A sample of 150 patients with rheumatoid arthritis (RA) participated in a predictive, descriptive, cross-sectional study which compared contextual factors of patients who perceived higher quality communication with those who perceived lower quality, and determined the predictive power of contextual factors for higher quality patient-provider communication.A validated, self-report scale measured patient perception of quality of patient-provider communication. Data were analyzed using chi-square tests of association, two-sample t-tests, and multiple linear regression.There were no differences in external environmental or internal personal factors between those who perceived higher and lower quality of communication. From the linear regression, patients with fewer years of education (p = .008), those taking a greater number of RA medications (p = .03), and those living in an urban area (p = .04) perceived the quality of communication more positively. The findings from this study suggest that contextual factors (years of education, residence, and the number of medications) may affect RA patient perception of the quality of patient-provider communication. This underscores the need for development of appropriate and effective interventions to improve communication and optimize RA patient outcomes.
Postoperative cognitive dysfunction, a subtle deterioration of cognitive function after exposure to anesthetics, is reported in 10% to 50% of surgical cases. Delivery of excessive inhalation anesthetics based on minimum alveolar concentration produces greater deep hypnotic times, which may contribute to postoperative cognitive dysfunction. This study tested the impact on cognitive function of balanced anesthetic using electroencephalographic (EEG) guidance vs usual anesthesia. We studied 88 surgical patients: 45 randomly assigned to balanced anesthetic technique with EEG guidance and 43 to standard treatment. Cognitive function was evaluated with the Cambridge Neuropsychological Test Automated Battery-Mild Cognitive Impairment at 3 intervals (preoperatively, 3-5 days postoperatively, and 3-5 months postoperatively). Additionally, 37 age- and sex-matched individuals not undergoing surgery or anesthesia were evaluated at the same intervals. Better outcomes were seen in the intervention group compared with usual care in the short-term/visual memory cognitive domain (P = .02) at 3 to 5 days, but not at 3 to 5 months. Delivery of anesthesia using EEG monitoring systems can reduce cumulative deep hypnotic time without negatively affecting patient physiologic stress, surgical conditions, or cognitive function. Our findings provide data to support optimal anesthetic approaches to improve cognitive function after anesthesia with volatile anesthetics.
SUMMARY Depressive symptoms may be associated with fluid and dietary non adherence which could lead to poorer outcomes. The purpose of this study was to examine the relationship between depressive symptoms and fluid and dietary adherence in 100 patients with end‐stage renal disease (ESRD) receiving haemodialysis. A descriptive, cross‐sectional design with a convenience sample of 100 patients with ESRD receiving maintenance haemodialysis completed instruments that measured self‐reported depressive symptoms and perceived fluid and dietary adherence. Demographic and clinical data and objective indicators of fluid and diet adherence were extracted from medical records. As many as two‐third of these subjects exhibited depressive symptoms and half were non adherent to fluid and diet prescriptions. After controlling for known covariates, patients determined to have moderate to severe depressive symptoms were more likely to report non adherence to fluid and diet restrictions. Depressive symptoms in patients with ESRD are common and may contribute to dietary and fluid non adherence. Early identification and appropriate interventions may potentially lead to improvement in adherence of these patients.
Susan K. Frazier, PhD, RN, FAHA Associate Professor, College of Nursing, University of Kentucky, Lexington. The author has no funding or conflicts of interest to disclose. Correspondence Susan K. Frazier, PhD, RN, FAHA, College of Nursing, University of Kentucky 751 Rose Street, Lexington, KY 40536-0232 ([email protected]).
Aims and objectives To examine the association of anxiety level and anxiolytic medication use with in‐hospital complications in patients following acute myocardial infarction (AMI). Background There are conflicting data about the protective effect of anxiolytic medication used in patients after acute myocardial infarction. Examination of the interaction of anxiolytic medication and anxiety level may explain these disparate results. Design This was a secondary analysis of existing data from a multisite, prospective study of the impact of anxiety on in‐hospital complications in patients with AMI. Methods Patients were primarily men, Caucasians, with Killip class 1 or 2, from the USA and A ustralia ( n = 156). Anxiety level in the emergency department and intensive care unit and in‐hospital complications were collected using self‐report measures and medical record review. Logistic regression analyses examined whether the use of anxiolytic medication influenced the relationship between anxiety and in‐hospital complications after controlling for demographic and clinical covariates. Results In the ED , 31% of participants were very or extremely anxious; anxiolytic medication was given to only 5%. In the intensive care unit, nearly half of participants received anxiolytic medication. There was no association between anxiety level and use of anxiolytic medication. Anxiety was an independent predictor of the probability of in‐hospital complications. The administration of anxiolytic medication did not alter the relationship between anxiety and in‐hospital complications. Conclusion Use of anxiolytics in patients with AMI was not associated with anxiety level and did not reduce the probability of in‐hospital complications. Relevance to clinical practice Clinicians need to regularly assess anxiety and treat it appropriately. Regular anxiety assessment may promote appropriate use of anxiolytic medication. Clinical guidelines for the management of patients with an AMI should address anxiety assessment and appropriate use of anxiolytic medication to improve patients' outcomes.
