Disparity in population structuring of Southwestern Willow Flycatchers based on geographic distance, movement patterns, and genetic analyses.

Estimates of population connectivity often are based on demographic analysis of movements among subpopulations, but this approach may fail to detect rare migrants or overestimate the contribution of movements into populations when migrants fail to successfully reproduce. We compared movement data of endangered Southwestern Willow Flycatchers among isolated populations in Nevada and Arizona from 1997 to 2008 to genetic analyses of samples collected between 2004 and 2008 to determine the degree to which these two methods were concordant in their estimates of population structuring. Given that documented movements of 13 color-banded adults and 23 juveniles over 10 years indicated low rates of long-distance movements, we predicted that genetic analyses would show significant population structuring between a northern (Nevada) deme and a southern (Arizona) deme. We genotyped 93 adult individuals at seven microsatellite loci and used two Bayesian clustering programs, STRUCTURE and GENELAND, to predict population structure. Both clustering algorithms produced the same structuring pattern; a cluster containing birds breeding in Pahranagat National Wildlife Refuge, the northern-most Nevada site, and a cluster comprised of all other populations. These results highlight that estimates of subpopulation connectivity based on demographic analyses may differ from those based on genetics, suggesting either temporal changes in the pattern of movements, the importance of undetected movements, or differential contribution of migrants to the subpopulations they enter.

Links between emotion perception and social participation restriction following stroke.

OBJECTIVES: Stroke can cause impairment in emotion perception, but the social consequences of these problems have not been explored to date. In a group of patients with stroke, this study investigated whether difficulties in emotion perception related to social participation and quality-of-life. It also assessed whether these relationships remained significant when controlling for activity limitations. METHOD: Individuals 1 year post-stroke (n = 28) and control participants (n = 40) were assessed on emotion perception across different modalities. Activity limitations, social participation, and multiple domains of quality-of-life were assessed in patients. RESULTS: Participants with stroke were impaired on emotion perception compared to controls. Emotion perception problems in stroke were significantly correlated with social participation and psychological aspects of QoL, but not with activity limitations. CONCLUSIONS: The strong relationships of emotion perception with social participation and psychological aspects of QoL following stroke may have implications for post-stroke outcomes.

Resistance to Care: contributing factors and associated behaviours in healthcare facilities.

AIMS: This article reports results of a study of contributing factors and associated behaviours in specific clinical areas to resistance to care episodes. BACKGROUND: Resistance to Care has previously been studied in aged care settings, and previous studies have reported patient behaviours and appropriate responses. Resistance to Care is a defensive response by patients towards healthcare staff and is demonstrated in various non-compliant behaviours. DESIGN: Cross-sectional study. METHODS: A cross-sectional survey of a representative sample of nurses (n = 5044), who were members of the New South Wales Nurses' Association in Australia, was conducted in 2008-2009. RESULTS: Resistance to Care episodes occur in various clinical settings and may be precipitated by a range of clinical diagnoses and symptoms. They may also be triggered during various nursing activities that nurses recognize as high-risk for these episodes. CONCLUSION: The reported Resistance to Care behaviours are similar to those reported in studies of aggression and violence; however, they require a substantially different response by nurses in various clinical contexts.

Organizational risk management of resistance to care episodes in health facilities.

AIMS: This article reports a study of organizational risk management approaches to resistance to care episodes in specific clinical areas: prevention measures, provision of subsequent support and follow-up by management and resultant organizational change. BACKGROUND: Resistance to care describes a patient's unwillingness to be assisted by healthcare staff and is manifested in defensive behaviours ranging from minor non-compliance/dissent to aggression. It has previously been studied in aged care settings and focused on patient behaviours and appropriate responses. METHODS: This was a cross-sectional survey of a representative sample of nurses (n = 5044) who were members of the New South Wales Nurses' Association in Australia, in 2008-2009. RESULTS: Of 1132 participants, 80% reported being involved in resistance to care episodes during the previous month and this was higher in some settings. Episodes were not routinely reported internally, and often did not lead to organizational change. Nurses reported that talking with other staff was the most effective action in dealing with the consequences of these episodes. Half of the respondents considered that they were provided with sufficient support and follow-up after a resistance to care episode. Prevention measures and follow-up strategies adopted by employers varied across clinical settings. CONCLUSION: Resistance to care is not confined to aged care settings, and risk management of resistance to care can increase safety in the workplace. Preventive strategies such as increased staff, training and security should be focused on high risk clinical areas; and appropriate support, follow-up and organizational change instituted in response to these episodes.

