Nursing's mandate in climate change

Science tells us that human-induced climate change is real and threatening health and well-being everywhere. Nurses have a key role as individuals and collectively to mitigate these effects. We are obligated to action, advocacy, and policy change at both a personal and professional level in this global emergency. This includes working to achieve climate justice and the United Nations' Sustainable Health Goals, which have a strong focus on climate action.

Nursing science and health policy - opportunities in the year of the nurse and the midwife

The 2020 International Year of the Nurse and the Midwife is an important opportunity to marry nursing science and health policy globally. Nurses and midwives are demonstrating strong intent towards evidence-based practice but often feel they lack the skills to implement it. Examples are provided of ways in which general and advanced practice nurses have succeeded in bringing evidence into practice and then into local and global policy.

IMPACT and CRASH prognostic models for traumatic brain injury: external validation in a South-American cohort

OBJECTIVE

To develop a robust prognostic model, the more diverse the settings in which the system is tested and found to be accurate, the more likely it will be generalisable to untested settings. This study aimed to externally validate the International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization after Significant Head Injury (CRASH) models for low-income and middle-income countries using a dataset of patients with severe traumatic brain injury (TBI) from the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure study and a simultaneously conducted observational study.

METHOD

A total of 550 patients with severe TBI were enrolled in the study, and 466 of those were included in the analysis. Patient admission characteristics were extracted to predict unfavourable outcome (Glasgow Outcome Scale: GOS<3) and mortality (GOS 1) at 14 days or 6 months.

RESULTS

There were 48% of the participants who had unfavourable outcome at 6 months and these included 38% who had died. The area under the receiver operating characteristic curve (AUC) values were 0.683-0.775 and 0.640-0.731 for the IMPACT and CRASH models respectively. The IMPACT CT model had the highest AUC for predicting unfavourable outcomes, and the IMPACT Lab model had the best discrimination for predicting 6-month mortality. The discrimination for both the IMPACT and CRASH models improved with increasing complexity of the models. Calibration revealed that there were disagreement between observed and predicted outcomes in the IMPACT and CRASH models.

CONCLUSION

The overall performance of all IMPACT and CRASH models was adequate when used to predict outcomes in the dataset. However, some disagreement in calibration suggests the necessity for updating prognostic models to maintain currency and generalisability.

Stroke impact symptoms are associated with sleep-related impairment

BACKGROUND

Sleep-related impairment is a common but under-appreciated complication after stroke and may impede stroke recovery. Yet little is known about factors associated with sleep-related impairment after stroke.

OBJECTIVE

The purpose of this analysis was to examine the relationship between stroke impact symptoms and sleep-related impairment among stroke survivors.

METHODS

We conducted a cross-sectional secondary analysis of a baseline (entry) data in a completed clinical trial with 100 community-dwelling stroke survivors recruited within 4 months after stroke. Sleep-related impairment and stroke impact domain symptoms after stroke were assessed with the Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment scale and the Stroke Impact Scale, respectively. A multivariate regression was computed.

RESULTS

Stroke impact domain-mood (B = -0.105, t = -3.263, p = .002) - and fatigue (B = 0.346, t = 3.997, p < .001) were associated with sleep-related impairment.

CONCLUSIONS

Our findings suggest that ongoing stroke impact symptoms are closely related to sleep-related impairment. An intervention targeting both stroke impact symptoms and sleep-related impairment may be useful in improving neurologic recovery and quality of life in stroke survivors.

Effect of symptoms on physical performance in COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients experience multiple symptoms including dyspnea, anxiety, depression, and fatigue, which are highly correlated with each other. Together, those symptoms may contribute to impaired physical performance.

OBJECTIVES

The purpose of this study was to examine interrelationships among dyspnea, anxiety, depressive symptoms, and fatigue as contributing factors to physical performance in COPD.

METHODS

This study used baseline data of 282 COPD patients from a longitudinal observational study to explore the relationship between depression, inflammation, and functional status. Data analyses included confirmatory factor analyses and structural equation modeling.

RESULTS

Dyspnea, anxiety and depression had direct effects on fatigue, and both dyspnea and anxiety had direct effects on physical performance. Higher levels of dyspnea were significantly associated with impaired physical performance whereas higher levels of anxiety were significantly associated with enhanced physical performance.

CONCLUSION

Dyspnea was the strongest predictor of impaired physical performance in patients with COPD.

