[Computerization and nursing: in search of an ideal!]. / L'informatisation en soins infirmiers: à la recherche d'un idéal!

The computerized systems that are currently available are frequently incompatible with the specific information needs of nursing practice (Grassert, 1990). It is not currently possible to analyze the computerization requirements of nursing practice, since we do not know towards what ideal situation the process of computerizing nursing should be evolving. This makes it impossible to measure the gap between the status quo and the ideal situation. This methodological study described the desired situation by identifying 43 criteria for ideal management procedures and the handling of data needed in nursing practice. Criteria were validated using the DELPHI technique on a non-probablist sampling of 22 nurses who had developed some expertise in computerization in nursing. The study paves the way for conducting a needs assessment, then measuring the capacity of current systems to meet specific needs in terms of management and handling of nursing data.

A randomized, double-blind, placebo-controlled study on the effect of conjugated estrogens on skin thickness.

OBJECTIVE: Our purpose was to assess the potential benefit of therapy with conjugated estrogens therapy on skin thickness in postmenopausal women. STUDY DESIGN: Sixty postmenopausal women were randomly allocated to receive conjugated estrogens or placebo treatment for 12 months. Neither participants nor investigators were aware of the group allocation. Skin thickness was measured by ultrasonography at baseline and after 6 to 12 months of treatment. Histologic changes were evaluated by skin biopsy at baseline and after 12 months' treatment. Quality of life and adverse events were recorded at each visit and at the end of treatment. RESULTS: Treatment with conjugated estrogens for 12 months significantly increases, at the level of the right great trochanter, the thickness of the skin (p < 0.01), as assessed by ultrasonography, and of the dermis (p < 0.05), as assessed by skin biopsy. No statistically significant difference was observed in the control population. Quality of life was reported to be improved (p < 0.05) in women treated with estrogen compared with those in the placebo group. CONCLUSION: The results may help postmenopausal women to better appraise the benefits of estrogen replacement therapy, and they provide further evidence of the potential of conjugated estrogens in preventing skin aging.

Left ventricular volume calculation using a count-based ratio method applied to first-pass radionuclide angiography.

Most count-based radionuclide methods for calculating left ventricular volume rely on measurement of radioactivity in a peripheral blood sample and a measurement of ventricle to collimator distance. We have developed a method which requires neither a blood sample nor a distance measurement and which is applicable to first-pass radionuclide angiography. The parameters used to calculate volume are the area of pixel, the total counts in the left ventricle and the maximum pixel count. The equation was used to calculate the volumes in 50 patients who had both resting first-pass radionuclide angiography (25 patients with a single crystal and 25 patients with a multicrystal camera) and contrast ventriculography on the same day. Correlation coefficients for end-diastolic and end-systolic volumes showed r ranging 0.93-0.98 and standard error of estimate ranging 23-35 ml for end-diastolic volume (14%-17% of mean end-diastolic volume) and 16-23 ml for end-systolic volume (18%-21% of mean end-systolic volume). Image processing software for extracting the needed values is generally available on most commercial nuclear medicine imaging systems and the additional time for the calculations is short. Although the theory is based on multiple assumptions, the volume calculation appears to be reasonably accurate and clinically applicable.

Patient-controlled analgesia: a double-blind study in burn patients.

A double-blind controlled study was performed to assess the efficacy and safety of patient-controlled analgesia in burn patients. This method was compared with conventional analgesic therapy consisting of intermittent intravenous morphine injections. Twenty-four adult patients hospitalised for burn injuries participated in the study. The McGill Pain Questionnaire, visual analogue scales and verbal-numeric scales were administered at regular intervals to measure various components of the patients' pain experience, degree of pain relief, anxiety levels, adverse side effects and overall treatment efficacy. Although statistical significance was found in only one measure, the results suggested better pain control in patients who were administered morphine by patient-controlled analgesia as compared with intermittent injections. Analysis of the side effects showed no difference between the groups. The amount of morphine administered over the trial period was also similar for the two groups but considerable interpatient variability was seen. Although further research is needed to determine the conditions for optimal use of patient-controlled analgesia, it is concluded that it is a safe, effective and improved method for controlling pain in selected burn patients.

