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Virtual reality simulation (VRS) has emerged as an educational methodology in nursing professional development. A cluster randomized controlled trial was conducted with a sample of clinical registered nurses to compare effectiveness of VRS and traditional education on knowledge and behavior related to Clostridioides difficileprevention. No significant differences were found in the effectiveness of the two modalities, suggesting the usefulness of VRS as a teaching methodology.

ABSTRACT Objective: This systematic review describes effects of body temperature alterations defined as fever, controlled normothermia, and spontaneous or induced hypothermia on outcome after traumatic brain injury (TBI) in adults. [...]

Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

BACKGROUND:Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. The purpose of this quality improvement project was to determine whether the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. METHODS:The sample included all adults presenting to the emergency department with TIA at a low-to-moderate risk for stroke. Risks were defined by the ABCD2score and noninvasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within 7 days. These patients were compared with those who were admitted before clinic launch. Medical record reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. RESULTS:Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic and admission groups were 72.8 and 75.2 years, respectively (P= .37). Women comprised 45% of patients in the clinic group, compared with 51.2% in the admission group (P= .58). The mean ABCD2scores were 4.08 and 3.95 in the clinic and admission groups, respectively (P= .63). The median clinic follow-up time was 6 days. There was no stroke incidence in the clinic group and 1 in the admission group within 90 days post TIA. Patient satisfaction score metrics for the NP exceeded the institutional benchmark of 90%. CONCLUSION:Referral to an NP-led clinic in patients with low- to moderate-risk TIA was equally safe as hospital admission.

ASTRACT Studies have demonstrated that the stress of family caregiving places caregivers at risk for developing depression, poor quality of life, and health problems. The purpose of this review was [...]

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients’ daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

A secondary data analysis of nine cross-sectional studies is presented to identify and discuss the various clusters of symptoms of acute myocardial infraction (AMI). The analysis reveals five distinct clusters in AMI that normally vary with age, race and sex, and hence should be taught about to the public clearly so that they can assess their symptoms more efficiently and can seek the necessary treatment.

Purpose: Stable angina is ischemic chest pain on exertion or with emotional stress. Despite guideline-directed therapy, up to 30% of patients have suboptimal pain relief. The aims of this study were to: (1) determine the feasibility and acceptability of a randomized controlled trial (RCT) of acupuncture; and (2) evaluate preliminary efficacy of acupuncture with respect to reduction of pain and increased functional status and health-related quality of life (HRQoL).Methods: Participants with stable angina for ⩾1 month received either a standardized acupuncture protocol, twice per week for 5 weeks, or an attention control protocol. Measures included the McGill Pain Questionnaire (average pain intensity (API), pain now) and the Seattle Angina Questionnaire–7 (functional status, symptoms, and HRQoL). Feasibility was defined as ⩾80% recruitment, ⩾75% retention following enrollment, and ⩾80% completion. Descriptive statistics and mixed-effects linear regression were used for analysis.Results: The sample (n = 24) had a mean age of 59 ± 12 years, was predominantly female (63%), and represented minority groups (8% White, 52% Black, 33% Hispanic, and 8% Other). Feasibility was supported by 79% retention and 89% completion rates. The recruitment rate (68%) was slightly lower than expected. Acceptability scores were 87.9% for the acupuncture group and 51.7% for the control group. Outcomes were significantly better for the acupuncture versus control groups (API, b = −2.1 (1.1), p = 0.047; functional status, b = 27.6 (7.2), p < 0.001; and HRQoL, b = 38.8 (11.9), p = 0.001).Conclusions and implications: Acupuncture was feasible and acceptable in our diverse sample. We were slightly under the recruitment target of 80%, but participants who started the study had a high likelihood of completing it. Acupuncture shows promise for stable angina, but its effectiveness needs to be confirmed by a larger, adequately powered RCT.Trial registration number: NCT02914834 (ClinicalTrials.gov).

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A study was conducted, to identify the effect of selected demographic, clinical, cognitive and environmental variables on the length of the time of delay. Further, an analysis conducted to determine the time delay for the treatment, taken by women and men, and African Americans and non-Hispanic Whites reveals that women did not delay longer than men, and African Americans delayed significantly longer than non-Hispanic Whites.

The differences between women and men in the epidemiology, presentation, and outcomes of coronary heart disease are highlighted. It was found that men and women have the same symptoms during an episode of unstable angina, although a higher proportion of women have less typical symptoms.