Randomized trial of telephone versus in-person delivery of a brief psychosocial intervention in post-stroke depression

Background

A psychosocial behavioral intervention delivered in-person by advanced practice nurses has been shown effective in substantially reducing post-stroke depression (PSD). This follow-up trial compared the effectiveness of a shortened intervention delivered by either telephone or in-person to usual care. To our knowledge, this is the first of current behavioral therapy trials to expand the protocol in a new clinical sample. 100 people with Geriatric Depression Scores ≥ 11 were randomized within 4 months of stroke to usual care (N = 28), telephone intervention (N = 37), or in-person intervention (N = 35). Primary outcome was response [percent reduction in the Hamilton Depression Rating Scale (HDRS)] and remission (HDRS score < 10) at 8 weeks and 12 months post treatment.

Results

Intervention groups were combined for the primary analysis (pre-planned). The mean response in HDRS scores was 39% reduction for the combined intervention group (40% in-person; 38% telephone groups) versus 33% for the usual care group at 8 weeks (p = 0.3). Remission occurred in 37% in the combined intervention groups at 8 weeks versus 27% in the control group (p = 0.3) and 44% intervention versus 36% control at 12 months (p = 0.5). While favouring the intervention, these differences were not statistically significant.

Conclusions

A brief psychosocial intervention for PSD delivered by telephone or in-person did not reduce depression significantly more than usual care. However, the comparable effectiveness of telephone and in-person follow-up for treatment of depression found is important given greater accessibility by telephone and mandated post-hospital follow-up for comprehensive stroke centers.

Clinical Trial Registration URL: https://register.clinicaltrials.gov, unique identifier: NCT01133106, Registered 5/26/2010

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2819-y) contains supplementary material, which is available to authorized users.

Frequency of and factors associated with emergency department intracranial pressure monitor placement in severe paediatric traumatic brain injury

OBJECTIVE

To examine the frequency of and factors associated with emergency department (ED) intracranial pressure (ICP) monitor placement in severe paediatric traumatic brain injury (TBI).

METHODS

Retrospective, multicentre cohort study of children <18 years admitted to the ED with severe TBI and intubated for >48 hours from 2007 to 2011.

RESULTS

Two hundred and twenty-four children had severe TBI and 75% underwent either ED, operating room (OR) or paediatric intensive care unit (PICU) ICP monitor placement. Four out of five centres placed ICP monitors in the ED, mostly (83%) fibreoptic. Nearly 40% of the patients who received ICP monitors get it placed in the ED (29% overall). Factors associated with ED ICP monitor placement were as follows: age 13 to <18 year olds compared to infants (aRR 2.02; 95% CI 1.37, 2.98), longer ED length of stay (LOS) (aRR 1.15; 95% CI 1.08, 1.21), trauma centre designation paediatric only I/II compared to adult/paediatric I/II (aRR 1.71; 95% CI 1.48, 1.98) and higher mean paediatric TBI patient volume (aRR 1.88;95% CI 1.68, 2.11). Adjusted for centre, higher bedside ED staff was associated with longer ED LOS (aRR 2.10; 95% CI 1.06, 4.14).

CONCLUSION

ICP monitors are frequently placed in the ED at paediatric trauma centres caring for children with severe TBI. Both patient and organizational level factors are associated with ED ICP monitor placement.

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.

Variation in seizure prophylaxis in severe pediatric traumatic brain injury

OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.

Lifestyle Physical Activity for Individuals with Spinal Cord Injury: A Pilot Study

Purpose.

To evaluate the acceptability and feasibility of a lifestyle physical activity program for people with spinal cord injury (SCI).

Methods.

Sixteen nonexercising adult volunteers with SCI participated in a single group pre-post–test of the “Be Active in Life Program” comprising stage-matched educational materials, home visit by a nurse, construction of a personal plan to increase activity, and four follow-up phone calls. Program acceptability, stage of change, barriers to health-promoting activities, abilities for health practices, health, depression, and muscle strength were rated. Physical activity was monitored using actigraphy and a self-report record.

Results.

Participants rated the program positively, although some preferred a structured exercise approach. Eighty-one percent of participants progressed in stage of change and 60% increased physical activity. There were significant changes in motivational barriers, exercise self-efficacy, self-rated health, and muscle strength.

Discussion.

Lifestyle physical activity is feasible and acceptable and could be effective in promoting greater physical activity among people with SCI.

Incident Atrial Fibrillation and Disability-Free Survival in the Cardiovascular Health Study

OBJECTIVES

To assess the associations between incident atrial fibrillation (AF) and disability-free survival and risk of disability.

DESIGN

Prospective cohort study.

SETTING

Cardiovascular Health Study.

PARTICIPANTS

Individuals aged 65 and older and enrolled in fee-for-service Medicare followed between 1991 and 2009 (MN = 4,046). Individuals with prevalent AF, activity of daily living (ADL) disability, or a history of stroke or heart failure at baseline were excluded.

