Repeatability and comparability of automated keratometry: the Nikon NRK-8000, the Nidek KM-800 and the Bausch and Lomb keratometer

This study assessed the repeatability of the Nikon NRK-8000, the Nidek KM-800 and the Bausch and Lomb keratometer. In addition, the comparability of the Nikon NRK-8000 and the Nidek KM-800 are evaluated relative to the Bausch and Lomb keratometer. Measurements were taken with all three techniques on two separate occasions with a test-retest separation of at least 24 hr. The right eyes of 30 normal subjects were used. Repeatability and comparability statistics and plots were generated using matrix representations of dioptric power. The Nidek KM-800 coefficient of repeatability values were found to be 0.345, 0.187, and 0.321 in the vertical, torsional, and horizontal meridians while the Nikon NRK-8000 values were 0.346, 0.232, and 0.276 respectively.

Osteopenia in children surviving brain tumours

Osteopenia has been reported in children surviving acute lymphoblastic leukaemia, apparently as a consequence of therapy. It has been suggested that cranial irradiation may play a crucial role in this disorder. To explore that possibility, survivors of brain tumours in childhood, all of whom had received radiotherapy, were examined for evidence of bone mineral loss. 19 children were assessed, on average at 7 years after treatment. Measurements of growth velocities, plain radiography of the skeleton, bone densitometry, health-related quality of life and physical activity were undertaken. Growth hormone (GH) deficiency had been detected in 6 children and 5 had received GH replacement, for a minimum of more than 3 years. 9 children were radiographically osteopenic (including the 5 who had received GH). Z scores for bone mineral density (BMD) were negative in the majority of children. Health-related quality of life was less and pain more frequent in those with low BMD scores. Pain was correlated negatively with both free-time activity and seasonal activity (P < 0.01). Osteopenia is a common sequel of therapy in children with brain tumours. Those with osteopenia have more pain and more compromised, health-related quality of life than those who are not osteopenic, and pain significantly limits physical activity. The pathogenesis of osteopenia in these children is still uncertain, but is likely to be multifactorial.

Advancing nursing practice: acute care nurse practitioners meet challenges at and beyond the health care horizon

Preparation of advanced practice nurses (APNs) with acute care skills relevant to today's health care environment is a challenge faced by nurse educators, care providers, professional organizations, and regulatory agencies. The acute care nurse practitioner (ACNP) is prepared to provide multidimensional, risk-appropriate management of medically vulnerable patients with serious illness in a variety of settings. ACNPs conduct comprehensive health assessments, order and interpret diagnostic tests, diagnose and manage health problems and disease-related symptoms, prescribe and evaluate drugs and treatments, and coordinate care during setting transitions. Working independently and collaboratively the ACNP enhances access to care and quality of care for patients and families through cost-effective, outcome-oriented practice. This article describes health care market factors fostering ACNP practice, ACNP practice domain, the University of Washington ACNP program, and collaborative contributions from educators, care providers, professional organizations, and regulatory groups needed to implement the role.

A patient questionnaire approach to estimating the prevalence of dry eye symptoms in patients presenting to optometric practices across Canada

OBJECTIVE

To collect questionnaire data from patients in a large clinical population that would allow for an estimate of the prevalence of self-reported symptoms of dry eyes.

METHODS

A 13-point questionnaire (The Canada Dry Eye Epidemiology Study, CANDEES) was mailed to all optometric practices in Canada in October 1994, with the request that it be completed by 30 successive nonselected patients.

RESULTS

Four hundred fifty sets of questionnaires (total, 13,517) were analyzed (a 15.7% return rate) from patients aged from < 10 years to > 80 years; 55% were in the 21- to 50-year age group; 60.7% were female; and 24.3% were contact lens wearers. A total of 28.7% reported dry eye symptoms, of whom 24.2% reported concurrent dry mouth, 24.5% had worse symptoms in the morning, 30.3% reported concurrent lid problems, and 35.7% reported a history of allergies. Of the 3716 patients reporting symptoms, 62 (1.6%) were in the "severe" category and 290 (7.8%) were in the "constant but moderate" category. Contact lens wear, concurrent allergies, dry mouth, lid problems, or use of medications increased the chance of a patient reporting dry eye symptoms.

CONCLUSIONS

The prevalence of patients reporting any level of symptoms of dry eyes was approximately 1 in 4; severe symptoms were reported by 1 in 225 patients.

Repeatability and accuracy of automated refraction: a comparison of the Nikon NRK-8000, the Nidek AR-1000, and subjective refraction

This study assessed the repeatability of the Nikon NRK-8000, the Nidek AR-1000, and subjective refraction. In addition, the accuracy of the Nikon and the Nidek were evaluated in comparison to subjective refraction. Measurements were taken with all 3 techniques on 2 separate occasions with a test-retest separation of at least 24 h. The right eyes of 30 normal subjects were used. Repeatability and accuracy statistics and plots were generated using matrix representations of dioptric power. Subjective refraction was the most repeatable method, with the coefficient of repeatability (COR) found to be 0.611, 0.224, and 0.490 in the vertical, torsional, and horizontal meridians. The autorefractors' COR was found to range from 0.712 to 0.826 for the vertical and horizontal meridians, whereas the torsional meridian ranged from 0.224 to 0.319.