This research examined the effect of regular home- and hospital-based cardiac rehabilitation exercise on state and trait hopelessness levels in 324 patients with coronary heart disease. For individuals with moderate to severe baseline hopelessness, home exercise was significantly associated with decreased state hopelessness, even after adjusting for other key variables. Baseline hopelessness was a predictor of attrition in this cohort, especially for home exercisers, but this effect was mediated in hospital-based exercise programs.

Background:Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety.Purpose:The purpose of this quality improvement project was to determine if the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days.Methods:The sample included all adults (18 years or older) presenting to the emergency department (ED) with TIA at low-to-moderate risk for stroke. Risks were defined by the ABCD2score and non-invasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within seven days. These patients were compared to those who were admitted to the hospital prior to clinic launch. Chart reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher’s Exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey.Results:Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic group and the admission group were 72.8 and 75.2 years, respectively (p=0.37). Females comprised 45% of patients in the clinic group, compared to 51.2% in the admission group (p=0.58). The mean ABCD2scores were 4.08 and 3.95 in the clinic and admission groups, respectively (p=0.63). The median clinic follow-up time was six days. There was no stroke incidence in the clinic group and one incidence in the admission group (p=1.0) within 90 days of index TIA. Patient satisfaction score of the NP was 92.6%.Conclusions:In conclusion, referral to an NP-led clinic in patients with low-to-moderate risk TIA was equally safe as hospital admission.

Introduction:Comorbidities are associated with increased risk of mortality in adults with ischemic heart disease (IHD). Hopelessness, a negative outlook and sense of helplessness towards the future, is identified in 27–52% of patients with IHD and associated with a 3.4 times increased risk of mortality or nonfatal myocardial infarction. The relationship between comorbidities and hopelessness in adults with IHD is unknown.Hypothesis:A higher comorbidity score is positively associated with state and trait hopelessness levels in adults hospitalized with an IHD event.Methods:Participants completed the State-Trait Hopelessness Scale and reported basic demographics. Continuous (range 0-14) and categorical scores for the Charlson Comorbidity Index (CCI) were generated based on patient medical records.Results:Participants (n=132) were typical of the U.S. IHD population except for race/ethnicity. Ninety-one were male (68.4%), mean age was 62.6 years (SD= 9.6), and 97% were non-Latinx White (3.0%). The mean CCI was 3.5 (SD=2.2), with 36.4% having a score of 1-2 (mild), 41.2% with a score of 3-4 (moderate) and 22.7% with a score of ≥5 (severe). The CCI was positively associated with both state and trait hopelessness in unadjusted and adjusted (demographics, medical history, and exercise history) analyses (unadjusted: r=0.26, p=0.002 (state); r=0.23, p=0.009 (trait) and adjusted: r=0.22, p=0.008 (state); r=0.18, p=0.052 (trait)). Components of the CCI showing the strongest relationships with higher levels of hopelessness were cerebrovascular accident (n=8), organ damage from diabetes (n=17), COPD (n=24), and renal failure (n=9). Interaction terms were evaluated and there was no evidence that the relationship between the CCI and hopelessness differed by age, gender, education level, or cardiac intervention type.Conclusions:Our hypothesis of a positive association between comorbidity score and state and trait hopelessness was confirmed. Knowledge of hopelessness in IHD patients with comorbidities is important for health care professionals in acute care and outpatient settings so at-risk patients can be identified and appropirate interventions employed. Future work should be conducted in larger, more heterogeneous samples.

Introduction:Acute coronary syndrome (ACS) is a potential life-threatening emergency; therefore, rapid diagnosis and life-saving reperfusion therapies are essential to prevent adverse outcomes. Patients with suspected ACS experience an array of symptoms, which cause patients to seek care (9-1-1 or self-transport) to the emergency department [ED]). Little is known, however, about the prognostic value of symptom characteristics experienced in the very early period of evolving ACS and its impact on adverse patient outcomes. The purpose of this study was to determine if early symptom changes reported in the prehospital period are associated with adverse outcomes.MethodsAdults >21 years of age with non-traumatic chest pain and/or anginal equivalent symptoms transported by ambulance were included. Cardiac symptoms were measured prospectively with the ACS Symptom Checklist, a validated 13-item tool that takes approximately one-minute to complete. Trained EMS personnel administered the ACS Symptom Checklist during ambulance transport (T1) and research specialists measured symptoms again in the ED (T2), after acute triage care was completed. Symptom changes were categorized as an increase, decrease, or both from T1 to T2. Changes in symptoms between T1 and T2 were defined as stable (0-3 symptoms) or dynamic (>4 symptoms). Adverse hospital outcomes included death, reinfarction, and/or new onset heart failure.ResultsTo date, a total of 280 patients presenting to the ED by ambulance with suspected ACS have been enrolled (mean age 60.1 +15.5 years; 51.2% female; 14.3% final diagnosis of ACS). Of 255(91.1%) patients with complete data, 143(51.1%) experienced stable symptoms and 112(40%) experienced dynamic symptoms. Patients with stable changes had significantly higher rates of adverse outcomes compared to patients with dynamic changes (11.9 versus 2.9%, p=0.007). Patients reporting shortness of breath at T1 or T2 were over 4 times likely to experience an adverse event (p=0.003, p=0007).ConclusionsPatients with suspected ACS who have stable symptom changes were more likely to have an adverse hospital outcome. The underlying mechanism of plaque rupture in ACS may account for these differences in symptom characteristics but needs further study.