Application of a new nuclear scintigraphy camera to evaluate flow and mechanical pumping of artificial hearts.

To assist in the development of an artificial blood pump, The Milwaukee Heart (MH-1), a new nuclear scintigraphy camera was used to study the wash-in and wash-out patterns of the MH-1. These studies indicate the MH-1 has an ejection fraction of 59.3%, with a stroke volume of 72 +/- 3 ml, and an afterload of 130 mmHg. Flow through the device is highly uniform, with no areas of stagnation. Regional ejection fraction images demonstrate homogeneous ejection from apex to base. The ability to scan through the first pass images allows study of wash-in, mixing, and wash-out of the tracer. In conclusion, this technique may provide a new approach to evaluating artificial heart pumps.

Attenuation of mild hyperandrogenic activity in postpubertal acne by a triphasic oral contraceptive containing low doses of ethynyl estradiol and d,l-norgestrel.

The effect of a low dose triphasic oral contraceptive (OC) was evaluated during a 6-month treatment period in 41 patients (mean age, 25.4 +/- 0.7 yr) who had grade I-IV postpubertal acne and normal menses. The OC contained three dose levels of ethynyl estradiol and dl-norgestrel. Acne lesions were assessed, and serum androgen levels were measured during a control cycle and between days 17-21 of treatment cycles 1, 2, 3, and 6. Four patients dropped out after 3 months of treatment. Acne was significantly improved after the first OC cycle. After six cycles, the number of comedones had decreased by 79.6 +/- 3.2% (range, 50-100%) in 69.4% of the patients. Mean baseline levels of testosterone, 17-hydroxyprogesterone, and dehydroepiandrosterone sulfate were in the upper third of the normal range, with elevated individual values in 18.9%, 36.5%, and 26.8% of the women, respectively. Mean baseline levels of androstenedione, free testosterone (T), and 3 alpha-androstanediol glucuronide (3 alpha-diol-G) were above the normal range, with elevated individual values in 51.2%, 75.0%, and 85.4% of the patients, respectively. Sex hormone-binding globulin (SHBG) levels were below the normal range in 26.8% of the cases. At the end of the first OC cycle, there was a significant (P less than 0.01) decrease in all androgen precursors and a 2-fold increase in SHBG. Androstenedione and free T decreased into the normal range during OC intake. Serum 3 alpha-diol-G levels remained elevated, but had decreased by 34.5% at cycle 6 (P less than 0.05). These results show that the triphasic OC has significantly improved acne in postpubertal women for whom acne was the main manifestation of mild hyperandrogenic activity. The improvement in acne corresponded to a decrease in adrenal/ovarian androgens and free T, which led to a decreased metabolism to 3 alpha-diol-G, presumably by the sebaceous glands. The increase in SHBG is considered an estrogenic effect, and the triphasic formulation containing low dose dl-norgestrel is not androgenic but, rather, an estrogen-dominant formulation; as such, this product is recommended in women requiring contraception who also have idiopathic acne.

Left ventricular volume calculation using a count-based ratio method applied to multigated radionuclide angiography.

The purpose of this study was to investigate the accuracy of a new count-proportional method for the measurement of left ventricular volume when applied to gated equilibrium blood-pool imaging. An equation is developed that relates total chamber volume, Vt, to the area of a pixel (M) and the ratio (R) of total counts within the chamber to the counts within the hottest pixel in the chamber such that Vt = 1.38 M3R3/2. The value of M is a constant for the particular scintillation camera-collimator system and R is obtained from observed count rates. All calculated volumes were compared to volumes measured using biplane contrast ventriculography. In 25 patients, the method for ventricular volumes gave an r of 0.95 and an s.e.e. of 23 ml [Volume (nuclear) = 0.94 Volume (cath) + 1.3]. Endsystolic volume was best calculated from end-diastolic volume and ejection fraction. Manual regions of interest were more accurate than automated regions of interest. This method appears to be as accurate as more complex approaches and has the advantage of not requiring attenuation correction or blood sampling.

