Allometric scaling for left ventricular mass and geometry in male and female athletes of mixed and endurance sports.

BACKGROUND: The athlete's heart (AH) defines the phenotypical changes that occur in response to chronic exercise training. Echocardiographic assessment of the AH is used to calculate LV mass (LVM) and determine chamber geometry. This is, however, interpreted using standard linear (ratiometric) scaling to body surface area (BSA) whereas allometric scaling is now widely recommended. This study (1) determined whether ratiometric scaling of LVM to BSA (LVMiratio) provides a size-independent index in young and veteran athletes of mixed and endurance sports (MES), and (2) calculated size-independent beta exponents for allometrically derived (LVMiallo) to BSA and (3) describes the physiological range of LVMiallo and the classifications of LV geometry. METHODS: 1373 MES athletes consisting of young (< 35 years old) (males n = 699 and females n = 127) and veteran (> 35 years old) (males n = 327 and females n = 220) were included in the study. LVMiratio was calculated as per standard scaling and sex-specific LVMiallo were derived from the population. Cut-offs were defined and geometry was classified according to the new exponents and relative wall thickness. RESULTS: LVMiratio did not produce a size independent index. When tested across the age range the following indexes LVMi/BSA0.7663 and LVMi/BSA0.52, for males and females respectively, were size independent (r = 0.012; P = 0.7 and r = 0.003; P = 0.920). Physiological cut-offs for LVMiallo were 135 g/(m2)0.7663 in male athletes and 121 g/(m2)0.52 in female athletes. Concentric remodelling / hypertrophy was present in 3% and 0% of young male and female athletes and 24% and 17% of veteran male and female athletes, respectively. Eccentric hypertrophy was observed in 8% and 6% of young male and female athletes and 9% and 11% of veteran male and female athletes, respectively. CONCLUSION: In a large cohort of young and veteran male and female MES athletes, LVMiratio to BSA is not size independent. Sex-specific LVMiallo to BSA with LVMi/BSA0.77 and LVMi/BSA0.52 for male and female athletes respectively can be applied across the age-range. Population-based cut-offs of LVMiallo provided a physiological range demonstrating a predominance for normal geometry in all athlete groups with a greater percentage of concentric remodelling/hypertrophy occurring in veteran male and female athletes.

The impact of image and performance enhancing drugs on atrial structure and function in resistance trained individuals.

BACKGROUND: Image and performance enhancing drugs (IPEDs) are commonly used in resistance trained (RT) individuals and negatively impact left ventricular (LV) structure and function. Few studies have investigated the impact of IPEDs on atrial structure and function with no previous studies investigating bi-atrial strain. Additionally, the impact of current use vs. past use of IPEDs is unclear. METHODS: Utilising a cross-sectional design, male (n = 81) and female (n = 15) RT individuals were grouped based on IPED user status: current (n = 57), past (n = 19) and non-users (n = 20). Participants completed IPED questionnaires, anthropometrical measurements, electrocardiography, and transthoracic echocardiography with strain imaging. Structural cardiac data was allometrically scaled to body surface area (BSA) according to laws of geometric similarity. RESULTS: Body mass and BSA were greater in current users than past and non-users of IPEDs (p < 0.01). Absolute left atrial (LA) volume (60 ± 17 vs 46 ± 12, p = 0.001) and right atrial (RA) area (19 ± 4 vs 15 ± 3, p < 0.001) were greater in current users than non-users but this difference was lost following scaling (p > 0.05). Left atrial reservoir (p = 0.008, p < 0.001) and conduit (p < 0.001, p < 0.001) strain were lower in current users than past and non-users (conduit: current = 22 ± 6, past = 29 ± 9 and non-users = 31 ± 7 and reservoir: current = 33 ± 8, past = 39 ± 8, non-users = 42 ± 8). Right atrial reservoir (p = 0.015) and conduit (p = 0.007) strain were lower in current than non-users (conduit: current = 25 ± 8, non-users = 33 ± 10 and reservoir: current = 36 ± 10, non-users = 44 ± 13). Current users showed reduced LV diastolic function (A wave: p = 0.022, p = 0.049 and E/A ratio: p = 0.039, p < 0.001) and higher LA stiffness (p = 0.001, p < 0.001) than past and non-users (A wave: current = 0.54 ± 0.1, past = 0.46 ± 0.1, non-users = 0.47 ± 0.09 and E/A ratio: current = 1.5 ± 0.5, past = 1.8 ± 0.4, non-users = 1.9 ± 0.4, LA stiffness: current = 0.21 ± 0.7, past = 0.15 ± 0.04, non-users = 0.15 ± 0.07). CONCLUSION: Resistance trained individuals using IPEDs have bi-atrial enlargement that normalises with allometric scaling, suggesting that increased size is, in part, associated with increased body size. The lower LA and RA reservoir and conduit strain and greater absolute bi-atrial structural parameters in current than non-users of IPEDs suggests pathological adaptation with IPED use, although the similarity in these parameters between past and non-users suggests reversibility of pathological changes with withdrawal.