Organizational risk management and nurses' perceptions of workplace risk associated with sharps including needlestick injuries in nurses in New South Wales, Australia.

This study aimed to determine nurse reported organizational risk management and nurses' perceptions of workplace risk associated with sharps-related injuries. A cross-sectional survey was carried out on a sample of nurses from the New South Wales Nurses' Association, Australia in 2007 (n =7423), and there were 1301 eligible participants. Overall, 73% participants reported that organizational policies were followed in the event of a "sharps including needlestick" injury. Participants reported working in sharps safety oriented organizations, routine hepatitis B vaccination, sharps disposal containers at point-of-use locations and availability of safety engineered devices in their organizations. Sharps including needlestick injury data were not routinely provided to staff, many nurses reported recapping and just one-third had recently attended sharps injury prevention training. Nurses' perceptions of risk associated with sharps including needlestick injury were variable. Health-care organizations are responsible for provision of safe workplaces and work practices, policies, workplace culture and prevention strategies, and appropriate responses when nurses are injured. These results have been used to propose recommendations to improve some of these risk management strategies.

Factors associated with non-adherence to therapy with warfarin in a population of chronic heart failure patients.

BACKGROUND: Adherence to heart failure therapy is important in reducing morbidity and mortality over the course of the disease process. The aim of this study was to examine factors associated with non-adherence to warfarin in chronic heart failure patients. METHODS: Eighty patients receiving warfarin therapy in 2002 were included. Adherence was defined as maintenance of international normalized ratio (INR) between 2 and 3.5 and keeping scheduled appointments for INR checks at least 75% of the time. Clinical variables examined included age, gender, race, insurance, left ventricular ejection fraction (LVEF), etiology, New York heart association (NYHA) class, comorbidities, smoking, and alcohol use. RESULTS: Of 80 patients studied, 59 were male with mean age ( +/- standard deviation) 52 +/- 13 years, 24 had ischemic etiology with mean LVEF of 24% +/- 9%. Non-adherence was associated with tobacco use, odds ratio of 6.5 (p <0.01). Ischemic etiology was associated with adherence, odds ratio of 4.5 (p <0.01). Non-adherent patients were more likely to be insured with Medicare/Medicaid (p = 0.04) and have better NYHA class (p = 0.04). Adherence positively correlated with older age and lower LVEF, and negatively correlated with number of hospitalizations (p<0.01 for all). In a multiple regression model, patients with improvement in LVEF had decreased adherence over the year (p<0.01). CONCLUSIONS: The profile of heart failure patients who demonstrated non-adherence to warfarin therapy included younger age, nonischemic etiology, better NYHA class, smoking, insurance with Medicare/Medicaid and improved LVEF over the study. Measures targeting these patients may result in improved adherence to other pharmacologic treatments of heart failure.

Patterns and predictors of physical functional disability at 5 to 10 years after heart transplantation.

BACKGROUND: Researchers have not examined relationships between perception of physical functional disability and demographic, clinical, and psychological variables at 5 to 10 years after heart transplantation. Therefore, the purposes of this study were to describe physical functional disability over time and identify predictors of physical functional disability from 5 to 10 years after heart transplantation. METHODS: The study enrolled 555 patients who were between 5 and 10 years post-heart transplant (age, 54 +/- 9 years; 78% male, 88% white, 79% married). Patients completed 6 instruments that measure physical functional disability and factors that may impact physical functional disability. Statistical analyses included calculation of frequencies, means +/- standard deviation (plotted over time), Pearson correlation coefficients, and multiple regression coupled with repeated measures. RESULTS: Between 5 and 10 years after heart transplantation, physical functional disability was low, and 34% to 45% of patients reported having no functional disability. More physical functional disability was associated with having more symptoms, having depression/mood/negative affect and lower use of negative coping strategies, having more comorbidities and more specific comorbidities (e.g., more orthopedic problems and diabetes); higher New York Heart Association functional class; having more acute rejection, infection, or cardiac allograft vasculopathy; being female, older, less educated, and unemployed; higher body mass index; and more hospital readmissions (explaining 46% of variance [F = 84.75, p < 0.0001]). CONCLUSIONS: Demographic, clinical, and psychological factors were significantly related to physical functional disability. Knowledge of these factors provides the basis for development of therapeutic plans of care.

