A scoping review of incidence and assessment tools for post-intensive care syndrome following cardiac surgery.

BACKGROUND: Post-intensive care syndrome is a new or worsening persistent deterioration in cognitive, mental, and/or physical health following a prolonged admission to an intensive care unit. Post-intensive care syndrome remains underexplored following cardiac surgery, with a lack of understanding of the incidence and tools used to measure the symptoms. A scoping review was conducted to determine the incidence and to identify the tools commonly used to measure symptoms of post-intensive care syndrome following cardiac surgery. METHODS: The electronic databases Medline (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Scopus, and CINAHL (EBSCOhost) and Google Scholar were searched with keywords and controlled vocabulary to describe both cardiac surgery and post-intensive care syndrome (cardiac surgical procedures, heart surgery, and post-intensive care symptoms) and symptoms (delirium, depression, mobility and quality of life). Included were articles written in English and published after 2005 that described cognitive, mental, and physical symptoms of post-intensive care syndrome following cardiac surgery. 3,131 articles were found, with 565 duplicates, leaving 2,566 articles to be screened. Of these, seven unique studies were included. RESULTS: Five studies explored cognitive health, three mental health, one cognitive and mental health, and none physical health. No identified studies reported the overall incidence of post-intensive care syndrome following cardiac surgery. The incidence of cognitive health issues ranged from 21% to 38%, and mental health issues ranged from 16% to 99%. In total, 17 different tools were identified - 14 for cognitive health and three for mental health. No identified studies used the same tools to measure symptoms. No single tool was found to measure all three domains. CONCLUSION: This scoping review identified a literature gap specific to the incidence and inconsistency of assessment tools for post-intensive care syndrome in cardiac surgery patients. CLINICAL IMPLICATIONS: This work impacts clinical practice for the bedside nurse by raising awareness of an emerging health issue.

Multimodal Analgesic Effectiveness on Acute Postoperative Pain Management After Adult Cardiac Surgery: Protocol for a Systematic Review.

BACKGROUND: Many patients report moderate to severe pain in the acute postoperative period. Enhanced recovery protocols recommend multimodal analgesics, but the optimal combination of these is unknown. PURPOSE: The aim of this study was to synthesize the best available evidence about effectiveness of multimodal analgesics on pain after adult cardiac surgery. METHODS: A systematic review to determine the effect of multimodal postoperative analgesics is proposed (International Prospective Register of Systematic Reviews Registration CRD42022355834). Multiple databases including the Cochrane Library, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, American Psychological Association, the Education Resources Information Centre, the Excerpta Medica database, the Medical Literature Analysis and Retrieval System Online, Scopus, Web of Science, and clinical trials databases will be searched. Screening in Covidence and quality assessment will be conducted by 2 authors. A grading of recommendations, assessment, development, and evaluation summary of findings will be presented if meta-analysis is possible.

Continuing education with a holistic approach to the Brazilian LGBT+ population through use of the m-health App.

AIM: This article aims to discuss the development of a continuing education course for health care professionals to provide competent healthcare assistance to the Brazilian LGBT+ population and the implementation of this course using a m-Health solution. BACKGROUND: There is a scarcity of continuing education courses in the Brazilian context that update provides evidenced-informed education to ensure health care professional competence in the delivery of health care to LGBT+ individuals. METHODS: Based on Bloom's taxonomy, with a main focus on the cognitive domain, the course "Ally: A Holistic Approach to the LGBT+ Individual'' was developed in five months. This was based on the Nurse's Health Education for LGBT Seniors (HEALE), the Curriculum Implementation and Institutional Climate manual, Changes to Improve Healthcare for LGBT People, Gender Nonconforming or Born with DSD" and the National Comprehensive Health Policy for LGBT+ People, among others. RESULTS: Comprising six modules: i) human sexuality; ii) equitable care and appropriate terminology; iii) public health policy for the LGBT+ population; iv) cultural skills for health professionals; v) aging and health care for the LGBT+ population; and vi) mental health of LGBT+ people. Content validity indexing was established using an expert panel and was Ally was supported by a m-Health Solution called "Over the Rainbow'' and totals of 60 h of education. CONCLUSIONS: This m-Health solution and continuing education course for health professionals can be an opportunity to change health professionals' practice to offer more equitable health care for the LGBT+ population.

