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Objective: The aims of this study were (1) to understand the practice patterns and decision-making factors of physical therapists (PTs) when choosing ankle-foot orthoses (AFOs) or functional electrical stimulation (FES) for patients with mobility deficits secondary to poststroke hemiplegia and (2) to explore perceived gaps in knowledge to inform development of a clinical practice guideline (CPG). Methods: A mixed-methods web-based survey collected quantitative and qualitative data from practicing PTs. Descriptive analysis of quantitative data and thematic content analysis of the qualitative data were completed. Results: The 103 PTs were practicing clinicians with a doctoral degree and specialized board certification. A higher level of confidence with AFOs compared with FES was reported, along with increased inclusion of AFOs compared with FES for assessments and treatments. The PTs considered outcomes across the International Classification of Functioning, Disability and Health (ICF) when choosing devices, noting barriers in access and reimbursement as influential factors in clinical decision making. Fewer than 50% participated in continuing education on AFO or FES. Perceived knowledge gaps and educational needs included assessment and intervention strategies to support clinical decision making. The PTs considered themselves influential in the decision-making process and more than 95% of the respondents replied that a CPG on AFO and FES poststroke would impact clinical practice. Conclusion: Themes related to education, clinical decision-making, access, and reimbursement were identified. A CPG may provide valuable information to address gaps in knowledge to improve clinical practice and decision-making. Clinical Relevance: This research aims to inform the development of a CPG to address needs and gaps in knowledge identified by practicing clinicians. The information gained will inform knowledge translation strategies to promote best practices when implementing AFO and FES to improve activity and participation levels of individuals poststroke. [ABSTRACT FROM AUTHOR]

Objective: To determine the effectiveness of the revised Risk Analysis Index (RAI-rev), administrative Risk Analysis Index (RAI-A), cancer-corrected Risk Analysis Index [RAI-rev (cancer-corrected)], and 5-variable modified Frailty Index for predicting 30-day morbidity and mortality in patients undergoing high-risk surgery. Background: There are several frailty composite measures, but none have been evaluated for predicting morbidity and mortality in patients undergoing high-risk surgery. Methods: Using the National Surgical Quality Improvement Program database, we performed a retrospective study of patients who underwentcolectomy/proctectomy, coronary artery bypass graft (CABG), pancreaticoduodenectomy, lung resection, or esophagectomy from 2006 to 2017. RAI-rev, RAI-A, RAI-rev (cancer corrected), and 5-variable modified Frailty Index scores were calculated. Pearson's chi-square tests and C-statistics were used to assess the predictive accuracy of each score's logistic regression model. Results: In the cohort of 283,545 patients, there were 178,311 (63%) colectomy/proctectomy, 38,167 (14%) pancreaticoduodenectomy, 40,328 (14%) lung resection, 16,127 (6%) CABG, and 10,602 (3%) esophagectomy cases. The RAI-rev was a fair predictor of mortality in the total cohort (C-statistic, 0.71, 95% CI 0.70–0.71, P < 0.001) and for patients who underwent colectomy/proctectomy (C-statistic 0.73, 95% CI 0.72–0.74, P < 0.001) and CABG (C-statistic 0.70, 95% CI 0.68–0.73, P < 0.001), but a poor predictor of mortality in all other operation cohorts. The RAI-A was a fair predictor of mortality for colectomy/proctectomy patients (C-statistic 0.74, 95% CI 0.73– 0.74, P < 0.001). All indices were poor predictors of morbidity. The RAI-rev (cancer corrected) did not improve the accuracy of morbidity and mortality prediction. Conclusion: The presently studied frailty indices are ineffective predictors of 30-day morbidity and mortality for patients undergoing high-risk operations. [ABSTRACT FROM AUTHOR]

