Health-related quality of life following isolated aortic valve surgery: is earlier intervention better?

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine the health-related quality of life (HRQL) in conjunction with clinical outcomes following aortic valve replacement (AVR) surgery. In these times of healthcare change, quality measures of the success of a procedure go beyond clinical outcomes, with patient reports of HRQL considered important. METHODS: All patients who had undergone AVR surgery were followed prospectively through the authors' valve registry and the local Society of Thoracic Surgery (STS) database. The HRQL (Short-Form 12 and Minnesota Living with Heart Failure Questionnaire) was collected preoperatively, and at six and 12 months after surgery. RESULTS: Since 2005, a total of 459 patients have undergone isolated AVR surgery. The mean age, ejection fraction and STS risk score were 65.8 +/- 13.6 years, 57.7 +/- 11.0%, and 2.8 +/- 3.5 (range: 0.4-47.9), respectively. The median (IQR) length of hospital stay was 5 (3-7) days. Compared to the STS national norms, all clinical outcomes were excellent. A Kaplan-Meier analysis showed the two year cumulative survival as 92.0%. After 12 months the physical and mental HRQL had improved significantly, surpassing age and heart disease norms (p < 0.001 and p = 0.02, respectively). Multivariate analysis determined that a higher 12-month physical HRQL was predicted by a lower STS risk score (B = -1.3, p < 0.001) and a lower perioperative morbidity (B = -5.5, p = 0.02) after adjustment for baseline HRQL, age, and gender. In a subset of patients classified as 'symptomatic', as determined by higher MLHF scores, the HRQL scores were increased to age norms and surpassed the heart disease norms. CONCLUSION: Patients who undergo AVR can expect excellent clinical and HRQL outcomes, with greater benefits the earlier the surgery is carried out. The tracking of HRQL is valuable in understanding the success of a procedure from the patients' perspective.

Current management of patients with nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) and its progressive form, nonalcoholic steatohepatitis (NASH) are the most common causes of chronic liver disease in industrialized countries. NAFLD has also been strongly associated with type II diabetes and cardiovascular diseases. This study was a multipurposed review, which included discussion of recent studies investigating the cellular and genetic basis of these diseases, the pathogenesis of NAFLD and the current treatment and management of nonalcoholic steatohepatitis. Currently, maintaining a healthy weight through dietary changes and exercise, the use of insulin-modulating pharmacologic agents for diabetes control and the use of lipid-lowering, anti-oxidants have been the most widely recommended treatments. Inclusion of pathogenic mechanisms in treatment design will allow future therapies to target-specific pathways involved in NAFLD pathogenesis.

Health-related quality of life after coronary artery bypass grafting surgery and the role of gender.

OBJECTIVE: Heart disease is the leading cause of death for women. Previous studies suggest that women undergoing coronary artery bypass (CABG) surgery present with a higher severity of disease and that this may be an indicator of delays in treatment preceding diagnosis thus presenting challenges for recovery. The aim of this study was to examine gender differences in CABG morbidity and reported health-related quality of life (HRQL) at baseline and six months post-surgery. It was hypothesized that female gender would be an independent predictor for lower HRQL at six months following CABG surgery. METHODS: Four hundred and ninety-six (n=496) adult patients who underwent a first-time, isolated CABG procedure with baseline and 6-month follow-up were included. Stepwise multivariate regressions were conducted to evaluate the factors predictive of 6-month HRQL scores. RESULTS: Females had more preoperative co-morbidities and scored significantly lower on HRQL compared to males at both baseline (p values<0.01) and six months (p values<0.01) on all ten domains. Gender was a significant predictor of 6-month HRQL in regression models for 8 out of 10 HRQL domains including Physical Component Summary score (B=-2.54, p=0.02). CONCLUSIONS: Female patients were at higher risk as reflected by their perioperative risk factors and baseline HRQL. These findings may reflect a delayed referral for surgery. Results indicated that female gender predicts lower HRQL 6-months post-CABG surgery, which can have an impact on recovery and outcomes. Efforts should be made to identify and treat female patients earlier to improve post-surgical outcomes.

