The rights and responsibilities of citizenship for service users: some terms and conditions apply.

ACCESSIBLE SUMMARY: What is known about the subject? Citizenship is an important yet largely overlooked concept within psychiatric and mental health nursing practice Many service users are subject to legally mandated restrictions that place conditions on their rights and responsibilities as citizens. What this paper adds to existing knowledge? Even though service users have legal status as citizens, they continue to experience many conditions on their rights and responsibilities. Concerns about services users' trustworthiness and doubts about their levels of insight impact on their status as full citizens. What are the implications for practice? Nurses' understandings of the conditions placed on the citizenship rights and responsibilities of service users will ensure inclusive and less restrictive care and treatment Integration of the principles of therapeutic reciprocity and procedural justice within practice will help nurses balance both the rights of services users and legal restrictions on their liberty and autonomy INTRODUCTION: Service users have long been lobbying for equal participation as citizens, yet citizenship is an important and largely overlooked concept within nursing education and practice. AIMS: The study explored service users' understandings of their rights and responsibilities of citizenship and the conditions placed on these. METHODS: A total of 17 service users participated in semi-structured interviews. Isin's theory of the content of citizenship was used to analyze the data using a framework approach. RESULTS: Service users experience conditional citizenship that includes barriers to their participation and their rights and responsibilities that others in society enjoy. DISCUSSION: When the world of the service user is constructed through the language of the biomedical model, nurses may unwittingly reinforce psychiatric labels and thus perpetuate the stereotype that service users lack the competence to fully enact their rights and responsibilities. IMPLICATIONS FOR PRACTICE: When providing care, nurses should incorporate the notion of therapeutic jurisprudence and the principles of reciprocity, procedural justice and the implementation of advanced directives to reduce conditions on service users' status as citizens.

Validity of conjoint analysis to study clinical decision making in elderly patients with aortic stenosis.

OBJECTIVE: Written case simulations are increasingly being used to investigate clinical decision making. Our study was designed to determine the validity of written case simulations within a conjoint analysis approach. STUDY DESIGN AND SETTING: We developed a series of 32 written case simulations that differed with respect to nine clinical characteristics. These case simulations represented elderly patients with aortic stenosis. The clinical characteristics varied according to a fractional factorial design. We analyzed retrospectively all consecutive patients of 70 years of age or older with an aortic stenosis in three university hospitals. RESULTS: 34 cardiologists from three Dutch hospitals gave their treatment advice to each of these case simulations on a six-point scale (ranging from 'certainly no' to 'certainly yes' to surgical treatment). We compared the influence that the clinical characteristics had on the responses to these case simulations with their influence on the actual treatment decision for 147 actual patients in the same three hospitals. We found a strong agreement. This agreement was only slightly affected by the cut-off value used to dichotomize the treatment advice into a recommendation in favor of or against surgical treatment. CONCLUSION: Written case simulations reflect well how clinicians are influenced by specific clinical characteristics of their patients.

To operate or not on elderly patients with aortic stenosis: the decision and its consequences.

OBJECTIVE: To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients. DESIGN: Cohort analysis based on a prospective inclusive registry. SETTING: 205 consecutive patients (>/= 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands. RESULTS: The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment. CONCLUSIONS: In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.

Sharp incision of the anterior mitral leaflet due to penetrating trauma: report of a case and long-term follow-up.

A case is described of sharp incision of the anterior leaflet of the mitral valve, due to penetrating trauma to the chest with a knife. The lesion of the mitral leaflet was diagnosed with echocardiography and successfully repaired with autologous pericardial tissue. Follow up after 15 years showed normal mitral valve function.

Usefulness of multiplane transesophageal echocardiography to improve the assessment of severity of mitral regurgitation.

This study was designed to examine the accuracy of multiplane transesophageal echocardiography (TEE) color Doppler measurements in comparison to monoplane or biplane measurements in estimating the severity of mitral regurgitation (MR). Multiplane TEE potentially increases diagnostic accuracy of transesophageal examinations; it is unknown if multiplane is more accurate in assessing the severity of MR than monoplane or biplane TEE. Left ventricular cineangiograms of 91 patients with MR (40 no or mild, 30 moderate, and 21 severe) were compared with systolic pulmonary venous flow reversal and transesophageal color Doppler measurements: jet area and length in the transverse and longitudinal plane, maximal and average of those 2 planes (biplane), and maximal and average of 11 different planes (multiplane). Flow reversal (16 patients) identified severe MR with a specificity of 96% and a sensitivity of 62%; these were 96% and only 10% to 43%, respectively, for color Doppler measurements. In the absence of flow reversal, multiplane maximal jet area predicted severe MR with a sensitivity of 88% and a specificity of 75%, which were 85% and 76%, respectively, for no or mild MR; this did not differ significantly from results obtained by monoplane or biplane measurements. Color Doppler measurements of eccentric jets were not reliable for identification of severe MR. Systolic pulmonary venous flow reversal identifies 2 of 3 patients with severe MR with a high accuracy. In patients without flow reversal, multiplane color Doppler TEE is very capable of assessing MR severity, but biplane and monoplane TEE are equally accurate.

