911 Calls for Emergency Medical Services in Heart Failure: A Descriptive Qualitative Study.

BACKGROUND: Heart failure (HF) is a common condition leading to activation of emergency medical services (EMS). OBJECTIVE: The aim of this study was to describe reasons given by persons with HF, family members, or other caregivers for requesting EMS activation during 911 calls. METHODS: In this descriptive qualitative study, a content analysis was performed on transcribed audio files of 383 EMS requests involving 383 persons with HF in the community. RESULTS: One hundred forty-seven calls (38.4%) were placed by the family members, 75 (19.6%) were placed by the patients, 56 (14.6%) were placed by healthcare workers or personnel from living facilities, and the remaining calls (n = 105, 27.4%) were placed by others (eg, friends, neighbors, officers). Three broad categories of symptoms, signs, and events were identified as the reasons for an EMS request. Frequently reported symptoms were breathing problems (55.4%), chest pain (18.3%), and other pain (eg, head, extremities) (16.7%). Signs included decreased consciousness (15.4%), swelling (5.7%), and bleeding (5.0%). The reported events involved falls (8.1%), heart attack (6.3%), hypoxic episodes (6.0%), stroke (5.2%), and post-hospital-discharge complications (4.7%). In most calls (74.9%), multiple reasons were reported and a combination of symptoms, signs, and events were identified. Heart failure diagnosis was mentioned in fewer than 10% of the calls. CONCLUSIONS: Overall, symptoms and signs of HF exacerbation were common reasons to activate 911 calls. Falls were frequently reported. Under the duress of the emergent situations surrounding the 911 call, callers rarely mentioned the existence of HF. Interventions are needed to guide patients with HF and their family members to promote the management of HF to reduce EMS activation as well as to activate EMS quickly for acute changes in HF conditions.

Leadership, health systems and policy: Doctoral education and integrated clinical application.

Scientifically rigorous and readily transferable nursing research as a foundation for development of sound local and national policy can be further delivered into the policy arena by PhD prepared nurse leaders. Core curricular elements in the preparation of nurse scientists to advance the profession must therefore include competencies in leadership, health care systems, health economics, and policy. We present a curriculum model from a university in the southern United States that includes both a theoretical and application approach to incorporate a Leadership in Health Care Systems Course and Field Experience. Implementation of this approach is thought to result in a nurse scientist to have better preparation to engage in and with the broader health care system, policy, and interprofessional collaboration more quickly. We then present a student exemplar of a doctoral student's leadership field experience in a national advocacy and legislative process and discuss educational and professional gains from this lived experience.

Self-management Needs of Adults With Congenital Heart Disease.

BACKGROUND: Adults with congenital heart disease (CHD) are an emerging adult heart disease subset, now outnumbering the pediatric population with CHD. OBJECTIVE: We aimed to gain understanding and knowledge of what adults with CHD perceive as important for self-management and describe these needs across demographic factors, developmental characteristics, lesion severity, and quality of life. METHODS: We used a descriptive mixed-methods online survey merging 4 instruments: Adult CHD Self-management Experience Questionnaire; Adult CHD Demographic Questionnaire; Adaptive Behavior Assessment System, Third Edition; and Stanford Quality of Life Visual Numeric. Participants with CHD 18 to 30 years of age with initial defect repair before 12 months of age were recruited through support from the Adult Congenital Heart Association, clinic adult CHD support groups, and newspaper advertising. Thematic analysis for short-answer questions, descriptive analysis for demographic data and the visual numeric, and intrument-specific scoring assistant software for the Adaptive Behavior Assessment System were used. RESULTS: We received 22 responses from 13 women and 9 men. These individuals represented 15 different heart defect diagnoses, mostly of moderate or complex lesion severity. Most had postsecondary education and were employed. Four prominent themes emerged related to self-management: desire for connectivity-psychological support; a plan for the future-education about health and life expectations; coping needs-skills for mental stress; and access to care-navigation of healthcare systems. CONCLUSIONS: Future longitudinal research and replication studies with larger samples are needed. Educational materials and targeted interventions that promote self-management benefit the aging adult with CHD population.

