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Purpose: To explore a set of International Classification of Functioning, Disability and Health (ICF) categories that cover the spinal cord injury (SCI) nursing practice in China through a national expert survey., Methods: An internet-based email survey was used. An original set of ICF categories specifically for SCI nursing has been developed from the preliminary studies based on an international perspective. For cultural adaptation in China, a national expert survey was conducted with Chinese experts on SCI nursing to identify the ICF categories that were specifically for SCI nursing in China. The ICF categories which received more than 80% support from the experts would be reported., Results: Twenty-nine Chinese experts on SCI nursing participated. There were 81 ICF categories which received more than 80% agreement among the experts, including 33 Body Functions categories, eight Body Structures, 24 Activities and Participation, six Environmental Factors and 10 Personal Factors items., Conclusions: A set of ICF categories that cover the SCI nursing practice in China was identified. It reflects the main issues that Chinese nurses focus on in caring SCI patients. These categories can facilitate Chinese nurses to use the ICF in multidisciplinary teamwork and improve the participation of nurses in the team. Implications for Rehabilitation In China, nurses lack of an effective model or tool to communicate with the other health professionals in the rehabilitation team for spinal cord injury (SCI) patients. International Classification of Functioning, Disability and Health (ICF) is a tool for multidisciplinary use, which can promote the communication and collaboration in the healthcare team by establishing a common language across different disciplines and sectors. This set of ICF categories developed from this study can serve as a roadmap for important items for use in clinical practice of Chinese SCI nursing.

The cellular microenvironment is extremely complex, and a plethora of materials and methods have been employed to mimic its properties in vitro. In particular, scientists and engineers have taken an interdisciplinary approach in their creation of synthetic biointerfaces that replicate chemical and physical aspects of the cellular microenvironment. Here the focus is on the use of synthetic materials or a combination of synthetic and biological ligands to recapitulate the defined surface chemistries, microstructure, and function of the cellular microenvironment for a myriad of biomedical applications. Specifically, strategies for altering the surface of these environments using self-assembled monolayers, polymer coatings, and their combination with patterned biological ligands are explored. Furthermore, methods for augmenting an important physical property of the cellular microenvironment, topography, are highlighted, and the advantages and disadvantages of these approaches are discussed. Finally, the progress of materials for prolonged stem cell culture, a key component in the translation of stem cell therapeutics for clinical use, is featured.

Students had difficulty integrating leadership and outcomes management skills into their burgeoning novice practice. Further, the Baccalaureate Completion Program for RNs, an online program, expanded student enrollment, which created difficulty in finding enough clinical placements in agencies with staff experienced in leading teams and conducting performance improvement projects. The Leadership and Outcomes Management course was changed from a live clinical agency placement course to a virtual clinical agency experience. Students worked in teams on a virtual quality care delivery case within a virtual health care system. Students selected the case and where they worked within our full-service virtual health system. The virtual health system required interactions with staff, and faculty assumed several roles within the virtual health system as they guided the students through leadership skill development and the creation of a performance improvement system process. It also eliminated the need for live clinical agency placements., (Copyright 2014, SLACK Incorporated.)

Background: Suicide continues to be a leading cause of death globally. Friends and family are considered best positioned to provide initial assistance if someone is suicidal. Expert consensus guidelines on how to do this were published in 2008. Re-developing these guidelines is necessary to ensure they contain the most current recommended helping actions and remain consistent with the suicide prevention literature., Methods: The Delphi consensus method was used to determine the importance of including helping statements in the guidelines. These statements describe helping actions a member of the public can take, and information they should have, to help someone who is experiencing suicidal thoughts. Systematic searches of the available suicide prevention literature were carried out to find helping statements. Two expert panels, comprising 41 suicide prevention professionals and 35 consumer advocates respectively, rated each statement. Statements were accepted for inclusion in the guidelines if they were endorsed by at least 80% of each panel., Results: Out of 436 statements, 164 were endorsed as appropriate helping actions in providing assistance to someone experiencing suicidal thoughts or engaging in suicidal behaviour. These statements were used to form the re-developed guidelines., Conclusion: The re-development of the guidelines has resulted in more comprehensive guidance than the earlier version, with the endorsement of 164 helping actions, compared to 30 previously. These guidelines will form the basis of a suicide prevention course aimed at educating members of the public on providing first aid to someone who is experiencing suicidal thoughts.

Background: Up to 12% of Australian adults and almost one in five adolescents are estimated to have engaged in non-suicidal self-injury (NSSI) at some time in their life. Friends and family are most likely to notice signs of NSSI, but may be unsure how to intervene. Mental health first aid guidelines were developed in 2008 on how to do this through providing initial support and encouraging appropriate professional help-seeking. This study aims to re-develop the 2008 NSSI first aid guidelines to ensure they contain current recommended helping actions and remain consistent with the NSSI intervention literature., Methods: The Delphi consensus method was used to determine the importance of the inclusion of helping statements in the guidelines. These statements describe helping actions a member of the public can take, and information they should have, to help someone who is engaging in NSSI. Systematic searches of the available NSSI intervention literature were conducted to find helping statements. Two expert panels, comprising 28 NSSI professionals and 33 consumer advocates, rated the importance of each statement., Results: 98 out of 220 statements were endorsed as appropriate helping actions in providing assistance to someone engaging in NSSI. These statements were used to form the updated mental health first aid guidelines for NSSI., Conclusion: The re-development of the guidelines has resulted in more comprehensive guidance than the original version (98 versus 30 statements containing helping actions). This substantial increase in endorsed statements adds detail and depth to the guidelines, as well as covers additional ways of providing guidance and support.