MEASUREMENTS

Incident AF was identified according to annual study electrocardiogram, hospital discharge diagnosis, or Medicare claims. Disability-free survival was defined as survival free of ADL disability (any difficulty or inability in bathing, dressing, eating, using the toilet, walking around the home, or getting out of a bed or chair). ADLs were assessed at annual study visits or in a telephone interview. Association between incident AF and disability-free survival or risk of disability was estimated using Cox proportional hazards models.

RESULTS

Over an average of 7.0 years of follow-up, 660 individuals (16.3%) developed incident AF, and 3,112 (77%) became disabled or died. Incident AF was associated with shorter disability-free survival (hazard ratio (HR) for death or ADL disability = 1.71, 95% confidence interval (CI) = 1.55-1.90) and a higher risk of ADL disability (HR = 1.36, 95% CI = 1.18-1.58) than in individuals with no history of AF. This association persisted after adjustment for interim stroke and heart failure.

CONCLUSION

These results suggest that AF is a risk factor for shorter functional longevity in older adults, independent of other risk factors and comorbid conditions.

A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines

Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.

Evidence-based practice beliefs and behaviors of nurses providing cancer pain management: a mixed-methods approach

PURPOSE/OBJECTIVES

To describe evidence-based practice (EBP) beliefs and behaviors of nurses who provide cancer pain management.

DESIGN

Descriptive, cross-sectional with a mixed-methods approach.

SETTING

Two inpatient oncology units in the Pacific Northwest.

SAMPLE

40 RNs.


METHODS

Data collected by interviews and web-based surveys.

MAIN RESEARCH VARIABLES

EBP beliefs, EBP implementation, evidence-based pain management.

FINDINGS

Nurses agreed with the positive aspects of EBP and their implementation ability, although implementation level was low. They were satisfied with their pain management practices. Oncology nursing certification was associated with innovativeness, and innovativeness was associated with EBP beliefs. Themes identified were (a) limited definition of EBP, (b) varied evidence-based pain management decision making, (c) limited identification of evidence-based pain management practices, and (d) integration of nonpharmacologic interventions into patient care.

CONCLUSIONS

Nurses' low level of EBP implementation in the context of pain management was explained by their trust that standards of care and medical orders were evidence-based.

IMPLICATIONS FOR NURSING

Nurses' EBP beliefs and behaviors should be considered when developing strategies for sustaining evidence-based pain management practices. Implementation of the EBP process by nurses may not be realistic in the inpatient setting; therefore, hospital pain management policies need to be evidence-based and reinforced with nurses.

Telephone Assessment and Skill-Building Kit for Stroke Caregivers: A Randomized Controlled Clinical Trial

BACKGROUND AND PURPOSE

There are few evidence-based programs for stroke family caregivers postdischarge. The purpose of this study was to evaluate efficacy of the Telephone Assessment and Skill-Building Kit (TASK II), a nurse-led intervention enabling caregivers to build skills based on assessment of their own needs.

METHODS

A total of 254 stroke caregivers (primarily female TASK II/information, support, and referral 78.0%/78.6%; white 70.7%/72.1%; about half spouses 48.4%/46.6%) were randomized to the TASK II intervention (n=123) or to an information, support, and referral group (n=131). Both groups received 8 weekly telephone sessions, with a booster at 12 weeks. General linear models with repeated measures tested efficacy, controlling for patient hospital days and call minutes. Prespecified 8-week primary outcomes were depressive symptoms (with Patient Health Questionnaire Depressive Symptom Scale PHQ-9 ≥5), life changes, and unhealthy days.

RESULTS

Among caregivers with baseline PHQ-9 ≥5, those randomized to the TASK II intervention had a greater reduction in depressive symptoms from baseline to 8, 24, and 52 weeks and greater improvement in life changes from baseline to 12 weeks compared with the information, support, and referral group (P<0.05); but not found for the total sample. Although not sustained at 12, 24, or 52 weeks, caregivers randomized to the TASK II intervention had a relatively greater reduction in unhealthy days from baseline to 8 weeks (P<0.05).

CONCLUSIONS

The TASK II intervention reduced depressive symptoms and improved life changes for caregivers with mild to severe depressive symptoms. The TASK II intervention reduced unhealthy days for the total sample, although not sustained over the long term.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01275495.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee.

RESULTS

Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated.

CONCLUSIONS

Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Abstract W P125: Telephone versus In-person Psychosocial Behavioral Treatment in Post-Stroke Depression

Background: We previously showed that a brief psychosocial behavioral intervention delivered in-person by advanced practice nurses was effective in reducing post-stroke depression (PSD).

Purpose: This randomized clinical trial compared a shortened (6 week) intervention by telephone or in-person to usual care in volunteers within 4 months of an ischemic or hemorrhagic stroke.

