Time of day for exercise on blood pressure reduction in dipping and nondipping hypertension.

UNLABELLED: Time of day (TOD) for exercise may influence blood pressure (BP) reduction in hypertension because of the diurnal variation of BP and the duration of BP reduction following a single bout of exercise. The purpose of this study was to observe the effects of TOD for exercise on ambulatory blood pressure reduction in dipping (n=5) and nondipping (n=9) hypertension (<10% drop in nighttime BP (BP(night))). HYPOTHESES: (1) evening exercise (PM(ex)) would exhibit a greater BP(night) reduction in Non-Dippers than Dippers, (2) morning exercise (AM(ex)) would exhibit similar daytime BP (BP(day)) reduction in Dippers and Non-Dippers, (3) AM(ex) would exhibit greater 24 h BP (BP(24 h)) reduction than PM(ex) in Dippers, and (4) AM(ex) and PM(ex) would exhibit similar BP(24 h) reduction in Non-Dippers. BP responses to AM(ex) (0600-0800 h; 30 min at 50% VO(2peak)) and PM(ex) (1700-1900 h) were compared to each control day in a randomized design. Systolic (S) and diastolic (D) BP were averaged for BP(24 h), BP(day), and BP(night). A two-way ANOVA (dipping X time of exercise) using BP reduction with repeated measures were performed at P<0.05. FINDINGS: (1) Non-Dippers respond to exercise despite of TOD for exercise, (2) PM(ex) exhibited a greater SBP(night) reduction in Non-Dippers than Dippers, (3) AM(ex) exhibited similar SBP(day) reductions in Dippers and Non-Dippers, and (4) AM(ex) and PM(ex) exhibited similar SBP(24 h) reduction in Dippers and Non-Dippers. Dippers and Non-Dippers respond differently to TOD for exercise. The duration of the BP reduction persists up to 24 h after exercise.

Reproducibility of postexercise ambulatory blood pressure in Stage I hypertension.

The accuracy and reproducibility of ambulatory blood pressure monitoring used in intervention and treatment studies is essential to assure the desired health outcomes. The reproducibility of ambulatory variables in pharmacological studies has been reported, however, the reproducibility of ambulatory blood pressure variables associated with exercise has not been reported. Thus, the purpose of this study was to investigate the reproducibility of the postexercise ambulatory blood pressure in Stage I hypertensive adults. It was hypothesized that the reproducibility of the ambulatory blood pressure variables would not be different following two corresponding exercise and control treatments. A total of 18 Stage I hypertensive adults (142.1+/-3.15/91.6+/-1.80 mmHg) performed four randomized, 24 h AmBP monitoring sessions: two following a 50 min treadmill walk (50% VO(2) peak) and two on control days. Variables measured were: (1) average systolic and diastolic pressures for 24 h, daytime (06:00-22:00 h) and night time (22:00-06:00 h) and (2) systolic and diastolic load for the same time periods. Both a nonsignificant paired t-test and an excellent intraclass correlation were used to define reproducibility of the variables between the 1st and 2nd exercise trials and between the 1st and 2nd control trials. Reproducibility was found for all the control variables except for nighttime diastolic load. Reproducibility was found for all the systolic and diastolic exercise variables. Ambulatory blood pressure measurements, including average systolic and diastolic blood pressures and systolic and diastolic loads for 24 h, daytime and night time periods are reproducible following exercise.

Nonphysician clinicians in the ICU.

Until very recently the medical care of the patient in the intensive care unit (ICU) was provided primarily by physicians. Many of these physicians were specifically trained as intensivists to manage the critically ill and provide minute to minute titration of care to improve the outcomes of these patients. However there has been a change in the delivery of critical care in many centers with the addition of NPCs (nonphysician clinicians) to the team. A 1998 article in JAMA listed 10 nonphysician disciplines that will affect the demand for physicians in the future; this article focuses on only two of these disciplines: physician assistants (PAs) and acute care nurse practitioners (ACNPs). A driving force for the addition of these NPCs to the ICU team is the downsizing of resident programs. This article explores the utilization of NPCs in the ICU, including the perceived advantages and potential controversies associated with these practitioners.

ICU bedside environment. A nursing perspective.

The physical design of most ICUs is a source of inadvertent and undesirable stress for patients, family, and staff. The importance of developing a healing environment will have a great impact on the ICU bedside environment of the future. Using the research on the effects of noise, light, and other environmental stressors on patient outcomes, the ICU bedside environments of the future will combine the "high tech" and "high touch" components of care in one setting. The patients and the care providers will benefit from this focus on the humane, healing environment.

Clinical decision support systems for outcome measurement and management.

