Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management

OBJECTIVE: To determine the impact of intraoperative transesophageal echocardiography (IOTEE), an important adjunct in many types of cardiac surgical cases, on the surgical decisions made perioperatively in adult patients undergoing cardiac surgery. PATIENTS AND METHODS: All adult patients who had cardiac surgery between 1993 and 1997 and who also had IOTEE were studied. New findings before and after cardiopulmonary bypass and alterations in the planned surgical procedure or management were documented prospectively. RESULTS: A total of 3245 patients (60% men, 40% women; aged 18-93 years with a mean +/- SD age of 62 +/- 15 years) were included in the study. The most common operations performed were mitral valve repair (26%) and aortic valve replacement (22%). Over the 5-year period, 41% of patients had IOTEE. New information was found before bypass in 15% of patients, directly affecting surgery in 14% of the patients. The most common new prebypass information found was patent foramen ovale resulting in closure in the majority of patients. New information was found after bypass in 6% of the patients, resulting in a change in surgery or hemodynamic management in 4% of the total. The most common postbypass finding was valvular dysfunction with repeat bypass in most patients for re-repair or replacement. No major complications occurred. CONCLUSION: In adult patients undergoing cardiac surgery, IOTEE provides important important information both before and after bypass that affects surgical and hemodynamic management.     

Quality of life among long-term survivors of intensive care

Quality of life was examined in 717 individuals 1 yr after their admission to a multidisciplinary ICU. Of these, 87% were able to live at home 6 months after their admission. Of patients 65 yr and older, 90% had been living independently before admission compared to 80% 1 yr afterward. Of those younger than 65 yr, most of the 65% who had been working before admission could return to work. The length of hospitalization during the first year after admission varied greatly; 10% of the patients stayed more than 145 days. The patients who needed mechanical ventilation or who stayed 1 wk or more in the ICU tended to have worse outcomes than others. These data indicate that there is no great deterioration in quality of life among long-term survivors of intensive care.     

Assessment of the relation between IVUS measurements and clinical outcome in elderly patients after sirolimus-eluting stent implantation for de novo coronary lesions

This study aimed to evaluate the impact of vascular response assessed by intravascular ultrasound (IVUS) imaging on clinical outcomes in elderly patients (≥75?years) undergoing percutaneous coronary intervention (PCI) for de novo lesions with sirolimus-eluting stent (SES) implantation. Repeat coronary angiography with IVUS was performed 1?year after SES-based PCI for de novo lesions in 136 elderly patients (≥75?years) and 427 younger counterparts (<75?years) (219 lesions and 635 lesions, respectively). Major adverse cardiac events (MACE) including cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR) during 2-year follow-up were recorded. Despite similar angiographic in-stent restenosis and TLR and IVUS-detected incomplete stent apposition (ISA), absolute intimal hyperplasia and percentage of volumetric obstruction were lower in elderly than in younger patients. At 2-year follow-up, cumulative survival freedom from composite death and myocardial infarction or MACE was significantly reduced in elderly patients, but very late stent thrombosis was similar in the two groups. Cox proportional hazards model identified age, diabetes, left ventricular ejection fraction, lesion length,minimal stent cross-sectional area and plaque progression as independent predictors of non-fatal myocardial infarction or mortality. In elderly patients undergoing SES-based PCI, despite similar TLR, neointimal hyperplasia was significantly lower than in younger patients. IVUS measurements except for minimal stent cross-sectional area did not correlate with stent thrombosis and clinical outcomes at 2?years.     

Stressors and anxiety in patients undergoing coronary artery bypass surgery.

BACKGROUND: Patients undergoing coronary artery bypass surgery who have increased anxiety levels have poorer outcomes than patients with lower levels, yet few studies have identified the concerns associated with this anxiety. OBJECTIVE: To describe the concerns of patients undergoing coronary artery bypass surgery and to identify concerns that were associated with higher levels of anxiety. METHOD: Patients (n = 172) were interviewed to determine their concerns and anxiety levels before surgery, before discharge, and 10 days after discharge. Multiple regression was used to determine the predictors of anxiety. RESULTS: Although individual concerns changed over time, anxiety levels did not change from before to after surgery, remaining low to moderate. Being female and having more concerns about waiting for the surgery, being in pain/discomfort, and resuming lifestyle were predictors of increased anxiety before surgery. Predictors of increased anxiety while hospitalized after the surgery included taking anxiolytic or antidepressant medications, higher anxiety levels before surgery, concerns about personal things being inaccessible, and difficulty sleeping. Patients with higher anxiety levels after discharge were older, more anxious before surgery, and had concerns about being in pain/discomfort. CONCLUSION: Patients waiting for coronary artery bypass surgery should be routinely assessed for anxiety before the procedure, and interventions to prevent or reduce anxiety should be provided. Interventions must be multifactorial, including information and support for pain management and realistic information about surgery schedules and resuming lifestyle after the surgery. Women and older patients may need to be targeted for intervention.     

