Counseling Guidelines that Facilitate Acceptance of Death

Individuals who experience the death of a spouse, close friend or family member can receive counseling to faci1itate acceptance of death. A review of literature explains the stages the bereaved person will normally progress through. It was also found in the review of literature the terminally ill person will progress through similar stages and both the bereaved and terminally ill person will react similarly in most of the stages. Guidelines are suggested from a synthesis of the literature for the helping person and counselor to facilitate acceptance of death for the bereaved person so that he can once again redirect his energies and cope with the challenges of life. The guidelines suggested may also facilitate acceptance of impending death by the terminally ill patient. This study deals primarily with the role of a counselor/helper in aiding bereaved persons to cope successfully with the challenges of life following the death of a friend, family member or mate

Validation of the cognitive recovery assessments with the Postoperative Quality of Recovery Scale in patients with low-baseline cognition

Patients with pre-surgery cognitive impairment cannot currently be assessed for cognitive recovery after surgery using the Postoperative Quality of Recovery Scale (PostopQRS),as they would mathematically be scored as recovered. The group nonetheless represent a frail cohort at high risk of recovering poorly. We aimed to validate a novel method to score cognitive recovery in patients with low baseline cognition, using the number of low-score tests rather than their numerical values. Face validity was demonstrated in 86 participants in whom both PostopQRS and an 11-item neuropsychological battery were performed. The PostopQRS agreed with neuropsychological categorization of low versus normal cognition 74% of the time, with all but 5 incorrectly coded participants deviating by only 1 neurocognitive test. Cognitive recovery over time was comparable for groups with differing baseline cognitive function, irrespective of whether PostopQRS or neuropsychological methods were used. Discriminant validation was demonstrated in a post hoc analysis of the Steroids in Cardiac Surgery (SIRS) substudy by allocating groups to normal (n=246) or low baseline cognition (n=231) stratified by cognitive recovery on day 1. Recovery was similar for participants with low and normal baseline cognition. Postoperative length of stay was longer in patients with failed cognitive recovery whether they had normal (10.4±10.0 vs. 8.0±5.9 days, P=0.02) or low baseline cognition (12.0±11.1 vs. 8.2±4.7 days, P<0.01). Overall quality of recovery, as well as cognitive, emotive, and physiological recovery in those who recovered was independent of baseline cognition. The modified scoring method for the PostopQRS cognitive domain therefore demonstrates acceptable face and discriminant validity

Improving Folic Acid Consumption in Women at Risk for Neural Tube Defects in Florida

Two providers who participated in the Florida VitaGrant program, a site providing early childhood services to primarily Mexican Hispanic families (Site A) and a site providing home visiting services to pregnant women and families with infants (Site B), are presented as alternative models for improving folic acid levels in reproductive aged women in Florida. Site A distributed multivitamins and education in the context of health education provided to women in a group setting, once a month. Site B provided the services primarily through home visits of varying frequency. Folic acid knowledge and consumption were measured at program initiation and at a follow-up date to determine levels of improvements for both sites, by demographic characteristics. Analyses comparing age, race, and ethnicity of women served by Site A were compared to women served by Site B. These programs were then evaluated in-depth with respect to baseline and follow-up levels of folic acid knowledge and consumption of their participants. Site A seemed to be somewhat more effective at improving the knowledge and consumption patterns of its participants than Site B, although both experienced significant improvement overall. Initially, women who received services from Site A reported lower levels of baseline knowledge and multivitamin consumption than Site B clients. However, Site A clients reported higher levels of knowledge and consumption at follow up than Site B clients. The findings suggest that free multivitamin distribution and pre/interconception education can dramatically increase MVC among all participants. Program delivery that takes place in the context of a group setting may be a particularly effective way to reach women at-risk for neural tube defects

A human volunteer study to identify variability in performance in the cognitive domain of the postoperative quality of recovery scale

Background: The Postoperative Quality of Recovery Scale found lower than anticipated recovery in the cognitive domain. The definition of cognitive recovery did not allow for performance variability, and may have been too sensitive. This study aimed to examine variability in cognitive performance in volunteers. Methods: One hundred forty-three volunteers completed the cognitive domain questions at baseline, after 15 min and 40 min, and on days 1 and 3. Delivery via face-to-face interview was conducted for the first three measurements,and then randomized for day 1 and 3 measurements (faceto-face only, telephone only, telephone then face-to-face, face-to-face then telephone)

Effect of vegetation cover and sediment type on 3D subsurface structure and shear strength in saltmarshes

