Muscle insulin resistance in type 1 diabetes with coronary artery disease.

AIMS/HYPOTHESIS: The risk for coronary artery disease (CAD) is substantially increased in type 1 diabetes and it has been postulated that insulin resistance may contribute to this risk. The current study measured insulin resistance in type 1 diabetes with vs without CAD and with a focus upon skeletal muscle, to test the hypothesis that insulin resistance is more severe in participants who have type 1 diabetes and CAD. Additionally, in type 1 diabetes, we examined the hypothesis that insulin resistance is more severe in soleus (an oxidative type muscle) vs tibialis anterior (a more glycolytic type of muscle). METHODS: Insulin resistance was measured in participants with type 1 diabetes with (n = 9, CAD+) and without CAD (n = 10, CAD-) using euglycaemic insulin infusions combined with positron emission tomography (PET) imaging of [18F]fluorodeoxyglucose (FDG) uptake into soleus and tibialis anterior skeletal muscles. Coronary artery calcium (CAC) score was quantified by electron beam tomography. RESULTS: CAD+ participants with type 1 diabetes had a >100-fold higher CAC score than did CAD- participants with type 1 diabetes but groups did not differ in HbA1c or insulin dose. During clamp studies, CAD+ and CAD- groups had similar glucose disposal but were insulin resistant compared with historical non-diabetic participants (n = 13). FDG uptake by soleus muscle was similarly reduced, overall, in individuals with type 1 diabetes with or without CAD compared with non-diabetic individuals. However, FDG uptake by tibialis anterior muscle was not reduced in CAD- participants with type 1 diabetes while in CAD+ participants with type 1 diabetes it was 75% greater (p < 0.01). Across all participants with type 1 diabetes, FDG uptake by tibialis anterior muscle correlated positively with CAC severity. CONCLUSIONS/INTERPRETATION: Our study confirms that systemic and skeletal muscle-specific insulin resistance is seen in type 1 diabetes but found that it does not appear to be more severe in the presence of CAD. There were, however, sharp differences between soleus and tibialis anterior muscles in type 1 diabetes: while insulin resistance was clearly manifest in soleus muscle, and was of equal severity in CAD+ and CAD- participants, tibialis anterior did not suggest insulin resistance in participants with type 1 diabetes, as FDG uptake by tibialis anterior correlated positively with CAC severity and was significantly increased in participants with type 1 diabetes and clinical CAD. Graphical abstract.

Prevalence of Cervical Cancer Overscreening: Review of a Wellness Registry.

Appropriately matching preventive health services and screenings with patient risk is an important quality indicator. Adherence by both providers and patients to cervical cancer screening guidelines has been inconsistent, resulting in overscreening and increased costs. This study examined the prevalence of cervical cancer overscreening following changes in screening guidelines in a wellness registry database. Cervical cancer overscreening after guideline implementation decreased for 18- to 20-year-old patients from 26.8% to 24.8% (P < .001) and increased for those aged 65 years and older from 11.1% to 12.5% (P = .0005). Black race, Hispanic ethnicity, Medicaid insurance, and the presence of a personal health record were associated with overscreening. Reliability and accuracy of data are a concern when data intended for one purpose, such as clinical care, are used for research. Correctly identifying screening tests in the electronic health record is important so that appropriate screening can be reliably assessed. In this study on the prevalence of cervical cancer overscreening, we used a focused chart review to identify whether screening Pap tests were accurately identified in the electronic medical record. Pap tests were correctly identified as screening in 85% of those aged 18 to 20, and in 74% of those aged 65 and older.

PET imaging reveals distinctive roles for different regional adipose tissue depots in systemic glucose metabolism in nonobese humans.