The impact of surgical ablation for atrial fibrillation in high-risk patients.

BACKGROUND: Data reported by The Society of Thoracic Surgeons adult cardiac surgery database demonstrate that only 38% of patients with atrial fibrillation (AF) underwent a concomitant surgical ablation. Surgeons are reluctant to add complexity and potential morbidity by including an additional procedure when performing surgery in higher operative risk patients. We investigated perioperative and long-term outcomes in high-risk patients who underwent open heart surgery with or without surgical ablation for AF. METHODS: An additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) higher than 6 defined high-risk patients. Perioperative outcomes were captured prospectively, and long-term survival and quality of life were assessed. Propensity score matching using a 0.25 caliper was conducted between the surgical ablation group and the nonablation group (no history of AF). RESULTS: The propensity score matching analysis included 178 patients per group. The groups were similar on preoperative characteristics including age, ejection fraction, EuroSCORE, and surgical procedures. The perioperative outcomes were similar between groups, including length of stay, permanent stroke, renal failure, 30-day readmissions, and operative (<30 days) mortality. Cumulative survival over 5 years also did not differ between groups (74.4% versus 69.7%, p=0.34). CONCLUSIONS: The addition of an AF surgical ablation procedure did not add operative risk to patients considered high risk, and potentially improved long-term outcome for the subgroup of patients who had their AF ablated. This study suggests that the degree of surgical risk should not be the only decision factor when evaluating this challenging group of patients for surgical ablation.

Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: a prospective randomized controlled trial.

OBJECTIVE: The purpose of this study was to test the hypothesis that a liberal blood glucose strategy (121-180 mg/dL) is not inferior to a strict blood glucose strategy (90-120 mg/dL) for outcomes in patients after first-time isolated coronary artery bypass grafting and is superior for glucose control and target blood glucose management. METHODS: A total of 189 patients undergoing coronary artery bypass grafting were investigated in this prospective randomized study to compare 2 glucose control strategies on patient perioperative outcomes. Three methods of analyses (intention to treat, completer, and per protocol) were conducted. Observed power was robust (>80%) for significant results. RESULTS: The groups were similar on preoperative hemoglobin A(1c) and number of diabetic patients. The liberal group was found to be noninferior to the strict group for perioperative complications and superior on glucose control and target range management. The liberal group had significantly fewer patients with hypoglycemic events (<60 mg/dL; P < .001), but severe hypoglycemic events (<40 mg/dL) were rare and no group differences were found (P = .23). These results were found with all 3 methods of analysis except for blood glucose variability, maximum blood glucose, and perioperative atrial fibrillation. CONCLUSIONS: This study demonstrated that maintenance of blood glucose in a liberal range after coronary artery bypass grafting led to similar outcomes compared with a strict target range and was superior in glucose control and target range management. On the basis of the results of this study, a target blood glucose range of 121 to 180 mg/dL is recommended for patients after coronary artery bypass grafting as advocated by the Society of Thoracic Surgeons.

A quality improvement project to optimize patient outcomes following the maze procedure.

Atrial fibrillation (AF) is the most common of all clinically sustained heart arrhythmias with associated morbidities (shortness of breath, fatigue, and stroke). The maze cardiac surgical procedure is a new treatment option available for patients who have medical refractory AF. The purpose of this study was to determine whether a written postdischarge protocol was necessary to improve outcomes following the maze procedure. Only 3 (27%) patients with AF were actively treated by an arrhythmia protocol for restoration of sinus rhythm. Unnecessary pharmacologic management for AF was found in 44 patients with normal sinus rhythm. A postdischarge protocol was developed that improved outcomes.

Public health reporting: the United States perspective.

