A model for a nurse-led programme of bedside placement of peripherally inserted central catheters in neonates and infants with congenital cardiac disease.

BACKGROUND: Neonates and infants with congenital and acquired cardiac disease often require placement of central venous lines for extended intravenous therapy. It may be advantageous to avoid the larger venous vessels of the head and neck and lower extremities in order to preserve these for future interventions and therapies. We evaluated the results of a nursing led peripherally inserted central catheter team in our congenital cardiac centre. MATERIALS AND METHODS: Bedside peripherally inserted central catheter the insertion procedures were evaluated for success, complications, and completion of therapy. RESULTS: A total of 125 peripherally inserted central catheters were successfully placed in 105 patients. The mean age at the time of placement was 13.5 plus or minus 19.1 days; median age was 7 days; mean weight was 3.5 plus or minus 1.1 kilogram. Cyanotic cardiac disease accounted for 76% of the diagnoses. Central placement of these lines was successful in 78% of patients. Complications during insertions were limited to inadvertent arterial access in five (3%) infants and oxygen desaturations during sedation for the procedure in two (1%) patients. None of the infants suffered long-term compromise from arterial access; none required intubation for the desaturations. The team was able to respond to 90% of their requests within 24 hours. Median catheter dwell time was 14 days. CONCLUSION: In a population of infants with cardiac disease, a nursing staffed peripherally inserted central catheter team achieved an insertion rate of 78% with few complications and a rapid response time. Reliance on bedside insertion permits continuous critical care monitoring and may eliminate the need for fluoroscopy.

A Katrina experience: lessons learned.

PURPOSE: Almost no data exist on how best to respond to the medical needs of civilians displaced by natural disasters. After Hurricane Katrina destroyed the Gulf Coast and seriously damaged the infrastructure of Jackson, Miss, the University of Mississippi Medical Center (UMMC) was challenged with serving a large group of evacuees at a major Red Cross evacuation shelter near our campus. We reviewed our experiences and share lessons learned. METHODS: This is a retrospective review of administrative and clinical records for patients served by a medical clinic established emergently after Hurricane Katrina. RESULTS: Red Cross regulations precluded their volunteers from providing medical care other than first aid. Faced with numerous evacuees seeking medical assistance, UMMC established an ambulatory clinic at the shelter. The majority of patients had multiple medical problems, no medical insurance, and limited ability to purchase medications. The greatest need was for management of chronic illnesses. The clinic provided 2394 patient visits and filled more than 4902 prescriptions over 17 days. CONCLUSION: While medical facilities have emergency response plans for epidemics and mass trauma, little attention has focused on plans for care of evacuated populations. Shelter operators should consider advance coordination of medical care with existing health care systems. Medical facilities along evacuation routes should be aware that they may be asked to provide care for sheltered evacuees.

Drug-induced metabolic syndrome.

The metabolic syndrome is a cluster of risk factors associated with an increased risk for cardiovascular disease and type 2 diabetes. Based on data from 1988 to 1994, it is estimated that 24% of adults in the United States meet the criteria for diagnosis of the metabolic syndrome. The use of certain medications may increase the risk of the metabolic syndrome by either promoting weight gain or altering lipid or glucose metabolism. Health providers should recognize and understand the risk associated with certain medications and appropriately monitor for changes related to the metabolic syndrome. Careful attention to drug choices should be paid in patients who are overweight or have other risk factors for diabetes or cardiovascular disease.

Exercise, insulin resistance, and hypertension: a complex relationship.

More than 300,000 deaths occur annually in the United States alone as a result of obesity, poor dietary habits, or physical inactivity. Obesity is now an increasingly recognized independent risk factor for cardiovascular disease and leads to numerous other comorbidities. The causal relationships between obesity and both insulin resistance and hypertension have been consistently demonstrated in numerous studies. The relationships consist of cascading events involving insulin, leptin, adiponectin, and other hormones that often precipitate the development of metabolic syndrome. As we learn more about the metabolic activity of the adipose tissue, we can better identify the mechanisms that associate weight reduction with a decrease in health risks. Evidence suggests that exercise produces a positive effect on weight reduction, insulin sensitivity, and blood pressure. Therefore, weight reduction and therapeutic changes in lifestyle should be encouraged in all overweight and obese patients. It is imperative to increase the awareness of the obesity epidemic and to emphasize the importance of exercise as both treatment and prevention of metabolic disease.

Effectiveness of a school-based intervention to increase health knowledge of cardiovascular disease risk factors among rural Mississippi middle school children.

BACKGROUND: Few school-based interventions have been evaluated to assess health awareness among children in rural southern areas. The purpose of this controlled investigation was to increase health awareness among middle school-aged children residing in a racially diverse rural community in Mississippi. METHODS: This investigation assessed health knowledge before and after a 16-week school-based intervention in 205 fifth-grade students. Height, weight, BMI, body composition, waist circumference, dietary intake, blood lipids and lipoprotein concentrations, blood glucose concentrations, and resting blood pressure were measured to enhance student awareness of cardiovascular disease risk factors. Values in the intervention school were compared with those obtained simultaneously in a control school within the same community. RESULTS: The school-based intervention was effective in increasing health knowledge in the intervention as compared with the control school. Secondarily, it was effective in improving certain dietary behaviors. Utilizing health care professionals in the classroom to teach students appropriate lifestyles and actually measuring cardiovascular risk factors to increase awareness among students was effective in increasing overall health knowledge. CONCLUSIONS: Health knowledge of rural adolescents can be increased through partnerships with schools and multidisciplinary teams of health care professionals. Ongoing efforts to reduce childhood obesity and cardiovascular disease risk factors are urgently needed, and information obtained during this investigation may be used in planning school-based interventions in other diverse, rural communities.