Excess amounts of abdominal subcutaneous (SAT) and visceral (VAT) adipose tissue (AT) are associated with insulin resistance, even in normal-weight subjects. In contrast, gluteal-femoral AT (GFAT) is hypothesized to offer protection against insulin resistance. Dynamic PET imaging studies were undertaken to examine the contributions of both metabolic activity and size (volume) of these depots in systemic glucose metabolism. Nonobese, healthy volunteers (n = 15) underwent dynamic PET imaging uptake of [¹8F]FDG at a steady-state (20 mU·m⁻²·min⁻¹) insulin infusion. PET images of tissue [¹8F]FDG activity were coregistered with MRI to derive K values for insulin-stimulated rates of fractional glucose uptake within tissue. Adipose tissue volume was calculated from DEXA and MRI. VAT had significantly higher rates of fractional glucose uptake per volume than SAT (P < 0.05) or GFAT (P < 0.01). K(GFAT) correlated positively (r = 0.67, P < 0.01) with systemic insulin sensitivity [glucose disappearance rate (R(d))] and negatively with insulin-suppressed FFA (r = -0.71, P < 0.01). SAT (r = -0.70, P < 0.01) and VAT mass (r = -0.55, P < 0.05) correlated negatively with R(d), but GFAT mass did not. We conclude that rates of fractional glucose uptake within GFAT and VAT are significantly and positively associated with systemic insulin sensitivity in nonobese subjects. Furthermore, whereas SAT and VAT amounts are confirmed to relate to systemic insulin resistance, GFAT amount is not associated with insulin resistance. These dynamic PET imaging studies indicate that both quantity and quality of specific AT depots have distinct roles in systemic insulin resistance and may help explain the metabolically obese but normal-weight phenotype.

Interactions between delivery, transport, and phosphorylation of glucose in governing uptake into human skeletal muscle.

Skeletal muscle accounts for a large proportion of insulin-stimulated glucose utilization. It is generally regarded that much of the control over rates of uptake is posited within the proximal steps of delivery, transport, and phosphorylation of glucose, with glucose transport as the main locus of control. Whether insulin modulates the distribution of control across these steps and in what manner remains uncertain. The current study addressed this in vivo using dynamic positron emission tomography (PET) imaging of human muscle with sequential injections of three tracers ([(15)O]H(2)O, [(11)C]3-O-methyl glucose [3-OMG], and [(18)F]fluoro-deoxy glucose [FDG]) that enabled quantitative determinations of glucose delivery, transport, and its phosphorylation, respectively. Lean, healthy, research volunteers were studied during fasting conditions (n = 8) or during a euglycemic insulin infusion at 30 mU/min per m(2) (n = 8). PET images were coregistered with magnetic resonance imaging to contrast glucose kinetics in soleus, a highly oxidative muscle, with tibialis anterior, a less oxidative muscle. During fasting conditions, uptake of [(11)C]3-OMG was similar in soleus and tibialis anterior muscles, despite higher delivery to soleus (by 35%; P < 0.01). Uptake of [(18)F]FDG was also similar between muscle during fasting, and glucose transport was found to be the dominant locus of control (90%) for glucose uptake under this condition. Insulin increased uptake of [(11)C]3-OMG substantially and strongly stimulated the kinetics of bidirectional glucose transport. Uptake of [(11)C]3-OMG was higher in soleus than tibialis anterior muscle (by 22%; P < 0.01), a difference partially due to higher delivery, which was again found to be 35% higher to soleus (P < 0.01). The uptake of [(18)F]FDG was 65% greater in soleus compared with tibialis anterior muscle, a larger difference than for [(11)C]3-OMG (P < 0.01), indicating an added importance of glucose phosphorylation in defining insulin sensitivity. Analysis of the distribution of control during insulin-stimulated conditions revealed that most of the control was posited at delivery and transport and was equally divided between these steps. Thus, insulin evokes a broader distribution of control than during fasting conditions in governing glucose uptake into skeletal muscle. This redistribution of control is triggered by the robust stimulation of glucose transport, which in turn unmasks a greater dependence upon delivery and glucose phosphorylation.

Chronically critically ill patients: health-related quality of life and resource use after a disease management intervention.

