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The robust advances in pain management for companion animals underlie the decision of AAHA and AAFP to expand on the information provided in the 2007 AAHA/AAFP Pain Management Guidelines for Dogs and Cats . The 2015 guidelines summarize and offer a discriminating review of much of this new knowledge. Pain management is central to veterinary practice, alleviating pain, improving patient outcomes, and enhancing both quality of life and the veterinarian-client-patient relationship. The management of pain requires a continuum of care that includes anticipation, early intervention, and evaluation of response on an individual-patient basis. The guidelines include both pharmacologic and nonpharmacologic modalities to manage pain; they are evidence-based insofar as possible and otherwise represent a consensus of expert opinion. Behavioral changes are currently the principal indicator of pain and its course of improvement or progression, and the basis for recently validated pain scores. A team-oriented approach, including the owner, is essential for maximizing the recognition, prevention, and treatment of pain in animals. Postsurgical pain is eminently predictable but a strong body of evidence exists supporting strategies to mitigate adaptive as well as maladaptive forms. Degenerative joint disease is one of the most significant and under-diagnosed diseases of cats and dogs. Degenerative joint disease is ubiquitous, found in pets of all ages, and inevitably progresses over time; evidence-based strategies for management are established in dogs, and emerging in cats. These guidelines support veterinarians in incorporating pain management into practice, improving patient care.

Background: Restoring health-related quality of life (HRQOL) is a therapeutic goal for older patients with advanced heart failure. We aimed to describe change in HRQOL in older patients (60–80 years) awaiting heart transplantation (HT) with or without pretransplant mechanical circulatory support (MCS) or scheduled for long-term MCS, if ineligible for HT, from before to 6 months after these surgeries and identify factors associated with change. Methods: Patients from 13 US sites completed the EuroQol 5-dimension 3L questionnaire and Kansas City Cardiomyopathy Questionnaire-12 at baseline and 3 and 6 months after HT or long-term MCS. Analyses included univariate comparisons and multivariable linear regression. Results: Among 305 participants (cohort mean age=66.2±4.7 years, 78% male, 84% White, 55% New York Heart Association class IV), 161 underwent HT (n=68 with and n=93 without pretransplant MCS), and 144 received long-term MCS. From baseline to 3 months, EuroQol 5-dimension visual analog scale scores improved in HT patients without pretransplant MCS (54.5±24.3 versus 75.9±16.0, P P P P P =0.002). No further HRQOL improvement was found from 3 to 6 months. Factors most significantly associated with change in HRQOL, baseline 3 months, were right heart failure and 3-month New York Heart Association class, and 3 to 6 months, were 6-month New York Heart Association class and major bleeding. Conclusions: In older heart failure patients, HRQOL improved from before to early after HT and long-term MCS. At 6 postoperative months, HRQOL of long-term MCS patients was lower than one or both HT groups. Understanding change in HRQOL from before to early after these surgeries may enhance decision-making and guide patient care. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02568930.

Background There is a paucity of research describing health‐related quality of life (HRQOL) in older adults considered for advanced heart failure surgical therapies. Using data from our SUSTAIN‐IT (Sustaining Quality of Life of the Aged: Heart Transplant or Mechanical Support) study, we aimed to compare HRQOL among 3 groups of older (60–80 years) patients with heart failure before heart transplantation (HT) or long‐term mechanical circulatory support (MCS) and identify factors associated with HRQOL: (1) HT candidates with MCS, (2) HT candidates without MCS, or (3) candidates ineligible for HT and scheduled for long‐term MCS. Methods and Results Patients from 13 US sites completed assessments, including self‐reported measures of HRQOL (EuroQol‐5 Dimension Questionnaire, Kansas City Cardiomyopathy Questionnaire–12), depressive symptoms (Personal Health Questionnaire–8), anxiety (State‐Trait Anxiety Inventory–state form), cognitive status (Montreal Cognitive Assessment), and performance‐based measures (6‐minute walk test and 5‐m gait speed). Analyses included ANOVA, χ 2 tests, Fisher’s exact tests, and linear regression. The sample included 393 patients; the majority of patients were White men and married. Long‐term MCS candidates (n=154) were significantly older and had more comorbidities and a higher New York Heart Association class than HT candidates with MCS (n=118) and HT candidates without MCS (n=121). Long‐term MCS candidates had worse HRQOL than HT candidates with and without MCS (EQ‐5D visual analog scale scores, 46±23 versus 68±18 versus 54±23 [ P P Conclusions Our findings demonstrate important differences in overall and domain‐specific HRQOL of older patients with heart failure before HT or long‐term MCS. Understanding HRQOL differences may guide decisions toward more appropriate and personalized advanced heart failure therapies.

Purpose: Caregivers (CGs) provide essential support to older (60-80 years) patients with advanced heart failure (HF), yet caregiving may be burdensome. Understanding the caregivers time spent and difficulty in caring for patients may inform CG support needs before and after cardiac surgery. We compared CG burden before and 24 months after heart transplantation (HT), with or without baseline mechanical circulatory support (MCS), and long-term MCS as destination therapy (DT). Methods: Between 10/1/15-12/31/18, we enrolled 301 CGs of HF patients from 13 U.S. hospitals: 193 awaiting HT (92 with and 101 without MCS), and 108 scheduled for long-term MCS. At baseline (pre-surgery) and 24 months post-surgery, CGs completed the Oberst Caregiving Burden Scale (OCBS), which has 15 items with 2 subscales: (1) time: range=1-5, higher score=more time spent on task and (2) difficulty: range=1-5, higher score=higher task difficulty. Statistical analyses included t-tests and baseline-adjusted linear regression models. Results: CGs’ average age was 60.9±10 years, 83% were spouses, 85% female, and 85% white. Across all groups and both time points, time spent on caregiving tasks was moderate and task difficulty was rated low. Time spent on caregiving decreased significantly from baseline to 24-months for all groups (p-value Conclusions: CG time on tasks decreased from baseline to 24-months post-surgery in all groups, and both time and difficulty scores were persistently higher for CGs of DT patients. These results may inform identification of support options to reduce time and difficulty of CG tasks, particularly for those who care for destination therapy HF patients.