An educator's toolkit for virtual simulation: A usability study.

BACKGROUND: The rapid change brought on by COVID-19 meant that many educators adopted virtual simulation quickly, often without having a strong background in the pedagogical principles of virtual simulation. To address this resource gap, a team of 21 Ontario virtual simulation-experienced educators created the freely available, online, interprofessional Virtual Simulation Educator's Toolkit. The Toolkit provides the theory, practical strategies and resources needed to teach effectively with virtual simulation. Because the Toolkit would include new content, resources and numerous untested design elements, the team conducted a usability test. DESIGN: A usability study, that followed a three-step process, was conducted. Participants were asked to carefully review the Toolkit, including all interactive components and complete an online survey based on the Technology Acceptance Model, to measure the ease of use and utility of the Toolkit. Lastly, participants were interviewed. PARTICIPANTS: In keeping with sampling principles for usability studies, twenty experienced virtual simulation educators from different disciplines participated in the study. METHODS: A validated survey and one-on-one interviews were used to measure educators' perceptions of the ease of use and utility of the Toolkit and their recommendations to improve it. Quantitative data were analyzed using descriptive statistics and qualitative data were coded and themes developed. CONCLUSION: The score of 90 % on the Toolkit Experience Survey indicated that participants found the Toolkit both easy to use and useful. Results from the interviews indicated that a practical, accessible professional development tool is urgently needed to support education with virtual simulation. Because the Toolkit introduces educators to different ways of implementing virtual simulation, as well as options, process considerations, and tools to enhance their teaching with virtual simulation, different disciplines and educators with different levels of simulation experience may benefit by using it.

Recognizing pain as an early warning symptom of ischemic cardiovascular disease: A qualitative artistic representation of the journey.

Background: Understanding the experience of prodromal ischemic cardiac pain and associated symptoms through use of literary and visual art evokes heightened a wareness of the emotional journey. AIMS: The aim of this study was to describe the initial early prodromal pain-related symptoms and feelings associated with adjusting to this new cardiac health concern and explore the subjective experience of coming to the realization and awareness of developing heart disease. MATERIALS AND METHODS: This study is a secondary supplemental qualitative analysis, using an arts-based embodied layered exploration assisted to translate the experiences of 23 individuals' journeys through symptom recognition. The analytic process involved three iterative layers: qualitative descriptive analysis of participant pain narratives, interpretation with thematic poetry, and representation via visual art to evoke an aesthetic, heightened level of understanding of the data. RESULTS: Denial and disbelief, encroaching pain and symptoms of heart disease, and self-recrimination were three themes that emerged from the data. Pain described by participants brought forward the emotional dimensions of the experience. Participants described their process of realization as a tumultuous time, fraught with feelings of vulnerability and uncertainty, where anger and self-effacing ridicule permeated their thoughts that were tempered with profound gratitude at survival. CONCLUSION: Bridging the connection between science and art to disseminate awareness of the nature of living with cardiac-related prodromal pain and disease is novel. Providing invitation and entrance into an individual's pain experience through qualitative inquiry with use of arts-based approaches makes visible the emotional meaning of pain.

