The Costs of Caring: Quantifying Compassion Fatigue and Compassion Satisfaction in Burn Therapists.

Recovery from a severe burn injury requires early and aggressive therapy, which is often painful and distressing to the patient. Burn therapists who guide these interventions may be prone to experiencing secondary trauma and compassion fatigue through repeated exposure to difficult situations. At the same time, therapists may gain a sense of purpose and altruism from their work, fostering compassion satisfaction. Despite being well documented in other health professions, compassion fatigue and compassion satisfaction have not been sufficiently explored among burn therapists. This study aimed to quantify and characterize burn therapists' compassion fatigue and satisfaction using the Professional Quality of Life scale and to answer the question of what job-related factors may impact these outcomes. A total of 143 burn therapists participated in this study. Results revealed compassion fatigue subsale scores of burnout and secondary traumatic stress in the low or moderate range and compassion satisfaction scores in the moderate or high ranges for all participants. This study presents new knowledge for the field of burn care in its quantification of professional quality of life in burn therapists. While burn therapists experienced moderate-to-high levels of compassion satisfaction in their work, burnout and stress also approached moderate levels. Years of practice was a significant predictor of compassion. Although the reasons for this are not clear, it may be related to increased competence or confidence in practice and may suggest a need for different support strategies for practitioners at each stage of their burn therapy career.

A Qualitative Descriptive Exploration of the Experiences of Burn Therapists.

Exposure to patients who have experienced major traumatic events places burn therapists at risk of developing high levels of anxiety and stress, directly impacting their quality of life. Poor professional quality of life has been associated with negative physical and emotional characteristics in healthcare professionals and may subsequently influence patient safety and satisfaction, job retention, and productivity. The purpose of this study was to understand and describe the experiences of occupational and physical therapists who provide acute therapy to people who have sustained burn injuries. Semistructured interviews were completed with 10 participants (8 females and 7 physical therapists) for this qualitative descriptive study. Conventional content analysis was used to analyze the data collected from semistructured interviews. Six themes emerged after content analysis: (1) the importance of therapeutic relationships to patient successes and therapists' retention; (2) the autonomy and flexibility of burn therapists; (3) the impact of career longevity on compassion; (4) the uniqueness of burn team relationships and camaraderie; (5) the challenges of operating within the business of a healthcare system; and (6) the physical, mental, and emotional challenges to the burn therapists' resiliency. This research brings to light the physical, mental, and emotional challenges that impact burn therapists' resiliency, and which should be considered when creating programs to increase retention and professional quality of life in this professional population.

Perinatal Telehealth: Meeting Patients Where They Are.

INTRODUCTION: Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of innovative telehealth perinatal care models showed similar clinical outcomes and perceived quality of care between groups receiving a combination of virtual video and in-person visits. However, these studies included primarily White, English-speaking participants, excluding those who were economically disenfranchised or did not speak English. The purpose of this qualitative study was to describe perinatal patients' and providers' experiences with telehealth during and after the acute phase of the COVID-19 pandemic to inform future utilization of telehealth to drive the delivery of high-quality, accessible, and equitable perinatal care to diverse communities. METHODS: This descriptive qualitative study included a purposive sample of 14 patients and 17 providers who received or provided perinatal care via telehealth in either a certified nurse-midwifery practice or the nurse-family partnership care model between March 2020 and April 2022. Maximum variation sampling offered a diverse population based on race, ethnicity, and rurality. Researchers conducted 2 rounds of semistructured interviews with a focus on understanding social and geographic context. RESULTS: Six themes were identified through inductive analysis: (1) unexpected advantages of telehealth, (2) patient empowerment, (3) providers' fear of adverse outcomes, (4) concern for equitable care, (5) strategies to enhance the telehealth experience, and (6) strategies to address access to perinatal telehealth. Patients appreciated the increased ease and reduced cost of accessing visits, which led to fewer missed appointments. Health care providers saw great opportunity in telehealth but expressed concerns about accessibility for patients with language barriers or limited resources. DISCUSSION: This study provides insight into priorities for continued telehealth utilization focused on providing equitable access to perinatal care. Rather than returning to practices from before the COVID-19 pandemic formed from longstanding routines and perceived limitations, providers are encouraged to capitalize on the rapid innovations in telehealth to build a more effective, equitable, and patient-centered approach to perinatal care.