Introduction: Caregivers (CGs) of heart failure (HF) patients (PTs) who undergo heart transplantation (HT) or Destination Therapy Mechanical Circulatory Support (DT MCS) provide support to PTs before and after surgery, which may affect their own health-related quality of life (HRQOL). In SUSTAIN-IT, we previously reported that CG HRQOL was good at baseline (i.e., before HT and DT MCS surgery) and was impacted by CG comorbidities and CG anxiety. This report explores change in CG overall HRQOL, depression, and anxiety from baseline to 12 months after HT or DT MCS surgery. Methods: From 10/1/15-12/31/18, 13 U.S. centers enrolled 301 CGs of HF PTs: 193 awaiting HT (92 HT with MCS as a bridge to transplant [HT BTT] and 101 HT without MCS [HT non-BTT]), and 108 awaiting DT MCS. At baseline, 3, 6, and 12 months post HT or DT MCS surgery, CGs completed the following instruments: EQ-5D-3L (Visual Analog Scale [VAS]: 0 [worst] to 100 [best] imaginable health state), PHQ-8 (range=0-24; score ≥10=depressive symptoms requiring evaluation), and STAI-State (range=20-80, higher score=more anxiety). Analyses included unadjusted and baseline-adjusted linear regression models. Results: CGs were age 61.0±10.3 years; the majority were Caucasian (86%), female (86%), spouses (85%) of enrolled HF PTs. At baseline, CG EQ-5D-3L VAS and PHQ-8 average scores were 83.8 ± 13.99 (high) and 2.6 ± 2.85 (low), respectively, for the entire cohort. No significant interval changes in CG HRQOL and depressive symptoms were found within or between groups. DT MCS and HT non-BTT CG anxiety significantly decreased over time (baseline to 12 months) (Figure). Levels of CG anxiety were similar among all groups at 12 months after HT or DT MCS surgery. Conclusions: The demonstrated reduction in anxiety among CGs in the post-operative period provides clinicians with important information to share with CGs when PTs are considering surgical treatment options for HF.

Purpose: Caregivers (CGs) for patients with advanced heart failure (HF) assist in HF-specific disease management. In the SUSTAIN-IT study, we reported CG perception of difficulty and time needed to perform tasks for patients awaiting surgery in 3 groups: HF patients awaiting heart transplant (HT) without mechanical support (HT-non-MCS), HF patients awaiting HT bridged with mechanical support (HT-MCS), and HF patient awaiting left ventricular device implantation as destination therapy (DT-MCS). In this report, we compare CG perceived burden from baseline to 1 year after surgery. Methods: We enrolled 301 CGs of HF patients between 10/1/15-12/31/18 from 12 U.S. hospitals: 193 awaiting HT (92 with and 101 without MCS), and 108 scheduled for DT-MCS. Prior to surgery and 3, 6, and 12 months after surgery, CGs completed the Oberst Caregiver Burden Scale (OCBS) which has 15 items with 2 subscales: (1) time and (2) difficulty: range=1-5, higher score=more time required for tasks and more task difficulty. Analyses included t-tests, chi-square tests, and baseline-adjusted linear regression models. Results: CGs were age 61.0±10.3 years, the majority were spouses (85%), female (86%), and white (86%). Average time spent on caregiving was moderate and decreased significantly from baseline to 12 months after surgery for all groups (Figure). DT-MCS CGs spent significantly more time than HT CGs on tasks 12 months after surgery. There were no significant differences in perceived difficulty (which was low) in performing CG tasks in all groups from baseline to 12 months. DT-MCS CGs did perceive tasks to be more difficult than HT CGs at 12 months. Conclusion: CGs of advanced HF patients adapted well to assisting with care, without increased burden, 1 year after HT and DT-MCS surgery. CGs of DT-MCS patients required more time and reported CG tasks to be more difficult than HT CGs. Understanding differences in CG burden will aid in pre surgical risk discussions and post-surgical follow-up.

Purpose Factors related to health-related quality of life (HRQOL) of older patients (pts) with advanced heart failure (HF) scheduled for left ventricular assist device (LVAD) implantation as destination therapy (DT) or while a candidate for heart transplantation (HT) with or without an LVAD, may guide therapeutic strategies. We sought to identify pt and caregiver (cg) factors related to HRQOL of pts (60-80 years) awaiting these surgeries. Methods From 10/1/15-12/31/18, we enrolled 302 pts with cgs (n=302) from 13 U.S. sites: 193 pts awaiting HT (92 with and 101 without LVAD) and 109 DT LVAD pts. Pts completed the EQ-5D-3L Visual Analog Scale (VAS): 0-100 (worst-best) health; KCCQ-12 summary score (SS), 0-100=low-high; PHQ-8 (0-24; score > 10=significant depressive symptoms) and STAI-state (20-80; higher score=more anxiety). Cgs completed the EQ-5D, STAI, PHQ-8 and Oberst Caregiving Burden Scale (OCBS): 2 subscales (time and difficulty, 1-5; higher score=more time and more task difficulty). Analyses included multivariable logistic regression models; the binary outcomes were whether individual EQ-5D VAS and KCCQ-12 SSs were higher than the cohort median of 60 and 46, respectively. Results Pts were 66.1±4.5 years, 82% male, and 86% white. Pts reported relatively low generic HRQOL (VAS mean=55.3±23.5) and low HF-specific HRQOL (SS mean=47.5±22.5), both with significant group differences. HT pts with LVADs were more likely to have higher EQ-5D VAS scores; DT pts had the lowest VAS scores (p > 10 was related to lower VAS scores (p > 10 was related to lower KCCQ-12 SSs (p Conclusion Implant strategy, pt depression, and cg time spent on care were significantly related to older advanced HF pt HRQOL. Findings may inform interventions for HF pts awaiting surgery.

