High-Intensity, High-Frequency, Parallel Ultrasound Beams for Cellulite of the Buttocks and Thighs

BACKGROUND

Ultrasound energy can successfully treat fine lines and wrinkles, as well as lift the eyebrow and submentum. Ultrasound waves of high intensity induce thermal injury in the dermis with subsequent tissue remodeling.

OBJECTIVE

To examine the utility of a novel ultrasound device that utilizes high-intensity, high-frequency, parallel ultrasound beams to improve the clinical appearance of cellulite on the thighs and buttocks.

MATERIALS AND METHODS

A prospective, multicenter, clinical study investigated this novel ultrasound device using 2 treatments.

RESULTS

Sixty-five subjects completed both treatments. The mean age was 46 years, and 100% were women. Fitzpatrick skin types I to VI were represented. Assessments compared 3-month follow-up with baseline. Two blinded reviewers agreed in identifying pretreatment and post-treatment photographs for 89.2%. For Cellulite Severity Scale rating, there was significant improvement of 1.61 units (p < .001). For cellulite Global Aesthetic Improvement Scale (GAIS), 89.2% had improvement, with a mean of 0.87 units (p < .001). For Laxity Scale rating, there was significant improvement of 0.70 units (p < .001). For skin laxity GAIS, 89.2% had improvement, with a mean of 0.76 units (p < .001). No device-related adverse events occurred.

CONCLUSION

A novel ultrasound device that utilizes high-intensity, high-frequency, parallel ultrasound beams can safely and effectively improve the clinical appearance of cellulite on the thighs and buttocks.

Metabolomic Profiles of Human Glioma Inform Patient Survival

Aims: Targeting tumor metabolism may improve the outcomes for patients with glioblastoma (GBM). To further preclinical efforts targeting metabolism in GBM, we tested the hypothesis that brain tumors can be stratified into distinct metabolic groups with different patient outcomes. Therefore, to determine if tumor metabolites relate to patient survival, we profiled the metabolomes of human gliomas and correlated metabolic information with clinical data. Results: We found that isocitrate dehydrogenase-wildtype (IDHwt) GBMs are metabolically distinguishable from IDH mutated (IDHmut) astrocytomas and oligodendrogliomas. Survival of patients with IDHmut gliomas was expectedly more favorable than those with IDHwt GBM, and metabolic signatures can stratify IDHwt GBMs subtypes with varying prognoses. Patients whose GBMs were enriched in amino acids had improved survival, while those whose tumors were enriched for nucleotides, redox molecules, and lipid metabolites fared more poorly. These findings were recapitulated in validation cohorts using both metabolomic and transcriptomic data. Innovation: Our results suggest the existence of metabolic subtypes of GBM with differing prognoses, and further support the concept that metabolism may drive the aggressiveness of human gliomas. Conclusions: Our data show that metabolic signatures of human gliomas can inform patient survival. These findings may be used clinically to tailor novel metabolically targeted agents for GBM patients with different metabolic phenotypes. Antioxid. Redox Signal. 39, 942-956.

Revolutionizing Dermatology Residency: AI for Knowledge and Clinical Milestones Assessment

Artificial intelligence can be adapted and utilized to augment resident education in order to assess clinical milestones in real-time, providing powerful insights for educators and trainees alike. Further research on integrating such technology into our models of learning fosters the growth of our specialty and trainees' aptitudes.

