Kawasaki disease: patients' transition journey and recommendations for adult care.

BACKGROUND: Children who develop coronary artery aneurysms after Kawasaki disease are at risk for cardiovascular morbidity, requiring health care transition and lifelong follow-up with an adult specialist. Follow-up losses after health care transition have been reported but without outcome and patient experience evaluation. OBJECTIVE: The Theoretical Domains Framework underpinned our aim to explore the required self-care behaviours and experiences of young adults' post-health care transition. METHODS: A qualitative description approach was used for virtual, 1:1 interviews with 11 participants, recruited after health care transition from a regional cardiac centre in Ontario. Directed content analysis was employed. RESULTS: Health, psychosocial, and lifestyle challenges were compounded by a sense of loss. Six themes emerged within the Theoretical Domains Framework categories. Participants offered novel health care transition programme recommendations. CONCLUSIONS: The realities of health care transition involve multiple, overlapping stressors for young adults with Kawasaki disease and coronary artery aneurysms. Our findings will inform a renewed health care transition programme and will include outcome evaluation.

Exploring Barriers and Facilitators to Indirect Cascade Screening for Familial Hypercholesteraemia in a Paediatric/Parent Population.

Background: Familial hypercholesteraemia (FH), an inherited disorder of cholesterol metabolism, has a prevalence of 1:250 and an associated 6- to 22-fold increased risk for cardiovascular disease. Despite the prevalence and availability of effective risk-reduction treatments, 90% of at-risk Canadians are undiagnosed. Indirect cascade screening from an index case is useful but the uptake is low (<4%), suggesting that barriers may exist. Using the Theoretical Domains Framework, we sought to determine barriers and facilitators among parents of children diagnosed with FH that may influence the uptake of cascade screening among families. Methods: A qualitative description approach was used for virtual interviews with 10 parents of children with FH, recruited from a regional Lipid Clinic in Toronto, Canada. Semistructured interviews were conducted. The data were analysed using a directed content analysis method. Results: Five interconnecting themes were identified that captured both facilitators and barriers of indirect cascade screening: a high level of knowledge about FH after clinic attendance; parents' surprise of their child's diagnosis and ongoing worry; parents' willingness to communicate the need for cholesterol screening; parents' desire for educational materials, dictated by an external vs internal locus of control; and social and societal influences including the lack of awareness about FH in professional and public domains. Conclusions: The themes identified will inform next steps in programme development. An urgent need was identified for strategies to educate the public and primary care providers about FH and blood cholesterol/genetic screening.

Contexte: L'hypercholestérolémie familiale (HF) est un trouble génétique du métabolisme du cholestérol qui touche une personne sur 250 et qui est associé à un risque de 6 à 22 fois plus élevé de maladie cardiovasculaire (MCV). Malgré la prévalence élevée et la présence d'options thérapeutiques pour réduire ce risque, 90 % des Canadiens qui y sont exposés demeurent sans diagnostic. Le dépistage en cascade avec contact indirect à partir d'un proposant est une méthode utile, mais son adoption est faible (< 4 %), ce qui laisse croire qu'il existe des obstacles à son utilisation. À l'aide du cadre des domaines théoriques (TDF, pour Theoretical Domains Framework), nous avons cherché à déterminer les facteurs facilitateurs et les obstacles pour les parents d'enfants ayant reçu un diagnostic d'HF afin d'établir leur influence sur l'adoption du dépistage en cascade dans les familles. Méthodologie: Une approche par description qualitative a été utilisée lors d'entretiens virtuels semi-dirigés menés auprès de 10 parents d'enfants atteints d'HF ayant été recrutés dans une clinique régionale en troubles lipidiques de Toronto (Canada). Les données ont fait l'objet d'une analyse de contenu dirigée. Résultats: Nous avons cerné cinq thèmes interconnectés pour rendre compte à la fois des facteurs qui facilitent le dépistage en cascade par contact indirect et de ceux qui y font obstacle : des connaissances poussées sur l'HF après la visite de la clinique; la surprise des parents au sujet du diagnostic posé chez leur enfant et l'inquiétude qui s'installe; la volonté des parents de communiquer l'importance d'un dépistage des taux de cholestérol; le désir des parents d'obtenir du matériel éducatif, déterminé par un lieu de contrôle interne ou externe; et des facteurs d'influence sociaux et sociétaux, dont le manque de connaissances sur l'HF dans les sphères professionnelles et publiques. Conclusions: Les thèmes relevés guideront les prochaines étapes de la mise en place d'un programme. Il semble urgent d'adopter des stratégies visant à informer le public et les fournisseurs de soins primaires au sujet de l'HF ainsi que du dépistage génétique et du dépistage du taux de cholestérol sanguin.

