Strengthening Non-Communicable Disease Research Capacity in Thailand: Leveraging PhD Nurses and other Health Professionals.

The mounting burden of non-communicable disease (NCD) in lower-to-middle income countries (LMIC) was recognized two decades ago by the World Health Organization (WHO). In 2012, the WHO reported that NCDs were responsible for 71% of total deaths in Thailand. Thus, the goal of our ongoing NIH D43 training grant is to increase the quantity and quality of NCD research in Thailand by producing nurse scientists with the capacity to design, implement, guide, and evaluate cutting-edge research projects. The three components of the program are 1) a long-term component to train 10 Thai postdoctoral scholars that includes one year of intensive mentored research training in the US and one year implementing a research project back in Thailand; 2) a short-term component that provides an opportunity for Thai scientists, teachers, administrators and policy makers to take classes in areas relevant to NCD; 3) a yearly two-day NCD workshop to be held in different regions of Thailand. To date, 8 long-term trainees have completed various stages of their training. Eleven short-term trainees have taken courses at the University of Michigan. Two NCD workshops have been held so far under the auspices of the grant with a third planned for 2018. The ability to participate in the in-depth activities provided by the grant have not only expanded knowledge around NCD's, but also has enabled US and Thai investigators to grow in the area of culturally informed research.

Survey of distance technology use in AACN member schools.

The American Association of Colleges of Nursing surveyed its members by using a 104-item instrument to determine the state of the art in distance technology use. Survey results indicated a recent acceleration of course offerings through distance technology at all levels of nursing education. The most cited reason for this was to improve access to nursing education. Resources for distance technology tended to reside in public, rather than private, institutions. Trends were for greater use of video and computer-based technologies. Although technology use is increasing, computers and other technologies are not used in the didactic or clinical educational experience in many schools. Areas for further evaluation are identified.

Adaptation after treatment for heart disease: preliminary examination within a stress appraisal context.

OBJECTIVE: To examine, within a stress appraisal framework, intrapersonal psychosocial factors that may affect adaptation after treatment for heart disease. Hostility was examined as a variable that may affect cognitive appraisal of stress and, thus, adaptation. DESIGN: Quasi-experimental design with measures before and after treatment. SETTING: Large, Midwest hospital preadmitting department with follow-up by mail 1 month after treatment. OUTCOME MEASURE: Adaptation, operationalized as perceived quality of life. RESULTS: There was a significant, positive relation between hostility and cognitive appraisal of heart disease threat. Threat appraisal and state anxiety before treatment were significantly inversely related to posttreatment quality of life. Hostility was modestly, although nonsignificantly inversely related to posttreatment quality of life. Results provide tentative support for the theory-defined role of appraisal as a mediator between hostility and quality of life. CONCLUSIONS: Stress appraisal theory is tentatively supported as a useful framework for examining the adaptational outcome of quality of life in patients with heart disease.

Anxiety, depression and coping methods of hospitalized patients with myocardial infarction in Taiwan.

The purpose of this study was to determine the relationship among anxiety, depression, and coping methods reported by myocardial infarction (MI) patients in Taiwan. Forty post-MI patients were interviewed in the general cardiovascular unit. A subset of patients (n = 15) had high levels of anxiety and depression, however, most patients displayed low levels of anxiety and depression. A significant, moderately positive relationship was found between anxiety and the use of coping styles. An association between depression and coping styles was not found. The optimistic coping style of the Jalowiec Coping Scale was the most often used and most helpful coping method described by subjects. Emotional reactions and coping methods were related to age, social class, and actual or perceived severity of MI. Results of this study lend further support for the need to evaluate the presence, intensity and influencing factors of anxiety and depression in the recovery phase of MI.

Benefits of aerobic exercise after stroke.

The debilitating loss of function after a stroke has both primary and secondary effects on sensorimotor function. Primary effects include paresis, paralysis, spasticity, and sensory-perceptual dysfunction due to upper motor neuron damage. Secondary effects, contractures and disuse muscle atrophy, are also debilitating. This paper presents theoretical and empirical benefits of aerobic exercise after stroke, issues relevant to measuring peak capacity, exercise training protocols, and the clinical use of aerobic exercise in this patient population. A stroke, and resulting hemiparesis, produces physiological changes in muscle fibres and muscle metabolism during exercise. These changes, along with comorbid cardiovascular disease, must be considered when exercising stroke patients. While few studies have measured peak exercise capacity in hemiparetic populations, it has been consistently observed in these studies that stroke patients have a lower functional capacity than healthy populations. Hemiparetic patients have low peak exercise responses probably due to a reduced number of motor units available for recruitment during dynamic exercise, the reduced oxidative capacity of paretic muscle, and decreased overall endurance. Consequently, traditional methods to predict aerobic capacity are not appropriate for use with stroke patients. Endurance exercise training is increasingly recognised as an important component in rehabilitation. An average improvement in maximal oxygen consumption (VO2max) of 13.3% in stroke patients who participated in a 10-week aerobic exercise training programme has been reported compared with controls. This study underscored the potential benefits of aerobic exercise training in stroke patients. In this paper, advantages and disadvantages of exercise modalities are discussed in relation to stroke patients. Recommendations are presented to maximise physical performance and minimise potential cardiac risks during exercise.