Smart Speaker and ICT Use in Relationship With Social Connectedness During the Pandemic: Loneliness and Social Isolation Found in Older Adults in Low-Income Housing.

BACKGROUND AND OBJECTIVES: Social well-being of older adults living in low-income housing was disproportionately affected by the coronavirus disease 2019 pandemic. We explored low-income residents' experiences of social isolation and loneliness and strategies to remain socially connected during the pandemic. RESEARCH DESIGN AND METHODS: As part of a larger, 3-phase user-centered design study, we conducted a qualitative study using focus groups to gain insights into social isolation experiences and the role of information and communication technologies (ICTs), including smart speakers, in social connectedness (N = 25, 76% African American). We also collected survey data to describe social isolation, loneliness, and current ICT use in the sample. Participants included both smart speaker users and nonusers. RESULTS: Experiences of social isolation and loneliness varied by participants' sociodemographic characteristics and previous experiences with smart speakers. Qualitative analysis showed participants demonstrated coping strategies developed during the pandemic to adapt to new norms of connecting with others, including technology-enabled social interactions. Participants expressed a strong desire to build community together in their facilities and highlighted the potential role of smart speakers in making meaningful social connections, encompassing safety checks to have a means for emergencies, and providing a virtual companion. Access, digital literacy, training, security, and privacy issues were discussed as factors affecting their adoption of new ICT for enhanced social connectedness. DISCUSSION AND IMPLICATIONS: This study highlights the importance of understanding the unique social isolation experience, demographics, and social determinants of health of low-income residents to develop ICT-based interventions for social connectedness.

Strategies to Strengthen Nursing PhD Enrollment: An Ecological Systems Perspective.

BACKGROUND: Nurses with a Doctor of Philosophy (PhD) degree are essential to developing nursing knowledge, promoting health outcomes, and educating the next generation of nurses. Declining enrollment in nursing PhD programs calls for purposeful action. Guided by Bronfenbrenner's Ecological Systems Framework, this article outlines barriers and facilitators, and offers strategies to increase PhD enrollment. METHOD: Extant literature and the authors' cumulative experiences in PhD education and research were reviewed to identify strategies to increase PhD enrollment. RESULTS: Multilevel influences impede or facilitate enrollment in PhD programs. Strategies addressing individual and interpersonal influences included intentional personalized recruiting and early outreach to students at various levels of education. Institutional and organizational strategies included research partnerships and programs, and financial and infrastructure support. Sociocultural strategies included image branding and a positive social media presence supporting nurse scientists. CONCLUSION: Strategies to enhance PhD enrollment across all levels can spark interest in nursing science and PhD enrollment. [J Nurs Educ. 2023;62(12):669-678.].

A mixed-methods exploration of nurse loneliness and burnout during COVID-19.

AIM: This study investigated the phenomenon of nurse loneliness as a potential contributor to burnout. BACKGROUND: Nurse wellbeing is critical for safe and efficient healthcare delivery. However, evidence indicates nurses' wellbeing is at risk. The levels of burnout, the most commonly measured symptom of suboptimal wellbeing, are rising and may relate to a largely unexplored phenomenon: loneliness. METHODS: A mixed-methods approach was used to investigate burnout and loneliness in direct-care nurses in four diverse hospitals in the midwestern and southeastern United States. Burnout and loneliness were measured, prevalence was estimated, and correlation was examined. Interpretive descriptive inquiry and analysis was used to develop a richer understanding of nurse loneliness in the context of burnout. While this study did not explicitly explore the impact of the global pandemic, data was collected in late 2021 and early 2022, during the Delta variant wave. RESULTS: In the study population (n = 117), rates of burnout are high and positively correlate with loneliness. Qualitative interviews (n = 11) revealed that nurses feel unseen, emotionally detached from their work, and dehumanized. However, social connection with peers is protective and nurses still report a strong sense of devotion to the profession and solidarity with peers. CONCLUSIONS: This study offers insight into nurse loneliness, highlighting the importance of social connectedness to improve nurse wellbeing.

Loneliness and Burnout in Nephrology Nurses: A Review of the Literature and Indications for Future Research.