The release of 2 landmark reports by the Institute of Medicine titled, "To Err Is Human: Building a Safer Health System" and "Crossing the Quality Chasm" were instrumental in the identification of safety and quality issues. Since their release, federal and state programs of public reporting of performance measures have attempted to close the quality gap of care that is inappropriate, not timely, or lacking an evidence base. Cardiac surgery has long been the focus of public scrutiny, and now, as we move from an era of managed care to public reporting, reimbursement for cardiac surgery procedures will be tied to performance. However, the question is whether public reporting and pay for performance will ultimately improve the quality of patient care, safety, and provide the consumer with enough information to make surgeon and institutional choices. Will the cost and focus of achieving perfection with performance standards overshadow any real improvement in clinical outcomes?

Tobacco use triggers for mothers of infants: implications for pediatric nursing practice.

PURPOSE: To extend current knowledge of tobacco use by exploring whether subsets of mothers of infants have unique triggers for smoking relapse during the early stages of becoming a mother. METHOD: Using data from a study of smoking relapse among mothers of infants (N = 133), comparative analyses were conducted for groups formed on the basis of their intention to be nonsmokers after delivery (yes/no) and their actual smoking behavior during the first 2 weeks of infant life (yes/no). FINDINGS: The identified groups of mothers were found to be significantly different from one another in several ways, including self-reports that their baby's crying episodes caused them to think about smoking and their level of self-confidence to not smoke as response to infant crying. CONCLUSIONS: Pediatric nurses in primary and acute care settings are in a unique position to support mothers for whom the challenge of handling infant cry episodes is a trigger for smoking behavior. Interventions that teach mothers how to cope with infant irritability are likely to support the smoking cessation efforts, and consequently, interrupt the intergenerational cycle of tobacco-related maternal and child health morbidities.

Identifying risk factors for postpartum tobacco use.

PURPOSE: To identify factors associated with becoming a mother that may contribute to postpartum smoking-related outcomes. DESIGN: Cross-sectional, correlational. METHODS: Postpartum women (N=133) who were clients in a nutrition supplement program for low-income families responded to questionnaires about smoking and early motherhood experiences. Inferential statistical tests included hierarchical multiple and logistic regression. FINDINGS: After controlling for factors known to be associated with smoking outcomes for the general population, factors associated with becoming a mother significantly contributed to the amount of explained variance in both postpartum self-efficacy to refrain from smoking and smoking within 2 weeks after delivery. CONCLUSIONS: Study findings indicated that prenatal intentions about postpartum tobacco use and maternal response to infant cry episodes were areas for risk assessment that might lead to effective smoking cessation interventions uniquely tailored to women who experience becoming a mother.

Childhood obesity: what can be done to help today's youth?

Childhood obesity is at epidemic proportions in the United States today. This epidemic has created a public health crisis. Although several initiatives are under way to address childhood obesity, including legislative bills before Congress and a call by the National Academy of Sciences for society to band together to stop the rise in the rates of childhood obesity, none of these efforts address what can be done today to help those youth that are considered morbidly obese and who have failed to find solutions with the standard medical treatment plan. This article discusses the use of bariatric surgery as a possible solution, presents a case study to illustrate the impact bariatric surgery can have on youth who are morbidly obese, and defines the pediatric nurse's role in helping to assure that youth are included in the current legislative process.

Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.

The Institute of Medicine report, To Err Is Human: Building a Safer Health System, has spurred public concern over hospitals' ability to deliver safe care. The health care industry continues to struggle to address these concerns. These efforts have driven the growing expectation that health care practitioners or systems disclose unanticipated outcomes to patients and family members. Although the tort system has been cited as an impediment to medical error disclosure, some organizations and systems have successfully implemented policies calling for full disclosure of errors and unanticipated outcomes. However, most organizations have yet to develop policies concerning error disclosure. This article provides an overview of error disclosure and a model framework for an error disclosure policy. The ethical principle of respect for patient autonomy is emphasized as the driving force in developing an institutional disclosure policy and changing the organizational culture to one that supports development and implementation of such a policy.