Challenges contributing to disrupted transition from paediatric to adult diabetes care in young adults with type 1 diabetes.

AIM: To examine challenges contributing to disruptions in care during the transition from paediatric to adult care among young adults with Type 1 diabetes who are primarily in ethnic minority groups and have low socio-economic status. METHODS: Participants (n = 20) were newly enrolled patients in a transition clinic for young adults with Type 1 diabetes with a history of loss to medical follow-up. Participants completed qualitative semi-structured interviews detailing their transition experiences in addition to demographic, HbA1c and psychosocial measures. Descriptive statistics were completed for quantitative data, and narrative thematic analysis of interviews was used to identify common themes. A mixed-method analysis was used to identify the associations between stressors identified in interviews and clinical and psychosocial variables. RESULTS: Three categories of challenges contributing to loss to follow-up were identified: psychosocial challenges, health provider and health system challenges and developmental challenges. Participants experienced a high degree of stressful life circumstances which were associated with higher HbA1c (r = 0.60, P = 0.005), longer duration of loss to follow-up (r = 0.51, P = 0.02), greater emergency department utilization (r = 0.45, P = 0.05), and lower life satisfaction (r = -0.62, P = 0.003). CONCLUSIONS: A confluence of challenges, including stressful life circumstances, healthcare system barriers and the developmental trajectory of young adulthood, contributes to a high risk of loss to follow-up and poor health in this population of young adults with Type 1 diabetes. An integrated approach to transition addressing medical and psychosocial needs may facilitate improved follow-up and health outcomes in clinical settings.

Famalismo Primero and Puerta Cerrada in Self-Managing Diabetes Among Hispanics: A Qualitative Meta-Synthesis.

INTRODUCTION: Type 2 diabetes (T2D) prevalence is increasing at concerning rates for Hispanics. Researchers have attempted to understand why through quantitative or qualitative studies. This meta-synthesis examines qualitative studies concerning barriers and facilitators that Hispanics face while managing their diabetes. METHOD: Noblit and Hare's (1988) defined method of analysis was used to synthesize 15 qualitative studies on Hispanics' diabetes self-management. RESULTS: Findings revealed two themes: (a) famalismo primero and (b) puerta cerrada, translating to family first and closed door, respectively. In famalismo primero, Hispanics with T2D prioritize family, and receive support, motivation, and knowledge from them first; puerta cerrada is tied to barriers such as cost of services and patient-provider relationships. DISCUSSION: Inclusion of family in diabetes self-management provides support and motivation for Hispanics. Hispanics experience barriers to access health care that may interfere with diabetes self-management, which need to be addressed to promote health equity.

A second-generation study of 427 probands with congenital heart defects and their 837 children.

OBJECTIVES: This study attempted to answer the question, Do mothers with congenital cardiovascular defects have more affected children than fathers with cardiac anomalies? BACKGROUND: In the 1950s to 1960s, concern was expressed about the safety of pregnancy in women with cardiac anomalies and the possibility of inheritance. METHODS: In a prospective study over 25 years, 236 women with cardiac defects were followed through pregnancy, and their 418 offspring were examined during their 1st 3 years. A high incidence of congenital cardiac malformations was noted. Then, a retrospective study of 191 men from the same clinic group and their total family (419 children) was performed to compare the incidence of affected children between the maternal study and this subsequent paternal study. RESULTS: Of 837 live children of these 427 probands, 14.1% (118) had a congenital heart defect (13.4% in the maternal study, 14.8% in the paternal study). There was no correlation with the surgical status of the proband. Concordance was somewhat greater among the children of affected mothers compared with those of affected fathers. Included in these studies were 31 high risk probands, 10 with genetic syndromes and 21 who had an affected sibling. Respectively, 53% and 41% of their children had cardiac anomalies, with a concordance > 50%; three fourths of these children had moderate to severe anomalies. CONCLUSIONS: The incidence of congenital heart defects in the children was not statistically different between the maternal and paternal studies. With removal of the high risk probands from the total study group, the risk of one affected parent having a child with a cardiac anomaly was 10.7%. Of the entire 837 children, only 7.5% had moderate or severe defects.

Pregnancy and its outcome in women with and without surgical treatment of congenital heart disease.

In the state of Connecticut, 233 women with congenital heart defects were prospectively followed up through 482 pregnancies that resulted in 372 infants who were examined frequently during their first 3 years of life. Approximately half of the women had undergone cardiac surgery and they were compared with the women without operation. There was no maternal mortality, and no patient had infective endocarditis, brain abscess or a cerebrovascular accident. The proportion of pregnancies resulting in live births did not differ significantly in mothers with and without cardiac surgery; the average live birth rate was 77 percent in all. However, the number and size of live-born infants was much greater in mothers who had become acyanotic as a result of reparative surgery than in the still cyanotic women, whether or not they had had palliative surgery. In cyanotic women, placental size was abnormally large in relation to birth weight, which was abnormally low. When the mothers were classified according to cardiac function, there was a significant difference between the number of infants born alive to mothers in good to excellent status and the number born to mothers in fair to poor condition. The latter had a significant increase in interrupted pregnancies as well as in cardiovascular complications during pregnancy. The total group had a 16.1 percent incidence rate of infants with congenital heart disease. This rate was corrected to 14.2 percent by removal of seven mothers, two with Noonan's syndrome, one with hypertrophic cardiomyopathy and four with a family history of congenital heart defects.

