The efficacy and safety of intravenous hydralazine for the treatment of hypertension in the hospitalized child

Background

Intravenous (IV) hydralazine is frequently used for the treatment of elevated blood pressure (BP) in hospitalized children. Its safety and efficacy have not been examined.

Methods

This is a retrospective chart review of IV hydralazine use in hospitalized children (birth to 17 years) over a 3-year period. Demographic data and data on adverse effects (AE), BP, and heart rate (HR) prior to and after each first dose were collected.

Results

The patient cohort comprised 110 children admitted to the hospital during the study period, of whom 77 received the recommended dose. Mean age of the children was 8.5?±?5.4 years; 33 % were male, and 32.5 % were white. Pre-dose systolic and diastolic BP indexes were 1.3 and 1.2, respectively. The median reduction in systolic and diastolic BP was 8.5 and 11.5 %, respectively. Sixteen (21 %) children achieved a 25 % reduction in systolic or diastolic BP, and BP increased in 30 % of patients; 10 % of children had a BP of <95th percentile for age, sex, and height after one dose. Seven (9 %) children had a documented AE. HR increased by a median of 3.5 %. In the multivariable models examining percentage change in systolic and diastolic BP, male gender was significantly associated with a change in systolic BP.

Conclusions

In hospitalized children, IV hydralazine was well tolerated, BP response was variable, and 21 % of the patients achieved a ≥25 % reduction of systolic or diastolic BP. Further studies are needed to compare the safety and efficacy of IV hydralazine to other short-acting antihypertensive agents.     

Does additional support by nurses enhance the effect of a brief smoking cessation intervention in people with moderate to severe chronic obstructive pulmonary disease? A randomised controlled trial

BACKGROUND: Smoking cessation is the primary disease modifying intervention for chronic obstructive pulmonary disease (COPD). SETTING: A Regional Respiratory Centre (RRC) out-patient department in Northern Ireland. METHODS: A randomised controlled trial (RCT) evaluated the effectiveness of brief advice alone or accompanied by individual nurse support or group support facilitated by nurses. Smoking status was biochemically validated and stage of change, nicotine addiction and dyspnoea were recorded at 2, 3, 6, 9 and 12 months. PARTICIPANTS: Ninety-one cigarette smokers with COPD were enrolled in the study (mean age 61 years, 47 female). RESULTS: After 12 months cessation rates were not significantly different between groups (p=0.7), but all groups had a significant reduction in their nicotine addiction (p=0.03-0.006). No changes in subjects' motivation or dyspnoea were detected over the 12 months. CONCLUSION: Patients with COPD were unable to stop smoking regardless of the type of support they received. Harm reduction may be a more appropriate goal than complete cessation for intractable smokers and nurses must evaluate their role in this arena.     

A single topical dose of erythropoietin applied on a collagen carrier enhances calvarial bone healing in pigs

Background and purpose

The osteogenic potency of erythropoietin (EPO) has been documented. However, its efficacy in a large-animal model has not yet been investigated; nor has a clinically safe dosage. The purpose of this study was to overcome such limitations of previous studies and thereby pave the way for possible clinical application. Our hypothesis was that EPO increases calvarial bone healing compared to a saline control in the same subject.

Methods

We used a porcine calvarial defect model. In each of 18 pigs, 6 cylindrical defects (diameter: 1 cm; height: 1 cm) were drilled, allowing 3 pairwise comparisons. Treatment consisted of either 900 IU/mL EPO or an equal volume of saline in combination with either autograft, a collagen carrier, or a polycaprolactone (PCL) scaffold. After an observation time of 5 weeks, the primary outcome (bone volume fraction (BV/TV)) was assessed with high-resolution quantitative computed tomography. Secondary outcome measures were histomorphometry and blood samples.

Results

The median BV/TV ratio of the EPO-treated collagen group was 1.06 (CI: 1.02–1.11) relative to the saline-treated collagen group. Histomorphometry showed a similar median effect size, but it did not reach statistical significance. Autograft treatment had excellent healing potential and was able to completely regenerate the bone defect independently of EPO treatment. Bony ingrowth into the PCL scaffold was sparse, both with and without EPO. Neither a substantial systemic effect nor adverse events were observed. The number of blood vessels was similar in EPO-treated defects and saline-treated defects.