Three-Dimensional-Derived Echocardiographic Left Ventricular Structure and Function and Indices from the 12-Lead Electrocardiogram across the Menstrual Cycle in Healthy Physically Active Females: An Exploratory Study.

Background: The impact of the menstrual phases on left ventricular (LV) structure and function using 3D echocardiography and resting electrocardiogram (ECG) in healthy, eumenorrheic, and physically active females has not been investigated. Methods: sixteen females (20 y ± 2) underwent 3D echocardiography and an ECG at three time points in the menstrual cycle phases (follicular, ovulation, luteal). LV end-diastolic volume (LVEDVi), LV ejection fraction (LVEF), LV mass allometrically indexed to height2.7 (LVMi), torsion, and global longitudinal, circumferential, and radial strain (GLS, GCS, and GRS) were evaluated. ECG data of the P and QRS waves were presented as well as axis deviation, chamber enlargement, and any rhythm abnormalities. Results: LVMi was significantly higher in the luteal phase (36.4 g/m2.7 ± 3.3) compared to the follicular (35.0 g/m2.7 ± 3.7) and ovulation (34.7 g/m2.7 ± 4.3) phases (p = 0.026). There were no differences in other indices of LV structure and function or ECG variables across all phases of the menstrual cycle or evidence of arrhythmia. Conclusions: In physically active females, there is a small but significantly higher LVMi associated with the luteal phase of the menstrual cycle with no concomitant change in LV function or ECG parameters. These findings are important to consider when conducting clinical or research serial assessments.

Masters athlete screening study (MASS): incidence of cardiovascular disease and major adverse cardiac events and efficacy of screening over five years.

BACKGROUND: The efficacy of cardiovascular screening in Masters athletes (MAs) (≥35 y), and whether screening decreases their risk of major adverse cardiac events (MACEs) is unknown. PURPOSE: To evaluate the effectiveness of yearly cardiovascular screening, and the incidence of cardiovascular disease (CVD) and MACE over five years. METHODS AND RESULTS: MAs (≥35 y) without previous history of CVD underwent yearly cardiovascular screening. Participants with an abnormal screen underwent further evaluations. In the initial year, 798 MAs (62.7% male, 55 ± 10 y) were screened; 11.4% (n = 91) were diagnosed with CVD. Coronary artery disease (CAD) was the most common diagnosis (n = 64; 53%). During follow-up, there were an additional 89 CVD diagnoses with an incidence rate of 3.58/100, 4.14/100, 3.74/100, 1.19/100, for years one to four, respectively. The most common diagnoses during follow-up were arrhythmias (n = 33; 37%). Increasing age (OR = 1.047, 95% confidence interval (CI): 1.003-1.094; P = 0.0379), Framingham Risk Score (FRS) (OR = 1.092, 95% CI: 1.031-1.158; P = 0.003), and LDL cholesterol (OR = 1.709, 95% CI: 1.223-2.401; P = 0.002) were predictive of CAD, whereas moderate intensity activity (min/wk) (OR = 0.997, 95% CI: 0.996-0.999; P = 0.002) was protective. Ten MACE (2.8/1000 athlete-years) occurred. All of these MAs were male, and 90% had ≥10% FRS. All underwent further evaluations with only two identified to have obstructive CAD. CONCLUSION: MACE occurred despite yearly screening. All MAs who had an event had an abnormal screen; however, cardiac functional tests failed to detect underlying CAD in most cases. It may be appropriate to offer computed coronary tomography angiography in MAs with ≥10% FRS to overcome the limitations of functional testing, and to assist with lifestyle and treatment modifications.