Radionuclide assessment of right and left ventricular exercise reserve after total correction of tetralogy of Fallot.

First pass radionuclide angiocardiography under conditions of rest and exercise was utilized to evaluate a group of 16 postoperative patients who had undergone total surgical correction of tetralogy of Fallot. Functional data were related to thallium-201 myocardial imaging at rest, a noninvasive means of detecting right ventricular hypertrophy. All 16 patients were asymptomatic and 15 demonstrated normal right ventricular ejection fraction (equal to or greater than 45 percent) at rest. However, 13 patients manifested abnormal right ventricular ejection fraction responses to exercise (normal response is an absolute increment in an ejection fraction of 5 or greater percent). For the entire group, right ventricular ejection fraction at rest was 55 +/- 2 percent, whereas at exercise it was 52 +/- 2 percent (p = not significant). In contrast, left ventricular ejection fraction responses were normal in all patients. Thallium-201 imaging revealed substantial right ventricular uptake consistent with residual right ventricular hypertrophy, which was quantifiable in all patients. Thus, abnormalities in right ventricular performance during exercise may be detected readily by this radionuclide approach in these postoperative patients despite their asymptomatic clinical status and generally normal right ventricular performance at rest.

Effect of phosphatase inhibition of in vitro dopamine sulfation and 3'-phosphoadenosine-5'-phosphosulfate catabolism in human brain.

The effects of inhibition of phosphatase activity in 100,000 g supernatant solution from human frontal cortex on dopamine (DA) conjugation were examined using the phosphatase substrate p-nitrophenyl phosphate (pNPO4). The increases in DA sulfation seen in the presence of pNPO4 suggested that inhibition of phosphatase activity in high speed supernatant solutions of brain may substantially alter the pattern of 3'-phosphoadenosine-5'-phosphosulfate (PAPS) metabolism and subsequently the rate of DA sulfation. Accordingly, the effects of the pyrophosphate analog phosphonoacetic acid (PAA) on the extent of DA sulfation and PAPS metabolism were examined in 100,000 g supernatant solution from human frontal cortex. At concentrations up to 10 mM, PAA markedly reduced PAPS hydrolysis to inorganic sulfate and 3'-phosphoadenosine-5'-phosphate (PAP) and significantly extended the linear time period for the sulfation of DA. These findings suggest that the phosphatase enzymes that degrade PAPS to produce the end product inhibitor, PAP, and possibly other break-down products of PAP, play an important role in determining the observed levels of phenol sulfotransferase activity in tissue from human brain in vitro.

A modified Ecteola cellulose assay for M and P phenol sulfotransferase.

The development and applications of a modified Ecteola cellulose, ion exchange assay for phenol sulfotransferase (EC 2.8.2.1, PST) are described. Mixtures containing dopamine or phenol and 35S-labeled 3'-phosphoadenosine-5'-phosphosulfate (PAPS) were incubated with 100,000 g supernatant solution from human frontal cortex and applied to 0.5 X 2 cm columns of Ecteola cellulose. Dopamine sulfate was eluted with 3 ml of distilled water, while phenyl sulfate, inorganic sulfate and unreacted PAPS were eluted with successive step gradients of 5, 20 and 200 mM NH4HCO3. The solution volume for phenyl sulfate was 11 ml, while those for inorganic sulfate and PAPS were both 6 ml. The new assay method yielded apparent Km values for dopamine, 3-methoxytyramine, tyramine and norepinephrine similar to those obtained by other methods. Comparison of the activities of various amine substrates at a concentration of 20 microM showed that dopamine was the preferred substrate, followed in decreasing order of relative activity by 3-methoxytyramine, norepinephrine, tyramine and octopamine. When mixed substrate inhibition of dopamine sulfation by phenol was examined, phenol was found to effectively inhibit dopamine sulfation over a range of 0.1 to 10 mM. The procedure described in this paper offers a number of significant advantages over currently available assays: these include a rapid, simple product isolation procedure and a complete, discrete separation of the radiolabeled products and reactants. This property allows the detailed study of the flux of radiolabel through the enzymatic system and also makes alternative substrate inhibition studies possible.

Management of coarctation of the aorta during pregnancy.

In this report, we shall describe the instantaneous electronic monitoring of the fetal heart rate at 24 weeks' gestation. The mother was undergoing resection of coarctation of the aorta. Because the fetal heart rate reflects by physiological and pharmacologic events, monitoring this rate enabled the anesthesiologists and surgeons to make therapeutic intervention sooner and on a more rational basis.