Purpose Heart transplantation (HT) and mechanical circulatory support (MCS) has improved heart failure (HF) patient (PT) outcomes; it has also led to increased caregiver (CG) responsibility pre and post-surgery. We assessed whether PT and CG factors were related to baseline CG perceived burden in 3 groups of CGs of HF PTs (60-80 years): (1) PT supported with MCS as a bridge to HT (HT BTT), (2) PT awaiting HT without MCS (HT non BTT), and (3) PT prior to MCS for destination therapy (DT MCS). Methods Between 10/1/15-12/31/18, we enrolled 302 CGs from 13 U.S. sites: 92 HT BTT, 101 HT non BTT, and 109 DT MCS. CG burden was measured with the Oberst Caregiving Burden Scale (OCBS: [1] time: higher score=more time spent on task and [2] difficulty: higher score=more difficulty of task). CGs also completed the EQ-5D-3L (Visual Analog Scale [VAS]: 0 [worst] to 100 [best] imaginable health state and 5 dimensions); STAI-State (higher score=more anxiety); PHQ-8 (score ≥10=significant depressive symptoms), and demographic/health history/impact of caregiving on own health questions. PTs completed the KCCQ-12, MoCA (measure of cognitive dysfunction) and all above measures except the OCBS. Analyses included multivariable logistic regression models in which the binary outcomes were whether individual OCBS difficulty and time scores were higher than the cohort median values of 1.20 and 2.26, respectively. Results CGs were 61.1±9.7 years, 85% spouses, 85% female, and 85% white. Overall CG difficulty was low and CG time spent was moderate. CGs who reported more difficulty on tasks perceived more impact on their own health and had more anxiety, with no differences by PT implant strategy (table). CGs with Conclusion Only CG factors, and not PT factors, were related to CG perceived burden. Understanding factors that affect CG burden may aid in preoperative advanced therapies discussions.

This article reviews the use of vasoactive medications prescribed in the postoperative management of patients who have undergone cardiac surgery. With a focus on the influence these medications have on the physiologic contributors to cardiac output and blood pressure, insight into decision making related to use, titration, and discontinuation of these medications is provided. Case studies offer vignettes to demonstrate the application of knowledge gleaned from the article.

Improving care of critically ill patients requires using an interprofessional care model and care standardisation.Determine whether collaborative patient care rounds in the intensive care unit increases practice consistency with respect to common considerations such as delirium prevention, device use, and indicated prophylaxis, among others. Secondary objective to assess whether collaborative interprofessional format improved nursing perceptions of collaboration.Single centre, pre- and post- intervention design. collaborative patient care rounding format implemented in three intensive care units in an academic tertiary care centre. format consisted of scripted nursing presentation, provider checklist of additional practice considerations, and daily priority goals documentation. measurements included nursing participation, consideration of selected practice items, daily goal verbalisation, and nursing perception of collaboration.Pre- and post-intervention measurements indicate gains in consideration of eight of thirteen bundle items (p 0.05), with the greatest gains seen in nurse-presented items. Increases were observed in verbalisation of daily goals (59.8% versus 89.1%, p 0.0001), nurse participation (83.9% versus 91.8%, p = 0.056), and nurse collaboration ratings (p 0.0001).This study describes implementation of collaborative patient care rounds with corresponding increases in consideration of selected practice items, verbalisation of daily goals, and perceptions of collaboration.

The goal of consistent, predictable, and improved outcomes has continued to elude the scientific community in the 30 years since lung transplantation became the procedure of choice for patients with terminal, nonmalignant lung disease. Background: Although there is consensus regarding disease-specific indications for lung transplant, ambiguity remains regarding how patient-specific attributes should influence lung transplant candidacy. This study had 3 aims (1) to establish the missing domains of the interdisciplinary assessment of the lung transplant candidate, (2) to have these domains validated by an international panel of lung transplant experts, and (3) to recommend the next step for inclusion of these domains into the lung transplant candidate selection process. Methods: Three levels of evidence were reviewed. A search for standards and guidelines, a comprehensive literature review, and a validation of domains by experts were conducted. Results: Seven domains of patient attributes were identified as relevant to lung transplant patient selection: cognitive performance, frailty, psychological factors, self-efficacy, social support, quality of life, and sociodemographic factors. Within each domain, several elements were identified to be incorporated in the process of patient assessment. Conclusion: Assessment of the missing domains and elements should be incorporated into the interdisciplinary lung transplant evaluation process. Standardized recognition and reporting of the patient-specific attributes will inform the work of individual transplant programs and the international transplant community. Further study is needed to associate these patient attributes with transplant outcomes. Improved understanding is needed regarding how nurses assess lung transplant candidates and how they communicate their findings within interdisciplinary settings.

Within a little more than a decade, the transplant of human organs for end-stage organ disease became a reality. The early barriers to successful long-term graft and patient survival were related to the inability to effectively control the immune system such that it would not attack the donor tissue but would still recognize and destroy invading organisms and cells. As immunosuppressive therapy has been refined and proper matching of donors and recipients has been improved, hyperacute rejection has become a rare occurrence and acute rejection has been markedly controlled. However, antibody-mediated rejection remains an important impediment to increased survival of transplanted organs. This article provides readers with a broad overview of the immune system, discusses mechanisms of transplant rejection, and details prevention, detection, and treatment of antibody-mediated rejection in solid organ transplant.

