Depressive symptoms and impaired physical function after acute lung injury: a 2-year longitudinal study.

RATIONALE: Survivors of acute lung injury (ALI) frequently have substantial depressive symptoms and physical impairment, but the longitudinal epidemiology of these conditions remains unclear. OBJECTIVES: To evaluate the 2-year incidence and duration of depressive symptoms and physical impairment after ALI, as well as risk factors for these conditions. METHODS: This prospective, longitudinal cohort study recruited patients from 13 intensive care units (ICUs) in four hospitals, with follow-up 3, 6, 12, and 24 months after ALI. The outcomes were Hospital Anxiety and Depression Scale depression score greater than or equal to 8 ("depressive symptoms") in patients without a history of depression before ALI, and two or more dependencies in instrumental activities of daily living ("impaired physical function") in patients without baseline impairment. MEASUREMENTS AND MAIN RESULTS: During 2-year follow-up of 186 ALI survivors, the cumulative incidences of depressive symptoms and impaired physical function were 40 and 66%, respectively, with greatest incidence by 3-month follow-up; modal durations were greater than 21 months for each outcome. Risk factors for incident depressive symptoms were education 12 years or less, baseline disability or unemployment, higher baseline medical comorbidity, and lower blood glucose in the ICU. Risk factors for incident impaired physical function were longer ICU stay and prior depressive symptoms. CONCLUSIONS: Incident depressive symptoms and impaired physical function are common and long-lasting during the first 2 years after ALI. Interventions targeting potentially modifiable risk factors (e.g., substantial depressive symptoms in early recovery) should be evaluated to improve ALI survivors' long-term outcomes.

Adequate health literacy is associated with higher heart failure knowledge and self-care confidence in hospitalized patients.

Heart failure (HF) patients with inadequate health literacy are at increased risk for poor self-care and negative health outcomes such as hospital readmission. The purpose of the present study was to examine the prevalence of inadequate health literacy, the reliability of the Dutch HF Knowledge Scale (DHFKS) and the Self-care of Heart Failure Index (SCHFI), and the differences in HF knowledge, HF self-care, and 30-day readmission rate by health literacy level among patients hospitalized with HF. The convenience sample included adults (n = 95) admitted to a large, urban, teaching hospital whose primary diagnosis was HF. Measures included the Short Test of Functional Health Literacy in Adults, the DHFKS, the SCHFI, and readmission at 30 days after discharge. The sample was 59 ± 14 years in age, 51% male, and 67% African American; 35% had less than a high school education, 35% were employed, 73% lived with someone who helps with their HF care, and 16% were readmitted within 30 days of index admission. Health literacy was inadequate for 42%, marginal for 19%, and adequate for 39%. Reliability of the DHFKS and SCHFI scales was comparable to prior reports. Mean knowledge score was 11.43 ± 2.26; SCHFI subscale scores were 56.82 ± 17.12 for maintenance, 63.64 ± 18.29 for management, and 65.02 ± 16.34 for confidence. Those with adequate health literacy were younger and had higher education level, HF knowledge scores, and HF self-care confidence compared with those with marginal or inadequate health literacy. Self-care maintenance and management scores and 30-day readmission rate did not differ by health literacy level. These findings demonstrate the high prevalence of inadequate and marginal health literacy and that health literacy is an important consideration in promoting HF knowledge and confidence in self-care behaviors, particularly among older adults and those with less than a high school education.

Nursing clinical practice guidelines to improve care for people undergoing percutaneous coronary interventions.

AIM: The aim of this paper is to present a set of nursing clinical practice guidelines for individuals undergoing percutaneous coronary interventions (PCIs) together with a summary of the evidence to support these recommendations. BACKGROUND: Percutaneous coronary intervention is a common procedure requiring expert nursing care delivered within an interdisciplinary team. Although evidence-based medical practice guidelines exist, they include minimal information to guide nursing-specific care. GUIDELINES DEVELOPMENT: The guidelines development process used a framework of the patient journey. Three steps leading up to this paper were undertaken: (1) a comprehensive literature review; (2) a consensus development workshop; and (3) a modified Delphi technique to refine the guideline recommendations. SUMMARY: Clinical practice guidelines to support interventional cardiology nursing care are limited. This paper represents an important contribution toward meeting this need. IMPLICATIONS FOR PRACTICE: These guidelines, developed within a context of Australian and New Zealand nursing practice, provide an important foundation to enable benchmarking and ongoing developing clinical practice standards.

Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: systematic review.

OBJECTIVE: This systematic review of recent randomized trials was conducted to determine if cardiovascular nursing interventions improve outcomes in patients with coronary artery disease (CAD) and/or heart failure. METHODS: Randomized controlled trials of nursing interventions in patients with CAD or heart failure published from January 2000 to December 2008 were eligible. Pilot studies and trials with greater than 25% attrition with no intention-to-treat analyses were excluded. Study characteristics and results were extracted and trials were graded for methodological quality. RESULTS: A total of 2,039 citations from electronic databases were identified; 55 articles were eligible for inclusion. The primary intervention strategy was education plus behavioral counseling and support (65% of interventions) using a combination of intervention modes. More than half of the trials (57%) reported statistically significant results in at least 1 outcome of blood pressure, lipids, physical activity, dietary intake, cigarette smoking, weight loss, healthcare utilization, mortality, quality of life, and psychosocial outcomes. However, there were no consistent relationships observed between intervention characteristics and the effects of interventions. The average measure of study quality was 2.8 (possible range, 0-4, with higher score equaling higher quality). CONCLUSION: Most trials reviewed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure. However, the optimal combination of intervention components, including strategy, mode of delivery, frequency, and duration, remains unknown. Establishing consensus regarding outcome measures, inclusion of adequate, representative samples, along with cost-effectiveness analyses will promote translation and adoption of cost-effective nursing interventions.

Nursing care practices following a percutaneous coronary intervention: results of a survey of Australian and New Zealand cardiovascular nurses.

BACKGROUND: Although there is high-level evidence to guide optimal medical care for percutaneous coronary interventions, there are less explicit guidelines to support nurses in providing care. AIM: This study describes the practice standards and priorities of care of cardiovascular nurses in Australia and New Zealand. METHOD: Item generation for the survey was informed by an integrative literature review and existing clinical guidelines. A 116-item Web-based survey was administered to cardiovascular nurses, via electronic mail lists of professional cardiovascular nursing organizations, using a secure online data collection system. RESULTS: Data were collected from March 2008 to March 2009. A total of 148 respondents attempted the survey, with 110 (74.3%) completing all items. All respondents were registered nurses with an average of 12.3 (SD, 7.61) years of clinical experience in the cardiovascular setting. A range of practice patterns was evident in ambulation time after percutaneous coronary intervention, methods of sheath removal, pain relief, and patient positioning. Respondents consistently rated psychosocial care a lower priority than other tasks and also identified a knowledge deficit in this area. CONCLUSION: This survey identified diversity of practice patterns and a range of educational needs. Increasing evidence to support evidence-based practice and guideline development is necessary to promote high-quality care and improved patient outcomes.

Exploring feasibility of home telemanagement in African Americans with congestive heart failure.

Existing telemonitoring systems provide limited support in implementing personalized treatment plans. We developed a Home Automated Telemanagement (HAT) system for patients with congestive heart failure (CHF) to provide support in following individualized treatment plans as well as to monitor symptoms, weight changes, and quality of life, while educating the patient on their disease. The system is designed to be placed in the patient's home and to communicate all patient data to a central server implementing real-time clinical decision support. The system questions the patient daily on their condition, monitors their weight, and provides the patient with instant feedback on their condition in the form of a 3-zone CHF action plan. Their medication regimen and suggested actions are determined by their care management team and integrated into the system, keeping a personalized approach to disease management while taking advantage of the technology available. The system is designed to be as simple as possible, making it usable by patients with no prior computer experience. A feasibility assessment in African American patients with CHF and without prior computer experience demonstrated high level of acceptance of the CHF HAT system.

Development of clinical practice guidelines for the nursing care of people undergoing percutaneous coronary interventions: An Australian & New Zealand collaboration.