Objective: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Summary Background Data: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Methods: Patients undergoing esophagectomy for cancer were identified from the 2007–2013 New York and Florida Healthcare Cost and Utilization Project’s State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18–57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age 71, ECI >4). Results: Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58–71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify independent predictors of hospital readmission for patients undergoing lobectomy for lung cancer. Summary Background Data: Hospital readmission after lobectomy is associated with increased mortality. Greater than 80% of the variability associated with readmission after surgery is at the patient level. This underscores the importance of using a data source that includes detailed clinical information. Methods: Using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD), we conducted a retrospective cohort study of patients undergoing elective lobectomy for lung cancer. Three separate multivariable logistic regression models were generated: the first included preoperative variables, the second added intraoperative variables, and the third added postoperative variables. The c statistic was calculated for each model. Results: There were 39,734 patients from 277 centers. The 30-day readmission rate was 8.2% (n ¼ 3237). In the final model, postoperative complications had the greatest effect on readmission. Pulmonary embolus {odds ratio [OR] 12.34 [95% confidence interval (CI),7.94–19.18]} and empyema, [OR 11.66 (95% CI, 7.31–18.63)] were associated with the greatest odds of readmission, followed by pleural effusion [OR 7.52 (95% CI, 6.01–9.41)], pneumothorax [OR 5.08 (95% CI, 4.16–6.20)], central neurologic event [OR 3.67 (95% CI, 2.23–6.04)], pneumonia [OR 3.13 (95% CI, 2.43–4.05)], and myocardial infarction [OR 3.16 (95% CI, 1.71–5.82)]. The c statistic for the final model was 0.736. Conclusions: Complications are the main driver of readmission after lobectomy for lung cancer. The highest risk was related to postoperative events requiring a procedure or medical therapy necessitating inpatient care. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Level of ambulation following stroke is a long-term predictor of participation and disability. Decreased lower extremity motor control can impact ambulation and overall mobility. The purpose of this clinical practice guideline (CPG) is to provide evidence to guide clinical decision-making for the use of either ankle-foot orthosis (AFO) or functional electrical stimulation (FES) as an intervention to improve body function and structure, activity, and participation as defined by the International Classification of Functioning, Disability and Health (ICF) for individuals with poststroke hemiplegia with decreased lower extremity motor control. Methods: A review of literature published through November 2019 was performed across 7 databases for all studies involving stroke and AFO or FES. Data extracted included time post-stroke, participant characteristics, device types, outcomes assessed, and intervention parameters. Outcomes were examined upon initial application and after training. Recommendations were determined on the basis of the strength of the evidence and the potential benefits, harm, risks, or costs of providing AFO or FES. Results/Discussion: One-hundred twenty-two meta-analyses, systematic reviews, randomized controlled trials, and cohort studies were included. Strong evidence exists that AFO and FES can each increase gait speed, mobility, and dynamic balance. Moderate evidence exists that AFO and FES increase quality of life, walking endurance, and muscle activation, and weak evidence exists for improving gait kinematics. AFO or FES should not be used to decrease plantarflexor spasticity. Studies that directly compare AFO and FES do not indicate overall superiority of one over the other. But evidence suggests that AFO may lead to more compensatory effects while FES may lead to more therapeutic effects. Due to the potential for gains at any phase post-stroke, the most appropriate device for an individual may change, and reassessments should be completed to ensure the device is meeting the individual's needs. Limitations: This CPG cannot address the effects of one type of AFO over another for the majority of outcomes, as studies used a variety of AFO types and rarely differentiated effects. The recommendations also do not address the severity of hemiparesis, and most studies included participants with varied baseline ambulation ability. Summary: This CPG suggests that AFO and FES both lead to improvements post-stroke. Future studies should examine timing of provision, device types, intervention duration and delivery, longer term follow-up, responders versus nonresponders, and individuals with greater impairments. Disclaimer: These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for people with poststroke hemiplegia who have decreased lower extremity motor control that impacts ambulation and overall mobility. A Video Abstract is available as supplemental digital content from the authors (available at: http://links.lww.com/JNPT/A335). [ABSTRACT FROM AUTHOR]

