The Effect on Cognition of Mitochondrial Respiratory System Proteins in Peripheral Blood Mononuclear Cells in the Course of Lung Cancer.

Peripheral blood mononuclear cells (PBMC) represent an easily available population of cells for the studies on remote effects of lung cancer. NADH dehydrogenase (ubiquinone) Fe-S protein-1 (Ndufs1), a marker of mitochondrial complex I, and mitochondrially encoded cytochrome c oxidase 1 (MTCO1), a marker of complex IV, may participate in cognitive decline during the course of lung cancer. In this study, Ndufs1 and MTCO1 expression in PBMC was evaluated by means of ELISA in 80 lung cancer patients. Mini-Mental State Examination (MMSE) were conducted Trail Making Tests (TMT-A and TMT-B) at baseline and after the 6 months' follow-up. Autoantibodies were identified by means of indirect immunofluorescence and line blot. We found that enhanced levels of Ndufs1 in PBMC were related to impaired cognitive performance; TMT-A of 13.6 ± 3.1 s and TMT-B of 162.5 ± 46.4 s compared with 8.6 ± 4.5 s (p = 0.003) and 124.8 ± 51.8 s (p < 0.05), respectively, in the case of low Ndufs-1 levels. The Ndufs1 expression at baseline was associated with MMSE - τb (Kendall's tau-b) = -0.31; p = 0.024; TMT-A - τb = 0.30; p = 0.001), and TMT-B - τb = 0.199; p = 0.012) after the 6 months' follow-up. Higher MTCO1 expression was accompanied by worse TMT-A results than in case of inhibited MTCO1; 11.1 ± 5.8 s vs. 8.5 ± 4.1 s; respectively; p = 0.048. MTCO1 expression was correlated with TMT-A results (τb = 0.17; p = 0.034) at baseline. We conclude that stimulation of PBMC mitochondrial function in lung cancer patients is associated with cognitive impairment. Mitochondrial dysfunction in PBMC may reflect cytotoxicity responsible for neurological deficits.

Humoral Immune Response against Neural Antigens and Its Effects on Cognition in Lung Cancer Patients.

Cognitive impairment develops as a clinical manifestation of immune-mediated indirect effects of malignancy in lung cancer patients. This study aimed to evaluate the effects of humoral immune response on cognition in lung cancer patients. Fifty-one lung cancer patients were subjected to neurological examination: Mini Mental State Examination (MMSE), Trail Making Test (TMT), and Hamilton scale. The Psychology Experiment Building Language software was used for the evaluation of digit span, simple reaction time (SRT), and choice reaction time (CRT) tests. Serum samples were tested for the presence of onconeuronal antibodies and antineural antibodies. The results demonstrate that autoantibodies were found in 31 % patients. MMSE scores were lower (26.7 ± 2.7) in seropositive patients than in seronegative subjects (28.7 ± 1.2; p = 0.013). Executive functions were also influenced by the presence of autoantibodies. The humoral immune response in lung cancer patients affected both SRT and CRT. We conclude that the humoral immune response in lung cancer patients is associated with cognitive impairment. Cognitive impairment is associated with both specific reactions against onconeuronal or antineural antigens and non-organ specific reactions against nucleosome antigens.

Disenrollment from an HMO and its relationship with the characteristics of Medicare beneficiaries.

To examine the relationship between Medicare beneficiaries' characteristics and disenrollment, a longitudinal study was conducted in an HMO in California. Approximately 10 percent of the Medicare beneficiaries disenrolled within the first year of enrollment. There was no difference between those who continuously enrolled and those who disenrolled in terms of age, gender, mental and physical health status, previous utilization, and anticipated utilization in the coming year. However, people with limited social activities and people not living in a single-family house were more likely to disenroll. The authors also examined the disenrollment rates among physicians groups. The rates were significantly different.

A comparison of temperature measurements using three ear thermometers.

Following anecdotal and research-based reports of inaccuracies encountered with the use of ear thermometers in patient care settings, this two-phase study was designed to compare the accuracy of three ear thermometers when used in a multioperator environment. The within-subject variation (limits of agreement) in ear temperature measurements obtained with the three ear thermometers in a multioperator condition by using an oral temperature reference standard ranged from +/- 1.25 degrees F to 1.85 degrees F. In multioperator, multisubject patient care environments using a pulmonary artery catheter core temperature as the reference standard, the limits of agreement for ear temperature measurements obtained with the three different ear thermometers ranged from +/- 2.19 degrees F to 2.85 degrees F. These results suggest that there is substantial variation in ear measurements and raise questions about the use of ear thermometers when there are multiple personnel taking temperatures, as occurs in hospital-based clinical practice environments. Handedness of the operator, position of the patient, and the ear used for measurement did not produce clinically significant variability in ear temperature measurements.