AIM: This paper describes the development of nursing practice guidelines for percutaneous coronary intervention (PCI). BACKGROUND: Clinical practice guidelines (CPGs) supporting PCI nursing care are limited. METHOD: The National Health and Medical Research Council's (NH&MRC) health and medical practice development guidelines were used for the guideline development process. A panel of experts (clinicians and consumers) attended a consensus conference to review existing evidence. Subsequently, nurses' opinions were identified via an online survey. This was followed by a modified Delphi method was used to refine a draft set of guidelines over two rounds. RESULTS: The consensus conference was attended by 41 participants (39 cardiovascular nurses and 2 consumer representatives). Eight additional members joined the panel for the modified Delphi rounds with 27 participants completing the online survey. The final guideline document consisted of 75 recommendations. Endorsement was then sought from key peak cardiovascular bodies in Australia and New Zealand. DISCUSSION/CONCLUSION: Inconclusive evidence precludes definitive recommendations. Therefore, consultation and consensus are important in developing guidelines to achieve standardised nursing care and monitoring of outcomes. IMPLICATIONS FOR PRACTICE: Nurses play a crucial role in PCI care, yet currently there are limited guidelines to inform practice. This paper describes the method developing clinical practice guideline and deriving consensus.

Patient-, provider-, and system-level barriers to heart failure care.

BACKGROUND: The effectiveness of many heart failure (HF) treatments has been demonstrated, and national guidelines have been widely disseminated, yet HF care remains suboptimal. Numerous studies have examined barriers to HF care, but to date, there has been limited synthesis of these findings. METHODS AND RESULTS: Sixty articles reporting data on barriers to HF care published between 1998 and 2007 met the criteria for inclusion in this review. Barriers to care were reported at the patient, provider, and system levels. Patient barriers were reported in 45 studies and were categorized in the main themes of knowledge, adherence, communication, functional limitations, comorbidities, psychosocial, and socioeconomic factors. Provider barriers were examined in 23 studies and included knowledge, diagnostic challenges, pharmacological concerns, communication issues, and personal factors. Barriers at the healthcare system level were reported in 13 studies and pertained to problems with organizational structure, communication, and lack of resources. Several barriers were interrelated and could not be exclusively categorized to a single level of care, with overlap also occurring within the main barrier themes. CONCLUSIONS: Barriers to HF care were common and pervasive throughout the continuum of care. To effectively improve the quality of care and outcomes among HF patients, obstacles to HF care must be addressed at multiple levels.

Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approach.

AIM: To evaluate the existing literature to inform nursing management of people undergoing percutaneous coronary intervention. BACKGROUND. Percutaneous coronary intervention is an increasingly important revascularisation strategy in coronary heart disease management and can be an emergent, planned or rescue procedure. Nurses play a critical role in delivering care in both the independent and collaborative contexts of percutaneous coronary intervention management. DESIGN: Systematic review. METHOD: The method of an integrative literature review, using the conceptual framework of the patient journey, was used to describe existing evidence and to determine important areas for future research. The electronic data bases CINAHL, Medline, Cochrane and the Joanna Briggs data bases were searched using terms including: (angioplasty, transulminal, percutaneous coronary), nursing care, postprocedure complications (haemorrhage, ecchymosis, haematoma), rehabilitation, emergency medical services (transportation of patients, triage). RESULTS: Despite the frequency of the procedure, there are limited data to inform nursing care for people undergoing percutaneous coronary intervention. Currently, there are no widely accessible nursing practice guidelines focusing on the nursing management in percutaneous coronary intervention. Findings of the review were summarised under the headings: Symptom recognition; Treatment decision; Peri-percutaneous coronary intervention care, describing the acute management and Postpercutaneous coronary intervention management identifying the discharge planning and secondary prevention phase. CONCLUSIONS: Cardiovascular nurses need to engage in developing evidence to support guideline development. Developing consensus on nurse sensitive patient outcome indicators may enable benchmarking strategies and inform clinical trial design. RELEVANCE TO CLINICAL PRACTICE: To improve the care given to individuals undergoing percutaneous coronary intervention, it is important to base practice on high-level evidence. Where this is lacking, clinicians need to arrive at a consensus as to appropriate standards of practice while also engaging in developing evidence. This must be considered, however, from the central perspective of the patient and their family.

Intensive care unit hypoglycemia predicts depression during early recovery from acute lung injury.

