A Candidate Locus Approach Identifies a Long QT Syndrome Gene Mutation

Long QT syndrome is an inherited disorder that results in lengthened cardiac repolarization. It can lead to sudden onset of torsades de pointes, ventricular fibrillation, and death. The authors obtained a family history, performed electrocardiograms, and drew blood for DNA extraction and genotyping from 15 family members representing 4 generations of an affected family. Seven individuals demonstrated prolonged QT intervals. The authors used polymorphic short tandem repeat markers at known LQTS loci, which indicated linkage to chromosome 11p15.5 where the potassium channel, KCNQ1, is encoded. Polymerase chain reaction was used to amplify the coding region of KCNQ1. During survey of the KCNQ1 coding region, a G-to-A transition (G502A) was identified. DNA from all clinically affected but from none of the clinically unaffected family members carried the G-to-A transition. The candidate locus approach allowed an efficient mechanism to uncover the potassium channel mutation causing LQTS in this family.

Adolescent Workers’ Experiences of and Training for Workplace Violence

Adolescent workers may not be aware that violence is a safety concern in the workplace. As part of a larger mixed-methods pilot study, investigators used a self-administered survey and individual interviews with 30 adolescent workers from a chain of food service stores in a Midwestern metropolitan area to explore experiences of workplace violence (WPV) and ways of learning WPV-specific information. Participants reported experiencing verbal and sexual harassment and robberies. Most participants reported awareness of WPV-specific policies and procedures at their workplace; the ways participants reported learning WPV-specific information varied. Findings support the need for occupational safety training to assist adolescent workers prevent and mitigate potential WPV.

Teaching differential diagnosis to nurse practitioner students in a distance program

An interactive case study (ICS) is a novel way to enhance the teaching of differential diagnosis to distance learning nurse practitioner students. Distance education renders the use of many teaching strategies commonly used with face-to-face students difficult, if not impossible. To meet this new pedagogical dilemma and to provide excellence in education, the ICS was developed. Kolb's theory of experiential learning supported efforts to follow the utilization of the ICS. This study sought to determine whether learning outcomes for the distance learning students were equivalent to those of on-campus students who engaged in a live-patient encounter. Accuracy of differential diagnosis lists generated by onsite and online students was compared. Equivalency testing assessed clinical, rather than only statistical, significance in data from 291 students. The ICS responses from the distance learning and onsite students differed by 4.9%, which was within the a priori equivalence estimate of 10%. Narrative data supported the findings.

Genetic and genomic testing in clinical practice: what you need to know

The clinical applications of genetic testing are growing rapidly and they now account for a significant percentage of total laboratory testing procedures. Many clinicians are uncomfortable with the types and applications of genetic tests and the dependable resources that are available for self-education. Furthermore, Direct to Consumer genetic testing has presented several challenges to healthcare providers as consumers now have an access to tests that they may not fully understand and results they may act upon inappropriately. This article presents some of the issues and resources to help nurses navigate this changing landscape.

Adolescents' experience with workplace aggression: school health implications

Aggression exposure is a critical health issue facing adolescents in the United States. Exposure occurs in various settings including home, school, and the community. An emerging context for aggression exposure is in the workplace. Thirty adolescent employees age 16-18 participated in a qualitative study exploring proposed responses to future workplace aggression. Semistructured interviews were used to gather participants' proposed responses to a series of hypothetical aggressive incidents in the workplace. Conventional content analysis identified patterns and themes among the participants' responses. Results indicated adolescent employees' proposed responses to workplace aggression are similar to other forms of aggression such as peer-bullying and teen dating violence. Education and training are needed within the school setting to promote appropriate responses to various forms of aggression encountered by adolescents. Implications for school health professionals' involvement in addressing responses to such aggression and further research opportunities are explored.

Measuring sports participation decisional conflict in youth with cardiac pacemakers and/or ICDs

AIMS

We examined the Decisional Conflict Scale to determine if it would be useful to measure conflict around sports participation decision-making in youth with cardiac pacemakers and/or implantable cardioverter defibrillators.