Recruitment Issues in Emerging Adult Populations: Focus on Adult Congenital Heart Disease.

High-quality nursing research is important to healthcare and is precipitated by successful participant recruitment. Young adults aged 18 to 30 years are particularly difficult to recruit due to transitions during this time, which makes it more problematic to locate these individuals and may make it more difficult for them to prioritize the need for participation. This paper includes data from two cross-sectional survey design pilot studies that aimed to enroll young adults with congenital heart disease using a variety of recruitment methods. The number of participants enrolled in these two pilot studies (7 and 22) was much lower than expected but the recruitment challenges encountered were consistent with other research studies that have recruited young adult populations. After presenting these data and a discussion of the relevant literature, we conclude with proposed strategies for research recruitment of young adults for nurse scientists who directly impact evidence-based literature and practice with research contributions.

Societal value of newborn screening for severe combined immune deficiency in Arkansas: An economic analysis.

Newborn screening (NBS) is a public health program that detects genetic conditions in neonates enabling treatment before clinical symptoms manifest. Severe combined immune deficiency (SCID) is a primary immune deficiency found in the absence of functioning T and B lymphocytes. Hematopoietic cell transplantation is a potentially curative treatment if received within the first 42 months of life; without treatment, this condition is fatal in the first 2 years of life due to severe opportunistic infections. SCID was added to the recommended uniform panel of conditions for inclusion in state NBS programs in 2010. This manuscript examines the societal costs and benefits of NBS for SCID in Arkansas and implications to health services and social welfare. Total cost per year of all NBS for SCID and resulting early treatment for one patient with SCID in Arkansas is estimated at $1,078,714. Cost of late treatment of one patient with SCID is estimated at $1.43 million. Based on an expected diagnosis of one patient per year in Arkansas, this results in an estimated net cost savings for NBS for SCID in Arkansas of $351,286 per year. Based on cost-effectiveness analysis, NBS for SCID in Arkansas is cost-effective, with higher societal benefit than cost.

Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews.

OBJECTIVES: Examine Peer Support (PS) for complex, sustained health behaviors in prevention or disease management with emphasis on diabetes prevention and management. DATA SOURCES AND ELIGIBILITY: PS was defined as emotional, motivational and practical assistance provided by nonprofessionals for complex health behaviors. Initial review examined 65 studies drawn from 1442 abstracts identified through PubMed, published 1/1/2000-7/15/2011. From this search, 24 reviews were also identified. Extension of the search in diabetes identified 30 studies published 1/1/2000-12/31/2015. RESULTS: In initial review, 54 of all 65 studies (83.1%) reported significant impacts of PS, 40 (61.5%) reporting between-group differences and another 14 (21.5%) reporting significant within-group changes. Across 19 of 24 reviews providing quantifiable findings, a median of 64.5% of studies reviewed reported significant effects of PS. In extended review of diabetes, 26 of all 30 studies (86.7%) reported significant impacts of PS, 17 (56.7%) reporting between-group differences and another nine (30.0%) reporting significant within-group changes. Among 19 of these 30 reporting HbA1c data, average reduction was 0.76 points. Studies that did not find effects of PS included other sources of support, implementation or methodological problems, lack of acceptance of interventions, poor fit to recipient needs, and possible harm of unmoderated PS. CONCLUSIONS: Across diverse settings, including under-resourced countries and health care systems, PS is effective in improving complex health behaviors in disease prevention and management including in diabetes.

Cytokine overproduction and crosslinker hypersensitivity are unlinked in Fanconi anemia macrophages.