Assessment of quantitative hypertrophy scores in hypertrophic cardiomyopathy: magnetic resonance imaging versus echocardiography.

To compare the diagnostic value of spin-echo magnetic resonance (MR) imaging and transthoracic echocardiography in quantitative assessment of the extent of hypertrophy in patients with hypertrophic cardiomyopathy (HCM), we examined 52 consecutive patients with HCM. The Spirito-Maron and Wigle hypertrophy scores were calculated with wall thickness measurements obtained by both imaging modalities. MR imaging yielded complete assessment of anatomic features and allowed calculation of hypertrophy scores in 49 patients (94%). Adequate echocardiograms were obtained in 33 patients (63%) and correlated well with MR imaging for wall thickness measurements and for determination of the two hypertrophy scores (both r> 0.9). MR imaging provided additional information not available by echocardiography in 16 patients (31%). We conclude that the Spirito-Maron and Wigle hypertrophy scores correlated well between echocardiography and MR imaging. Because echocardiography was of insufficient quality for calculating adequate hypertrophy scores in 19 (37%) patients, MR imaging provided the most comprehensive diagnostic information in patients with HCM.

Biplane transesophageal color-flow Doppler imaging in assessing severity of mitral regurgitation: influence of hemodynamic circumstances and mechanism of regurgitation.

OBJECTIVE: To determine the value of biplane transesophageal echocardiography in the assessment of severity of mitral regurgitation compared with left ventricular angiography. DESIGN: Prospective study of consecutive patients. SETTING: Two university hospitals, one community hospital. PARTICIPANTS: Thirty-seven patients with angiographically proven mitral regurgitation. INTERVENTION: Transthoracic and biplane transesophageal echocardiography. In 19 patients, transesophageal echocardiography was performed during general anesthesia. MEASUREMENTS AND MAIN RESULTS: The largest mitral regurgitation jet area and longest jet as obtained with Doppler color-flow mapping from transthoracic and biplane transesophageal echocardiography and pulsed-Doppler pulmonary venous flow characteristics. Sensitivity and 100-minus-specificity were plotted to constitute receiver operating characteristics (ROC) curves. Areas under ROC curve for transverse, longitudinal, and biplane jet area were 0.77, 0.75, and 0.81, and for jet length, 0.82, 0.84, and 0.88, respectively; this was for biplane jet area in conscious patients; 0.99 compared with 0.72 in anesthetized patients (p < 0.05). CONCLUSIONS: Biplane measurements identified severe mitral regurgitation slightly more reliably than the transverse or longitudinal measurements alone. In conscious patients, jet area was an excellent test for estimating severity of mitral regurgitation. In anesthetized patients, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted angiographic severity of mitral regurgitation. In anesthetized patients, the optimal cut-off value for jet area to distinguish between moderate and severe mitral regurgitation was lower than in conscious patients. In the total population, regardless of hemodynamic and technical variations, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted the severity of mitral regurgitation.

Value of systolic pulmonary venous flow reversal and color Doppler jet measurements assessed with transesophageal echocardiography in recognizing severe pure mitral regurgitation.

