Influence of hospital volume and outcomes of adult structural heart procedures

Hospital volume is regarded amongst many in the medical community as an important quality metric. This is especially true in more complicated and less commonly performed procedures such as structural heart disease interventions. Seminal work on hospital volume relationships was done by Luft et al more than 4 decades ago, when they demonstrated that hospitals performing > 200 surgical procedures a year had 25%-41% lower mortality than those performing fewer procedures. Numerous volume-outcome studies have since been done for varied surgical procedures. An old adage "practice makes perfect" indicating superior operator and institutional experience at higher volume hospitals is believed to primarily contribute to the volume outcome relationship. Compelling evidence from a slew of recent publications has also highlighted the role of hospital volume in predicting superior post-procedural outcomes following structural heart disease interventions. These included transcatheter aortic valve repair, transcatheter mitral valve repair, septal ablation and septal myectomy for hypertrophic obstructive cardiomyopathy, left atrial appendage closure and atrial septal defect/patent foramen ovale closure. This is especially important since these structural heart interventions are relatively complex with evolving technology and a steep learning curve. The benefit was demonstrated both in lower mortality and complications as well as better economics in terms of lower length of stay and hospitalization costs seen at high volume centers. We present an overview of the available literature that underscores the importance of hospital volume in complex structural heart disease interventions.     

Vascular cell adhesion molecule-1 is involved in mediating hypoxia- induced sickle red blood cell adherence to endothelium: potential role in sickle cell disease

We investigated the effects of hypoxia on red blood cell (RBC)- endothelial cell (EC) adherence and the potential mechanism(s) involved in mediating this effect. We report that hypoxia significantly increased sickle RBC adherence to aortic EC when compared with the normoxia controls. However, hypoxia had no effect on the adherence of normal RBCs. In additional studies, we found that the least dense sickle RBCs containing CD36+ and VLA-4+ reticulocytes were involved in hypoxia-induced adherence. We next evaluated the effects of hypoxia on the expression of EC surface receptors involved in RBC adherence to macrovascular ECs, including vascular cell adhesion molecule-1 (VCAM- 1), intracellular adhesion molecule-1 (ICAM-1), and the vitronectin receptor (VnR). Hypoxia upregulated the expression of both VCAM-1 and ICAM-1, whereas no effect on VnR was noted. Potential involvement of VCAM-1 and ICAM-1 in mediating hypoxia-induced sickle RBC-EC adhesion was next investigated using monoclonal antibodies against these receptors. Whereas anti-VCAM-1 had no effect on basal adherence, it inhibited hypoxia-induced sickle RBC adherence in a concentration- dependent manner, with 50% to 75% inhibition noted at 10 to 60 micrograms/mL antibody (n = 6, P < .05 to P < .01). Anti-ICAM-1 (10 to 60 micrograms/mL, n = 8) had no effect on either basal or hypoxia- induced adherence. As noted in the bovine aortic ECs, hypoxia stimulated the adherence of sickle RBCs to human retinal capillary ECs, and this response appeared to be mediated via mechanisms similar to those observed with macro-endothelium, ie, via the adhesive receptor combination VCAM-1-VLA-4. Our studies show that hypoxia enhances sickle RBC adhesion to both macrovascular and human microvascular ECs via the adhesive receptor VCAM-1. Our findings are of interest because hypoxia is an integral part of the pathophysiology of the vaso-occlusive phenomenon in sickle cell anemia.     

Phenomenology as research method or substantive metaphysics? An overview of phenomenology's uses in nursing

In exploring phenomenological literature, it is evident that the term ‘phenomenology’ holds rather different meanings depending upon the context. Phenomenology has been described as both a philosophical movement and an approach to human science research. The phenomenology of Husserl, Heidegger, Gadamer, and Merleau‐Ponty was philosophical in nature and not intended to provide rules or procedures for conducting research. The Canadian social scientist, van Manen, however, introduced specific guidelines for conducting human science research, which is rooted in hermeneutic phenomenology and this particular method has been employed in professional disciplines such as education, nursing, clinical psychology, and law. The purpose of this paper is to explore the difference between the phenomenological method as described by van Manen and that of other philosophers such as Husserl, Heidegger, Gadamer, and Merleau‐Ponty. In so doing, the author aims to address the blurred boundaries of phenomenology as a research method and as a philosophical movement and highlight the influence of these blurred boundaries on nursing knowledge development.     