Understanding the Educational Support and Psychosocial Needs of Parents and Adolescents With Kawasaki's Disease and Coronary Artery Aneurysms.

INTRODUCTION: Kawasaki disease (KD) with coronary artery aneurysms (complex KD) presents relentless challenges for families. Psychosocial experiences and needs were explored. METHOD: A descriptive, exploratory study of adolescents and parents using a needs survey and psychosocial instruments (anxiety, depression, and functional impairment). RESULTS: Fifty-one parents and 38 adolescents participated. Predominant interests were for information sheets, newsletters, Web sites, and phone applications. Gaps in disease-specific knowledge and awareness of coronary artery aneurysms between parents and adolescents were identified. Psychosocial concerns for adolescents included symptoms of anxiety (22%), depression (13%), and functional impairment (22%). Multivariable analyses indicated higher depression scores associated with longer travel distance from specialists (p = .04). Parent-reported social concerns for their adolescent were associated with higher anxiety (p = .005) and functional impairment (p = .005). Written commentary complemented the findings. DISCUSSION: Care protocols require psychosocial assessment/referral and the use of virtual platforms. The groundwork was laid for developing patient and family-centered strategies.

Dyslipidemia management in overweight or obese adolescents: A mixed-methods clinical trial of motivational interviewing.

BACKGROUND: Lifestyle management for dyslipidemic adolescents often occurs in the context of family-centered care, which necessitates adaptation of counseling strategies. OBJECTIVE: To determine the effectiveness of motivational interviewing for lifestyle behavior change for dyslipidemic adolescents in a dyad with a parent versus alone. METHODS: A total number of 32 adolescents were randomized 1:1 to receive a series of motivational interviewing sessions either together with a parent or alone for a 6-month intervention, with both quantitative and qualitative assessment of outcomes. RESULTS: Both groups were similar at baseline. Following the intervention, there were no significant differences between groups in physical, laboratory, lifestyle or psychosocial measures, except for a reduction in dietary fats/sugars (p = 0.02) and in screen time (p = 0.02) in the alone group. When both groups were combined, significant reductions at 6 months were noted for body mass index (p < 0.001), waist circumference (p < 0.001), total cholesterol (p < 0.001), low-density lipoprotein cholesterol (p < 0.001), triglycerides (p = 0.01), non-high-density lipoprotein cholesterol (p < 0.001), fasting insulin (p = 0.01), and homeostatic model (p = 0.02). Reduced screen time and increased fruit and vegetable intake were also noted for both groups combined. These changes were also reflected in self-efficacy (p = 0.004), self-esteem (p = 0.03), and improvement in quality of life measures. Interview data provided insights into the utility and acceptability of the motivational interviewing intervention. CONCLUSION: Motivational interviewing was an efficient strategy for inspiring healthy lifestyle and physiological changes among adolescents in both groups. Family centered pediatric approaches should consider the autonomy and individual preferences of the adolescent prior to counseling.

Kawasaki Disease With Coronary Artery Aneurysms: Psychosocial Impact on Parents and Children.