BACKGROUND: Chronically critically ill patients often have high costs of care and poor outcomes and thus might benefit from a disease management program. OBJECTIVES: To evaluate how adding a disease management program to the usual care system affects outcomes after discharge from the hospital (mortality, health-related quality of life, resource use) in chronically critically ill patients. METHODS: In a prospective experimental design, 335 intensive care patients who received more than 3 days of mechanical ventilation at a university medical center were recruited. For 8 weeks after discharge, advanced practice nurses provided an intervention that focused on case management and interdisciplinary communication to patients in the experimental group. RESULTS: A total of 74.0% of the patients survived and completed the study. Significant predictors of death were age (P = .001), duration of mechanical ventilation (P = .001), and history of diabetes (P = .04). The disease management program did not have a significant impact on health-related quality of life; however, a greater percentage of patients in the experimental group than in the control group had "improved" physical health-related quality of life at the end of the intervention period (P = .02). The only significant effect of the intervention was a reduction in the number of days of hospital readmission and thus a reduction in charges associated with readmission. CONCLUSION: The intervention was not associated with significant changes in any outcomes other than duration of readmission, but the supportive care coordination program could be provided without increasing overall charges.

Racial differences in perceptions held by caregivers of long-term ventilator patients at end of life.

AIM: The purpose of this pilot study was to describe and compare perceptions of preparation for death and satisfaction with end-of-life care in African American and Caucasian caregivers of long-term ventilator (LTV) patients. DESIGN: A comparative descriptive design was used to pilot test items from specific domains from the After-Death Bereaved Family Member Interview. Interviews were conducted on 37 bereaved caregivers of LTV patients who participated in a large experimental study. FINDINGS: There was a statistically significant association between African American and Caucasian caregivers in the area of being informed of the patient's condition. African American caregivers felt more informed than Caucasian caregivers. Over half of African American and Caucasian caregivers reported feeling 'fairly to very confident' about what to expect when their loved one was dying. CONCLUSION: Health care providers should be sensitive to potential differences between African American and Caucasian family caregivers in providing end-of-life care.

Mindful Communication: Being Present.

OBJECTIVES: To review how mindfulness can be elicited in and strategically managed through communication, with a goal toward enhancing the patient/family relationship in the experience of cancer care. DATA SOURCES: Published, peer-reviewed literature, research reports, and Web-based resources. CONCLUSION: Mindful communication, an active process whereby the health care provider and patient /family unit are attentive to the timing, nature, and context of the dialogue exchange, helps direct care that is patient-centered, reflective, and relational. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses using a patient-centered approach to communication will be more equipped to use mindfulness-based strategies that can potentially shift the way cancer care is delivered.

Stress and Coping of Critical Care Nurses After Unsuccessful Cardiopulmonary Resuscitation.

BACKGROUND: Participation by a critical care nurse in an unsuccessful resuscitation can create a unique heightened level of psychological stress referred to as postcode stress, activation of coping behaviors, and symptoms of posttraumatic stress disorder (PTSD). OBJECTIVES: To explore the relationships among postcode stress, coping behaviors, and PTSD symptom severity in critical care nurses after experiencing unsuccessful cardiopulmonary resuscitations and to see whether institutional support attenuates these repeated psychological traumas. METHODS: A national sample of 490 critical care nurses was recruited from the American Association of Critical-Care Nurses' eNewsline and social media. Participants completed the Post-Code Stress Scale, the Brief COPE (abbreviated), and the Impact of Event Scale-Revised, which were administered through an online survey. RESULTS: Postcode stress and PTSD symptom severity were weakly associated (r = 0.20, P = .01). No significant associations between coping behaviors and postcode stress were found. Four coping behaviors (denial, self-distraction, self-blame, and behavioral disengagement) were significant predictors of PTSD symptom severity. Severity of postcode stress and PTSD symptoms varied with the availability of institutional support. CONCLUSIONS: Critical care nurses show moderate levels of postcode stress and PTSD symptoms when asked to recall an unsuccessful resuscitation and the coping behaviors used. Identifying the critical care nurses most at risk for PTSD will inform the development of interventional research to promote critical care nurses' psychological well-being and reduce their attrition from the profession.

Factors Related to Successful Transition to Practice for Acute Care Nurse Practitioners.