Interpretation

Topical administration of EPO on a collagen carrier moderately increased bone healing. The dosing regime was safe, and could have possible application in the clinical setting. However, in order to increase the clinical relevance, a more potent but still clinically safe dose should be investigated.Erythropoietin (EPO) is a hematopoietic growth factor that stimulates the formation of red blood cells. In recent years, the non-hematopoietic effects of EPO have been investigated. Of interest for skeletal tissue engineering, the pleiotropic capabilities of EPO include osteogenic and angiogenic potencies (Rölfing et al. 2012). Subcutaneous injections of 250 IU/kg EPO were found to enhance bone formation 6 weeks after operation in a spinal fusion model in rabbits (Rölfing et al. 2012). The validity of the methodology of this study was confirmed in a recently published meta-analysis (Riordan et al. 2013, Rölfing and Bünger 2013). Other independent research groups have reported increased bone formation in mice and rats after daily treatment with 200–6,000 IU/kg EPO (Bozlar et al. 2006, Holstein et al. 2007, 2011, Shiozawa et al. 2010, Garcia et al. 2011, Kim et al. 2012). Furthermore, vascularization of 3-dimensional scaffolds for bone tissue regeneration remains a challenge. The described pleiotropic functions of EPO may overcome this limitation of skeletal tissue engineering in the future. EPO could possibly facilitate angiogenesis directed into the core of the scaffold, thereby facilitating bony ingrowth. Moreover, EPO promotes a direct and indirect osteogenic stimulation of mesenchymal stromal cells (Shiozawa et al. 2010, Rölfing et al. 2013).Translation of these promising in vitro and in vivo data into clinical trials requires a physiological dosage of EPO in order to avoid its known complications, such as thromboembolism (Ehrenreich et al. 2009, Shiozawa et al. 2010, Kim et al. 2012, Rölfing et al. 2012). Notably, we observed an extremely high hematocrit level after 250 IU/kg EPO for 20 days in a rabbit model (Rölfing et al. 2012). In other in vivo studies, repetitive EPO injections ranging from 500 to 6,000 IU/kg were administered. These treatment regimes have a systemic effect, and thus hold the risk of adverse events. Testing of the efficacy of a clinically safe dose of EPO is therefore necessary before clinical trials can be considered. Aiming for clinical progress and feasibility, the present study was carried out with a view to evaluating the efficacy of a single, low-dose EPO to stimulate bone healing in a large-animal study. The dose of EPO was chosen based on the following considerations. The translation of the minimally effective dose in cell studies into large-animal models is difficult (Rölfing et al. 2013). The rather low dosage of 2,700 IU/animal, equivalent to 18.5 ± 2.0 IU/kg, was chosen in order to minimize the systemic effect of EPO due to safety concerns and in order to minimize the potential effect on the within-subject controls. In anemic patients, 20–240 IU/kg are injected subcutaneously or intravenously 3 times a week. The hypothesis was that 900 IU site-specifically applied EPO would increase bony ingrowth compared to a saline-treated control in a porcine calvarial defect model.     

The effect of the intrathoracic pressure regulator on hemodynamics and cardiac output

The intrathoracic pressure regulator (ITPR) (CirQLator; Advanced Circulatory Systems Inc, Roseville, Minn) is a novel, noninvasive device intended to increase cardiac output and blood pressure in hypovolemic or cardiogenic shock by generating a continuous low-level intrathoracic vacuum in between positive pressure ventilations. Although there are robust data supporting the benefit of the ITPR in multiple animal models of shock, the device has not been used in humans.The goals of this study were to evaluate both the safety and efficacy of the ITPR in humans. Twenty patients undergoing coronary artery bypass graft surgery were enrolled in this phase 1 study. Intraoperative use of both pulmonary artery pressure monitoring and transesophageal echocardiography (TEE) was required for study inclusion. Hemodynamic variables as well as TEE measurements of left ventricular performance were collected at baseline and after the ITPR device was activated, before surgical incision. Thermodilution cardiac output increased significantly with the application of the ITPR (4.9 vs. 5.5 L/min; P = 0.017). Similarly, cardiac output was measured by TEE (5.1 vs. 5.7 L/min; P = 0.001).There were significant increases in pulmonary artery systolic blood pressures (35 vs. 38 mmHg; P G 0.001) and mean pulmonary artery pressures (24 vs. 26 mmHg; P = 0.008). There were no significant differences in systemic blood pressures, left ventricular volumes, stroke volume, or ejection fraction as measured by TEE. Using two different measurement techniques, application of the ITPR increased cardiac output in normovolemic anesthetized patients who underwent coronary artery bypass graft before sternotomy. These data suggest that the ITPR has the potential to safely and effectively increase cardiac output in humans.     

Planning locally relevant Internet programs for secondary prevention of cardiovascular disease

Background

Although the Internet has been shown to be an effective tool for supporting behavioural change in other chronic diseases, less in known about the efficacy of, or need for, Internet-based interventions in the prevention of coronary heart disease (CHD).

Aims

We investigated computer literacy, consumer need and perceived usefulness of the Internet as a secondary prevention tool in people with CHD.

Methods

A two-step mixed-method process was used that included a survey and two focus groups. The 12-item survey explored participants' access and confidence using the Internet. For the focus groups, we used standard methodology.