OBJECTIVE: To evaluate the association between intensive care unit blood glucose levels and depression after acute lung injury. DESIGN: Prospective cohort study. SETTING: Twelve intensive care units in four hospitals in Baltimore, MD. PATIENTS: Consecutive acute lung injury survivors (n = 104) monitored during 1717 intensive care unit patient-days and screened for depression at 3 months after acute lung injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prevalence of a positive screening test for depression (Hospital Anxiety and Depression subscale score > or = 8) at follow-up was 28%. After adjustment for confounders, patients with a mean daily minimum intensive care unit glucose level < 100 mg/dL had significant increases in mean depression score (2.1 points, 95% confidence interval 0.6-3.7) and in the likelihood of a positive depression screening test (relative risk 2.6, 95% confidence interval 1.2-4.2). Patients with documented hypoglycemia < 60 mg/dL during their intensive care unit stay also had greater symptoms of depression (2.0 points, 95% confidence interval 0.5-3.5; relative risk 3.6, 95% confidence interval 1.8-5.1). Other factors independently associated with a positive depression screening test included body mass index > 40 kg/m2 (relative risk 3.3, 95% confidence interval 1.2-4.2), baseline depression/anxiety (relative risk 3.9, 95% confidence interval 1.5-6.5), and mean daily intensive care unit benzodiazepine dose > 100 mg of midazolam-equivalent agent (relative risk 2.4, 95% confidence interval 1.1-3.8). CONCLUSIONS: Hypoglycemia in the intensive care unit is associated with an increased risk of positive screening for depression during early recovery from acute lung injury. Baseline depressive symptoms, morbid obesity, and intensive care unit benzodiazepine dose were also associated with postacute lung injury depressive symptoms. These findings warrant increased glucose monitoring for intensive care unit patients at risk for hypoglycemia and further research on how patient and intensive care unit management factors may contribute to postintensive care unit depression.

Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury.

BACKGROUND: Barriers to evidence-based practice are not well understood. Within the intensive care unit (ICU) setting, low tidal volume ventilation (LTVV) in patients with acute lung injury (ALI) significantly decreases mortality. However, LTVV has not achieved widespread adoption. OBJECTIVES: To evaluate patient demographic and clinical factors, and ICU organizational factors associated with its use. DESIGN, SETTING AND PATIENTS: Prospective cohort study of 250 patients with ALI in 9 ICUs at 3 teaching hospitals in Baltimore, MD. MEASUREMENTS: Use of LTVV the day after ALI onset and association of patients' demographic and clinical factors and ICU organizational factors with LTVV using a multivariable logistic regression model adjusted for clustering of patients within ICUs. RESULTS: On the day after ALI onset, 46% and 81% of patients received a tidal volume < or = 6.5 and < or = 8.5 mL/kg predicted body weight (PBW), respectively, with no significant changes at 3 and 5 days after ALI. Using a strict definition of LTVV (< or = 6.5 mL/kg PBW), no patient demographic factors were independently associated with LTVV; however, two patient clinical and ICU organizational factors (odds ratio, 95% confidence interval) were independently associated: serum HCO3 level (< 22: .3, .1-.9, and > 26: .6, .1-3.5, versus 22-26) and use of a written protocol for LTVV (6.0, 1.3-27.2). In a sensitivity analysis using tidal volume < or = 8.5 mL/kg PBW, use of a written protocol remained significantly associated with LTVV. CONCLUSIONS: Patient demographic factors were not associated with LTVV. Given its strong association with LTVV, ICUs should use a written protocol for ventilation of ALI patients to help translate this evidence-based therapy into practice.

Determinants of target organ damage in black hypertensive patients attending primary health care services in Cape Town: the Hi-Hi study.

BACKGROUND: In South Africa (SA) cardiovascular disease (CVD) is the second leading cause of death, with hypertension (HTN) being the predominant contributor to morbidity and mortality associated with this disease. We examined the prevalence and determinants of target organ damage (TOD) among urban black hypertensive South Africans attending primary health-care (PHC) services in Cape Town. METHODS: Patients on HTN treatment, 35-65 years of age, participated in this cross-sectional study. Data relating to sociodemographic factors, medical history, lifestyle patterns, and HTN care regimens were obtained. Blood and urine samples were analyzed and electrocardiographs (ECGs) were recorded. Sokolow-Lyon and Minnesota Code (MC) criteria were used for identifying left ventricular hypertrophy (LVH). Reduced creatinine clearance (Cockroft-Gault), microalbuminuria, proteinuria, and elevated serum creatinine levels were used for identifying "renal impairment by any criteria" (RIC). Ischemic ECG patterns were classified in terms of MC criteria. Multivariate logistic regression analyses were carried out to identify variables independently associated with TOD. RESULTS: The study sample comprised 403 participants. RIC was identified in 26%, LVH in 35%, and ischemic ECG patterns in 49% of the participants. Uncontrolled HTN and an absence of diabetes were associated with LVH as per Sokolow-Lyon criteria. Older age, the presence of diabetes, and the use of beta-blockers were associated with RIC. Ischemic ECG patterns were associated with uncontrolled HTN, older age, male gender, the consumption of less alcohol, and higher levels of low-density lipoprotein cholesterol (LDL-C). CONCLUSIONS: TOD is common in this group of black hypertensive patients attending PHC sites. Uncontrolled HTN and older age were most often associated with TOD. Reducing the burden of TOD will require improving the quality of HTN care in PHC settings.