BACKGROUND

Sports participation decisions made by parents and youth with implanted cardiac devices can have profound implications. Contact sports can result in damage to the device and leads, but the value of exercise is well documented and restriction from a cherished activity can increase resistance and distress in the young. The extent of this problem is unknown.

METHODS

An explanatory mixed methods design was used with a convenience sample (N=35) of youth aged 12-21 (Mean=16.5; sd=3) years awaiting services at an electrophysiology clinic. Data were collected between 2007 and 2008. The Decisional Conflict Scale is a self-report measure, used worldwide in adult populations. Analyses and interviews determined the properties of the measure and whether the instrument captured conflict.

RESULTS

The scale showed strong internal consistency (Cronbach alpha=0.87). Overall scores were low (Mean=17.31; SD=10.99; range=0-37). There was no statistically significant difference (P>0.05) in total scores between boys (n=25) and girls (n=10) using independent t-tests. Qualitative analysis documented conflict and non-adherence to clinician recommendation despite low scores.

CONCLUSIONS

Analyses indicate that youth aged 12-21 years understand and can effectively complete the Decisional Conflict Scale, but this instrument alone did not capture all conflict. These results can guide study of the extent of this problem and eventual development of an intervention to support sports participation decision-making.

Genetic characterization of familial CPVT after 30 years

INTRODUCTION

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a stress-related, bidirectional ventricular tachycardia and atrial tachyarrhythmia in the absence of either structural heart disease or prolonged QT interval. Autosomal dominant and recessive forms of CPVT because of mutations in the cardiac ryanodine receptor (RyR2) or calsequestrin 2 (CASQ2) have been reported. The objective of this study was the clinical and genetic characterization of the family of an individual initially diagnosed as a child in 1978.

METHOD

We collected family medical history and recorded a four-generation pedigree. We performed mutation analysis of RyR2 "critical regions'' in the N-terminus, FKBP12.6 binding domain, Ca2+ binding domain, and transmembrane domains of the C-terminus by direct sequencing.

RESULTS

CPVT was diagnosed in two of the nine family members evaluated. Pedigree analysis suggested autosomal dominant disease transmission. There were no additional reports of seizures, pregnancy loss, neonatal death, or sudden cardiac death in family members. A novel RyR2 gene variant (W4645R) was found in four family members including two without symptoms. RyR2-W4645R segregates with disease in this family with incomplete penetrance. The W4645 residue is evolutionarily conserved in the transmembrane region adjacent to previously reported disease-causing mutations. Based on sorting intolerant from tolerant analysis of protein structure, RyR2-W4645R is predicted to be deleterious.

CONCLUSIONS

All current evidence supports RyR2-W4645R as a disease-causing variant, which was silent in persons for two generations before causing symptoms in persons for the next two generations, beginning in 1978.

Pharmacogenetics in critical care: atrial fibrillation as an exemplar

Pharmacogenetic testing is currently not routine in critical care settings but recent changes in the warfarin label are likely to lead to critical care nurses encountering physician or nurse practitioner orders for such testing. Although the science for pharmacogenetics is complex, the components of patient teaching are not beyond that which nurses already provide about other laboratory, disease, and treatment-based information. It is reasonable to expect that as the science of pharmacogenetics and pharmacogenomics expands and discoveries are translated in clinical settings, the additional information from pharmacogenetic test results will help prescribers select or adjust medication doses to reduce the risk for adverse drug reactions and improve the chances of achieving therapeutic targets in a timely fashion.

Risk reduction and health promotion behaviors following genetic testing for adult-onset disorders

Although clinical genetic testing is available for over 1,000 inherited disorders, consequences of predictive genetic testing have been most extensively examined for hereditary breast and ovarian cancer (HBOC), hereditary colon cancer, and Huntington disease (HD). These focus primarily on psychological, ethical, legal, and social aspects of genetic testing. Genetic testing may also provide information that can lead to behaviors that promote health and reduce risk for disease, reflecting options available for the disorder for which the person is at risk. However, regardless of condition, people completing a genetic test may inform relatives about the results of the test and implications for their risk to develop the condition. Literature on risk reduction behaviors and communication focuses on families with HBOC or colorectal cancer. Few reports document behaviors for other conditions. This paper presents a systematic review of the research literature on risk reduction and health promotion behaviors following clinical genetic testing for adult onset conditions, primarily HBOC, familial colon cancers, and HD. Insights gleaned from this review are discussed as a basis for planning monitoring of health promotion and risk-reduction behaviors for genetic testing for present and future use.