Methods: 100 stroke survivors who screened positive for depression (Geriatric Depression Score >11) were randomized to usual care (UC), telephone intervention (TI), or in-person intervention (IPI). Primary outcomes were percent reduction in the Hamilton Depression Rating Scale (HDRS) at 8 weeks, 21 weeks and 12 months following study entry. Outcome assessors were masked to randomization status.

Results: All three groups had similar depression scores at baseline (HDRS mean 18 for UC and TI, 19 for IPI). The mean percent reduction in HDRS scores for telephone and in-person groups was 42% and 40% immediately following the intervention at 8 weeks compared to a 30% reduction in the usual care group. However the difference only trended toward significance, controlling for age, with older age associated with better response (p = 0.31). There was a greater early reduction in depression in the UC group than in our previous work (30% HDRS reduction vs 18% at 8 weeks). By 21 weeks and 12 months following entry there was no significant difference between groups in HDRS reduction (40% UC, 40% TI, 39% IPI and 37% UC, 42% TI and 44% IPI, respectively).

Conclusions: A brief psychosocial intervention for PSD reduced depression somewhat more than usual care (p=.31) right after treatment but the difference between groups was even less at 21 weeks and one year following entry. The reduction in depression was slightly smaller than in our earlier study for the intervention groups, and the usual care group improved more. The comparability of telephone and in-person follow-up and treatment for depression is important given mandated post-hospital follow-up for comprehensive stroke centers. The improved response to brief therapy for older participants suggests tailoring of care to provide individualized follow-up.

Chapter 5 cerebral perfusion pressure and intracranial pressure in traumatic brain injury

Nearly 300,000 children and adults are hospitalized annually with traumatic brain injury (TBI) and monitored for many vital signs, including intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Nurses use these monitored values to infer the risk of secondary brain injury. The purpose of this chapter is to review nursing research on the monitoring of ICP and CPP in TBI. In this context, nursing research is defined as the research conducted by nurse investigators or research about the variables ICP and CPP that pertains to the nursing care of the TBI patient, adult or child. A modified systematic review of the literature indicated that, except for sharp head rotation and prone positioning, there are no body positions or nursing activities that uniformly or nearly uniformly result in clinically relevant ICP increase or decrease. In the smaller number of studies in which CPP is also measured, there are few changes in CPP since arterial blood pressure generally increases along with ICP. Considerable individual variation occurs in controlled studies, suggesting that clinicians need to pay close attention to the cerebrodynamic responses of each patient to any care maneuver. We recommend that future research regarding nursing care and ICP/CPP in TBI patients needs to have a more integrated approach, examining comprehensive care in relation to short- and long-term outcomes and incorporating multimodality monitoring. Intervention trials of care aspects within nursing control, such as the reduction of environmental noise, early mobilization, and reduction of complications of immobility, are all sorely needed.

Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury

OBJECTIVE

The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes.

DESIGN

Retrospective multicenter cohort study.

SETTING

Five regional pediatric trauma centers affiliated with academic medical centers.

PATIENTS

Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86).

CONCLUSIONS

Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.

National variability in intracranial pressure monitoring and craniotomy for children with moderate to severe traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood.

OBJECTIVE

To analyze sources of variability in the use of ICPM and CRANI.

METHODS

Retrospective cross-sectional study of patients with moderate/severe pediatric TBI with the use of data submitted to the American College of Surgeons National Trauma Databank.

RESULTS

We analyzed data from 7140 children at 156 US hospitals during 7 continuous years. Of the children, 27.4% had ICPM, whereas 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than among children treated at adult-only trauma centers (relative risk = 0.80; 95% confidence interval 0.66-0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency toward performing these procedures.

CONCLUSION

Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.

Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

Abstract 86: Methodological Issues in Telephone Interventions for Stroke Survivors and Family Caregivers

Background: Post-stroke follow-up interventions are increasingly delivered by telephone. Though many studies report comparable outcomes for phone and in-person delivery, little is reported regarding the feasibility of using this technology in stroke.

Purpose: We report positive and negative aspects of phone interventions in two ongoing stroke studies, including strategies to overcome limitations

Methods: Study A is comparing a tailored phone intervention with an active listening phone intervention for 254 stroke family caregivers. Study B is comparing tailored in-person versus phone interventions in 100 stroke survivors. Researchers in both studies identified facilitators and barriers to using the telephone.

