQOL was predicted by (baseline) psychologic well-being (β = −.37; 95% CI, −.99 to −.09), vital exhaustion (β = −.21; 95% CI, −.69 to −.03), and baseline HRQOL (β = −.76; 95% CI, −1.03 to −.44). Ejection fraction did not significantly predict HRQOL.Conclusion: Psychosocial factors (psychologic well-being, vital exhaustion) seem to be more important predictors of change in HRQOL compared with some objective medical indicators (ejection fraction) among patients with coronary disease.

Adherence to prophylactic asthma medication: Habit strength and cognitions - Corrected Proof

Catherine Bolman, Titia G. Arwert, Trijntje Völlink — 2010-05-14

Objective: To explain adherence to prophylactic asthma medication (PAM, inhaled corticosteroids) by the attitude, social influence, and self-efficacy (ASE) model added with the concept of habit strength and to study whether habit moderates or mediates relationships between ASE factors and adherence.Methods: A mail-out survey was conducted among 139 asthmatic adults. Multiple regression analysis was conducted, with self-reported adherence as the outcome and ASE factors and habit as the independent variables. Simple slope analyses and bootstrapping mediation analyses were also conducted.Results: Having more severe asthma, taking PAM habitually, and perceiving few negative consequences of taking PAM were associated with better adherence. Self-efficacy influenced adherence indirectly through habit. The relationship between social norms and adherence was moderated by habit: In the case of weak habits, a supportive norm in a patient's environment toward taking PAM was positively related to PAM adherence; in the case of strong habits, a supportive norm led to less adherence.Conclusion: Interventions to increase adherence should enhance the formation of habits by stimulating patients to perform the behavior frequently in similar situations by increasing self-efficacy and providing environmental cues, such as reminder devices and pill organizers. In addition, the disadvantages of PAM use should be negated.

The association between bathing and weaning trial duration - Corrected Proof

2010-05-14

Objective: To describe patterns of bath care for patients who are weaning from prolonged mechanical ventilation (PMV) and to explore the association between bathing and weaning trial duration.Methods: Descriptive correlational study. Clinical records from 439 weaning trial days for 30 patients who required PMV were abstracted for bathing occurrences during weaning trials, within 1 hour before a trial, and nocturnally.Results: Most baths occurred during weaning trials (30.8%) or at night (35.3%), and less frequently (16%) within 1 hour before a trial. No significant effects were found on trial duration for nocturnal bathing or bathing within 1 hour before a trial. By using random coefficient modeling, weaning duration was shown to be longer when bathing occurred during a weaning trial (P < .05), even when controlling for age, severity of illness, and days on bedrest.Conclusion: Bathing occurred during approximately one third of PMV weaning trials. Baths during PMV weaning trials were associated with longer weaning trial duration.

Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery - Corrected Proof

2010-05-10

Objective: We sought to determine whether preoperative and postoperative anxiety, depression, and stress symptoms were associated with atrial fibrillation (AF) after cardiac surgery.Methods: Two hundred and twenty-six cardiac surgery patients completed measures of depression, anxiety, and general stress before surgery, and 222 patients completed these measures after surgery. The outcome variable was new-onset AF, confirmed before the median day of discharge (day 5) after cardiac surgery during the index hospitalization.Results: Fifty-six (24.8%) patients manifested incident AF, and they spent more days in hospital (mean [M], 7.3; standard deviation [SD], 4.6) than patients without AF (M, 5.5; SD, 1.4; P < .001). No baseline psychological predictors were associated with AF. When postoperative distress measures were considered, anxiety was associated with increased odds of AF (odds ratio, 1.09; 95% confidence interval, 1.00 to 1.18; P = .05). This analysis also showed that age was significantly associated with AF (odds ratio, 1.07; 95% confidence interval, 1.03 to 1.12; P < .001). Analyses specific to the symptomatic expression of anxiety indicated that somatic (ie, autonomic arousal) and cognitive-affective (ie, subjective experiences of anxious affect) symptoms were associated with incident AF.Conclusion: Anxiety symptoms in the postoperative period were associated with AF. Hospital staff in acute cardiac care and cardiac rehabilitation settings should observe anxiety as related to AF after cardiac surgery. It is not clear how anxious cognitions influence the experience of AF symptoms, and whether symptoms of anxiety commonly precede AF.