Baccalaureate nurse educators' and critical care nurse managers' perceptions of clinical competencies necessary for new graduate baccalaureate critical care nurses

BACKGROUND: Although nurse educators and nurse managers have disagreed about which clinical competencies are necessary for new graduates to begin working in critical care, the competencies are in need of revision and reassessment. OBJECTIVES: To validate a list of beginning-level competencies and to compare baccalaureate nurse educators' and critical care nurse manager's current perceptions of beginning clinical competencies for new baccalaureate graduates in critical care settings. METHODS: An expert panel of nurses from across the United States critiqued a questionnaire about which clinical competencies were considered relevant to critical care nursing practice. The revised questionnaire, containing 105 clinical competencies, was mailed to a randomly selected sample across the United States. Forty-one baccalaureate nurse educators and 41 critical care nurse managers completed the mail survey questionnaire (94% response rate) by rating the necessity ("essential," "desired," or "not required") of the clinical competencies for new baccalaureate nurses. RESULTS: A high degree of agreement was generally seen between nurse educators and nurse managers on the necessity ratings of the 105 competencies. The majority of nurse educators and nurse managers rated 81 of the 105 competencies as either "essential" or "desirable." Only five competencies showed considerable disagreement between nurse educators and nurse managers, and none of these competencies were rated "essential" by more than a few raters in either group. CONCLUSIONS: The agreement between nurse educators and nurse managers supports a competency list for baccalaureate nursing curricula and hospital inservice programs to integrate new graduates into critical care.

Baccalaureate nurse educators' and critical care nurse managers' perceptions of clinical competencies necessary for new graduate baccalaureate critical care nurses

BACKGROUND

Although nurse educators and nurse managers have disagreed about which clinical competencies are necessary for new graduates to begin working in critical care, the competencies are in need of revision and reassessment.

OBJECTIVES

To validate a list of beginning-level competencies and to compare baccalaureate nurse educators' and critical care nurse manager's current perceptions of beginning clinical competencies for new baccalaureate graduates in critical care settings.

METHODS

An expert panel of nurses from across the United States critiqued a questionnaire about which clinical competencies were considered relevant to critical care nursing practice. The revised questionnaire, containing 105 clinical competencies, was mailed to a randomly selected sample across the United States. Forty-one baccalaureate nurse educators and 41 critical care nurse managers completed the mail survey questionnaire (94% response rate) by rating the necessity ("essential," "desired," or "not required") of the clinical competencies for new baccalaureate nurses.

RESULTS

A high degree of agreement was generally seen between nurse educators and nurse managers on the necessity ratings of the 105 competencies. The majority of nurse educators and nurse managers rated 81 of the 105 competencies as either "essential" or "desirable." Only five competencies showed considerable disagreement between nurse educators and nurse managers, and none of these competencies were rated "essential" by more than a few raters in either group.

CONCLUSIONS

The agreement between nurse educators and nurse managers supports a competency list for baccalaureate nursing curricula and hospital inservice programs to integrate new graduates into critical care.

Implementation and evaluation of a liberalized visiting policy

BACKGROUND

Visiting policies have been liberalized in ICUs, but the process and outcome of policy modifications have not been well described.

OBJECTIVES

To describe the process by which nurses in one critical care unit modified visiting from a restricted to a liberalized (i.e., modified open) policy, and to evaluate the nurses' perceptions about visiting before and after the policy was liberalized.

METHODS

A group of ICU/coronary care unit nurses met to discuss changes in their unit's visiting policy. Before the change was initiated, nurses (N = 36) in the unit were informally surveyed regarding their perceptions and attitudes about visiting. After a 3-month trial of liberalized visiting, in which visiting hours were increased at the discretion of the nursing staff, nurses (N = 32) were surveyed using a questionnaire about their beliefs, attitudes, level of satisfaction, and perceptions of their actual visiting policy.

RESULTS

Nurses confirmed that the visiting policy had become liberalized, and they believed that liberalized visiting had positive effects on patients' emotional well-being. Nurses had more positive attitudes about the effects of liberalized visiting on families than on patients and unit function. Most nurses were satisfied with liberalized visiting. However, attitudes differed about how liberalized visiting affected patients' physiological responses or the unit function.

CONCLUSIONS

Effective implementation of liberalized visiting depends on assessment of the following: nurses' beliefs, attitudes, and satisfaction about a change toward a more open visiting policy; staff involvement in determining the policy; and nurse manager and clinical nurse specialist support.