Results: Advantages of phone delivery included ease of access for both caregivers and survivors, less time commitment, and no pressure to present a good appearance (of the home or self). Study A sessions averaged 30 minutes for the tailored intervention versus 16 minutes for active listening. Caregiver rapport was easily established with both interventions. Nurses expressed relief that the study was conducted by phone given the number of rescheduled appointments. Study B phone sessions were shorter than in-person (25 minutes vs. 35-40). There were particular challenges for survivors who had expressive language difficulty, and motor deficits made it hard for some to hold the phone. Hearing deficits posed difficulty, as well as background noise and the lack of ability to “see” nonverbal cues. Investigators used speaker phones when possible for persons with limitations and also recorded conversations to further interpret responses.

Conclusions: Though telephone delivery poses some challenges, these can be overcome. For stroke caregivers, advantages clearly outweigh the disadvantages, though for stroke survivors, speakerphones and/or videoconferencing may improve quality. Further research using telephone technologies needs to be conducted, particularly in today’s cost-sensitive health care environment where in-person delivery methods are increasingly under scrutiny.

Triage of children with moderate and severe traumatic brain injury to trauma centers

Outcomes after pediatric traumatic brain injury (TBI) are related to pre-treatment factors including age, injury severity, and mechanism of injury, and may be positively affected by treatment at trauma centers relative to non-trauma centers. This study estimated the proportion of children with moderate to severe TBI who receive care at trauma centers, and examined factors associated with receipt of care at adult (ATC), pediatric (PTC), and adult/pediatric trauma centers (APTC), compared with care at non-trauma centers (NTC) using a nationally representative database. The Kids' Inpatient Database was used to identify hospitalizations for moderate to severe pediatric TBI. Pediatric inpatients ages 0 to 17 years with at least one diagnosis of TBI and a maximum head Abbreviated Injury Scale score of ≥3 were studied. Multinomial logistic regression was performed to examine factors predictive of the level and type of facility where care was received. A total of 16.7% of patients were hospitalized at NTC, 44.2% at Level I or II ATC, 17.9% at Level I or II PTC, and 21.2% at Level I or II APTC. Multiple regression analyses showed receipt of care at a trauma center was associated with age and polytrauma. We concluded that almost 84% of children with moderate to severe TBI currently receive care at a Level I or Level II trauma center. Children with trauma to multiple body regions in addition to more severe TBI are more likely to receive care a trauma center relative to a NTC.

Preliminary competencies for comparative effectiveness research

The Clinical and Translational Science Award (CTSA) Workgroup for Comparative Effectiveness Research (CER) Education, Training, and Workforce Development identified a need to delineate the competencies that practitioners and users of CER for patient-centered outcomes research, should acquire. With input from CTSA representatives and collaborators, we began by describing the workforce. We recognize the workforce that conducts CER and the end users who use CER to improve the health of individuals and communities. We generated a preliminary set of competencies and solicited feedback from the CER representatives at each member site of the CTSA consortium. We distinguished applied competencies (i.e., skills needed by individuals who conduct CER) from foundational competencies that are needed by the entire CER workforce, including end users of CER. Key competency categories of relevance to both practitioners and users of CER were: (1) asking relevant research questions; (2) recognizing or designing ideal CER studies; (3) executing or using CER studies; (4) using appropriate statistical analyses for CER; and (5) communicating and disseminating CER study results to improve health. Although CER is particularly broad concept, we anticipate that these preliminary, relatively generic competencies will be used in tailoring curricula to individual learners from a variety of programmatic perspectives.

Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Current US guideline statements regarding primary and secondary cardiovascular risk prediction and prevention use absolute risk estimates to identify patients who are at high risk for vascular disease events and who may benefit from specific preventive interventions. These guidelines do not explicitly include patients with stroke, however. This statement provides an overview of evidence and arguments supporting (1) the inclusion of patients with stroke, and atherosclerotic stroke in particular, among those considered to be at high absolute risk of cardiovascular disease and (2) the inclusion of stroke as part of the outcome cluster in risk prediction instruments for vascular disease.

METHODS AND RESULTS

Writing group members were nominated by the committee co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee and the AHA Manuscript Oversight Committee. The writers used systematic literature reviews (covering the period from January 1980 to March 2010), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard AHA criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive AHA internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. There are several reasons to consider stroke patients, and particularly patients with atherosclerotic stroke, among the groups of patients at high absolute risk of coronary and cardiovascular disease. First, evidence suggests that patients with ischemic stroke are at high absolute risk of fatal or nonfatal myocardial infarction or sudden death, approximating the ≥20% absolute risk over 10 years that has been used in some guidelines to define coronary risk equivalents. Second, inclusion of atherosclerotic stroke would be consistent with the reasons for inclusion of diabetes mellitus, peripheral vascular disease, chronic kidney disease, and other atherosclerotic disorders despite an absence of uniformity of evidence of elevated risks across all populations or patients. Third, the large-vessel atherosclerotic subtype of ischemic stroke shares pathophysiological mechanisms with these other disorders. Inclusion of stroke as a high-risk condition could result in an expansion of ≈10% in the number of patients considered to be at high risk. However, because of the heterogeneity of stroke, it is uncertain whether other stroke subtypes, including hemorrhagic and nonatherosclerotic ischemic stroke subtypes, should be considered to be at the same high levels of risk, and further research is needed. Inclusion of stroke with myocardial infarction and sudden death among the outcome cluster of cardiovascular events in risk prediction instruments, moreover, is appropriate because of the impact of stroke on morbidity and mortality, the similarity of many approaches to prevention of stroke and these other forms of vascular disease, and the importance of stroke relative to coronary disease in some subpopulations. Non-US guidelines often include stroke patients among others at high cardiovascular risk and include stroke as a relevant outcome along with cardiac end points.