The efficacy of heart screening in Masters athletes (MAs) (≥35 y) is not well understood. This study of 798 MAs reported 10 major adverse cardiac event (MACE) over 5 years (2.8/1000 athlete-years), despite undergoing yearly screening. The MAs who had a MACE occurred only in males whom had an abnormal screen with 90% having an intermediate or higher cardiovascular risk. All of these MAs underwent further testing, however, stress tests (i.e. echocardiogram, electrocardiogram, nuclear) failed to detect underlying heart disease in most cases. Therefore, it may be appropriate to offer computed coronary tomography angiography in MAs with intermediate or higher cardiovascular risk to overcome the limitations of functional testing in this population, and to assist with lifestyle and treatment modifications.

Effects of endurance exercise training on left ventricular structure in healthy adults: a systematic review and meta-analysis.

AIMS: To determine the impact of endurance training (ET) interventions on left ventricular (LV) chamber size, wall thickness, and mass in healthy adults. METHODS AND RESULTS: Electronic databases including CINAHL, MEDLINE, PsycINFO, SPORTDiscus, Cochrane library, and EBM Reviews were searched up to 4 January 2022. Criteria for inclusion were healthy females and/or males (>18 years), ET intervention for ≥2 weeks, and studies reporting pre- and post-training LV structural parameters. A random-effects meta-analysis with heterogeneity, publication bias, and sensitivity analysis was used to determine the effects of ET on LV mass (LVM) and diastolic measures of interventricular septum thickness (IVSd), posterior wall thickness (PWTd), and LV diameter (LVDd). Meta-regression was performed on mediating factors (age, sex, training protocols) to assess their effects on LV structure. Eighty-two studies met inclusion criteria (n = 1908; 19-82 years, 33% female). There was a significant increase in LVM, PWTd, IVSd, and LVDd following ET [standardized mean difference (SMD) = 0.444, 95% confidence interval (CI): 0.361, 0.527; P < 0.001; SMD = 0.234, 95% CI: 0.159, 0.309; P < 0.001; SMD = 0.237, 95% CI: 0.159, 0.316; P < 0.001; SMD = 0.249, 95% CI:0.173, 0.324; P < 0.001, respectively]. Trained status, training type, and age were the only mediating factors for change in LVM, where previously trained, mixed-type training, young (18-35 years), and middle-aged (36-55 years) individuals had the greatest change compared with untrained, interval-type training, and older individuals (>55 years). A significant increase in wall thickness was observed in males, with a similar augmentation of LVDd in males and females. Trained individuals elicited an increase in all LV structures and ET involving mixed-type training and rowing and swimming modalities conferred the greatest increase in PWTd and LVDd. CONCLUSION: Left ventricular structure is significantly increased following ET. Males, young and trained individuals, and ET interventions involving mixed training regimes elicit the greatest changes in LV structure.

Heart structure significantly increases the following endurance training (ET) ≥2 weeks.Changes in heart structure were most prominent in males, who are young (18­35 years), already trained, and following concurrent continuous and interval training.Changes in heart size were not shown in older individuals (>55 years) compared with young and middle-aged individuals.While both males and females similarly increase their cavity size and heart mass, sex differences were revealed for wall thickness where significant increases were seen in males but not females.

Automated external defibrillator and emergency action plan preparedness amongst masters athletes.