Goals: The aims of this study were to determine if the infection rate differs between the first and recurrent ischemic stroke/transient ischemic attack (TIA), if the pattern of the peripheral immune response (PIR) differs between the first and recurrent ischemic stroke/TIA and if infection further influenced the pattern of the PIR., Methods: Retrospective review of 500 stroke cases with strict exclusion criteria (e.g., hemorrhagic stroke, subarachnoid hemorrhage, or spontaneous intracerebral hemorrhage; history of cancer; on steroids or immune suppressive drugs; recent invasive procedure) resulted in inclusion of 198 cases. Independent variables were first stroke or recurrent stroke and not infected or infected cases. Main-effect dependent variables were the white blood cell (WBC) and differential leukocyte counts (percentages of 100 cell counts for neutrophils, lymphocytes, and monocytes and absolute counts of neutrophils, lymphocytes, and monocytes)., Findings: Infection rate was not different between the first versus recurrent stroke (p = .279). The pattern of WBC and differential counts were not different between groups, but addition of the covariate of infection showed group differences (p = .05). A four-group comparison of the dependent variables with the laboratory normal ranges showed lymphocyte percentages below the lower range limit in all four groups. Generalized linear modeling showed a modest rise (15%) in WBC counts in both groups with concomitant infection, a modestly low (-18%) lymphocyte percentage in recurrent stroke with infection, and a more substantial rise (22%-26%) in absolute neutrophil count in both groups with concomitant infection., Conclusions: Infection influences the pattern of the PIR in the first and recurrent stroke/TIA, and this difference can be quantified.

This study used qualitative methods and quantitative statistical analyses to examine whether race and gender are associated with reasons for which adults perceive a situation or object as fearful. The sample consists of 197 African-American and White adults (ages 18-85) recruited through a convenience sample and community sources in the Midwest. A cognitive interviewing instrument was utilized to examine respondents understanding of words and phrases from a mental health instrument. Using qualitative methods, free-response answers were content coded using 5 "fear-codes" (i.e., harm/danger, external locus of control, self-perception, and past experience), developed by the researchers. Results from logistic regression analyses indicate that race significantly predicts usage of specific fear codes (p<.05). In addition, a race by gender interaction was found.

This paper starts a discussion amongst nurse educators internationally regarding the nature of curricula for initial nursing licensure. Nursing is compelled by traditional views of nursing into taking a long-established and expected place in the health care hierarchy, which is reflected in current curricula. In order to establish a re-valued nursing currency within healthcare, nursing educators are required to re-examine these established norms and re-design these curricula, based on the premise that nursing is now set in a complex and unpredictable system., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

For more than a decade, the long wars in Afghanistan and Iraq have placed tremendous and cumulative strain on U.S. military personnel and their families. The high operational tempo, length, and number of deployments-and greater in-theater exposure to threat-have resulted in well-documented psychological health concerns among service members and veterans. In addition, there is increasing and compelling evidence describing the significant deleterious impact of the deployment cycle on family members, including children, in military-connected families. However, rates of engagement and service utilization in prevention and intervention services continue to lag far below apparent need among service members and their families, because of both practical and psychological barriers. The authors describe the dynamic and ultimately successful process of engaging military families with young children in a home-based reintegration program designed to support parenting and strengthen parent-child relationships as service member parents move back into family life. In addition to the integration of existing evidence-based engagement strategies, the authors applied a strengths-based approach to working with military families and worked from a community-based participatory foundation to enhance family engagement and program completion. Implications for engagement of military personnel and their loved ones are discussed.

Immobilization of biomolecules, such as proteins or sugars, is a key issue in biotechnology because it enables the understanding of cellular behavior in more biological relevant environment. Here, poly(4-ethynyl-p-xylylene-co-p-xylylene) coatings have been fabricated by chemical vapor deposition (CVD) polymerization in order to bind bioactive molecules onto the surface of the material. The control of the thickness of the CVD films has been achieved by tuning the amount of precursor used for deposition. Copper-catalyzed Huisgen cycloaddition has then been performed via microcontact printing to immobilize various biomolecules on the reactive coatings. The selectivity of this click chemistry reaction has been confirmed by spatially controlled conjugation of fluorescent sugar recognizing molecules (lectins) as well as cell adhesion onto the peptide pattern. In addition, a microstructured coating that may undergo multiple click chemistry reactions has been developed by two sequential CVD steps. Poly(4-ethynyl-p-xylylene-co-p-xylylene) and poly(4-formyl-p-xylylene-co-p-xylylene) have been patterned via vapor-assisted micropatterning in replica structures (VAMPIR). A combination of Huisgen cycloaddition and carbonyl-hydrazide coupling was used to spatially direct the immobilization of sugars on a patterned substrate. This work opens new perspectives in tailoring microstructured, multireactive interfaces that can be decorated via bio-orthogonal chemistry for use as mimicking the biological environment of cells.

Background. The age at which most young people are in tertiary education is also the age of peak onset for mental illness. Because mental health problems can have adverse effects on students' academic performance and welfare, institutions require guidance how they can best provide support. However, the scientific evidence for how best to do this is relatively limited. Therefore a Delphi expert consensus study was carried out with professional and consumer experts. Methods. A systematic review of websites, books and journal articles was conducted to develop a 172 item survey containing strategies that institutions might use to support students with a mental illness. Two panels of Australian experts (74 professionals and 35 consumers) were recruited and independently rated the items over three rounds, with strategies reaching consensus on importance written into the guidelines. Results. The overall response rate across three rounds was 83% (80% consumers, 85% professionals). 155 strategies were endorsed as essential or important by at least 80% of panel members. The endorsed strategies provided information on policy, measures to promote support services, service provision, accessibility of support services, relationships between services, other types of support and issues associated with reasonable adjustments. They also provided guidance on the procedures the institutions should have for making staff aware of issues associated with mental illness, mental illness training, support for staff and communicating with a student with a mental illness. They also covered student rights and responsibilities, the procedures the institutions should have for making students aware of issues associated with mental illness, dealing with mental health crises, funding and research and evaluation. Conclusions. The guidelines provide guidance for tertiary institutions to assist them in supporting students with a mental illness. It is hoped that they may be used to inform policy and practice in tertiary institutions.

