Long-term (5-year) effects of a reduced-fat diet intervention in individuals with glucose intolerance.

OBJECTIVE: To determine whether reducing dietary fat would reduce body weight and improve long-term glycemia in people with glucose intolerance. RESEARCH DESIGN AND METHODS: A 5-year Follow-up of a 1-year randomized controlled trial of a reduced-fat ad libitum diet versus a usual diet. Participants with glucose intolerance (2-h blood glucose 7.0-11.0 mmol/l) were recruited from a Workforce Diabetes Survey. The group that was randomized to a reduced-fat diet participated in monthly small-group education sessions on reduced-fat eating for 1 year. Body weight and glucose tolerance were measured in 136 participants at baseline 6 months, and 1 year (end of intervention), with follow-up at 2 years (n = l04), 3 years (n = 99), and 5 years (n = 103). RESULTS: Compared with the control group, weight decreased in the reduced-fat-diet group (P < 0.0001); the greatest difference was noted at 1 year (-3.3 kg), diminished at subsequent follow-up (-3.2 kg at 2 years and -1.6 kg at 3 years), and was no longer present by 5 years (1.1 kg). Glucose tolerance also improved in patients on the reduced-fat diet; a lower proportion had type 2 diabetes or impaired glucose tolerance at 1 year (47 vs. 67%, P < 0.05), but in subsequent years, there were no differences between groups. However, the more compliant 50% of the intervention group maintained lower fasting and 2-h glucose at 5 years (P = 0.041 and P = 0.026 respectively) compared with control subjects. CONCLUSIONS: The natural history for people at high risk of developing type 2 diabetes is weight gain and deterioration in glucose tolerance. This process may be ameliorated through adherence to a reduced fat intake

Cardiac surgery in the octogenarian: evaluation of risk, cost, and outcome.

BACKGROUND: Nationwide, cardiac surgery is being performed more frequently in patients aged 80 years and older. METHODS: One hundred four octogenarians undergoing a variety of heart-lung procedures were prospectively studied between 1995 and 1998 for comparison with similar patients aged 65 to 75 years (n = 351). RESULTS: Octogenarians were more likely to be of female gender, and be nondiabetic than the younger group. The 30-day mortality rate for patients aged 65 to 75 years was 3.4% (12 of 351 patients), versus 13.5% (14 of 104) for patients aged 80+ (p = 0.0004), which ranged from 2% (1 of 50) in nonemergent coronary artery bypass grafting to 75% (3 of 4) in double valve procedures. Complications occurring more frequently in octogenarians were severe low output state, reintubation, and atrial fibrillation. Elders experienced a longer intensive care (69.2 versus 43.3 hours, p = 0.002) and postoperative stay (10.09 versus 7.45 days, p = 0.001), and were discharged to a skilled nursing facility more often than younger patients (47% versus 21.1%, p = 0.0001). Total direct costs were $4,818 higher in the octogenarian group (p = 0.0007). CONCLUSIONS: Although emergency operations and complex procedures carried high risks for the octogenarian, the majority of these patients can be offered operation with short-term morbidity, mortality, and resource use that only modestly exceeds that of younger patients.

Quality care outcomes in cardiac surgery: the role of evidence-based practice.

An internal database and research methods were used to evaluate the impact of clopidogrel on cardiac surgical bleeding. This quality improvement initiative, led by the clinical nurse specialist, showed that preoperative exposure to clopidogrel was associated with significant increases in chest tube output, blood product use, and reoperation for bleeding rates that were 10-fold higher than for control patients (0.85% versus 8.3%, P = 0.027). Acute care costs averaged $2,680 more for patients who received clopidogrel (P = 0.1936). After implementation of an interdepartmental clinical practice guideline, preoperative exposure to clopidogrel dropped from 39% to 6.3% (P = 0.0000). This drop was accompanied by reductions in chest tube output, blood product use, and bleeding complications, with improved achievement of clinical benchmarks. The availability of internal evidence to support achievement of best practices was an essential factor in the implementation of this interdepartmental change. Comprehensive database systems and advanced practice nurses are highlighted as essential components of evidence-based programs.

Body size and composition in Polynesians.

OBJECTIVES: To compare the relationship between body size and body composition in New Zealanders of Polynesian and European descent and to develop specific regression equations for fat mass for Polynesians. SUBJECTS: 189 Maori (93 males, 96 females), 185 Samoans (88 males, 97 females) and 241 Europeans (89 males, 152 females) aged 20-70 y. MEASUREMENTS: Height, weight, four skinfold thicknesses, bioelectrical impedance analysis (BIA) and dual energy X-ray absorptiometry (DXA). RESULTS: At higher body mass index levels, Polynesians (Maori and Samoans combined) had a significantly higher ratio of lean mass:fat mass compared with Europeans. Four multiple regression equations incorporating resistance and reactance, height and weight, sum of four skinfolds or sum of two skinfolds were developed in two-thirds of the Polynesian participants using DXA fat mass as the dependent variable. In the remaining one-third of participants, the mean difference between fat mass predicted by these equations (r2 range 0.89-0.93) and DXA fat mass ranged from -0. 06 to +0.25 kg (s.d. -3.67 to +3.71 kg). CONCLUSION: At higher BMI levels, Polynesians were significantly leaner than Europeans, implying the need for separate BMI definitions of overweight and obesity for Polynesians. The regression equations using BIA, height and weight or skinfold thicknesses were good predictors of body composition in Polynesians.