Contexte: La compréhension de l'expérience de la douleur cardiaque ischémique avant-coureuse et des symptômes qui lui sont associés par l'utilisation de la littérature et des arts visuels permet de mieux prendre conscience du cheminement émotionnel.Objectifs: Cette étude avait pour but de décrire les premiers symptômes avant-coureurs liés à la douleur et les sentiments suscités par l'adaptation à ce nouveau problème de santé cardiaque, ainsi que d'étudier l'expérience subjective de la prise de conscience d'être en train de déveloper une maladie cardiaque.Matériel et méthodes: Cette étude constitue une analyse qualitative supplémentaire secondaire utilisant une méthode d'exploration par les arts à plusieurs niveaux pour traduire le cheminement de 23 personnes en ce qui concerne la reconnaissance des symptômes. Le processus d'analyse comportait trois niveaux itératifs : une analyse descriptive qualitative des récits sur la douleur des participants, l'interprétation par la poésie thématique et la représentation par l'art visuel, afin de susciter un niveau de compréhension esthétique et plus élevé des données.Résultats: Le déni, l'incrédulité, la douleur envahissante et les symptômes de maladie cardiaque, de même que l'autorécrimination, sont trois des thèmes qui sont ressortis des données. La description que les participants ont faite de la douleur a révélé les dimensions émotionnelles de l'expérience. Les participants ont décrit leur processus de prise de conscience comme une période tumultueuse, marquée par la vulnérabilité et l'incertitude, où la colère et une dérision discrète imprégnaient leurs pensées, lesquelles étaient tempérées par une profonde gratitude pour avoir survécu.Conclusion: L'établissement d'un lien entre la science et l'art pour faire connaître la vie avec la douleur avant-coureuse et la maladie cardiaque consistue une approche novatrice. Le fait d'être invité à pénétrer à l'intérieur de l'expérience de la douleur vécue par un individu par le truchement d'une enquête qualitative ayant recours à des approches axées sur les arts rend visible la signification émotionnelle de la douleur.

Moving toward a better understanding of the experience and measurement of breastfeeding-related pain.

Purpose: Despite how commonly breastfeeding-related pain is experienced in the postpartum period, and its frequent implication in breastfeeding cessation, this unique type of pain is not well evaluated nor assessed. The purpose of this study was to gain a comprehensive description and understanding of breastfeeding-related pain among postpartum breastfeeding women. Methods: This study employed a mixed methods approach using a descriptive-interpretive qualitative approach, in addition to administering the Short-Form McGill Pain Questionnaire, second version, to comprehensively gain both quantitative and qualitative descriptors of breastfeeding-related pain. Fourteen partnered and educated women living in Southern Ontario with experience of breastfeeding-related pain took part in this study. Results: The results from this study suggest that breastfeeding-related pain is often experienced as severe and distressing, and comprises various elements of pain including continuous, intermittent, neuropathic, and affective components. Conclusion: Breastfeeding-related pain is multidimensional and can be severe and distressing for women. Current measurement tools may not adequately reflect the multidimensional components of this unique type of pain, which may limit the effectiveness of health care providers to help with its identification and management.

Self-management of cardiac pain in women: an evidence map.

OBJECTIVE: To describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping. DESIGN AND SETTING: Literature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age. INTERVENTIONS: Self-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain. PRIMARY AND SECONDARY OUTCOMES MEASURES: Outcomes included those related to knowledge, self-efficacy, function and health-related quality of life. RESULTS: The literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%-100% women and the mean age was 63 years. CONCLUSIONS: Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain. PROSPERO REGISTRATION NUMBER: CRD42016042806.

Caregiver Contribution to Heart Failure Self-Care (CACHS).

AIM: While caregivers (CGs) make an important contribution to the self-care of heart failure (HF) patients, there are no reliable and valid tools for measuring such contributions. Current interventions that strive to optimize patient outcomes through self-care strategies neglect to account for CG contributions, a potential confounder on outcomes. The aim of the study was to develop an instrument that measures CG contributions to HF patients' self-care. DESIGN: The study design follows an established process for instrument development. METHODS: A systematic literature review and semi-structured interviews of CGs were conducted to identify measureable CG activities. Items were derived from thematic analysis of CG narratives. A content validity index was computed for each item (I-CVI). Items with an I-CVI of >0·70 were retained. Items with an I-CVI of 0·50-0·70 were revised for clarification and items with an I-CVI <0·5 were discarded, except in instances where fulsome theoretical or empirical evidence supported their retention. RESULTS: 14 CGs completed interviews and 10 CGs with 4 expert nurses completed I-CVI testing. Major interview themes included arranging appointments, medication adherence, monitoring, coordinating care, encouraging independence and taking action. A total of 36 items were constructed and underwent I-CVI testing. Following I-CVI testing, 27 items were retained, seven items were retained after revision based on CG feedback and two items were removed. This newly developed 34-item questionnaire represents current literature, CGs' experiences, excellent I-CVI scores and ready for further psychometric testing.