Results

We recruited 66 (88% response rate) consecutive cardiac patients; age 36–73 years (mean 64 ± 13), mostly male (85%), whose primary language was predominantly English (67%). Seventy percent had a home computer with Internet access but only 20% reported researching their heart-health online. There was polarity between those with and without Internet access. Further, we found less women than men could complete online forms (p = 0.03) and that participants aged over 65 years were less likely to access the Internet (p < 0.01) and had lower confidence (p < 0.01) than younger counterparts. Focus groups revealed challenges of an online secondary prevention service, but participants valued relevant, practical advice and placed strong emphasis on simple web design.

Conclusion

Using a mixed-methods process we collected locally sensitive information about Internet usage and recommendations for future online health-management strategies. Some patients have more confidence using the Internet, therefore a range of multi-technological secondary prevention interventions should be considered based on individual need.     

Understanding disparities in donor behavior: race and gender differences in willingness to donate blood and cadaveric organs.

BACKGROUND: Recent efforts to recruit blood and organ donors have only marginally improved demographic disparities in willingness to donate. Few studies have examined which factors are most important in explaining race and gender disparities in willingness to donate. OBJECTIVES: To assess race and gender differences in willingness to donate blood and cadaveric organs, and to determine the extent to which several factors (including sociodemographic characteristics and attitudes about religion and mistrust of hospitals) might explain differences in willingness to donate. RESEARCH DESIGN: Cross-sectional telephone survey of Maryland households contacted via random-digit dialing. MEASURES: Past blood donation, organ-donor status on driver's license, and measures of medical mistrust and religious and spiritual salience. SUBJECTS: Persons age 18 to 75 living in the Baltimore, Maryland metropolitan area. RESULTS: Of 385 respondents (84% of randomized households), 114 were black females, 46 were black males, 110 were white females, and 69 were white males. Before adjustment, black females were least willing to donate blood (41%), and black males were least willing to become cadaveric donors (19%) among all race-gender groups. Adjustment for respondent concerns about mistrust of hospitals and discrimination in hospitals explained most differences in willingness to donate blood, whereas adjustment for respondents' beliefs regarding the importance of spirituality and religion explained most differences in willingness to donate cadaveric organs. CONCLUSIONS: Both race and gender are important identifiers of those less willing to donate. To maximize efficiency, donor recruitment efforts should focus on race-gender groups with lowest levels of willingness. Potential donor concerns regarding mistrust in hospitals and religion/spirituality may serve as important issues to address when developing programs to improve donation rates.     

Physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs

BACKGROUND AND PURPOSE: Elevated fear-avoidance beliefs are believed to be a precursor of chronic disability, yet effective intervention options have not been described in the literature. The purpose of this case report is to describe physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs. CASE DESCRIPTION: The patient was a 42-year-old sales manager with acute low back pain. The patient had no previous history of activity-limiting low back pain and initially had limitations in straight leg raising, limitations in lumbar movement, and elevated fear-avoidance beliefs. INTERVENTION: Treatment-based classification and graded exercise were used. OUTCOME: Disability, fear-avoidance beliefs, and pain decreased 4 weeks after starting physical therapy. Six months later, disability and fear-avoidance beliefs had increased, but were still improved when compared with the initial measurements. DISCUSSION: Disability and fear-avoidance beliefs improved following a fear-avoidance-based physical therapy intervention. Research is warranted to investigate the effectiveness of this approach.     

Cost and resource implications of clinical supervision in nursing: an Australian perspective

AIM: The aim of this article was to explore the resource and management issues in introducing and maintaining a clinical supervision programme for nurses. BACKGROUND: A number of federal, state and non-governmental agency reports have recently indicted the quality of present-day mental health service provision in Australia. Clinical supervision in nursing has been widely embraced in many parts of the developed world, as a positive contribution to the clinical governance agenda, but remains largely underdeveloped in Australia. METHOD: Using data derived from several empirical clinical supervision research studies conducted in mental health nursing settings, preliminary financial modelling has provided new information for Nurse Managers, about the material implications of implementing clinical supervision. FINDINGS AND CONCLUSIONS: It is suggested that, on average, the cost of giving peer group one-to-one supervision to any nurse represented about 1% of an annual salary. When interpreted as a vanishingly small cap on clinical nursing practice necessary to reap demonstrable benefits, it behoves Nurse Managers to comprehend clinical supervision as bona fide nursing work, not an activity which is separate from nursing work.     

Acute fluid shifts influence the assessment of serum vitamin D status in critically ill patients

Introduction  

Recent reports have highlighted the prevalence of vitamin D deficiency and suggested an association with excess mortality in critically ill patients. Serum vitamin D concentrations in these studies were measured following resuscitation. It is unclear whether aggressive fluid resuscitation independently influences serum vitamin D.