Apheresis on aged patients/donors with complicated backgrounds like ischemic heart disease,arrhythmia, and others

Peripheral blood stem cells (PBSCs) are currently one of the most important stem cell sources for hematopoietic stem cell transplantation as well as cell therapy for ischemic heart disease or critical limb ischemia. Thus, it is sometimes necessary to collect autologous PBSCs from donors who have comorbidities.In terms yield, a sufficient number of PBSCs can be collected from donors with comorbidities for performing cell therapy if their age is < 60 years or up to a maximum of 70 years, although the number of PBSCs collected from older donors would probably be lower than that obtained from younger donors. On the other hand, granulocyte colony-stimulating factor (G-CSF) administration sometimes results in severe adverse events (AEs), such as ischemic heart disease and vascular thrombosis. Therefore, it is very important to perform strict medical check-ups according to the standards for donor operations in each country before apheresis. The apheresis procedure and G-CSF administration should be performed after administering the appropriate treatment. There is very less information available regarding AEs related to citrate administration during apheresis in aged donors with complicated medical histories. Medical staff should have knowledge of the electrocardiogram (ECG) QTc prolongation that occurs during apheresis owing to hypocalcemia caused by citrate administration, necessitating electrocardiographic monitoring of patients. Calcium should be administered during apheresis to prevent citrate related symptoms.     

Low‐fidelity simulation for patients and caregivers in the use of lubricants in clean intermittent catheterization

Can low‐fidelity simulation improve the knowledge and skills of patients undergoing clean intermittent catheterization (CIC) and their caregivers to prevent complications? Patients undergoing CIC are exposed to risks, such as urethral trauma and urinary tract infections. Objective of this paper was to assess the implications of low‐fidelity simulations for patients and caregivers in the use of clean intermittent catheterization in the event of urethral trauma and for its prevention. A quasi‐experimental study carried out between November 2015 and February 2016 in the rehabilitation centre of a university hospital, with patients undergoing CIC and/or their caregivers. Following the ethical precepts, data collection was performed during nursing consultations by means of interviews, structured observation, and a knowledge test applied before and after the low‐fidelity simulation. Patients undergoing CIC and/or caregivers underwent a low‐fidelity simulation of CIC with urethral trauma and then they were guided by the researchers following the protocol established in the department. They then underwent another simulation with the same characteristics. Fifty‐five patients participated in this study, in which most of them (33 [60·0%]) were men, with an average age of 31·7 years. Bleeding was reported by 19 patients (34·5%), of which 18 were men. The performance of low‐fidelity simulations proved to be effective for patients or caregivers in adverse situations, such as bleeding, resistance to the introduction of the catheter and negative urine drainage. The performance of low‐fidelity simulation is easily accessible and shows efficiency when used in teaching‐learning processes of health education and development of skills and competencies.     

Evaluating the effectiveness of two teaching strategies for patients diagnosed with hypertension

? This study investigated whether a structured patient-centred education programme was more effective than the normal ad hoc information that patients receive in improving their knowledge of hypertension whilst in hospital. ? Forty patients were assessed to determine their knowledge level regarding the management of risk factors related to hypertension. ? A pre-test was performed shortly after admission to hospital. Twenty patients in the test group received a structured education programme, and 20 patients in the control group received the usual ad hoc information. Two post-tests were performed, one at the time of discharge and the other approximately 8 weeks after discharge, to determine the change in knowledge levels. ? Comparison of the pre- and post-tests of the test group revealed a significant increase in knowledge level at the time of discharge from hospital. Patients were found to retain this new knowledge at 8 weeks and 1 year after discharge. No significant difference was found for the control group. ? This study has shown that a structured approach to health education is more effective in improving patients' knowledge about their condition than relying on the ad hoc information that patients traditionally receive during their hospitalization.     