OBJECTIVES: Sudden cardiac arrest/death (SCA/D) is the leading medical cause of death in athletes. Masters athletes (≥35 years old) are increasing in numbers and are responsible for the vast majority of sport-related SCDs. Automated external defibrillators (AEDs) and emergency action plans (EAPs) have been shown to unequivocally reduce SCD, however, their prevalence in masters athletics remains unknown. We sought to identify the perceived AED accessibility and EAP preparedness amongst a group of masters athletes. METHODS: A 40-item survey was sent to 735 master athletes identified through the Masters Athlete Screening Study. Participants were athletes with no known significant cardiac history. The survey inquired on the availability and location of AEDs within exercise settings, the presence of EAPs, and participants' cardiac concerns. RESULTS: Sixty-eight percent of athletes completed the survey. Ninety-seven percent and 99% of athletes believed CPR and AEDs were effective at saving lives, respectively. Thirty-eight percent of athletes were aware of an AED in proximity to where they exercise, with 40% aware of one available during competition events, and 28% during training events. Only 10% of athletes were aware of an EAP active in their place of exercise. Half of the athletes perceive their risk of cardiac arrest during exercise to be ≤0.5 in 100,000. CONCLUSIONS: These findings indicate that nearly all athletes believe CPR and AED are effective at saving lives, but only a minority are aware of an AED near their place of exercise, with even fewer aware of an active EAP. Master athletes underestimate their own risk for exercise-related cardiac events, affirming the importance of educating masters athletes on their increased cardiac risk and the importance of EAPs.

The 12-lead electrocardiogram of the elite female footballer as defined by different interpretation criteria across the competitive season.

ABSTRACTPre-participation screening (PPS), using a 12-lead electrocardiogram (ECG), is recommended to identify athletes at risk of sudden cardiac death (SCD). ECG interpretation criteria have been developed to address the concern arising from high false-positives in athletes. There are limited ECG data in elite female footballers. The aims of this study were to (1) compare the ECG outcomes using three published ECG criteria (European Society of Cardiology [ESC], Seattle, International) in elite female footballers and (2) compare ECG data at three different stages of a competitive season. Eighty-one elite female footballers (21 ± 4 yr) completed a medical assessment, anthropometrics, resting blood pressure and a resting 12-lead ECG. Each 12-lead ECG was interpreted in accordance with (1) ESC; (2) Seattle; (3) International Criteria to determine training-related and non-training-related ECG changes. A subset of thirteen (26 ± 4 yr) footballers had repeated resting ECG tests at three time points across the competitive season. Eighty percent of females had training-related ECG patterns. Sinus bradycardia (65%) and early repolarization (42%) were the most common. Using the ESC Criteria 25% (20/81) of the athletes were considered to have an abnormal ECG, compared to 0% using the Seattle and International Criteria, mainly due to alterations in QT length criteria. There were no clinically significant differences in ECG data across a competitive season. The Seattle and International ECG Criteria significantly reduced the number of ECG false-positives in elite female footballers and the time point of PPS within a competitive season is unlikely to alter the PPS outcomes.Abbreviations: AMSSM: American Medical Society for Sports Medicine; ANOVA: Analysis of Variance; BSA: Body Surface Area; ECG: Electrocardiogram; ESC: European Society of Cardiology; FA: Football Association; FIFA: The Fédération Internationale de Football Association (FIFA); F-MARC: FIFA Medical Assessment and Research Centre; LAE: Left atrial enlargement; LVH: Left ventricular hypertrophy; PPS: Pre-participation screening; SCD: Sudden cardiac death.

Masters Athlete Screening Study (MASS): Insights Into the Psychological Impact of Cardiovascular Preparticipation Screening.