Medication adherence self-report instruments: implications for practice and research.

BACKGROUND: After an acute cardiac event, adhering to recommendations for pharmacologic therapy is important in achieving optimal health outcomes. Considering the impressive evidence base for cardiovascular pharmacotherapy, strategies for promoting adherence are less well developed. Furthermore, accessing reliable, valid, and cost-effective mechanisms of monitoring adherence in the research and clinical settings is challenging. AIM: The aim of this article was to review published self-report measures assessing and monitoring medication adherence in cardiovascular disease and provide recommendations for research into medication adherence. METHODS: The electronic databases CINAHL, Medline, and Science Direct were searched using the key search terms medication adherence and/or compliance, cardiovascular, self-report measures, and questionnaires. The World Wide Web was searched using the Google and Google Scholar search engines, and reference lists of retrieved documents were reviewed. The search strategy was verified by a health librarian. Instruments were included if they specifically addressed medication adherence as a discrete construct rather than a disease-specific or a generic health status measurement. FINDINGS: Despite of the problems with medication adherence identified in the literature, only 7 instruments met the search criteria. There was limited use of instruments across studies and settings to enable comparison across populations and extensive psychometric evaluation. CONCLUSIONS: Medication adherence is a complex, multifaceted construct dependent on a range of physical, social, economic, and psychological considerations. In spite of the importance of adherence in ensuring optimal cardiovascular outcomes, conceptual underpinnings and methods of assessing medication adherence require further discussion and debate.

Systematic review identifies number of strategies important for retaining study participants.

OBJECTIVE: Loss to follow-up threatens internal and external validity yet little research has examined ways to limit participant attrition. We conducted a systematic review of studies with a primary focus on strategies to retain participants in health care research. STUDY DESIGN AND SETTINGS: We completed searches of PubMed, CINAHL, CENTRAL, Cochrane Methodology Register, and EMBASE (August 2005). We also examined reference lists of eligible articles and relevant reviews. A data-driven thematic analysis of the retention strategies identified common themes. RESULTS: We retrieved 3,068 citations, 21 studies were eligible for inclusion. We abstracted 368 strategies and from these identified 12 themes. The studies reported a median of 17 strategies across a median of six themes. The most commonly reported strategies were systematic methods of participant contact and scheduling. Studies with retention rates lower than the mean rate (86%) reported fewer strategies. There was no difference in the number of different themes used. CONCLUSION: Available evidence suggests that investigators should consider using a number of retention strategies across several themes to maximize the retention of participants. Further research, including explicit evaluation of the effectiveness of different strategies, is needed.

Underserved urban african american men: hypertension trial outcomes and mortality during 5 years.

BACKGROUND: African American men with hypertension (HTN) in low socioeconomic urban environments continue to achieve poor rates of HTN control. METHODS: In a 5-year randomized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years, the effectiveness of a more intensive educational/behavioral/pharmacologic intervention provided by a nurse practitioner/community health worker/physician team was compared to less intensive information and referral intervention. Changes in behavioral factors, health care utilization, blood pressure (BP) control, left ventricular hypertrophy (LVH), and renal insufficiency were evaluated. RESULTS: Follow-up rates exceeded 89% of available men. The ranges of mean annual systolic BP/diastolic BP change from the baseline to each year follow-up were -3.7 to -10.1/-4.9 to -12.3 mm Hg for the more intensive group and +3.4 to -3.0/-1.8 to -8.7 mm Hg for the less intensive group. The annual proportion of men with controlled BP (<140/90 mm Hg) ranged from 17% to 44% in the more intensive group and 21% to 36% in the less intensive group. At 5 years the more intensive group had less LVH than the less intensive group and 17% of the men were deceased primarily due to narcotic or alcohol intoxication (36%) and cardiovascular causes (19%). CONCLUSIONS: An appropriate educational/behavioral intervention significantly improved BP control and reduced some sequelae of HTN in a young African American male population. Improvement in risk factors other than HTN was limited and sustained control of HTN was difficult to maintain during 5 years.