Physiological outcomes of aerobic exercise training in hemiparetic stroke patients.

BACKGROUND AND PURPOSE: In hemiparetic individuals, low endurance to exercise may compound the increased energy cost of movement and contribute to poor rehabilitation outcomes. The purpose of this investigation was to describe how hemiparetic stroke patients responded to intense exercise and aerobic training. METHODS: Forty-two subjects were randomly assigned to an exercise training group or to a control group. Treatments were given three times per week for 10 weeks in similar laboratory settings. Baseline and posttest measurements were made of maximal oxygen consumption, heart rate, workload, exercise time, resting and submaximal blood pressures, and sensorimotor function. RESULTS: Only experimental subjects showed significant improvement in maximal oxygen consumption, workload, and exercise time. Improvement in sensorimotor function was significantly related to the improvement in aerobic capacity. After treatment, experimental subjects showed significantly lower systolic blood pressure at submaximal workloads during the graded exercise test. CONCLUSIONS: We conclude that hemiparetic stroke patients may improve their aerobic capacity and submaximal exercise systolic blood pressure response with training. Sensorimotor improvement is related to the improvement in aerobic capacity.

The role of catecholamines, age, and fitness on blood pressure reactivity to dynamic exercise in patients with essential hypertension.

OBJECTIVE: To determine the relationship between exercise blood pressure (BP) and catecholamine levels in hypertensive subjects and, secondarily, to evaluate the influence of age and fitness level. DESIGN: Descriptive correlational. SETTING: Midwestern, university-affiliated medical center. SUBJECTS: 27 hypertensive subjects, mean age 45 years, who were free of antihypertensive medications. OUTCOME MEASURES: BP and plasma catecholamines (norepinephrine and epinephrine). INTERVENTION: Subjects were given an incremental maximal exercise test on a cycle ergometer beginning at 25 watts with workloads increasing by 25 watts every 2 minutes until exhaustion. Plasma catecholamines were measured at rest, at 100 watts, and at maximal exercise. BP, heart rate, and oxygen consumption (VO2) were measured at rest and at the end of each workload. RESULTS: Systolic and diastolic BP were unrelated to catecholamines at rest and during exercise. When subjects were evaluated according to fitness level (VO2max), resting BP was not significantly different among groups (low fitness = VO2max < or = 25 ml/kg/min; moderate fitness = VO2max 26 to 39 ml/kg/min; high fitness = VO2max > or = 40 ml/kg/min). However, an inverse relationship was observed between fitness level and rate of rise of systolic and diastolic BP during submaximal work. Multiple regression showed that fitness predicted diastolic BP response (p = 0.02) at 100 watts. Age, however, predicted systolic BP response (p = 0.015). CONCLUSIONS: Neither the level of resting nor the magnitude of BP response to exercise in hypertensive subjects was directly related to level of plasma catecholamines. The magnitude of change in BP during exercise was modulated by age and fitness level.

An overview of the role of cardiovascular reactivity to stressful challenges in the etiology of hypertension.

There is significant variability among individuals in the cardiovascular responses to both physical and psychologic stimuli, a phenomenon called cardiovascular reactivity. The magnitude of cardiovascular reactivity may distinguish those prone to develop cardiovascular disease or differentiate pathophysiologic states among individuals who have existing pathologies such as hypertension. This article describes the cardiovascular reactivity hypothesis as a proposed mechanism of hypertension development. Furthermore, proposed mechanisms underlying the pathophysiology of hyperreactivity are also discussed. The value of assessing stress-induced cardiovascular reactivity is evaluated with special regard to hypertension, and future avenues for nursing research are presented.

Blood pressure reactivity in the evaluation of resting blood pressure and mood responses to pindolol and propranolol in hypertensive patients.