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

BACKGROUND: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. OBJECTIVE: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). METHODS: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. RESULTS: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. CONCLUSIONS: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.

Development of the Prodromal Symptoms-Screening Scale (PS-SS): Preliminary Validity and Reliability.

UNLABELLED: Every 40 seconds a person dies of cardiovascular disease.Individuals do not recognize the warning signs--prodromalsymptoms--of an imminent myocardial ischemic event. TheProdromal Symptoms-Screening Scale (PS-SS) is a nine-itemmeasure designed to evaluate PS in individuals with coronaryartery disease. AIM: This article reports onfour studies (systematic review,focusgroup study, content validity testing and factor analysis) that contributed to the development and psychometric examination ofthe PS-SS. RESULTS: PS experienced included: unusual fatigue, sleep disturbance, chest pain, anxiety, gastrointestinal symptoms andshortness of breath. The CVI derived was 0.85. The PS-SS presented a two-factor structure pertaining to Specific ProdromalSymptoms and Non-Specific Prodromal Symptoms. Internal consistency reliability was 0.61. CONCLUSIONS: The PS-SS reflects current prodromal literature,clinical practice and ACS patients' experiences of PS. Furtheritem generation, clarity of symptom description and psychometricevaluation needs to occur prior to use in clinical practice.Keywords: prodromal symptoms, acute coronarysyndrome, psychometric testing, tool development

Impact of Prodromal Symptoms on Future Adverse Cardiac-Related Events: A Systematic Review.

BACKGROUND: Recognition of specific and nonspecific cardiac-related prodromal symptoms, indicative of myocardial ischemia, is critical for preemptive coronary heart disease (CHD) screening and effective diagnosis and treatment. In this systematic review, we examined whether prodromal symptoms were predictive of acute symptom presentations, cardiac events, or treatment interventions. METHODS: Studies that measured the association of prodromal symptoms with acute coronary syndrome (ACS) symptom presentation, acute cardiac event, and/or intervention in men and/or women with confirmed CHD were included. DATA SOURCES: Electronic searches in the Cochrane Library, MEDLINE, PubMed, PsyhINFO, Embase, CINAHL, and Scopus databases from 1990 to 2013 were conducted using medical subject heading terms including prodromal symptoms, ACS, acute myocardial infarction, unstable angina, and CHD. Key words such as shortness of breath, anxiety, atypical pain, sleep disturbance, fatigue, and nausea/vomiting were also used. Abstracts, relevant journals, key authors, and reference lists were reviewed. RESULTS: Seven studies that included 6716 individuals with prodromal symptoms (65.7% women). Mean age was 68 ± 13 and 58.5 ± 9 years for women and men, respectively. Cardiac-related prodromal symptoms were predictive of patients' ACS-related symptoms and associated events from 3 to 24 months. Across studies, the prodromal symptoms consistently reported before cardiac event were chest discomfort/pain (n = 4, 57%), arm pain/discomfort (n = 6, 86%), jaw pain (n = 3, 43%), back/shoulder blade pain (n = 3, 43%), unusual fatigue (n = 7, 100%), shortness of breath (n = 6, 86%), sleep disturbance (n = 2, 29%), dizziness (n = 3, 43%), headache (n = 3, 43%), anxiety (n = 7, 100%), and gastrointestinal complaints (nausea, vomiting, indigestion; n = 5, 71%). Patients with prodromal arm, jaw, and back pain; fatigue; and shortness of breath had increased risk of experiencing similar symptoms during an ACS episode. Prodromal symptoms were predictive of adverse cardiac events and cardiac interventions. There is some preliminary evidence to suggest that prodromal symptoms of headache, sleep disturbance, and anxiety may predict ACS symptom presentation during an acute cardiac event. CONCLUSION: Future research is warranted that would examine prospectively the predictive value of prodromal headache, sleep disturbance, and anxiety within this cardiovascular population on major adverse cardiac events. Preemptive screening for cardiac-related prodromal symptoms in men and women should be considered as a standard in clinical practice. This may potentiate early diagnosis, effective risk modification, timely pain management, and treatment intervention and decrease CHD-related morbidity and mortality.