Current practices to maintain human pluripotent stem cells (hPSCs), which include induced pluripotent stem cells and embryonic stem cells, in an undifferentiated state typically depend on the support of feeder cells such as mouse embryonic fibroblasts (MEFs) or an extracellular matrix such as Matrigel. Culture conditions that depend on these undefined support systems limit our ability to interpret mechanistic studies aimed at resolving how hPSCs interact with their extracellular environment to remain in a unique undifferentiated state and to make fate-changing lineage decisions. Likewise, the xenogeneic components of MEFs and Matrigel ultimately hinder our ability to use pluripotent stem cells to treat debilitating human diseases. Many of these obstacles have been overcome by the development of synthetic coatings and bioreactors that support hPSC expansion and self-renewal within defined culture conditions that are free from xenogeneic contamination. The establishment of defined culture conditions and synthetic matrices will facilitate studies to more precisely probe the molecular basis of pluripotent stem cell self-renewal and differentiation. When combined with three-dimensional cultures in bioreactors, these systems will also enable large-scale expansion for future clinical applications., (Copyright © 2012 AlphaMed Press.)

Background: The scientific literature on stigma has been confused because there are multiple components of stigma with different correlates. In order to help make sense of this confusion, the present review focuses on research on one of the most commonly measured components - belief in dangerousness., Method and Results: The review examines: measurement of belief in dangerousness; prevalence of belief in dangerousness; characteristics of people who believe in dangerousness; experiences associated with belief in dangerousness; characteristics of people that elicit belief in dangerousness; the effects of psychiatric labelling; the effects of causal explanations; interventions to reduce belief in dangerousness; and effects on help-seeking., Conclusion: It is concluded that future research needs to focus on rigorous evaluation of interventions to reduce belief in dangerousness and the impact of this belief on people affected by mental disorders.

Aim: Most young people fail to receive professional treatment for mental disorders; however, they do indicate a preference for sharing problems with peers. This article describes key messages about knowledge and actions to form the basis of a basic mental health first aid (MHFA) course for adolescents to increase recognition of and help seeking for mental health problems by teaching the best knowledge and helping actions a young person can undertake to support a peer with a mental health problem., Methods: The Delphi method was used to achieve consensus among Australian and Canadian youth mental health experts regarding the importance of statements that describe helping actions a young person can take, and information they should have, to support a friend with a mental health problem. There were two expert panels, one consisting of 36 youth mental health consumer advocates and the other of 97 Youth MHFA instructors. Panellists rated each statement according to how appropriate it would be as a basic mental health first aid message for both a junior adolescent (12-15 years) and a senior adolescent (16-18 years)., Results: Out of 98 statements, 78 were endorsed as key basic MHFA messages for junior adolescents and 81 were endorsed for senior adolescents., Conclusion: The study has identified key messages for adolescents on how they can help a peer. These messages will form the basis of the curriculum for an MHFA course for adolescents, which will aim to facilitate early recognition of and help seeking for mental health problems in adolescents., (© 2012 Blackwell Publishing Asia Pty Ltd.)

Human-induced pluripotent stem cells (hiPSCs) may represent an ideal cell source for research and applications in regenerative medicine. However, standard culture conditions that depend on the use of undefined substrates and xenogeneic medium components represent a significant obstacle to clinical translation. Recently, we reported a defined culture system for human embryonic stem cells using a synthetic polymer coating, poly[2-(methacryloyloxy)ethyl dimethyl-(3-sulfopropyl)ammonium hydroxide] (PMEDSAH), in conjunction with xenogeneic-free culture medium. Here, we tested the hypothesis that iPSCs could be maintained in an undifferentiated state in this xeno-free culture system and subsequently be differentiated into mesenchymal stem cells (iPS-MSCs). hiPSCs were cultured on PMEDSAH and differentiated into functional MSCs, as confirmed by expression of characteristic MSC markers (CD166+, CD105+, CD90+,CD73+, CD31-, CD34-, and CD45-) and their ability to differentiate in vitro into adipogenic, chondrogenic, and osteoblastic lineages. To demonstrate the potential of iPS-MSCs to regenerate bone in vivo, the newly derived cells were induced to osteoblast differentiation for 4 days and transplanted into calvaria defects in immunocompromised mice for 8 weeks. MicroCT and histologic analyses demonstrated de novo bone formation in the calvaria defects for animals treated with iPS-MSCs but not for the control group. Moreover, positive staining for human nuclear antigen and human mitochondria monoclonal antibodies confirmed the participation of the transplanted hiPS-MSCs in the regenerated bone. These results demonstrate that hiPSCs cultured in a xeno-free system have the capability to differentiate into functional MSCs with the ability to form bone in vivo., (Copyright © 2012 AlphaMed Press.)

The prevailing model of care for psychiatric patients in the emergency room (ER) is evaluation and disposition, with little or no treatment provided. This article describes the results of a pilot study of a family-based crisis intervention (FBCI) for suicidal adolescents and their families in a large, urban pediatric ER. FBCI is an intervention designed to sufficiently stabilize patients within a single ER visit so that they can return home safely with their families. Of the 100 suicidal adolescents and their families in the sample, 67 met eligibility criteria for FBCI. Demographic and clinical characteristics and disposition outcomes from the sample were compared with those obtained retrospectively from a matched comparison group (N = 150). Statistical analyses compared group inpatient admission rates and disposition outcomes. Patients in the pilot cohort were significantly less likely to be hospitalized than were those in the comparison group (36 percent versus 55 percent). Only two of the patients in the FBCI cohort were hospitalized immediately after receiving the intervention during their ER visit. FBCI with suicidal adolescents and their families during a single ER visit is feasible and safely limits the need for inpatient psychiatric hospitalization, thereby avoiding disruption of family, academic, and social activities and increasing use of less intrusive and more cost-effective psychiatric treatment.

