Pilot of Patient Engagement in Continence Care on Geriatric Rehabilitation Units.

PURPOSE: The aim of this study was to pilot a process of engaging geriatric rehabilitation patients in the assessment and management of their continence concerns. DESIGN: A descriptive study was conducted. METHODS: The study has four phases: (1) staff education on continence with a pre-post knowledge quiz, (2) design of patient engagement process by a working group, (3) a 6-week pilot of a patient symptom questionnaire and process of engaging patients with audits of disciplinary admission histories and documentation, and (4) patient and staff feedback surveys. RESULTS: Patients in geriatric rehabilitation identify a range of bladder and bowel symptoms. However, there was little documented evidence from the interprofessional team that corresponded to patients' reported symptoms. CONCLUSION: Further research into symptoms bothersome to patients and engagement of both patients and the interprofessional team in addressing these in the rehabilitation setting is needed. CLINICAL RELEVANCE TO REHABILITATION NURSING: Patients admitted to geriatric rehabilitation have a range of bladder and bowel symptoms which need to be addressed.

Evolution of the fetal atrioventricular interval from 6 to 40 weeks of gestation

Doppler-based methods of estimating the atrioventricular interval are commonly used as a surrogate for the electrical PR in fetuses at risk of conduction abnormalities; however, to date, normal values for the fetal atrioventricular interval and an understanding of the evolution of its components in the late first trimester are lacking. We sought to investigate changes in the fetal atrioventricular interval from the first trimester to 40 weeks gestational age, and to explore functional and electrophysiological events that potentially impact its evolution. We prospectively examined healthy pregnancies by fetal echocardiography from 6 to 40 weeks' gestational age. The atrioventricular interval, heart rate, isovolumic contraction time, and A-wave duration were measured from simultaneous ventricular inflow-outflow Doppler tracings. Regression analysis was used to examine relations with gestational age, and linear relations with heart rate were assessed by Pearson's correlation coefficient. Data were collected in 305 fetuses from 279 pregnancies. Atrioventricular interval demonstrated an inverse relation with heart rate (r = -0.45, p <0.0001), dramatically decreasing before 10 weeks and slowly increasing thereafter. Between 6 and 9 weeks, isovolumic contraction time acutely decreasedapproaching 0, thereafter minimally increasing to term. In contrast, from 6 weeks, the A-wave duration linearly increased through gestation, and negatively correlated with heart rate (r = -0.62, p <0.0001). In conclusion, we have established normal measures of the atrioventricular interval from 6 to 40 weeks' gestational age. Before 10 weeks, a prolonged atrioventricular interval in healthy fetuses largely reflects the lengthened isovolumic contraction time which is likely influenced by the evolution of ventricular function and afterload. (AU)

Evolution of the Fetal Atrioventricular Interval from 6 to 40 Weeks of Gestation.

Doppler-based methods of estimating the atrioventricular interval are commonly used as a surrogate for the electrical PR in fetuses at risk of conduction abnormalities; however, to date, normal values for the fetal atrioventricular interval and an understanding of the evolution of its components in the late first trimester are lacking. We sought to investigate changes in the fetal atrioventricular interval from the first trimester to 40 weeks gestational age, and to explore functional and electrophysiological events that potentially impact its evolution. We prospectively examined healthy pregnancies by fetal echocardiography from 6 to 40 weeks' gestational age. The atrioventricular interval, heart rate, isovolumic contraction time, and A-wave duration were measured from simultaneous ventricular inflow-outflow Doppler tracings. Regression analysis was used to examine relations with gestational age, and linear relations with heart rate were assessed by Pearson's correlation coefficient. Data were collected in 305 fetuses from 279 pregnancies. Atrioventricular interval demonstrated an inverse relation with heart rate (r = -0.45, p <0.0001), dramatically decreasing before 10 weeks and slowly increasing thereafter. Between 6 and 9 weeks, isovolumic contraction time acutely decreased approaching 0, thereafter minimally increasing to term. In contrast, from 6 weeks, the A-wave duration linearly increased through gestation, and negatively correlated with heart rate (r = -0.62, p <0.0001). In conclusion, we have established normal measures of the atrioventricular interval from 6 to 40 weeks' gestational age. Before 10 weeks, a prolonged atrioventricular interval in healthy fetuses largely reflects the lengthened isovolumic contraction time which is likely influenced by the evolution of ventricular function and afterload.