INTRODUCTION: For those living with Kawasaki disease and coronary artery aneurysms, little is known about the psychosocial burden faced by parents and their children. METHODS: Exploratory, descriptive, mixed-methods design examining survey and interview data about health-related uncertainty, intrusiveness, and self-efficacy. RESULTS: Parents' uncertainty was associated with missed diagnosis, higher income, and maternal education. Higher uncertainty scores among children were associated with absence of chest pain and lower number of echocardiograms. High intrusiveness scores among parents were associated with previous cardiac catheterization, use of anticoagulants, lower parent education and income, and missed diagnosis. High intrusiveness scores among children were associated with high paternal education. Children's total self-efficacy scores increased with chest pain and larger aneurysm size. Qualitative analysis showed two central themes: Psychosocial Struggle and Cautious Optimism. DISCUSSION: Negative illness impact is associated with a more intense medical experience and psychosocial limitations. Timely assessment and support are warranted to meet parents' and children's needs.

Enhancing Role Clarity for the Practical Nurse: A Leadership Imperative.

OBJECTIVE: The aim of this study was to determine factors contributing to practical nurse (PN) role confusion and the impact on nursing intraprofessional team collaboration. BACKGROUND: There is limited literature describing the intraprofessional relationship of the RN and PN in areas such as role conflict, scope of practice, and team collaboration. METHODS: A mixed-methods design was used targeting Ontario RNs and PNs, including an online survey and focus groups. RESULTS: Results (N = 1101) revealed varying levels of knowledge regarding the distinct and overlapping scope of practice for each role, with shared opinions regarding areas such as respect, teamwork, and the role of leadership. CONCLUSIONS: Nurses' roles will continue to evolve in response to changes in patient populations and healthcare systems. As such, role clarity is essential to support optimal use of nursing knowledge for safe patient care. Leadership is key to establishing parameters for professional practice and creating a culture of collaboration and respect.

An educational innovation to foster evidence-informed practice.

This article describes an innovation in baccalaureate nursing education that is intended to assist in the preparation of nursing students for careers in which evidence-informed practice is an imperative. The innovation involves the combination of central aspects of the internationally recognized Registered Nurses' Association of Ontario Best Practice Guidelines Program with existing curricular goals and themes in a baccalaureate nursing program at a small university in southern Ontario in Canada.

Efficacy of glucarpidase (carboxypeptidase g2) in patients with acute kidney injury after high-dose methotrexate therapy.

STUDY OBJECTIVE: Because the incidence rate of renal impairment is 2-10% for patients treated with high-dose methotrexate and renal impairment develops in 0-12.4% of patients treated for osteosarcoma, we sought to evaluate the efficacy of glucarpidase, a recently approved drug that rapidly hydrolyzes methotrexate to inactive metabolites, which allows for nonrenal clearance in patients with delayed renal methotrexate elimination. DESIGN: Pooled analysis of efficacy data from four multicenter single-arm compassionate-use clinical trials using protocols from 1993 to 2007. PATIENTS: Of 476 patients with renal toxicity and delayed methotrexate elimination who were treated with intravenous glucarpidase for rescue after high-dose methotrexate, 169 patients had at least one preglucarpidase (baseline) plasma methotrexate concentration greater than 1 µmol/L and one postglucarpidase methotrexate concentration measurement by high-performance liquid chromatography and were included in the efficacy analysis; renal recovery was assessed in 436 patients who had at least one recorded preglucarpidase and postglucarpidase serum creatinine concentration measurement. MEASUREMENTS AND MAIN RESULTS: Efficacy was defined as rapid and sustained clinically important reduction (RSCIR) in plasma methotrexate concentration, with a concentration of 1 µmol/L or lower at all postglucarpidase determinations. Median age of efficacy-evaluable patients was 20 years (range 5 weeks-84 years). Osteosarcoma (36%), non-Hodgkin lymphoma (27%), and acute lymphoblastic leukemia (20%) were the most frequent underlying diagnoses. Median preglucarpidase serum methotrexate was 11.7 µmol/L. At the first (median 15 minutes) through the last (median 40 hours) postglucarpidase measurement, plasma methotrexate concentrations demonstrated consistent 99% median reduction. RSCIR was achieved by 83 (59%) of 140 patients. A total of 64% of patients with renal impairment greater than or equal to Common Terminology Criteria for Adverse Events grade 2 recovered to grade 0 or 1 at a median of 12.5 days after glucarpidase administration. CONCLUSION: Glucarpidase caused a clinically important 99% or greater sustained reduction of serum methotrexate levels and provided noninvasive rescue from methotrexate toxicity in renally impaired patients.