The cellular environment impacts a myriad of cellular functions by providing signals that can modulate cell phenotype and function. Physical cues such as topography, roughness, gradients, and elasticity are of particular importance. Thus, synthetic substrates can be potentially useful tools for exploring the influence of the aforementioned physical properties on cellular function. Many micro- and nanofabrication processes have been employed to control substrate characteristics in both 2D and 3D environments. This review highlights strategies for modulating the physical properties of surfaces, the influence of these changes on cell responses, and the promise and limitations of these surfaces in in-vitro settings. While both hard and soft materials are discussed, emphasis is placed on soft substrates. Moreover, methods for creating synthetic substrates for cell studies, substrate properties, and impact of substrate properties on cell behavior are the main focus of this review., (Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Objectives: Patients who present to the emergency department (ED) and require psychiatric hospitalization may wait in the ED or be admitted to a medical service because there are no available inpatient psychiatric beds. These patients are psychiatric "boarders." This study describes the extent of the boarder problem in a large, urban pediatric ED, compares characteristics of psychiatrically hospitalized patients with boarders, and compares predictors of boarding in 2 ED patient cohorts., Methods: A retrospective cohort study was conducted in 2007-2008. The main outcome measure was placement into a psychiatric facility or boarding. Predictors of boarding in the present analysis were compared with predictors from a similar study conducted in the same ED in 1999-2000., Results: Of 461 ED patient encounters requiring psychiatric admission, 157 (34.1%) boarded. Mean and median boarding duration for the sample were 22.7(SD, 8.08) and 21.18 hours, respectively. Univariate generalized estimating equations demonstrated increased boarding odds for patients carrying Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of autism, mental retardation, and/or developmental delay (P = 0.01), presenting during the weekend (P = 0.03) or presenting during months without school vacation (P = 0.02). Suicidal ideation (SI) significantly predicted boarding status, with increased likelihood of boarding for severe SI (P = 0.02). Age, race, insurance status, and homicidal ideation did not significantly predict boarding in the 2007-2008 patient cohort, although they did in the earlier study. Systemic factors and SI predicted boarding status in both cohorts., Conclusions: Suicidal patients continue to board. Limits within the system, including timing of ED presentation and a dearth of specialized services, still exist, elevating the risk of boarding for some populations. Implications for pediatric ED psychiatric care delivery are discussed.

Biomolecular interactions between proteins and synthetic surfaces impact diverse biomedical fields. Simple, quantitative, label-free technologies for the analysis of protein adsorption and binding of biomolecules are thus needed. Here, we report the use of a novel type of substrate, poly-p-xylylene coatings prepared by chemical vapor deposition (CVD) polymerization, for surface plasmon resonance enhanced ellipsometry (SPREE) studies and assess the reactive coatings as spatially resolved biomolecular sensing arrays. Prior to use in binding studies, reactive coatings were fully characterized by Fourier transform infrared spectroscopy, electrochemical impedance spectroscopy, and ellipsometry. As a result, the chemical structure, thickness, and homogeneous coverage of the substrate surface were confirmed for a series of CVD-coated samples. Subsequent SPREE imaging and fluorescence microscopy indicated that the synthetic substrates supported detectable binding of a cascade of biomolecules. Moreover, analysis revealed a useful thickness range for CVD films in the assessment of protein and/or antigen-antibody binding via SPREE imaging. With a variety of functionalized end groups available for biomolecule immobilization and ease of patterning, CVD thin films are useful substrates for spatially resolved, quantitative binding arrays.

Young children (birth through 5 years of age) are disproportionately represented in U.S. military families with a deployed parent. Because of their developmental capacity to deal with prolonged separation, young children can be especially vulnerable to stressors of parental deployment. Despite the resiliency of many military families, this type of separation can constitute a developmental crisis for a young child. Thus, the experience may compromise optimal child growth and development. This article reviews what is known about the effects of the military deployment cycle on young children, including attachment patterns, intense emotions, and behavioral changes and suggests an ecological approach for supporting military families with infants, toddlers, and preschoolers. Specifically, home-based family focused interventions seem to warrant the most serious consideration., (© 2010 American Orthopsychiatric Association.)

Objective: Cardiogenic shock is a major cause of death in ST elevation myocardial infarction. We investigated whether determination of plasma [corrected] B-type natriuretic peptide and the N-terminal fragment of its pro-hormone in the acute phase of ST elevation myocardial infarction could identify patients prone to development of cardiogenic shock., Design: Retrospective analysis of a multicenter, randomized open-label trial (ASSENT-4 PCI; ClinicalTrials.gov Identifier: NCT00168792)., Methods: Plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone were determined in available stored samples of 1016 ST elevation myocardial infarction patients without signs of cardiogenic shock at randomization to primary percutaneous coronary intervention or to full-dose tenecteplase before percutaneous coronary intervention. The end point of the present analysis was in-hospital cardiogenic shock., Interventions: None., Measurements and Main Results: In total, 57 (5.6%) patients had cardiogenic shock during index hospitalization. In-hospital cardiogenic shock increased precipitously with higher baseline concentrations of plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone (B-type natriuretic peptide and the N-terminal fragment of its pro-hormone < or =67 pg/mL: 1.9%; 68-1482 pg/mL: 5.9%; >1482 pg/mL: 14.9%; p < .001). Higher plasma [corrected] B-type natriuretic peptide and the N-terminal fragment of its pro-hormone concentrations were predictors of in-hospital shock, especially among those patients with relatively low clinical risk (no requirement of inotropic support before angiography, systolic blood pressure >100 mm Hg, heart rate <100 bpm, Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries score of <122). In multivariate Cox regression analysis, higher plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone concentrations remained significant predictors of shock, in addition to age, systolic blood pressure, heart rate, and randomization to facilitated percutaneous coronary intervention and Killip classification. Furthermore, plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone significantly predicted in-hospital shock independently of the validated Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries score (p = .014)., Conclusion: Plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone concentrations measured early in the acute phase of ST elevation myocardial infarction are useful in predicting the development of in-hospital cardiogenic shock.