Healthy diet in Canadians of low socioeconomic status with coronary heart disease: Not just a matter of knowledge and choice - Corrected Proof

2010-05-10

Abstract: People of low socioeconomic status (SES) are prone to premature coronary heart disease (CHD) and tend to have more risk factors and worse health and mortality. Yet, little is understood about the specific challenges faced by people of low SES with CHD in changing behavior around the consumption of dietary risk factors, such as salt, fat, and cholesterol, and adding heart-healthy foods, such as fruit, vegetables, lean meat, and fish. The aim of this study was to understand factors promoting and reducing willingness and capacity to consume a healthy diet in people of low SES with CHD. Qualitative research via semistructured interviewing and a critical realist theoretic framework was used, along with a questionnaire to provide context for the interviews. Food consumption and diet were not principally related to knowledge but were constrained by an ever-present scarcity of resources and the need to prioritize other daily living expenses perceived as being more important than diet. Having use of a vehicle also promoted access to dietary support from physicians and cardiac rehabilitation.

Gender and age differences in symptom distress and functional disability one year after heart transplant surgery - Corrected Proof

Anne Jalowiec, Kathleen L. Grady, Connie White-Williams — 2010-05-10

Objective: Symptoms and functional status are major concerns for heart transplant (HT) recipients. The study objective was to examine gender and age differences in symptom distress and functional disability 1 year after HT surgery.Methods: The sample (N = 237) consisted of 44 female and 193 male patients who were divided into younger (n = 66) and older (n = 171) groups with the breakpoint at age 50 years. Data from chart review and 2 questionnaires (Heart Transplant Symptom Checklist and Sickness Impact Profile) were analyzed with chi-square test, t tests, analysis of variance, and multivariate analysis of variance.Results: Women reported worse symptom distress (overall, plus cardiovascular, gastrointestinal, dermatologic symptoms) and more functional disability (overall, plus disability in ambulation, mobility, self-care, home management). Older patients reported more disability in ambulation and work. Gender by age interactions showed that older men reported worse genitourinary symptoms and younger women reported worse dermatologic symptoms.Conclusion: There were more gender than age differences in symptoms and disability.

Wash and wean: Bathing patients undergoing weaning trials during prolonged mechanical ventilation - Corrected Proof

2010-05-10

Background: Bathing is a fundamental nursing care activity performed for or with the self-assistance of critically ill patients. Few studies address caregiver or patient–family perspectives about bathing activity during weaning from prolonged mechanical ventilation (PMV).Objective: To describe practices and beliefs about bathing patients during weaning from PMV.Methods: Secondary analysis of qualitative data (observational field notes, interviews, and clinical record review) from a larger ethnographic study involving 30 patients weaning from PMV and the clinicians who cared for them using basic qualitative description.Results: Bathing, hygiene, and personal care were highly valued and equated with “good” nursing care by families and nurses. Nurses and respiratory therapists reported “working around” bath time and promoted conducting weaning trials before or after bathing. Patients were nevertheless bathed during weaning trials despite clinicians' expressed concerns for energy conservation. Clinicians recognized individual patient response to bathing during PMV weaning trials.Conclusion: Bathing is a central care activity for patients on PMV and a component of daily work processes in the intensive care unit. Bathing requires assessment of patient condition and activity tolerance and nurse–respiratory therapist negotiation and accommodation with respect to the initiation or continuation of PMV weaning trials during bathing. Further study is needed to validate the impact (or lack of impact) of various timing strategies for bathing patients who are on PMV.

Diagnostic accuracy of the rapid shallow breathing index to predict a successful spontaneous breathing trial outcome in mechanically ventilated patients with chronic obstructive pulmonary disease - Corrected Proof