Clinical significance of cerebrovascular gas emboli during polidocanol endovenous ultra-low nitrogen microfoam ablation and correlation with magnetic resonance imaging in patients with right-to-left shunt.

BACKGROUND: Foam generated by manual agitation of liquid sclerosant with air or gas is routinely utilized to treat refluxing veins. Although generally well tolerated, serious neurological events have been reported. The composition and properties of the foam, including bubble size and gaseous components, may contribute to the potential for microcirculatory obstruction and cerebral ischemia. We tested an ultra-low nitrogen polidocanol endovenous microfoam with controlled bubble size and density and hypothesized that patients at risk due to the presence of middle cerebral artery (MCA) bubble emboli during microfoam injection would not demonstrate evidence of clinical or subclinical cerebral infarction. METHODS: Patients with great saphenous vein incompetence were treated with ultra-low nitrogen (≤ 0.8%) polidocanol endovenous microfoam injected under ultrasound guidance. Patients with right-to-left shunt were included to evaluate the safety of cerebral arterial bubbles. All patients with MCA emboli detected by transcranial Doppler during endovenous microfoam ablation received intensive surveillance for microinfarction, including brain magnetic resonance imaging and measurement of cardiac troponin-I. RESULTS: MCA bubble emboli were detected in 60 of 82 treated patients; 22 patients had no detectable emboli. Among patients with MCA bubbles detected, 49 (82%) had ≤ 15 bubbles. No patients developed magnetic resonance imaging abnormalities, neurological signs, or elevated cardiac troponin. CONCLUSIONS: Patients treated with foamed liquid sclerosants are commonly exposed to cerebrovascular gas bubbles. In this series of 60 high-risk patients with MCA bubble emboli during or after treatment with ultra-low nitrogen polidocanol endovenous microfoam, there was no evidence of cerebral or cardiac microinfarction. The results of this study cannot be generalized to foams compounded using bedside methodologies, since the composition of these foams is substantially different.

High prevalence of right-to-left shunt in patients with symptomatic great saphenous incompetence and varicose veins.

BACKGROUND: Varicose veins are common and increasingly are being treated by less invasive endoscopic methods such as foam sclerotherapy. Patent foramen ovale (PFO) is also common, present in approximately one-quarter of adults. PFO allows bubbles introduced by foam sclerotherapy to cross into the general circulation, potentially causing cerebral artery gas embolization with unevaluated consequences. METHODS: Men and women aged 18 to 60 years with symptomatic varicose veins (CEAP C(3-5)) responded to an advertisement to recruit volunteers for a study on endovenous microfoam ablation (EMA). Participants' veins were screened by duplex ultrasound imaging, and those with isolated great saphenous vein (GSV) incompetence were tested for right-to-left (R-L) vascular shunt using transcranial Doppler (TCD) of the middle cerebral artery to detect the presence of bubble emboli after an injection of an agitated saline, blood, and air mixture as a contrast at rest and with the Valsalva maneuver. RESULTS: Of 221 participants tested for R-L shunt, 85 (38.5%) were positive at rest (95% confidence interval [CI], 32.5-45.2) and 114 (51.8%) were positive after the Valsalva maneuver (95% CI, 45.4-58.5). A total 130 patients (58.8%) were positive for R-L shunt at rest or after Valsalva (95% CI, 52.5%-65.1%). This is significantly higher than the reported 26% prevalence of PFO in the general population (95% CI, 24.4-30.1). CONCLUSIONS: The prevalence of R-L shunt in patients with GSV incompetence CEAP C(3-5) in this study was higher than expected in the general population. TCD does not differentiate between intracardiac shunts and intrapulmonary shunts, so this observation needs further investigation. This link between R-L shunt and varicose veins is novel and, whether etiologic or functional, may improve the understanding of both conditions. The findings have importance in the treatment of varicose veins with foam sclerotherapy and EMA.