Implementation and evaluation of a liberalized visiting policy

BACKGROUND: Visiting policies have been liberalized in ICUs, but the process and outcome of policy modifications have not been well described. OBJECTIVES: To describe the process by which nurses in one critical care unit modified visiting from a restricted to a liberalized (i.e., modified open) policy, and to evaluate the nurses' perceptions about visiting before and after the policy was liberalized. METHODS: A group of ICU/coronary care unit nurses met to discuss changes in their unit's visiting policy. Before the change was initiated, nurses (N = 36) in the unit were informally surveyed regarding their perceptions and attitudes about visiting. After a 3-month trial of liberalized visiting, in which visiting hours were increased at the discretion of the nursing staff, nurses (N = 32) were surveyed using a questionnaire about their beliefs, attitudes, level of satisfaction, and perceptions of their actual visiting policy. RESULTS: Nurses confirmed that the visiting policy had become liberalized, and they believed that liberalized visiting had positive effects on patients' emotional well-being. Nurses had more positive attitudes about the effects of liberalized visiting on families than on patients and unit function. Most nurses were satisfied with liberalized visiting. However, attitudes differed about how liberalized visiting affected patients' physiological responses or the unit function. CONCLUSIONS: Effective implementation of liberalized visiting depends on assessment of the following: nurses' beliefs, attitudes, and satisfaction about a change toward a more open visiting policy; staff involvement in determining the policy; and nurse manager and clinical nurse specialist support.

Optical blur and the perception of global coherent motion in random dot cinematograms

We evaluated the effect of +3.25 dioptres of optical blur on the discrimination of motion direction in random dot cinematograms. Dot displacement between frames varied from 2.1 to 63' of visual angle while the temporal interval was held constant. Optical blur worsened discrimination in three normal subjects at displacements below 16', but improved discrimination at displacements of 21' or more. In a second experiment, two subjects viewed equivalent velocity stimuli constructed with different combinations of temporal interval and spatial displacement. Results showed that the effect of blur was specific to displacement and not velocity. Furthermore, varying the dot density of the display showed that the effect of blur correlated with dot displacement and not the probability of dot mismatches. Since optical blur attenuates high spatial frequencies, this suggests that high spatial frequencies are important for motion perception when dot displacements are less than 16' to 21', but reduce motion perception at larger dot displacements. The use of random dot cinematograms in populations must take into account stimulus displacement and optical causes of reduced spatial acuity.

Functional MRI of lateral occipitotemporal cortex during pursuit and motion perception

We performed functional imaging with a conventional 1.5-T magnetic resonance scanner in 9 normal subjects. We used a gradient-echo technique to examine changes in signal between periods when subjects viewed a stationary black-and-white grating, a moving grating, and when they followed a moving spot. We located image pixels with significant differences between the viewing conditions. In 7 subjects, these occurred in the lateral occipitotemporal cortex, a region previously identified as a putative human homologue of the motion-sensitive middle temporal area (MT, or V5) of monkeys. Signal intensity was greater during pursuit of the moving dot than during viewing of the moving grating with the eyes still, despite the fact that the moving grating generated more retinal image motion. In contrast, signal intensity in striate cortex was least during pursuit of the moving dot. These findings suggest that the lateral occipitotemporal cortex has extraretinal signals during pursuit. Such signals may include attentional input, corollary eye movement information, or even a pursuit command. Extraretinal signals suggest that the lateral occipitotemporal cortex may contain a human homologue not only of MT but also of other components of the monkey V5 complex, such as the medial superior temporal area.

Role of endogenous renin-angiotensin system in c-fos activation and PKC-epsilon translocation in adult rat hearts

Myocardial stretch and the renin-angiotensin system have been implicated in the development of cardiac hypertrophy through the activation of specific target genes. However, the relative importance of these putative hypertrophic stimuli has not been established in vivo. We used an isolated isovolumic heart preparation in which coronary perfusion pressure (CPP), left ventricular end-diastolic pressure, and pharmacological therapy can be independently manipulated to study this relationship. High CPP (140 cmH2O), which increased coronary flow (8.99 vs. 17.6 ml/min) and left ventricular systolic pressure (50 vs. 91 mmHg), increased steady state c-fos mRNA expression 2.3-fold (all P < 0.01 vs. low CPP). In contrast, increased left ventricular end-diastolic pressure (25 mmHg) and/or infusion of angiotensin II in the absence of increased CPP was not associated with an increase in c-fos mRNA expression. The change in c-fos gene expression seen with increased CPP was largely reversed by treatment with an angiotensin type 1 (AT1) receptor blocker. Hearts perfused at high CPP demonstrated increased translocation/activation of protein kinase C-epsilon relative to controls. None of the hearts studied were ischemic during perfusion. Thus, in the perfused adult rat heart, dynamic, but not static, stretch activates the early response gene, c-fos, and may involve the endogenous reninangiotensin system and protein kinase C.

Relationships among sleep dimensions and factors that impair sleep after cardiac surgery

Factors associated with the attempted length, disturbance, effectiveness, and nap supplementation of sleep were analyzed in 97 patients recovering from cardiac surgery a few days before hospital discharge. Patients rated sleep for the prior night and factors that impaired their sleep after transfer from the critical care unit. The group averaged little sleep, with moderate disturbance and effectiveness and low nap supplementation. The disturbance, effectiveness, and attempted length of sleep were associated with an inability to perform their usual routine before sleep, inability to get comfortable, pain, noises, procedural care, and an unfamiliar bed. Patients encounter difficulties with sleep, even near discharge from the hospital. Interventions should be tested to mitigate specific factors that affect selected dimensions of sleep.

Patients' perceptions of environmental factors that disturb sleep after cardiac surgery

BACKGROUND

Effective management of sleep disturbances after cardiac surgery requires insight into patients perceptions of which factors disturb sleep in the intensive care unit and after transfer from the intensive care unit.