OBJECTIVE: To determine the psychological impact of a cardiovascular disease (CVD) diagnosis identified during preparticipation screening (PPS) of masters athletes. DESIGN: Cross-sectional study. SETTING: Masters athletes diagnosed with CVD through the Masters Athletes Screening Study. PARTICIPANTS: Sixty-seven athletes (89.6% male, mean age at diagnosis 60.1 ± 7.1 years, range 40-76) with diagnoses of coronary artery disease (CAD) (73.1%), high premature ventricular contraction burden (9.0%), mitral valve prolapse (7.5%), atrial fibrillation (AF) (3.0%), bicuspid aortic valve (3.0%), aortic dilatation (1.5%), coronary anomaly (1.5%), and rheumatic heart disease (1.5%). Three participants had multiple diagnoses. INTERVENTION: Online survey distributed to masters athletes identified with CVD. MAIN OUTCOME MEASURES: Assessment of psychological distress [Impact of Event Scale-Revised (IES-R)], perceptions of screening, and preferred support by CVD type. RESULTS: The median total IES-R and subscale scores were within the normal range {median [interquartile range (IQR)] total 2.0 [0-6.0]; intrusion 1.0 [0-3.0]; avoidance 0 [0-3.0]; hyperarousal 0 [0-1.0]}. Athletes with bicuspid aortic valve [20.5 (IQR, 4.0-37.0)], AF [7.0 (IQR, 0-14.0)], and severe CAD [5.5 (IQR, 1.0-12.0)] had the highest total IES-R scores. One individual with bicuspid aortic valve reported a significant stress reaction. Ten athletes (14.9%) had scores >12. Ninety-three percent of athletes were satisfied having undergone PPS. Preferred type of support varied by cardiovascular diagnosis. CONCLUSIONS: The majority of masters athletes diagnosed with CVD through PPS do not experience significant levels of psychological distress. Athletes diagnosed with more severe types of CVD should be monitored for psychological distress. Support should be provided through a multidisciplinary and individualized approach.

Do athletes play by different rules? Obstructive coronary artery disease in asymptomatic competitive Masters athletes: a case series.

BACKGROUND: Both the age and number of endurance Masters athletes is increasing; this coincides with increasing cardiovascular risk. The vast majority of sports-related sudden cardiac deaths (SCDs) occur among athletes >35 years of age. Coronary artery disease (CAD) is the most common cause of SCD amongst Masters athletes. CASE SUMMARY: In our prospective screening trial, six asymptomatic Masters athletes with ischaemia on electrocardiogram exercise stress testing had their coronary anatomy defined either by cardiac computed tomography or coronary angiography. Three patients underwent coronary angiography, with fractional flow reserve (FFR) testing performed when indicated. Subsequent percutaneous revascularization was performed in one patient after a shared-decision making process involving the patient and the referring cardiologist. All six athletes identified with obstructive CAD were male. The mean age and Framingham risk score was 61.8 years (±9.5) and 22.7% (±6.1), respectively. The mean metabolic equivalent of task achieved was 14.4 (±3.8). All athletes were treated with optimal medical therapy as clinically indicated. No cardiac events occured in 4.3 years of follow-up. DISCUSSION: Guidelines recommend revascularization of Masters athletes to alleviate the ischaemic substrate despite a paucity of evidence that revascularization will translate into a reduction in myocardial infarct or sudden cardiac arrest/death. Herein, although a limited study population, we demonstrate a lack of clinical events after 4.3 years of follow-up whether or not revascularization was performed. A prospective multicentre registry for asymptomatic Masters athletes with documented obstructive CAD is needed to help establish the role of revascularization in this population.

Increasing Attendance at Scheduled Appointments for Group Classes at a Diabetes Education Center.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve attendance at scheduled appointments for group classes at a Pennsylvania diabetes education center.

Assessment of cardiovascular risk and preparticipation screening protocols in masters athletes: the Masters Athlete Screening Study (MASS): a cross-sectional study.

