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BackgroundThe combined spinal-epidural (CSE) technique for relief of labour pain offers both rapid onset and superior first-stage analgesia. Nevertheless, the known increased risk for early profound fetal bradycardia (EPFB) following CSE continues to be a concern that often limits its use. The purpose of this study was to determine if giving prophylactic intravenous ephedrine at the time of CSE administration would reduce EPFB.MethodsWe conducted this clinical trial at a large community hospital and enrolled healthy patients requesting epidural analgesia for labour. Patients were randomly assigned to receive either normal saline placebo or ephedrine 10 mg iv at the time of CSE. The primary outcome of EPFB (defined as bradycardia < 90 beats·min(-1) for > two minutes and occurring within the first 30 min after CSE) was compared between groups. The secondary outcomes included the incidence of urgent cesarean delivery, the requirement for additional doses of ephedrine, maternal blood pressure, uterine hypertonus and tachysystole, and abnormal fetal heart rate (FHR) patterns before and after CSE.ResultsThere were 299 women randomized to the ephedrine (EPH) group and 297 randomized to the normal saline placebo (NS) group. There was no difference between groups in the incidence of EPFB (2.7% EPH group vs 4.7% NS group; relative risk, 0.57; 95% confidence interval, 0.24 to 1.33; P = 0.184). There was also no difference between groups in the incidence of urgent cesarean delivery, uterine hypertonus, uterine tachysystole, and abnormal FHR patterns.ConclusionsWe conclude that prophylactic intravenous ephedrine administration at the time of CSE during labour was ineffective at reducing the risk for EPFB associated with CSE. Nevertheless, a lower than expected rate of EPFB resulted in the trial being underpowered. This trial was registered at ClinicalTrials.gov, identifier: NCT02062801.

BackgroundThe current fragmented healthcare system, characterized by a lack of collaborative, patient-centered care processes, creates significant barriers to providing quality patient care. The clinical nurse leader (CNL) is theorized to provide clinical leadership at the point-of-practice to maintain cross-disciplinary collaborative processes that lead to integrated quality care.ObjectivesThe aim of this study was to assess the impact of CNL integration into an acute care microsystem on care quality, as measured by patient satisfaction with care.MethodsA short interrupted time series design was used to measure patient satisfaction with multiple aspects of care 10 months before and 12 months after integration of the CNL role on a progressive care unit, compared with a control unit. Data were obtained from Press Ganey surveys, and analysis was completed using a publicly available program for short time series data streams.ResultsClinical nurse leader implementation was correlated with significantly improved patient satisfaction with admission processes (r = + .63, p = .02) and nursing care (r = +.75, p = .004), including skill level (r = .83, p = .003) and keeping patients informed (r = .70, p = .003). There was no significant correlation with improved patient satisfaction with physician care (r = .31, p = .14) or discharge processes (r = .33, p = .23) postimplementation. Control data showed no significant changes in patient satisfaction measures throughout the study time frame.DiscussionThe positive correlation between CNL-mediated collaborative care processes and improvements in patient satisfaction with care quality provides empirical evidence of outcomes achievable through CNL implementation. Research is needed to explore the full range of achievable outcomes and to determine the specific processes by which these outcomes are realized.

While the use of complementary, alternative and integrative medicine (CAIM) is substantial, it continues to exist at the periphery of allopathic medicine. Understanding the attitudes of medical students toward CAIM will be useful in understanding future integration of CAIM and allopathic medicine. This study was conducted to develop and evaluate an instrument and assess medical students' attitudes toward CAIM. The Complementary, Alternative and Integrative Medicine Attitudes Questionnaire (CAIMAQ) was developed by a panel of experts in CAIM, allopathic medicine, medical education and survey development. A total of 1770 CAIMAQ surveys (51% of US medical schools participated) were obtained in a national sample of medical students in 2007. Factor analysis of the CAIMAQ revealed five distinct attitudinal domains: desirability of CAIM therapies, progressive patient/physician health care roles, mind-body-spirit connection, principles of allostasis and a holistic understanding of disease. The students held the most positive attitude for the "mind-body-spirit connection" and the least positive for the "desirability of CAIM therapies". This study provided initial support for the reliability of the CAIMAQ. The survey results indicated that in general students responded more positively to the principles of CAIM than to CAIM treatment. A higher quality of CAIM-related medical education and expanded research into CAIM therapies would facilitate appropriate integration of CAIM into medical curricula. The most significant limitation of this study is a low response rate, and further work is required to assess more representative populations in order to determine whether the relationships found in this study are generalizable.