Intensive care unit exposures for long-term outcomes research: development and description of exposures for 150 patients with acute lung injury.

PURPOSE: Long-term follow-up studies in critical care have described survivors' outcomes, but provided less insight into the patient/disease characteristics and intensive care therapies ("exposures") associated with these outcomes. Such insights are essential for improving patients' long-term outcomes. This report describes the development of a strategy for comprehensively measuring relevant exposures for long-term outcomes research, and presents empiric results from its implementation. MATERIALS AND METHODS: A multistep, iterative process was used to develop the exposures strategy. First, a comprehensive list of potential exposures was generated and subsequently reduced based on feasibility, redundancy, and relevance criteria. Next, data abstraction methods were designed and tested. Finally, the strategy was implemented in 150 patients with acute lung injury with iterative refinement. RESULTS: The strategy resulted in the development of more than 60 unique exposures requiring less than 45 minutes per patient-day for data collection. Most exposures had minimal missing data and adequate reliability. These data revealed that evidence-based practices including lower tidal volume ventilation, spontaneous breathing trials, sedation interruption, adequate nutrition, and blood glucose of less than 6.1 mmol/L (110 mg/dL) occurred in only 23% to 50% of assessments. CONCLUSIONS: Using a multistep, iterative process, a comprehensive and feasible exposure measurement strategy for long-term outcomes research was successfully developed and implemented.

Cardiovascular risk and comorbid conditions among Black South Africans with hypertension in public and private primary care settings: the HiHi study.

OBJECTIVE: To describe the HiHi Study and assess cardiovascular disease (CVD) risk profile and comorbid conditions of Black patients receiving hypertension (HTN) care. DESIGN: Cross sectional, descriptive. SETTING: Public and private primary care sites in three townships near Cape Town, South Africa. PARTICIPANTS: 403 hypertensive Black patients (183 men, 220 women), ages 35-65 years. METHODS: Self-reported sociodemographic, lifestyle, and medical history factors were assessed. Height, weight, and blood pressure (BP) were measured and 12-lead electrocardiogram recorded. Blood and urine were collected to assess lipid profile, diabetes, and renal impairment. Type and number of medications were abstracted from medical records. RESULTS: Antihypertensive medication was prescribed for all participants, with HTN controlled (BP<140/90 mm Hg) for 36% of public and 51% of private patients. Mean systolic and diastolic BP were higher in the public than private sector (148/90 +/- 28/13 and 138/ 86 +/- 21/13 mm Hg) as was LVH (37% and 30%) but diabetes (18% and 29%) and obesity (55% and 75%) were less common in the public sector. There were no significant differences between public and private settings in use of antihypertensive medications, total cholesterol > or =5 mmol/L, daily tobacco use, or total CVD risk. More men than women smoked tobacco daily (30% and 6%) and used alcohol excessively (53% and 15%). CONCLUSIONS: Despite attending HTN primary care, CVD risk factors were addressed inadequately. Differences in risk factor prevalence and control were identified by healthcare sector and sex. A critical need exists to improve HTN care and CVD risk management programs for this high risk group.

Determinants of hypertension care and control among peri-urban Black South Africans: the HiHi study.