Analysis of clinical trends in a program of emergent ECLS for cardiovascular collapse.

Between June 1986 and October 1995, 81 patients were emergently resuscitated with a portable extracorporeal life support (ECLS) system. Venoarterial perfusion was achieved using a centrifugal pump (BioMedicus; Medtronic, Anaheim, CA) and a hollow fiber oxygenator (BARD in 56 patients; Medtronic heparin-bonded MAXIMA, [MAXIMA, Medtronic, Minneapolis, MN] in the last 25 patients. The ECLS system was used at various locations in the hospital with the setup, priming, and initiation of perfusion done by ECLS trained intensive care unit nurses. Clinical data in these patients were reviewed to analyze variables influencing survival and trends that develop as the authors' experience accumulated and the technology evolved. The indication for ECLS was cardiac arrest in 68 patients and refractory cardiogenic shock in 13 patients. Thirty-five patients (43.2%) survived > 24 hrs after termination of ECLS, whereas 20 patients (24.7%) are long-term survivors (> 30 days). The ECLS system permitted an additional therapeutic surgical intervention in 45 cases. Patients who had a surgically remediable problem were more likely to survive. Prolongation of cardiopulmonary resuscitation beyond 30 mins before initiation of ECLS correlated with a decreased likelihood of survival.

Development of an instrument to measure cardiac illness dependency.

OBJECTIVE: Dependency is frequently mentioned in the literature as a response of patients with cardiac disease. The purpose of this study was to develop and test a measure of dependency occurring in response to a cardiac illness. Illness dependency is defined as the need for emotional protection and social support after a significant change in health. DESIGN: Instrument development study. SAMPLE: Convenience sample of 311 patients with cardiac disease. RESULTS: The final version of the instrument has 25 items, each of which is measured on a 5-point Likert-type scale. Content validity was demonstrated using a panel of experts. Internal consistency of the total scale was 0.90; subscale alpha coefficients ranged from 0.64 to 0.81. Exploratory factor analysis supported a four factor solution: Attention, Reassurance, Concern, and Assistance, which accounted for 57.4% of the variance in scores. Discriminant validity was demonstrated by a low correlation with neuroticism. Social desirability of responses was minimal. CONCLUSION: Internal consistency reliability, content validity, and discriminant validity of the Illness Dependency Scale have initial support. This instrument is ready for use in research in which the investigator wishes to measure dependency associated with cardiac illness.

Effectiveness of a program of early hospital discharge of cardiac surgery patients.

Managed care was the impetus for a program designed to move adult patients from acute care to the lowest level of appropriate services after cardiac surgery. Clinical pathways and a home care cardiac specialty team were the major components of the Early Discharge Program. The program was evaluated based on both financial and clinical outcomes. A convenience sample of 119 pretest patients was compared with 101 posttest patients 3 months after program implementation. Hospital length of stay decreased only 0.34 days on average, but inpatient direct variable costs decreased by an average of $1,790 per patient. Based on the 101 patients in the posttest group, $180,790 in direct variable hospital costs were saved. The largest decrease in resource use was in those patients who were discharged to home care. Complications and home caregiver burden after discharge were no higher in patients discharged early. Early discharge of cardiac surgery patients appears to be safe and cost-effective.

Are nurses still practicing coronary precautions? A national survey of nursing care of acute myocardial infarction patients.

