组织多普勒成像技术评价高危妊娠对胎儿心脏功能影响的临床价值

目的 探讨组织多普勒成像技术在评价高危妊娠胎儿心脏功能的临床价值.方法 应用组织多普勒成像技术测量50例高危妊娠胎儿二、三尖瓣环处心肌运动速度( Ea,Aa,Sa 峰) 来反映左、右心室的心肌舒张及收缩功能.另外测定了与其年龄匹配的120例正常妊娠胎儿心脏的组织多普勒参数作为对照组.结果 (1)高危妊娠组及正常妊娠组胎儿二、三尖瓣环的运动速度( Ea,Aa )均与孕周呈正相关,随孕周的增长而增加;高危妊娠组及正常妊娠组胎儿二、三尖瓣环的运动速度(Sa)均与孕周无相关性.(2)高危妊娠组及正常妊娠组胎儿三尖瓣环的速度均大于相应二尖瓣环的运动速度(Ea、Aa、Sa峰).(3)高危妊娠组胎儿二、三尖瓣环的运动速度( Ea,Aa,Sa 峰) 均低于正常妊娠组.结论 高危妊娠组胎儿左、右心室心肌收缩及舒张功能均受到影响,组织多普勒技术可以评价高危妊娠胎儿心脏的收缩及舒张功能.     

Effect of Structured Bed Exercise on Uterine Contractions,Fetal Heart Rate Patterns,and Maternal Psychophysical Symptoms of Hospitalized High-Risk Pregnant Women: A Randomized Control Trial

Purpose

This study examined the effect on uterine contraction frequency (UCF), blood pressure (BP), heart rate (HR), fetal heart rate (FHR) patterns and psychophysical symptoms (physical discomfort, anxiety, and depression) of structured bed exercise (SBE) in hospitalized high-risk pregnant women prescribed bed rest.

The Ex Utero Intrapartum Treatment (EXIT) Procedure for Fetal Head and Neck Masses

A congenital head or neck mass increases the risk of airway obstruction and imminent respiratory failure at birth. The ex utero intrapartum treatment (EXIT) procedure is an option to secure the infant's airway in some clinical situations when an antenatal diagnosis of a head or neck mass or potential airway obstruction has been established.This article discusses an EXIT procedure performed on a maternal patient whose 38-week gestational age fetus was diagnosed with a lymphatic malformation. Planning and coordination between surgical teams at two clinical sites allowed the multidisciplinary teams to achieve a safe, successful outcome for the mother and child. AORN J 90 (November 2009) 661-672. © AORN, Inc, 2009.     

Care coordination for children with complex care needs significantly reduces hospital utilization

Purpose. The purpose was to evaluate an ambulatory care coordination program for children with complex care needs. Design and Methods. A pre‐ and postcohort evaluation design was implemented to analyze the impact on hospital utilization. Results. Results included a decrease in emergency department presentations (15%, p < .001), hospital admissions (9%, p < .019), and hospital bed days (43%, p < .001). Economic analysis indicated a cost savings of $A1.9 million per annum. Practice Implications. Hospital utilization is significantly reduced for children with complex care needs through 24/7 care coordination.     

Fetal Alcohol Spectrum Disorders: Implications for Primary Care Nurse Practitioners

Fetal alcohol spectrum disorders (FASDs) encompass a myriad of biological, psychological, and physiological variants. In primary care, FASDs are not routinely screened for, while prevalence rates remain high at 5% to 9%. Alcohol screening and brief intervention is an evidence-based practice that identifies those who may be consuming alcohol at risky levels and provides a brief motivation-enhancing intervention. FASDs are completely preventable when women do not consume alcohol during the prenatal period, and nurse practitioners who provide patient-centered primary care to women are ideally positioned to help in the prevention FASDs     

“Patient Care in Radiology”—The Staff's Perspective

The aim of this study was to research how the staff experience care expressed during the brief encounter with the patients in a diagnostic imaging department. This was a qualitative study with a phenomenological and hermeneutical frame of reference. The data were collected using field observations and semistructured interviews and analyzed according to the guidelines for meaning condensation by Giorgi. The imaging staff found that care is expressed in an administrative, an instrumental, and a compassionate sense. The imaging staff perceived care in a way that clearly differs from the traditional perception of care understood as the close relations between people. In their self-understanding, the staff found that care not only comprised the relational aspect but also that it was already delivered during the preparatory phases before the actual meeting with the patient and up until the image was electronically forwarded. And, care expressed in between was perceived as care in the traditional sense and termed as “patient care in radiology.”     