Neonatal long QT syndrome due to a de novo dominant negative hERG mutation

A 4-day-old girl with ventricular tachyarrhythmias, sinus bradycardia, and 2:1 atrioventricular block had prolongation of the QT interval. She was symptomatic with arching, gasping, and cyanosis presumably due to a life-threatening ventricular tachyarrhythmia such as torsades de pointes. Molecular genetic studies indicated a heterozygous, de novo, dominant negative mutation in hERG, a gene that encodes a protein in a potassium ion channel. The parents do not have the mutation. The patient's clinical scenario was produced by the convergence of 3 events: a de novo mutation occurred in hERG, the mutation was dominant negative, and the action of the mutation resulted in neonatal long QT syndrome. The child was treated aggressively and is doing well at age 6 years.

Neonatal Long QT Syndrome Due to a De Novo Dominant Negative hERG Mutation

A 4-day-old girl with ventricular tachyarrhythmias, sinus bradycardia, and 2:1 atrioventricular block had prolongation of the QT interval. She was symptomatic with arching, gasping, and cyanosis presumably due to a life-threatening ventricular tachyarrhythmia such as torsades de pointes. Molecular genetic studies indicated a heterozygous, de novo, dominant negative mutation in hERG, a gene that encodes a protein in a potassium ion channel. The parents do not have the mutation. The patient’s clinical scenario was produced by the convergence of 3 events: a de novo mutation occurred in hERG, the mutation was dominant negative, and the action of the mutation resulted in neonatal long QT syndrome. The child was treated aggressively and is doing well at age 6 years.

Experiences of college-age youths in families with a recessive genetic condition

Growing up in a family with a recessive genetic condition can trigger questions about progeny effect. This study explored perceptions of family hardiness and information sharing by 18- to 21-year-olds about genetic risk. Semistructured interviews, the Family Hardiness Index (FHI), and a Family Information Sharing Analog Scale (FISAS) were used. Participants included 11 youths who had relatives with hemophilia and 4 with sickle cell anemia. Findings revealed seven themes: assimilating premature knowledge; caring for others, denying self; cautioning during development; experiencing continual sickness; feeling less than; magnifying transition experiences; and sustaining by faith. There was no significant correlation between total FHI and FISAS. However, there was a statistically significant difference in FISAS between genetic condition variance. Specifically, higher hardiness was found and information sharing correlated among college youths in families with hemophilia. Additional research can lead to nursing interventions to provide genetic information to youths in families for illness variance.

Development of the implanted devices adjustment scale

Advances in microelectronics have resulted in exponential growth in the number of implanted medical devices. Most people do well adjusting to their devices, but others show signs of depression and/or anxiety. The Implanted Device Adjustment Scale (IDAS) was developed to measure how well a person is adjusting to an implanted device. First, a pool of items was generated and reviewed by 2 panels of clinicians and psychometricians for content validity. The revised version was then administered to a small sample that provided information about problematic items. Finally, a convenience sample of 45 persons (66% males) with implanted devices (18 pacemakers only, 37 cardioverter/defibrillators) completed the revised IDAS twice. After deleting weak items, the Cronbach alpha was 0.90. No age, gender, or device differences were found. Test-retest reliability was 0.92. The IDAS may be useful to evaluate how well a person is adjusting to her/his device. This may lead to more timely and appropriate interventions to improve outcomes.