Clinical decision support systems are the foundation for outcome management programs through the measurement of specific outcomes, data storage, data analysis, predictive modeling, and risk-adjusted comparison of actual outcomes with predicted outcomes. Many clinical decision support tools or databases are available to clinicians. This article reviews two widely available tools that provide clinical decision support for critical care clinicians, the Project IMPACT and APACHE III Critical Care Series clinical decision support systems. These tools are discussed with regard to risk adjustment methodology, validity, reliability, database size and representation, retrospective and prospective data and analysis, and quality control. Clinical application of clinical decision support systems for benchmarking and use in process improvement and outcome management is reviewed.

Nursing informatics. Issues for critical care medicine.

The demands of today's health care arena have forced the issue of automation and computerization. Nursing, as the major stakeholder in the collecting, managing, processing, transforming, and communicating of information regarding the patient, has developed a new approach to these tasks. Nursing informatics, which is the application of computer science and information science, is being used to manage and process the data, information, and knowledge necessary in the discipline. Although still in its infancy, nursing informatics has started to have a major effect on health care information gathering and clinical practice despite the multiple barriers to its advancement. Critical care is a data-rich environmental that can benefit from better management and processing of the data derived from the critically ill patient. Nursing and medical informatics joining together to organize the data, coupled with the introduction of good DSS and the addition of information retrieval systems at the bedside and the on-line medical record, will have a positive effect on the critical care environment and on the critical care patient outcomes.

The magnitude and duration of ambulatory blood pressure reduction following acute exercise.

The purpose of this study was to observe the magnitude and duration of the ambulatory blood pressure (BP) reduction following exercise and to identify the peak intervals of BP reduction throughout the 24-h diurnal period. Subjects were 25 normo- (N = 116.7/ 78.2+/-10.0/7.2 mm Hg) and 21 hypertensive (H = 140.8/96.9+/-13.9/9.6 mm Hg) adults. Twenty-four hour ambulatory blood pressures (SBP = systolic and DBP = diastolic) were recorded following exercise (E = 50 min @ 50% VO2 max) and during a non-exercise control day (C). The 24-h pressures were compared between the E and C days for (1) duration and magnitude of the BP reduction following exercise, and for (2) the time of day for the diurnal patterns to exhibit reductions in BP. No BP differences were found for N between E and C days. Significant reductions in BP were found for 24-h average SBP (decrease 6.8 mm Hg) and DBP (decrease 4.1 mm Hg), daytime (06.00-22.00 hrs) SBP (decrease 6.9 mm Hg) and DBP (decrease 3.3 mm Hg), and sleep (22.00-06.00) SBP (decrease 5.1 mm Hg) and DBP (decrease 4.4 mm Hg) for H subjects only. H also demonstrated an 11 h reduction in SBP (chi = decrease 8.3+/-2.2 mm Hg) and 4h reduction in DBP (chi = decrease 6.0+/-1.7 mm Hg) following exercise. For the diurnal variation, the peak interval of reduction in SBP (chi = 17.0+/-2.6 mm Hg) was for 11 h; from 11.00-21.00 hrs. For DBP, a significant reduction (chi = decrease 5.7+/-0.7 mm Hg) was found for 5 h; from 11.00-15.00 h. Thus, exercise reduces both systolic and diastolic BP for a significant length of time postexercise as well as reduces pressures during the time of day that typically exhibits higher diurnal pressures.

Making changes to improve the intensive care unit experience for patients and their families.

With the technology explosion and scientific advances in the field of critical care in the past three decades came an era in which ICUs were referred to as an arena for punitive survivalists. Although clinicians have developed an increased ability to improve the quality and quantity of life for patients in the long term post discharge, patients and their families often suffered more than is necessary in the short term, during the critical care phase of the illness. It is well documented that physiologic and psychologic stress impacts negatively on both short-term and long-term patient outcomes. In the last 10 yrs, the attention of individual caregivers, units, organizations, and researchers has turned to improving the ICU experience for patients and families. This article reviews the relevant literature and also reports the experience of those who have created and applied unique strategies that address the patient and family needs, thus promoting their comfort and relieving their distress. Although more outcome studies are needed in this area of care, applying some of the lessons already learned can significantly improve the ICU experience for most patients and families.

A comparison of 24-h average blood pressures and blood pressure load following exercise.