Prodromal symptoms associated with acute coronary syndrome acute symptom presentation.

OBJECTIVE: Prodromal symptoms (PS), indicative of myocardial ischemia, are frequently unrecognized by individuals prior to an acute coronary syndrome (ACS). ACSs are the leading cause of death worldwide. This study describes (1) the prevalence and association of PS with patients' baseline ACS-related acute symptoms of pain intensity and state anxiety and (2) the relationship of PS to co-morbidity. METHODS: An exploratory sub-analysis was performed. Cross sectional data identified prodromal predictors of ACS pain intensity (numeric rating scale 0-10 (NRS)) and state anxiety (Speilberger state-trait anxiety personality inventory (STAI)). ACS patients (n=121) admitted to a community rural emergency department completed the prodromal symptom screening scale (PS-SS) and reported baseline cardiac pain intensity, state, and trait anxiety. RESULTS: Increased ACS pain intensity was associated with PS. Median pain scores were higher by two points for those with prodromal headache, p=0.006, and anxiety, p=0.017, and one point higher for those with sleep disturbances, p=0.012. PS were not associated with state or trait anxiety. Hypertensive individuals were 7.5 times more likely to experience prodromal fatigue prior to their ACS event. CONCLUSION: Results extend current knowledge of the predictive value that prodromal headache, sleep disturbance and anxiety may have on individuals' acute symptom presentation. A prospective, prognostic study is required in order to determine whether PS are predictive of adverse cardiac events and if PS are a stronger predictor of ACS acute symptom presentation, compared with typical ACS-related co-morbidities.

A Novel Noninvasive Device to Assess Sympathetic Nervous System Function in Patients With Heart Failure.

BACKGROUND: Heart failure is a complex syndrome associated with sympathetic nervous system and renin-angiotensin-aldosterone system hyperactivity. Sympathoinhibition and downregulation of sympathetic activity using medications and exercise training improve outcomes in patients with heart failure. Impedance cardiography provides data on hemodynamic and autonomic function that may assist with safe medication, exercise monitoring, and titration. PURPOSE: The purpose of this pilot study was to evaluate the sensitivity of the Vrije Universiteit Ambulatory Monitoring System (VU-AMS) version 5fs to detect hemodynamic and sympathetic nervous system changes associated with postural shift in persons with heart failure with reduced ejection fraction. METHODS: In this descriptive study, participants (N = 28) were recruited from an outpatient device clinic at a tertiary care hospital in Ontario, Canada. They completed a sit-to-stand posture protocol wearing an ambulatory blood pressure (ABP) and a noninvasive VU-AMS version 5fs impedance cardiography system. RESULTS: Most (n = 18, 64%) participants were eliminated from the final analyses in this sample because of difficulty in Q-onset and B-point identification in peculiar electrocardiogram and impedance cardiogram waveforms. The remaining participants (n = 10) had a mean age of 69 years (SD = 10 years) and responses to a sit-to-stand posture protocol that included a 5% increase in heart rate (p = .001), an 18% decrease in stroke volume (p = .01), and an 8% decrease in left ventricular ejection time (p = .01). Participants had an increased preejection period (11%, p = .01), a drop in cardiac output of 13% (p = .02), and a reduced mean arterial pressure of approximately 4% (p = .09) with standing. DISCUSSION: Although the VU-AMS version 5fs system detected anticipated hemodynamic and sympathetic nervous system changes to postural shift in participants (n = 10), the elimination of 64% (n = 18) of the sample because of scoring difficulties limits the use of this impedance cardiography device using standard scoring algorithms in persons with heart failure with reduced ejection fraction.