Nurses are crucial to the health care workforce, yet their well-being is often overlooked, adversely affecting patient care. This article examines the intersection of loneliness and burnout among nephrology nurses, and its impact on their well-being and job performance. Loneliness, defined as inadequate social connections, is identified as a significant contributor to burnout and suboptimal well-being among nurses. Findings emphasize the importance of addressing loneliness and promoting social connectedness within the nursing profession. Strategies, such as fostering supportive relationships, creating support groups, and implementing policies to reduce emotional burdens and workload pressures, are recommended. We emphasize the need to prioritize nurse well-being for a resilient health care workforce and improved patient outcomes, and discuss its implications for nursing practice, education, and policy.

The connection between loneliness and burnout in nurses: An integrative review.

Nurse burnout is a threat to safe, efficient health care delivery, yet estimated rates of nurse burnout are above 40 %. A critical step in reducing burnout is identifying phenomena that are amenable to intervention. Loneliness may be one such factor, yet the relationship between loneliness and burnout is not clearly described. This review aims to summarize existing literature documenting this connection. A systematic search was performed to identify studies reporting a relationship between burnout and loneliness with social support serving as a proxy construct. Twenty-four articles met inclusion criteria: 18 quantitative, two mixed-methods, and four qualitative studies. These studies identified a relationship between burnout and social support, with social support explaining approximately a third of the variability in burnout. Qualitative data suggest that social support is critical to coping with work stressors and is likely related to burnout. This review provides evidence that reducing nurse loneliness is a promising strategy for improving nurse wellbeing.

Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing With Cost Savings and Reduced Greenhouse Gas Emissions.

Anesthetic agents are known greenhouse gases with hundreds to thousands of times the global warming impact compared with carbon dioxide. We sought to mitigate the negative environmental and financial impacts of our practice in the perioperative setting through multidisciplinary staff engagement and provider education on flow rate reduction and volatile agent choice. These efforts led to a 64% per case reduction in carbon dioxide equivalent emissions (163 kg in Fiscal Year 2012, compared with 58 kg in Fiscal Year 2015), as well as a cost savings estimate of $25,000 per month.

Effects of Intermittent Versus Continuous Energy Intakes on Insulin Sensitivity and Metabolic Risk in Women with Overweight.

OBJECTIVE: This study aimed to compare intermittent fasting (IF) versus continuous energy intakes at 100% or 70% of calculated energy requirements on insulin sensitivity, cardiometabolic risk, body weight, and composition. METHODS: Women with overweight (n = 88; 50 ± 1 years, BMI 32.3 ± 0.5 kg/m2 ) were randomized to one of four diets (IF70, IF100, dietary restriction [DR70], or control) in a 2:2:2:1 ratio for 8 weeks. IF groups fasted for 24 hours after breakfast on three nonconsecutive days per week. All foods were provided and diets matched for macronutrient composition (35% fat, 15% protein, 50% carbohydrate). Insulin sensitivity by hyperinsulinemic-euglycemic clamp, weight, body composition, and plasma markers were assessed following a "fed" day (12-hour fast) and a 24-hour fast (IF only). RESULTS: IF70 displayed greater reductions in weight, fat mass, total- and low-density lipoprotein cholesterol, and nonesterified fatty acids compared with DR70 and IF100 (all P ≤ 0.05). IF100 lost more weight and fat than control. However, fasting insulin was increased. There were no group differences in insulin sensitivity by clamp; however, a 24-hour fast transiently reduced insulin sensitivity. CONCLUSIONS: When prescribed at matched energy restriction, IF reduced weight and fat mass and improved total and low-density lipoprotein cholesterol more than DR. IF prescribed in energy balance did not improve health compared with other groups, despite modest weight loss.

Do intermittent diets provide physiological benefits over continuous diets for weight loss? A systematic review of clinical trials.

Energy restriction induces physiological effects that hinder further weight loss. Thus, deliberate periods of energy balance during weight loss interventions may attenuate these adaptive responses to energy restriction and thereby increase the efficiency of weight loss (i.e. the amount of weight or fat lost per unit of energy deficit). To address this possibility, we systematically searched MEDLINE, PreMEDLINE, PubMed and Cinahl and reviewed adaptive responses to energy restriction in 40 publications involving humans of any age or body mass index that had undergone a diet involving intermittent energy restriction, 12 with direct comparison to continuous energy restriction. Included publications needed to measure one or more of body weight, body mass index, or body composition before and at the end of energy restriction. 31 of the 40 publications involved 'intermittent fasting' of 1-7-day periods of severe energy restriction. While intermittent fasting appears to produce similar effects to continuous energy restriction to reduce body weight, fat mass, fat-free mass and improve glucose homeostasis, and may reduce appetite, it does not appear to attenuate other adaptive responses to energy restriction or improve weight loss efficiency, albeit most of the reviewed publications were not powered to assess these outcomes. Intermittent fasting thus represents a valid--albeit apparently not superior--option to continuous energy restriction for weight loss.