CONCLUSIONS

Patients with atherosclerotic stroke should be included among those deemed to be at high risk (≥20% over 10 years) of further atherosclerotic coronary events. Inclusion of nonatherosclerotic stroke subtypes remains less certain. For the purposes of primary prevention, ischemic stroke should be included among cardiovascular disease outcomes in absolute risk assessment algorithms. The inclusion of atherosclerotic ischemic stroke as a high-risk condition and the inclusion of ischemic stroke more broadly as an outcome will likely have important implications for prevention of cardiovascular disease, because the number of patients considered to be at high risk would grow substantially.

An academic-health service partnership in nursing: lessons from the field

PURPOSE

To describe the development of an academic-health services partnership undertaken to improve use of evidence in clinical practice.

APPROACH

Academic health science schools and health service settings share common elements of their missions: to educate, participate in research, and excel in healthcare delivery, but differences in the business models, incentives, and approaches to problem solving can lead to differences in priorities. Thus, academic and health service settings do not naturally align their leadership structures or work processes. We established a common commitment to accelerate the appropriate use of evidence in clinical practice and created an organizational structure to optimize opportunities for partnering that would leverage shared resources to achieve our goal.

FINDINGS

A jointly governed and funded institute integrated existing activities from the academic and service sectors. Additional resources included clinical staff and student training and mentoring, a pilot research grant-funding program, and support to access existing data. Emergent developments include an appreciation for a wider range of investigative methodologies and cross-disciplinary teams with skills to integrate research in daily practice and improve patient outcomes.

CONCLUSIONS

By developing an integrated leadership structure and commitment to shared goals, we developed a framework for integrating academic and health service resources, leveraging additional resources, and forming a mutually beneficial partnership to improve clinical outcomes for patients.

CLINICAL RELEVANCE

Structurally integrated academic-health service partnerships result in improved evidence-based patient care delivery and in a stronger foundation for generating new clinical knowledge, thus improving patient outcomes.

Response to psychosocial treatment in poststroke depression is associated with serotonin transporter polymorphisms

BACKGROUND AND PURPOSE

The Living Well With Stroke study has demonstrated effectiveness of a brief psychosocial treatment in reducing depressive symptoms after stroke. The purpose of this analysis was to determine whether key variables associated with prevalence of poststroke depression also predicted treatment response.

METHODS

Response to a brief psychosocial/behavioral intervention for poststroke depression was measured with the Hamilton Rating Scale for Depression. Analysis of covariance models tested for interaction of potential predictor variables with treatment group on percent change in Hamilton Rating Scale for Depression from pre- to post-treatment as an outcome.

RESULTS

Initial depression severity, hemispheric location, level of social support, age, gender, and antidepressant adherence did not interact with the treatment with respect to percent change in Hamilton Rating Scale for Depression when considered 1 at a time. Participants who carried 1 or 2 s-alleles at the 5-HTTLPR serotonin transporterpolymorphism or 1 or 2 9- or 12-repeats of the STin2 VNTR polymorphism had significantly better response to psychosocial treatment than those with no s-alleles or no 9- or 12-repeats.

CONCLUSIONS

Opposite to the effects of antidepressant drug treatment with selective serotonin reuptake inhibitors, the Living Well With Stroke psychotherapy intervention was most effective in 5-HTTLPR s-allele carriers and STin2VNTR 9- or 12-repeat carriers.

CLINICAL TRIAL REGISTRATION

URL: www.clinicaltrials.gov/ct/show/NCT00194454?order_1. Unique identifier: NCT00194454.

Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches to the implementation of guidelines and their use in high-risk populations.

Hypothermia and rapid rewarming is associated with worse outcome following traumatic brain injury

PURPOSE

The purpose of the present study was to determine (1) the prevalence and degree of hypothermia in patients on emergency department admission and (2) the effect of hypothermia and rate of rewarming on patient outcomes.