The Fanconi anemia proteins participate in a canonical pathway that repairs cross-linking agent-induced DNA damage. Cells with inactivated Fanconi anemia genes are universally hypersensitive to such agents. Fanconi anemia-deficient hematopoietic stem cells are also hypersensitive to inflammatory cytokines, and, as importantly, Fanconi anemia macrophages overproduce such cytokines in response to TLR4 and TLR7/8 agonists. We questioned whether TLR-induced DNA damage is the primary cause of aberrantly regulated cytokine production in Fanconi anemia macrophages by quantifying TLR agonist-induced TNF-α production, DNA strand breaks, crosslinker-induced chromosomal breakage, and Fanconi anemia core complex function in Fanconi anemia complementation group C-deficient human and murine macrophages. Although both M1 and M2 polarized Fanconi anemia cells were predictably hypersensitive to mitomycin C, only M1 macrophages overproduced TNF-α in response to TLR-activating signals. DNA damaging agents alone did not induce TNF-α production in the absence of TLR agonists in wild-type or Fanconi anemia macrophages, and mitomycin C did not enhance TLR responses in either normal or Fanconi anemia cells. TLR4 and TLR7/8 activation induced cytokine overproduction in Fanconi anemia macrophages. Also, although TLR4 activation was associated with induced double strand breaks, TLR7/8 activation was not. That DNA strand breaks and chromosome breaks are neither necessary nor sufficient to account for the overproduction of inflammatory cytokines by Fanconi anemia cells suggests that noncanonical anti-inflammatory functions of Fanconi anemia complementation group C contribute to the aberrant macrophage phenotype and suggests that suppression of macrophage/TLR hyperreactivity might prevent cytokine-induced stem cell attrition in Fanconi anemia.

Infective endocarditis: call for education of adults with CHD: review of the evidence.

Advanced surgical repair procedures have resulted in the increased survival rate to adulthood of patients with CHD. The resulting new chronic conditions population is greater than one million in the United States of America and >1.2 million in Europe. This review describes the risks and effects of infective endocarditis - a systemic infectious process with high morbidity and mortality - on this population and examines the evidence to determine whether greater patient education on recognition of symptoms and preventative measures is warranted. The literature search included the terms "infective endocarditis" and "adult congenital heart disease". Search refinement, the addition of articles cited by included articles, as well as addition of supporting articles, resulted in utilisation of 24 articles. Infective endocarditis, defined by the modified Duke Criteria, occurs at a significantly higher rate in the CHD population due to congenitally or surgically altered cardiac anatomies and placement of prosthetic valves. This literature review returned no studies in the past five years assessing knowledge of the definition, recognition of symptoms, and preventative measures of infective endocarditis in the adult CHD population. Existing data are more than 15 years old and show significant knowledge deficits. Studies have consistently shown the need for improved CHD patient knowledge with regard to infective endocarditis, and there is no recent evidence that these knowledge deficits have decreased. It is important to address and decrease knowledge deficits in order to improve patient outcomes and decrease healthcare utilisation and costs.

A Randomized Comparative Effectiveness Trial for Preventing Type 2 Diabetes.

OBJECTIVES: We evaluated the weight loss effectiveness of a YMCA model for the Diabetes Prevention Program (DPP) lifestyle intervention. METHODS: Between July 2008 and November 2010, we individually randomized 509 overweight or obese, low-income, nondiabetic adults with elevated blood glucose in Indianapolis, Indiana, to receive standard care plus brief lifestyle counseling or be offered a group-based YMCA adaptation of the DPP (YDPP). Primary outcome was mean weight loss difference at 12 months. In our intention-to-treat analyses, we used longitudinal linear or logistic regression, multiply imputing missing observations. We used instrumental variables regression to estimate weight loss effectiveness among participants completing 9 or more intervention lessons. RESULTS: In the YDPP arm, 161 (62.6%) participants attended ≥ 1 lesson and 103 (40.0%) completed 9 or more lessons. In intention-to-treat analysis, mean 12-month weight loss was 2.3 kilograms (95% confidence interval [CI] = 1.1, 3.4 kg) more for the YDPP arm than for standard care participants. In instrumental variable analyses, persons attending 9 or more lessons had a 5.3-kilogram (95% CI = 2.8, 7.9 kg) greater weight loss than did those with standard care alone. CONCLUSIONS: The YMCA model for DPP delivery achieves meaningful weight loss at 12 months among low-income adults.