OBJECTIVE

To describe patients perceptions of environmental factors that disturbed sleep after cardiac surgery.

SAMPLE

A convenience sample of 102 patients was surveyed in a 300-bed, acute-care teaching hospital.

METHOD

Patients were interviewed several days before discharge from the hospital and rated the extent to which specific factors disturbed their sleep while in the intensive care unit and after transfer.

RESULTS

The group mean for the extent of disturbance scores, averaged across all 35 environmental factors studied, was low during and after stay in the intensive care unit. However, selected items such as pain, and inability to get comfortable and perform a familiar nighttime routine, were moderately disturbing to many patients across phases of recovery. Patients varied widely in the number of factors, ranging from 0 to 33 factors, that disturbed sleep at least to some extent. Patients added factors that were not included in the original monitoring instrument.

CONCLUSIONS

Patients attribute disturbed sleep to specific factors after cardiac surgery. The number of factors that disturb sleep varies among patients. Nurses can modify many of the factors that disturb sleep to promote an environment that will facilitate improved sleep, thereby enhancing the acute phase of recovery from cardiac surgery.

Patients' perceptions of environmental factors that disturb sleep after cardiac surgery

BACKGROUND: Effective management of sleep disturbances after cardiac surgery requires insight into patients perceptions of which factors disturb sleep in the intensive care unit and after transfer from the intensive care unit. OBJECTIVE: To describe patients perceptions of environmental factors that disturbed sleep after cardiac surgery. SAMPLE: A convenience sample of 102 patients was surveyed in a 300-bed, acute-care teaching hospital. METHOD: Patients were interviewed several days before discharge from the hospital and rated the extent to which specific factors disturbed their sleep while in the intensive care unit and after transfer. RESULTS: The group mean for the extent of disturbance scores, averaged across all 35 environmental factors studied, was low during and after stay in the intensive care unit. However, selected items such as pain, and inability to get comfortable and perform a familiar nighttime routine, were moderately disturbing to many patients across phases of recovery. Patients varied widely in the number of factors, ranging from 0 to 33 factors, that disturbed sleep at least to some extent. Patients added factors that were not included in the original monitoring instrument. CONCLUSIONS: Patients attribute disturbed sleep to specific factors after cardiac surgery. The number of factors that disturb sleep varies among patients. Nurses can modify many of the factors that disturb sleep to promote an environment that will facilitate improved sleep, thereby enhancing the acute phase of recovery from cardiac surgery.

Individual factors that influence sleep after cardiac surgery

BACKGROUND: Up to 50% of patients who undergo cardiac surgery report problems with sleep after cardiac surgery. Knowledge about which individual factors are associated with sleep problems after cardiac surgery would help nurses identify patients who are at greater risk for sleep problems during hospitalization. OBJECTIVE: To compare patients perceptions of sleep before and during hospitalization for cardiac surgery and identify and analyze individual factors in relation to patients perceptions of sleep. METHOD: A sample of 102 patients who underwent elective or emergent cardiac surgery were studied at a 300-bed teaching hospital in the northwestern United States. A few days before their anticipated discharge from the hospital, consenting patients completed questions about their sleep before hospitalization and the night before their interview. RESULTS: Patients reported that they slept fewer hours in the hospital than at home. No differences were found in patients perceived depth and sufficiency of sleep, or refreshment before and after surgery. Patients who slept poorly at home did not report any worse sleep after surgery than patients who slept well at home. Women's perceptions about the sufficiency, refreshment, and quality of sleep were consistent before and after surgery, but no relationships were found among men's ratings. The length of sleep at home was positively related to the length of sleep after surgery in older patients. CONCLUSIONS: Sleep length is related to patients perceptions of sleep after cardiac surgery. Gender and age are also related to qualitative aspects of sleep before and after surgery and can be instrumental in an individualized assessment of sleep patterns anticipated after cardiac surgery.

Individual factors that influence sleep after cardiac surgery

BACKGROUND

Up to 50% of patients who undergo cardiac surgery report problems with sleep after cardiac surgery. Knowledge about which individual factors are associated with sleep problems after cardiac surgery would help nurses identify patients who are at greater risk for sleep problems during hospitalization.

OBJECTIVE

To compare patients perceptions of sleep before and during hospitalization for cardiac surgery and identify and analyze individual factors in relation to patients perceptions of sleep.

METHOD

A sample of 102 patients who underwent elective or emergent cardiac surgery were studied at a 300-bed teaching hospital in the northwestern United States. A few days before their anticipated discharge from the hospital, consenting patients completed questions about their sleep before hospitalization and the night before their interview.

RESULTS

Patients reported that they slept fewer hours in the hospital than at home. No differences were found in patients perceived depth and sufficiency of sleep, or refreshment before and after surgery. Patients who slept poorly at home did not report any worse sleep after surgery than patients who slept well at home. Women's perceptions about the sufficiency, refreshment, and quality of sleep were consistent before and after surgery, but no relationships were found among men's ratings. The length of sleep at home was positively related to the length of sleep after surgery in older patients.

CONCLUSIONS

Sleep length is related to patients perceptions of sleep after cardiac surgery. Gender and age are also related to qualitative aspects of sleep before and after surgery and can be instrumental in an individualized assessment of sleep patterns anticipated after cardiac surgery.

