Cytokine profiles of peripheral blood and airway CD4 and CD8 T lymphocytes in horses with recurrent airway obstruction

Equine recurrent airway obstruction (RAO) is thought to result from an aberrant immune response to inhaled antigens, modulated by T lymphocytes via the secretion of pro-inflammatory cytokines. However data relating to the phenotypes of the T lymphocytes present in peripheral blood and bronchoalveolar lavage fluid of RAO horses and their cytokine profiles are contradictory. The aim of this study was to further investigate the cytokine (IL-4, IL-5, IL-13 and INF-gamma) mRNA expression profile in peripheral blood lymphocytes and bronchoalveolar lavage lymphocytes from RAO and control horses, before and at 48 h after horses were exposed to hay/straw. In contrast to previous studies, cytokine expression was quantified in populations of CD4 and CD8 T lymphocytes which were purified using magnetic bead antibody cell separation. Hay/straw exposure induced clinical airway obstruction, airway neutrophilia and airway lymphocytosis in RAO horses, and, induced a mild, but significant, airway neutrophilia in controls. However, hay/straw exposure had no significant effect on peripheral blood lymphocyte or bronchoalveolar lavage lymphocyte cytokine expression in either group. In conclusion, RAO was not associated with alterations in lymphocyte cytokine expression that are consistent with Th1 or Th2 responses, but rather with a general down-regulation in expression of the measured cytokines in peripheral blood lymphocytes and bronchoalveolar lavage lymphocytes.

The Iowa Model of Evidence-Based Practice to Promote Quality Care

The UIHC Department of Nursing is nationally known for its work on use of research to improve patient care. This reputation is attributable to staff members who continue to question "how can we improve practice?" or "what does the latest evidence tell us about this patient problem?" and to administrators who support, value, and reward EBP. The revisions made in the original Iowa Model are based on suggestions from staff at UIHC and other practitioners across the country who have implemented the model. We value their feedback and have set forth this revised model for evaluation and adoption by others.

Parents as distraction coaches during i.v. insertion: a randomized study

This study investigated the effectiveness of a brief Distraction Education intervention for parents prior to their preschool children's medical procedures. Forty-four preschool children with chronic non-life-threatening conditions were having intravenous catheters (IVs) placed for medical tests. Parent-child dyads were randomized into two groups. The experimental group received Distraction Education prior to IV insertion; the control group received standard care. Data were analyzed for two phases of the IV procedure. Phase 1 was the preparation for needle insertion; Phase 2 began with needle insertion. Experimental group parents used significantly more distraction than did control group parents during both phases (P < 0.001). There were no group differences for child behavioral distress or self-report of pain. There was a trend toward a group by phase interaction for behavioral distress (P = 0.07); more experimental group children showed decreased behavioral distress over time (from phase 1 to phase 2) than did control group children (P = 0.02).

Saline for peripheral intravenous locks in neonates: evaluating a change in practice

PURPOSE

To evaluate the efficacy of saline versus 10 units/ml heparin for peripheral i.v. flushes in neonates.

DESIGN

A nonexperimental group design was used to compare the longevity of heparin and saline i.v. locks. A research utilization method was chosen to increase the study power while simultaneously implementing a practice change and evaluating the outcomes. Power analysis showed that a sample size of approximately 120 per group was needed to decrease the risk of beta error to 0.1.

SAMPLE

Subjects included neonates in the Special Care Nurseries at a Level III large midwestern university teaching hospital. Data were collected from a convenience sample of 123 neonates receiving 10 units/ml heparin flush into a peripheral i.v. Practice was then changed to preservative-free normal saline, and data collection continued for 117 neonates.

MAIN OUTCOME VARIABLE

I.v. catheter longevity.

RESULTS

There was no significant statistical difference in i.v. catheter longevity between i.v. locks flushed with 10 units/ml heparin and those flushed with normal saline. Patient weight accounted for a significant proportion of the variance in i.v. catheter life.

Parent behavior and child distress during urethral catheterization

ISSUES AND PURPOSE

Researchers need a clear understanding of the natural behaviors parents use to help their children cope. This study describes the relationships between naturally occurring parent behaviors and child distress behaviors during urethral catheterization.

DESIGN AND METHODS

In this descriptive study, researchers videotaped the behaviors of parent-child interactions during urethral catheterization.