Rehabilitation after proximal femur fracture surgery in the oldest old

OBJECTIVE: To assess the course and results of rehabilitation after proximal femur fracture (PFF) in patients 85 years of age or older, compared with younger elderly patients, with an emphasis on functional status. DESIGN: Prospective cohort study. SETTING: A rehabilitation geriatric ward in a tertiary university hospital in southern Israel. PARTICIPANTS: The study group included 127 elderly patients 85 years of age or older who were hospitalized for rehabilitation following surgery for PFF. The comparison group was comprised of 297 patients aged 75 to 84 years who were hospitalized for the same indication in the same time period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional studies by FIM trade mark instrument, mental status by the Folstein Mini-Mental State Examination, Geriatric Depression Screening (GDS) scale, length of rehabilitation, and complications and mortality during rehabilitation. RESULTS: Compared with patients aged 75 to 84 years, the older study group was in a worse mental state (P=.00005), even though the groups did not differ in their GDS scores. There were no significant differences between the groups in rehabilitation length of stay, in the rate of most postoperative complications, or in death rates during rehabilitation. FIM values before PFF, at the beginning of rehabilitation and at its end, and the difference between the beginning and end of rehabilitation were lower in the older group (P<.00001 for all tests). CONCLUSIONS: From the functional standpoint, rehabilitation after PFF surgery is much less successful in the 85+ age group than in the 75-to-84 age group but did not differ in its duration, rates of most complications, or mortality. Nonetheless, a significant percentage of patients in this age group have successful rehabilitation so they should not be deprived the chance.     

Information needs of women with recently diagnosed ovarian cancer--a longitudinal study.

The aim of this study was to investigate the information needs among patients with ovarian cancer and whether these information needs change over time. The information needs were evaluated three times, through structured interviews, and were based on the paired comparison approach developed by Degner and colleagues. A consecutive sample of patients (n = 82) with recently diagnosed ovarian cancer was asked to participate. Sixty-four patients (78%) chose to participate. The three different measurements of participants' information needs revealed only small changes in these needs. The three most important information needs, in all measurements, were information about the likelihood of cure, information about the stage and spreading of the disease, and information about different treatment options. Information regarding sexual attractiveness was the lowest ranked item in all measurements. Regarding subgroups (age, education) the only significant difference throughout all measurements was that younger patients rated issues of sexual attractiveness higher than older patients (p = 0.005). In this longitudinal study patients with ovarian cancer ranked information about the disease and its treatment (i.e. likelihood of cure, stage of disease, and treatment options) highest, and information about psychosocial aspects and self-care lowest. These findings are in accordance with the results from studies of women diagnosed with other types of cancer, which used the same methodology.     

Coronary artery bypass graft surgery in older women and men.

OBJECTIVE: To compare women and men younger than 70 years of age and 70 years or older undergoing coronary artery bypass surgery. DESIGN: Retrospective chart review, case-control series. SETTING: University medical center. PATIENTS: All women (n = 465) having first-time isolated coronary artery bypass surgery between 1983 and 1988, and 465 men matched for age and year of surgery. Predominantly white; 33% were 70 years or older. MEASURES: Medical record data: demographics, preoperative comorbidities, perioperative and postoperative complications, mortality, length of stay. RESULTS: Preoperatively, women 70 years of age or older had a higher incidence of congestive heart failure, renal disease and hypertension, and a lower incidence of smoking history compared with women less than 70 years old. Men 70 years or older had a higher incidence of congestive heart failure and renal disease, and a lower incidence of smoking history compared with men less than 70 years old. There was no difference in mortality between older and younger women, whereas the mortality rate for older men was higher than that for younger men. There were fewer differences between women younger than 70 and those 70 years or older in incidence of postoperative complications than between men of those same age groups. Among patients 70 years or older, incidence of postoperative congestive heart failure was greater in women than in men. There were no other differences between women and men younger than 70 and those 70 years or older in incidence of postoperative complications. Controlling for the influence of postoperative complications, age was related to length of stay for women and men. CONCLUSIONS: Older women were at no greater risk of mortality or the occurrence of postoperative complications compared with younger women or older men. A functional component influencing recovery and length of hospital stay needs to be considered to provide optimal nursing care after surgery.     

The relationship between in-hospital information and patient satisfaction after acute myocardial infarction.