Patterns and predictors of quality of life at 5 to 10 years after heart transplantation.

BACKGROUND: Although studies have provided us with a cross-sectional analysis of long-term quality of life (QOL) after transplantation, relatively few longitudinal studies have been done that allow us to understand changes in QOL over time. The purposes of our study were to describe QOL over time and identify predictors of QOL longitudinally from 5 to 10 years after heart transplantation. METHODS: All 555 subjects enrolled in this study completed booklets of questionnaires. These patients had a mean age of approximately 54 years (range 21 to 75 years) at time of transplant. Seventy-eight percent were men and 88% were white. Participants completed nine self-report QOL instruments for this study. Statistical analyses included frequencies, means +/- standard deviations (plotted over time), Pearson correlation coefficients and multiple regression coupled with repeated measures. RESULTS: At 5 to 10 years after heart transplantation, recipients reported high levels of satisfaction with overall QOL and with health-related QOL, which was stable over the 5-year period. Predictors of satisfaction with overall QOL (that individually accounted for 1% variance or more) were primarily psychosocial variables (overall model explaining 71% of variance), whereas predictors of satisfaction with QOL related to health and functioning (that also explained > or =1% variance) included symptom distress and physical function, as well as psychosocial variables (overall model explaining 72% of variance). CONCLUSIONS: At 5 to 10 years after heart transplantation, QOL remained positive and stable. Bio-psychosocial variables predicted satisfaction with overall QOL and health-related QOL. Understanding of these bio-psychosocial variables provides direction for the development of long-term therapeutic strategies after heart transplantation so that patients can have good post-transplant outcomes.

Predictors of quality of life at 5 to 6 years after heart transplantation.

BACKGROUND: Only a few researchers have examined quality of life (QOL) outcomes more than 5 years after heart transplantation. Therefore, the purpose of this study was to describe QOL (overall, satisfaction with, and perceived importance); identify differences in QOL by age, sex, and race; and identify predictors of QOL at 5 to 6 years after heart transplantation. METHODS: A nonrandom sample of 231 patients (60 years of age, 76% men, 90% white, 79% married, and fairly well educated) who were 5 to 6 years after heart transplantation were investigated. Patients completed 12 QOL instruments via self-report. Data analyses included descriptive statistics, chi2, independent t-tests, correlations, and stepwise multiple regression. Level of significance was set at 0.05. RESULTS: Patient satisfaction with all areas of life was high at 5 to 6 years after heart transplantation. Similarly, patients believed that these same areas of life were very important. Yet areas of QOL with lower levels of satisfaction were identified. Patients who were > or =60 years were more satisfied with their QOL than patients <60 years. At 5 to 6 years after heart transplantation, almost 80% of variance in QOL was explained by psychological, physical, social, clinical, and demographic variables. CONCLUSIONS: At 5 to 6 years after heart transplantation, patients were very satisfied with their QOL, although differences in level of satisfaction were identified by demographic variables, and areas of QOL with lower levels of satisfaction were identified. Understanding those variables that contribute to QOL in the long term after heart transplantation provides direction for assisting patients to improve their QOL.

Relationship between bridging with ventricular assist device on rejection after heart transplantation.

BACKGROUND: Ventricular assist devices (VADs) are commonly used to bridge patients to heart transplantation. Recipients of VADs may develop anti-human histocompatibility leukocyte antigen antibodies, as reflected by elevated panel-reactive antibodies (PRA). The purpose of this study was to evaluate the relationship between bridging with VAD before heart transplantation and development of cellular rejection, humoral rejection, and allograft vasculopathy after transplantation. METHODS: Data on all patients who underwent cardiac transplantation between July 1994 and February 2001 at Rush Presbyterian St Luke's Medical Center were retrospectively reviewed. Data collected included sex, age, etiology of cardiomyopathy, percentage panel reactive antibodies (by cytotoxic method), type and duration of mechanical circulatory support, transfusion history, rejection history (both cellular and humoral) after cardiac transplantation, and development of allograft vasculopathy. Cellular rejection was treated when International Society of Heart and Lung and Transplantation Grade 2 or greater in the first 12 months after transplant and Grade 3 or greater after 12 months and treated with intensification of immunosuppression. Humoral rejection was defined clinically as allograft dysfunction by echocardiography without evidence of cellular rejection on endomyocardial biopsy or allograft vasculopathy. Allograft vasculopathy was defined by presence of any degree of luminal narrowing or pruning of distal vessels by coronary arteriography. Statistical analyses were performed by chi-square test, Fisher's exact test, and Wilcoxon rank sum test, as appropriate. RESULTS: Ninety-eight patients underwent cardiac transplantation during the study period (87 men, mean age 49 years, 46 ischemic etiology). Of these, 48 were bridged with HeartMate VAD (20 patients received vented electric device, 28 received pneumatic device). Nineteen percent of VAD patients had a peak pretransplant PRA > or =10% vs 2% of patients without VAD (p = 0.014). PRA > or =10%, use of VAD, or duration of VAD support did not predict development of humoral rejection. Use of VAD did not predict development of cellular rejection or allograft vasculopathy. VAD use was not associated with sudden death after heart transplantation. In the entire group of 98 patients, neither humoral nor cellular rejection predicted development of allograft vasculopathy. Longer ischemic time correlated with increased cellular rejection and humoral rejection after transplantation (p = 0.01). CONCLUSIONS: Some patients bridged to cardiac transplantation with VADs have increased PRA before heart transplantation, but this does not appear to translate into increased risk of either humoral or cellular rejection after transplantation or development of allograft vasculopathy as detected by coronary angiography.