The CREATE Method for Expressing Continuous Outcome Data in Absolute Terms for Use in Patient Treatment Decision Aids: A Validation Study.

BACKGROUND: Patient decision aids (PtDAs) supplement advice from health care professionals by communicating the absolute risk or benefit of treatment options (i.e., X/100). As such, PtDAs have been amenable to binary outcomes only. We aimed to develop and test the validity of the Conversion to Risk Estimates through Application of Normal Theory (CREATE) method for estimating absolute risk based on continuous outcome data. METHODS: CREATE is designed to derive an estimate of the proportion of those who experience a clinically relevant degree of change (CRDoC). We used a 2-stage validation process using real and simulated change score data, respectively. First, using raw data from published intervention trials, we calculated the proportion of patients with a CRDoC and compared that with our CREATE-derived estimate using chi-square tests of association. Second, 200,000 simulated distributions of change scores were generated with widely varying distribution characteristics. Actual and CREATE-derived estimates were compared for each simulated distribution, and relative differences were summarized graphically. RESULTS: The absolute difference between the estimated and actual CRDoC did not exceed 5% for any of the samples based on real data. Applying the CREATE method to 200,000 simulated scenarios demonstrated that the CREATE method should be avoided for outcomes where the underlying distribution can be reasonably assumed to have high levels of skew or kurtosis. CONCLUSION: Our results suggest that standard statistical theory can be used to estimate continuous outcomes in absolute terms with reasonable accuracy for use in PtDAs; caution is advised if outcome summary statistics are assumed to have been derived from highly skewed distributions.

Pain and Anxiety in Rural Acute Coronary Syndrome Patients Awaiting Diagnostic Cardiac Catheterization.

CONTEXT: In rural areas of Canada, people with acute coronary syndromes (ACS) can wait up to 32 hours for transfer for diagnostic cardiac catheterization (CATH). While awaiting CATH, it is critical that pain and anxiety management be optimal to preserve myocardial muscle and minimize the risk of further deterioration. OBJECTIVES: The aim of this study was to examine the relationship between clinical management, cardiac pain intensity, and state anxiety for rural ACS patients awaiting diagnostic CATH. METHODS: In a prospective, descriptive-correlational repeated-measures design involving 121 ACS rural patients, we examined the associations of analgesic and nitroglycerin administration with cardiac pain intensity (numeric rating scale) and state anxiety (Spielberger State Anxiety Inventory) and also nurses' pain knowledge and attitudes (Toronto Pain Management Inventory-ACS Version and Knowledge and Attitudes Survey Regarding Pain) using linear mixed models. RESULTS: The mean age of patients was 67.6 ± 13, 50% were men, and 60% had unstable angina and the remainder had non-ST-elevated myocardial infarction. During follow-up, cardiac pain intensity scores remained in the mild range from 1.1 ± 2.2 to 2.4 ± 2.7. State anxiety ranged from 44.0 ± 7.2 to 46.2 ± 6.6. Cumulative analgesic dose was associated with a reduction in cardiac pain by 1.0 points (numeric rating scale, 0-10) (t108 = -2.5; SE, -0.25; confidence interval, -0.45 to -0.06; P = .013). Analgesic administration was not associated with state anxiety. Over the course of follow-up, ACS patients reported consistently high anxiety scores. CONCLUSIONS: Whereas cardiac pain declines in most patients in the early hours after admission, many patients experience a persistent anxious state up to 8 hours later, which suggest that development and testing of protocols for anxiety reduction may be needed. More urgently, the development and examination of a treatment intervention, early on in the ACS trajectory, are warranted that targets pain and anxiety for those for whom immediate angioplasty is not possible and who continue to experience cardiac pain and persistent high levels of anxiety. Moreover, a larger prognostic study is required to determine whether high levels of anxiety in rural ACS patients are predictive of major adverse cardiac events.

Caregivers' contributions to heart failure self-care: a systematic review.