2010-05-05

Objective: To evaluate the diagnostic accuracy of 2 threshold values (105 breaths per minute [bpm]/L and 130 bpm/L) of the rapid shallow breathing index (RSBI) to predict a successful weaning trial outcome in a homogenous group of patients with chronic obstructive pulmonary disease (COPD).Methods: A consecutive population of patients with COPD who were intubated for hypercapnic respiratory failure during a 2-year period were studied prospectively. RSBI was measured by 2 investigators at minute 5 of the T-piece trial, whereas 2 other physicians evaluated the 30 minute T-piece trial as successful or unsuccessful, according to clinical criteria.Results: Of 64 patients with COPD (53 male, 11 female) who constituted the study population, 42 patients (35 male, 7 female; aged 70 ± 9.2 years) completed the spontaneous breathing trial (SBT) and remained clinically stable (group 1). The remaining 22 patients (18 male, 4 female; aged 71.9 ± 4.7 years) had to return to ventilatory support by the end of the SBT because of clinical deterioration (group 2). The 2 threshold values that were evaluated had low specificity (38.1% for < 105 bpm/L and 66.7% for < 130 bpm/L), low sensitivity (63.6% for < 105 bpm/L and 54.5% for < 130 bpm/L), and low diagnostic accuracy (46.8% for < 105 bpm/L and 65.6% for < 130 bpm/L) in predicting a successful T-piece trial outcome.Conclusion: RSBI measured early during an SBT cannot accurately predict the successful outcome of a T-piece trial in a homogenous population of patients with COPD.

Medications and associated symptoms/problems after coronary artery bypass surgery - Corrected Proof

2010-05-05

Objective: The purpose of this secondary analysis was to describe medication use and examine the relationship between medications and postoperative symptoms/problems in the first 3 months after coronary artery bypass surgery (CABS).Methods: The sample consisted of older (≥65 years) men and women (n = 232) who had undergone CABS. Medication data were collected through self-report 3 and 6 weeks and 3 months after surgery.Results: Most patients reported taking aspirin (88.2%–85.7%), statins or cholesterol-lowering drugs (88.6%–87%), and beta-blockers (68%–55.6%). No significant differences were found between the proportion of patients taking and not taking beta-blockers, antiarrhythmics, cholesterol-lowering drugs, or angiotensin-converting enzyme inhibitor medications for common medication-specific symptoms/problems.Conclusion: Patients experience symptoms after surgery, but these symptoms did not seem to be side effects from medications. Nursing assessments and interventions targeting postoperative symptoms, symptom management, and medication side effects can enhance recovery and reinforce medication adherence.

Comparison of effects of manual versus ventilator hyperinflation on respiratory compliance and arterial blood gases in patients undergoing mitral valve replacement - Corrected Proof

Faizan Ahmed, Aamir Mohammed Shafeeq, Jamal Ali Moiz, Muhammed Abid Geelani — 2010-04-26

Objective: To compare the effects of manual hyperinflation (MHI) and ventilator hyperinflation (VHI) delivered to completely sedated and paralyzed patients undergoing mitral valve replacement (MVR) while maintaining minute ventilation.Methods: This was a randomized study with a 2-group, pre-test, post-test experimental design. Effects of hyperinflation were studied on static compliance (Cstat), dynamic compliance (Cdyn), oxygenation (Pao2:Fio2), partial pressure of carbon dioxide in arterial blood (Paco2), and cologarithm of activity of dissolved hydrogen ions in arterial blood (pH). A sample of 30 patients in the immediate postoperative phase of MVR surgery were included in the study.Results: No significant differences were found between the groups. Significant improvements were found in oxygenation at both 1minute and 20minutes after MHI, but only at 1minute after VHI (P < .05). VHI led to improved Cdyn (P < .05).Conclusion: In the immediate postoperative phase of MVR, both techniques produced similar effects on respiratory compliance and oxygenation. MHI produced longer lasting improvements in oxygenation than VHI, whereas VHI produced better improvements in dynamic compliance. Paco2 and pH were maintained by both.

Predictors of depressive symptoms among coronary heart disease patients: A cross-sectional study nine years after coronary artery bypass grafting - Corrected Proof

Meeri Koivula, Nina Halme, Päivi Åstedt-Kurki — 2010-04-26

Objective: This study sought to identify the incidence of depression and its associations with demographic, lifestyle, perceived health, symptoms, treatment, and social support variables in patients 9 years after a coronary artery bypass graft.Methods: The questionnaire was mailed to 152 surviving patients who had undergone a coronary artery bypass graft 9 years earlier, and who had been respondents in an earlier study. Depressive symptoms were measured using the Zung Self-Rating Depression Scale, and social support was measured using Social Support from the Network Scale. Descriptive statistics and the linear regression method were used for analysis.Results: Depressive symptoms were reported by one fourth of the patients. The predictors for depressive symptoms included gender, perceived health, cardiac ischemic symptoms at rest, and emotional social support, which explained 24% of the variance. Controlling for gender revealed that the predictors for women and men were different.Conclusions: Depression is more difficult to predict in men than in women.