The role of preterm placental calcification in high-risk pregnancy as a predictor of poor uteroplacental blood flow and adverse pregnancy outcome

This prospective cohort study aims to clarify the role of preterm placental calcification in high-risk (i.e., hypertension, diabetes, placenta previa or severe anemia) pregnant women as a predictor of poor uteroplacental blood flow (absent or reverse end-diastolic velocity [AREDV]) and adverse pregnancy outcome. Monthly ultrasound was performed starting at 28 weeks' gestation to establish the diagnosis of Grade III placental calcification, with measurement of Doppler velocimetry in the umbilical vessels at 32 weeks' gestation. The participants were classified into three groups: Group A (n = 776), a low-risk group without antenatal complication; group B (n = 42), a high-risk group with preterm (28 to 36 weeks) placental calcification; and group C (n = 71), a high-risk control group without preterm (<36 weeks) placental calcification. Analyzed by logistic regression, the risks of AREDV (OR 4.32, 95%CI 1.25 to 14.94), adverse maternal outcome including postpartum hemorrhage (OR 3.98, 95% CI 1.20 to 13.20), placental abruption (OR 4.80, 95% CI 1.19 to 19.35), maternal transfer to intensive care unit (OR 3.83, 95% CI 1.10 to 13.33) and adverse fetal outcome including preterm birth (OR 3.86, 95% CI 1.32 to 11.29), low birth weight (OR 2.99, 95% CI 1.11 to 8.03), low Apgar score (OR 5.14, 95% CI 1.64 to 16.08) and neonatal death (OR 4.52, 95% CI 1.15 to 17.73) were greater in group B compared with group C. In contrast, the risks of AREDV and adverse pregnancy outcome were significantly lower in group A than those in group C, except postpartum hemorrhage (OR 0.53, 95% CI 0.19 to 1.46). We conclude that in high-risk pregnant women, the presence of preterm placental calcification is a predictor of poor uteroplacental flow and adverse pregnancy outcome, requiring closer surveillance for maternal and fetal well-being. This finding helps identify the most dangerous population among high-risk pregnant women.     

Effect of Patient and Family Centred Care interventions for adult intensive care unit patients and their families: A systematic review and meta-analysis

ObjectivesTo assess the evidence for the feasibility and effect of patient and familycentred care interventions provided in the intensive care unit, single or multicomponent, versus usual care, for reducing delirium, anxiety, depression and post-traumatic stress disorder in patients and family-members.DesignA systematic review and meta-analysis following the PRISMA guidelines and GRADE approach. A systematic literature search of relevant databases, screening and inclusion of studies, data extraction and assessment of risk of bias according to Cochrane methodology. The study is preregistered on PROSPERO (CRD42020160768).SettingAdult intensive care units.ResultsNine randomised controlled trials enrolling a total of 1170 patients and 1226 family-members were included. We found moderate to low certainty evidence indicating no effect of patient and family centred care on delirium, anxiety, depression, post-traumatic stress disorder, in-hospital mortality, intensive care length of stay or family-members’ anxiety, depression and post-traumatic stress disorder. No studies looked at the effect of patient and family centred care on pain or cognitive function in patients. Evaluation of feasibility outcomes was scarce. The certainty of the evidence was low to moderate, mainly due to substantial risk of bias in individual studies and imprecision due to few events and small sample size.ConclusionIt remains uncertain whether patient and family centred care compared to usual care may reduce delirium in patients and psychological sequelae of intensive care admission in patients and families due to limited evidence of moderate to low certainty. Lack of systematic process evaluation of intervention feasibility as recommended by the Medical Research Council to identify barriers and facilitators of patient and family centred care in the adult intensive care unit context, further limits the conclusions that can be drawn.     

Honoring Veterans' Preferences: The Association Between Comfort Care Goals and Care Received at the End of Life

ContextAs part of its Life-Sustaining Treatment (LST) Decisions Initiative, the Veterans Health Administration (VA) in January 2017 began requiring electronic documentation of goals of care and preferences for Veterans with serious illness and at high risk for life-threatening events.ObjectivesTo evaluate whether goals of “to be comfortable” were associated with greater palliative care (PC) use and lesser acute care use.MethodsWe identified Veterans with VA inpatient or nursing home stays overlapping July 2018–January 2019, with LST templates documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). From template documentation, we identified a “to be comfortable” goal. Using VA and Medicare data, we determined PC use (consultations and hospice) and hospital, intensive care unit, and emergency department use 7 and 30 days before death. Multivariate logistic regression examined the associations of interest.ResultsSixty-four percent of the 18,163 Veterans had comfort-care goals; 80% with comfort care goals received hospice and 57% PC consultations (versus 57% and 46%, respectively, for decedents without comfort-care goals). In adjusted analyses, comfort care documented on the LST template prior to death was associated with significantly lower odds of hospital, intensive care unit, and emergency department use near the end of life. In the last 30 days of life, Veterans with a comfort care goal had 44% lower odds (adjusted odds ratio 0.57; 95% CI: 0.51, 0.63) of being hospitalized.ConclusionFindings support the VA's commitment to honoring of Veterans' preferences post introduction of its Life Sustaining Treatment Decisions Initiative.     