The detrimental effects of prenatal stress on maternal-infant well-being have been well established and highlight increased concern for pregnant African American women. Research supports the notion that positive emotions may have a beneficial impact on the stress process and outcomes. However, the data have been largely restricted to non-African American pregnant women. This study's purpose was to examine potential relationships of both positive (happiness) and negative (stress, anxiety, and depressive symptoms) emotions and pro-inflammatory cytokines (interleukins-1β, -6, -8, -12, -17, tumor necrosis factor, and interferon-γ) in 72 pregnant African American women for a more complete picture of the stress process in this at-risk population. Results of this exploratory secondary data analysis show strong positive correlations between negative emotions and strong negative correlations between happiness and negative emotions. Interleukin-8 was positively correlated with negative emotions and negatively correlated with happiness. Results show mean ratings of negative emotions were higher than previously reported with more heterogeneous samples, while happiness ratings were in the moderate range. Findings suggest that pregnant African American women may experience higher stress and depressive symptoms than women in more heterogeneous samples. However, moderate levels of happiness might contribute to buffering the stress response. [ABSTRACT FROM AUTHOR]

The authors discuss the role of rehabilitation in the provision of palliative care services in the U.S. They describe palliative care as dealing with suffering prevention and improving the patient and their families' quality of life by managing symptoms and providing relief. They suggest that rehabilitation can maintain the physical abilities of a patient and an early integration of it can provide more patient functionality. Other topics include palliative care targets and patient capabilities.

Objective: This study examined potential predictors of nurses' intentions to work during the 2009 influenza A (H1N1) pandemic. Methods: A questionnaire was mailed to a random sample of 1,200 nurses chosen from all RNs and LPNs registered with the Maine State Board of Nursing during the second wave of the flu pandemic. Results: Of the 735 respondents, 90% initially indicated that they intended to work during a flu pandemic. Respondents were significantly more likely to work if provided with adequate personal protective equipment (PPE) but significantly less likely without adequate PPE or if they feared family members could become ill with pandemic flu. They were also significantly less likely to work if assigned to direct care of a flu patient; if a colleague were quarantined for or died of pandemic flu; if they feared their own family members might die of pandemic flu; if they themselves were ill for any reason; if a family member or loved one were sick at home and needed care; if they lacked a written family protection plan; or if certain incentives were offered: antiviral medication or vaccine for nurse and family, double pay, or free room and board at work. About 7% of RNs reported that they would not be willing to work during a flu pandemic, regardless of incentives or other factors. An inverse relationship was found between the perceived level of threat posed by a flu pandemic and nurses' willingness to work. Conclusions: To maintain an adequate nursing workforce during a flu pandemic, employers should ensure that policies and procedures include providing adequate PPE for nurses and safeguarding the health of nurses and their families.The level of perceived threat is likely to affect the proportion of nurses willing to work. Some nurses will not work during a flu pandemic no matter what protections and incentives are offered; efforts intended to force or entice all nurses to work are unlikely to succeed. [ABSTRACT FROM AUTHOR]

The purpose of this phenomenological study was to examine the experiences of mothers of preterm infants during the first 6 months at home following discharge from a neonatal intensive care unit (NICU). A purposeful sample of 8 mothers was gathered and interviews were conducted over a 4-month period. Each interview was audio recorded and took place in the study participant's home or another place of her choosing. Interviews were transcribed verbatim and analyzed independently with themes being identified and organized for each participant. From these analyses, the themes of fear, exhaustion, determination, and thankfulness were identified as being common to all study participants and became the basis for developing the essence of the phenomenon. The essence of this experience for these mothers was their resolve to do whatever was necessary to ensure the best possible outcomes for their infants. The data gathered from these personal interviews will serve to further inform our understanding of this important time from the perspective of those who experienced it, as well as aid in the design of interventions to address the specific needs of these mothers prior to NICU discharge. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study on the development of a classification tree to group hospital patients with acute lung injury based on mortality risk. Factors considered in the creation of classification tree include age, blood urea nitrogen, respiratory rate, shock, and minute ventilation. The prediction error in the training set and the receiver operating characteristic curve of the classification tree is similar to Acute Physiology and Chronic Health Evaluation III.

The article discusses key issues concerning the Impact of Event Scale-Revised (IES-R) questionnaire and its applications in the measurement of the response of patients to trauma. The IES-R questionnaire measures the distress felt by patients due to trauma. Also cited are the issues' implications for nurses and nursing.