OBJECTIVE: To examine determinants of hypertension (HTN) care and control among peri-urban hypertensive Black South Africans. DESIGN: Cross-sectional, descriptive. SETTING: Public and private primary care sites in three townships near Cape Town, South Africa. PARTICIPANTS: 403 hypertensive Black patients (183 men, 220 women), ages 35-65 years. METHODS: The Precede-Proceed Model guided the study. Self-report sociodemographics, medical history, health behaviors, health service utilization, quality of life, social support, and exposure to life threats and illness were assessed. Blood pressure (BP) was measured and height and weight recorded. RESULTS: Mean BP (mm Hg) was 151/99 for men, 142/88 for women with BP controlled (<140/90 mm Hg) among 33% of men, 44% of women. Patient-related barriers to HTN care included limited HTN-related knowledge, poor quality of life and stressors such as family death. An unhealthy lifestyle involving smoking cigarettes, physical inactivity and using alcohol excessively was common. In regression models of select socioeconomic, lifestyle risk and HTN care variables, significant predictors of lower SBP and DBP or BP control included: fewer antihypertensive medications, better compliance to HTN recommendations, younger age, female, higher education level, not using alcohol excessively, and private sector healthcare. CONCLUSION: This study identified a high level of barriers to HTN control and the need for comprehensive multilevel interventions to improve HTN care and control in this high-risk population. Furthermore, the data illustrate that the Hill-Bone compliance scale can be a practical tool in primary healthcare settings to identify patient-related factors and guide counseling to improve adherence in HTN care.

Quality of life after acute respiratory distress syndrome: a meta-analysis.

OBJECTIVE: To summarize long-term quality of life (QOL) and the degree of variation in QOL estimates across studies of acute respiratory distress (ARDS) survivors. DESIGN: A systematic review of studies evaluating QOL in ARDS survivors was conducted. Medline, EMBASE, CINAHL, pre-CINAHL, and the Cochrane Library were searched, and reference lists from relevant articles were evaluated. Two authors independently selected studies reporting QOL in adult survivors of ARDS or acute lung injury at least 30 days after intensive care unit discharge and extracted data on study design, patient characteristics, methods, and results. MEASUREMENTS AND RESULTS: Thirteen independent observational studies (557 patients) met inclusion criteria. Eight of these studies used eight different QOL instruments, allowing only qualitative synthesis of results. The five remaining studies (330 patients) measured QOL using the Medical Outcomes Study 36-Item Short Form survey (SF-36). Mean QOL scores were similar across these studies, falling within a range of 20 points for all domains. Pooled domain-specific QOL scores in ARDS survivors 6 months or later after discharge ranged from 45 (role physical) to 66 (social functioning), or 15-26 points lower than population norms, in all domains except mental health (11 points) and role physical (39 points). Corresponding confidence intervals were no wider than +/-9 points. Six studies all found stable or improved QOL over time, but only one found significant improvement beyond 6 months after discharge. CONCLUSIONS: ARDS survivors in different clinical settings experience similar decrements in QOL. The precise magnitude of these decrements helps clarify the long-term prognosis for ARDS survivors.

Study protocol: The Improving Care of Acute Lung Injury Patients (ICAP) study.

INTRODUCTION: The short-term mortality benefit of lower tidal volume ventilation (LTVV) for patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) has been demonstrated in a large, multi-center randomized trial. However, the impact of LTVV and other critical care therapies on the longer-term outcomes of ALI/ARDS survivors remains uncertain. The Improving Care of ALI Patients (ICAP) study is a multi-site, prospective cohort study that aims to evaluate the longer-term outcomes of ALI/ARDS survivors with a particular focus on the effect of LTVV and other critical care therapies. METHODS: Consecutive mechanically ventilated ALI/ARDS patients from 11 intensive care units (ICUs) at four hospitals in the city of Baltimore, MD, USA, will be enrolled in a prospective cohort study. Exposures (patient-based, clinical management, and ICU organizational) will be comprehensively collected both at baseline and throughout patients' ICU stay. Outcomes, including mortality, organ impairment, functional status, and quality of life, will be assessed with the use of standardized surveys and testing at 3, 6, 12, and 24 months after ALI/ARDS diagnosis. A multi-faceted retention strategy will be used to minimize participant loss to follow-up. RESULTS: On the basis of the historical incidence of ALI/ARDS at the study sites, we expect to enroll 520 patients over two years. This projected sample size is more than double that of any published study of long-term outcomes in ALI/ARDS survivors, providing 86% power to detect a relative mortality hazard of 0.70 in patients receiving higher versus lower exposure to LTVV. The projected sample size also provides sufficient power to evaluate the association between a variety of other exposure and outcome variables, including quality of life. CONCLUSION: The ICAP study is a novel, prospective cohort study that will build on previous critical care research to improve our understanding of the longer-term impact of ALI/ARDS, LTVV and other aspects of critical care management. Given the paucity of information about the impact of interventions on long-term outcomes for survivors of critical illness, this study can provide important information to inform clinical practice.