Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association.

The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.

Receipt of Tobacco Treatment and One-Year Smoking Cessation Rates Following Lung Cancer Screening in the Veterans Health Administration.

BACKGROUND: Implementation of effective smoking cessation interventions in lung cancer screening has been identified as a high-priority research gap, but knowledge of current practices to guide process improvement is limited due to the slow uptake of screening and dearth of data to assess cessation-related practices and outcomes under real-world conditions. OBJECTIVE: To evaluate cessation treatment receipt and 1-year post-screening cessation outcomes within the largest integrated healthcare system in the USA-the Veterans Health Administration (VHA). Design Observational study using administrative data from electronic medical records (EMR). Patients Currently smoking Veterans who received a first lung cancer screening test using low-dose CT (LDCT) between January 2014 and June 2018. Main Outcomes Tobacco treatment received within the window of 30 days before and 30 days after LDCT; 1-year quit rates based on EMR Smoking Health Factors data 6-18 months after LDCT. Key Results Of the 47,609 current smokers screened (95.3% male), 8702 (18.3%) received pharmacotherapy and/or behavioral treatment for smoking cessation; 531 (1.1%) received both. Of those receiving pharmacotherapy, only one in four received one of the most effective medications: varenicline (12.1%) or combination nicotine replacement therapy (14.3%). Overall, 5400 Veterans quit smoking-a rate of 11.3% (missing=smoking) or 13.5% (complete case analysis). Treatment receipt and cessation were associated with numerous sociodemographic, clinical, and screening-related factors. CONCLUSIONS: One-year quit rates for Veterans receiving lung cancer screening in VHA are similar to those reported in LDCT clinical trials and cohort studies (i.e., 10-17%). Only 1% of Veterans received the recommended combination of pharmacotherapy and counseling, and the most effective pharmacotherapies were not the most commonly received ones. The value of screening within VHA could be improved by addressing these treatment gaps, as well as the observed disparities in treatment receipt or cessation by race, rurality, and psychiatric conditions.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association.

Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.

Challenges to Educating Smokers About Lung Cancer Screening: a Qualitative Study of Decision Making Experiences in Primary Care.

We sought to qualitatively explore how those at highest risk for lung cancer, current smokers, experienced, understood, and made decisions about participation in lung cancer screening (LCS) after being offered in the target setting for implementation, routine primary care visits. Thirty-seven current smokers were identified within 4 weeks of being offered LCS at seven sites participating in the Veterans Health Administration Clinical Demonstration Project and interviewed via telephone using semi-structured qualitative interviews. Transcripts were coded by two raters and analyzed thematically using iterative inductive content analysis. Five challenges to smokers' decision-making lead to overestimated benefits and minimized risks of LCS: fear of lung cancer fixated focus on inflated screening benefits; shame, regret, and low self-esteem stemming from continued smoking situated screening as less averse and more beneficial; screening was mistakenly believed to provide general evaluation of lungs and reassurance was sought about potential damage caused by smoking; decision-making was deferred to providers; and indifference about numerical educational information that was poorly understood. Biased understanding of risks and benefits was complicated by emotion-driven, uninformed decision-making. Emotional and cognitive biases may interfere with educating and supporting smokers' decision-making and may require interventions tailored for their unique needs.

Attitudes and Perceptions About Smoking Cessation in the Context of Lung Cancer Screening.