Association between parental anxiety and compliance with preoperative requirements for pediatric outpatient surgery.

PURPOSE: The purpose of this study was to determine if parental anxiety interferes with the ability to follow preoperative requirements. METHOD: In a single center observational study of parents of children admitted to a same-day surgical unit at a tertiary pediatric hospital, parental preoperative anxiety was measured by the State-Trait Anxiety Inventory (STAI) questionnaire. Anxiety was correlated to a four points assessment of adherence with the following preoperative requirements: dietary restrictions, timely arrival at the hospital, arrival at the assigned room, and completion of required medical forms, because those requirements are the greatest external contributors to surgical cancellation according to hospital statistics. RESULTS: A total of 203 families completed the study. The average STAI score on the day of surgery was 38+/-12 (population average, 36+/-11). Only 130 families (66%) complied with all four preoperative requirements. A higher level of anxiety was significantly associated with lower probability of compliance (odds ratio, 0.88; 95% confidence interval, 0.78-1.00, P=05). In univariate models, factors associated with higher STAI scores included younger parent age, younger children, only child, child's first surgery, and no medical consultation between surgical assessment and surgery. DISCUSSION: Parental anxiety could be associated with a lower likelihood of parents following preoperative requirements and could contribute to increased likelihood of surgical cancellation.

Nursing alumni as student mentors: nurturing professional growth.

Mentorship is a commonly used strategy for role and career development that has potential benefits for students in undergraduate nursing programs. In contrast to preceptorship, which generally involves clinical supervision and performance evaluation, mentorship is more focused on sharing and nurturing to promote personal and professional growth. This article describes a mentoring program at McMaster University School of Nursing in Canada in which baccalaureate nursing students are mentored by alumni from the same nursing program. Following a successful pilot project with level one students, the program was expanded to include nursing students in all levels who were interested in having a mentor. Both student mentees and alumni mentors have reported positive outcomes. Students felt supported in making personal, academic and career decisions whereas alumni found satisfaction in providing this supportive function, having re-connection with their alma matter, and sharing their professional experience and knowledge. Given the prospective gains not only for the individuals who take part in mentorship programs but also for the profession and beyond, consideration should be given to providing opportunities for nursing students to be mentored during their formative years.

Influence of patient characteristics and renal function on factor Xa inhibition pharmacokinetics and pharmacodynamics after enoxaparin administration in non-ST-segment elevation acute coronary syndromes.

BACKGROUND: The current standard of care for patients with non-ST-segment elevation acute coronary syndromes (ACS) includes antithrombotic therapy with aspirin and heparin. Although emerging data suggest that low-molecular weight preparations offer distinct advantages over unfractionated heparin, limited information on patient-related factors that may influence dosing, safety, and efficacy is available. PURPOSE: The purpose of our study was the determination of the impact of patient age, sex, body weight, and renal function on factor Xa inhibition pharmacokinetics and pharmacodynamics after enoxaparin administration in patients with ACS. METHODS AND RESULTS: Patients enrolled in the TIMI 11A trial received a full complement of antiischemic therapy, aspirin, and enoxaparin (30 mg intravenously, followed by weight-adjusted doses of either 1 mg/kg or 1.25 mg/kg subcutaneously every 12 hours). Before and after the third and last doses, blood samples were obtained from 445 patients for measurement of anti-Xa activity. The mean apparent clearance, distribution volume, and plasma half-life were 0.733 L/h, 5.24 L, and 5 hours, respectively. Among a wide range of clinical and laboratory covariates, creatinine clearance emerged as the most influential factor on apparent clearance, area under the curve, and anti-Xa activity. Patients with marked renal impairment (creatinine clearance <40 mL/min) had higher trough and peak anti-Xa activity compared with those with normal renal function and were more likely to have major hemorrhagic events. CONCLUSION: The pharmacokinetic and pharmacodynamic profiles after enoxaparin administration are consistent across a broad range of patients with ACS. Dose adjustments or anti-Xa coagulation monitoring or both will be necessary rarely in routine clinical practice, with the exception of patients with severe renal insufficiency.