DDRE-24. TARGETING PURINE METABOLISM TO OVERCOME GLIOBLASTOMA THERAPY RESISTANCE

Intratumoral genomic heterogeneity in glioblastoma (GBM) is a barrier to overcoming radiation (RT) resistance. To discover genotype-independent mediators of RT resistance, we correlated RT resistance with the concentration of approximately 700 metabolites across 23 GBM cell lines. Purine metabolites, especially those containing the base guanine, were most correlated with RT resistance. Similarly, increased abundance of tumor purines was associated with decreased survival in GBM patients treated with RT. This relationship is causal. Purine supplementation protected RT-sensitive GBMs from RT and promoted the repair of RT-induced double strand DNA breaks (DSBs). In vitro and in vivo stable isotope tracing confirmed that GBM cell lines and orthotopic patient-derived xenografts primarily generated purines through the de novo synthetic pathway. RT treatment further increased de novo purine synthesis in GBM through signaling via the DNA damage response. Inhibition of de novo GTP synthesis with mycophenolic acid (MPA) sensitized multiple GBM cell lines and neurospheres to RT by slowing the repair of RT-induced DSBs. MPA-induced radiosensitization was GTP-dependent as it was rescued by nucleoside supplementation. Modulating pyrimidine metabolism affected neither RT resistance nor DSB repair, suggesting these GTP-specific effects are due to active signaling rather than its ability to act as a physical substrate for DNA repair and candidate signaling molecules have been identified. These results were recapitulated in vivo with mycophenolate mofetil (MMF), the orally bioavailable FDA-approved prodrug of MPA. MMF potentiated RT efficacy, reduced tumor guanylates and slowed the repair of RT-induced DSBs across multiple models. Because de novo purine synthesis is activated by many of the oncogenic alterations that drive GBM, its inhibition is a promising genotype-independent strategy to overcome GBM RT resistance. We have now begun a clinical trial to determine whether combining MMF and RT is safe and potentially efficacious in patients with GBM.

Intermediate clinical endpoints for surrogacy in localised prostate cancer: an aggregate meta-analysis

BACKGROUND

The international Intermediate Clinical Endpoints in Cancer of the Prostate working group has established metastasis-free survival as a surrogate for overall survival in localised prostate cancer based on the findings of 19 predominantly radiotherapy-based trials. We sought to comprehensively assess aggregate trial-level performance of commonly reported intermediate clinical endpoints across all randomised trials in localised prostate cancer.

METHODS

For this meta-analysis, we searched PubMed for all trials in localised or biochemically recurrent prostate cancer published between Jan 1, 1970, and Jan 15, 2020. Eligible trials had to be randomised, therapeutic, reporting overall survival and at least one intermediate clinical endpoint, and with a sample size of at least 70 participants. Trials of metastatic disease were excluded. Intermediate clinical endpoints included biochemical failure, local failure, distant metastases, biochemical failure-free survival, progression-free survival, and metastasis-free survival. Candidacy for surrogacy was assessed using the second condition of the meta-analytical approach (ie, correlation of the treatment effect of the intermediate clinical endpoint and overall survival), using R2 weighted by the inverse variance of the log intermediate clinical endpoint hazard ratio. The intermediate clinical endpoint was deemed to be a surrogate for overall survival if R2 was 0·7 or greater.

FINDINGS

75 trials (53 631 patients) were included in our analysis. Median follow-up was 9·1 years (IQR 5·7-10·6). Biochemical failure (R2 0·38 [95% CI 0·11-0·64]), biochemical failure-free survival (R2 0·12 [0·0030-0·33]), biochemical failure and clinical failure (R2 0·28 [0·0045-0·65]), and local failure (R2 0·085 [0·00-0·37]) correlated poorly with overall survival. Progression-free survival (R2 0·46 [95% CI 0·22-0·67]) showed moderate correlation with overall survival, and metastasis-free survival (R2 0·78 [0·59-0·89]) correlated strongly.

INTERPRETATION

Intermediate clinical endpoints based on biochemical and local failure did not meet the second condition of the meta-analytical approach and are not surrogate endpoints for overall survival in localised prostate cancer. Our findings validate metastasis-free survival as the only identified surrogate endpoint for overall survival to date.

FUNDING

Prostate Cancer Foundation and National Institutes of Health.

FLASH: A Novel Tool to Identify Vision-Threating Eye Emergencies

BACKGROUND

Two million patients visit emergency departments due to eye complaints annually in the United States, yet nearly one-quarter of these visits are for non-urgent ocular problems. Other patients often present a significant length of time after the onset of their symptoms, which may cause progression to irreversible vision loss. A major reason for this discrepancy is that many patients are unsure what symptoms constitute eye emergencies. The challenge is helping patients understand what constitutes a vision-threatening eye emergency, as well as the risks and complications that are associated with delaying their visit to the ophthalmologist or Emergency Department.

OBJECTIVES

To describe relevant literature on incidence, prevalence, presentation times, associated prognoses, risks, and complications of individual vision-threating eye emergencies, and present a novel acronym, FLASH (Floaters and flashes, Loss of vision, Aching pain, Second Image, Help), to better educate patients at risk for these conditions, fostering better symptom recognition and timely care. This manuscript is aimed at reaching public health departments, educational institutions, primary care offices and eye care centers as part of a dedicated patient education effort for vision-threatening eye emergencies.