IMPORTANCE: Broad adoption of lung cancer screening may inadvertently lead to negative population health outcomes if it is perceived as a substitute for smoking cessation. OBJECTIVE: To understand views on smoking cessation from current smokers in the context of being offered lung cancer screening as a routine service in primary care. DESIGN, SETTING, AND PARTICIPANTS: As an ancillary study to the launch of a lung cancer screening program at 7 sites in the Veterans Health Administration, 45 in-depth semi-structured qualitative interviews about health beliefs related to smoking and lung cancer screening were administered from May 29 to September 22, 2014, by telephone to 37 current smokers offered lung cancer screening by their primary care physician. Analysis was conducted from June 15, 2014, to March 29, 2015. MAIN OUTCOMES AND MEASURES: Attitudes and perceptions about the importance of smoking cessation in the context of lung cancer screening. RESULTS: Lung cancer screening prompted most current smokers to reflect for the first time on what smoking means for their current and future health. However, 17 of 35 (49%) participants described mechanisms whereby screening lowered their motivation for cessation, including the perception that undergoing an imaging test yields the same health benefits as smoking cessation. Other misperceptions include the belief that everyone who participates in screening will benefit; the belief that screening and being able to return for additional screening offers protection from lung cancer; the perception by some individuals that findings from screenings have saved their lives by catching their cancer early when indeterminate findings are identified that can be monitored rather than immediately treated; and a reinforced belief in some individuals that a cancer-free screening test result indicates that they are among the lucky ones who will avoid the harms of smoking. CONCLUSIONS AND RELEVANCE: In this qualitative, lung cancer screening prompted many current smokers to reflect on their health and may serve as a potential opportunity to engage patients in discussions about smoking cessation. However, several concerning pathways were identified in which screening, when offered as part of routine care and described as having proven efficacy, may negatively influence smoking cessation. Health care professionals should be aware that the opportunity for early detection of lung cancer may be interpreted as a way of avoiding the harms of smoking. To promote cessation, discussions should focus on the emotional response to screening rather than clinical details (eg, nodule size) and address misperceptions about the value of early detection so that screening does not lower motivation to quit smoking.

Trainee underperformance: a guide to achieving resolution.

BACKGROUND: Underperformance and the disharmony it can cause are not commonly faced by trainees. However, when it occurs, a process to recognize and manage the issues compassionately must be put in place. METHOD: A literature review was undertaken to outline processes and themes in addressing and resolving these types of issues. A PubMed search using 'surgical underperformance' and 'remedial teaching' was used as a broad template to find papers that illustrated key concepts. One thousand four hundred and fifteen papers were identified. In papers where the titles were in line with the stated topic, 294 abstracts were reviewed. Key papers were used to develop themes. Additional cross-referenced papers were also included where relevant. RESULTS: There can be a variety of reasons for trainee underperformance. The root cause is not always clear. Disharmony can result in a surgical unit during this time. The involved trainee as well as the members of the clinical unit may experience a variety of stressors. A systematic process of management can be used to evaluate the situation and bring some resolution to difficulties in working relationships. CONCLUSION: Early constructive intervention improves outcomes. There should be a process to systematically and compassionately resolve underlying issues. This paper outlines the disharmony that can result from trainee underperformance and offers guidance for resolution to those involved.

Cardiovascular genomics: implications for acute and critical care nurses.

As genomic health care becomes commonplace, nurses will be asked to provide genomic care in all health care settings including acute care and critical care. Three common cardiac conditions are reviewed, Marfan syndrome, bicuspid aortic valve, and hypertrophic cardiomyopathy, to provide acute care and critical care nurses with an overview of these pathologies through the lens of genomics and relevant case studies. This information will help critical care nursing leaders become familiar with genetics related to common cardiac conditions and prepare acute care and critical care nurses for a new phase in patient diagnostics, with greater emphasis on early diagnosis and recognition of conditions before sudden cardiac death.

Neurobehavioral assessment of infants born at term and in utero exposure to serotonin reuptake inhibitors.