Background: We investigated the prognostic significance of plasma N-terminal fragment of the prohormone B-type natriuretic peptide (Nt-proBNP) concentrations in addition to time to reperfusion and Thrombolysis in Myocardial Infarction (TIMI) flow before and after coronary intervention in patients with ST elevation myocardial infarction (STEMI) from the database of the Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT IV-PCI) trial., Methods: Plasma Nt-proBNP was available in 1,037 patients with STEMI. Patients were randomized either to primary (p-PCI) or to full-dose tenecteplase before PCI (f-PCI).The study end point was the composite of death, cardiogenic shock, or congestive heart failure at 90 days., Results: According to classification tree analysis, patients with Nt-proBNP levels >694 pg/mL had the highest primary end point rates (33.8% vs 11%, P < .001). In Cox regression analysis, Nt-proBNP >694 pg/mL strongly predicted 90-day survival even among patients with short treatment delay (f-PCI < or =3 hours: hazard ratio [HR] 2.63, P = .002 and p-PCI < or =3 hours: HR 4.87, P < .001, respectively). Patients with TIMI 3 flow after coronary intervention were at significantly higher risk of the primary end point if admission Nt-proBNP exceeded 694 pg/mL (f-PCI: HR 2.88, P < .001 and p-PCI: HR 3.84, P < .001, respectively). In multivariable analysis, Nt-proBNP >694 pg/mL significantly (P = .001) predicted 90-day survival in addition to age (P < .001), TIMI flow after PCI (P < .001), body mass index (P = .026), anterior wall infarction (P = .035), and systolic blood pressure at randomization (P = .036), respectively., Conclusion: Elevated plasma concentrations of Nt-proBNP in the early phase of STEMI determine in-hospital and 90-day outcome after infarction irrespective of time to treatment and pre- or postinterventional TIMI flow., (Copyright 2010 Mosby, Inc. All rights reserved.)

Objectives: We have performed a retrospective analysis of the data stratified by time to treatment and by enrollment site: percutaneous coronary intervention hospitals (PCIH), nonpercutaneous coronary intervention hospitals (NoPCIH), or in a pre-hospital setting (PreH)., Background: The ASSENT-4 PCI (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention) trial intended to test the hypothesis that in ST-segment elevation myocardial infarction (STEMI) patients an upfront fibrinolytic bolus before PCI ("facilitated PCI") compared with primary PCI would benefit STEMI patients facing a long pre-PCI delay., Methods: Seven hundred forty-nine patients (45%) presented directly to PCIH, 578 (34%) presented to NoPCIH, and 334 (20%) were randomized and initially treated in the PreH setting., Results: Patients in the PreH-facilitated group had the shortest delays (pain-to-fibrinolytic treatment 125 min) and the lowest 90-day mortality (3.1%). Among patients randomized to primary PCI, the shortest time from pain to first balloon was similarly in the PreH group (223 min). They had the lowest mortality of the primary PCI patient groups (4.1%). The highest mortality (8.4%) was in patients presenting to a PCIH and assigned to the facilitated strategy. Their pain-to-lysis time was 174 min and pain-to-PCI time 266 min (or 92 min after lysis)., Conclusions: Few patients fit the target population, long delays to PCI for whom facilitated PCI was designed. Patients treated early after pain onset in the PreH setting do well after a facilitated approach. Despite limitations of post hoc subgroup analysis, these observations suggest caution in extrapolating the results of the ASSENT-4 trial to the "real world" where many patients might have potentially short pain-to-fibrinolysis time but are facing a long transport time to primary PCI.

Preparing undergraduate nursing students to practice nursing in the 21st century requires a focus on the development of evidence-based practice and outcomes management knowledge and skills throughout the nursing curriculum. To this end, seven learning activities were created that spiral and increase in complexity while building on previously acquired skills. Working in teams and practicing team-building techniques, students learned how to develop a clinical question, search the literature, synthesize the current knowledge, identify the significance of the issue in an ecological model, decipher existing quality data and compare that data to national benchmarks, investigate a health care quality issue using quality improvement methods, and draft a proposal for implementation of a continuous quality improvement initiative. Work was presented in both written and oral presentation formats, with emphasis on engaging various audiences in a compelling health care issue.

Understanding referral patterns to chaplains is essential not only to ensure proper patient treatment, but also to assist chaplains seeking to expand the range of patient situations in which they are called to intervene. Information about more than 58,000 chaplain visits was documented during the first two years (2005-2006) of the Metropolitan Chaplaincy Study. Data from 15,655 of these visits, which were made in response to referrals (26.9% of all visits), were analyzed in the present study. Seventy-eight percent of referral requests were met within the same day, and 94.9% of requests and were met within 2 days. Nurses were the most frequent source of referrals to chaplains (45.0%), followed by self-referrals from patients or requests from their family members (30.3%), with the remainder coming from a variety of hospital disciplines. The most common reason for referrals was that patients requested to see a chaplain. Other relatively common reasons for referrals were problems or issues related to illness or treatment, and end-of-life issues, concerns about death and the death of patients, with reasons for referrals differing by referral source. The most common reason for referrals among professional staff was that patients were feeling bad or in pain, followed by medical issues, and end-of-life issues. Patient and family referrals usually involved positive patient affect, whereas staff referrals usually involved negative patient affect.