Objectives Heart transplantation (HT) and mechanical circulatory support (MCS) as destination therapy (DT) are life-saving options for 60-80 year-old patients (pts) with advanced heart failure (HF). We compared pt health-related quality of life (HRQOL) before and 1 year (yr) after surgery in pts undergoing HT (with or without MCS) and DT MCS. Methods Among 393 pts at 13 US sites awaiting HT (n=239; 118 awaiting HT with MCS, 121 awaiting HT without MCS; 66% transplanted) and DT MCS (n=154) between 10/1/15-12/31/18, we collected self-report data on: HRQOL (EQ-5D-3L Visual Analog Scale [VAS]: 0-100=worst to best) and (KCCQ-12: 0-100=lowest to highest), depressive symptoms (PHQ-8: 0-24=fewer to more) and anxiety (STAI-state: 20-80=lower to higher]). There were 337 pts at 1 year follow up. Statistical analyses included paired t-tests, chi-square tests, and baseline-adjusted linear regression models. Results The majority of pts were white and male. DT pts were older than HT pts (DT = 68.6±5.2 vs HT with MCS = 64.4±3.3 vs HT without MCS = 64.0±2.9 years, p Conclusions HRQOL and mood improved in all 3 groups over time with better overall 1-yr scores observed in those undergoing HT. These unique findings may guide HRQOL-related therapeutic strategies.

Purpose Caregivers (CGs) of patients (PTs) with heart failure (HF) experience substantial CG burden. Poor PT health-related quality of life (HRQOL) correlates with increased CG burden in other chronic disease. We evaluated the relationship between PT HRQOL and CG burden in older PTs receiving left ventricular assist devices (LVAD) as destination therapy (DT) or awaiting heart transplant (HT) with or without an LVAD. Methods Data were from SUSTAIN-IT, a study of PT and CG HRQOL in adults age 60-80 receiving DT LVAD or HT. PT HRQOL was assessed by EQ-5D-3L Visual Analog Scale (VAS) score: 0-100 (worst-best) & HF-specific KCCQ-12 summary score (SS), 0-100=low-high. CG burden was assessed by Oberst Caregiving Burden Scale (OCBS) assessing perceptions of CG difficulty & time (1-5; higher score=more time & difficulty). Baseline CG burden, PT HRQOL, and changes from 0 to 6 months were compared by linear regression. Results Data from 302 PTs and CGs were analyzed: 109 DT LVAD, 193 HT (101 without LVAD & 92 with LVAD). KCCQ-12 and EQ-5D VAS scores increased significantly from 0 to 6 months (p Conclusion PT HRQOL generally correlated with CG burden in older HF PTs before and early after DT and HT. Improved PT HRQOL did not correlate with decreased CG burden in HT, but may be associated in DT LVAD. These findings may guide support needs of CGs of PTs undergoing advanced therapies.

Purpose Understanding health-related quality of life (HRQOL) informs support needs for caregivers (CGs) of patients (pts) with advanced heart failure (HF). We compared HRQOL before/6 months post surgery for CGs of pts undergoing heart transplantation (HT), with or without mechanical circulatory support (MCS), and destination therapy (DT) MCS. Methods Between 10/1/15-12/31/18 we enrolled 302 CGs from 12 U.S. sites: 89 HT with MCS, 104 HT without MCS, and 109 DT MCS. CGs completed the EQ-5D-3L (Visual Analog Scale [VAS]: 0 [worst] to 100 [best] imaginable health state and 5 HRQOL dimensions), PHQ-8 (range = 0-24 with ≥10 = significant depressive symptoms), and STAI-state (range = 20-80; higher score = more anxiety). Results CGs were aged 61.0±10.3 years, majority were spouses (85%), female (86%), and white (86%). CGs reported high overall HRQOL before (83.9±14.0) and after (82.9±15.7) surgery, with no significant differences between groups. CGs in all 3 groups reported low baseline (2.6±2.9) and follow-up (2.9±3.9) depressive symptoms. DT CGs reported significantly higher baseline anxiety levels compared to HT-MCS and HT-non MCS. DT and HT-non MCS caregivers showed significantly reduced anxiety levels over time. See Figure. There were no significant differences in anxiety between groups 6 months post-surgery. Conclusions CGs of pts with advanced HF reported relatively high levels of HRQOL and low levels of depression at baseline and early after surgery. DT CGs reported higher baseline anxiety levels when compared to CGs of HT pts. At 6 months, anxiety levels were similar and low for all groups, suggesting CG adjustment. Identifying CG psychological distress may inform support options and potential treatment.