The incremental benefit of color tissue doppler in fetal arrhythmia assessment

BACKGROUND: Accurate fetal arrhythmia (FA) diagnosis is key for effective management. Currently, FA assessment relies on standard echocardiography-based techniques (M mode and spectral Doppler), which require adequate fetal position and cursor alignment to define temporal relationships of mechanical events. Few data exist on the application of color Doppler tissue imaging (c-DTI) in FA assessment. The aim of this study was to examine the feasibility and clinical applicability of c-DTI in FA assessment in comparison with standard techniques. METHODS: Pregnancies with diagnosed FA were prospectively recruited to undergo c-DTI following fetal echocardiography. Multiple-cycle four-chamber clips in any orientation were recorded (mean frame rate, 180 ± 16 frames/sec). With offline analysis, sample volumes were placed on atrial (A) and ventricular (V) free walls for simultaneous recordings. Atrial and ventricular rates, intervals (for atrial-ventricular conduction and tachyarrhythmia mechanism), and relationships were assessed to decipher FA mechanism. FA diagnosis by c-DTI, conventional echocardiographic techniques, and postnatal electrocardiography and/or Holter monitoring were compared. RESULTS: FA was assessed by c-DTI in 45 pregnancies at 15 to 39 weeks, including 16 with atrial and/or ventricular ectopic beats; 18 with supraventricular tachyarrhythmias, including ectopic atrial tachycardia in 11, atrioventricular reentrant tachycardia in four, atrial flutter in two, and intermittent atrial flutter and junctional ectopic rhythm in one; three with ventricular tachycardias; and eight with bradycardias or atrioventricular conduction pathology, including five with complete atrioventricular block (AVB), one with first-degree AVB evolving into complete AVB, one with second-degree AVB, and one with sinus bradycardia. After training, FA diagnosis by c-DTI could be made irrespective of fetal orientation within 10 to 15 min. FA diagnosis by c-DTI concurred with standard techniques in 41 cases (91%), with additional findings identified by c-DTI in 10. c-DTI led to new FA diagnoses in four cases (9%) not definable by standard techniques. FA diagnosis by c-DTI was confirmed in all 20 with persistent arrhythmias after birth, including three with new diagnoses defined by c-DTI. c-DTI was particularly helpful in deciphering SVT mechanism (long vs short ventricular-atrial interval) in all 18 cases, whereas standard techniques permitted definition in only half. CONCLUSIONS: c-DTI with offline analysis permits rapid and accurate definition of FA mechanism, providing new information in nearly one-third of affected pregnancies. AU

The Incremental Benefit of Color Tissue Doppler in Fetal Arrhythmia Assessment.

BACKGROUND: Accurate fetal arrhythmia (FA) diagnosis is key for effective management. Currently, FA assessment relies on standard echocardiography-based techniques (M mode and spectral Doppler), which require adequate fetal position and cursor alignment to define temporal relationships of mechanical events. Few data exist on the application of color Doppler tissue imaging (c-DTI) in FA assessment. The aim of this study was to examine the feasibility and clinical applicability of c-DTI in FA assessment in comparison with standard techniques. METHODS: Pregnancies with diagnosed FA were prospectively recruited to undergo c-DTI following fetal echocardiography. Multiple-cycle four-chamber clips in any orientation were recorded (mean frame rate, 180 ± 16 frames/sec). With offline analysis, sample volumes were placed on atrial (A) and ventricular (V) free walls for simultaneous recordings. Atrial and ventricular rates, intervals (for atrial-ventricular conduction and tachyarrhythmia mechanism), and relationships were assessed to decipher FA mechanism. FA diagnosis by c-DTI, conventional echocardiographic techniques, and postnatal electrocardiography and/or Holter monitoring were compared. RESULTS: FA was assessed by c-DTI in 45 pregnancies at 15 to 39 weeks, including 16 with atrial and/or ventricular ectopic beats; 18 with supraventricular tachyarrhythmias, including ectopic atrial tachycardia in 11, atrioventricular reentrant tachycardia in four, atrial flutter in two, and intermittent atrial flutter and junctional ectopic rhythm in one; three with ventricular tachycardias; and eight with bradycardias or atrioventricular conduction pathology, including five with complete atrioventricular block (AVB), one with first-degree AVB evolving into complete AVB, one with second-degree AVB, and one with sinus bradycardia. After training, FA diagnosis by c-DTI could be made irrespective of fetal orientation within 10 to 15 min. FA diagnosis by c-DTI concurred with standard techniques in 41 cases (91%), with additional findings identified by c-DTI in 10. c-DTI led to new FA diagnoses in four cases (9%) not definable by standard techniques. FA diagnosis by c-DTI was confirmed in all 20 with persistent arrhythmias after birth, including three with new diagnoses defined by c-DTI. c-DTI was particularly helpful in deciphering SVT mechanism (long vs short ventricular-atrial interval) in all 18 cases, whereas standard techniques permitted definition in only half. CONCLUSIONS: c-DTI with offline analysis permits rapid and accurate definition of FA mechanism, providing new information in nearly one-third of affected pregnancies.