RESULTS

Parents used distraction to maintain calm behavior during the first part of the procedure and used more reassurance when the children started to become distressed. Seven of the nine children displayed calm behavior at least half the time following distraction. Parental reassurance did not decrease distress behavior in most children.

PRACTICE IMPLICATIONS

Early implementation of developmentally appropriate nursing interventions to decrease child distress is imperative. Parents may need specific instruction and practice to continue the use of distraction throughout procedures, even when the child is upset.

Phenotypic analysis of bronchoalveolar lavage fluid lymphocytes in horses with chronic pulmonary disease

A panel of specific antibodies against CD3, CD4, CD5, CD8, MHC I and II was used in single and two colour flow cytometry to define T cell subpopulations in bronchoalveolar lavage fluid of horses affected with chronic obstructive pulmonary disease and of healthy controls. According to the results of the clinical examination including bronchoscopy and cytology of the tracheal aspirate the horses were divided into four groups (healthy, subclinically to mildly affected; moderately affected, and severely affected). All groups of horses had a similar percentage of CD3+ cells in the BALF. Compared to controls, severely affected horses had a significantly increased number of CD4+ cells in the BALF, but a similar percentage of CD4+ cells whereas mildly and moderately affected horses had a decreased percentage. The percentage and number of CD8+ cells and the percentage of CD8+/MHCII+ cells in the BALF was found to be higher than normal and varied according to the disease state. This novel finding raises the possibility that not only the CD4+ cells but also the CD8+ cells are involved in the pathogenesis of COPD. The percentage and the number of CD8+ cells in BALF might be of diagnostic value to detect subclinical to mild cases of COPD.

Effects of distraction on children's pain and distress during medical procedures: a meta-analysis

BACKGROUND

It is difficult to determine the usefulness of distraction to decrease children's distress behavior and pain during medical procedures because many studies use very small samples and report inconsistent findings.

OBJECTIVES

To investigate the mean effect sizes across studies for the effects of distraction on young children's distress behavior and self-reported pain during medical procedures.

METHOD

Hunter and Schmidt's (1990) procedures were used to analyze 16 studies (total n = 491) on children's distress behavior and 10 studies (total n = 535) on children's pain.

RESULTS

For distress behavior, the mean effect size was 0.33 (+/-0.17), with 74% of the variance accounted for by sampling and measurement error. For pain, the mean effect size was 0.62 (+/-0.42) with 35% of the variance accounted for. Analysis of studies on pain that limited the sample to children 7 years of age or younger (total n = 286) increased the amount of explained variance to 60%.

CONCLUSIONS

Distraction had a positive effect on children's distress behavior across the populations represented in this study. The effect of distraction on children's self-reported pain is influenced by moderator variables. Controlling for age and type of painful procedure significantly increased the amount of explained variance, but there are other unidentified moderators at work.

A randomized trial of heparin and saline for maintaining intravenous locks in neonates

PURPOSE

To determine the effects of saline, heparin 2 units (U) per ml saline, and heparin 10 U/ml saline flush solutions on the duration of intravenous (i.v.) locks and the incidence of i.v. infiltration in neonates.

DESIGN

Randomized double-blind experiment.

SETTING

Tertiary-care nursery.

PARTICIPANTS

Neonates (N = 90) hospitalized at birth in the intensive, intermediate care, or newborn units.

MAIN OUTCOME MEASURES

Total hours from the time the i.v. was inserted to the time the i.v. was removed; hours from the time the i.v. was first flushed to the time the i.v. was removed; number of i.vs. removed because of infiltration.

RESULTS

No statistical or clinical differences between the three groups for duration of i.v. nor for incidence of complications.

CONCLUSIONS

The use of heparin in i.v. lock flush solution did not affect the duration of i.v. locks nor the incidence of infiltration in neonates.

Perceived changes in adult family members' roles and responsibilities during critical illness

An exploratory design was used to study the effects of critical care hospitalization on family roles and responsibilities of adult family members and how these effects changed over time. A convenience sample of 52 subjects from pediatric, neonatal, surgical, medical, and cardiovascular intensive care units was used. Data were collected using an open-ended question contained in the Iowa ICU Family Scale (IIFS). Using qualitative techniques, seven themes were identified: (a) Pulling together, (b) Fragmentation of families, (c) Increased dependence, (d) Increased independence, (e) Increased responsibilities, (f) Change in routine, and (g) Change in feelings. These findings indicate that nurses need to implement family-centered interventions such as role supplementation programs or identification of support systems to decrease role strain and role overload in families during a crisis.