METHODS

Secondary data analysis was conducted on patients admitted to a level I trauma center following severe traumatic brain injury (n = 147). Patients were grouped according to temperature on admission according to hypothermia status and rate of rewarming (rapid or slow). Regression analyses were performed.

FINDINGS

Hypothermic patients were more likely to have lower postresuscitation Glasgow Coma Scale scores and a higher initial injury severity score. Hypothermia on admission was correlated with longer intensive care unit stays, a lower Glasgow Coma Scale score at discharge, higher mortality rate, and lower Glasgow outcome score-extended scores up to 6 months postinjury (P < .05). When controlling for other factors, rewarming rates more than 0.25°C/h were associated with lower Glasgow Coma Scale scores at discharge, longer intensive care unit length of stay, and higher mortality rate than patients rewarmed more slowly although these did not reach statistical significance.

CONCLUSION

Hypothermia on admission is correlated with worse outcomes in brain-injured patients. Patients with traumatic brain injury who are rapidly rewarmed may be more likely to have worse outcomes. Trauma protocols may need to be reexamined to include controlled rewarming at rates 0.25°C/h or less.

Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

CONCLUSIONS

Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

THE SELECTIVE ABSORPTION OF POTASSIUM BY ANIMAL CELLS : II. THE CAUSE OF POTASSIUM SELECTION AS INDICATED BY THE ABSORPTION OF RUBIDIUM AND CESIUM

1. Frog muscles perfused with Ringer solution in which potassium chloride has been replaced by an equivalent amount of rubidium or cesium chloride take up rubidium or cesium and incorporate them into the tissue substance in such form as to be retained during a subsequent perfusion with potassium-free Ringer solution, provided the muscles contract during the first perfusion. Retention of rubidium or cesium by a resting muscle does not occur. 2. Rats on synthetic diets, adequate in all respects except that potassium was replaced by an equivalent amount of rubidium or cesium, died after a period varying from 10 to 17 days with characteristic symptoms including tetanic spasms. Muscle, heart, liver, kidney, spleen, and lung tissues were then found to contain significant amounts of rubidium or cesium. The concentration of these metals in the muscle amounted, in some cases, as shown by a spectroscopic estimation, to about half the concentration of potassium normally found in mammallian muscle. 3. The results are regarded as tending to confirm the theory that the peculiarities in the physiological effects of potassium, including the facility with which it is "selected" by living cells in preference to sodium, are related to the electronic structure of the potassium ion as compared with that of similar ions. The possible relationship of the comparative migration velocity, a function of the electronic structure, to physiological effects is suggested.

ELECTROMETRIC DETERMINATIONS OF THE DISSOCIATION OF GLYCOCOLL AND SIMPLE PEPTIDES

1. The apparent acid and basic dissociation constants were determined potentiometrically by the methods of hydrolysis and of titration for the following ampholytes: Glycocoll, glycylglycocoll, alanylglycocoll, valylglycocoll, leucylglycocoll, methylleucylglycocoll, phenylalanylglycocoll and glycylglycylglycocoll. The constants were also determined in the presence of KCl and of K₂SO₄ at equal ionic strength. 2. In general, the relative order of magnitude of the constants decreased as the number of carbon atoms between amino and carboxyl groups increased. An explanation of this is offered on the basis of theories of electronic structure. 3. The application of the modern concepts of solutions to the case of the ampholytic ions is discussed. The inadequacy of the present theories is pointed out. 4. The constants were found, in general, to be functions of the hydrogen ion activity and the ionic strength of the solutions. Apparent contradictions to the Debye-Hückel theory are pointed out and partially explained on the basis of specific ion effects.

THE SELECTIVE ABSORPTION OF POTASSIUM BY ANIMAL CELLS : I. CONDITIONS CONTROLLING ABSORPTION AND RETENTION OF POTASSIUM

1. Individual variations in the potassium content of the fresh muscles of frogs are notable even when computed as percentages of the dry solids. The potassium content averaged higher in freshly collected summer frogs than in winter frogs after a period of captivity. 2. Muscles show a loss of from 8 to 15 per cent of their potassium during perfusion with potassium-free Ringer solution but tenaciously hold the remainder. 3. Muscles, stimulated to contract under conditions that do not produce irreversible stages of fatigue, show losses of potassium no greater than those attributable to the presence of a potassium-free medium. 4. A condition favorable to the taking up of potassium probably occurs in a contracting muscle because rubidium and cesium, substances very similar to potassium in chemical and physiological behavior, are absorbed in retainable form by a contracting muscle but not by a resting one.

Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial

BACKGROUND AND PURPOSE

Depression after stroke is prevalent, diminishing recovery and quality of life. Brief behavioral intervention, adjunctive to antidepressant therapy, has not been well evaluated for long-term efficacy in those with poststroke depression.

METHODS

One hundred one clinically depressed patients with ischemic stroke within 4 months of index stroke were randomly assigned to an 8-week brief psychosocial-behavioral intervention plus antidepressant or usual care, including antidepressant. The primary end point was reduction in depressive symptom severity at 12 months after entry.

RESULTS

Hamilton Rating Scale for Depression raw score in the intervention group was significantly lower immediately posttreatment (P<0.001) and at 12 months (P=0.05) compared with control subjects. Remission (Hamilton Rating Scale for Depression <10) was significantly greater immediately posttreatment and at 12 months in the intervention group compared with the usual care control. The mean percent decrease (47%+/-26% intervention versus 32%+/-36% control, P=0.02) and the mean absolute decrease (-9.2+/-5.7 intervention versus -6.2+/-6.4 control, P=0.023) in Hamilton Rating Scale for Depression at 12 months were clinically important and statistically significant in the intervention group compared with control.

CONCLUSIONS

A brief psychosocial-behavioral intervention is highly effective in reducing depression in both the short and long term.

Detrended fluctuation analysis of intracranial pressure predicts outcome following traumatic brain injury

Detrended fluctuation analysis (DFA) is a recently developed technique suitable for describing scaling behavior of variability in physiological signals. The purpose of this study is to explore applicability of DFA methods to intracranial pressure (ICP) signals recorded in patients with traumatic brain injury (TBI). In addition to establishing the degree of fit of the power-law scaling model of detrended fluctuations of ICP in TBI patients, we also examined the relationship of DFA coefficients (scaling exponent and intercept) to: 1) measures of initial neurological functioning; 2) measures of functional outcome at six month follow-up; and 3) measures of outcome, controlling for patient characteristics, and initial neurological status. In a sample of 147 moderate-to-severely injured TBI patients, we found that a higher DFA scaling exponent is significantly associated with poorer initial neurological functioning, and that lower DFA intercept and higher DFA scaling exponent jointly predict poorer functional outcome at six month follow-up, even after statistical control for covariates reflecting initial neurological condition. DFA describes properties of ICP signal in TBI patients that are associated with both initial neurological condition and outcome at six months postinjury.

Comparing perceived burden for Korean and American informal caregivers of stroke survivors

Little is known about the burden of cross-cultural care for stroke patients. This article compares the perceived burden for caregivers of stroke survivors in Korea and the United States. A brief interview was conducted to determine specific problem areas for caregivers. Caregiver burden (using the Sense of Competence Questionnaire) and social support (using the ENRICHD Social Support Inventory) also were measured. The overall-sense-of-burden-from-caregiving score was significantly higher in the Korean cohort than in the American cohort, as was the scale regarding satisfaction with the relationship with the recipient of care. The primary predictors of overall burden for the combined sample were caregiver and patient depression and insufficient social support. Lower perceived social support among Korean caregivers was strongly related to caregiver depression, while it was more strongly related to increased hours of caregiving in the American sample. These findings can help rehabilitation nurses plan supportive interventions that incorporate cultural values for stroke survivors and their caregivers.

Intracranial pressure variability and long-term outcome following traumatic brain injury

BACKGROUND

Research suggests that intracranial pressure (ICP) dynamics beyond just absolute ICP level provide information reflecting intracranial adaptive capacity. Specifically, evidence indicates that physiologic variability provides information about system functioning that may reflect dimensions of adaptive capacity. The purpose of this study was to examine the association between ICP variability in patients following moderate to severe traumatic brain injury (TBI) and outcome at hospital discharge and 6 months post-injury.

METHODS

ICP was monitored continuously for 4 days in 147 patients (78% male; mean (SD) age = 37 years (18 years)). ICP variability indices were calculated for four time scales (24 h, 60 min, 5 min and 5 s). Functional outcome was assessed using the Extended Glasgow Outcome Scale (GOSE). Logistic regression was used to estimate odds of survival or favorable outcome, and ordinal regression was used to estimate odds for outcome above versus below GOSE thresholds, predicted by ICP variability, controlling for age, gender, Glasgow Coma Scale motor score, craniectomy, and ICP level.

FINDINGS

ICP variability indices were better predictors of 6-month outcome than mean ICP. Survival was significantly associated with greater 5-s ICP variability (p < 0.001). Higher ICP variability on shorter time scales was associated with better functional outcome (5-s RMSSD, 5-min SD: p < 0.002; 60-min SD: p < 0.011).

CONCLUSIONS

ICP variability may reflect the degree of intactness of intracranial adaptive ability.