Variations in intrathoracic pressure generated by different ventilator weaning modes may significantly affect intrathoracic hemodynamics and cardiovascular stability. Although several investigators have attributed cardiovascular alterations during ventilator weaning to augmented sympathetic tone, there is limited investigation of changes in autonomic tone during ventilator weaning. Heart rate variability (HRV), the analysis of beat-to-beat changes in heart rate, is a noninvasive indicator of autonomic tone that might be useful in the identification of patients who are at risk for weaning difficulty due to underlying cardiac dysfunction. The authors describe HRV and hemodynamics in response to 3 ventilatory conditions: pressure support (PS) 10 cmH2O, continuous positive airway pressure (CPAP) 10 cmH2O, and a combination of PS 10 cmH2O and CPAP 10 cmH2O (PS+CPAP) in a group of canines with normal ventricular function. Six canines were studied in the laboratory. Continuous 3-lead electrocardiographic data were collected during baseline (controlled mechanical ventilation) and following transition to each of the ventilatory conditions (PS, CPAP, PS+CPAP) for analysis of HRV. HRV was evaluated using power spectral analysis to define the power under the curve in a very low frequency range (0.0033 to < 0.04 Hz, sympathetic tone), a low frequency range (0.04 to < 0.15 Hz, primarily sympathetic tone), and a high frequency range (0.15 to < 0.40 Hz, parasympathetic tone). A thermodilution pulmonary artery catheter measured cardiac output and right ventricular end-diastolic volume to describe global hemodynamics. There were significant increases in very low frequency power (sympathetic tone) with a concomitant significant reduction in high-frequency power (parasympathetic tone) with exposure to PS+CPAP. These alterations in HRV were associated with significantly increased heart rate and reduced right ventricular end-diastolic volume. Although there was a small but significant increase in cardiac output with exposure to PS, HRV was unchanged. These data indicate that there was a relative shift in autonomic balance to increased sympathetic and decreased parasympathetic tone with exposure to PS+CPAP. The increase in intrathoracic pressure reduced right ventricular end-diastolic volume (preload). This hemodynamic alteration generated a change in autonomic tone, so that cardiac output could be maintained. Individuals with autonomic and/or cardiovascular dysfunction may not be capable of this type of response and may fail to successfully wean from mechanical ventilation.
The immediate transition from positive pressure mechanical ventilation to spontaneous ventilation may generate significant cardiopulmonary hemodynamic alterations based on the mode of weaning selected, particularly in individuals with preexisting cardiac dysfunction. The purpose of this study was to compare hemodynamic responses associated with the initial transition to 3 modes of ventilator weaning (spontaneous ventilation/T-piece, pressure support [PS], and continuous positive airway pressure [CPAP]). Right ventricular hemodynamic responses were evaluated with a thermodilution pulmonary artery catheter; while left ventricular hemodynamic responses were measured by a transducer-tipped Millar catheter and conductance catheter. Two groups of canines were studied. Group 1: normal biventricular function (n = 10) and group 2: propranolol-induced biventricular failure (n = 10). Dependent variables were measured at baseline on controlled mechanical ventilation (MV) and following the initial transition to each of 3 randomized spontaneous ventilatory conditions: T-piece, PS 5 cmH2O, and CPAP 5 cmH2O. Both groups significantly increased cardiac output in response to T-piece. Right ventricular stroke work was also significantly increased with T-piece and CPAP in both groups of subjects. Left ventricular response depended on baseline ventricular function. Baseline ventricular function influenced hemodynamic response to the immediate transition from mechanical to spontaneous ventilation. There were also differential hemodynamic responses based on the ventilatory mode. Consideration of baseline cardiac function may be an important factor in the selection of an appropriate mode of spontaneous ventilation following controlled MV.
Primary pulmonary hypertension (PPH) is a pulmonary vascular disease characterized by an elevation in mean pulmonary artery pressure and pulmonary vascular resistance. Recently, PPH gained national attention because of its association with appetite suppressants. PPH may also be associated with pregnancy, hypothyroidism, autoimmune disorders, human immunodeficiency virus infection, and the use of drugs such as oral contraceptives and cocaine. Patients with PPH may report dyspnea on exertion and fatigue. Early diagnosis is crucial. New therapeutic regimens have dramatically reduced morality rates and improved quality of life by halting the progression of pulmonary vascular remodeling and averting right-sided heart failure. These therapies include high-dose calcium channel antagonists, anticoagulants, and continuous intravenous prostacyclin. Lung or heart-lung transplantation remains a vlable therapeutic option for patients who are treated late in the disease process, who are not responsive to medical management, or who remain symptomatic and continue to deteriorate.