Family caregivers contribute services valued at $450 billion to the U.S. economy annually. Although family members frequently lack training in the techniques of health care, providers routinely turn to them to provide care when a patient's condition no longer meets criteria for hospitalization. This article explores the concepts of caregiver empowerment and disempowerment, offers strategies for enhancing caregiver empowerment, and describes actions that may unintentionally disempower those same individuals. Case examples are used to draw attention to cues health care personnel may encounter that signal a need to look deeper into the caregiver's capacity to provide the needed care. Early identification of barriers to capacity will permit the health care team to bring resources to bear on the patient's situation to facilitate safe transitions of care.Keywords: caregiver; chronic illness; empowerment; disempowerment; family caregiver"There are only four kinds of people in the world: those who have been caregivers, those who currently are caregivers, those who will be caregivers, and those who will need caregivers."-Rosalynn Carter, former first lady of the United States (Alzheimer 's Association, 1997)The relevance and accuracy of Rosalynn Carter's observation persisted more than a decade later in data published by the AARP Public Policy Institute (Feinberg, Reinhard, Houser, & Choula, 2011). These authors reported that, at any given point in time, more than 42 million family caregivers in the United States were providing care to an adult with limitations in activities of daily living. They went on to state that almost 62 million Americans had provided care at some time during the year. The average caregiver in their report was characterized as a 49-year-old woman (65% of caregivers are female) who worked outside the home. She spent nearly 20 hours per week providing unpaid care to her parent (80% of care recipients are relatives or friends older than 50 years) and would do so for an average of 5 years. With an estimated value of $450 billion annually, the contribution of family caregivers to the health care economy must be acknowledged (Feinberg et al., 2011). It reflects the commitment that many Americans have made to their family members, their partners, and their friends experiencing acute and chronic illness. That fully one in four Americans has taken on care responsibilities beyond their daily life commitments is a reminder of the complexity of life outside of public view.Becoming a family caregiver can be daunting. Becoming a competent and confident caregiver can be overwhelming. Yet, everyday conversations occur in hospitals and care facilities about who will be the support person or caregiver for a patient when he or she no longer qualifies for inpatient treatment. Families and friends may be willing but are unprepared for unfamiliar with the kinds of care the patient needs. They may lack knowledge about the illness, about strategies for disease management, or about the basics of providing care to an individual dependent on them for accomplishing activities of daily living (bathing, eating, toileting, dressing) or instrumental activities of daily living (transportation, financial management, shopping, housekeeping). As individuals with acute and/or chronic illness are discharged from the hospital with increasingly complicated care needs, that knowledge gap can be a barrier to caregiver empowerment.The other side of the caregiver challenge occurs when giving the responsibility for care back to the patient. Not to do so is disempowering to those individuals who may be able to assume more of their own care but who have grown dependent on others' caring for them. Worse, the care recipient may fear alienating the caregiver on whom he or she has depended for weeks, months, or years. There is no guidebook for successfully navigating the challenging waters of care transitions.BARRIERS TO CAREGIVER EMPOWERMENTStajduhar et al. …

Mechanical circulatory support (MCS) offers a surgical option for advanced heart failure when optimal medical therapy is inadequate. MCS therapy improves prognosis, functional status, and quality of life.1,2 The INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) tracks patient selection and outcomes for all implanted US Food and Drug Administration–approved MCS devices. From June 2006 until December 2014, >15 000 patients received MCS, and >2000 implantations are performed annually. One-year survival with current continuous-flow devices is reported to be 80%, and 2-year survival, 70%.3 In patients awaiting heart transplantation, MCS provides a bridge to transplantation, and for others who are ineligible for heart transplantation, MCS provides permanent support or destination therapy. Indications and absolute and relative contraindications to durable MCS are listed in Table 1. View this table: Table 1. Indications and Contraindications to Durable Mechanical Support As of July 2014, 158 centers in the United States offer long-term MCS.3 Patients often live a substantial distance from the implanting center, necessitating active involvement of local first responders (emergency medical technicians, police, and fire department personnel), emergency department staff, primary care, and referring cardiologists. Because patients with MCS are becoming increasingly mobile, basic knowledge of equipment is necessary for personnel in public areas such as schools, public transportation, and airplanes/airports. Ambulatory patients with MCS can span the entire age spectrum from pediatrics to geriatrics. The aim of this document is to provide guidance for nonexperts in MCS and to facilitate the informed assessment, stabilization, and transport of the patient with MCS back to the MCS center for definitive therapy. In addition, the principles herein provide a foundation for emergency management and a framework to address the management of known MCS-associated complications and expected comorbid medical problems. Currently in the United States, the most frequently used durable devices are continuous-flow devices with …

The senior companion animal is the fastest growing segment of the pet population. End-of-life care, quality of life, and pain management (PM) are extremely important to pet owners. Research into PM and end-of-life care is essential due to lack of information on owner knowledge, attitudes, and beliefs. A survey was developed to gather information from owners. Surveys were developed using expert focus groups, and participants were recruited through social media. Survey validation employed emergent themes and grounded theory. Data from respondents (n = 986) were analyzed using descriptive statistics, Kruskal-Wallis, Jonckheere-Terpstra, or Wilcoxon rank-sum tests, with post hoc adjustment. Approximately 87% of respondents felt that euthanizing for unmitigated pain was appropriate. Households where there were multiple pets, both cats and dogs, and owners who were not first-time pet owners showed even greater preferences (P < .05) for euthanasia with unmitigated pain. Pain control was important to respondents, but owners lacked knowledge and had unrealistic attitudes and beliefs about treatment options, costs, and long-term feasibility. Limitations of this research included homogeneity of online survey respondents and convenience sampling. Translational research should be fostered to increase the availability and affordability of PM techniques in veterinary practice.