An exploratory study of body awareness in persons with heart failure treated medically or with transplantation

Heart failure is a chronic disabling problem afflicting a growing number of adults. These individuals experience episodes of exacerbation demonstrated by increasing shortness of breath, fatigue, and fluid retention. The symptoms often develop in a slow and insidious manner making perception of worsening difficult to determine. Theoretically, an increase in body awareness may help individuals recognize symptoms of worsening heart failure earlier, but it is not known whether increased body awareness leads to somatization, an abnormal dwelling on body symptoms. This study was conducted to describe body awareness in 90 persons with heart failure or after transplant. We found that the Body Awareness Quesionnaire was a reliable measure of this concept in this sample. When body awareness was examined for age, gender, and treatment (HF or transplant) group were examined, no significant differences were found. Furthermore, there were no significant relationships between body awarenss and negative moods such as anxiety, depression, or anger. Interventions to enhance body awareness may be a fruitful new direction that will improve symptom recognition without increasing somatization in persons with heart failure.

Genetic Practice, Education, and Research

PURPOSE/OBJECTIVES

The purpose of this article is to describe how the new genomic era will affect advanced practice registered nurses (APRNs) patient care, education, and research.

BACKGROUND/RATIONALE

Given the exponential growth of genetic information and that 9 of the top 10 leading causes of mortality have genetic components (www.cdc.gov), it is imperative to educate advanced practice nurses about this salient topic.

DESCRIPTION OF THE PROCESS

Because few APRNs in practice or academia have had formal education on genetics, the first step of nursings' own gene discovery is recognizing that there is an ongoing need to understand state of the science genetic information to gain clinical and educational utility.

OUTCOMES

By recognizing APRNs need to know genetics, APRNs will clamor within their workplace for continuing education about this dynamic information. It is critical knowledge for APRNs to classify risk based on family history, target individualized patient prevention and education, modify pharmacologic interventions, and refer when genetic testing is necessary.

INTERPRETATION/CONCLUSION

This article stresses the timely relevance of applying genetics and genomics to practice, teaching, and research.

IMPLICATIONS FOR NURSING PRACTICE

APRNs need to maintain a place at the genetic table with all healthcare providers by developing strategies to expand this nursing knowledge to their practice, teaching, and research. Nurses need to be cognizant of the keen genetic value of family histories, how risk classification will individualize prevention recommendations, and the exciting role of pharmacogenetics, given many APRNs' prescriptive authority. Our core professional belief that each human is highly unique has probably never been more accurate than with the future in genetic and genomic nursing.

Sex differences in infection and sepsis

Sex and gender-based differences in responses to infection and sepsis are evident. Estrogens increase immune function, sometimes to the point of inducing autoimmune disease. Testosterone suppresses immune function, sometimes leading to a worsened outcome following traumatic injury. Therapies using sex hormones to improve outcomes after sepsis and hemorrhagic shock and to reduce exacerbations of autoimmune diseases are being studied. Differences in sex hormone levels may not tell the whole story. Studies of immune function in girls and boys before puberty may be helpful. Differences found early might indicate that factors other than estrogen and androgen levels are contributing. Variations in societal role acculturation and exposures that are gender based also may be involved. Clinicians must consider sex and gender when attempting to determine the risk of infection, sepsis, and immune dysfunction in populations. Clinical applications of sex and gender differences are just beginning to occur with the genesis of sex hormone-based treatments. The large-scale efficacy of such treatments has yet to be reported. Innovative strategies based on sex or gender differences in immune responses may soon be available and may lead to essential data for clinical decision making. The impact of sex and gender differences on long-term health outcomes remains to be seen.

Accuracy of the precordial V-Quick patch in persons with cardiac or pulmonary disease

The aim of this study was to demonstrate the equivalence of 12-Lead Electrocardiograms (EKG) obtained with the new V-Quick patch and traditional tab-style electrodes. Using a within-subject design, a convenience sample of 100 subjects with either cardiac or pulmonary disease underwent two 12-lead EKGs, one with the traditional tab-style electrodes and one with the precordial patch. Computer-generated measurements of waveform axes and amplitude were obtained for both EKGs. Comparison of mean and 95% confidence intervals revealed no significant differences in Q, R or S wave amplitude across the six precordial leads. Furthermore, a four-factor ANOVA found no significant difference (p > 0.05) in the Q, R and S wave amplitude between the type of electrode, gender and type of disease. A subset of 29 EKGs read by three experts found intra- (.90) and inter-rater (.84) reliability to be strong. In conclusion, the precordial V-Quick patch provided equivalent EKGs to those obtained using standard tab-style electrodes.