Funder: Queen Mary; Id: http://dx.doi.org/10.13039/100009148Abstract: The vulnerability of saltmarshes to lateral erosion at their margin depends on the local biogeomorphological properties of the substrate. In particular, the 3D architecture of pore and root systems is expected to influence shear strength, with repercussions for the wider‐scale stability of saltmarshes. We apply X‐ray computed microtomography (μCT) to visualize and quantify subsurface structures in two UK saltmarshes at Tillingham Farm, Essex (silt/clay rich substrate) and Warton Sands (sand‐rich substrate), with four types of ground cover: bare ground, Spartina spp, Salicornia spp and Puccinellia spp. We extracted μCT structural parameters that characterize pore and root morphologies at each station, and compared them with field measurements of shear strength using a principal component analysis and correlation tests. The 3D volumes show that species‐dependent variations in root structures, plant colonization events and bioturbation activity control the morphology of macropores, while sediment cohesivity determines the structural stability and persistence of these pore structures over time, even after the vegetation has died. Areas of high porosity and high mean pore thickness were correlated to lower values of shear strength, especially at Tillingham Farm, where well‐connected vertical systems of macropores were associated with current or previous colonization by Spartina spp. However, while well‐connected systems of macropores may lower the local deformation threshold of the sediment, they also encourage drainage, promote vegetation growth and reduce the marsh vulnerability to hydrodynamic forces. The highest values of shear strength at both sites were found under Puccinellia spp, and were associated with a high density of mesh‐like root structures that bind the sediment and resist deformation. Future studies of marsh stability should ideally consider time series of vegetation cover, especially in silt/clay‐dominated saltmarshes, in order to consider the potential effect of preserved buried networks of macropores on water circulation, marsh functioning and cliff‐face erosion

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

Background: Early treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve. Methods: SURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected. Results: The study population comprised 78 patients (mean \ub1 SD: age 73.6 \ub1 7.6 years, logistic EuroSCORE 18.0 \ub1 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n\ua0= 45) or replacement (n\ua0= 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean \ub1 SD overall aortic cross-clamp time was 109 \ub1 41 min and cardiopulmonary bypass time was 152 \ub1 49 min. Mean \ub1 SD aortic pressure gradients decreased from 37.6 \ub1 17.7 mmHg preoperatively to 13.0 \ub1 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 \ub1 28.7 to 23.4 \ub1 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study. Conclusions: These results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes

Training in critical care echocardiography

Echocardiography is useful for the diagnosis and management of hemodynamic failure in the intensive care unit so that competence in some elements of echocardiography is a core skill of the critical care specialist. An important issue is how to provide training to intensivists so that they are competent in the field. This article will review issues related to training in critical care echocardiography

The effect of total arterial grafting on medium-term outcomes following coronary artery bypass grafting

<p>Abstract</p> <p>Background</p> <p>While it is believed that total arterial grafting (TAG) for coronary artery bypass grafting (CABG) confers improved long-term outcomes when compared to conventional grafting with left internal mammary artery and saphenous vein grafts (LIMA+SVG), to date, this has not become the standard of care. In this study, we assessed the impact of TAG on medium-term outcomes after CABG.</p> <p>Methods</p> <p>Peri-operative data was prospectively collected on consecutive first-time, isolated CABG patients between 1995 and 2005. Patients were divided into two groups based on grafting strategy: TAG (all arterial grafts no saphenous veins) or LIMA+SVG. Patients who had an emergent status or underwent fewer than two distal bypasses were excluded. Medium term univariate and risk-adjusted comparisons between TAG and LIMA+SVG cases were performed.</p> <p>Results</p> <p>A total of 4696 CABG patients were included with 1019 patients undergoing TAG (22%). Unadjusted in-hospital mortality was 1.5% for TAG patients compared to 2.0% for LIMA+SVG (p = 0.31). The mean follow-up was 4.8 ± 2.0 years for TAG patients compared to 6.1 ± 3.0 years for LIMA+SVG patients (p < 0.0001). At follow-up total mortality (8% vs 19%; p < 0.0001), and the incidence of readmission to hospital for cardiac reasons (29% vs 38%; p < 0.0001) were significantly lower in TAG compared to LIMA+SVG patients. However, after adjusting for clinical covariates, TAG did not emerge as a significant independent predictor of long-term mortality (HR 0.92; CI 0.71–1.18), readmission to hospital (HR 1.02; CI 0.89–1.18) or the composite outcome of mortality and readmission (HR 1.00; CI 0.88–1.15). Risk adjusted survival was better than 88% in both TAG and LIMA-SVG patients at 5 years follow-up.</p> <p>Conclusion</p> <p>Patients undergoing TAG appear to experience lower rates of medium-term all-cause mortality and readmission to hospital for any cardiac cause when compared to patients undergoing LIMA+SVG. However, after adjusting for clinical variables, this difference no longer persists suggesting that at median follow-up there are no mortality or morbidity benefit based on the choice of conduit.</p

Short term outcomes of total arterial coronary revascularization in patients above 65 years: a propensity score analysis

<p>Abstract</p> <p>Background</p> <p>Despite the advantages of bilateral mammary coronary revascularization, many surgeons are still restricting this technique to the young patients. The objective of this study is to demonstrate the safety and potential advantages of bilateral mammary coronary revascularization in patients older than 65 years.</p> <p>Methods</p> <p>Group I included 415 patients older than 65 years with exclusively bilateral mammary revascularization. Using a propensity score we selected 389 patients (group II) in whom coronary bypass operations were performed using the left internal mammary artery and the great saphenous vein.</p> <p>Results</p> <p>The incidence of postoperative stroke was higher in group II (1.5% vs. 0%, P = 0.0111). The amount of postoperative blood loss was higher in group I (908 ± 757 ml vs. 800 ± 713 ml, P = 0.0405). There were no other postoperative differences between both groups.</p> <p>Conclusion</p> <p>Bilateral internal mammary artery revascularization can be safely performed in patients older than 65 years. T-graft configuration without aortic anastomosis is particularly beneficial in this age group since it avoids aortic manipulation, which is an important risk factor for postoperative stroke.</p