BACKGROUND: Underlying coronary artery disease (CAD) is the primary cause of sudden cardiac death in masters athletes (>35 years). Preparticipation screening may detect cardiovascular disease; however, the optimal screening method is undefined in this population. The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and the American Heart Association (AHA) Preparticipation Screening Questionnaire are often currently used; however, a more comprehensive risk assessment may be required. We sought to ascertain the cardiovascular risk and to assess the effectiveness of screening tools in masters athletes. METHODS: This cross-sectional study performed preparticipation screening on masters athletes, which included an ECG, the AHA 14-element recommendations and Framingham Risk Score (FRS). If the preparticipation screening was abnormal, further evaluations were performed. The effectiveness of the screening tools was determined by their positive predictive value (PPV). RESULTS: 798 athletes were included in the preparticipation screening analysis (62.7% male, 54.6±9.5 years, range 35-81). The metabolic equivalent task hours per week was 80.8±44.0, and the average physical activity experience was 35.1±14.8 years. Sixty-four per cent underwent additional evaluations. Cardiovascular disease was detected in 11.4%, with CAD (7.9%) being the most common diagnosis. High FRS (>20%) was seen in 8.5% of the study population. Ten athletes were diagnosed with significant CAD; 90% were asymptomatic. A high FRS was most indicative of underlying CAD (PPV 38.2%). CONCLUSION: Masters athletes are not immune to elevated cardiovascular risk and cardiovascular disease. Comprehensive preparticipation screening including an ECG and FRS can detect cardiovascular disease. An exercise stress test should be considered in those with risk factors, regardless of fitness level.

Detecting Underlying Cardiovascular Disease in Young Competitive Athletes.

BACKGROUND: Sudden cardiac death (SCD) is frequently the first manifestation of underlying cardiovascular disease in young competitive athletes (YCAs), yet there are no Canadian guidelines for preparticipation screening in this population. The goal of this study was to determine the prevalence of potentially lethal cardiovascular disease in a sample of Canadian YCAs by comparing 2 screening strategies. METHODS: We prospectively screened 1419 YCAs in British Columbia, Canada (age 12-35 years). We initially screened 714 YCAs using the American Heart Association 12-element recommendations, physical examination, and electrocardiogram (ECG) examination (phase 1). This strategy yielded a high number of false positive results; 705 YCAs were subsequently screened using a novel SportsCardiologyBC (SCBC) questionnaire and ECG examination in the absence of a physical examination (phase 2). RESULTS: Overall, 7 YCAs (0.52%) were found to have clinically significant diagnoses associated with SCD (4 pre-excitation, 1 long QT syndrome, 1 mitral valve prolapse, 1 hypertrophic cardiomyopathy). Six of the 7 athletes (85.7%) with disease possessed an abnormal ECG. Conversely, only 2 had a positive personal or family history (1 athlete had an abnormal ECG and family history). The SCBC questionnaire and protocol (phase 2) was associated with fewer false positive screens; 3.7% (25 of 679) compared with 8.1% (55 of 680) in phase 1 (P = 0.0012). CONCLUSIONS: The prevalence of conditions associated with SCD in a cohort of Canadian YCAs was comparable with American and European populations. The SCBC questionnaire and protocol were associated with fewer false positive screens. The ECG identified most of the positive cases irrespective of screening strategy used.

Interruptions to breastfeeding Dyads in an DRP Unit.

PURPOSE: The critical period for establishing breastfeeding (BF) is during the first days after birth. However, some routine maternity unit care practices may be experienced as interruptions interfering with BF opportunities and satisfaction. Therefore, we wanted to describe the frequency and duration of interruptions; amount of time alone; number, length, success of, and satisfaction with BF sessions; and maternal perceptions of the influence of interruptions on BF experiences in an LDR unit on postpartum day 1 (PD1). STUDY DESIGN AND METHODS: For 12 hours on PD1 we continuously observed the door to the rooms of 30 mother-newborn dyads in a community hospital birthing center. We recorded duration of visit by each person entering the room. Length of BF and maternal perception of success and satisfaction were measured after each feeding and at the end of the day using visual analog scales. RESULTS: One thousand five hundred ninety-three interruptions (53 ± 13.4/dyad, range 27-85) and 703 episodes of time alone (23 ± 5.5/dyad, range 11-32) occurred across 360 hours of observation. Duration of interruptions and time alone were 18.5 ± 34.5 and 15.4 ± 17.3 minutes, respectively. However, median duration of interruptions was 5 minutes and of time alone 10 minutes. One hundred thirty-eight BF sessions were recorded (2-9 sessions) and lasted 25 ±14.98 minutes. Perceived maternal success and satisfaction with BFs were moderate, and interruptions only marginally interfered with BF opportunities. CLINICAL IMPLICATIONS: Too many interruptions occur and mothers perceive them as interfering with BF. Therefore, interruptions need to be minimized.