Fat oxidation over a range of exercise intensities: fitness versus fatness.

Maximal fat oxidation (MFO), as well as the exercise intensity at which it occurs (Fatmax), have been reported as lower in sedentary overweight individuals but have not been studied in trained overweight individuals. The aim of this study was to compare Fatmax and MFO in lean and overweight recreationally trained males matched for cardiorespiratory fitness (CRF) and to study the relationships between these variables, anthropometric characteristics, and CRF. Twelve recreationally trained overweight (high fatness (HiFat) group, 30.0% ± 5.3% body fat) and 12 lean males (low fatness (LoFat), 17.2% ± 5.7% body fat) matched for CRF (maximal oxygen consumption (V̇O2max) 39.0 ± 5.5 vs. 41.4 ± 7.6 mL·kg(-1)·min(-1), p = 0.31) and age (p = 0.93) performed a graded exercise test on a cycle ergometer. V̇O2max and fat and carbohydrate oxidation rates were determined using indirect calorimetry; Fatmax and MFO were determined with a mathematical model (SIN); and % body fat was assessed by air displacement plethysmography. MFO (0.38 ± 0.19 vs. 0.42 ± 0.16 g·min(-1), p = 0.58), Fatmax (46.7% ± 8.6% vs. 45.4% ± 7.2% V̇O2max, p = 0.71), and fat oxidation rates over a wide range of exercise intensities were not significantly different (p > 0.05) between HiFat and LoFat groups. In the overall cohort (n = 24), MFO and Fatmax were correlated with V̇O2max (r = 0.46, p = 0.02; r = 0.61, p = 0.002) but not with % body fat or body mass index (p > 0.05). Fat oxidation during exercise was similar in recreationally trained overweight and lean males matched for CRF. Consistently, substrate oxidation rates during exercise were not related to adiposity (% body fat) but were related to CRF. The benefits of high CRF independent of body weight and % body fat should be further highlighted in the management of obesity.

Reproducibility of Fatmax and fat oxidation rates during exercise in recreationally trained males.

Aerobic exercise training performed at the intensity eliciting maximal fat oxidation (Fat(max)) has been shown to improve the metabolic profile of obese patients. However, limited information is available on the reproducibility of Fat(max) and related physiological measures. The aim of this study was to assess the intra-individual variability of: a) Fat(max) measurements determined using three different data analysis approaches and b) fat and carbohydrate oxidation rates at rest and at each stage of an individualized graded test. Fifteen healthy males [body mass index 23.1 ± 0.6 kg/m(2), maximal oxygen consumption (VO2max) 52.0 ± 2.0 ml/kg/min] completed a maximal test and two identical submaximal incremental tests on ergocycle (30-min rest followed by 5-min stages with increments of 7.5% of the maximal power output). Fat and carbohydrate oxidation rates were determined using indirect calorimetry. Fat(max) was determined with three approaches: the sine model (SIN), measured values (MV) and 3rd polynomial curve (P3). Intra-individual coefficients of variation (CVs) and limits of agreement were calculated. CV for Fat(max) determined with SIN was 16.4% and tended to be lower than with P3 and MV (18.6% and 20.8%, respectively). Limits of agreement for Fat(max) were -2 ± 27% of VO2max with SIN, -4 ± 32 with P3 and -4 ± 28 with MV. CVs of oxygen uptake, carbon dioxide production and respiratory exchange rate were <10% at rest and <5% during exercise. Conversely, CVs of fat oxidation rates (20% at rest and 24-49% during exercise) and carbohydrate oxidation rates (33.5% at rest, 8.5-12.9% during exercise) were higher. The intra-individual variability of Fat(max) and fat oxidation rates was high (CV>15%), regardless of the data analysis approach employed. Further research on the determinants of the variability of Fat(max) and fat oxidation rates is required.