Spirituality in persons with heart failure

Spiritual expression has been proposed as a dimension of quality of life. Persons with chronic diseases such as AIDS or cancer have described the value of spiritual expression in living with their illnesses. The authors examined the role spirituality plays in the lives of 58 people with heart failure being treated medically or by transplant. Instruments used included the Medical Outcome Survey Short Form 36 and Index of Well-Being measures of quality of life, the Spiritual Well-Being Scale, and the Relative Importance Scale. Combined spirituality scores predicted 24% of the variance in global quality of life. There were no significant gender differences in spiritual well-being or quality of life.

Focused life stories of women with cardiac pacemakers

Biotechnical devices such as cardiac pacemakers are implanted into people to manage a range of disorders, yet comparatively little is known about the emotional impact of this experience. Women may have a unique response to implanted devices due to cultural messages about the masculinity of technology. In this qualitative study using Hall's focused life stories design, 11 women from teenagers to elders with permanent cardiac pacemakers were asked to describe their experiences using semistructured interviews. The themes that emerged are relinquishing care, owning the device, experiencing fears and/or resistance, imaging the body, normalizing, positioning as caretaker, finding resilience, and sensing omnipotence. Understanding what it means for women to live with an implanted biotechnical device may facilitate planning interventions to support their psychological and physiological health. Effective pacemaker function may depend, in part, on recipients' successful emotional attachment to the device.

The evolving role of genetics in the diagnosis and management of heart disease

The role of genetics in heart disease diagnosis and management is expanding daily. Clear genetic components have been found for diseases such as hypertrophic cardiomyopathy, heart failure, and coronary artery disease. Rhythm disturbances with genetic components are atrial fibrillation and long QT syndrome. Gene therapies to treat cardiac diseases include those designed to prevent vein graft stenosis and those that promote coronary angiogenesis.

An exploratory study of developmental growth in adults with heart failure

Persons with heart failure face a myriad of challenges due to the physical limitations imposed by the chronic illness. Despite these changes, each person must continue to face the developmental challenges of adulthood. This exploratory study was conducted to examine the impact that this chronic illness has on the developmental processes of adults. Methods triangulation was used to examine the content of unprompted, written goals and the results of surveys of life satisfaction and mood states of 138 persons with heart failure. Younger adults had higher anger, depression, and anxiety scores than older or middle-aged adults and had lower scores of life satisfaction. This may reflect the emotional reaction to the realization that their lives may be shortened by this chronic illness. Analysis of their goals reflected the developmental challenges described by Erikson. Despite severe physical limitations, these individuals demonstrated growth and achievement of developmental tasks by transcending usual time lines.

A blueprint for an undergraduate healthcare informatics course

Healthcare informatics has been taught at the graduate level for a number of years. With the proliferation of computer uses and information management systems, all nurses must interface with computer technologies. Healthcare informatics courses can no longer remain limited to specialists at the graduate level. Undergraduate nursing educators must incorporate information management content into their curricula. The authors provide a detailed description of an undergraduate healthcare informatics course.

Care and safety of pacemaker electrodes in intensive care and telemetry nursing units

BACKGROUND

Temporary pacing leads with electrodes are a potential risk, because microshock inadvertently transmitted across the catheter or wire can paradoxically cause lethal dysrhythmias. Much attention has been paid to this complication in clinical guidelines, but little is known about actual practices used to protect patients.

OBJECTIVES

A national survey was done to describe current practices related to the care of patients with temporary epicardial or transvenous pacing catheters. The survey focused on environmental factors that affect generation of static electricity, equipment used with temporary pacing, and nursing practices used when handling temporary pacing electrodes.

METHODS

The Pacemaker Electrical Care and Safety Survey was developed, validated, and pilot tested before it was mailed to all 895 hospitals that perform cardiac surgery. Surveys were sent to the coronary care unit, cardiac surgical ICU, and telemetry units of each hospital.