OBJECTIVE: The purpose of this exploratory study was to evaluate the relationship of blood pressure reactivity during exercise to treatment responsiveness to two commonly used beta-adrenergic blocking agents, propranolol and pindolol. DESIGN: Prospective, placebo-controlled, balanced, cross-over clinical trial. SETTING: University-affiliated medical center. PATIENTS: A convenience sample of 19 white male subjects with mild to moderate essential hypertension were studied. The mean age was 63.4 years (SD = 5.2). The mean resting systolic blood pressure (SBP) was 158.6 mm Hg (SD = 12.3) and mean resting diastolic blood pressure (DBP) was 96.4 mm Hg (SD = 8.6). They had no clinical evidence of secondary hypertension, diabetes, heart, liver, pulmonary, or renal disease. OUTCOME MEASURES: Resting blood pressure; blood pressure reactivity to exercise; self-report measures of depressive symptoms, and mood disturbances. INTERVENTION: Antihypertensive medication was tapered off and subjects were free of all prescription drugs for 2 weeks. Subjects were randomly assigned to propranolol-pindolol or pindolol-propranolol group. Each 4- to 6-week treatment phase was preceded by a 2-week placebo phase. At the end of the initial placebo phase and each active drug treatment phase, subjects were assessed for depression and mood disturbances by use of standardized measures and were given a graded exercise test on a cycle ergometer. Resting blood pressure was assessed weekly and before each exercise test. RESULTS: Significant relationships between DBP reactivity to exercise during the placebo phase and the degree of blood pressure and mood responsiveness to pindolol and propranolol treatment were observed. Subjects demonstrating high DBP reactivity required high doses of beta-blocker for resting DBP reduction, and these subjects showed the least change in mood at high doses. Similar patterns were found for the relationship of SBP reactivity and blood pressure and mood responsiveness to drug treatment, but these relationships were not statistically significant. CONCLUSIONS: DBP reactivity to exercise during the placebo phase provides unique information about the essential hypertensive patient. DBP reactivity and drug dose were important determinants of resting blood pressure and mood responsiveness to both pindolol and propranolol. DBP reactivity and perhaps SBP reactivity may be useful measures in the study of central adrenergic and peripheral cardiovascular pathophysiology.

Blood pressure and mood responses in hypertensive patients on antihypertensive medications.

Nurse practitioners who are responsible for the clinical management of patients with hypertension must choose antihypertensive medications that minimize side effects. Nurse practitioners must be aware of the drugs' potential influences on physiologic and psychological variables and include adequate assessment of these responses in patients during treatment. Pindolol, propranolol, and hydrochlorothiazide were equally effective in reducing systolic and diastolic blood pressure in essential hypertensives, although pindolol and hydrochlorothiazide did not affect resting heart rate (an advantage in some patients). Hydrochlorothiazide was associated with a trend for several negative mood changes in black subjects; depression scores of black subjects were significantly increased with hydrochlorothiazide. The results of this study indicate the need to consider race and other factors in research about antihypertensive mood responses.

The relationship of resting and exercise blood pressure in subjects with essential hypertension before and after drug treatment with propranolol.

OBJECTIVE: To investigate the relationship between clinic resting blood pressure (BP) and exercise BP in subjects with established essential hypertension during placebo and propranolol-treated phases. DESIGN: Prospective, placebo-controlled, cross-over trial. SETTING: University-affiliated medical center. PATIENTS: A convenience sample of 38 patients with essential hypertension, 34 men and four women, who ranged in age from 22 to 62 years (mean = 44 years, SD = 10.7). Subjects were diagnosed with mild to moderate diastolic or mixed systolic/diastolic essential hypertension at least 1 year before study entry. They had no clinical evidence of secondary hypertension, diabetes, heart, liver, pulmonary, or renal disease. OUTCOME MEASURES: Resting and exercise BP. INTERVENTION: Antihypertensive medication was tapered off and subjects were free of all prescription drug treatment for 2 weeks. They received placebo for an additional 2 weeks. Subjects then received treatment with propranolol at a dose necessary to control resting blood pressure for 4 to 6 weeks. At the end of both the untreated and treated phases, subjects were given a graded maximal exercise test on a bicycle ergometer. RESULTS: Propranolol effectively reduced mean resting and maximal exercise BP. The nonsignificant correlation between clinic resting and maximal exercise systolic BP was low in both phases. The correlation between clinic resting and maximal exercise diastolic BP was only moderate, but statistically significant (untreated, r = 0.43; p < 0.01; treated, r = 0.53; p < 0.001). For systolic BP or diastolic BP, there were no significant relationships between percent drop in BP because of propranolol at rest or maximal exercise. Clinic resting BP was not a valid predictor of maximal exercise BP. Degree of control of clinic resting BP was not a valid predictor of control observed at maximal exercise. CONCLUSIONS: Resting BP should not be used as a predictor of BP during maximal exercise in the untreated condition or with treatment with propranolol.