Technically suboptimal first-pass radionuclide angiographic studies.

First-pass radionuclide angiography (FPRNA) has proven to correctly assess left ventricular function, however, technical difficulties do occur. One hundred and thirty one patients had contrast angiography and resting radionuclide angiography within 24 h. Of the 131 patients, 86 (66%) had adequate studies and 45 (34%) were technically suboptimal studies. In the latter group, low counts affected the quality of the images but did not change the left ventricular ejection fraction (LVEF) or regional wall motion (RWM) scores. Patients with high background activity showed overestimation of LVEF, however, by using a formula that was derived from the linear regression the LVEF could be calculated accurately in most cases. Multiple technical problems were noted in 14 patients in whom the best correlation was between contrast LVEF and background uncorrected LVEF from FPRNA (r = 0.87). In the latter group, FPRNA showed overestimation of RWM in 8 patients (57%), mainly in the inferior wall. We conclude that for most technically compromised first-pass radionuclide angiographic data, accurate LVEF values can be achieved but errors in regional wall motion interpretation will occur, especially when multiple technical problems exist.

Background correction in first-pass radionuclide angiography: comparison of several approaches.

This study was designed to test the comparative accuracy of several commonly used background correction techniques in first-pass radionuclide angiography (FPRNA). Thirty patients underwent FPRNA and single plane contrast angiography (CA) within 1 hr of each other. The left ventricular ejection fractions (LVEF) calculated from the different background subtraction approaches to FPRNA were compared to the CA LVEF. When applied to a representative cycle, a horseshoe-shaped background region of interest (BKROI) underestimated LVEF (p less than 0.005, r = 0.91, s.e.e. = 0.06) while a ring shaped BKROI adjusted at end-systole for aortic valve motion insignificantly overestimated LVEF (p = NS, r = 0.91, s.e.e. = 0.07). A lung background approach applied to a representative cycle gave the best correlation with CA (p = NS, r = 0.96, s.e.e. = 0.04). Without using a representative cycle, time-activity curves from a horseshoe-shaped BKROI and the LV ROI were created and the LV curve was normalized to the peak counts in the BKROI curve. LVEF calculated from the normalized curve correlated favorably with CA LVEF (p = NS, r = 0.91, s.e.e. = 0.08). The influence of some recently described improvements in representative cycle generation are also documented.

High count rate first-pass radionuclide angiography using a digital gamma camera.

In this study, first-pass radionuclide angiography (FPRNA) was performed using a digital single-crystal gamma camera. Twenty-nine men and six women (ages 43-80, mean 61 yr) underwent FPRNA in the supine position immediately prior to cardiac catheterization. Total counts/sec in the whole field-of-view in the right ventricular phase were 150,352 +/- 26,006. Background uncorrected counts in the representative cycle were 7,651 +/- 2,527 at end-diastolie and 4,904 +/- 2,314 at end-systolie. A linear correlation between FPRNA left ventricular (LV) ejection fraction and contrast LV ejection fraction gave an r = 0.95 with an s.e.e. of 0.05. Analyses of intra- and interobserver variability gave r = 0.99 and 0.98 and an s.e.e. of 0.02 and 0.03, respectively. Spearman-Rank correlation coefficients between FPRNA and contrast angiographic wall-motion scores were greater than 0.8 for all walls, while sensitivity/specificity were 0.86/0.90, 0.76/1.00, 0.76/1.00 for anterior, apical, and inferior wall-motion abnormalities, respectively. We conclude that satisfactory counting statistics for FPRNA can be obtained with a digital gamma camera, and that accurate and reproducible measurements of global and regional left ventricular function can be obtained with this technique.