BACKGROUND: Some studies report neurobehavioral symptoms in neonates exposed to serotonin reuptake inhibitors (SRIs) in utero. However, maternal psychiatric illness during the last trimester of pregnancy, as a confounding factor, has not always been assessed. AIMS: In this prospective study we compared neurobehavioral complications among neonates who were born to euthymic women who either took or did not take an SRI during the last trimester of pregnancy. STUDY DESIGN: Exposed and unexposed infants were assessed for: 1) temperament as measured by the Neonatal Behavioral Assessment Scale (NBAS); 2) activity via Actiwatch electronic monitoring; 3) sleep state using trained observer ratings; and 4) perinatal complications through medical record review. T-tests, Fisher's exact tests, and analyses of covariance were used to assess the relationship between clinical and neurobehavioral factors and exposure status. SUBJECTS: 67 infants (61 controls and 6 exposed to SRIs). OUTCOME MEASURES: Neonatal Assessment Behavioral Scale, APGAR scores, infant sleep state (% sleep, % wakeful), startles and tremulousness, gestational age, birth weight, and head circumference. RESULTS: Infants exposed to SRIs in the third trimester had poorer motor development, lower 5-minute APGAR scores, and shorter mean gestational age as compared to unexposed infants. CONCLUSION: Results of this study show differences in autonomic and gross motor activity between neonates who were or were not exposed to SRIs in utero after controlling for active maternal psychiatric illness. Future longitudinal work should compare longer term outcomes of exposed and unexposed infants of depressed mothers.

Pain assessment in the intensive care unit: development and psychometric testing of the nonverbal pain assessment tool.

BACKGROUND: Few standardized tools measure pain in nonverbal patients in the intensive care unit (ICU). Evidence exists that patient behaviors provide important information about pain in those unable to report their pain. OBJECTIVE: The Nonverbal Pain Assessment Tool (NPAT), a behavioral pain assessment tool, was developed for the nonverbal adult patient in the ICU. Content and criterion validity and internal and interrater reliability were evaluated. METHODS: The validity of NPAT was assessed against the patients' self-reports of pain. Interrater reliability was tested by 5 teams of 2 nurses assessing pain in nonverbal adult patients in 4 different ICUs. RESULTS: The tool underwent 2 revisions and involved 270 patients. During the final evaluation, strong internal reliability (chronbach's α, .82; 95% confidence interval), moderately strong interrater reliability (concordance coefficient, .72; 95% confidence interval; and weighted κ statistic, .35), and moderately strong validity (concordance coefficient, .66; 95% confidence interval) were achieved. CONCLUSION: The NPAT was found to possess moderately strong validity and strong internal and interrater reliability. It is easy to use, and provides a standard approach to assessing pain in the nonverbal adult patient.

An examination of policies addressing resident smoking in nursing homes.

OBJECTIVES: To report findings of a nationwide project that examined nursing homes' tobacco policies for residents. DESIGN: A random selection procedure was used to sample nursing homes proportional to the geographic distribution of nursing homes in the United States. Rubrics were developed to objectively describe and compare policies. SETTING: Policies were obtained from 4 types of facilities: (1) facilities that allow smoking indoors and outdoors (I/O-SFs), (2) facilities that allow residents to smoke outdoors only (O-SFs), (3) facilities that do not allow residents to smoke indoors or out of doors (NSFs), and (4) facilities in transition (TFs) from a smoking facility to an NSF. MEASURES: Rubrics used to score policies had common categories: administrative/authority issues, notification, resident smoking, safety, cessation assistance/encouragement, and smoking areas. Criteria within each category varied to reflect the smoking regulations of each type of facility (eg, policies of facilities that do not allow smoking indoors were not examined for inclusion of issues related to ventilation). RESULTS: Facilities' policies from geographically diverse facilities are described. Across all facilities, mean percentages reflecting policies' overall comprehensiveness were low, and when examining specific components of the policies, few areas were consistently addressed across facilities. CONCLUSIONS: Considerable gaps were found in written policies regarding smoking. Although nursing homes may in fact have practices that are more extensive than their policies portray, creating policies that guide practice can assist these long-term care facilities to promote an environment that aligns with their goals and desired practices to protect the health of residents and staff.

Ethical review issues in collaborative research between us and low-middle income country partners: a case example.