The need for mental health interventions in disasters has long been recognized. The Florida Center for Public Health Preparedness (FCPHP) has been providing disaster mental health training to employees of the Florida Department of Health and others since 2001, One of the training programs was Bioterrorism Trauma Intervention Specialist Training (BTIST), offered between May 2003 and January 2004, The FCPHP has also developed three distance learning courses, including one that provides advice to responders who are experiencing compassion fatigue. The BTIST curriculum prepares participants to provide mental health interventions during and following disasters. The four hurricanes that struck Florida in a 7-week period in 2004 created a great demand for mental health services. The FCPHP supported the Florida Department of Health response effort by providing a roster of BTIST trainees and hundreds of copies of the compassion fatigue audio CD. The FCPHP conducted a Web-based survey of the BTIST participants after the hurricanes, A large majority of respondents reported that the training had given them greater knowledge of disaster mental health, provided many disaster mental health skills, and the skills had been valuable in their professional and personal lives. Most of those who had actively responded to the hurricanes indicated that the training had given them confidence for their response and that they had used the acquired skills in their response efforts. [ABSTRACT FROM AUTHOR]

The authors reflect on the fluid management strategy with used to irrigate extravascular lung water (EVLW). They say that the use of EVLW has been important to the reduction in mortality which was impressive especially such trial was performed before the low tidal volume era. They also argue on the use of indexed EVLW for the prediction of body weight not counting the etiology of lung cancer.

Background: Interruptions that occur during clinical nursing care are gaining increased attention with the growing concern for their impact on patient care, patient safety, and the work environment. An interruption can be a distraction or disruption that diverts attention away from the task at hand. In the newborn intensive care unit (NICU), a regularly occurring nursing task is bottle feeding infants. Nursing "presence" is important to best support infants with their emerging oral feeding skills. Interruptions can challenge a nurse's ability to attend to the baby's cues. Purpose: The purpose of this pilot study is 3-fold: (1) to determine the number and type of interruptions that occur during bottle feeding of infants by nursing staff in the NICU; (2) to determine whether certain feeding times of the day are more prone to interruptions; and (3) to describe the nature of interruptions that occur during feeding as reported by nurses. Methods: In this descriptive, exploratory study, a trained observer recorded the number of interruptions, the type of interruptions that occurred during a bottle feeding in the infant's private room. To examine the nurses' perceptions of interruptions, nurses were invited via e-mail to complete a brief electronic survey. A convenience sample of 80 feeding observations was collected, 10 observations for the 8 routine feeding times that occur over 24 hours. Observations occurred with infants more than 32 weeks' gestational age and taking on average more than 30% of the prescribed volume orally. The observation began at the time the nurse approached the infant for feeding and concluded when the feeding was completed and the infant returned to the crib or incubator. Results: Total observation time was 31 hours. There were 795 interruptions across feeding times with 50% occurring during the day shift (9 AM to 3 PM ), 24% during the evening (6 PM and 9 PM ), and 26% occurring at night (12 AM to 6 AM ). Fifty-three percent of interruptions were patient alarms from the nurse's assignment. Ascom phone calls (2.8%), monitor alarms from the buddy nurse (4%), and personal cell phone calls (1.2%) represented the least interruptions. Forty-two nurses completed the electronic survey, with a response rate of 45%. Survey results showed that although some interruptions are necessary (88%) all nurses (100%) agreed that the interruptions can affect the infant's feeding. Interruptions make it hard to concentrate on cues (90.2%), and 71% found it hard to get back to the task after being interrupted. Monitor alarms to their Ascom phone from other babies were considered the most distracting (69%) and the most disruptive to feeding (59.5%). Phone calls and someone coming to the room were considered a "little distracting" (62%). Implications for Practice and Research: Interruptions in care can potentially have a negative impact on an infant's oral feeding and the nursing care associated with feeding. Identifying times more prone to interruptions is important for developing strategies to reduce the frequency and provide uninterrupted care during oral feeding. [ABSTRACT FROM AUTHOR]

A person may suffer debilitating anxiety and other physical and psychological symptoms without recognizing that they're a response to a traumatic event. And older adults in particular may be reluctant to admit to experiencing such symptoms. The Impact of Event Scale--Revised (IES-R) is an easy-to-administer questionnaire used to evaluate the degree of distress a patient feels in response to trauma. It provides a structured way for a patient to communicate distress when she or he may not have the words to do so. For a free online video showing nurses using the IES-R with an older patient, go to http://links.lww.com/A316.