Information Needs of the Siblings of Critically Ill Children

This study explored parental and sibling perceptions and feelings about sibling information needs during a pediatric admission to an intensive care unit (ICU). Using a qualitative research design, parents (n = 14) and school-age siblings (n = 12) of children who were patients in ICU were interviewed using open-ended questions. Themes of information that the parents report having given to the siblings were similar to the themes that siblings report having heard. However, parents reported that the siblings had numerous questions about the reasons for hospitalization and expectations for the future of the family. The findings indicate that parents may neither be aware of the effects of the ICU experience on the siblings nor have the knowledge and skill to assist them. Parents may need counseling to increase their awareness of the siblings' need for information and teaching to increase skill in providing the information.

Evaluation of saline for i.v. locks in children

A practice change to saline for peripheral IV maintenance was evaluated in a large teaching hospital in the Midwest. Subjects (N = 126) were children over 28 days of age, with peripherally placed IVs. Group I (n = 68) were children randomly selected to receive saline flush in an experimental study. Group II (n = 58) consisted of children receiving the saline flush after the change in practice was made. There was no significant difference between groups for either of two measures of IV duration. The mean duration of the IV from first flush was 35.38 hours for Group I and 44.09 hours for Group II; the time from insertion to discontinuation was 60.86 and 60.03 hours respectively. Patient age, site location, number of flushes, number of irritating medications, and site complications did not differ significantly between groups. The results of this clinical evaluation support previous findings that saline is efficacious for maintaining the patency of peripheral IVs in children over 28 days of age.

Infusing research into practice to promote quality care

This article describes the Iowa Model of Research in Practice, a heuristic model used at the University of Iowa Hospitals and Clinics for infusing research into practice to improve the quality of care. The components of the model are presented with examples. The impact of the model on patient, staff, and fiscal outcomes is delineated.

Implementation of the AHCPR pain guidelines for children

Successful implementation of Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines must involve an institutional commitment and an interdisciplinary effort. This article describes how a pediatric nursing research committee took the leadership role in implementing the AHCPR acute pain guidelines for children. Steps toward implementation included assessment of current practice methods, nursing interventions, interdisciplinary interventions, and plans for evaluating the practice change through the institutional quality assessment and improvement program.

Emotional responses of family members during a critical care hospitalization

BACKGROUND: The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed. OBJECTIVE: To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization. METHODS: An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes. RESULTS: Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident. CONCLUSIONS: The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.

Justification of hospital days and epidemiology of discharge delays in a department of neurology

We have developed a protocol to identify unnecessary days of hospitalisation in the Department of Neurology of the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Seventy-four parameters (medical, social, type of investigation and treatment, degree of disability and of dependence) potentially associated with the length of stay were studied prospectively in 511 nonselected patients consecutively admitted to the Department over a period of 5 months. Each day spent on the wards was analyzed on a day-to-day basis and was classified into one of two groups: those due to a medical reason (4,700 hospital days), and those due to a nonmedical reason (1,184 days). These delays resulted chiefly from difficulties in obtaining laboratory investigations, especially in patients who were not disabled and who had been admitted for investigations (3.8% of hospital days, compared to 1.5% for patients with severe or total dependence) or from awaiting transfer to either another department or a nursing home. This second cause of delay markedly increased the length of stay of patients with severe or total dependence and with limited mobility on the first day (26.0 days, compared with 7.4 days for nondisabled patients) and, above all, on the last day spent in our Department (27.0 days, compared with 8.0 days). The ongoing analysis of these data may provide information as to which parameters could be influenced by neurologists in order to reduce the length of stay in hospital.

Emotional responses of family members during a critical care hospitalization

BACKGROUND

The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed.

OBJECTIVE

To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization.

METHODS

An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes.

RESULTS

Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident.

CONCLUSIONS

The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.

Behavioral responses of family members during critical illness

This articles describes the behavioral responses of adult family members to critical illness and how these responses change over the course of the hospitalization. A convenience sample of 52 family members of patients in intensive units completed the Iowa ICU Family Scale, a self-report tool measuring sleep, eating, activity, family role, and support behaviors. Scales were completed by family members each day during the first week and then weekly throughout the patient's ICU stay. Family members reported sleeping less with a poorer quality of sleep, less nutritional intake, an increased use of cigarettes, alcohol, and over-the-counter and prescription medications, and spending more time talking, visiting the patient, and waiting. Stress was highest at the time of the ICU admission, began to plateau at Day 6, and then dropped considerably by Day 28. These findings suggest that crisis intervention is important during the early phase of caring for critically ill patients and their family members.