Clinical and genetic investigation of pediatric cases of Wolff-Parkinson-White syndrome in Tunisian families - Corrected Proof

2010-04-26

Background: Wolff-Parkinson-White (WPW) syndrome is an autosomal-dominant heart disease characterized by an accessory pathway that arises from an aberrant conduction from the atria to the ventricles. Several mutations within the PRKAG2 gene were shown to be responsible for WPW. This gene encodes the γ2 regulatory subunit of adenosine monophosphate (AMP)-activated protein kinase, which functions as a metabolic sensor in cells, responding to cellular energy demands.Methods: This first study of WPW in a North African population comprises the clinical and genetic investigation of 3 Tunisian families, including 11 affected members. The involvement of the PRKAG2 and NKX2-5 genes was investigated.Results: Mutation screening showed that with the exception of two already reported single-nucleotide polymorphisms, no mutations were detected within the coding region of PRKAG2 or in the NKX2-5 gene.Conclusions: This study provides further evidence of the genetic heterogeneity of WPW.

Toward a new approach for the detection of pain in adult patients undergoing cardiac surgery: Near-infrared spectroscopy—A pilot study - Corrected Proof

2010-04-26

Objective: This pilot study examined the discriminant validity and criterion validity of regional cerebral oxygenation measurement (rSO2), using the near-infrared spectroscopy (NIRS) technique (INVOS-4100 system, Somanetics, Troy, MI) for measuring pain during nociceptive procedures in adults undergoing cardiac surgery.Methods: A repeated-measures, within-subjects design was used, and 40 adult patients participated. Data collection was completed during 2 test periods: (1) while patients were awake, before the induction of anesthesia (first test period); and (2) after the induction of anesthesia, while patients remained under the effects of anesthesia (second test period). Each test period included a baseline, a tactile stimulus (skin disinfection), nociceptive stimuli (e.g., intravenous and arterial line insertions, sternal bone incision and thorax opening), and a postprocedure evaluation.Results: Increased rSO2 values (P < .001) were acquired during nociceptive procedures in both test periods. No significant associations were evident between rSO2, pain behaviors, and the patient's self-report of pain intensity, but this may be attributable to a low range of variability.Conclusions: Although further research is needed in critically ill adult patients undergoing more painful procedures, the NIRS may become a promising technique for assessing pain.

Symptoms and treatment-seeking responses in women experiencing acute coronary syndrome for the first time - Corrected Proof

Robyn Gallagher, Andrea P. Marshall, Murray J. Fisher — 2010-04-26

Background and Objective: Many women do not recognize their risk for coronary heart disease, or identify and respond to cardiac symptoms by seeking medical assistance when symptoms occur. These factors contribute to delays in presentation at hospital, which means that women then have fewer treatment options. This study aimed to describe women's symptom experiences and treatment-seeking responses to first-time acute coronary syndrome (ACS).Subjects and Methods: Ten women who had experienced their first ACS event, and who had undergone a percutaneous coronary intervention within 24 hours of presentation, consented to participate in semistructured interviews that focused on their experiences. These women's narratives of their symptoms and treatment-seeking responses were thematically analyzed.Results and Conclusion: Women described several issues that contributed to quite complex, multifaceted decision-making processes, from symptom onset to treatment-seeking response, which often contributed to delays. These issues included the occurrence of sometimes intermittent early-warning or prodromal symptoms, the diversity of their symptom experience, beliefs in low vulnerability to coronary heart disease by the women themselves, and health professionals' responses, which did not always match their needs. Lack of awareness may be particularly important in first-time ACS event. Effective strategies need to be developed to address these issues, including public-education campaigns, and specific education regarding women for health professionals.

Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: The Macklin effect - Corrected Proof

Kleber J. Romero, Máximo H. Trujillo — 2010-04-23

Objective: We describe the clinical features of a 17-year-old girl with severe asthma exacerbations. On admission to the intensive care unit, she manifested expiratory dyspnea, cyanosis, and an unproductive cough. Her chest x-rays showed extensive pneumomediastinum (PM), mild subcutaneous emphysema at the right anterior triangle of the neck, and right upper-lobe atelectasis. Her PM resulted from the “Macklin effect,” which involves a three-step process: overly distended alveolar rupture, air dissection along the bronchovascular sheaths, and air spreading into the mediastinum.Methods: Treatment consisted of oxygen therapy, parenteral corticosteroids, and nebulized bronchodilators.Results: She made a good recovery, and was discharged from the intensive care unit after 2 days.Conclusion: This case illustrates that conservative management strategies in this severe and unusual complication of asthma exacerbation can result in rapid and complete recovery. Nonetheless, every asthma exacerbation should be considered potentially life-threatening, and must be treated promptly and adequately.

Leisure physical activity and quality of life after coronary artery bypass graft surgery for patients with metabolic syndrome in Taiwan - Corrected Proof

2010-04-23

Objective: The purpose of this correlational study was to explore the physical activity and quality of life of postcoronary artery bypass graft patients with metabolic syndrome.Methods: Seventy patients were recruited via purposive sampling. Data were collected through three instruments: a demographic questionnaire, the Modifiable Activity Questionnaire, and the Medical Outcomes Study Short Form 36-Health Survey. The data were analyzed using SPSS software, version 17.0 (SPSS, Inc., Chicago, IL), and data analysis included percentages, means, standard deviations, correlation coefficients, and forward regressions.Results: Patients with a higher level of physical activity tended to have better quality of life. Our findings also indicated that the total Modifiable Activity Questionnaire score and age explained 15.1% of the variance in the physical component summary of quality of life, and 13.6% of the variance in the mental component summary of quality of life.Conclusion: Based on this research, nursing staff should develop physical activity-related interventions to promote quality of life.

Impact of diabetes mellitus on patients over 70 years of age undergoing coronary artery bypass grafting - Corrected Proof

2010-04-19

Objective: We evaluated in-hospital outcomes of diabetic and nondiabetic patients aged over 70 years after isolated coronary artery bypass grafting (CABG).Patients And Setting: All patients aged over 70 years at our center, who underwent CABG between January 2003 and December 2008, were entered into this study. Diabetes in this study was defined as the need for oral medication or insulin.Methods: The relevant preoperative, intraoperative, and postoperative characteristics of selected patients were investigated, compiled, and retrospectively analyzed.Results: One hundred and twenty-one diabetic patients aged over 70 years, accounting for 30.8% of the total population, were entered into this study. Diabetic patients aged over 70 years were more likely to present with left main trunk disease (P=.0194), and less likely to have undergone previous percutaneous coronary intervention (P=.0121), compared with their nondiabetic counterparts. Univariate and multivariate logistic regression analysis showed that diabetic patients aged over 70 years had a higher rate only of deep sternal wound infection (odds ratio, 2.28; 95% confidence interval, 1.29 to 6.84; P=.0028), while sharing similar rates for other morbidities and mortality compared with nondiabetic patients aged over 70 years.Conclusions: Elderly diabetic patients are not at significantly increased risk from CABG, compared with their nondiabetic peers.

Reply to Bauer et al - Corrected Proof

Nancy M. Albert — 2010-04-19

To the Editor: We appreciated reading the comments of Dr. Bauer et al on their research results of massage therapy after cardiovascular surgery. At the time we conducted our study, massage therapy after cardiovascular surgery was primarily confined to a patient's feet. There was a lack of research regarding the massage of other body areas, and massage techniques were not carefully described in many studies. In the study at the Cleveland Clinic, we made an attempt to standardize massage therapy in as controlled a fashion as possible. Thus a standard dose of massage therapy was administered to standard areas of the body. The study at the Mayo Clinic used nonstandard doses and areas. Other factors may also have differed between studies, e.g., the length of each session. In the absence of knowing their study design and assessment instruments, it is difficult for us to respond to the comments of Dr. Bauer et al.