DESIGN / METHODS

Narrative overview of the available literature on specific eye conditions presenting with the aforementioned symptoms, synthesizing findings retrieved from searches of computerized databases and authoritative texts.

CONCLUSIONS

In each condition presented in this article, symptom interval significantly impacts treatment prognoses. The cited literature demonstrates that patients often present late in emergent eye conditions resulting in vision loss.

Automated histologic diagnosis of CNS tumors with machine learning

The discovery of a new mass involving the brain or spine typically prompts referral to a neurosurgeon to consider biopsy or surgical resection. Intraoperative decision-making depends significantly on the histologic diagnosis, which is often established when a small specimen is sent for immediate interpretation by a neuropathologist. Access to neuropathologists may be limited in resource-poor settings, which has prompted several groups to develop machine learning algorithms for automated interpretation. Most attempts have focused on fixed histopathology specimens, which do not apply in the intraoperative setting. The greatest potential for clinical impact probably lies in the automated diagnosis of intraoperative specimens. Successful future studies may use machine learning to automatically classify whole-slide intraoperative specimens among a wide array of potential diagnoses.

MR1 in combination with tumor mutational burden and PD-1/PD-L1 expression as a potentially novel clinical predictor for T cell exhaustion and immune checkpoint inhibitor response

3109

Background: Immune checkpoint inhibitors (ICIs) restore T cell function by reversing T cell exhaustion. Variable response to ICIs warrants the development of precise predictive biomarkers, which is challenging due to difficulty in capturing the interplay of factors involved with tumor cell immune recognition. High intratumoral expression of MR1, the MHC-I related protein basally expressed on cancer cells, may drive T cell exhaustion through presentation of cancer-specific antigens. Here, we construct a database to study the relationship between MR1, tumor mutational burden (TMB), the PD-1/PD-L1 axis and T cell exhaustion across 8,975 sequenced tumors and 27 cancer types. Methods: RNA Seq by expectation maximization (RSEM) values from the TCGA were collected and normalized along with expression data for markers of interest (Table). TMB was defined as the number of non-synonymous somatic mutations per sample. For each cancer, 5 cohorts were created based on ascending mean expression levels of MR1, PD-1, PD-L1, and increasing TMB. For each cancer, an “immunogenicity score” for these factors was computed, and its relationship with T cell exhaustion signatures was assessed via linear regression. Data is presented as adjusted R2 and p-value. Results: While PD-1 and T cell exhaustion marker expression were correlated across cancers, the “immunogenicity score” (IS) correlated with exhaustion markers specifically in cancers with FDA-approved ICIs. Excluding MR1 from the score weakened the correlation with EOMES and TBET expression (Table). Each component of the score analyzed independently failed to show a statistically significant correlation for both EOMES and TBET expression. Conclusions: In this cross-cancer analysis, we support the hypothesis that presentation of metabolic intermediates in cancer cells via MR1 may drive T cell exhaustion. Also, the novel “immunogenicity score”, which incorporates MR1 into standard biomarkers for response to ICIs may convey the global picture of cancer cell recognition by the immune system and warrants further investigation as a tool for predicting clinical response. [Table: see text]