Group functioning of a collaborative family research team

Collaborative research teams are an attractive means of conducting nursing research in the clinical setting because of the many opportunities that collaboration can supply. These opportunities include a chance to: (1) network with other nurses who have similar interests, (2) share knowledge and expertise for designing clinical studies that directly affect daily practice, (3) develop instruments, (4) write grant proposals, (5) collect and analyze data, and (6) prepare manuscripts for publication. The effectiveness of research teams, however, is strongly influenced by group functioning. This article describes the functioning of a collaborative family interventions research team of nursing faculty members and CNSs at a large Midwestern university setting. The formation of the group and membership characteristics are described, along with strategies used to identify the research focus and individual and group goals. Aspects related to the influence of the group on members and the internal operations of the group are also addressed. Future strategies to be explored will focus on the size of the group and joint authorship issues. The authors also set forth a number of recommendations for development of collaborative research groups.

Heparin vs. saline for peripheral i.v. locks in children

PURPOSE

To determine the efficacy of saline versus heparin flush solution to maintain peripheral i.v. locks in a pediatric population.

METHOD

A prospective, randomized, double-blind design was used. A sample of 124 peripheral i.vs. were flushed with either saline or heparin in saline. Subjects were infants over 28 days of age and children.

FINDINGS

The heparin and saline groups were comparable for total hours duration of the i.v. and for incidence of complications.

CONCLUSIONS

Saline is efficacious in maintaining patency of peripheral i.v. locks in children over 28 days of age.

Improving practice through research: the case of heparin vs. saline for peripheral intermittent infusion devices

Peripheral intermittent infusion devices are commonly used to administer periodic doses of medications to adults and children. Research findings provide a strong base for changing practice to using saline instead of heparin to flush these devices in children over 28 days old and in adults. This research-based change in practice will enhance the quality of care that patients receive and decrease the costs of their care.

Effects of child visitation in adult critical care units: a pilot study

OBJECTIVE

To examine the behavioral and emotional responses of the child and of the nonhospitalized adult family member (NHAFM) to facilitated child visitation in the critical care setting.

DESIGN

Quasi-experimental, posttreatment design.

SETTING

An adult surgical intensive care unit at a large Midwestern teaching hospital.

PARTICIPANTS

Twenty families participated in the study, 10 families in a restricted and 10 families in a facilitated visitation group. Each family unit had a child, an NHAFM, and a critically ill family member. In the control group the NHAFMs visited the patient in the customary routine, but children were restricted from visiting. After a 2-week waiting period a facilitated child visitation intervention was implemented for the experimental group.

OUTCOME MEASURES

The child completed measures on anxiety as measured by the Manifest Anxiety Scale and behavioral and emotional changes as measured by the Perceived Change Scale. The NHAFM completed measures on anxiety as measured by the State-Trait Anxiety Inventory and mood as measured by the Mood Adjective Check List. Family functioning, as measured by the Feetham Family Functioning Survey, and life event changes, as measured by the Life Event Scale, were examined as extraneous variables.

INTERVENTION

The Child Visitation Intervention encompassed systematic facilitation and supervision of children visiting a critically ill adult family member in a surgical intensive care unit and provision of emotional support before, during, and after visitation (the intervention protocol may be obtained from the investigators on request).

RESULTS

Children in the facilitated visitation group had a greater reduction (t = 4.0, df = 18, p = 0.0004) in negative behavioral and emotional changes as measured by the Child-Perceived Change Scale when compared with children in the restricted visitation group.

CONCLUSION

Facilitated child visitation may help children deal with the critical illness of an adult family member and deserves further study.

A meta-analysis of effects of heparin flush and saline flush: quality and cost implications

The purpose of this meta-analysis was to estimate the effects of heparin flush and saline flush solutions on maintaining patency, preventing phlebitis, and increasing duration in peripheral heparin locks. The average effect size (d value) across 15 studies with a total sample size of 3,490 was .0573 for patency (clotting). The 95% credibility interval ranged from -.2267 to .3413. The average effect size across 13 studies with a total sample size of 2,356 was -.0757 for phlebitis. The 95% credibility interval ranged from -.2497 to .0983. The average effect size for duration across six samples with a total sample size of 1,960 was -.0550. The 95% credibility interval ranged from -.2424 to .1324. It can be concluded that saline is as effective as heparin in maintaining patency, preventing phlebitis, and increasing duration in peripheral intravenous locks. Quality of care can be enhanced by using saline as the flush solution, thereby eliminating problems associated with anticoagulant effects and drug incompatibilities. In addition, an estimated yearly savings of $109,100,000 to $218,200,000 U.S. health care dollars could be attained.