Multiple sclerosis can cause visual processing deficits specific to texture-defined form

We performed the following tests in 25 patients with multiple sclerosis (MS) and 25 age-matched control subjects: recognition of texture-defined (TD) letters; recognition of motion-defined (MD) letters; and recognition of luminance-defined (LD) letters of 96% and 11% contrasts. Six patients with normal visual acuity were abnormal on recognizing TD letters, of whom one gave normal results on all other tests. Eleven patients were abnormal on MD letter recognition, of whom four gave normal results on all other tests. Visual acuity for letters of 11% contrast were abnormally low in seven patients, of whom two gave normal results on all other tests. We conclude that the neural mechanisms underlying recognition of TD, MD, and low-contrast LD letters in subjects with normal visual acuity are sufficiently different that they can be differentially damaged by MS. Therefore, TD, MD, and LD letter tests provide complementary information. We suggest that the detection of TD letters can be disrupted by demyelination of long-range horizontal connections between orientation-tuned neurons in the striate cortex.

A pilot study of pain, analgesia use, and pulmonary function after colectomy with or without a preoperative bolus of epidural morphine

OBJECTIVE

To determine whether patients who received a preoperative bolus of epidural morphine plus postoperative parenteral analgesia had less pain and better pulmonary function over the first 2 days after a colectomy than patients who received postoperative parenteral analgesia alone.

DESIGN

Repeated measures, quasi-experimental, random assignment.

SETTING

Northeastern general hospital.

SUBJECTS

Thirteen patients were randomized to receive parenteral with (n = 6) or without (n = 7) epidural analgesia.

OUTCOME MEASURES

Indicators of pain (intensity of pain and pain-related distress, intensity of words used to describe pain, intramuscular-equivalent amount of morphine administered, duration from start of surgery to first request for analgesia) and pulmonary function (forced expiratory volume in one second FEV1], forced vital capacity [FVC], inspiratory capacity [IC], peripheral oxygen saturation [SaO2] values).

MEASUREMENT

Indicators of pain and pulmonary function were obtained the day before surgery, approximately 6 hours after surgery, and the first two mornings after surgery.

RESULTS

Six hours after surgery, patients in the epidural group had less pain (p = 0.0177) and related distress (p = 0.0303) and greater FVC (p = 0.0303) and FEV1 (p = 0.0025) than patients in the no-epidural group. On the first postoperative morning, patients in the epidural group had less distress related to pain (p = 0.0350) but similar respiratory rates and spirometry values. Inspiratory capacity was not statistically different but was always larger in the epidural group. Of patients who breathed room air, SaO2 was higher in the epidural group over the first two postoperative days (p = 0.0286 each occasion). Patients in the epidural group received their first on-demand analgesic an average of 30 hours after the start of surgery compared with 6 hours for patients in the no-epidural group (p = 0.0022). There were no significant differences in the total number of words used to describe the type of pain, and both groups described the pain with fewer words than expected on the first and second mornings after surgery.

CONCLUSIONS

Results should be confirmed through study of a larger sample with the hypothesis that pain relief, selected aspects of pulmonary function, and peripheral oxygenation may be superior for patients who receive a preoperative bolus of epidural analgesia for abdominal surgery.

Visit preferences of middle-aged vs older critically ill patients

OBJECTIVE: To differentiate between middle-aged and older adults' visiting preferences in critical care settings. DESIGN: Patients' preferences for visiting, perceptions of illness severity and extent of fatigue associated with visiting and an objective measurement of illness severity while in critical care were surveyed within 3 days after transfer from the critical care unit. SETTING: Interviews occurred on the transitional care units with patients who transferred from either the coronary care or surgical intensive care units in a large Northeast teaching hospital. PATIENTS: Fifty-three middle-aged (35 through 65 years) and 46 older (over 65 years) patients were surveyed (N = 99). RESULTS: Both middle-aged and older patients consistently wanted to limit the number of visitors to two or three persons per visit. Compared with middle-aged patients, a greater proportion of older patients preferred to limit visits to once a day and wanted the visit length to be unlimited. A greater proportion of older coronary care unit patients preferred to limit visits to two times a day than older surgical unit patients. CONCLUSIONS: Middle-aged and older patients differed in their preferences for visits, with sufficient variation in responses to warrant tailoring visits to the unique preferences of patients based on age and clinical setting.

Visit preferences of middle-aged vs older critically ill patients

OBJECTIVE

To differentiate between middle-aged and older adults' visiting preferences in critical care settings.

DESIGN

Patients' preferences for visiting, perceptions of illness severity and extent of fatigue associated with visiting and an objective measurement of illness severity while in critical care were surveyed within 3 days after transfer from the critical care unit.

SETTING

Interviews occurred on the transitional care units with patients who transferred from either the coronary care or surgical intensive care units in a large Northeast teaching hospital.

PATIENTS

Fifty-three middle-aged (35 through 65 years) and 46 older (over 65 years) patients were surveyed (N = 99).

RESULTS

Both middle-aged and older patients consistently wanted to limit the number of visitors to two or three persons per visit. Compared with middle-aged patients, a greater proportion of older patients preferred to limit visits to once a day and wanted the visit length to be unlimited. A greater proportion of older coronary care unit patients preferred to limit visits to two times a day than older surgical unit patients.