NIMG-69. RAPID INTRAOPERATIVE DIAGNOSIS OF GLIOMA RECURRENCE USING STIMULATED RAMAN HISTOLOGY AND DEEP NEURAL NETWORKS

Accurate intraoperative diagnosis of recurrence versus treatment effect (TE) is essential for determining the management of suspected recurrent gliomas. Cytologic and histoarchitectural changes related to chemoradiation overlap with common findings in recurrent tumors (e.g. atypia, abnormal vasculature, necrosis). Moreover, H&E tissue processing artifact complicates interpretation. Stimulated Raman histology (SRH) uses the intrinsic biochemical properties of fresh, unprocessed surgical specimens to provide rapid label-free digital histologic images. Here, we report an automated technique using deep convolutional neural networks (ConvNet) that differentiates recurrent glioma and TE in fresh surgical specimens imaged using SRH with equivalent accuracy and 10x faster (tissue-to-diagnosis, 2 minutes) than conventional methods. Our ConvNet, based on Google’s Inception-ResNet-v2 architecture, was first trained on 3.6 million SRH images from 441 patients with the most common brain tumor subtypes. To optimize the network for classifying glioma recurrence, we used cross-validation (CV) on 35 patients (24 recurrent, 9 TE) for model hyperparameter tuning and to identify an optimal probability threshold to classify recurrence. To perform rigorous model validation, we used a 50 patient external testing set to evaluate overall model accuracy. Over 5 iterations of CV, the mean held-out classification accuracy was 94.8% (range, 91.4 - 97.1%). Using ROC analysis, we found that a probability of recurrence greater than 25% was the optimal threshold to render a recurrence diagnosis for whole-slide SRH images. Using our external testing set, we achieved a classification accuracy of 96% (total 48/50; 30/30 recurrences, 18/20 TE). Moreover, our method effectively identifies regions of glioma recurrence in whole slide SRH at no additional computational cost. Our study demonstrates the feasibility of applying deep learning for intraoperative diagnosis of recurrent gliomas in SRH imaged tissues. In the future, ConvNets may ultimately be used to guide decision-making in the surgical care of recurrent gliomas, independent of conventional neuropathology resources.

The occlusion balloon reduction technique for de novo placement and salvage of malpositioned enteric tubes

PURPOSE

Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops.

MATERIALS AND METHODS

Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32 mm × 120 cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded.

RESULTS

The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56 days.

CONCLUSION

The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.

Transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias

PURPOSE

To report the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias.

MATERIALS AND METHODS

Four patients, including three (75%) females and one (25%) male, with mean age of 77.5 years (range 73-78 years), and with a hiatal hernia and intrathoracic stomach precluding gastrostomy placement and loop snare placement into the mid-jejunum underwent the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement. In all patients, a duodenal stent was inserted into the jejunum in a transnasal fashion. The stent was partially unsheathed in an anterior loop of jejunum and percutaneously targeted using an 18-gauge needle through which a guidewire was advanced, trapped within the stent, and removed through the nose. The tract was serially dilated and a jejunostomy was placed. Technical success, procedure time, fluoroscopy time, radiation exposure, complications, time to enteral feeding, and follow-up were recorded.

RESULTS

Technical success was 100% (4/4) with all four patients requiring only one needle pass before successful jejunal cannulation. Mean procedure time was 108 min. Mean fluoroscopy time was 44 min. Mean dose area product was 3969.3 μGym². No minor or major complications occurred. All four patients received enteral feeding one day after the procedure. Mean follow-up was 366 days.

CONCLUSION

The transnasal stent-assisted targeting technique is a novel method for primary jejunostomy placement in patients with hiatal hernias.

Intra-arterial ampicillin and gentamicin and the incidence of splenic abscesses following splenic artery embolization: A 20-year case control study

PURPOSE

Splenic abscesses represent a major complication following splenic artery embolization. The purpose of this study was to assess the effectiveness of intra-arterial antibiotics administered during splenic artery embolization in reducing splenic abscess formation.

MATERIALS AND METHODS

406 patients were screened. 313 (77.1%) patients who underwent splenic artery embolization and were >18 years old were included. Mean age of the cohort was 58 ± 15 years (range: 18-88 years). There were 205 (65.5%) male patients and 108 (34.5%) female patients. 197 (62.9%) patients underwent embolization without intra-arterial antibiotics and 116 (37.1%) patients underwent embolization with 1 g ampicillin and 80 mg gentamicin administered in an intra-arterial fashion. Primary outcome was splenic abscess formation. Secondary outcomes included type of splenic artery embolization, embolic agent, and technical success.

RESULTS

Partial splenic embolization was performed in 229 (73.1%) patients. Total splenic embolization was performed in 84 (26.8%) patients. Platinum coils were the most commonly used embolic agent overall (n = 178; 56.9%) followed by particulates (n = 114; 36.4%). Embolization technical success was achieved in 312 (99.7%) patients. 7 (3.6%) splenic abscesses were detected in the non-intra-arterial antibiotic group and 1 (0.9%) in the intra-arterial antibiotic cohort (P = 0.27). Coils were found to be statistically more likely to result in splenic abscesses than any other embolic agent (P = 0.03). Mean time to abscess identification was 74 days ±120 days (range: 9-1353 days).