The content, integrity, and efficacy of a nurse coaching intervention in type 2 diabetes.

PURPOSE: The purpose of this study was to systematically evaluate the content, integrity, and efficacy of a nurse coaching intervention provided after diabetes education that focused on dietary and exercise lifestyle change in persons with type 2 diabetes. METHODS: A multimethod design incorporated an interpretive approach to examine the content and integrity of the intervention and a multiple-baseline, single-subject method to determine the preliminary efficacy of the intervention. RESULTS: The primary strategies of the nurse coaching intervention consisted of facilitating lifestyle change through educational reinforcement, psychosocial support, and motivational guidance. Aggregate quantitative outcomes revealed a modest increase in health-promoting behaviors and a decrease in fasting blood glucose, indicating a trend toward physiologic adaptation. Participants demonstrated a significant increase in integration reflective of psychosocial adaptation. CONCLUSIONS: Providing individualized nursing care after diabetes education may improve health outcomes and the quality of life of persons newly diagnosed with type 2 diabetes. This multimethod design is a cost-effective approach for preliminary evaluation of complex and/or novel interventions.

Intrathecal morphine analgesia for vaginal delivery in a woman with a single ventricle. A case report.

In a pregnant woman with a single cardiac ventricle, the coexisting cardiac anomalies provided a means of compensation. For vaginal delivery, intrathecal morphine was used for analgesia.

Validity in qualitative research.

Much contemporary dialogue has centered on the difficulty of establishing validity criteria in qualitative research. Developing validity standards in qualitative research is challenging because of the necessity to incorporate rigor and subjectivity as well as creativity into the scientific process. This article explores the extant issues related to the science and art of qualitative research and proposes a synthesis of contemporary viewpoints. A distinction between primary and secondary validity criteria in qualitative research is made with credibility, authenticity, criticality, and integrity identified as primary validity criteria and explicitness, vividness, creativity, thoroughness, congruence, and sensitivity identified as secondary validity criteria.

The peer advisor experience providing social support.

Research shows a link between increased social support and decreased complications after myocardial infarction (MI). In a current randomized controlled trial (RCT), a social support intervention administered by nurse and peer advisors is being examined to determine its influence on the health outcomes of unpartnered, post-MI elders. This qualitative study (as part of the larger RCT) sought a better understanding regarding the experience of the peer advisor. Data sources included peer advisor logs, a focus group, and telephone interviews with peer advisors. Findings revealed that helping, mutual sharing, committing, and benefiting are characteristics of peer experiences. Primarily because of their personal experience of recovery from MI, peer advisors had a remarkable ability to relate to assigned post-MI elders, offering a unique form of social support complementary to current health practices.

Mandinka mothers and nurslings: power and reproduction.

In a traditional Mandinka village of the Casamance Region of Senegal, indigenous understanding of the interdependencies of women and their children include not only patterns of nursing but the prospects for continued fertility as an outcome of the mother/nursling relationship. Based on two years of participant-observation and focused observations of 40 nursing mothers and their children from birth to over 12 months of age, this study examines breastfeeding as a relationship that is part of the process of dali lo, or socialization to the "Mandinka way." Patterns of nursing are elaborated by women's recognition of the power of fetuses and young children to control fertility, a power that affirms the concomitant role of nursing mothers as being agents of culture who nurture and wean cultural novices. The methodological implications of the female ethnographer as a social location for traditional fertility work and the ethnographers' child as resistant cultural novice are also discussed.

Consequences of not "knowing the patient".

"Knowing the patient" is an emerging concept in nursing that appears to be a central aspect of practice. "Knowing the patient" encompasses the complex process whereby the nurse acquires understanding of a specific patient as a unique individual, which subsequently enhances clinical decision-making, selection of optimal nursing interventions, and patient outcomes. Despite these heralded benefits, "knowing the patient" is severely undervalued in contemporary health care. Organizational arrangements, economic restraints, and efficiency of healthcare systems currently are of top priority. The potential effect on nursing practice is disconcerting; the effect on the discipline and the patient potentially devastating. This article explores the specific bureaucratic obstacles that impinge on "knowing the patient" within the context of nursing practice. It is hoped that illumination of the issues will beget viable alternative solutions, facilitating the transformation of awareness into action.

Genetic counseling for young adults who have a congenital heart defect.

Early individual guidance is needed for all adolescents and young adults with congenital heart defects. This should include not only a personal interest in the individual but also an attempt to identify concerns about sex education, smoking, drugs and the risks of pregnancy and possible inheritance. In a prospective study of 252 women with various cardiac malformations, the incidence of congenital heart defects in their progeny was 15.7% (13% exclusive of genetic syndromes and those with a positive family history). In those with a positive family history or a genetic syndrome the incidence was 56% in the offspring. Genetic syndromes with cardiac components are increasingly apparent. The role of teratogens such as medications, illicit drugs, and environmental exposure play a not yet clearly defined role. Careful discussion with potential parents, giving facts but with a positive approach, is an obligation of every physician.