CONCLUSIONS

Middle-aged and older patients differed in their preferences for visits, with sufficient variation in responses to warrant tailoring visits to the unique preferences of patients based on age and clinical setting.

Unreliability of platelet glucose-6-phosphatase for the diagnosis of glycogen storage disease type Ia

The diagnosis of glycogen storage disease type Ia currently uses enzyme analysis of liver tissue. This requires liver biopsy in the at-risk neonate or fetus. Conflicting reports have appeared in the literature on the use of peripheral platelet glucose-6-phosphatase activity for the diagnosis of this disorder. We have applied a sensitive radiometric assay system to the measurement of glucose-6-phosphatase activity in peripheral platelets. Two families with affected members were analysed, revealing no differences in glucose-6-phosphatase activity as compared with control values. Platelet measurement of glucose-6-phosphatase does not appear to be useful for the diagnosis of glycogen storage disease type Ia.

Monocular acuity in the presence and absence of fusion

Because little is known about monocular acuity during binocular fusion, acuity of the right eye was measured in binocularly normal subjects, with the fellow eye open or fully occluded. The target was flashed for 65 ms or presented sinusoidally for 1 s. Subjects had both eyes optimally focused, or the right eye defocused by +3.00 D. Monocular acuities were equivalent during fusion or occlusion when both eyes were optimally focused. Acuity of the defocused eye was reduced when the fellow eye was open compared to when it was occluded. Suppression of the blur, therefore, produced a measurable reduction in recognition thresholds. As monocular acuity was not measurably affected by the fellow eye when each eye was in focus, the finding that monocular vision is improved with the fellow eye occluded should be ascribed to something other than suppression or more sensitive spatial measures of the suppression should be obtained.

Surgical treatment of ductal carcinoma in situ of the breast. 10- to 20-year follow-up

Between 1967 and 1977, 36 patients received treatment at the Virginia Mason Medical Center in Seattle, Wash, for ductal carcinoma in situ of the breast. Twenty-five patients had modified radical mastectomies, 10 had radical mastectomies, and one had a simple mastectomy. Twenty-seven patients have been followed up for at least 10 years and are without known recurrence (mean follow-up, 17.7 years; range, 8 to 24 years), eight patients died without known recurrence (mean follow-up, 10.6 years; range, 6 to 14 years), and one patient with a prior contralateral mastectomy for infiltrating cancer of the breast had a recurrence in the scalene nodes on the side of the infiltrating cancer and died of metastatic cancer. No patients with ductal carcinoma in situ had local recurrences in the ipsilateral breast or chest wall, and no patients developed cancers in the contralateral breast; one patient had axillary metastasis. Twenty-eight (78%) of 36 patients had multicentric ductal carcinoma in situ in their mastectomy specimens. Twenty-three (88%) of 26 patients with comedocarcinoma-type ductal carcinoma in situ had multicentric lesions. Conversely, patients with low-grade nuclear papillary ductal carcinoma in situ did not have multicentric lesions. Five (14%) of 36 patients had incidental microinvasion discovered in the mastectomy specimens; all had comedocarcinoma. In summary, our study of patients with ductal carcinoma in situ revealed that (1) mastectomy provided excellent local and systemic control; (2) cancer in the contralateral breast was infrequent; (3) axillary metastasis was rare; and (4) histologic features of tumors markedly affected the frequency of multicentricity and chance for microinvasion.

The effects of epidural versus parenteral opioid analgesia on postoperative pain and pulmonary function in adults who have undergone thoracic and abdominal surgery: a critique of research

Studies comparing epidural and parenteral opioid analgesia for patients experiencing thoracic or abdominal surgery are analyzed with respect to differences in postoperative pain and pulmonary function. Although most studies suggest that epidural analgesia is superior for postoperative pain relief, few clearly demonstrate an improvement in pulmonary function attributable to epidural analgesia. Recommendations for future research are proposed to improve the design, measurement, analysis, and reporting of studies. Research relevant to the nursing care of patients receiving epidural analgesia is suggested.

Critical care patients' perceptions of visits

Although visiting has been studied from nurses' and families' perspectives, patients' preferences for visits and their evaluations of visits have not been explored. In addition, coronary care unit (CCU) and surgical intensive care unit (SICU) patients' visit preferences have not been compared. Relationships among patients' preferences for visits, select personal and illness characteristics, and the perceived impact of visits were compared in a sample of 50 CCU and 50 SICU patients. Patients' preferences for the length of visits differed according to their age, particularly for CCU patients. Patients' preferences for the frequency of visits were similar to their usual preferences for being with others. Perceived illness severity, especially for SICU patients, was positively related to the preferred number of visitors. A greater proportion of SICU patients preferred visits any time, day or night, compared with CCU patients. Patients predominantly evaluated visits as helpful and not tiring. Results suggest the need to tailor visits to patients' preferences by considering personal and illness-related characteristics.