CONCLUSION

Splenic abscesses occurred more frequently in patients who did not receive intra-arterial antibiotics during splenic embolization; however, this did not reach statistical significance.

Childhood smoking: the research, clinical and theoretical imperative for nursing action

BACKGROUND

Tobacco smoking is a major international health issue which nurses are ideally positioned to address. Childhood represents a critical period for intervention to prevent/reduce smoking. During childhood, the majority of smokers first experiment with smoking, are initiated into the smoking subculture and become addicted to tobacco. Children are highly susceptible to smoking as a result of developmental factors, which promote or facilitate high-risk behaviours, limited coping skills, limited defences and inadequate legal protection against youth-focused marketing of tobacco.

AIM

This paper is intended to sensitize nurses to the magnitude of childhood smoking as an international health problem and to familiarize them with current intervention approaches and care issues pertinent to child and adolescent populations.

METHOD

An extensive literature review was conducted to determine the impact of childhood smoking at the personal and community level, characteristics of child smokers, the processes associated with smoking cessation, intervention approaches and intervention models for use by nurses across the spectrum of clinical settings.

FINDINGS

Evidence exists that behaviourally based interventions by nurses for smoking prevention/cessation are effective with children. Key components of effective behaviourally based antismoking approaches for smokers include addressing self-efficacy to quit, providing social support, resisting temptation to smoke and discussing issues related to relapse and relapse prevention. For all children, the reinforcement of non-smoking behaviour is essential. Intervention models, which can be incorporated into routine clinical care of individual children or with groups, emphasize the importance of parental involvement, routine screening for tobacco use and provision of a clear message that smoking and tobacco use is unhealthy.

Implications of gender differences on coronary artery disease risk reduction in women

Differences in the clinical presentation and resultant treatment of coronary artery disease (CAD) for men and women have sensitized advanced practice nurses to the importance of addressing gender issues when caring for women with CAD. Certain patient characteristics and clinical conditions may place women at higher risk of CAD development or progression. These factors include depression, African American status, menopausal status, age, type 2 diabetes, and thyroid function. In addition, female gender may adversely influence the relative benefits of cholesterol lowering in elderly women with borderline high serum cholesterol levels and response to interventions for modification of sedentary behavior and for smoking cessation. This article addresses emerging knowledge regarding gender differences in CAD risk factors and responsiveness to risk reduction interventions, issues regarding patient management, the implications of emerging knowledge on early detection of CAD risk factors more prevalent in women, and the development of targeted intervention approaches.

A strategy for converting clinical data into research databases

The process of converting clinical information into a research database is complex. Following assemblage of a team including clinicians and researchers (supplemented by statisticians and informatics personnel as needed) a three-phase, eight-step process may be followed for clinical information conversion and database generation. The amount, type, and variety of data stored will greatly increase in the future. This increased availability of databases is useful in research and can expand the opportunities to conduct clinical nursing research. The case study presentation illustrates how individuals from various organizations collaborate to develop accountability systems that best serve the public interest. The purpose of this joint venture was the development and conversion of measures into a database to determine the quality of care for people with diabetes. In addition, opportunities exist for extracting data to examine outcome criteria for patient care.

Patient expectations and anticipated responses to postsurgical pain

This descriptive study investigated the factors that influenced the intended pain management behaviors of a sample of 186 patients awaiting major surgical procedures. Pain management behaviors were defined as those related to reporting of postsurgical pain and seeking postsurgical pain management. Less than 44% of respondents specified the type of sensation, duration, similarity to previous pain, and source of pain as factors affecting the decision to seek help for pain. Only 9% expected complete relief with appropriate treatment, and 19% of respondents would wait for treatment to be given or offered, if pain returned following treatment. Moreover, less than 5% of respondents identified physicians or nurses as ways "by which you have learned about pain control." These findings underscore the need for comprehensive, individualized pain education protocols throughout the period of care delivery. Special emphasis should be placed on patient empowerment and decision making to seek appropriate pain management.