The incremental benefit of color tissue doppler in fetal arrhythmia assessment

BACKGROUND: Accurate fetal arrhythmia diagnosis is key for effective management. Standard echo-based techniques (M-mode and spectral Doppler) require adequate fetal position and cursor alignment to define temporal relationships of mechanical events. Little data exists on the application of cTDI in fetal rhythm assessment. OBJECTIVE: We sought to determine the benefit of color tissue Doppler imaging (cTDI) in fetal arrhythmia assessment over conventional fetal echo techniques. METHODS: Pregnancies with a diagnosis of fetal arrhythmia were prospectively recruited to undergo cTDI following fetal echocardiography. Multiple cycle 4-chamber clips in any orientation were recorded (frame rates >180 fps). With offline analysis, sample-volumes were placed on atrial (A) and ventricular (V) free walls with simultaneous recordings. A and V rates, intervals and relationships were evaluated. RESULTS: Arrhythmias were assessed in 45 fetuses by cTDI at 15-39 weeks and included: 11 atrial and 5 ventricular ectopic beats; 18 supraventricular tachyarrhythmias (SVT) including ectopic atrial tachycardia in 11, AV re-entry SVT in 4, atrial flutter (AF) in 2, intermittent AF and junctional ectopic rhythm in 1; ventricular tachycardias in 3; 8 bradycardias or AV conduction pathology including complete AV block (AVB) in 5, 1 AVB evolving into complete AVB in 1, 2 AVB in 1, sinus bradycardia in 1. Arrhythmia diagnosis by cTDI could be made irrespective of orientation of the fetus, after training, within 10-15 minutes. cTDI findings concurred with the diagnosis by standard techniques in 95% of cases and added new findings in 29%. In 5%, cTDI provided a new diagnosis, confirmed postnatally. In cases with SVT, cTDI permitted assessment of A-V and V-A intervals elucidating arrhythmia mechanism in all, whereas standard techniques had failed to define mechanism in 45%. CONCLUSION: cTDI with offline analysis permits rapid and accurate definition of fetal arrhythmia mechanism, providing new information in a significant proportion of affected pregnancies. (AU)

First-Trimester Fetal Echocardiography: Identification of Cardiac Structures for Screening from 6 to 13 Weeks' Gestational Age.