Background:National stroke campaigns have been implemented to improve stroke knowledge and awareness for the Thai public. Despite these efforts, only a minority of people recognize stroke symptoms and seek treatments within 4.5 hours after symptom onset. Studies reveal sex differences in stroke knowledge, which contributes to delayed treatment-seeking actions.Purpose:This study aimed to examine sex differences in stroke knowledge, symptoms, stroke recognition, and initial action between men and women after experiencing acute strokes.Methods:A cross-sectional study was conducted at three hospitals in Thailand between September and November 2020. Medical record reviews and patient interviews were completed within seven days of admission. Standardized questionnaires for prior stroke knowledge (stroke warning signs & proper actions), clinical manifestation, stroke recognition, first action, and the activation of the emergency medical service (EMS) were used.Results:A total of 170 patients (54% men) with a median age of 63 years were included. Mean scores for prior stroke knowledge were higher in men compared to women (2.97 vs. 2.23, p = .02). Men were more likely than women to identify sudden numbness or weakness and sudden trouble walking or dizziness as stroke warning signs (62% vs. 42%, p = .01; 57% vs. 40%, p = .03, respectively). Women more frequently experienced severe headache (37% vs. 18%, p < .01). No significant differences between men and women were found in stroke recognition (20% vs. 26%) and activation of the EMS system (22% vs. 19%). Seeking support from someone nearby or on the phone was the most frequent first action in men (47%) and women (55%), which often delayed EMS activation.Conclusion:Even though men scored higher in stroke knowledge than women, challenges to activating the EMS were found in both sexes, highlighting the need to explore targeted educational material and knowledge translation among high-risk stroke patients and their relatives, regardless of sex.

Introduction:Despite a notable 32.7% decline in mortality from ischemic heart disease since 1999, the prevalence of stable angina has not decreased. Up to 30% of patients have suboptimal pain relief even though they receive guideline-directed care. The aims of this pilot study were to evaluate preliminary efficacy of a standardized 12-point acupuncture prescription for reduction of pain, and improved functional status and health-related quality of life (HRQoL) for individuals with stable angina.Hypothesis:Acupuncture therapy would result in a reduction in pain and associated symptoms in individuals with stable angina.Methods:We conducted a randomized attention-controlled trial. Participants were enrolled from a predominantly urban minority community. Eligibility criteria included a diagnosis of stable angina for ≥1 month and experiencing symptoms at least once per week. Patients received either the standardized acupuncture protocol, twice a week for 5 weeks, or viewed videos unrelated to pain or heart disease. Outcome variables were measured with the McGill Pain Questionnaire Average Pain Intensity and pain now (at each visit) scales, and the Seattle Angina Questionnaire. Descriptive statistics and multivariable analyses of variance tests were performed.Results:The sample (n=24) had a mean age 59+12 years, was predominantly female (63%), and minority (8% White, 46% Black, 38% Hispanic, and 8% other). At study completion, primary outcomes of average pain intensity, worst pain in the last 24 hours, and pain now, were significantly lower in the acupuncture group. There was a significant improvement in functional status, symptoms, and HRQoL for the acupuncture group (Table).Conclusions:A standardized acupuncture protocol shows promise as a complementary therapy for symptom control for individuals with stable angina who are receiving care in a cardiology clinic which serves urban minorities.