The current study analyzes data from 30,995 chaplain visits with patients and families that were part of the New York Chaplaincy Study. The data were collected at 13 healthcare institutions in the Greater New York City area from 1994-1996. Seventeen chaplain interventions were recorded: nine that were religious or spiritual in nature, and eight that were more general or not specifically religious. Chaplains used religious/spiritual interventions, alone or in conjunction with general interventions, in the vast majority of their visits with patients and families. The types of interventions used varied by the patient's medical status to some degree, but the pattern of interventions used was similar across faith group and medical status. The results document the unique role of the chaplain as a member of the healthcare care team and suggest there is desire among a broad range of patients, including those who claim no religion, to receive the kind of care chaplains provide.

Clinical Pastoral Education (CPE) is experiential learning of the art and science of pastoral care. CPE students increase capacities in psychological strengths such as self-awareness and empathy, and improve skills in interpersonal and inter-professional relationships. Previous research has documented different kinds of change and experiences for students depending on the length of the CPE unit (short/intensive vs. long/extended). The current study involves CPE students who have taken either an intensive unit or an extended unit and compares the average amount of change in pastoral skills, emotional intelligence, self-reflection, and insight while controlling for the influence of social desirability. Intensive and extended unit students were different from each other in terms of age and experience, beginning level of pastoral skill, and amount of change in the measured abilities. Limitations and strengths of this study and the need for future research are discussed.

The peripheral inflammatory response, as a proxy for the acute-phase response (a known mechanism for ischemic preconditioning), and non-damage-producing transient ischemia must exist together in humans if this candidate mechanism confers ischemic tolerance. The present study was aimed at determining whether the peripheral inflammatory response (ie, elevated white blood cell, neutrophil, and monocyte counts) exists in transient ischemic attack (TIA) and stroke patients at the time of emergency room admission. The null hypothesis was tested for the variables of the peripheral inflammatory response between the mean of the laboratory normal population versus stroke and TIA patients. A retrospective review of 1041 medical records yielded 12 first-time TIA patients and 34 first-time stroke patients with no confounding evidence of other inflammatory processes. In both groups, neutrophil and monocyte percentages were significantly higher than the laboratory means (in TIA cases: neutrophils, 67.9% [12.67%], P = .001; monocytes, 8.2% [2.7%], P = .020; in stroke cases: neutrophils, 64.9% [9.1%], monocytes, 7.7% [1.6%]; both P < .001). Absolute neutrophil count was significantly higher than the laboratory mean for the stroke cases (5.13 [1.88] K/UL; P = .022). Lymphocyte percentages and absolute lymphocyte count in both groups were significantly and abnormally lower than the laboratory mean (in TIA cases, 21.7% [10.5%] and 1.4 [0.6] K/UL, respectively; in stroke cases, 24.7% [8.4%] and 1.9 [0.7] K/UL, respectively; all P

We developed a regional strategy to decrease the time to percutaneous coronary intervention (PCI) for patients with acute ST-segment elevation myocardial infarction (STEMI). Protocols were created for paramedics and referring hospitals to identify and directly triage all patients with STEMI to a single PCI center. Time to PCI reperfusion and in-hospital mortality were assessed in 233 consecutive patients with STEMI. Ninety-minute initial hospital door-to-patent infarct artery was achieved in 58.3% of paramedic-diagnosed and directly triaged patients compared with 37.5% of "walk-ins" to the PCI hospital and with only 5.2% of those transferred from another hospital emergency department (ED; p <0.001). Overall in-hospital mortality was 2.1%, 0% in paramedic identified patients, and 0% in those walk-ins to the PCI hospital ED compared with 4.3% for those transferred from a referring hospital ED (p = 0.007). Paramedic diagnosis of STEMI and direct triage to a prealerted interventional hospital for primary PCI was associated with a high percentage of patients achieving <90-minute infarct artery patency. Substantial delays remained for those who presented initially to a non-PCI hospital ED despite the expedited protocol. In conclusion, this observational study suggests that wider use of paramedic electrocardiographic STEMI diagnosis and direct triage to a prealerted PCI hospital catheterization team may help improve outcomes of patients with STEMI.

Aims: The purpose of this analysis was to determine whether the efficacy of adenosine vs. placebo was dependent on the timing of reperfusion therapy in the second Acute Myocardial Infarction Study of Adenosine (AMISTAD-II)., Methods and Results: Patients presenting with ST-segment elevation anterior AMI were randomized to receive placebo vs. adenosine (50 or 70 microg/kg/min) for 3 h starting within 15 min of reperfusion therapy. In the present post hoc hypothesis generating study, the results were stratified according to the timing of reperfusion, i.e. > or = or < the median 3.17 h, and by reperfusion modality. In patients receiving reperfusion < 3.17 h, adenosine compared with placebo significantly reduced 1-month mortality (5.2 vs. 9.2%, respectively, P = 0.014), 6-month mortality (7.3 vs. 11.2%, P = 0.033), and the occurrence of the primary 6-month composite clinical endpoint of death, in-hospital CHF, or rehospitalization for CHF at 6 months (12.0 vs. 17.2%, P = 0.022). Patients reperfused beyond 3 h did not benefit from adenosine., Conclusion: In this post hoc analysis, 3 h adenosine infusion administered as an adjunct to reperfusion therapy within the first 3.17 h onset of evolving anterior ST-segment elevation AMI enhanced early and late survival, and reduced the composite clinical endpoint of death or CHF at 6 months.