Methodological considerations for meal-induced thermogenesis: measurement duration and reproducibility.

Meal-induced thermogenesis (MIT) research findings have been highly inconsistent, in part, due to the variety of durations and protocols used to measure MIT. In the present study, we aimed to determine the following: (1) the proportion of a 6 h MIT response completed at 3, 4 and 5 h; (2) the associations between the shorter durations and the 6 h measures; (3) whether shorter durations improved the reproducibility of the measurement. MIT was measured in response to a 2410 kJ mixed composition meal in ten individuals (five males and five females) on two occasions. Energy expenditure was measured continuously for 6 h post-meal using indirect calorimetry, and MIT was calculated as the increase in energy expenditure above the pre-meal RMR. On average, 76, 89 and 96 % of the 6 h MIT response was completed within 3, 4 and 5 h, respectively, and MIT at each of these time points was strongly correlated with the 6 h MIT response (range for correlations, r 0·990-0·998; P< 0·01). The between-day CV for the 6 h measurement was 33 %, but it was significantly lower after 3 h of measurement (CV 26 %; P= 0·02). Despite variability in the total MIT between days, the proportion of MIT that was completed at 3, 4 and 5 h was reproducible (mean CV: 5 %). While 6 h are typically required to measure the complete MIT response, the 3 h measures provide sufficient information about the magnitude of the MIT response and may be applicable for testing individuals on repeated occasions.

Radiocarbon dating casts doubt on the late chronology of the Middle to Upper Palaeolithic transition in southern Iberia.

It is commonly accepted that some of the latest dates for Neanderthal fossils and Mousterian industries are found south of the Ebro valley in Iberia at ca. 36 ka calBP (calibrated radiocarbon date ranges). In contrast, to the north of the valley the Mousterian disappears shortly before the Proto-Aurignacian appears at ca. 42 ka calBP. The latter is most likely produced by anatomically modern humans. However, two-thirds of dates from the south are radiocarbon dates, a technique that is particularly sensitive to carbon contaminants of a younger age that can be difficult to remove using routine pretreatment protocols. We have attempted to test the reliability of chronologies of 11 southern Iberian Middle and early Upper Paleolithic sites. Only two, Jarama VI and Zafarraya, were found to contain material that could be reliably dated. In both sites, Middle Paleolithic contexts were previously dated by radiocarbon to less than 42 ka calBP. Using ultrafiltration to purify faunal bone collagen before radiocarbon dating, we obtain ages at least 10 ka (14)C years older, close to or beyond the limit of the radiocarbon method for the Mousterian at Jarama VI and Neanderthal fossils at Zafarraya. Unless rigorous pretreatment protocols have been used, radiocarbon dates should be assumed to be inaccurate until proven otherwise in this region. Evidence for the late survival of Neanderthals in southern Iberia is limited to one possible site, Cueva Antón, and alternative models of human occupation of the region should be considered.

Can venous occlusion plethysmography be used to measure high rates of arterial inflow?

To investigate whether venous occlusion plethysmography (VOP) may be used to measure high rates of arterial inflow associated with exercise, venous occlusions were performed at rest, and following dynamic handgrip exercise at 15, 30, 45, and 60% of maximum voluntary contraction (MVC) in seven healthy males. The effect of including more than one cardiac cycle in the calculation of blood flow was assessed by comparing the cumulative blood flow over one, two, three, or four cardiac cycles. The inclusion of more than one cardiac cycle at 30 and 60% MVC, and more than two cardiac cycles at 15 and 45% MVC resulted in a lower blood flow compared to using only the first cardiac cycle (P < 0.05). Despite the small time interval over which arterial inflow was measured (~1 s), this did not affect the reproducibility of the technique. Reproducibility (coefficient of variation for arterial inflow over three trials) tended to be poorer at the higher workloads, although this was not significant (12.7 +/- 6.6, 16.2 +/- 7.3, and 22.9 +/- 9.9% for the 15, 30, and 45% MVC workloads; P = 0.102). There was also a tendency for greater reproducibility with the inclusion of more cardiac cycles at the highest workload, but this did not reach significance (P = 0.070). In conclusion, when calculated over the first cardiac cycle only during venous occlusion, high rates of forearm blood flow can be measured using VOP, and this can be achieved without a significant decrease in the reproducibility of the measurement.