Introduction:Increasing prevalence of multimorbidity (>2 conditions) put individuals, especially older adults, at increased risk for acute coronary syndrome (ACS). Machine learning techniques provide an opportunity to identify clinical factors associated with multimorbidity that may aid in identifying subgroups of multimorbid patients that are at higher risk for ACS. Our primary objective was to use machine learning techniques to identify factors associated multimorbidity in individuals presenting to the emergency department (ED) for potential ACS.Hypothesis:Markers of chronologic and physiologic aging are associated with multimorbidity and vary by functional status and inflammatory profiles.Methods:This was a secondary analysis of data collected from a large multi-site study aimed at characterizing sex differences in symptoms suggestive of ACS in the ED. Variables of interests were measured with the Charlson Comorbidity Index, the Duke Activity Status Index, and serum cytokines (TNF-α, IL-6, and IL-18). A logistic regression model was applied to a sample of 414 patients utilizing a 70/30 test/train split to determine if biomarkers, functional status, sex, and age were associated with multimorbidity.Results:Patients were predominantly male (62.5%), white (73.0%), and had a mean age of 58.9 years. The accuracy of the model in predicting multimorbidity was 86.8% in the training set (n=290). In validation testing, accuracy was 73.0% (n=124). Functional status (OR .960, 95% CI .94-.206, p<0.000), age (OR 1.10, 95% CI 1.04-1.10, p<0.000), and TNF- α (OR 2.21, 95% CI 1.17-4.45, p<0.000), were associated with multimorbidity. The overall model was significant with a χ2(286, N=71.1) = 6, p>0.05. A responder operator curve was run on the individual variables and age, functional status, and TNF- α and showed significant discrimination levels (c-statistic 0.74, 0.73, and 0.65, respectively).Conclusions:Multimorbidity increases the risk for ACS. TNF-α, functional status, and age improved models of ACS risk stratification in a heterogeneous sample of multimorbid patients. Machine learning methodologies exhibit utility in identifying potential clinical markers of multimorbidity.

Introduction:Acute coronary syndrome is a time sensitive condition requiring rapid identification, but nurses only identify 40%-50% of high-risk patients at emergency department (ED) triage. Symptoms are the driving force behind prompt ED care of patients with ACS. Symptom data are recorded as free text in nursing narratives. Standardized extraction of symptoms via natural language processing will create usable clinical data that could be used in predictive analytics, to improve early identification of ACS and ensure life-saving treatments.Hypothesis:The Apache Clinical Text Analysis and Knowledge Extraction System (cTAKES) will recognize symptom concepts in nursing narratives with an acceptable F1 score of greater than or equal to 0.9.Methods:A nurse scientist and a physician annotated 1200 ED nursing narratives of patients with suspicion of ACS for the following symptoms predictive of ACS: chest pain, chest discomfort, shortness of breath, fatigue and sweating. Inter-rater reliability (Cohen’s kappa statistic) was calculated with 10% overlap. cTAKES, which is an open-source natural language processing platform, was applied to extract evidence of the 5 annotated symptoms. Recall (sensitivity), precision (positive predictive value) and F1 score (harmonic mean of precision and recall) were calculated to assess extraction quality for each symptom.Results:Recall, precision and F1 score for each symptom are as follows: chest pain: 0.71, 0.97, 0.823; chest discomfort: 0.6, 0.9, 0.72; fatigue: 0.9, 0.26, 0.41; shortness of breath: 0.93, 0.96, 0.95; and sweating: 0.54, 1, 0.7, respectively. Cohen’s kappa was 0.9.Conclusions:cTAKES had fair results across all 5 ACS predictive symptoms, with shortness of breath meeting our hypothesized F1 score goal. Failure to recognize symptoms at a clinically acceptable value might be due to the linguistic and content variation present in ED nursing initial narratives. Customized natural language processing pipelines trained specifically for ED nursing narratives have significant potential for accurately identifying symptoms and improving early identification of ACS.

Background:Delay in seeking treatment for symptoms of atrial fibrillation (AF) represents a missed opportunity for early treatment that is critical for reducing serious complications of AF such as stroke and heart failure. Delays ranging from a few days to years after symptom onset have been reported. Little is known about the symptom experiences and cognitive behavioral responses that differentiate those who seek treatment early after symptom onset from those who delay treatment-seeking.

Background:The prevalence of atrial fibrillation (AF) is expected to increase 2.5-fold by 2050. As a result, there will be a greater demand for clinicians to provide patient education regarding the nature of AF and its management. Early self-management education is critical to provide patients with knowledge and skills they need to recognize AF, control its progression, and reduce associated complications of stroke and heart failure. Greater understanding of patients’ experiences from symptom onset through initial treatment for AF is needed to guide development of patient centered interventions to promote early effective self-management.