A case of Starr-Edwards valve thrombosis in pregnancy.

Starr-Edwards ball-in-cage prosthetic heart valves, although durable, are associated with a particularly high rate of thromboembolic complications. This valve is seldom used in North America, and is certainly not the valve of choice in a woman of childbearing age. Few reports exist from the 1970s of thrombotic complications in pregnant women with Starr-Edwards prostheses, and the optimal management strategy for such valves is unclear. Here, the case is reported of a 31-year-old woman with a Starr-Edwards prosthesis in the mitral position who was transferred to the authors' center at six weeks' gestation with pulmonary edema. Transthoracic echocardiography demonstrated thrombosis of the prosthetic valve, with a mean gradient of 23 mmHg. When treated initially with intravenous heparin and furosemide the patient improved significantly; however, the optimal management going forward was unclear. Here, the options for anticoagulation during pregnancy and for management in the event of valve thrombosis are reviewed. In the absence of any clear guidelines, a thorough discussion of the various risks and benefits with the patient is necessary, but ultimately any consideration of the risk to the mother is paramount.

Brief screen to identify 5 of the most common forms of psychosocial distress in cardiac patients: validation of the screening tool for psychological distress.

OBJECTIVE: To develop and validate a brief psychosocial screening tool (Screening Tool for Psychological Distress [STOP-D]) for use in the outpatient cardiology setting. BACKGROUND: Psychosocial factors contribute significantly to the morbidity and mortality associated with coronary artery disease. Yet, it is often considered overly burdensome to implement full-scale psychological assessments for every patient. METHODS: Over 3 months, 194 cardiac patients were consecutively recruited from 3 cardiac clinics: heart transplant (pre and post), cardiac rehabilitation, and adult congenital heart. Subjects filled out a questionnaire that included: (1) demographics, (2) STOP-D, (3) Beck Depression Inventory-II, (4) Beck Anxiety Inventory, (5) State-Trait Anger Expression Inventory-2, and (6) MOS Social Support Survey. RESULTS: Analyses reveal all STOP-D items are highly correlated with the corresponding measures and have robust receiver operating characteristic curves. Severity scores on STOP-D-depression and STOP-D-anxiety correlate well with established severity cutoff scores on the Beck Depression Inventory and the Beck Anxiety Inventory, respectively. CONCLUSIONS: Overall, the STOP-D performs very well when compared with other longer and validated measures. The STOP-D is a 5-item self-report measure, which provides severity scores for: depression, anxiety, stress, anger, and poor social support. The STOP-D is self-administered and takes between 1 and 2 minutes to fill out, gives valid severity scores on 5 key areas of psychological distress (depression, anxiety, stress, anger, and poor social support), requires no scoring, and is free to use.

Efficacy of a smoking-cessation intervention for elective-surgical patients.

We tested an intervention to help smokers abstain (fast) from smoking before surgery, maintain abstinence postoperatively, and achieve long-term cessation. A randomized experiment included 237 patients admitted for presurgical assessment who smoked. The intervention included counseling and nicotine replacement therapy. Treatment group participants (73.0%) were more likely to fast than were controls (53.0%): chi(2)(1, N = 228) = 8.89, p =.003, and more likely to be abstinent 6 months after surgery (31.2% vs. 20.2%). There was no significant difference in the abstinence rates at 12 months after surgery, chi(2)(1, N = 169) <.001, p = 1.00. Encouraging patients to fast from smoking before surgery and postoperative support are efficacious ways to reduce preoperative and immediate post-operative tobacco use.

Synchronizing clinician engagement and client motivation in telephone counseling.

Health care increasingly incorporates telephone counseling, but the interactions supporting its delivery are not well understood. The authors' clinical trial of a tailored, nurse-administered smoking cessation intervention for surgical patients included a telephone counseling component and provided an opportunity to describe the interaction dynamics of proactive telephone counseling over the course of 4 months. Tape-recorded telephone counseling calls for 56 consecutively enrolled individuals randomized to the intervention group resulted in a data set of 368 calls, which were transcribed and analyzed using constant comparative methods. The findings revealed varying interaction dynamics depending on the nurse's level of engagement with participants and participants' motivation to stop smoking. The authors identified four interaction dynamics: affirming/working, chasing/skirting, controlling/withdrawing, and avoiding commitment. Shifts in interaction dynamics were common and influenced the provision of support both positively and negatively. The findings challenge many assumptions underlying telephone counseling and suggest strategies to improve its delivery.