We evaluated the value of color and pulsed Doppler transesophageal echocardiographic parameters and of V waves in estimating the severity of mitral regurgitation (MR) in 62 consecutive patients (38 men and 24 women, aged 39 to 80 years) with angiographically proven chronic pure MR (15 grade I/II, 47 grade III/IV). Twenty patients were examined before cardiac surgery under general anesthesia. Sensitivity, specificity, and positive and negative predictive values of systolic pulmonary venous flow reversal for the presence of grade III/IV MR were 87%, 93%, 98%, and 64%, respectively, these were for jet areas > or = 8.0 cm2--66%, 100%, 100%, and 48%, for jet lengths > or = 50 mm--70%, 87%, 94%, and 48%, for enlarged V waves--86%, 38%, 83%, and 43%, and for either flow reversal or a jet area > or = 8.0 cm2--96%, 93%, 98%, and 88%. We conclude that a combination of measurements improved the negative predictive value considerably, which is of importance in a population with a high pretest probability of severe MR. Enlarged V waves are not reliable in predicting severe MR. The optimal cutoff value for jet area and jet length was lower in anesthesized patients than in conscious patients; in anesthesized patients, sensitivity, specificity, and positive and negative predictive values of jet area > or = 5.0 CM2 for grade III/IV MR were 67%, 100%, 100%, and 50%, respectively; these were 87%, 100%, 100%, and 71% for flow reversal. Because the results of mitral repair are often evaluated with transesophageal echocardiography during surgery, our findings have clinical implications for evaluation of severe MR in anesthesized patients: pulmonary venous flow direction is the first-choice measure; jet area can be used when a low cutoff point is chosen.

Comparative effects of diltiazem and lisinopril on left ventricular structure and filling in mild-to-moderate hypertension.

The comparative effects on echocardiographically determined left ventricular (LV) mass and pulsed Doppler derived indexes of LV diastolic filling were studied in previously untreated hypertensive patients after 6 months of treatment with diltiazem 300 mg once daily (o.d.) (n = 16), and lisinopril 20 mg o.d. (n = 20). LV mass index decreased in the lisinopril group (from 98 to 96 g/m2; mean difference after 6 months of treatment with diltiazem-lisinopril was 13.7 g/m2 [95% confidence interval (CI) 0.8 to 26.6, p < 0.05]. In both groups diastolic filling parameters improved, but there was no statistically significant difference between the groups. Both treatment regimens showed a similar decrease in office and maximal exercise systolic blood pressure (SPB). Ambulatory daytime BP was lower after lisinopril treatment (from 147/96 to 126/83 mm Hg) than after diltiazem treatment (from 142/93 to 135/87 mm Hg); mean difference between diltiazem and lisinopril after 6 months of treatment was 9.7 (95% CI 3.4 to 16.0, p < 0.05)/9.4 (95% CI 2.5 to 16.3, p < 0.05) mm Hg. Nighttime BP decreased from 129/81 to 113/70 mm Hg in the lisinopril group, but not in the diltiazem group (from 125/79 to 122/77 mm Hg); mean difference between diltiazem and lisinopril after 6 months of treatment was 4.4 (95% CI - 0.2 to 8.9)/6.6 (95% CI 1.1 to 12.0) mm Hg. Changes in diastolic filling parameters were significantly correlated with changes in LV mass index in the lisinopril group, suggesting that the improvements in diastolic filling in the diltazem group may be partly due to an effect on factors other than LV mass.

Additional value of biplane transesophageal echocardiography in assessing the genesis of mitral regurgitation and the feasibility of valve repair.

To determine the additional diagnostic value of biplane transesophageal echocardiography (TEE) in patients undergoing mitral valve surgery, we studied 48 patients with severe mitral regurgitation. Transesophageal echocardiographic video recordings were reorganized in separate transverse and longitudinal sections to allow independent evaluation. Mechanism of mitral regurgitation and anatomic abnormalities of the mitral valve were assessed by all 3 transesophageal echocardiographic modalities and were related to surgical findings. Biplane TEE detected increased leaflet mobility with a sensitivity of 91% and a specificity of 84%, and restricted leaflet mobility with a sensitivity of 100% and a specificity of 97%. Biplane TEE was accurate in the diagnosis of most of the anatomic abnormalities associated with these mechanisms. However, the sensitivity for detecting subvalvular abnormalities (including papillary muscle abnormalities) was poor, and measurement of the annular diameter had a poor correlation with annular dilatation. Although the yield of biplane TEE was better than either transverse or longitudinal TEE alone, the differences did not reach statistical significance, because of the size of the patient group. The surgical procedure (either valve repair or replacement) was correctly predicted with transverse TEE in 71%, with longitudinal TEE in 69%, and with biplane TEE in 79% of the patients. All 3 transesophageal echocardiographic modalities are very capable of assessing the anatomic abnormalities and mechanism of mitral regurgitation, as well as predicting the feasibility of valve repair.

Increased dispersion of refractoriness in the absence of QT prolongation in patients with mitral valve prolapse and ventricular arrhythmias.