The suppression effect of simulated anisometropia

Although there is evidence that differential interocular image clarity degrades binocular performance (for example, reducing stereo sensitivity) little is known about how this sensitivity reduction occurs. As there is evidence that suppression scotomas are induced in the more defocused eye, the presence and approximate size of suppression scotomas induced with uni-ocular defocus was investigated in five binocularly normal subjects. The targets comprised a fusional lock and a suppression check for each eye and the task of each subject was to report the presence of the suppression check with varying amount of defocus. There was a range of simulated anisometropia over which suppression did not occur (approximately +/- 0.50 DS). Thereafter the probability of suppressing a small foveal target increased approximately linearly until the target was always suppressed. Greater amounts of simulated anisometropia produced larger suppression scotomas. However, less anisometropia was required to produce an equivalent sized suppression scotoma if greater amounts of fusional detail were provided. These results suggest that the decrement in binocular performance which accompanies simulated anisometropia may occur because of localized inhibition in the more defocused eye and is not solely due to loss of resolution in that eye.

A comparison of hypertensive and nonhypertensive coronary care patients' cardiovascular responses to visitors

Patients with and without hypertension in a coronary care unit (n = 24) were compared with respect to cardiovascular responses to both a family visit and an interview by an investigator. Variables for each of the four cardiovascular indicators (systolic blood pressure, diastolic blood pressure, heart rate, and premature ventricular contractions) included the value before, the highest value during, the lowest value during, and the value after each social interaction condition. The highest group means for systolic blood pressure and heart rate were significantly higher for patients with hypertension than for patients without hypertension under both the interview and visit conditions. Differences in cardiovascular responses were not significantly greater for family visits than for interviews for patients with hypertension compared with those without hypertension. Thus, although hypertensive patients had greater cardiovascular reactivity to both social interaction conditions than nonhypertensive patients in the coronary care unit, family visits were no more physiologically stressful than a comparative interaction condition.

The family as a source of support for the critically ill adult

A conceptual framework of supportive family functions derived from a previous analysis of taped visits to coronary care unit (CCU) patients was used to analyze CCU and surgical intensive care unit (SICU) patients' recollections about visits. The framework of family functions was supported by the patients' recollections. However, CCU patients recall behaviors in a different order of frequency than previously described with visit transcript analysis. Both CCU and SICU patients frequently recall caring actions of the family and evaluated visits overall as helpful. Principles are proposed for nurses in assisting families and patients to cope with the critical illness episode and thus provide a supportive visiting environment for patients.

The cost of nursing excellence in critical care

The results of the American Association of Critical-Care Nurses Demonstration Project support the contention that high quality critical care nursing can be provided to patients at a reasonable cost. In addition, the data refute the notion that elements influenced by nurses--supplies and nursing care--are the most costly portion of the total hospital charge.

Cardiovascular responses to family visits in coronary care unit patients

Changes in four cardiovascular indicators: systolic blood pressure, diastolic blood pressure, heart rate, and premature ventricular contractions, were studied as responses to family visits and a 10-minute interview with the investigator in 24 patients in a coronary care unit. By use of a repeated-measures design, data were compared by multivariate analysis of variance. No significant differences were found between the group mean systolic and diastolic blood pressure, heart rate, and rate of premature ventricular contractions during family visits and interviews. The lowest systolic and diastolic blood pressure values were significantly lower during the visit than during the interview, suggesting that the visit had a calming effect on patients. Although the highest heart rate was significantly higher during the visit than during the interview, the difference was clinically inconsequential. The wide variance in premature ventricular contraction values suggests individual variation in responses, but no significant differences were found between visits and interviews. Although family visits were no more physiologically stressful than a comparative social interaction, select subsamples of patients with cardiac disease should be studied for more specific reaction patterns.

Skeletal muscle oxidative capacity, antioxidant enzymes, and exercise training

The purposes of this study were to determine whether exercise training induces increases in skeletal muscle antioxidant enzymes and to further characterize the relationship between oxidative capacity and antioxidant enzyme levels in skeletal muscle. Male Sprague-Dawley rats were exercise trained (ET) on a treadmill 2 h/day at 32 m/min (8% incline) 5 days/wk or were cage confined (sedentary control, S) for 12 wk. In both S and ET rats, catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase (GPX) activities were directly correlated with the percentages of oxidative fibers in the six skeletal muscle samples studied. Muscles of ET rats had increased oxidative capacity and increased GPX activity compared with the same muscles of S rats. However, SOD activities were not different between ET and S rats, but CAT activities were lower in skeletal muscles of ET rats than in S rats. Exposure to 60 min of ischemia and 60 min of reperfusion (I/R) resulted in decreased GPX and increased CAT activities but had little or no effect on SOD activities in muscles from both S and ET rats. The I/R-induced increase in CAT activity was greater in muscles of ET than in muscles of S rats. Xanthine oxidase (XO), xanthine dehydrogenase (XD), and XO + XD activities after I/R were not related to muscle oxidative capacity and were similar in muscles of ET and S rats. It is concluded that although antioxidant enzyme activities are related to skeletal muscle oxidative capacity, the effects of exercise training on antioxidant enzymes in skeletal muscle cannot be predicted by measured changes in oxidative capacity.