Purpose Heart transplantation (HT) with or without prior mechanical circulatory support (MCS) and MCS as destination therapy (DT) are life-saving options for 60-80 year-old patients (pts) with advanced heart failure (HF). We prospectively collected and compared pts' health-related quality of life (HRQOL) before and 6 months (mos) after surgery in pts undergoing HT (with or without MCS) and DT MCS. Methods Among 344 pts from 13 U.S. sites awaiting HT (n=207; 100 awaiting HT with MCS and 107 awaiting HT without MCS) and DT MCS (n=137) between 10/1/15-9/15/18, we collected generic (EQ-5D-3L Visual Analog Scale [VAS]: 0-100=worst to best) and HF-specific HRQOL (KCCQ-12: 0-100=lowest to highest), as well as depressive (PHQ-8: 0-24=fewer to more) and anxiety (STAI-state: 20-80=lower to higher]) symptoms. Statistical analyses included t-tests , chi-square tests , and baseline-adjusted linear models. Results The majority of pts were white, male, and well-educated. The DT MCS group was older than the HT group (DT = 68.6±5.1 vs HT with MCS = 64.5±3.3 vs HT without MCS = 64.0±2.9 years, p Depressive symptoms and anxiety did not change significantly over time in the HT with MCS group, although these scores were similar among all three groups at 6 mos (Figure panels A-D). Conclusion While all three groups improved over time, HRQOL at 6 mos was best in those undergoing HT without MCS. Change in depressive symptoms and anxiety varied by group. These data provide unique insights into pts’ experiences after alternative surgical treatments for advanced HF.

Institutional Affiliations Co-chairs Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, Georgia Institute of Technology and Morehouse School of Medicine; Pamboukian SV: University of Alabama at Birmingham, Birmingham, Alabama; Teuteberg JJ: University of Pittsburgh, Pittsburgh, Pennsylvania Task force chairs Birks E: University of Louisville, Louisville, Kentucky; Lietz K: Loyola University, Chicago, Maywood, Illinois; Moore SA: Massachusetts General Hospital, Boston, Massachusetts; Morgan JA: Henry Ford Hospital, Detroit, Michigan Contributing writers Arabia F: Mayo Clinic Arizona, Phoenix, Arizona; Bauman ME: University of Alberta, Alberta, Canada; Buchholz HW: University of Alberta, Stollery Children’s Hospital and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Deng M: University of California at Los Angeles, Los Angeles, California; Dickstein ML: Columbia University, New York, New York; El-Banayosy A: Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Elliot T: Inova Fairfax, Falls Church, Virginia; Goldstein DJ: Montefiore Medical Center, New York, New York; Grady KL: Northwestern University, Chicago, Illinois; Jones K: Alfred Hospital, Melbourne, Australia; Hryniewicz K: Minneapolis Heart Institute, Minneapolis, Minnesota; John R: University of Minnesota, Minneapolis, Minnesota; Kaan A: St. Paul’s Hospital, Vancouver, British Columbia, Canada; Kusne S: Mayo Clinic Arizona, Phoenix, Arizona; Loebe M: Methodist Hospital, Houston, Texas; Massicotte P: University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada; Moazami N: Minneapolis Heart Institute, Minneapolis, Minnesota; Mohacsi P: University Hospital, Bern, Switzerland; Mooney M: Sentara Norfolk, Virginia Beach, Virginia; Nelson T: Mayo Clinic Arizona, Phoenix, Arizona; Pagani F: University of Michigan, Ann Arbor, Michigan; Perry W: Integris Baptist Health Care, Oklahoma City, Oklahoma; Potapov EV: Deutsches Herzzentrum Berlin, Berlin, Germany; Rame JE: University of Pennsylvania, Philadelphia, Pennsylvania; Russell SD: Johns Hopkins, Baltimore, Maryland; Sorensen EN: University of Maryland, Baltimore, Maryland; Sun B: Minneapolis Heart Institute, Minneapolis, Minnesota; Strueber M: Hannover Medical School, Hanover, Germany Independent reviewers Mangi AA: Yale University School of Medicine, New Haven, Connecticut; Petty MG: University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota; Rogers J: Duke University Medical Center, Durham, North Carolina

Introduction Cognitive dysfunction (CD), a risk factor for poor outcomes, is common in older patients (pts) with advanced heart failure (HF). Given these pts may be candidates for heart transplantation (HT) or mechanical circulatory support as destination therapy (DT MCS), we compared CD in older advanced HF pts prior to HT and DT MCS. Methods A total of 263 advanced HF pts from 11 U.S. sites either listed for HT (n=164; 75 HT-MCS and 89 HT-non-MCS) or scheduled for DT MCS (n=99) were enrolled between 10/1/15-1/1/18 and completed the Montreal Cognitive Assessment (MoCA), a 10-minute screening instrument (worst-to-best total score range=0-30), including 7 cognitive domains, to detect CD (MoCA total score less than 26). Risk-unadjusted statistical analyses included descriptive statistics, ANOVA, and chi-square tests. To risk-adjust for baseline age differences, we used linear regression and polytomous logistic regression models. Results The majority of advanced HF pts were white males. DT MCS candidates were older than HT candidates and had more co-morbidities (DT = 4.6±2.1 vs HT-MCS = 3.9±2.0 vs HT-non-MCS =3.7±1.7, p=0.008). More DT MCS candidates had CD than HT candidates. DT MCS candidates had lower total MoCA scores and lower scores in all domains except naming, abstraction and orientation (strong trend), compared with HT-MCS and HT-non-MCS candidates. See table. The same conclusions were reached after baseline age-adjustment. See table. Conclusions CD exists in older pts with advanced HF who are candidates for DT MCS and HT. DT MCS pts may be at highest risk. Baseline CD in these pts may inform shared decision making discussions about remaining on medical therapy vs choosing these surgical treatment options.