Experience of intravenous sedation for pediatric gastrointestinal endoscopy in a large tertiary referral center in a developing country

Background: The aim of this study was to evaluate the clinical efficacy of intravenous sedation for pediatric gastrointestinal endoscopy (GIE) at a tertiary care teaching hospital in a developing country. Methods: We undertook a retrospective review of the sedation service records of pediatric patients who underwent GIE. All endoscopies were performed by a pediatric gastroenterologist. All of the sedation was administered by staff anesthesiologist or anesthetic personnel in the gastroenterology procedure room. Results: Sedation was provided for 222 procedures in 214 patients ranged in age from younger than 1 to 17 years and in weight from 2.7 to 80.0 kg. Intravenous sedation was provided in 176 patients (82.2%). Of these patients, 185 procedures were performed and reviewed, with 152 (82.2%) procedures were esophagogastroduodenoscopy (EGD) alone, 14 (7.6%) procedures were colonoscopy alone, 18 (9.7%) procedures were EGD and colonoscopy, and one procedure was endoscopic ultrasonography (EUS). Most common indications of the procedure were screening for esophageal varices (25.2%), abdominal pain (15.9%), history of upper gastrointestinal hemorrhage (13.6%), and unexplained anemia (10.3%). The majority of preanesthetic problems were hematologic disease, anemia (38.2%); liver disease, cirrhosis (13.5%); and electrolyte imbalance (13.5%). Propofol (94.0%), fentanyl (87.0%), and midazolam (67.8%) were frequently used. The mean dose of propofol was 7.8 ± 4.1 mg·kg^?1·h^?1, fentanyl 2.3 ± 1.1 mcg·kg^?1·h^?1, and midazolam 0.1 ± 0.1 mg·kg^?1·h^?1. Most of them were used in combination. The combination of propofol, fentanyl, and midazolam was commonly employed (46.4%). The mean sedation time of all procedures was 28.2 min and was different according to procedure type. Complications occurred infrequently (13.5%) and were medication or airway related. All complications were easily treated, with no adverse sequelae. Intravenous sedation was successful except for one patient who required general anesthesia. However, all procedures were completed successfully. Conclusions: In the setting of the developing country, intravenous sedation for pediatric GIE by trained anesthetic personnel with appropriate monitoring was safe and effective. Serious adverse events were rare in our population.     

Is coronary artery bypass grafting without cardiopulmonary bypass safe?

Summary Three hundred and fifty patients underwent coronary artery bypass surgery on a beating heart. This technique is easy to learn and is suitable in selected patients.     

夜班护士麻痹症状群:临床心理学的一种新现象?

夜间工作被认为可破坏生理节奏[1] ,而另一些卫生学专家认为夜间工作能引起抑郁症状反应[2 ] 。夜班护理工作确实可能成为一种特别的应激[3 ] ;因此实习护士常常需要心理支持 ,以帮助他们作好应对和适应的准备[4] 。对“夜班护士麻痹症状群”(ｎｉｇｈｔｎｕｒｓｅｓ’ｐａｒａｌｙｓ ｉｓ)这一现象曾有过报导[5] ,但尚没有科学研究来证明这种现象的存在。这种现象被描述为往往当护士在寂静不动时 ,有一种无力的感觉。例如护士在夜间坐病室观祭台执行观察任务时 ,神志清醒 ,但在短时间内不能按要求移动肢体。在这种情况下 ,他人的触动或低声…     

Needs and anxiety levels in relatives of intensive care unit patients

The purpose of this study was to explore the perceived needs and anxiety levels of adult family members of intensive care unit (ICU) patients. The study was conducted over a 3-month period, on a convenience sample of 166 subjects selected from the total adult population of family members visiting an ICU patient in three Sudbury hospitals. Data were gathered using a self-report questionnaire, the Critical Care Family Needs Inventory (CCFNI) and Spielberger's State Trait Anxiety Inventory (STAI). Interviews were conducted in French or English according to the subject's preference. The major variables examined were: family needs; state and trait anxiety; on-site sources of worry; spiritual needs; level of knowledge of ICU from past experience or pre-surgery education; sociodemographic data. The Situational Anxiety Scale yielded a mean score of 45.24 and the Trait Anxiety Scale a mean score of 37.3. Inferential statistics demonstrated that family needs and situational anxiety were significantly related (P less than 0.0002). Furthermore, worries, trait anxiety, age and family needs explained 38% of the variation of situational anxiety. As well, spiritual needs and situational anxiety explained 33% of the variation of family needs.