Aim. This paper is a report of a study describing nurses‘ practices, knowledge, and attitudes related to evidence-based nursing, and the relation of perceived barriers to and facilitators of evidence-based practice.Background. Evidence-based practice has been recognized by the healthcare community as the gold standard for the provision of safe and compassionate healthcare. Barriers and facilitators for the adoption of evidence-based practice in nursing have been identified by researchers. Healthcare organizations have been challenged to foster an environment conducive to providing care based on evidence.Methods. A descriptive, cross-sectional research study was conducted in 2006-2007 with a convenience sample of 458 nurses at an academic medical center in California (Response rate 44.68%). Two reliable and valid questionnaires were electronically formatted and administered using a secured website. Relationships between responses to the two instruments were examined and results compared with previously published data.Results. Organizational barriers (lack of time and lack of nursing autonomy) were the top perceived barriers. Facilitators were learning opportunities, culture building, and availability and simplicity of resources. Statistically significant correlations were found between barriers and practice, knowledge and attitudes related to evidence-based practice.Conclusion. Similar barriers to the adoption of evidence-based practice have been identified internationally. Educators must work with managers and librarians to address organizational barriers and proactively support evidence-based practice.

BackgroundThe Minnesota Living With Heart Failure Questionnaire (LHFQ) is a commonly used measure of health-related quality of life in persons with heart failure. Researchers have questioned whether LHFQ is sensitive to subtle differences and sufficiently responsive to clinical interventions because the instrument has demonstrated variable performance in clinical trials.ObjectivesA secondary analysis was conducted to assess the LHFQ for sensitivity to different clinical states and responsiveness to varying intensities of clinical intervention.MethodsA convenience sample of nine experimental or quasi-experimental studies from eight clinical sites in the United States yielded data from 1,136 patients with heart failure. Data in the studies had been collected at enrollment and one, three, and/or six months later. Data were analyzed using descriptive, univariate, and multivariate techniques.ResultsTotal and subscale scores on LHFQ were poorer in those with worse New York Heart Association functional class, although there was no difference in LHFQ scores between classes III and IV. No difference in LHFQ scores was found when patients were classified by ejection fraction. Scores improved significantly following hospital discharge, even in those in the control group. Changes in LHFQ scores were greatest in those receiving high intensity interventions.ConclusionsThe LHFQ is sensitive to major differences in symptom severity but may not be sensitive to subtle differences. It is responsive to high intensity interventions. Investigators are cautioned against using this instrument without first maximizing intervention power or without a control group for comparison.

This study measured the effectiveness of a 9 a.m. nutrition break after it had been implemented for 1 academic year at an inner-city high school. Effectiveness was measured by student participation rates, student and teacher evaluations of hunger-associated symptoms experienced by students, and teacher evaluations of the effects on the learning environment. Sixty-nine percent of students participated. The most frequently cited reason for nonparticipation was dislike of the food offered (53%), with an additional 15% citing problems with food distribution. As the frequency of participation rose, the frequency of inability to focus, tiredness, stomachache, headache, and midmorning hunger fell. All of the associations were statistically significant except for headache. Seventy-four percent of staff stated that the nutrition break had positive effects on the learning environment, and 71% referred fewer students to the school nurse. (Contains 5 tables.)

Replies to commentaries on the four-step approach to structural equation modeling, pointing out the strengths and weaknesses of each argument and ultimately concluding that the four-step model is subject to criticisms that can be addressed to factor analysis as well. (SLD)

Focuses on the four-step method (four nested models) of structural equation modeling advocated by S. Mulaik (1997, 1998), discussing the limitations of the approach and considering the tests and criteria to be used in moving among the four steps. (SLD)

* BACKGROUND Clinicians need easy methods of screening for cognitive impairment in patients with heart failure. If correlates of cognitive impairment could be identified, more patients with early cognitive impairment [...]

Abstract Background People overeat because their hunger directs them to consume more calories than they require. The purpose of this study was to analyze the changes in experience and perception of hunger before and after participants shifted from their previous usual diet to a high nutrient density diet. Methods This was a descriptive study conducted with 768 participants primarily living in the United States who had changed their dietary habits from a low micronutrient to a high micronutrient diet. Participants completed a survey rating various dimensions of hunger (physical symptoms, emotional symptoms, and location) when on their previous usual diet versus the high micronutrient density diet. Statistical analysis was conducted using non-parametric tests. Results Highly significant differences were found between the two diets in relation to all physical and emotional symptoms as well as the location of hunger. Hunger was not an unpleasant experience while on the high nutrient density diet, was well tolerated and occurred with less frequency even when meals were skipped. Nearly 80% of respondents reported that their experience of hunger had changed since starting the high nutrient density diet, with 51% reporting a dramatic or complete change in their experience of hunger. Conclusions A high micronutrient density diet mitigates the unpleasant aspects of the experience of hunger even though it is lower in calories. Hunger is one of the major impediments to successful weight loss. Our findings suggest that it is not simply the caloric content, but more importantly, the micronutrient density of a diet that influences the experience of hunger. It appears that a high nutrient density diet, after an initial phase of adjustment during which a person experiences "toxic hunger" due to withdrawal from pro-inflammatory foods, can result in a sustainable eating pattern that leads to weight loss and improved health. A high nutrient density diet provides benefits for long-term health as well as weight loss. Because our findings have important implications in the global effort to control rates of obesity and related chronic diseases, further studies are needed to confirm these preliminary results.