BACKGROUND: Coronary precautions were common when coronary care units were instituted in the 1960s. However, research has failed to provide evidence of the validity of most of these restrictions. Only the avoidance of the Valsalva maneuver is clearly indicated as a universal precaution in patients who have experienced acute myocardial infarction. OBJECTIVES: To determine if nurses continue to restrict iced and hot fluids, caffeine, rectal temperature measurement, and vigorous back rubs, and to feed and mandate bedrest for acute myocardial infarction patients. METHODS: Survey techniques were used to describe practice patterns of nurses working in hospitals across the United States. Two sampling methods were used to access a random sample. The survey was mailed to members of the American Association of Critical-Care Nurses and nonmembers working in a hospital accredited by the American Hospital Association and with an intensive care unit. RESULTS: Of the 2549 mailed surveys, 882 were returned with usable data (34.8% response rate). Iced (28.1%) and hot (8.7%) fluids continued to be restricted by nurses. Most (85.6%) restricted stimulant beverages such as coffee. Rectal temperature measurement was avoided by 55.7%, and only 73.3% taught avoidance of the Valsalva maneuver. In terms of rest, 15.6% reported avoiding vigorous back rubs, 8.4% still fed patients, and 33.8% offered bedpans to pain-free patients on the first day after admission. A complete bedbath was offered by 19.8% of nurses to stable, pain-free patients even a day after admission. CONCLUSIONS: The data supporting liberalization of coronary precautions have not been adequately disseminated.

Gender differences in adjustment to acute myocardial infarction.

OBJECTIVE: To compare psychosocial adjustment, functional class, and return to work in a matched sample of women and men experiencing a first acute myocardial infarction (AMI). DESIGN: Longitudinal survey. SETTING: Subjects were identified from six hospitals in the Southern California area. Data were collected in the home setting 1 and 4 months after hospital discharge. SUBJECTS: Data on 32 women experiencing a first AMI were matched on neuroticism and cardiac dysfunction with 32 men from the same sample. MEASURES: The following instruments were administered 1 and 4 months after hospital discharge: Self-Perception Inventory (self-esteem); Profile of Mood States (emotional distress); General Health Perceptions Questionnaire (health perceptions); Interpersonal Dependency Inventory (dependency); and the UCLA Social Support Inventory (social support). The Eysenck Personality Inventory (neuroticism) was administered at 1 month. Cardiac dysfunction was measured with data available from the hospital record. Functional class was measured at 1 month with the Specific Activity Scale. Self-report of demographics and return to work were obtained 1 and 4 months, respectively. RESULTS: Women experienced improved perceptions of current health whereas their ratings of prior health decreased. Overall emotional distress, anxiety, and depression decreased significantly over time in women. Women reported wanting, receiving, and giving more support than men did at 1 month and receiving and giving more support than men did at 4 months, although stress in support relationships rose over time. In men anxiety, depression, and health concern all decreased significantly over time whereas their ratings of prior health rose. The match between social support wanted and received decreased over time in males as did their satisfaction with the support received. Men reported a higher functional class than women at 1 month, but return to work at 4 months did not differ. CONCLUSIONS: Both women and men experienced improved psychologic adjustment within 4 months after AMI, although the specific areas of improvement differed. Return to work was comparable in spite of differences in functional class. The women appeared to activate their social support system more effectively than the men after AMI. Further research is needed to determine whether differences in social support contribute to adjustment that is better than what normative data predict for women.

Monitoring electrocardiographic changes: results of a national survey.

This article describes the electrocardiographic (ECG) monitoring practices of a national sample of nurses caring for patients who have suffered an acute myocardial infarction (AMI). Of specific interest were lead section practices, diagnosis of infarct evolution, and use of right precordial leads. Two populations were randomly sampled in an attempt to minimize sampling bias. Of the 2,549 mailed surveys, 882 were returned (34.8% response rate) from 48 states. Lead II was used most commonly (66.3%) with a single-channel system. Lead II plus V1 (or MCL1) was selected most often (62.4%) with dual-channel systems. Few (20%) respondents reported "always" modifying lead selection based on location of AMI; selected most often (62.4%) with only 43.3% correctly identified classic ischemia, injury, and infarction. Right precordial leads are used infrequently in practice.

National survey of pediatric fever management practices among emergency department nurses.