Influence of race in heart failure and cardiac transplantation: mortality differences are eliminated by specialized, comprehensive care.

BACKGROUND: Differences in mortality are thought to exist between African Americans and Caucasians with heart failure. These differences may be due to a variety of factors, including differences in disease process, socioeconomic status, and access to health care. Additionally, little data exist on racial differences between these two groups after cardiac transplantation. This study examines a single center, urban experience in treating African Americans and Caucasians with heart failure and after cardiac transplantation. We hypothesize that treatment in a specialized, comprehensive heart failure/cardiac transplantation program results in similar survival between African Americans and Caucasians. METHODS: We retrospectively reviewed the Rush Heart Failure and Cardiac Transplant Database from July 1994 to August 2000. Variables analyzed in the cardiomyopathy patients included survival (until death, placement of left ventricular assist device or cardiac transplantation), number of hospitalizations per year, length of stay per year, and utilization of outpatient resources. Follow-up period was from initial visit to death, transplantation, or implantation of left ventricular assist device. In those who underwent cardiac transplantation, we examined rejection rates (cellular and humoral), rejection burden, hospitalization data, and 5-year survival. A subgroup bridged to cardiac transplantation with a left ventricular device was also analyzed. RESULTS: Seven hundred thirty-four cardiomyopathy patients were identified: 203 were African Americans and 531 were Caucasians. The etiology of cardiomyopathy was more commonly ischemic in Caucasians as compared to non-ischemic in African Americans (P <.01). African Americans had more admissions to the hospital per year compared with Caucasians, 1.2 +/- 2.1 versus.5 +/- 1.1 (P <.01) with longer length of stay per year, 1.4 +/- 25.2 days versus 4.4 +/- 14.3 days (P <.01). Utilization of outpatient resources was significantly higher in African Americans compared with Caucasians with more use of continuous inotropes (13% versus 6%, P <.01), intermittent inotropes (11% versus 5%, P <.01), and home nursing after hospital discharge (52% versus 32% of hospital discharges, P <.01). Survival by Kaplan-Meier analysis was comparable between the two groups (mean survival 1,470 +/- 72 days in African Americans versus 1521 +/- 46 days in Caucasians, log rank test [P =.6]). During this time, 30 African Americans and 73 Caucasians underwent cardiac transplantation. Fifty-three were bridged to transplantation with a left ventricular assist device (20 African Americans, 33 Caucasians). There were no differences in 5-year survival by Kaplan-Meier analysis despite higher peak preoperative panel reactive antibody levels in African Americans versus Caucasians (12% +/- 30% compared with 5% +/- 15%, P =.04), more overall treated rejection episodes per year in the African Americans (P <.01), as well as more posttransplant hospitalizations (2.2 +/- 1.2 times per year as compared with 1.7 +/- 2.1 times per year, P =.04). CONCLUSION: Delivery of care to heart failure patients in a comprehensive, specialized program results in similar survival regardless of race despite higher utilization of inpatient and outpatient resources. The finding that, after cardiac transplantation, African Americans do not have higher mortality rates, despite having higher rates of rejection overall and more hospitalizations, further supports the hypothesis that optimal care can improve outcomes despite unfavorable baseline clinical characteristics.