Vo2max in overweight and obese adults: do they meet the threshold criteria?

PURPOSE: The purpose of this study was to determine whether adiposity affects the attainment of (.)VO2max. METHODS: Sixty-seven male and 68 female overweight (body mass index (BMI) = 25-29.9 kg.m) and obese (BMI > or = 30 kg x m) participants undertook a graded treadmill test to volitional exhaustion (phase 1) followed by a verification test (phase 2) to determine the proportion who could achieve a plateau in (.)VO2 and other "maximal" markers (RER, lactate, HR, RPE). RESULTS: At the end of phase 1, 46% of the participants reached a plateau in (.)VO2, 83% increased HR to within 11 beats of age-predicted maximum, 89% reached an RER of > or = 1.15, 70% reached a blood lactate concentration of > or = 8 mmol x L, and 74% reached an RPE of > or = 18. No significant differences between genders and between BMI groups were found with the exception of blood lactate concentration (males = 84% vs females = 56%, P < 0.05). Neither gender nor fatness predicted the number of other markers attained, and attainment of other markers did not differentiate whether a (.)VO2 plateau was achieved. The verification test (phase 2) revealed that an additional 52 individuals (39%) who did not exhibit a plateau in (.)VO2 in phase 1 had no further increase in (.)VO2 in phase 2 despite an increase in workload. CONCLUSIONS: These findings indicate that the absence of a plateau in (.)VO2 alone is not indicative of a failure to reach a true maximal (.)VO2 and that individuals with excessive body fat are no less likely than "normal-weight" individuals to exhibit a plateau in (.)VO2 provided that the protocol is appropriate and encouragement to exercise to maximal exertion is provided.

Plasma ATP concentration and venous oxygen content in the forearm during dynamic handgrip exercise.

BACKGROUND: It has been proposed that adenosine triphosphate (ATP) released from red blood cells (RBCs) may contribute to the tight coupling between blood flow and oxygen demand in contracting skeletal muscle. To determine whether ATP may contribute to the vasodilatory response to exercise in the forearm, we measured arterialised and venous plasma ATP concentration and venous oxygen content in 10 healthy young males at rest, and at 30 and 180 seconds during dynamic handgrip exercise at 45% of maximum voluntary contraction (MVC). RESULTS: Venous plasma ATP concentration was elevated above rest after 30 seconds of exercise (P < 0.05), and remained at this higher level 180 seconds into exercise (P < 0.05 versus rest). The increase in ATP was mirrored by a decrease in venous oxygen content. While there was no significant relationship between ATP concentration and venous oxygen content at 30 seconds of exercise, they were moderately and inversely correlated at 180 seconds of exercise (r = -0.651, P = 0.021). Arterial ATP concentration remained unchanged throughout exercise, resulting in an increase in the venous-arterial ATP difference. CONCLUSIONS: Collectively these results indicate that ATP in the plasma originated from the muscle microcirculation, and are consistent with the notion that deoxygenation of the blood perfusing the muscle acts as a stimulus for ATP release. That ATP concentration was elevated just 30 seconds after the onset of exercise also suggests that ATP may be a contributing factor to the blood flow response in the transition from rest to steady state exercise.

The effect of changing limb position on the validity of venous occlusion plethysmography.

Venous occlusion plethysmography (VOP) is a technique used for the non-invasive measurement of limb blood flow. A fundamental technical consideration of venous occlusion plethysmography is that the limb in question must be placed above heart level. However, in light of advances in technology and methodology, the necessity of this has been questioned. We investigated the validity of the VOP technique with the forearm approximately 10 cm above and below the level of the heart in both resting and dynamic conditions. Nine healthy male participants performed four bouts of handgrip exercise, two at each of 15% and 30% maximum voluntary contraction (MVC) (one above and one below the heart). As hypothesized, resting forearm blood flow (FBF) measured below the level of the heart was significantly lower than for above the heart (p = 0.046). However, the opposite occurred during exercise, where FBF measured after the fifth minute of handgrip contractions was significantly higher below the level of the heart (p = 0.013). Furthermore, the ability to accurately quantify FBF below the level of the heart was severely impeded by artifact, and as such VOP appears to remain constricted to use above the phlebostatic level.