Continuous-flow left ventricular assist devices (LVAD) have emerged as the standard of care for advanced heart failure patients requiring long-term mechanical circulatory support. Evidence-based clinical management of LVAD-supported patients is becoming increasingly important for optimizing outcomes. In this state-of-art review, we propose key elements in managing patients supported with the new continuous-flow LVADs. Although most of the presented information is largely based on investigator experience during the 1,300-patient HeartMate II clinical trial, many of the discussed principles can be applied to other emerging devices as well. Patient selection, pre-operative preparation, and the timing of LVAD implant are some of the most important elements critical to successful circulatory support and are principles universal to all devices. In addition, proper nutrition management and avoidance of infectious complications can significantly affect morbidity and mortality during LVAD support. Optimizing intraoperative and peri-operative care, and the monitoring and treatment of other organ system dysfunction as it relates to LVAD support, are discussed. A multidisciplinary heart failure team must be organized and charged with providing comprehensive care from initial referral until support is terminated. Preparing for hospital discharge requires detailed education for the patient and family or friends, with provisions for emergencies and routine care. Implantation techniques, troubleshooting device problems, and algorithms for outpatient management, including the diagnosis and treatment of related problems associated with the HeartMate II, are discussed as an example of a specific continuous-flow LVAD. Ongoing trials with other continuous-flow devices may produce additional information in the future for improving clinical management of patients with these devices.

Objectives One of the goals of medical education is to bridge the gap between basic science and clinical practice. Students acquire basic science knowledge during their pre-clinical years, yet have limited opportunities to apply this knowledge clinically. This hands-on laboratory exercise was designed to facilitate a review of anatomy in the context of select clinical procedures, highlighting the application of anatomical concepts in clinical practice. Methods In 2008, Year 2 medical students participated in a clinical procedures laboratory taught by senior residents and attending physicians. Before participating, all students completed anatomy and clinical pre-tests and received syllabi detailing the select procedures and the anatomy pertinent to each. Students were organised into experimental (EG, n = 48) and control (CG, n = 17) groups. The EG observed and practised five procedures on cadavers and the CG participated in a traditional anatomy review laboratory with no procedural demonstrations or practice. Anatomy and clinical post-tests were administered to both groups following the 3-hour interventions. Surveys and focus sessions were used to assess student opinions. Results Scores on the anatomy pre- and post-tests were compared and were found to have significantly increased (P ≤ 0.015) in each group, with the EG performing better than the CG (P = 0.001). The EG also showed significant improvement in clinical post-test scores (P

Purpose The purpose of this study was to measure the daily prevalence of adhesive product use and related skin injuries in adult patients in a non-intensive care unit setting. Design Prospective, descriptive study. Subjects and setting The study sample consisted of patients cared for on 2 inpatient care units in a university-based acute care facility in the Midwestern United States. One was a 30-bed medical/surgical unit and the second was a 35-bed cardiac/telemetry unit. Their median age was 58 years; the average daily proportion of males and females was 56% and 42%, respectively. Methods Medical adhesive-related skin injury (MARSI) prevalence was calculated using 3 methods: (1) the proportion of subjects who had any MARSI injury (subject prevalence), (2) the prevalence of MARSI by injury type and severity (severity prevalence), and (3) the proportion of medical adhesive products that had any associated MARSI (product prevalence). Results The daily subject prevalence of any MARSI injury ranged from 3.4% to 25.0% with a mean and median of 13.0% and 12.7%, respectively. The severity prevalence of MARSI injury ranged from 8 to 149 per 1000 product-days with a mean and median of 63 and 56 MARSIs per 1000 product-days, respectively. The median (range) product prevalence among all adhesive products varied from a high of 70 injuries per 1000 product-days for surgical closure to a low of 0 injuries per 1000 product-days for peripheral intravenous line dressing. Conclusions Medical adhesive-related skin injury is a prevalent event in the acute care setting. Preventing skin injury has the potential to reduce complications, increase patient satisfaction, and improve clinical outcomes.

Rationale: The robust advances in pain management for companion animals underlie the decision of the American Animal Hospital Association (AAHA) and American Association of Feline Practitioners (AAFP) to expand on the information provided in the 2007 AAHA/AAFP Pain Management Guidelines. The 2015 Guidelines summarize and offer a discriminating review of much of this new knowledge. Relevance: Pain management is central to veterinary practice, alleviating pain, improving patient outcomes, and enhancing both quality of life and the veterinarian–client–patient relationship. These Guidelines support veterinarians in incorporating pain management into practice, improving patient care. Approaches: The management of pain requires a continuum of care that includes anticipation, early intervention, and evaluation of response on an individual patient basis. A team-oriented approach, including the owner, is essential for maximizing the recognition, prevention and treatment of pain in animals. Evidence base: The Guidelines include both pharmacologic and non-pharmacologic modalities to manage pain; they are evidence-based insofar as possible and otherwise represent a consensus of expert opinion. Behavioral changes are currently the principal indicator of pain and its course of improvement or progression, and the basis for recently validated pain scores. Post-surgical pain is eminently predictable but a strong body of evidence exists supporting strategies to mitigate adaptive as well as maladaptive forms. Chronic pain is dominated by degenerative joint disease (DJD), which is one of the most significant and under-diagnosed diseases of cats and dogs. DJD is ubiquitous, found in pets of all ages, and inevitably progresses over time; evidence-based strategies for management are established in dogs, and emerging in cats.

Background: Residency program directors and program coordinators have increasing demands placed on them by accrediting agencies and require educational development specifically tailored to their needs. Description: We created, piloted, and evaluated an educational development program consisting of 10 sessions spanning 1 year for program directors and a parallel set of sessions for program coordinators. Evaluation: On average, more than half the residency programs participated in the sessions. Programs improved in residency activities related to their program's handbook, interviewing, evaluations, rotation descriptions, and program evaluation. They did not improve in educational scholarly activities. Program directors and coordinators indicated that the program improved their skills, and they would recommend the program for others. Conclusions: This 10-session program improved important elements of residency education and was favorably received.