Although the use of 24-h ambulatory blood pressure monitoring has been recommended in the study of blood pressure and exercise, consistent results have not been found for average 24-h systolic or diastolic blood pressures. Systolic load and diastolic load (the percentage of pressures >140/90 mm Hg during daytime hours and >120/80 mm Hg during sleep) have recently been identified as an important variable, but has had limited use with exercise. The purpose of this study was to compare the average systolic and diastolic pressures to systolic and diastolic loads from 24-h data recorded after a 50-min treadmill walk at 50% VO2max to data from a nonexercise control day. Subjects were 36 normotensive (116.9 +/- 10.7/77.0 +/- 8.9 mm Hg) and 25 hypertensive (141.0 +/- 13.7/96.6 +/- 9.0 mm Hg) adults. No significant differences were found for systolic and diastolic pressures or loads between the control and exercise days for normotensives. Even though no significant changes were found for any of the average systolic and diastolic pressures between the control and exercise days for the hypertensives, significant reductions were found in systolic load for 24-h (-25.7%), day (6 AM to 10 PM, -23.1%), work (6 AM to 5 PM, -22.9%), and leisure (5 PM to 10 PM, -26.7%) periods; and in diastolic load for the work (-22.5%) period. Thus, the measurement of systolic and diastolic load may be more sensitive than average systolic and diastolic blood pressures for the detection of 24-h ambulatory blood pressure changes with exercise in borderline hypertension.

A model for technology assessment as applied to closed loop infusion systems. Technology Assessment Task Force of the Society of Critical Care Medicine.

OBJECTIVES: To test a model for the assessment of critical care technology on closed loop infusion control, a technology that is in its early stages of development and testing on human subjects. DATA SOURCES: A computer-assisted search of the English language literature and reviews of the gathered data by experts in the field of closed loop infusion control systems. STUDY SELECTION: Studies relating to closed loop infusion control that addressed one or more of the questions contained in our technology assessment template were analyzed. Study design was not a factor in article selection. However, the lack of well-designed clinical outcome studies was an important factor in determining our conclusions. DATA EXTRACTION: A focus person summarized the data from the selected studies that related to each of the assessment questions. The preliminary data summary developed by the focus person was further analyzed and refined by the task force. Experts in closed loop systems were then added to the group to review the summary provided by the task force. These experts' comments were considered by the task force and this final consensus report was developed. DATA SYNTHESIS: Closed loop system control is a technological concept that may be applicable to several aspects of critical care practice. This is a technology in the early stages of evolution and much more research and data are needed before its introduction into usual clinical practice. Furthermore, each specific application and each device for each application (e.g., nitroprusside infusion, ventilator adjustment), although based on the same technological concept, are sufficiently different in terms of hardware and computer algorithms to require independent validation studies. CONCLUSIONS: Closed loop infusion systems may have a role in critical care practice. However, for most applications, further development is required to move this technology from the innovation phase to the point where it can be evaluated so that its role in critical car practice can be defined. Each application of closed loop infusion systems must be independently validated by appropriately designed research studies. Users should be provided with the clinical parameters driving each closed loop system so that they can ensure that it agrees with their opinion of acceptable medical practice. Clinical researchers and leaders in industry should collaborate to perform the scientifically valid, outcome-based research that is necessary to evaluate the effect of this new technology. The original model we developed for technology assessment required the addition of several more questions to produce a complete analysis of an emerging technology. An emerging technology should be systematically assessed (using a model such as the model developed by the Society of Critical Care Medicine), before its introduction into clinical practice in order to provide a focus for human outcome validation trials and to minimize the possibility of widespread use of an unproven technology.

Twelve month adherence of adults who joined a fitness program with a spouse vs without a spouse.

OBJECTIVE: The purpose was to determine adherence of apparently healthy adults who joined an exercise program with a spouse (Married Pairs) vs. without a spouse (Married Singles). It was hypothesized that Married Pairs would have significantly higher adherence than Married Singles; and that self motivation would be associated with adherence. EXPERIMENTAL DESIGN: Twelve month adherence of Married Pairs and Married Singles were compared to self motivation in a retrospective design. SETTING: Subjects in this study did not volunteer for a scientific investigation, instead they were spontaneous participants in a university fitness program. PARTICIPANTS: Married Pairs were 16 couples and Married Singles were 16 married men and 14 married women. INTERVENTIONS: This study observed the 12 month spontaneous participation in a fitness program. The only intervention was the self motivation questionnaire. MEASURES: Adherence was defined as monthly attendance, compliance to the exercise prescription, dropout, and reason(s) for dropout. Self motivation was also measured. RESULTS: For Married Pairs, monthly attendance was significantly higher (54.2% +/- 10.3 vs 40.3% +/- 14.3) and dropout (6.3% vs 43.0%) was significantly lower than for Married Singles. Compliance to the exercise prescription was good for all of the groups except for the Married Single Men. Fifty percent of the dropouts left because of family responsibilities/lack of spousal support; 25% dropped-out to continue exercising on their own. Self motivation did not differ between Married Pairs and Married Singles. Monthly attendance of spouses in the Married Pairs demonstrated a significant correlation. CONCLUSIONS: Married Pairs had significantly higher attendance and lower dropout than Married Singles which appeared to be primarily influenced by spousal support rather than by self motivation.