The current ethical structure for collaborative international health research stems largely from developed countries' standards of proper ethical practices. The result is that ethical committees in developing countries are required to adhere to standards that might impose practices that conflict with local culture and unintended interpretations of ethics, treatments, and research. This paper presents a case example of a joint international research project that successfully established inclusive ethical review processes as well as other groundwork and components necessary for the conduct of human behavior research and research capacity building in the host country.

Tobacco use in six economically disadvantaged communities in the Dominican Republic.

The Dominican Republic is a tobacco-growing country, and tobacco control efforts there have been virtually nonexistent. This study provides a first systematic surveillance of tobacco use in six economically disadvantaged Dominican Republic communities (two small urban, two peri-urban, two rural; half were tobacco growing). Approximately 175 households were randomly selected in each community (total N = 1,048), and an adult household member reported on household demographics and resources (e.g., electricity), tobacco use and health conditions of household members, and household policies on tobacco use. Poverty and unemployment were high in all communities, and significant gaps in access to basic resources such as electricity, running water, telephones/cell phones, and secondary education were present. Exposure to tobacco smoke was high, with 38.4% of households reporting at least one tobacco user, and 75.5% allowing smoking in the home. Overall, 22.5% reported using tobacco, with commercial cigarettes (58.0%) or self-rolled cigarettes (20.1%) the most commonly used types. Considerable variability in prevalence and type of use was found across communities. Overall, tobacco use was higher in males, illiterate groups, those aged 45 or older, rural dwellers, and tobacco-growing communities. Based on reported health conditions, tobacco attributable risks, and World Health Organization mortality data, it is estimated that at least 2,254 lives could potentially be saved each year in the Dominican Republic with tobacco cessation. Although it is expected that the reported prevalence of tobacco use and health conditions represent underestimates, these figures provide a starting point for understanding tobacco use and its prevalence in the Dominican Republic.

The ectopic appendicolith from perforated appendicitis as a cause of tubo-ovarian abscess.

Acute appendicitis is a common surgical cause of abdominal pain in the pediatric population. History and physical examination are atypical in up to a third of patients. Known potential complications of untreated or delayed management of acute appendicitis include appendiceal perforation, periappendiceal abscess formation, peritonitis, bowel obstruction and rarely septic thrombosis of mesenteric vessels. We report an unusual complication of perforated appendicitis. A tubo-ovarian abscess developed secondary to appendicolith migration into the right fallopian tube in a patient who had undergone interval laparoscopic appendectomy for perforated appendicitis. The retained appendicolith was visualized within the obstructed and dilated fallopian tube on contrast-enhanced CT. We discuss the CT imaging features of this unusual complication of perforated appendicitis.

Minimal dataset for quitlines: a best practice.

OBJECTIVES: This paper discusses the development of a minimal dataset (MDS) for tobacco cessation quitlines across North America. The goal was to create a standardised instrument and protocol that would allow for comparisons and pooling of data across quitlines for evaluation and research purposes. Principles of utilisation focused evaluation were followed to achieve consensus across diverse stakeholder groups in two countries. METHODS: The North American Quitline Consortium (NAQC) assembled a working group with representatives from quitline service providers, funders, evaluators and researchers from Canada and the United States. An extensive, iterative consultation process over two years led to consensus on the evaluation domains, indicators and specific items. Descriptive information on quitline service models, data collection protocols and methodological issues were addressed. RESULTS: The resulting minimal dataset (MDS) includes 15 items collected from eligible callers at intake and eight items collected from smokers participating in evaluation. Recommendations for selecting evaluation participants, length of follow-up and repeat callers were developed. Full MDS questions and technical documents are available on the NAQC website. CONCLUSION: Adoption and implementation of the MDS occurred in the majority of North American quitlines by the end of 2006. Key success factors included a focus on utility and feasibility, a commitment to meeting multiple and varied needs, sensitivity to situational factors and investment in working interactively with stakeholders. The creation and implementation of a MDS across two countries is an important "first" in tobacco control which will help speed the creation of practice based evidence and facilitate practice based research.