Myocardial infarction patients' use of metaphors to share meaning and communicate underlying frames of experience

The onset of a myocardial infarction (MI) is frequently associated with distinct sensations that may shape the personal meaning of the MI illness experience. Although highly important, patients may have difficulty communicating the personal meaning of the MI illness experience because of lack of congruence between the clinician's and patient's frames of experience. The frame of experience defines the context and agenda for encounters from each participant's perspective. This secondary analysis of data explored MI patients' use of metaphorical language to convey aspects of their underlying frame of experience. Specifically, this paper addressed (a) the structural and linguistic features of metaphorical language used by patients to describe MI pain, (b) the content and structure of associated patient metaphors, and (c) the similarities and differences between the content of patient metaphors and descriptions of MI pain. Our findings confirm that even in encounters characterized by clinician imposition of an organizing framework upon the patient encounter, patients use metaphors to reveal their underlying frame of experience and aspects of the personal meaning of the MI illness experience. Furthermore, although non-metaphorical descriptions provide insights into the patients' cognitive understanding of events associated with the MI, metaphorical descriptions are particularly helpful in eliciting aspects of the affective response to the MI.

Using self-efficacy to increase physical activity in patients with heart failure

Increasing self-efficacy is not a state that develops quickly. It is unrealistic to expect that the factors contributing to illness and disability will be modified easily. The home care nurse can positively influence self-efficacy expectations in the heart failure population by creating a supportive environment to perform physical activities (performance mastery), assisting with encouragement and support (verbal persuasion), providing anticipatory guidance and sharing how others perform (vicarious experience), and providing a realistic assessment of a person's abilities (physiologic state). By enhancing self-efficacy, the home care nurse can increase physical activity levels in this population, leading to decreased symptomatology and improved quality of life.

Acute myocardial infarction: early recognition and management from the home healthcare nurses perspective

Acute myocardial infarction is the number one killer of men and women in the United States. Early recognition and treatment has been shown to decrease mortality and infarct size, and to improve left ventricular function. The home healthcare nurse is in a key position to perform a swift, pertinent assessment that can detect an acute myocardial infarction, provide the patient with the valuable information to decrease the time delay until thrombolytic therapy is initiated, participate in the rehabilitation post-myocardial infarction, and provide education and counseling for coronary heart disease risk reduction.

The effect of moderate exercise training on oxygen uptake post-aortic/mitral valve surgery

BACKGROUND

This study determined the response of aortic and/or mitral valve replacement/reconstruction (AVR/MVR) surgery patients to a 3-month exercise rehabilitation program (ERP) of moderate intensity, frequency, and duration that commenced approximately 9 weeks post-operatively.

METHODS

Based on geographic proximity and availability of transportation to attend ERP classes, 29 experimental subjects were enrolled in the ERP and 20 control subjects received standard care that did not include the ERP, but did not prohibit activity/exercise. Exercise tolerance was determined from estimated oxygen uptake (VO2) during exercise tolerance testing (GXT) before and after standard care or the ERP.

RESULTS

VO2 at the maximum stage of the GXT increased significantly (P < or = 05) for the experimental (4.89 +/- 5.07 mL/kg/min) and control (5.11 +/- 4.48 mL/kg/min) groups. No significant between-group differences were noted in VO2 at the maximum stage of the exercise testing or at the target heart rate (HR). Furthermore, reported exercise levels of subjects in both groups were comparable and sufficient for training effects to occur.

CONCLUSION

Alternate strategies to improve exercise tolerance such as home-based rehabilitation programs should be investigated for relatively healthy aortic and/or mitral valve surgical patients.

The Delphi methodology (Part Two): A useful administrative approach

The Delphi methodology can provide nurse administrators with relevant and accurate information to facilitate decision making. This paper, the second of a two part series, familiarizes nurse administrators with the application of the Delphi methodology in needs assessments, priority setting, changes in nursing practice, identification of cost containment approaches, development of effectiveness indicators, values clarification, and forecasting. Examples from the health sciences literature and our experiences in administration are presented to outline appropriate approaches for nurse administrators planning similar applications.

Strategies for motivating CCU patients

Changes in health care delivery have led to shorter hospital stays for sicker patients. These factors require the critical care nurse to become involved in rehabilitation. Cardiac patients, once stable, begin the cardiac rehabilitation program while in critical or intermediate care. This article discusses ways in which critical care nurses improve the motivation of medical and surgical patients with cardiac conditions to participate in cardiac rehabilitation.