Attention is needed to the high prevalence of vitamin D deficiency in our older population.

The aim of this study was to assess the prevalence of vitamin D deficiency in females residing in one large, aged-care facility in Auckland. Thirty-nine residents, most of whom were able to go outdoors without assistance, were tested for midwinter 25-hydroxyvitamin D, and, of these, 36 were tested again in midsummer. The prevalence of frank hypovitaminosis (<10 microg/L) was found to be 49% in midwinter and 33% in midsummer. The vitamin D status of such at-risk individuals could be normalised either by 15-30 minutes of daily sun exposure or, alternatively, a programme of supplementation.

Patient advocacy through outcomes management. A cardiac surgery example.

As we attempt to survive market forces that dominate the health care environment today, nurses must be active participants in finding solutions that improve patient care in a cost-effective manner. In our quest to reduce costs, however, health care providers know first-hand that good patient care is cheaper than bad, with its accompanying complications and readmissions. At our workplace, through our professional organizations, and from our political activities, nurses must offer a loud and unified voice towards the pursuit of patient-focused care. Practices such as early extubation and blood conservation are not only cost effective, they are clearly "the right thing to do."

Measurement of mechanical thresholds, plasma cortisol and catecholamines in control and lame cattle: a preliminary study.

The threshold response to a mechanical nociceptive stimulus was significantly lower on the lame hind limb of lame cows than on the same limb of sound cows. There were no significant differences between the concentrations of cortisol, noradrenaline, adrenaline or dopamine in the blood plasma of the sound and lame cows.

Intraoperative and postoperative blood salvage.

Surgical patients present unique opportunities for reducing allogeneic transfusions via perioperative blood salvage. Intraoperative cell saver techniques enable the collection of autologous blood from the surgical field and cardiopulmonary bypass circuit for return to the patient. Washing and hemoconcentration creates a product with an average hematocrit of 50% that carries normal erythrocyte survival, with minimal coagulation factors of platelets. Postoperative autotransfusion of shed blood from chest tubes or surgical drains enables additional blood conservation, reducing allogeneic transfusions by as much as 50%. Both intermittent and continuous autotransfusion systems using standard chest drainage equipment are available that require minimal setup and maintenance at the bedside. The hematocrit of shed blood is 20-25%, with depletion of clotting factors and platelet function. Potential advantages of perioperative blood salvage include the ready availability of large volumes of patient-compatible blood, with optimal oxygen-carrying capacity, that is virtually free from the risk of viral contamination. Specific indications, contraindications, and techniques for the salvage and administration of these vital products are presented.

A field study of the effect of lameness on mechanical nociceptive thresholds in sheep.

Threshold responses to a mechanical pressure test were measured in two groups of adult female sheep taken from 27 flocks in north Devon. The first group consisted of 470 healthy sheep and the second of 139 sheep suffering from obvious lameness, clinically diagnosed as foot rot. The lame sheep were assessed for the severity of the lesion and the level of lameness and assigned a score. In flocks with sheep with a severe degree of lameness, the sheep had a significantly lower threshold to a mechanical nociceptive stimulus than their matched sound controls and their thresholds remained low when tested three months later, after the apparent resolution of the foot rot lesion. In flocks where the lame sheep were less severely affected there was no difference in the threshold responses to a mechanical stimulus between the sound and lame sheep.

Effect of chronic pain associated with lameness on plasma cortisol concentrations in sheep: a field study.

Plasma cortisol concentrations were measured in two groups of sheep taken from 29 flocks in north Devon. The first group were healthy adult females and the second group were adult females suffering from footrot in one forefoot. These sheep were assessed for the severity of the lesion and the level of lameness and assigned a score. The plasma cortisol concentration was significantly higher in the lame sheep than in the healthy sheep and remained so for up to three months after the apparent resolution of the clinical lesion. There was no correlation between the severity of the footrot and the concentration of plasma cortisol.

Myocardial depression after cardiac surgery: pharmacologic and mechanical support.