BACKGROUND: Rehabilitation after acute myocardial infarction (AMI) presupposes that patients are provided with sufficient information and education to cope with the consequences of the disease. Furthermore, patient information is an important premise for patient satisfaction. AIMS: To explore and describe the relationship between received information and satisfaction with health care after AMI. In addition, we wanted to describe areas for improvement of patients' health care. METHODS: A questionnaire comprising 1) the Information Questionnaire and 2) the Patient Experience Questionnaire was sent to AMI patients, 6 weeks after discharge from hospital. One hundred and eleven patients participated. RESULTS: In general patients were highly satisfied with their health care and the more information the patient reported to receive, the more satisfied he/she was with the hospital stay. Patients were least satisfied with information about medication and possible future problems. These were the areas that patients received least information about and were also identified as the areas with greatest potential for improvement. Amount of information received was not associated to length of hospital stay. Although, younger patients reported receiving more information than older patients during the hospital stay, it was the youngest that missed information after discharge. CONCLUSION: The results indicate that it is necessary to examine the current provision of in-hospital information and education to AMI patients. Patients want more information at discharge and after returning home.     

Gait quality assessed by trunk accelerometry after total knee arthroplasty and its association with patient related outcome measures

BackgroundWith an increasingly younger population and more active patients, assessment of functional outcome is more important than ever in patients undergoing total knee arthroplasty. Accelerometers have been used successfully to objectively evaluate gait quality in other fields. The aim of this study was to assess gait quality with accelerometers before and after surgery, and to assess added value of resulting parameters to patient reported outcome measures scores.MethodsSixty-five patients (mean age 65 years (range 41–75)) who underwent primary total knee arthroplasty were evaluated using a tri-axial trunk accelerometer preoperatively and 1 year after surgery. Gait quality parameters derived from the accelerometry data were evaluated in three dimensions at both time points. Factor analysis was performed on all outcome variables and changes from before to 1 year after surgery in the most representative variable for each factor were studied.FindingsFactor analysis identified three separate gait quality factors, with questionnaire and gait quality parameters loading on different factors. Both gait quality factor scores and questionnaire factor scores improved significantly 1 year after surgery. As expected based on the factor analysis, only weak to moderate associations were found between patient reported outcome measures and gait quality before surgery, after surgery and in change scores.InterpretationThe independence of patient reported outcome measures and gait quality parameters measured with trunk accelerometry indicates that gait quality parameters provide additional information on functional outcome after total knee arthroplasty. Providing caretakers with objectively measurable targets using accelerometry could help improve outcome of these patients.     

冠脉介入患者健康信息需求现状的调查分析与对策

目的了解冠脉介入患者对健康信息的需求状况。方法自行设计健康信息需求调查问卷，主要包括介入术前后患者对疾病相关知识的了解程度及对冠心病信息需求内容。以方便抽样法抽取97例冠脉介入患者，在介入术前1d、术后3d进行调查。结果97例患者在介入术前后对冠心病相关知识普遍缺乏了解，对与生命和安全相关的信息需求迫切。结论护理人员应重视对患者作冠心病相关知识教育，以患者最希望得到的信息支持内容和方式，向患者提供最有效的信息。     

Pain Treatment for Older Adults During Prehospital Emergency Care: Variations by Patient Gender and Pain Severity

Older adults are less likely than younger adults to receive analgesic treatment during emergency department visits. Whether older adults are less likely to receive analgesics during protocolized prehospital care is unknown. We analyzed all ambulance transports in 2011 in the state of North Carolina and compared the administration of any analgesic or an opioid among older adults (aged 65 and older) versus adults aged 18 to 64. Complete data were available for 407,763 transports. Older men were less likely than younger men to receive an analgesic or an opioid regardless of pain severity. Among women with mild or moderate pain, older women were less likely than younger women to receive either form of pain treatment, but among women with more severe pain (pain score 8 or more), older women were more likely than younger women to receive pain treatment. Further, among women with mild or moderate pain, the oldest patients (aged 85 and older) were the least likely to receive any analgesic or an opioid, but among women with severe pain the oldest patients were the most likely to receive treatment. Further research is needed to assess the generalizability of this interaction between age, gender, and pain severity on pain treatment.PerspectiveDuring prehospital care in North Carolina in 2011, older adults were generally less likely to receive pain treatment. However, older women with severe pain were more likely to receive treatment than younger women with severe pain. These results suggest an interaction between age, gender, and pain severity on pain treatment.     