Reduced cardiac output and exercise capacity in patients after MI.

This article summarizes the literature and suggests directions for future research concerning rehabilitation potential, impairment, and reduced cardiac output after myocardial infarction (MI). Current evidence suggests that cardiac output and maximal exercise capacity are reduced in some post-MI patients. The conceptual model of rehabilitation potential presented emphasizes the need for careful assessment of the state of underlying pathology present after MI when evaluating the response to exercise or exercise training.

Drug use and effects in older adults in the United States.

Aging markedly influences drug use and drug effects. The purpose of this review is two-fold: (i) to examine how social, economic, and psychological factors, compliance, and prescribing patterns affect drug use in institutionalized and non-institutionalized older adults in the United States, and (ii) to illustrate how physiological aging, actions of drugs, and adverse drug reactions influence drug effects. Recommendations for further study include identification of adverse reactions, and examination of drug taking behavior in older adults who are alone or debilitated. Research is especially needed for those in nursing homes and for those who are old-old (over 85 years).

Fatigue in early pregnancy. An exploratory study.

The experience of fatigue in early pregnancy was studied, using a general model of fatigue as the conceptual framework. A convenience sample of 30 women, age 20-35 years, who were at less than 20 weeks' gestation and without health problems were included in the study. Physiologic, psychological, and environmental factors were measured and related to the occurrence and intensity of fatigue. Pearson correlations and content analysis were used to analyze the data. Results showed that a large portion of the sample (90%) experienced fatigue and that this fatigue had a significant impact on their ability to maintain personal and social activities. Significant correlations were observed between fatigue and the physiologic variables of nausea and feeling tired upon awakening from sleep. There was no significant relationship between fatigue and environmental variables such as number of hours worked or the number of children living in the home. In addition, significant correlations were observed between fatigue and psychological variables that included depression, anger, anxiety, and confusion. These data suggest that fatigue is a significant problem for pregnant women and is not relieved by rest. These data further suggest that the fatigue may be related to other physiologic changes, perhaps hormonal, that mediate physiologic and psychological variables, including fatigue.

Cardiovascular drugs and the older adult.

This case is typical of cardiovascular drug regimens in the elderly. Indeed, patients are often on several additional drugs for cardiovascular problems as well as other diseases. Familiarity with the pharmacology of all drugs is mandatory. Interactions of drugs can be complex, and a clinical pharmacologist can be a helpful resource. The classic interaction in cardiovascular drug regimens, as in this case, is with the combination of digoxin and potassium-depleting diuretics. The special interactions of cardiovascular and psychotropic drugs will be discussed elsewhere in this symposium. General clinical concerns in the care of patients taking cardiovascular drugs include scrutiny of drug choice, dosage, and combination. The dosage of drugs may need to be altered as the client ages. Drug types and combinations also may need to be changed to meet the needs of the patient's altered physiologic responses. The patient's response to drug therapy must be continuously evaluated. The best rule is to ensure that the patient takes the least number of drugs at the minimum dose required for desired effects. Starting drug dosages low and increasing them gradually often prevent toxicity. The nurse's assessment of subtle behavior or physical changes is important for the early detection of toxicity and adverse reactions. The possibility that a noted change is drug precipitated should always be considered. Health education of the client, family, or appropriate others is a significant nursing contribution to care. Awareness of drug side effects and specific offsetting interventions can prevent many discomforts and complications. Often making the patient aware of his changing body needs helps to elicit cooperation.

A system for using supplemental staff.

This article has outlined the development of a system for using temporary nurses. Steps in this process include reevaluation of department philosophy; formulation of criteria for temporary staffing; development of scheduling mechanisms and policies that reflect the criteria; and finally, the development of methods for evaluation. Our system uses scheduling components previously in existence at Rush-Presbyterian-St. Luke's Medical Center. We consider the computerized system an advantage for our purposes, but it was not essential. A written schedule could then be used to meet department needs. Defining goals and then determining methods is important, since several alternative methods might be possible to meet a goal. Our system emphasizes both continuity and accountability at the unit level. Because the unit leaders have close association with temporary staff, their input is vital. The unit leaders formally evaluate the temporary personnel and are accountable for making appropriate requests for temporary staff. The judgment of need is based on such factors as patient needs, budget allocation, and staff vacations. The system outlined was the necessary by-product of the interfacing of two staffing methods, permanent and temporary. Consistency is the key to resolving problems.