BACKGROUND: Early fetal echocardiography (FE), performed at 12 to 16 weeks' gestational age (GA), can be used to screen for fetal heart disease akin to that routinely performed in the second trimester. The efficacy of FE at earlier GAs has not been as well explored, particularly with recent advances in ultrasound technology. The aim of this study was to evaluate the efficacy of early FE in assessing fetal heart structure, and the added benefit of color Doppler (CD), from as early as 6 weeks through to 13+6 weeks' GA. METHODS: Pregnant women were prospectively recruited for first-trimester FE. All underwent two-dimensional (2D) cardiac imaging combined with CD assessment, and all were offered second-trimester fetal echocardiographic evaluations. Fetal cardiac anatomy was assessed both in real time during FE and additionally offline by two separate reviewers. RESULTS: Very early FE was performed in 202 pregnancies including a total of 261 fetuses, with 92% (n = 241) being reassessed at ≥18 weeks' GA. Mean GA at FE was 10+6 weeks (range, 6+1 to 13+6 weeks). Transabdominal scanning was used in all cases, and transvaginal scanning was used additionally in most at <11 weeks' GA (n = 103 of 117 [88%]). There was stepwise improvement in image resolution of the fetal heart in those pregnancies that presented at later gestation for assessment. CD assisted with definition of cardiac anatomy at all GAs. A four-chambered heart could be identified in 52% of patients in the eighth week (n = 12 of 23), improving to 80% (n = 36 of 45) in the 10th week and 98% (n = 57 of 58) by the 11th week. The inferior vena cava was visualized by 2D imaging in only 4% (n = 1 of 23) in the eighth week, increasing to 13% (n = 6 of 45) by the 10th week and 80% (n = 25 of 31) by the 13th week. CD improved visualization of the inferior vena cava at earlier GAs to >80% (n = 37 of 45) from 10 weeks. Pulmonary veins were not visualized by either 2D imaging or CD until after the 11th week. Both cardiac outflow tracts could be visualized by 2D imaging in the minority from 8+0 to 10+6 weeks (n = 18 of 109 [16%]) but were imaged in most from 11+0 to 13+6 weeks (n = 114 of 144 [79%]). CD imaging improved visualization of both outflow tracts to 64% (n = 29 of 45) in the 10th week. On 2D imaging alone, both the aortic and ductal arches were seen in only 29% of patients in the 10th week (n = 13 of 45), increasing to 58% when CD was used (58% [n = 26 of 45]) and to >80% (n = 47 of 58) using CD in the 11th week. CONCLUSIONS: Very early FE, from as early as 8 weeks, can be used to assess cardiac structures. The ability to image fetal heart structures between 6 and 8 weeks is currently nondiagnostic. The use of CD significantly increases the detection of cardiac structures on early FE. The ideal timing of complete early FE, excluding pulmonary vein assessment, appears to be after 11 weeks' GA.

Evolution of left ventricular function in the preterm infant.

BACKGROUND: The aim of this study was to evaluate left ventricular function in preterm infants from 28 days to near term using echocardiography. METHODS: Thirty clinically stable preterm infants delivered at <30 weeks' gestational age were prospectively enrolled. At 28 days, conventional, tissue Doppler, and speckle-tracking echocardiography evaluations of left ventricular function were performed, with comparison made to findings in 30 healthy term infants of similar postnatal age. Sixteen preterm infants underwent repeat examinations near term. RESULTS: Compared with controls, preterm infants at 28 days had decreased peak mitral valve (MV) E-wave velocities (P < .01), E/A ratios (P < .0001), annular e' velocities (P < .0001), and e'/a' ratios (P < .0001); increased MV E/e' ratios (P < .01); and lower basal circumferential early diastolic and higher late diastolic strain rates. No significant differences were found in fractional shortening, ejection fraction, and longitudinal or circumferential strain and strain rate between preterm infants and controls. Although preterm infants at 28 days had higher heart rates compared with controls (161 ± 15 vs 142 ± 16 beats/min), no significant correlations existed between heart rate and MV E, E/A ratio, e', e'/a' ratio, and E/e' ratio. Near term, the differences in diastolic function persisted, including decreased MV e'/a' ratio (P < .05), increased E/e' ratio (P < .01), and increased late diastolic strain rate. CONCLUSIONS: Clinically stable preterm infants have normal left ventricular systolic function but altered diastolic function, with greater dependence on atrial contraction, the latter of which persists despite nearing term. These findings may be relevant to the management of preterm infants and may relate to the longer term myocardial dysfunction observed in affected adults.

Antegrade late diastolic arterial blood flow in the fetus: insight into fetal atrial function.

OBJECTIVE: The purpose of this study was to examine the presence and frequency of antegrade late diastolic arterial blood flow (ALDAF) in the fetus and to determine its contribution to cardiac output. STUDY DESIGN: We evaluated the presence of ALDAF in 457 fetal and 21 postnatal echocardiograms. The timing of ALDAF to the ventricular systolic Doppler recording (ALDAF-V) was compared with the mechanical atrioventricular interval and, in neonates, the electrical PR interval. Velocity time integrals of ALDAF and the ventricular systolic Doppler signals were measured, and the percent contribution of ALDAF was calculated. RESULTS: ALDAF was observed in 365 of 457 studies and included all <11 weeks' gestations. Strong correlation between ALDAF-V, atrioventricular interval, and electrical PR interval suggests that ALDAF coincides with atrial contraction. ALDAF contributed substantially to cardiac output in early gestation with later decline. CONCLUSION: ALDAF results from atrial contraction. Increasing gestational age results in less ALDAF, and reduced ALDAF contribution to cardiac output likely due to improved diastolic function.