Age-Related 2-Year Mortality After Transcatheter Aortic Valve Replacement: the YOUNG TAVR Registry

ObjectiveTo comparatively assess the natural history of patients of different ages undergoing transcatheter aortic valve replacement (TAVR).Patients and MethodsFor this study, we used the YOUNG TAVR, an international, multicenter registry investigating mortality trends up to 2 years in patients with aortic valve stenosis treated by TAVR, classified according to 3 prespecified age groups: 75 years or younger (n=179), 76 to 86 years (n=602), and older than 86 years (n=221). A total of 1002 patients undergoing TAVR were included. Demographic, clinical, and outcome data in the youngest group were compared with those of patients 76 to 86 years and older than 86 years. Patients were followed up for up to 2 years.ResultsCompared with patients 75 years or younger (reference group), patients aged 76 to 86 years and older than 86 years had nonsignificantly different 30-day mortality (odds ratio, 0.76; 95% CI, 0.41-1.38; P=.37 and odds ratio, 1.27; 95% CI, 0.62-2.60; P=.51, respectively) and 1-year mortality (hazard ratio (HR), 0.72; 95% CI, 0.48-1.09; P=.12 and HR, 1.11; 95% CI, 0.88-1.40; P=.34, respectively). Mortality at 2 years was significantly lower among patients aged 76 to 86 years (HR, 0.62; 95% CI, 0.42-0.90; P=.01) but not among the older group (HR, 1.06; 95% CI, 0.68-1.67; P=.79). The Society of Thoracic Surgeons 30-day mortality score was lower in younger patients who, however, had a significantly higher prevalence of chronic obstructive pulmonary disease (P=.005 vs the intermediate group and P=.02 vs the older group) and bicuspid aortic valves (P=.02 vs both older groups), larger left ventricles, and lower ejection fractions.ConclusionIn the present registry, mortality at 2 years after TAVR among patients 75 years or younger was higher compared with that of patients aged 75 to 86 years and was not markedly different from that of patients older than 86 years. The findings are attributable at least in part to a greater burden of comorbidities in the younger age group that are not entirely captured by current risk assessment tools.     

Temporal changes in the causes of aortic stenosis: a surgical pathologic study of 646 cases

Among 646 patients with pure aortic stenosis who underwent valve replacement at our institution between 1981 and 1985, the three most frequent causes were calcification of congenitally bicuspid aortic valves (38%), degenerative (senile) calcification of tricuspid aortic valves (33%), and postinflammatory (presumably rheumatic) calcification and fibrosis (24%). Among the 324 patients younger than 70 years of age, calcified bicuspid valves were observed in 50%. In contrast, among 322 patients 70 years of age or older, degenerative calcification accounted for 48% of the stenotic aortic valves. During the 5 years of the study, the relative frequency of postinflammatory disease decreased from 30% to 18%, and that of bicuspid valves decreased from 37% to 33%. In contrast, the relative frequency of degenerative calcification increased from 30% to 46%. Consequently, degenerative (senile) calcification is currently the most common cause of aortic stenosis among patients undergoing valve replacement at our institution. This finding may be related to changes in life expectancy in the general population, alterations in patient referral practices, and an increased willingness of surgeons to operate on older patients. Regardless of cause, the observed temporal changes in etiologic factors for aortic stenosis may indicate a potential source of increasing health-care costs among the elderly population.     

气管切开患者主要照护者的压力研究

目的了解气管切开带管出院患者主要照护者的照顾感受及压力源。方法采用质性研究中的现象学研究方法,选取10名气管切开患者主要照护者进行半结构式深入访谈,并用现象学分析法进行资料分析。结果得出3个主题:心理受挫,应对无能,认识与成长。结论气管切开患者主要照护者内心受扰严重,可获得的信息支持不足,但其行为可干预。     

Medication management and older patients: an individualized and systematic approach

? The aim of this action research study was to evaluate the effectiveness of an individualized education programme on older patients’ knowledge of prescribed medication. ? A questionnaire for assessment of medication knowledge was used to collect data from 15 patients at two intervals, before and after an individualized education programme. Following the collection of pre‐intervention data, an individualized education programme was developed for each patient. As part of the education programme patients also had an opportunity to self‐administer their medication. ? The results of the study showed that all participants scored higher in the post‐test than the pre‐test although the degree of improvement varied between participants. Patient satisfaction with the education programme was also assessed and revealed a high level of satisfaction. ? The most significant finding was the importance of tailoring education programmes to meet the needs of the older person. This is borne out by case studies, which suggest that the most relevant characteristic of successful participants is a real desire to remain independent and in control of their medication. ? The findings question the value of standardized programmes of medication education that treat older people as a homogeneous population. The article concludes by emphasizing the need for nurses and other healthcare professionals to individualize their teaching and learning strategies to meet the needs of older patients.