Beyond scripts: a note on the capacity of right hemisphere-damaged patients to process social and emotional content

Individuals with right hemisphere damage (RHD) can comprehend simple scripts but have difficulties understanding more complex forms of discourse such as stories and jokes. This study sought to discover the point beyond simple scripts at which such patients begin to experience difficulties. Three-sentence, script-like vignettes which described everyday situations were created along two major dimensions: a social dimension (reflecting presence or absence of interactions between characters); and an emotional dimension (reflecting a positive, negative, or neutral emotion felt by a protagonist in the situation). Right hemisphere-damaged patients were asked to provide emotional characterizations of, and continuations to, these situational vignettes. Results indicated that individuals with right hemisphere damage were more likely than control subjects to attribute a positive emotional state to a character in a neutral situation. In other respects, there were no significant differences between RHD subjects and controls, although the RHD subjects made significantly more factual errors in their continuations than did control subjects.

Traumatogenicity: effects of self-reported noncombat trauma on MMPIs of male Vietnam combat and noncombat veterans treated for substance abuse

A recent review of the literature on Post-Traumatic Stress Disorder (PTSD) and the MMPI has shown that all previously published studies have been limited to clinical groups whose trauma occurred in Vietnam combat. The purpose of this study was to test hypotheses that predict higher MMPI and PTSD scale scores among combat veterans who differ in degrees of noncombat traumas. Results support predictions. Those who reported more noncombat traumas attain significantly higher MMPI scores for scales F, Hypochondriasis, Hysteria, Psychopathic Deviate, Psychasthenia, Schizophrenia, Mania, Social Introversion, and an MMPI PTSD score (Keane, Malloy, & Fairbank, 1984). Moreover, noncombat effects are manifested differentially: Combat veterans with higher noncombat trauma evidence greater social withdrawal, whereas noncombat veterans who report higher noncombat trauma are characterized by higher anxiety. MMPI elevations were progressively higher as groups increased in degrees of combat and noncombat trauma: noncombat and low combat trauma veterans were the better adjusted, and combat veterans with higher noncombat trauma were the worst adjusted. Results provide descriptive validity for PTSD as a construct and underscore the importance of assessing frequency and intensity, as well as types of traumas and stresses, in the background histories of substance abusers and other clinical groups as well.

Tenckhoff catheter placement: surgical aspects

A 3-year retrospective review of 110 consecutive Tenckhoff catheter placements was undertaken. Major complications were found in 3.6 per cent of cases and minor complications occurred in 30 per cent. Analysis of cases in which catheters failed revealed that obesity and prior abdominal surgery occurred in 75 per cent of these patients. Attention to these factors and the use of appropriate techniques of placement and, in special situations, the use of endoscopy and fluoroscopy have reduced the failure rate of these high-risk situations. Management of infective complications are outlined and should include continued antibiotic dialysis and catheter replacement only if persistent peritonitis or fungal peritonitis occur. With these guidelines, improved peritoneal dialysis can be undertaken with less morbidity to the patient.

Exercise after myocardial infarction: a controlled trial

Six weeks after acute myocardial infarction, 303 men were randomly divided into exercise and control groups. The exercise group attended the hospital gymnasium twice weekly for a three-month supervised exercise course. Both groups were exercise tested before and after the course and at subsequent follow-up. The exercise group increased their physical fitness greatly compared with the control group. Eight per cent of the exercise group died during the period of follow-up, compared with 14 per cent of the control group; this difference is not significant. There was an apparent improvement in mortality in those with inferior MI who completed the exercise course, which was not seen in those with MI in other sites. For many patients after MI progressive exercise is safe, improves physical fitness and may reduce mortality for those after inferior MI.

Chicken ovalbumin gene fused to a herpes simplex virus alpha promoter and linked to a thymidine kinase gene is regulated like a viral gene

We are describing a system for the introduction, selection, and expression of eucaryotic genes in higher eucaryotic cells. The carrier consisted of the herpes simplex virus 1 (HSV-1) tk gene covalently linked to an HSV-1 alpha promoter directed away from the tk gene. In this study we fused to the alpha promoter the 5' transcribed noncoding sequences and the coding sequences of the chicken oviduct ovalbumin gene. Cells converted to the TK+ phenotype with this chimeric fragment produced an ovalbumin precursor which was processed and secreted into the extracellular fluid. The ovalbumin gene utilized the HSV-1 alpha promoter and was regulated as a viral gene inasmuch as inversion of the genomic DNA relative to the alpha promoter resulted in no ovalbumin synthesis, and production of ovalbumin was enhanced after superinfection with HSV-1. Synthesis of ovalbumin was not detected when cDNA was linked to the HSV-1 alpha promoter. The carrier system described in this study is suitable for introduction, selection, and expression of eucaryotic genes whose natural promoter is either weak or requires the presence of regulatory elements which may be absent from undifferentiated cells in culture.

Differentiation of respiratory and abortigenic isolates of equine herpesvirus 1 by restriction endonucleases

Viruses classified by immunologic criteria as equine herpesvirus 1 cause respiratory disease and abortion in horses. Restriction endonuclease analyses of the DNA's of viruses from animals with respiratory disease and from aborted fetuses show that the patterns for respiratory viruses, while similar to each other, are entirely different from the patterns for fetal viruses. It is therefore proposed that the DNA restriction endonuclease patterns of fetal and respiratory viruses analyzed in this study be designated as prototypic of equine herpesvirus 1 and 4, respectively.