Seveso: The Tragedy Lingers On

Abstract

Clomipramine is a chlorinated tricyclic antidepressant commonly used in the treatment of depression (1). The drug is widely prescribed in Europe and Canada and has been recently approved for use in the USA. Its safety during pregnancy and breastfeeding, however, has not been fully established. Very few reports on its effect on the fetus and neonate have been published (2,3).

We report a case of a mother treated with clomipramine during pregnancy, and the side effects observed in the infant. The correlation between plasma clomipramine concentrations in the baby's blood and clinical effects are described. Subsequently, we present the pregnancy outcome of five prospectively collected cases.     

The Effect of CMS's Comprehensive Care for Joint Replacement Bundled Payment Model on Trajectories of Post-acute Rehabilitation Care After Total Hip Arthroplasty

ObjectiveTo evaluate the effect of the Comprehensive Care for Joint Replacement (CJR) policy on the 90-day trajectory of post-acute care after a total hip arthroplasty (THA).DesignMultivariable difference-in-difference models applied to Medicare beneficiaries undergoing a THA prior to (2014-2015) and post-CJR implementation (2017) in areas subjected to or exempt from the policy.SettingHospitals in standard metropolitan statistical areas.Participants357,844 elderly Medicare patients nationwide undergoing THA (N=357,844).InterventionsNone.Main Outcome MeasuresEscalation in care to institutionalization (ie, admission to an inpatient rehabilitation or skilled nursing facility during 90-days postdischarge for those initially discharged to the community and return to the community at the end of the episode of care among those initially discharged to an institutional setting).ResultsOf the 357,844 elderly Medicare patients nationwide undergoing THA during the study period, 47.6% were discharged directly to the community and 52.4% received post-acute care in an institution. Patients discharged to an institution post-policy in a CJR area were about 10% less likely to return to the community (odds ratio=0.91; 95% confidence interval, 0.84-0.98; P=.02) at the end of the 90-day episode of care than those treated in policy-exempt areas. Despite the large magnitude, estimates of escalation in care among patients treated in bundling areas post-CJR implementation were not statistically significant.ConclusionsOur findings support further exploration of unanticipated effects of mandatory bundled payment policies on outcomes, as well as further examination of outcomes among policy-relevant subgroups of patients undergoing hip replacement in the United States.     

Development of the Nurses’ Care Coordination Competency Scale for mechanically ventilated patients in critical care settings in Japan: Part 2 Validation of the scale

ObjectivesTo confirm the validity and reliability of the nurses' care coordination competency draft scale for mechanically ventilated patients in Japan.Design/MethodIn this cross sectional observational study, a draft scale measuring care coordination was distributed to 2189 nurses from 73 intensive care units in Japan from February–March 2016. Based on the valid 887 responses, we examined construct validity including structural validity (exploratory and confirmatory factor analysis), convergent and discriminant validity and internal consistency reliability.Settings73 Intensive care units.ResultsExploratory factor analyses yielded four factors with 22 items: 1) promoting team cohesion, 2) understanding care coordination needs, 3) aggregating and disseminating information, 4) devising and clearly articulating the care vision. The four-factor model was confirmed using a confirmatory factor analysis (confirmatory fit index = 0.942, root mean square error of approximation = 0.062). Scale scores positively correlated with team leadership and clearly identified and discriminated nurses’ attributes. Cronbach’s alpha coefficient for each subscale was between 0.812 and 0.890, and 0.947 for the total scale.ConclusionsThe Nurses’ Care Coordination Competency Scale with four factors and 22 items had sufficient validity and reliability. The scale could make care coordination visible in nursing practice. Future research on the relationship between this scale and patient outcomes is needed.     

Identifying the Fundamentals of Care within Cochrane Systematic reviews: The role of the Cochrane Nursing Care Field Fundamentals of Care Node

The role of the Fundamentals of Care (FoC) Node within the Cochrane Nursing Care Field (CNCF) is to identify universal aspects of patient care as they relate to and potentially affect the application of the results of systematic reviews. The CNCF was established to provide a nursing perspective of Cochrane reviews and to promote their dissemination and uptake. The core functions of the CNCF include identifying topics for nursing care not currently addressed by Cochrane Reviews, raising awareness of the Cochrane Collaboration and the resources it has that supports the delivery of nursing care and the dissemination of relevant reviews to the nursing care community. We outline how volunteers with an interest in the FoC can work to identify care‐related aspects for specific clinical reviews. This article describes the development of a tool designed to guide the review of a Cochrane Systematic Review from the vantage of the FoC. The FoC Node is seeking volunteers to undertake this review work, and we have outlined the steps used to do this. We also show how using the FoC Template can inform the tagging and classifying of existing reviews within the Cochrane library.     