Rapid clinical diagnosis of swine influenza (H1N1) using the Swine influenza diagnostic triad - Corrected Proof

Burke A. Cunha, Uzma Syed, Stephanie Strollo, Nardeen Mickail, Marianne Laguerre — 2010-04-19

To the Editor: We thank Dr Wiwanitkit for his commentary on the Winthrop-University Hospital Infectious Disease Division swine influenza (H1N1) pneumonia weighted diagnostic point score system for hospitalized patients with influenza-like illnesses and negative-rapid influenza diagnostic test results that was published in Heart & Lung. As mentioned in the article, during the “herald wave” of the swine influenza (H1N1) pandemic, the problem of false-negative rapid influenza diagnostic test results in patients with influenza-like illnesses became apparent because definitive reverse transcriptase-polymerase chain reaction testing for H1N1 was restricted. Necessity forced us to develop a system and identify patients with probable swine influenza (H1N1) pneumonia, which was the basis of selection from influenza precautions and oseltamivir therapy. There was no time to determine the sensitivity, specificity, or predictive value of this test given the crush of patients in the first wave of the pandemic. In regard to cost-effectiveness, the parameters used in the weighted diagnostic point system are inexpensive routine tests usually obtained for hospitalized patients. We agree that an accurate and user-friendly fast diagnostic tool is required for admitted adults with influenza-like illnesses and negative rapid influenza diagnostic test results who may have swine influenza (H1N1). During the “fall wave” of the swine influenza H1N1 pandemic, we developed a rapid and easy-to-use approach. The diagnostic swine influenza triad emerged. The diagnostic swine influenza triad was based on the previous weighted diagnostic point score system that maintains its accuracy and is rapid and easy to use. The diagnostic swine influenza triad was “in press” in Heart & Lung as the “winter wave” of the pandemic began. The diagnostic influenza triad should be of clinical use to you and others dealing with the swine influenza (H1N1) pandemic.

Patients' discharge experiences: Returning home after open-heart surgery - Corrected Proof

Jennifer Lapum, Jan E. Angus, Elizabeth Peter, Judy Watt-Watson — 2010-04-15

Purpose: This study explored patients' narratives of technology in heart surgery and recovery.Methods: A narrative inquiry was conducted with a sample of 16 individuals. Interviews were completed 2 to 4 days after transfer from cardiovascular intensive care, and 4 to 6 weeks after discharge. Participants completed journals between these 2 time periods.Results: Discharge and the return home were highlighted as key transitions. These transitions were driven by a technological script that included teachings and texts provided upon discharge. Complicating participants' narratives were their own personal dramas and self-characterizations of vulnerability, as they struggled to incorporate this script into the particularities of their daily lives.Conclusion: Comprehensive conceptualizations of technology that involve the associated logics and pathways of recovery provide deep insights into patients' stories of recovery from heart surgery. It is salient that discharge programs consider the ways that technology enters into patients' narratives, and also consider dialogical approaches to communication, education, and supportive interventions that are offered at multiple intervals and continue in the home.

Factors related to quality-of-life pattern changes in recipients of implantable defibrillators - Corrected Proof

Suzanne S. Dickerson, Mary Kennedy, Yow-Wu B. Wu, Meghan Underhill, Areej Othman — 2010-04-09

Purpose: The implantable cardioverter defibrillator (ICD) has proven life-saving, yet it is important to understand its psychological effects on recipients. This study examined longitudinal changes in patterns of quality-of-life (QOL) scores in the first 3 months after an implant, and determined what variables tested as predictors of patterns.Methods: This longitudinal, prospective, descriptive, correlational survey study followed 80 ICD patients, with data collection at a baseline preinsertion, and 1 and 3 months after implant.Results: Findings revealed eight patterns of QOL change that were recoded into 3 groups: no change (44.7%), worse (20.7%), and improved (34.2%). No significant difference was evident in groups according to age at implant, gender, education, ejection fraction, number of device discharges, and comorbidities. State anxiety was significantly higher for the worsening group.Conclusion: This finding supports the practice of identifying and supporting patients with anxiety, which correlates with a worsening QOL.