INTRODUCTION: Management of pediatric fever is controversial. Although many nursing texts advocate aggressive fever management, research provides evidence that fever is a normal physiologic process with beneficial effects. We sought to describe emergency nurses' pediatric fever management practices, their rationales for practice, and their practice consistency. METHODS: A researcher-developed tool was mailed to a systematic random sample of approximately 5% of ENA members. Surveys were mailed to 1136 nurses nationally; 731 surveys were returned (64% response rate). RESULTS: Temperature at which nurses initiate fever interventions varied from 37.8 degrees C (100 degrees F) to 40.6 degrees C (105 degrees F). Most frequently identified rationales for intervention were prevention of fever increase (83.3%), fever reduction (76.9%), comfort (74.7%), and seizure prevention (65.3%). Most nurses (79.8%) employ tepid sponging to reduce fever; 31% sponge routinely. Nurses reported sponging for temperatures higher than 38.9 degrees C (102 degrees F) to 40.6 degrees C (105 degrees F). Rationales for sponging included seizure prevention (58%), rapid cooling (56.8%), and treatment of fevers unresponsive to antipyretics (45.6%). Factors influencing rationales for practice included departmental standards of care (67.2%), physician practices (65.8%), and common sense (64.2%). DISCUSSION: The results of this nationwide survey demonstrate that fever management practices vary. ED nurses are practicing in a manner consistent with that advocated in many nursing texts but not necessarily the research literature. We believe that clinical trials of commonly used fever treatments are indicated. Standards of care could then be revised to reflect the research literature.

Infrared tympanic thermometry for neonatal temperature assessment.

OBJECTIVE: To investigate the accuracy and precision of infrared tympanic thermometer use with neonates by comparing with axillary and rectal measurements. DESIGN: Descriptive, comparative study. SETTING: Newborn nursery of a tertiary-level perinatal center. SUBJECTS: Thirty-four full-term newborns. INSTRUMENTS: Infrared thermometers were used to collect tympanic temperatures. An electronic thermometer was used to collect axillary and rectal temperatures. RESULTS: There was no significant difference between tympanic and axillary temperatures. The range of variation (95% CI) was +/- 0.7-.9 degrees C. The mean difference between tympanic and rectal measurements was 0.4 degrees C. The range of variation was +/- 0.7-0.75 degrees C. Right ear measurements produced the best approximation of axillary temperature, and protected ear measurements produced the best approximation of rectal temperature. The protected ear was 0.2-0.3 degrees C higher than the exposed ear. CONCLUSIONS: There was more variation between tympanic versus axillary and tympanic versus rectal measurements than between axillary and rectal measurements. Tympanic thermometry may be useful for rapid screening of neonatal temperature, but its usefulness for monitoring unstable neonates remains in question.

Adult respiratory distress syndrome: outcome in a community hospital.

BACKGROUND: Published reports indicate that survival rates of patients with adult respiratory distress syndrome have not improved dramatically since the first report of the condition in 1967. However, changes in ventilator strategies and improved critical care management may result in better survival rates in patients with well-defined, severe adult respiratory distress syndrome. OBJECTIVES: To report the outcomes of patients with adult respiratory distress syndrome treated in a community hospital and compare these findings with those in previously published reports. METHODS: A retrospective study design was used. All patients diagnosed with adult respiratory distress syndrome (N = 47) over a 2-year period were studied. RESULTS: For the study patients, the survival rate was 64%; 29% died from respiratory failure alone. Analysis demonstrated that advanced age was not associated with mortality. Pressure-control ventilation was used for 31 patients and there was no significant difference in the presence of barotrauma in the pressure-control mode vs volume ventilation. CONCLUSION: This survival rate exceeds most recently reported rates and thus supports the idea that improvement in treatment of adult respiratory distress syndrome is occurring.

Clinical safety and cost of heparin titration using bedside activated clotting time.

OBJECTIVE: To evaluate the clinical safety of heparin titration and the procedural cost of anticoagulation measurement using bedside low-range activated clotting time. DESIGN: Quasi-experimental study using data gathered through retrospective record review. SETTING: Coronary care, medical intensive care and telemetry units of a community hospital. SUBJECTS: Sample of 102 patients undergoing elective percutaneous transluminal coronary angioplasty. INTERVENTION: Intravenous heparin therapy was titrated using low-range activated clotting time in 51 percutaneous transluminal coronary angioplasty patients. Data from this group were compared to a matched sample of 51 angioplasty patients whose intravenous heparin therapy was titrated using activated partial thromboplastin time. RESULTS: No differences in procedural, early or late complications were found between the groups. The cost of managing heparin therapy with low-range activated clotting time was less than with activated partial thromboplastin time. CONCLUSION: These results suggest that titrating heparin therapy based on bedside low-range activated clotting time for the angioplasty patients in this sample was as safe as with activated partial thromboplastin time. Use of bedside low-range activated clotting time saved money for the hospital.