BACKGROUND: The mechanism responsible for the reported high incidence of ventricular arrhythmias in mitral valve prolapse is not clear. Electrocardiographic studies show an increased occurrence of repolarisation abnormalities on the 12 lead surface electrocardiogram, indicating regional differences in ventricular recovery. The purpose of this study was to investigate whether dispersion of refractoriness was an arrhythmogenic mechanism. METHODS: QT dispersion was measured in 32 patients with echocardiographically documented mitral valve prolapse and ventricular arrhythmias on 24 hour Holter recordings. QT dispersion was defined as the difference between the maximum and minimum average QT interval in any of the 12 leads of the surface electrocardiogram. QT dispersion corrected for heart rate was calculated by Bazett's formula. The results were compared with the data from 32 matched controls without a history of cardiac disease. Patients taking drugs that influence the QT interval and patients with a QRS duration > 120 ms were excluded. RESULTS: QT dispersion was greater in patients with mitral valve prolapse than in matched controls (60 (20) v 39 (11 ms) respectively, P < or = 0.001) as was corrected QT (64 (20 ms) v 43 (12 ms) respectively, P < or = 0.001). There was no significant difference in minimum or maximum QT intervals between the two groups. CONCLUSIONS: QT dispersion on the 12 lead surface electrocardiogram was greater in patients with mitral valve prolapse with ventricular arrhythmias than in normal controls, but the maximum QT interval was not increased. The results accord with the hypothesis that regional shortening and lengthening of repolarisation times in patients with mitral valve prolapse may account for the increased dispersion of refractoriness.

Changes in left and right atrial size after cardioversion of atrial fibrillation: role of mitral valve disease.

OBJECTIVES: The aim of this study was to examine the effect of cardioversion on left and right atrial volume in patients with chronic atrial fibrillation and to determine the influence of mitral valve disease on atrial size. BACKGROUND: Atrial enlargement is a common finding in atrial fibrillation and has been associated with an increased risk for embolic stroke. In addition, atrial enlargement may hamper long-term maintenance of sinus rhythm after cardioversion. METHODS: Forty-one patients with chronic atrial fibrillation (mean duration +/- SD, 45 +/- 62 months) underwent two-dimensional echocardiography before and 6 months after cardioversion to determine left and right atrial dimensions. Underlying heart disease was present in 26 patients: mitral valve disease in 12 (stenosis in 5, regurgitation in 5 and a combination in 2 patients) and other heart diseases in 14. Fifteen patients had lone atrial fibrillation. Patients with sustained sinus rhythm were compared with those who had a relapse of the arrhythmia 6 months after cardioversion. RESULTS: Six months after cardioversion, 28 patients still had sinus rhythm, whereas 13 patients had a relapse of the arrhythmia. In the 28 patients who had sinus rhythm after 6 months, left and right atrial volume decreased from a mean (+/- SD) 72.6 +/- 15.1 to 58.5 +/- 13.8 cm3 (-20%, p < 0.05) and from 68.7 +/- 14.6 to 58.6 +/- 11.6 cm3 (-14%, p < 0.05), respectively. Atrial dimensions also decreased significantly in the subgroup of patients with mitral valve disease. In contrast, no change in atrial size occurred in the 13 patients who had a relapse of atrial fibrillation. Left ventricular function did not change between the two echocardiographic studies, although New York Heart Association class improved in patients who had sinus rhythm after 6 months. CONCLUSIONS: Restoration of sinus rhythm reverts the process of left and right atrial enlargement in patients with chronic atrial fibrillation and mitral valve disease. Therefore, cardioversion may reduce the incidence of thromboembolic complications and prevent the arrhythmia from becoming refractory to medical therapy.

Efficacy and safety of flecainide acetate in the maintenance of sinus rhythm after electrical cardioversion of chronic atrial fibrillation or atrial flutter.

The efficacy and safety of flecainide were studied in the maintenance of sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter. Eighty-one patients were randomized to flecainide treatment or no treatment. Baseline characteristics of both groups were comparable. Compared to previous studies, patients could be classified as difficult-to-treat patients. Multiple regression analysis showed New York Heart Association class I for exercise tolerance (p = 0.0004) and flecainide treatment (p = 0.01) to be the main factors increasing the arrhythmia-free episode. However, Mantel-Cox lifetable analysis did not reveal significant differences between arrhythmia-free survival curves of both treatment groups. In the flecainide-treated group, 9% of patients experienced side effects, mostly related to negative dromotropic effects. The incidence of ventricular proarrhythmia in this group of patients was low. Thus, flecainide may be effective in postponing arrhythmia recurrence, even in difficult-to-treat patients. Caution should be excercised in treating patients with underlying conduction disturbances, sick sinus syndrome or characteristics favoring development of ventricular proarrhythmia.