AIMS: The purpose of this study was to conduct a systematic review answering the following questions: (a) what specific activities do caregivers (CGs) contribute to patients' self-care in heart failure (HF)?; and (b) how mature (or developed) is the science of the CG contribution to self-care? METHODS: MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library and ClinicalTrials.gov were searched using the terms heart failure and caregiv* as well as the keywords 'careers', 'family members' and 'lay persons' for studies published between 1948 and September 2012. Inclusion criteria for studies were: informal CGs of adult HF patients-either as dependent/independent variable in quantitative studies or participant in qualitative studies; English language. Exclusion criteria for studies were: formal CGs; pediatric, adult congenital, or devices or transplant CGs; mixed diagnosis; non-empiric reports or reports publishing duplicate results. Each study was abstracted and confirmed by two authors. After CG activities were identified and theoretically categorized, an analysis across studies was conducted. RESULTS: Forty papers were reviewed from a pool of 283 papers. CGs contribute substantively to HF patients' self-care characterized from concrete (weighing the patient) to interpersonal (providing understanding). Only two studies attempted to quantify the impact of CGs' activities on patients' self-care reporting a positive impact. Our analysis provides evidence for a rapidly developing science that is based largely on observational research. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: To our knowledge, this is the first systematic review to examine CGs' contributions in depth. Informal caregivers play a major role in HF self-care. Longitudinal research is needed to examine the impact of CGs' contributions on patient self-care outcomes.

Content validity of the Toronto Pain Management Inventory-Acute Coronary Syndrome Version.

BACKGROUND: Cardiac pain and/or discomfort arising from acute coronary syndromes (ACS) can often be severe and anxiety-provoking. Cardiac pain, a symptom of impaired myocardial perfusion, if left untreated, may lead to further myocardial hypoxia, which can potentiate myocardial damage. Evidence suggests that once ACS patients are stabilized, their pain may not be adequately assessed. Lack of knowledge and problematic beliefs about pain may contribute to this problem. To date, no standardized tools are available to examine nurses' specific knowledge and beliefs about ACS pain that could inform future educational initiatives. AIM: To examine the content validity of the Toronto Pain Management Inventory-ACS Version (TPMI-ACS), a 24-item tool designed to assess nurses' knowledge and beliefs about ACS pain assessment and management. METHODS: Eight clinical and scientific experts rated the relevance of each item using a four-point scale. A content validity index was computed for each item (I-CVI), as well as the total scale, expressed as the mean item CVI (S-CVI/AVE). Items with an I-CVI > or = 0.7 were retained, items with an I-CVI ranging from 0.5-0.7 were revised and clarified, and items with an I-CVI < or = 0.5 were discarded. RESULTS: I-CVIs ranged from 0.5-1.0 and the S-CVI/AVE was 0.90, reflecting high inter-rater agreement across items. The least relevant item was eliminated. CONCLUSIONS: Preliminary content validity was established on the TPMI-ACS version. All items retained in the TPMI-ACS version met requirements for content validity. Further evaluation of the psychometric properties of the TPMI-ACS is needed to establish criterion and construct validity, as well as reliability indicators.

Impact of self-management interventions on stable angina symptoms and health-related quality of life: a meta-analysis.

BACKGROUND: Chronic stable angina (CSA) has a major negative impact on health-related quality of life (HRQL) including poor general health status, psychological distress, and inability to self-manage. METHODS: We used meta-analysis to assess the effectiveness of self-management interventions for improving stable angina symptoms, HRQL and psychological well-being. Nine trials, involving 1,282 participants in total, were included. We used standard inverse-variance random-effects meta-analysis to combine the trials. Heterogeneity between trials was evaluated using chi-square tests for the tau-squared statistic and quantified using the I2 statistic. RESULTS: There was significant improvement in the frequency of angina symptoms (Seattle Angina Questionnaire [SAQ], symptom diary) across trials, standardized mean difference (SMD): 0.30 (95% Confidence interval [CI] 0.14, 0.47), as well as reduction in the use of sublingual (SL) nitrates, SMD: -0.49 (95% CI -0.77, -0.20). Significant improvements for physical limitation (SAQ), SMD: 0.38 (95% CI 0.20, 0.55) and depression scores (Hospital Anxiety and Depression Scale), SMD: -1.38 (95% CI -2.46, -0.30) were also found. The impact of SM on anxiety was uncertain due to statistical heterogeneity across trials for this outcome, I2 = 98%. SM did not improve other HRQL dimensions including angina stability, disease perception, and treatment satisfaction. CONCLUSIONS: SM interventions significantly improve angina frequency and physical limitation; they also decrease the use of SL nitrates and improve depression in some cases. Further work is needed to make definitive conclusions about the impact of SM on cardiac-specific anxiety.