Event-free survival in adults with heart failure who engage in self-care management - Corrected Proof

Christopher S. Lee, Debra K. Moser, Terry A. Lennie, Barbara Riegel — 2010-04-09

Background: Self-care management in heart failure (HF) involves decision-making to evaluate, and actions to ameliorate symptoms when they occur. This study sought to compare the risks of all-cause mortality, hospitalization, or emergency-room admission among HF patients who practice above-average self-care management, those who practice below-average self-care management, and those who are symptom-free.Methods: A secondary analysis was conducted of data collected on 195 HF patients. A Cox proportional hazards model was used to examine the association between self-care management and event risk.Results: The sample consisted of older (mean ± standard deviation=61.3±11 years), predominantly male (64.6%) adults, with an ejection fraction of 34.7% ± 15.3%; 60.1% fell within New York Heart Association class III or IV HF. During an average follow-up of 364±288 days, 4 deaths, 82 hospitalizations, and 5 emergency-room visits occurred as first events. Controlling for 15 common confounders, those who engaged in above-average self-care management (hazard ratio, .44; 95% confidence interval, .22 to .88; P < .05) and those who were symptom-free (hazard ratio, 0.48; 95% confidence interval, .24 to .97; P < .05) ran a lower risk of an event during follow-up than those engaged in below-average self-care management.Conclusion: Symptomatic HF patients who practice above-average self-care management have an event-free survival benefit similar to that of symptom-free HF patients.

Pleural fluid characteristics of tuberculous pleural effusions - Corrected Proof

Emmet E. McGrath, David Warriner, Paul B. Anderson — 2010-04-09

Abstract: Mycobacterium tuberculosis (TB) infection of the pleural space is an important cause of pleural effusion in areas of high TB prevalence. Microbiological analyses of pleural fluid in the acute setting may be negative. Consequently, investigations may proceed to more invasive techniques, such as pleural biopsy or thoracoscopy. Ongoing research has led to implementing a number of additional fluid analyses that may lead to a diagnosis without a need for further invasive procedures. In this review, we discuss the characteristics of tuberculous pleural fluid that may assist in this important diagnosis, and we highlight the benefits of specific biomarker analyses. English-language publications from a MEDLINE search and references from relevant articles from January 1, 1990 to September 1, 2009 were reviewed. The key words searched included tuberculosis, pleural fluid, effusion, diagnosis, adenosine deaminase, and interferon.

Illness knowledge moderates the influence of coping style on quality of life among women with congestive heart failure - Corrected Proof

Jamie L. Jackson, Charles F. Emery — 2010-04-09

Objective: This study evaluated the relationship of coping style with quality of life (QoL) among women with congestive heart failure (CHF), and the role of illness knowledge in this relationship.Methods: Thirty-five women with CHF completed measures of coping style (anger-in, alexithymia, and emotional expression), illness knowledge, and emotional/physical QoL.Results: Symptoms of depression and anxiety were positively associated with anger-in (P < .001) and alexithymia (P < .01), and were negatively correlated with emotional expression (P=.05). Furthermore, illness knowledge moderated the relationship between anger-in and depressive symptoms (P=.01), such that high anger-in individuals with greater illness knowledge displayed greater depressive symptoms. Knowledge also moderated the relationship between emotional expression and anxiety (P=.02), indicating that low emotional expression was associated with greater anxiety among those with less illness knowledge. Depressive and anxiety symptoms, anger-in, alexithymia, and emotional expression were not correlated with physical QoL.Conclusion: Illness knowledge is associated with poorer emotional QoL among those using denial-based coping styles, but a better QoL among those avoiding communication of their emotions.

Rosai–Dorfman disease of multiple organs, including the epicardium: An unusual case with poor prognosis - Corrected Proof

Jiquan Chen, Hao Tang, Bing Li, Qingyu Xiu — 2010-04-09

Abstract: Rosai–Dorfman disease (RDD) is a benign proliferative histiocytic disorder predominantly of the lymph nodes with extranodal involvement in some cases. However, serous membranes are seldom involved in the extranodal cases, and epicardial involvement is never reported. Most RDD cases show a self-limiting process with good prognosis and corticosteroid treatment in some patients exhibiting good effect. We recently observed a case of RDD primarily manifesting pericardial and bilateral pleural effusion that finally led to death, and corticosteroid treatment showed little effect. Autopsy showed the characteristic S100-positive and CD68-positive histiocytes exhibiting emperipolesis in the lungs, pleura, epicardium, mediastinal lymph nodes, and colon. This case illustrates the importance of RDD in the differential diagnosis of effusion in multiple serous cavities. The failure of corticosteroid therapy in this patient and her death showed the poor prognosis of some patients with RDD. Moreover, to our knowledge, epicardial involvement of RDD has not been reported.