The era of mechanical circulatory support (MCS) began in 1953 with the development of cardiopulmonary bypass to facilitate open heart surgery.1 In 1964, the National Heart Institute (now the National Heart, Lung, and Blood Institute) funded the Artificial Heart Program and became actively involved in MCS development. This led to requests for Proposals issued in 1977 and 1980, which laid the foundation for the development of implantable MCS for long-term use, including devices capable of hospital discharge, in the 1990s. Although heart transplantation is now commonplace at many hospitals, the inadequate supply of donor hearts and patient contraindications to transplantation continue to severely restrict its application. As the demand for long-term replacement of diseased hearts increases, there is a clear need for innovative, safe, and durable MCS to treat the growing population of patients with advanced heart failure (HF). Many exciting changes in the field of MCS have occurred in the past few years, including the development of smaller portable pumps and the concept of destination therapy (DT), or permanent pump placement as an alternative to heart transplantation. Currently, there are no published guidelines for the use of MCS. Thus, it is our intent that this statement will provide the contemporary cardiologist and other HF providers with an understanding of general considerations when determining the appropriateness of MCS. There is little hope that complete consensus will ever be reached on the definition of advanced HF, but most physicians caring for such patients on a regular basis readily identify the characteristics of these patients. Advanced HF patients are those with clinically significant circulatory compromise who require special care, including consideration for heart transplantation, continuous intravenous inotropic therapy, MCS, or hospice.2,3 Typically, such patients have symptoms at rest or with minimal exertion and cannot perform many activities of …

Since March 1986, we have performed 26 heart-lung transplantations, 42 single-lung transplantations, 9 bilateral single-lung transplantations, and 1 double-lung transplantation. The original lung donor requirements were as follows: age less than 40 years, no smoking history; no gram-negative rods or fungus on sputum Gram stain; arterial oxygen tension greater than 140 mm Hg on an inspired oxygen fraction of 0.40; no infiltrate or pneumothorax on the chest radiograph; and donor height within 15 cm (6 inches) of recipient height. As the number of potential recipients increased, so did the waiting time. To counter this delay, during the past year we have liberalized our donor criteria. We now accept lung donors up to age 60 years. Any kind of smoking history is acceptable unless there is chronic obstructive pulmonary disease or pulmonary fibrosis on the chest radiograph. Sputum must be free from fungus, but gram-negative rods are treated with appropriate antibiotics. The arterial oxygen tension on an inspired oxygen fraction of 0.40 should be greater than 100 mm Hg, and a small pulmonary infiltrate is not worrisome. This liberalization of the donor pool for lung and heart-lung transplantation has not adversely affected early outcome.

Reduction in contact hours has led to the use of more efficient teaching approaches in medical education, yet the efficacy of such approaches is often not fully investigated.This work provides a detailed analysis of alternating group dissections with peer-teaching in Medical Anatomy (MA).MA I and II percentages of the alternating (ALT) and nonalternating (NALT) groups were compared, scores of ALT subgroups (A and B) were compared, and subgroup performance on practical exam questions was compared.MA I and MA II percentages indicated no significant difference in median scores (pMAI=0.581, pMAII=0.223) between ALT and NALT. Subgroup analysis and assessment of question types showed that student performance and ability to identify a structure were not dependent on dissection group assignment.Alternating dissections offered students more unscheduled time for independent learning activities, such as studying or shadowing preceptors, and reduced student-to-cadaver and student-to-faculty ratios by 50%. Alternating dissections with peer teaching were not detrimental to student performance.

This brief review examines certain strategies for increasing community awareness and recognition of the warning signs and symptoms of stroke. Attention should be given to the intended audience, especially at-risk groups. To enhance stroke literacy, a complete message should include the following 4 aspects: (1) a stroke is a serious medical problem that involves the blood supply to the brain, (2) all 5 approved warning signs and symptoms, (3) the many risk factors involved in stroke, and (4) the need to promptly call 911 for emergency services and treatment. Such knowledge could lead to improvement in the rapid arrival to an emergency room and promote optimal and timely medical treatment. With several educational paradigms and strategies in existence, we propose that more rigorous study of their comparative performance and utility is needed. In a preliminary survey, our own program, called "KNOW FIVE - STAY ALIVE," provided greater posttest knowledge compared with the "FAST" program and a National Institutes of Health brochure called "Know Stroke. Know the signs, Act in time."

Background. Breaking bad news is 1 of cancer specialists’ most common and difficult duties, yet hematology-oncology fellowship programs typically offer little formal preparation for this daunting task. We designed the Breaking Bad News Standardized Patient Intervention (BBNSPI) as a standardized patient educational intervention to improve the communication skills of hematology-oncology fellows (HOFs) and advanced practice nurses (APNs) in breaking bad news to cancer patients. Methods. A total of 6 HOFs and 2 APNs participated in the preintervention test and an educational session designed to improve communication skills. A total of 5 HOFs and 1 APN participated in the postintervention test 1 week later. Results. The average test score of the participants improved from 56.6% in the preintervention test to 68.8% (P

The surgical procedure for patients undergoing lung and heart-lung transplantation, conventional discharge criteria following the surgery, and common transplant-related complications will be reviewed. The impact of transplant on the routine illnesses experienced by people living in the community will also be discussed, including special nursing considerations when caring for patients following lung or heart-lung transplantation. As transplant recipients return to their homes and communities, it is likely that they will first come to their local hospital to care of these illnesses. Knowledgeable care by nurses in that local hospital will promote successful recovery.

In the practice of nursing, we bring our clinical knowledge and our humanity to the intersection of professional and patient. We have the opportunity to learn and grow from each of these encounters to improve our practice and our insight into the care we provide. However, such learning and growth requires intentionally reflecting on those interactions with the goal of identifying successful and unsuccessful strategies in care delivery. This article explores ways in which nurses can reflect on their practice, with particular focus on the nursing salon.