Simulation in nursing staff development: a concept analysis.

The authors analyze the concept of simulation as it pertains to nursing staff development. The goal is to define clinical simulation and its attributes as well as to explore the historical origins. Although literature on simulation abounds as it pertains to other disciplines, including medicine, little has been written on the nursing implications. Improved understanding of the concept allows the nursing educator to better incorporate and expand simulation into a variety of multidisciplinary team building, quality improvement, and staff development programs.

Critical thinking in nurse managers.

Formal education and support is needed for nurse managers to effectively function in their role in the current health care environment. Many nurse managers assume their positions based on expertise in a clinical role with little expertise in managerial and leadership skills. Operating as a manager and leader requires ongoing development of critical thinking skills and the inclination to use those skills. Critical thinking can have a powerful influence on the decision making and problem solving that nurse managers are faced with on a daily basis. The skills that typify critical thinking include analysis, evaluation, inference, and deductive and inductive reasoning. It is intuitive that nurse managers require both the skills and the dispositions of critical thinking to be successful in this pivotal role at a time of transformation in health care. Incorporating critical thinking into education and support programs for the nurse manager is necessary to position the nurse manager for success.

Kangaroo care at birth for full term infants: a pilot study.

PURPOSE: To determine whether breastfeeding behaviors, skin temperature, and blood glucose values could be influenced through the use of kangaroo care at the time of birth in healthy full term infants. METHOD: Descriptive study with nine full term neonates given kangaroo care beginning within 1 minute of birth and continuing until completion of the first breastfeeding by mothers who intended to breastfeed. Infant skin temperature was taken at 1 and 5 minutes after birth and every 15 minutes thereafter. Blood glucose level was taken 60 minutes after birth, the time at which the infant latched onto the breast was recorded, and breastfeeding behaviors were observed during the first breastfeeding. RESULTS: Skin temperature rose during birth kangaroo care in eight of the nine infants, and temperature remained within neutral thermal zone for all infants. Blood glucose levels varied between 43 and 85 mg/dL for infants who had not already fed and between 43 and 118 mg/dL for those who had fed. All but one infant spontaneously crawled to and latched onto a breast by 74 minutes after birth. Physicians noted that mothers were distracted from episiotomy or laceration repair discomfort during birth kangaroo care. CLINICAL IMPLICATIONS: In this institution, birth kangaroo care was integrated into routine delivery room care, with nurses noting no change in nursing workload. Nurses have noted observing the crawling, latching, and successful breastfeeding of most infants. Because of the results of this pilot study, birth kangaroo care has been implemented successfully with all women who wish to participate.

Interruptions to breastfeeding dyads on postpartum day 1 in a university hospital.

OBJECTIVE: To describe interruptions (door openings and telephone calls) to breastfeeding dyads on postpartum day 1. DESIGN: A descriptive design of continuous observations of persons entering the mother's room plus record of phone calls from 8 a.m. to 8 p.m. on postpartum day 1. SETTING: Single bedded postpartum rooms in a tertiary level university hospital in northern Midwest United States. PARTICIPANTS: Twenty-nine healthy mother-infant dyads of singleton birth who intended to breastfeed. OUTCOME MEASURES: Frequency and duration of interruptions, number of episodes and duration of time alone, frequency and duration of breastfeeding sessions, and maternal perceptions of the day's activities and time with her newborn. RESULTS: Recorded interruptions totaled 1,555, yielding a mean of 54 interruptions each averaging 17 minutes in length. Half of the 24 episodes of time alone per dyad were less than or equal to 9 minutes; most commonly only 1 minute long. All mothers breastfed 2 to 10 times with an average duration of 20 minutes. CONCLUSION: Many interruptions occurred and were perceived to negatively influence breastfeeding.

Ethnicity and service delivery.

This paper reports research representing part of a systematic effort to operationalize ethnic issues in service delivery. An attitude scale was developed and applied to a national sample of child welfare workers and to minority workers in innovative ethnic settings. Significant differences were found related to sample, age, ethnicity, and agency type.