Objectives: The purpose of this research was to determine the effect of intravenous adenosine on clinical outcomes and infarct size in ST-segment elevation myocardial infarction (STEMI) patients undergoing reperfusion therapy., Background: Previous small studies suggest that adenosine may reduce the size of an evolving infarction., Methods: Patients (n = 2,118) with evolving anterior STEMI receiving thrombolysis or primary angioplasty were randomized to a 3-h infusion of either adenosine 50 or 70 microg/kg/min or of placebo. The primary end point was new congestive heart failure (CHF) beginning >24 h after randomization, or the first re-hospitalization for CHF, or death from any cause within six months. Infarct size was measured in a subset of 243 patients by technetium-99m sestamibi tomography., Results: There was no difference in the primary end point between placebo (17.9%) and either the pooled adenosine dose groups (16.3%) or, separately, the 50-microg/kg/min dose and 70-microg/kg/min groups (16.5% vs. 16.1%, respectively, p = 0.43). The pooled adenosine group trended toward a smaller median infarct size compared with the placebo group, 17% versus 27% (p = 0.074). A dose-response relationship with final median infarct size was seen: 11% at the high dose (p = 0.023 vs. placebo) and 23% at the low dose (p = NS vs. placebo). Infarct size and occurrence of a primary end point were significantly related (p < 0.001)., Conclusions: Clinical outcomes in patients with STEMI undergoing reperfusion therapy were not significantly improved with adenosine, although infarct size was reduced with the 70-microg/kg/min adenosine infusion, a finding that correlated with fewer adverse clinical events. A larger study limited to the 70-microg/kg/min dose is, therefore, warranted.

In December 2002, the National Cholesterol Education Program published its third expert panel report on the detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Since then, many new studies suggest that a more aggressive approach should be taken in cholesterol therapy. Based on these new clinical trials, the National Cholesterol Education Program published recommended modifications to the Adult Treatment Panel III guidelines in July 2004. There is good evidence to support the proposed modifications to Adult Treatment Panel III, but there is still much uncertainty in many patient subsets. More evidence is necessary to clarify if current treatment guidelines and low-density lipoprotein cholesterol goals are optimal for all patients within each risk category. These guidelines, and the proposed modifications, should be used as a tool to guide therapy that should be tailored to fit the overall risk assessment and needs of the individual patient.

Acute pericarditis is a common disease that typically is diagnosed on the basis of its classic chest pain, pericardial friction rub, and changes on ECG. Although most cases are idiopathic and self-limited, numerous causes should be considered. The diagnostic yield of extensive laboratory evaluation and pericardiocentesis is very low, and invasive procedures should be limited to patients in whom therapeutic intervention is necessary. Treatment should focus on symptomatic relief, usually through use of NSAIDs, and patients should be carefully evaluated and monitored for common complications of the disease.

Background: There is good evidence of reduced prescribing of antibiotics in recent years, but the reason for this has not been established., Aim: To study the incidence of respiratory tract infections presenting to general practitioners (GPs) in England and Wales in relation to the incidence of other infections and to the prescription of antibiotics., Setting: Sentinel practices in England and Wales who contribute to the Weekly Returns Service (WRS) of the Royal College of General Practitioners., Design: Time-series analysis of disease incidence data reported by the practices and of antibiotic prescription data from the Prescription Pricing Authority (PPA) during the years 1994-2000., Method: Incidence data reported weekly from 73 practices in England and Wales, serving a population of 600,000, for acute respiratory tract infections, otitis media, infectious mononucleosis, shingles, urinary tract infections, and skin infections, were consolidated into quarterly datasets and examined graphically for evidence of secular and seasonal trends. Trends in antibiotic prescription items (data for England only were supplied by the PPA) were examined for association after adjustment for seasonal variation., Results: The incidence of respiratory tract infections and antibiotic prescribing showed virtually identical seasonal variation, with both declining from 1995: respiratory tract infections by 48% in winter and 38% in summer, and antibiotic prescriptions by 34% and 21%, respectively. Trends in both were very highly correlated. The incidence of shingles and skin infections was constant. The incidence of urinary tract infections declined by 10%. The incidence of otitis media in children and acute bronchitis in the elderly followed the all-age trend in the reduction of respiratory tract infections., Conclusion: The considerable reduction in the incidence of respiratory tract infections between 1995 and 2000 is the main reason for the decline in antibiotic prescribing rather than changing prescribing thresholds for antibiotics.

Background: There is a nationally established mechanism for surveillance of accidents operating in a sample of accident and emergency (A&E) departments but no equivalent in primary care. Reduction of accidents presenting to hospitals or family doctors is a target set out in the Department of Health's Our Healthier Nation document., Aims: To assess the merit and feasibility of collecting information on accidents in primary care, and documentation of the range and severity of accidents presenting., Design of Study: General practitioner (GP) reports following accidents to persons presenting to primary care., Setting: GPs in six large practices in the Midlands (69,000 registered patients) completed questionnaires for 1233 persons sustaining accidents at home or during leisure activity during one year from September 1997., Results: Main outcome measures were validation of results and description of the type of accidents presenting to primary care. Recruitment varied considerably between practices, but it was not possible for this to be validated, chiefly because of the limitations of morbidity coding systems. Overall, 18 per 1000 registered persons a year reported an accident initially to the GP, approximately one-sixth of the number presenting to A&E departments. Nine-tenths of the injuries reported were trivial or minor. There were similarities between GP and A&E patients concerning the mechanism or location of injury, but proportionately more elderly and females presented to primary care., Conclusions: Surveillance of accidents in primary care is possible, but the discipline required for reliable data capture is considerable and hindered by limitations of morbidity coding systems regarding accidents. However, there are important differences in terms of the types of accidents and injuries seen and the age and sex of persons presenting in primary care and A&E departments.