Evaluation of a presurgical group program given at two different times.

This study was designed to test the outcomes of a preoperative teaching program for cholecystectomy patients and to determine the appropriate time to offer the program. The hypotheses were: (a) Patients in a preadmission program will recover better than those in a program given the eve of surgery, and (b) patients in the control group will have a poorer recovery than those in the two experimental groups. The outcomes measured were state-anxiety, ventilatory function, well-being, pain, functional ability, analgesics, and length of hospitalization. There were no significant differences between the three groups except in state-anxiety the eve of surgery which was higher in the control than in the two experimental groups. State-anxiety the eve of surgery and trait-anxiety were the most important variables affecting outcomes. There was a positive and significant linear relationship between pre- and postoperative state-anxiety.

Peak exercise and immediate postexercise imaging for the detection of left ventricular functional abnormalities in coronary artery disease.

Eleven patients without significant coronary artery disease (CAD) (group A), 22 patients with significant CAD and no prior myocardial infarction (MI) (group B), and 10 patients with CAD and a previous MI (group C) were imaged at rest, at peak exercise and immediately after exercise by first-pass radionuclide angiography. At peak exercise, mean left ventricular (LV) ejection fraction (EF) did not change significantly in group A or C and decreased significantly in group B. However, in all groups mean LVEF increased significantly immediately after exercise. Examination of potential criteria for an abnormal LVEF response showed that changes from rest to peak exercise were sensitive for detection of CAD but were not specific. Postexercise criteria were more specific but relatively insensitive: 15 of 32 patients (47%) with CAD showed a normal (greater than 5% increase over rest) response after exercise. Similarly, a regional abnormality at peak exercise was 100% sensitive, compared with a sensitivity of 78% after exercise for the whole group, and only 68% in patients without prior MI. Seven patients would have been misclassified as normal if postexercise imaging alone had been performed. The likelihood of an abnormal postexercise EF response was related to the extent of CAD: No patient with 1-vessel, 8 of 17 with 2-vessel and 9 of 12 with 3-vessel CAD showed such a response. Peak exercise imaging is necessary to achieve maximal sensitivity for the detection of CAD, and a high false-negative rate will be obtained if postexercise imaging only is used. The combination of peak exercise and postexercise imaging may be of value in assessing the severity of CAD.

Lens opacities appearing during therapy with methoxsalen and long-wavelength ultraviolet radiation.

Therapy with methoxsalen and type A (long-wavelength) ultraviolet radiation (PUVA) has recently become a common method of treating psoriasis and other dermatologic conditions. This treatment could induce cataractous changes in the human lens through a reaction between the psoralen in the lens and either UVA or ambient light. In a 28-month-long prospective study of 78 patients treated with PUVA, small lens opacities appeared in 3 patients, aged 67, 48 and 32 years. The two younger patients had not worn their protective glasses for 24 hours after each treatment, as recommended. Therefore, although it cannot be concluded that PUVA therapy caused these opacities, eye protection during treatment and for 24 hours thereafter should be emphasized to the patients.

First-pass radionuclide angiography via pulmonary arterial catheters. A critical analysis of background components.

Residual background activity following first-pass radionuclide angiography was assessed in 44 patients after eliminating activity in the right heart, left lung, and most of the right lung. The ejection fraction (EF) was calculated in two ways: (a) assuming background activity was present only in the right heart and lungs, and (b) correcting for scattered radiation by placing a circular region of interest around the left ventricle. With the first method, contrast EF was significantly underestimated in both AP and RAO views. With the second method, correlation was close in both views and absolute values agreed well with contrast EF. These results indicate that there is a substantial and measurable background component, due mainly to Compton scatter, even when activity from the right heart and lungs is eliminated.