Risk factors associated with pressure ulcers in the pediatric patient following open--heart surgery

From a retrospective chart audit conducted on 59 infants and children who had survived open-heart surgery, 16.9% were found to have developed ulcers on the occipital region of their scalps during the postoperative period. Four risk factors were identified: age, type of congenital heart defect, length of time intubated, and length of stay in the pediatric intensive care unit (PICU). A protocol designed to decrease the amount of pressure and shearing force applied to the occipital region of these patients postoperatively was implemented. A dramatic decline to 4.8% in the incidence of pressure ulcers was noted after implementation of the protocol.

Factors related to spontaneous endotracheal extubation in the neonate

Circumstances accompanying spontaneous endotracheal extubation (SE) in neonates reveal a trend that very low birth weight infants who are ventilated for several weeks are most prone to this complication.

[Hospital financing and information on hospital clients]

The health care system can be characterized, among other facts, by the multiplicity of involved actors (institutions and individuals) acting for final goals in competition, or even in opposition. The principal goal of the economic organization of the health care system consists in applying a regulation to grant the coordination of the great number of decisions taken by decentralized actors in order to introduce them in economic way into a common final goal. The market forces appear unable to realize the necessary regulation in the health care system and centralized planning can lead to lack of effectiveness. For this reason, it's necessary to make use of a decentralized economic regulation; in this view health care financing systems are essential and could positively influence the behaviour of the actors as well as the costs. Information on hospital Casemix represents an important contribution to better transparency of the working of the health care system and to facilitate competition.

Solving documentation problems with a pediatric flow sheet

In September/October 1988, Pediatric Nursing published a pediatric intensive care unit (PICU) flow sheet for documenting assessments and nursing interventions. In this article, a hospital's pediatric flow sheet that allows for entries related to general pediatric practice is presented. It decreases the amount of time required to chart as well as the number of medical record forms used to comply with JCAHO standards for nursing documentation.

Acute histologic changes in the tracheobronchial tree associated with different suction catheter insertion techniques

Anesthetized, intubated kittens were subjected to one of two procedures: (1) insertion of a suction catheter to a predetermined distance and withdrawal with or without the application of suction or (2) insertion of the catheter until resistance was met and withdrawal with or without the application of suction. There were 5 animals in each group. All 10 of the animals in the "predetermined distance" groups had normal tissues. Of the 10 animals in the "resistance" groups, nine displayed multifocal areas of denuded epithelium and varying degrees of inflammation. One subject from the "resistance/suction" group had normal tissues. One from the "resistance/no suction" group displayed a small hemorrhage into the soft tissue. The Kruskal-Wallis rank test revealed a significant difference (p less than 0.05) between the "predetermined" and the "resistance" groups. The application of suction had no effect on the amount of damage evident.

Nursing management of the infant with an intraoral appliance

A recently developed intraoral device is being used for infants who require orotracheal and orogastric intubation. The purpose of the appliance is to prevent complications associated with long-term intubation, such as palatal groove formation, acquired cleft palate, defective primary dentition, and chronic irritation of the airway. The nursing care required for an infant with this intraoral appliance is described. The procedure for daily removal of the appliance, oral hygiene, and assessment of the oral cavity is presented. Other nursing interventions addressed include provision of non-nutritive sucking, initiation of oral feedings, and parent teaching and support.

[Environment. Preventive health action in the creation of the environment]

The present quantitative importance of prevention is in Switzerland extremely low in comparison to the health budget of the national community. It has taken in recent years increasing place however in speeches and talks as well as in medical thinking. Prevention presently tends to be seen as a medical specialty among others and perhaps prefigures a new form of medicine, the object of which would be the societal body more than the body of the sick individual. In this perspective (would that be good?), a new type of physician-informatician-statistician might be trained, with the mission to manage and supervise the health status of the population. Preventive health action through the environment at large could fulfill an important role in the foreseeable developments. New health "morals" are currently emerging, which are bringing together numerous adepts. This might mean that the time of a "health society" (or health-determined society) is not far.