The clinically available IIb/IIIa antagonists have been studied in small angiographic trials of patients who receive these adjuncts combined with reduced doses of fibrinolytics for the purpose of evaluating their impact on infarct artery patency restoration in acute myocardial infarction. Larger clinical endpoint trials have then looked at some of these combinations, particularly with abciximab, to characterize mortality, morbidity and adverse event frequencies when compared with more traditional full dose fibrinolytic therapy. Similarly these agents have been evaluated (without fibrinolytics) for their potential to improve the results of mechanical reperfusion techniques. This article will summarize these experiences in terms of benefits and adverse events. The value of these drugs in STEMI seems modest at best.

Experimental verification of the ability to alter the sensitivity to fluorophore layers in turbid media by varying illumination-collection geometry is presented. Fiber-optic probes and two-layer, fluorophore-doped, turbid phantoms are used to elucidate the roles of spot size, illumination-collection fiber separation, and probe-sample spacing. Variations in single- and multiple-fiber probe design parameters produce significant changes in the relative sensitivity to sample layers in a manner that agrees with prior computational studies.

Objectives: The purpose of this study was to quantify the effect of time delays to reperfusion on ventricular function after myocardial infarction. This allows one to identify a group of patients in whom a strategy using antecedent pharmacologic reperfusion therapy before planned direct angioplasty may offer significant benefit., Background: Direct angioplasty for myocardial infarction is associated with a high rate of successful reperfusion compared with pharmacologic reperfusion. However, there is an inherent time delay to treatment with angioplasty compared with pharmacologic therapy. There currently are insufficient data to determine the consequences of incremental time delays to reperfusion on ventricular function., Methods: We determined, by logistic regression analysis, the probability of observing a decrement in postmyocardial infarction ventricular function as a function of incremental time delays to reperfusion., Results: Time delays of 30, 60, 90, or 120 minutes to reperfusion increased the likelihood of a worse ventricular function outcome by 1.1-, 1.3-, 1.5-, and 1.7-fold, respectively (P <.02). The upper 95% confidence limits around these odds ratios are as high as 1.3 or 2.7 for 30- and 120-minute delays, respectively. Time from symptom onset to patency remained a significant determinant of ventricular function after adjustment for clinical and procedural factors., Conclusions: Delay in time to reperfusion, measured in minutes, results in significant loss of ventricular function after myocardial infarction. Interventional strategies designed for treatment of myocardial infarction when "door-to-balloon" time is expected to exceed 60 minutes should strongly consider incorporation of pharmacologic reperfusion therapy into the therapeutic paradigm.

In the treatment of acute myocardial infarction, delayed reperfusion therapy is associated with increased mortality. Predictors of delay have been described for fibrinolysis but not for primary percutaneous transluminal coronary angioplasty (pPTCA). Therefore, we studied 40,017 consecutive patients with acute myocardial infarction who underwent pPTCA in the National Registry of Myocardial Infarction between June 1994 and April 2000. Median door-to-balloon times were calculated, and factors independently associated with a delay of >120 minutes were determined by logistic regression. The median door-to-balloon time among all patients was 111 minutes (interquartile range 84 to 152). The proportion of patients with a delay of >2 hours was greater among those aged > or = 65 years (49% vs 41%), women (50% vs 42%), patients with contraindications to fibrinolysis (60% vs 41%), and those without chest pain on admission (61% vs 43%, all p <0.0001). Delay was also more common with transfer from another hospital (87% vs 38%), with presentation outside the hours of 8 A.M. to 4 P.M. (51% vs 38%), and in hospitals performing <49 pPTCAs/year (47% vs 41%, all p <0.0001). The strongest independent predictor of delay was hospital transfer, along with non-daytime presentation and low-volume centers. Older age, female sex, and non-white race were weaker predictors. Both patient and hospital factors are associated with delay in pPTCA after presentation. These findings may help design treatment algorithms to minimize delay, thus improving the survival benefit of pPTCA. These results may also help design trials of combination reperfusion strategies.

The efficacy and safety of atorvastatin 10 mg versus simvastatin 20 mg and atorvastatin 80 mg versus simvastatin 80 mg was determined in a 6-week, prospective, randomized, open-label, blinded end-point trial of dyslipidemic patients with and without coronary heart disease. A total of 1,732 patients with hypercholesterolemia and triglycerides < or =600 mg/dl (6.8 mmol/L) were randomized to receive either atorvastatin 10 mg (n = 650), simvastatin 20 mg (n = 650), atorvastatin 80 mg (n = 216), or simvastatin 80 mg (n = 216). The primary efficacy parameter was the change in low-density lipoprotein (LDL) cholesterol from baseline to week 6. Secondary efficacy parameters included the percent change from baseline to week 6 in total cholesterol, triglyceride, high-density lipoprotein (HDL) cholesterol, very-low-density lipoprotein cholesterol, apolipoprotein B, and the percent of patients achieving their National Cholesterol Education Program (NCEP) LDL cholesterol goal at study end. Atorvastatin had significantly greater reductions from baseline in LDL cholesterol than simvastatin in both comparator groups: atorvastatin 10 mg (37.1%) versus simvastatin 20 mg (35.4%) (p = 0.0097), and atorvastatin 80 mg (53.4%) versus simvastatin 80 mg (46.7%) (p <0.0001). Atorvastatin 10 and 80 mg also provided significantly greater reductions in total cholesterol, triglycerides, very-low-density lipoprotein cholesterol, and apolipoprotein B than simvastatin 20 and 80 mg, respectively (all p <0.05). All treatment groups had a significantly decreased LDL cholesterol/HDL cholesterol ratio from baseline (all p <0.0001). In both comparator groups a higher proportion of atorvastatin-treated patients reached their NCEP LDL cholesterol goal compared with simvastatin. All 4 study treatments were well tolerated.