Acute Coronary Syndrome Pain and Anxiety in a Rural Emergency Department: Patient and Nurse Perspectives.

Rural patients can wait up to 32 hours for transfer to cardiac catheterization (CATH) for events related to acute coronary syndrome (ACS). Pain arising from myocardial ischemia can be severe and anxiety-provoking. Pain management during this time should be optimized in order to preserve vulnerable myocardial muscle. This qualitative focus group study solicited the perspectives of ACS patients and emergency staff nurses on the rural patient experience of cardiac pain and anxiety and priorities and barriers to optimal assessment and management of ACS pain. Patients described ACS pain as moderate to severe, with pain in the chest, arms, back, shoulders, and jaw. Pain was well assessed and managed upon arrival in the emergency department but anxiety was not routinely assessed or treated. Barriers identified were poor management of patients with different acuity levels, high patient volumes, and assumptions regarding patients' communication about pain. Research related to ACS pain and anxiety management in the rural context is recommended.

Les patients atteints d'un syndrome coronarien aigu (SCA) en milieu rural peuvent attendre jusqu'à 32 heures avant d'être transférés pour un cathétérisme cardiaque (CATH). La douleur associée à une ischémie myocardique peut être aiguë et provoquer de l'anxiété. La gestion de cette douleur devrait être optimisée afin de protéger le muscle myocardique, qui est en situation de vulnérabilité. Cette étude qualitative menée auprès d'un groupe cible visait à solliciter le point de vue de patients atteints d'un SCA et du personnel infirmier d'un service d'urgence en milieu rural concernant l'anxiété et la douleur cardiaque ressenties par les patients et concernant les priorités à adopter et les obstacles à surmonter pour une évaluation et une gestion optimales de la douleur liée à un SCA. Les patients ont décrit la douleur liée à un SAC comme étant légère ou aiguë et ont indiqué qu'elle se situait dans la poitrine, les bras, le dos, les épaules et les mâchoires. Selon les participants à l'étude, la douleur est évaluée et gérée adéquatement au moment de l'arrivée des patients au service d'urgence, mais l'anxiété, quant à elle, n'est pas évaluée ou traitée de façon systématique. Les obstacles mentionnés sont une mauvaise gestion des patients présentant des degrés de gravité différents, un volume important de patients et une tendance du personnel soignant à entretenir des a priori relativement à la communication par les patients de leur douleur. L'étude recommande que des recherches soient menées sur la gestion de la douleur et de l'anxiété liées au SCA en milieu rural.

Sampling Methods in Cardiovascular Nursing Research: An Overview.

Cardiovascular nursing research covers a wide array of topics from health services to psychosocial patient experiences. The selection of specific participant samples is an important part of the research design and process. The sampling strategy employed is of utmost importance to ensure that a representative sample of participants is chosen. There are two main categories of sampling methods: probability and non-probability. Probability sampling is the random selection of elements from the population, where each element of the population has an equal and independent chance of being included in the sample. There are five main types of probability sampling including simple random sampling, systematic sampling, stratified sampling, cluster sampling, and multi-stage sampling. Non-probability sampling methods are those in which elements are chosen through non-random methods for inclusion into the research study and include convenience sampling, purposive sampling, and snowball sampling. Each approach offers distinct advantages and disadvantages and must be considered critically. In this research column, we provide an introduction to these key sampling techniques and draw on examples from the cardiovascular research. Understanding the differences in sampling techniques may aid nurses in effective appraisal of research literature and provide a reference pointfor nurses who engage in cardiovascular research.