Development of the Nurses’ Care Coordination Competency Scale for mechanically ventilated patients in critical care settings in Japan: Part 1 Development of a measuring instrument

ObjectivesTo develop a draft scale measuring nurses’ care coordination competency for care of mechanically ventilated patients in critical care settings.MethodThe scale items and concepts were derived from semi-structured interviews with 28 professionals (14 nurses, eight physicians, three physical therapists, three clinical engineers) who are managing mechanically ventilated critical care patients. A grounded theory approach was used. After content validation by experts, two pilot tests were used to identify and correct non-discriminating items and vague items. After expert approval, the final draft scale was completed.SettingIntensive care units of acute care hospitals in Japan.FindingsA scale was drafted with the following six concepts including 51 items of nurses’ care coordination competency: (1) understanding care coordination needs (2) devising and clearly articulating the care vision (3) aggregating and disseminating information (4) employing resources (5) promoting team cohesion (6) engaging in situation-based negotiating. The interviewed participants argued that these competencies clearly reflect the inter-professional activities required for well-coordinated and individualised care and improved patient outcomes.ConclusionsThese findings could be utilised to educate and train nursesand establish the awareness that coordinating care is the nurses’ responsibility. Future research focusing on its validity and reliability are needed.     

Development and implementation of a high-quality clinical database: the Australian and New Zealand Intensive Care Society Adult Patient Database

OBJECTIVE: To describe the development of a binational intensive care database. SETTING: One hundred thirty-eight intensive care units (ICUs) in Australia and New Zealand. METHODS: A structure was developed to enable ICUs to submit data for central and local analysis. Reports were developed to allow comparison with similar ICU types and against published mortality prediction models. The database was evaluated according to (a) the criteria of the Directory of Clinical Databases (DoCDat) and (b) a proposed framework for data quality assurance in medical registries. RESULTS: Between January 1987 and December 2003, 444,147 data sets were collected from 121 (72.5%) of 167 Australian and 10 (37.0%) of 27 New Zealand ICUs. Data sets from more than 60000 ICU admissions were submitted in 2003. Overall hospital mortality was 14.5%. The mean quality level achieved according to DoCDat criteria was high as was performance against a proposed framework for data quality. The provision of no-cost software has been vitally important to the success of the database. CONCLUSION: A high-quality ICU database has successfully been implemented in Australia and New Zealand and is now used as a routine quality assurance and peer review tool. Similar developments may be both possible and desirable in other countries.     

Disorders of Consciousness and Disordered Care: Families,Caregivers, and Narratives of Necessity

By their nature, care decisions for patients with severe disorders of consciousness must involve surrogates. Patients, so impaired, have lost their decision-making capacity and the ability to direct their own care. Surrogates—family members, friends, or other intimates—must step in and make decisions about ongoing care or its withdrawal. This article shares the narrative experiences of these surrogate decision makers as they encounter the American health care system and accompany patients from injury through rehabilitation. Through their perspectives, the article considers challenges to ongoing care and rehabilitation that are a function of a prevailing medical infrastructure and reimbursement framework better suited to patients with acute care needs. Specific attention is paid to the ethical challenges posed by reimbursement strategies such as “medical necessity” as well as those proposed for the Affordable Care Act. The argument concludes that when it comes to care for a disorder related to consciousness, its provision is not discretionary, and its receipt is not an entitlement but a civil right.     

孕期微创手术中胎儿的麻醉方法:附6例次报告

目的:探讨孕期微创手术中安全有效的胎儿麻醉方法。方法:回顾分析6例次接受宫内输血术的胎儿及母体的一般资料、麻醉用药、给药途径、术中监测情况等相关资料。结果:6例次孕期微创手术、胎儿麻醉操作均成功,其中1例次孕期微创手术采用母体静脉麻醉,术中胎儿胎动频繁、胎心率较快,影响操作;4例次采用胎儿静脉注射麻醉以及1例次采用胎儿肌内注射麻醉的胎儿胎动控制良好。应用肌松药可抑制胎动,加用镇痛药可维持胎心率平稳。结论:对于接受孕期微创手术的胎儿,建议应用肌松药;对于孕中期的胎儿,则推荐加用阿片类镇痛药。