Cardiovascular surgery patients may experience a low cardiac output state as a result of anesthesia, cardiopulmonary bypass, and myocardial stunning. Prompt assessment and early intervention are critical to patient survival. A variety of pharmacologic agents are available to support the failing circulation, including several promising new experimental inotropic agents. Intraaortic balloon pumps (IABP) and ventricular assist devices (VAD) are additional therapies reserved for advanced cardiac decompensation that is unresponsive to pharmacologic treatment. A review of etiologic factors precipitating postcardiotomy failure is presented, and traditional and experimental inotropic agents are discussed. An overview of mechanical cardiac support with the IABP, centrifugal and pneumatic VAD, and the Hemopump (Johnson & Johnson Interventional Systems, New Brunswick, NJ) device is presented, all of which addresses information critical to optimal patient outcomes.

Effects of clinically occurring chronic lameness in sheep on the concentrations of plasma noradrenaline and adrenaline.

Plasma adrenaline (AD) and noradrenaline (NA) concentrations were measured by high performance liquid chromatography with electrochemical detection in blood samples from control and lame sheep. The lame sheep suffered from naturally occurring foot rot and showed behavioural characteristics normally associated with chronic pain. The lame sheep were scored both for impairment of gait and pathology of the foot and divided into mild and severely affected groups. Both the mildly and severely lame group showed a significant increase in plasma AD and plasma NA which tended to persist even after clinical resolution of the condition. The measurement of plasma AD and NA may provide information which can be used to assess animals experiencing chronic pain, when taken in conjunction with other parameters, such as nociceptive thresholds and plasma hormone levels.

Strength of continuous spinal catheters.

Several commercially available catheters are currently marketed for continuous intrathecal use. Initial studies using continuous spinal catheters have reported several occurrences of retained fragments after removal of the catheter. Accordingly, we measured the break strength of five commercially available catheters. The TFX/Rusch 28- and 32-gauge continuous spinal catheters required 3.18 and 1.92 lb to break, respectively. The Kendall 28-gauge, the Preferred Medical Products 24-gauge, and the 24-gauge Burron catheters averaged 1.22, 1.97, and 3.55 lb to break, respectively. We also tested a commonly used Burron 20-gauge catheter, which is marketed for epidural use, and found it had an average break strength of 6.35 lb. The tested values obtained for the TFX/Rusch catheters were lower than the break strength values supplied by the manufacturers. The authors conclude that the break strength of spinal catheters is one-third to one-half that found for a typical epidural catheter.

The Thoratec ventricular assist device: nursing guidelines.

The Thoratec ventricular assist device (VAD) offers a final hope for survival in patients with severe cardiogenic shock unresponsive to conventional therapy. In select patients, these pneumatically activated prosthetic ventricles maintain organ perfusion pending recovery of the native heart or cardiac transplant. A detailed review of Thoratec VAD operation, its impact on the circulatory pathway and hemodynamic monitoring, and troubleshooting guidelines specific to these patients are presented. A nursing diagnosis framework assists with the identification and management of problems such as impaired cardiac output and gas exchange, as well as altered mobility, nutrition, and coping. Current information regarding the etiology and management of complications such as bleeding, infection, and end-organ failure are reviewed. A case study presentation offers guidelines for weaning patients from the VAD and includes a comprehensive nursing care plan for these challenging patients.

Effects of chronic lameness on the concentrations of cortisol, prolactin and vasopressin in the plasma of sheep.

Plasma cortisol, prolactin and vasopressin concentrations were measured by radioimmunoassay in blood samples from control and lame sheep. The lame sheep were all suffering from naturally occurring clinical cases of footrot and showed all the behavioural characteristics of chronic pain; they were scored for impairment of gait and pathology of the foot and divided into mild and severely lame groups. The severely lame sheep had increased plasma prolactin and decreased plasma cortisol concentrations. Plasma vasopressin was variable and showed no consistent changes with lameness. The relationships between plasma cortisol, prolactin and vasopressin may be a useful index in the assessment of animals experiencing chronic pain, when taken in conjunction with other measurements.

Crystalloid versus colloid fluid therapy after cardiac surgery.

Differences in hemodynamic stability and fluid requirements were examined in patients randomly assigned to receive either normal saline crystalloid solution (N = 10) or hetastarch colloid solution (N = 11) after coronary artery bypass or valve operation. Both solutions were administered in the same manner for 8 hours after surgery, with hourly assessment of hemodynamic parameters and intake/output data. Infusion rates and 8-hour intake were higher for the group receiving normal saline solution (p less than 0.001), as was postoperative weight gain (p less than 0.01), although urine and chest tube outputs did not differ. Despite lower filling pressures, subjects receiving hetastarch exhibited higher systolic blood pressures and cardiac outputs (p less than 0.05). Hematocrits on postoperative day 1 were lower in the group given hetastarch (p less than 0.001), suggesting prolonged intravascular expansion. The subjects given hetastarch also required significantly less time in the intensive care unit (p less than 0.001). Thus, cardiac surgical patients receiving colloids exhibited reduced fluid requirements, superior hemodynamic performance, and shortened intensive care stay when compared with those given crystalloid resuscitation.