Body weight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi.

OBJECTIVES: Obesity and cardiovascular diseases are more prevalent in the Southeast as compared with other geographic regions of the United States. However, few investigations have addressed health disparities among children in rural Southeastern areas. The purpose of this investigation was to determine the risk of overweight and obesity in middle school-aged children residing in a racially diverse rural community, and to characterize their dietary and physical activity habits. METHODS: Two hundred and five middle school children from Scott County, Mississippi were enrolled in this investigation. Measurements included height, weight, body mass index, dietary intake using a 24-hour recall, and physical activity level using pedometers. RESULTS: Of the 205 children studied, 54% were "overweight" or "at risk for overweight" according to a body mass index-for-age sex-specific percentile. Intake of saturated fat and sodium exceeded recommended levels, whereas intake of calcium, fruits, and vegetables was inadequate. One third of the sample consumed 12 fluid ounces or more of soda on the day of the recall. Physical activity level was below that previously reported for children in this age range, and knowledge of the importance of diet and physical activity in the prevention of cardiovascular disease was poor, particularly among African-American children. CONCLUSIONS: The children in our sample are at increased risk for overweight and obesity. Factors that may be targeted for intervention include a reduction in dietary intake of fat, saturated fat, sodium, and soft drinks, and an increased intake of fruits and vegetables. Physical activity should be encouraged. Many of these factors could be improved through changes within the school environment.

The natural treatment of hypertension.

The goal of this review is to evaluate the efficacy of commonly available dietary supplements in the treatment of hypertension, using the average blood pressure reduction achieved with the implementation of lifestyle modifications as a standard. For this reason, the authors focus on the antihypertensive potential of these agents rather than pharmacology, pharmacokinetics, adverse effects, or supplement-drug interactions. For the purpose of this review, dietary supplements are defined as exhibiting some evidence of benefit if a systolic blood pressure reduction of 9.0 mm Hg or greater and/or a diastolic blood pressure reduction of 5.0 mm Hg or greater has been observed in previously published, peer-reviewed trials. These defining limits are based on the average blood pressure reduction associated with the implementation of certain lifestyle modifications. Agents with some evidence of benefit include coenzyme Q10, fish oil, garlic, vitamin C, and L-arginine.

Relationship between antihypertensive drugs and metabolic syndrome.

Metabolic syndrome is a cluster of risk factors associated with an increased risk for cardiovascular disease and type 2 diabetes. Based on data from 1988 to 1994, it is estimated that 24% of adults in the United States meet the criteria for diagnosis of metabolic syndrome. The use of certain medications increases the risk for metabolic syndrome by either promoting weight gain or the development of changes in lipid or glucose metabolism. Diuretics and beta-blockers are among the agents recommended for first-line therapy for hypertension, yet these medications increase the risk of metabolic syndrome. Healthcare providers should recognize and understand the risk associated with antihypertensive agents and should appropriately monitor for changes related to metabolic syndrome. Careful attention to drug choices should be given with patients who are overweight or have other risk factors for diabetes or cardiovascular disease.

Cognitive impairment associated with atorvastatin and simvastatin.

Clinical guidelines for cholesterol testing and management have been updated recently. With the evolving recognition of benefits and intensified recommendations for cholesterol management, many more patients will require cholesterol-lowering drugs. All the statins share similar adverse-effect profiles, with a low overall frequency of undesirable effects. Emerging data associate statins with a decreased risk of Alzheimer's disease; however, we report two women who experienced significant cognitive impairment temporally related to statin therapy. One woman took atorvastatin, and the other first took atorvastatin, then was rechallenged with simvastatin. Clinicians should be aware of cognitive impairment and dementia as potential adverse effects associated with statin therapy.

Does it matter how we lower blood pressure?

The risk of cardiovascular disease in patients with hypertension has decreased dramatically over the last 40 years. This impressive reduction is attributable in part to an increased awareness of the risk related to hypertension, to an emphasis on treatment to lower target blood pressures, and to the development of more effective antihypertensive drugs. Several recent studies have revealed potential blood pressure-independent protective effects of some agents, creating a debate on whether different drug classes actually confer a beneficial effect beyond the effect on blood pressure. Studies are needed to assess the contributions of blood pressure and its components versus blood pressure-independent effects on the reduction of cardiovascular risk.

Do over-the-counter medications for migraine hinder the physician?

The availability of many over-the-counter drugs that were formerly prescription medications enable patients with migraine to self-medicate easily and delay entry into the appropriate medical management. The potential for adverse effects, drug interactions, and analgesic rebound headaches can often be complications that hinder treatment. Over-the-counter products force the patient to employ a less effective step-care approach as opposed to evidence-based guidelines.

Secondary Hypertension: Detection and Management for the Primary Care Provider.

Of hypertensive patients, 95% have primary (essential) hypertension. The remaining 5% of adults with hypertension have an identifiable or "secondary" disorder responsible for the elevated blood pressure. Although relatively rare, the diagnosis of secondary hypertension is important as these forms require specific treatments based on the underlying pathophysiology and are potentially curable. Secondary causes of hypertension include renal disease, such as chronic parenchymal disease and renovascular hypertension, a number of endocrinopathies, such as primary aldosteronism, pheochromocytoma, or thyroid disease, as well as a variety of miscellaneous causes including obstructive sleep apnea and substance abuse. An evaluation for secondary causes in all hypertensive patients is not necessary or cost effective. Clinical clues obtained from a careful history, physical examination, and laboratory assessment guide the clinician through an appropriate evaluation for identifiable causes. A combination of the clinician's index of suspicion and interpretation of data provide guidance in the choice of diagnostic tests and therapies to target the mechanisms contributing to poor blood pressure control. (c)2000 by Le Jacq Communications, Inc.