Diarrhea and the patient receiving enteral feedings: a multifactorial problem

Diarrhea is often considered an inevitable consequence of enteral tube feeding. The pathogenesis of diarrhea in patients receiving enteral feeding is not well understood, but it has been attributed to hypoalbuminemia, bacterial contamination of formula, characteristics of enteral feeding formula, and concomitant drug therapy. The purpose of this article is to review research regarding the etiology and treatment of diarrhea in patients receiving enteral feeding and to identify implications for nursing practice and future research.

The Delphi methodology (Part one): A useful administrative approach

The Delphi methodology is used to determine, predict and explore group attitudes, needs and priorities. This paper, the first of a two part series on the Delphi methodology, will provide nurse administrators with the basic information necessary to participate in and conduct projects using the Delphi methodology. The methodology will be defined and issues related to design, sampling, instrumentation and methods of data analysis discussed. The role of the nurse administrator, when the Delphi methodology is used, will then be addressed. In the second paper, administrative applications of the Delphi methodology will be addressed.

The Generic Research Protocol: An Innovative Technique to Facilitate Research Skills Development and Protocol Preparation

Hospitals are increasingly delegating responsibility for initiating nursing research to nursing staff whose knowledge of and experience in conducting research may be limited. As a result, nurses involved in continuing education and staff development are increasingly involved in helping staff develop their research skills and prepare research protocols. The generic research protocol (GRP) is a computerized learning package that assists nursing staff in preparing a scholarly research protocol through step-by-step instruction and guidance. When used in two unrelated nursing studies, research skills of participating nursing staff were developed and protocol preparation facilitated. The time and editorial effort required for protocol preparation were reduced, and novice researchers were familiarized with research terminology and issues related to study design.

Hemodynamic responses and activity tolerance to stair climbing during the second week post-myocardial infarction

The purpose of this study was to evaluate the hemodynamic responses and activity tolerance to stair climbing of second week post-myocardial infarction (MI) patients. Forty MI patients were stratified into beta-blocker medication users and non-users and randomly assigned to the experimental or control conditions. The 21 experimental subjects performed a walk/stair climb, and the 19 control subjects, a walk/stand activity protocol. Changes in heart rate and blood pressure from before, to immediately after both the walk/stair and walk/stand activity protocols were clinically small. No significant differences existed in the distribution of hemodynamic signs among the experimental and control subjects. However, proportionately more experimental than control subjects had symptoms of activity intolerance (7/21 vs 1/19; p less than 0.05). No correlation existed between activity (in) tolerance and either days post-MI or time required for stair climbing. Based upon these preliminary findings, assessment of tolerance to stair climbing activities is warranted during the second week post-MI.

The Effect of Preceptorship Upon Diploma Program Nursing Students' Transition to the Professional Nursing Role

This quasi-experimental study determined the effect of a 17-week pregraduate preceptorship program upon diploma nursing students' (N = 22) performance of the professional nursing role. Nine students participated in the preceptorship program; 13 received the standard pregraduate clinical experience. Nursing performance was measured using Schwirian's Six Dimension Scale of Nursing Performance prior to, during, and upon completion of the pregraduate clinical experience. Based on the faculty adviser's appraisals, the preceptorship program was associated with significantly greater improvements in nursing performance within the teaching/collaboration and planning/evaluation dimensions.

Effective discharge preparation of elderly cataract day surgery patients

Nurses should ensure that prior to discharge, cataract surgery patients acquire basic knowledge about the surgical procedure, postsurgical recovery, and safe, appropriate health-care practices during early convalescence. The Modified Knowledge Test may be a functional, easy to administer tool to assess and track patient's knowledge about their post-cataract surgery recovery and safe, appropriate health-care practices during the early convalescent period. Patients can acquire most of the requisite knowledge regarding cataract extraction surgery prior to hospitalization. Some patients require reinforcement or remedial health teaching during hospitalization.

Guidelines for nursing research fellowship applications

A career in nursing research requires advanced and costly educational preparation. Research fellowships are financial awards which enable nurses to receive intensive research preparation at the master's or doctoral level. Potentially qualified nurses may not be awarded research fellowships however because of a lack of familiarity with the review process and the submission of inappropriate fellowship applications. In this paper, sources of research fellowships are identified, and a general description of the review process provided using the example of the Nursing Research Fellowship, Heart and Stroke Foundation of Canada. Guidelines for applying for research fellowships are also presented.