RESULTS

Responses were received from 476 units representing 388 (43%) of the 895 institutions. Most respondents reported using gloves, although few hospitals had policies mandating this practice. The insulating materials used most often, in order, were a glove or finger cot, tape, and gauze. Few units (25%) use any measure to reduce static electricity generated by movement over carpeting. Little attention was paid to insulating exposed epicardial temporary pacing electrodes at the generator.

CONCLUSIONS

Temporary pacing electrodes were usually handled in an electrically safe manner; however, little attention was paid to environmental sources of microshock or connections between the generator and the cable. Although the respondents reported using a variety of insulating materials, the ideal cover for the exposed tips of the electrodes has not yet been determined.

Care and safety of pacemaker electrodes in intensive care and telemetry nursing units

BACKGROUND: Temporary pacing leads with electrodes are a potential risk, because microshock inadvertently transmitted across the catheter or wire can paradoxically cause lethal dysrhythmias. Much attention has been paid to this complication in clinical guidelines, but little is known about actual practices used to protect patients. OBJECTIVES: A national survey was done to describe current practices related to the care of patients with temporary epicardial or transvenous pacing catheters. The survey focused on environmental factors that affect generation of static electricity, equipment used with temporary pacing, and nursing practices used when handling temporary pacing electrodes. METHODS: The Pacemaker Electrical Care and Safety Survey was developed, validated, and pilot tested before it was mailed to all 895 hospitals that perform cardiac surgery. Surveys were sent to the coronary care unit, cardiac surgical ICU, and telemetry units of each hospital. RESULTS: Responses were received from 476 units representing 388 (43%) of the 895 institutions. Most respondents reported using gloves, although few hospitals had policies mandating this practice. The insulating materials used most often, in order, were a glove or finger cot, tape, and gauze. Few units (25%) use any measure to reduce static electricity generated by movement over carpeting. Little attention was paid to insulating exposed epicardial temporary pacing electrodes at the generator. CONCLUSIONS: Temporary pacing electrodes were usually handled in an electrically safe manner; however, little attention was paid to environmental sources of microshock or connections between the generator and the cable. Although the respondents reported using a variety of insulating materials, the ideal cover for the exposed tips of the electrodes has not yet been determined.

Infection precautions with temporary pacing leads: a descriptive study

OBJECTIVE

To describe infection precautions used by nurses when caring for patients with temporary epicardial and transvenous pacemakers.

DESIGN

Descriptive, nation-wide survey.

SETTING

All U.S. hospitals performing cardiac surgery.

RESPONDENTS

Nurse managers and clinical specialists from cardiac and thoracic intensive care, coronary care, and telemetry units at all U.S. hospitals performing cardiac surgery.

INTERVENTION

The Pacemaker Electrode Care and Safety Survey.

RESULTS

Responses came from 43% (388) of the 895 hospitals. Most respondents indicated that they wore gloves when handling electrodes (approximately 96%); usually the gloves were nonsterile (73%). A sterile procedure was often used to perform site care (37% for epicardial and 65% for transvenous). The most common agent used for site cleansing was povidone-iodine. Concern has been expressed in the literature about use of this agent. Gauze was the most common type of dressing (used by 60% for epicardial dressings and 31% for transvenous).

CONCLUSION

There is diversity in clinical practice. Further study is recommended to establish the safety, efficacy, and cost-effectiveness of identified infection precautions.

Gender bias in the diagnosis and treatment of coronary artery disease

Women are at high risk for cardiovascular disorders, but referrals for both diagnostic and therapeutic procedures seem to reflect a gender bias. Procedures and therapies currently used have been developed predominantly or exclusively for men. Medical history demonstrates a disregard of women's health problems that still may be operative today. Women are older and sicker when they have angioplasty or bypass grafting, and they receive far fewer implantable cardioverter defibrillators and heart transplantations. They have more hypertension, diabetes, longer stays in intensive care units, and poorer outcomes. This may be the result of a problem with referral or a difference in the way women experience cardiac symptoms. It may also be related to the way women perceive themselves and their illness. Efforts are being made to provide equitable and relevant health care for women and to conduct research that will describe women's cardiac symptoms and their responses to cardiovascular technology.