The transition from student to acute care nurse practitioner (ACNP) has been recognized as a time of stress. The purpose of this descriptive, correlational-comparative design pilot study was to examine: (1) the relationships among personal resources, community resources, successful transition, and job retention; (2) the difference between ACNPs with 0 to 4 years and ACNPs with more than 4 years of prior experience as a registered nurse in an intensive care unit or emergency department; and (3) the skills/procedures that ACNPs found difficult to perform independently. Thirty-four participants were recruited from a social media site for nurse practitioners. Organizational support, communication, and leadership were the most important elements of successful transition into the ACNP role. This information can help ACNP faculty and hospital orientation/fellowship program educators to help ACNPs transition into their first position after graduation.

Quantitative assessment of glucose transport in human skeletal muscle: dynamic positron emission tomography imaging of [O-methyl-11C]3-O-methyl-D-glucose.

Insulin-stimulated glucose transport in skeletal muscle is regarded as a key determinant of insulin sensitivity, yet isolation of this step for quantification in human studies is a methodological challenge. One notable approach is physiological modeling of dynamic positron emission tomography (PET) imaging using 2-[18-fluoro]2-deoxyglucose ([(18)F]FDG); however, this has a potential limitation in that deoxyglucose undergoes phosphorylation subsequent to transport, complicating separate estimations of these steps. In the current study we explored the use of dynamic PET imaging of [(11)C]3-O-methylglucose ([(11)C]3-OMG), a glucose analog that is limited to bidirectional glucose transport. Seventeen lean healthy volunteers with normal insulin sensitivity participated; eight had imaging during basal conditions, and nine had imaging during euglycemic insulin infusion at 30 mU/min.m(2). Dynamic PET imaging of calf muscles was conducted for 90 min after the injection of [(11)C]3-OMG. Spectral analysis of tissue activity indicated that a model configuration of two reversible compartments gave the strongest statistical fit to the kinetic pattern. Accordingly, and consistent with the structure of a model previously used for [(18)F]FDG, a two-compartment model was applied. Consistent with prior [(18)F]FDG findings, insulin was found to have minimal effect on the rate constant for movement of [(11)C]3-OMG from plasma to tissue interstitium. However, during insulin infusion, a robust and highly significant increase was observed in the kinetics of inward glucose transport; this and the estimated tissue distribution volume for [(11)C]3-OMG increased 6-fold compared with basal conditions. We conclude that dynamic PET imaging of [(11)C]3-OMG offers a novel quantitative approach that is both chemically specific and tissue specific for in vivo assessment of glucose transport in human skeletal muscle.

Impact of a disease management program upon caregivers of chronically critically ill patients.

OBJECTIVES: Few studies have examined the effects of caregiving on the caregivers of chronically critically ill (CCI) patients, and no one has examined the impact of a disease management program (DMP) on physical and psychological outcomes for the caregivers of CCI patients. The purposes of this study of caregivers of CCI patients were as follows: (1) to describe the characteristics of CCI patients and caregivers and to examine the frequency of depression, subjective burden, and physical health; (2) to examine factors related to depression after hospital discharge; and (3) to examine the effects of a DMP on the physical health, depression, and burden of caregivers 2 months post-hospital discharge. DESIGN: Prospective experimental design. SETTING AND PARTICIPANTS: Caregivers of 290 patients who had received > 3 days of mechanical ventilation while in the ICU of a university medical center. MEASUREMENTS: Sociodemographics, caregiver burden, physical health status, and depression were measured using established tools. RESULTS: Interviews of caregivers were conducted at hospital discharge and 2 months later. Seventy-three percent of patients survived, completed the study period, and required caregiving 2 months later. Caregivers of patients residing in an institution reported higher depression (p = 0.0001), higher burden (ie, disrupted schedule, p = 0.0001; lack of family support, p = 0.036), and greater health problem scores (p = 0.0001) than did caregivers of patients residing at home. The DMP did not have a statistically significant impact on any of the outcome variables. However, by 2 months, 54% of caregivers in the experimental group had no depression or mild depression compared with 34.5% of the control group. CONCLUSION: Two months after hospital discharge, approximately 25% of caregivers were classified as depressed with 16.7% of the depressed group classified as moderately or severely depressed. The caregivers of CCI patients are at risk for post-hospital discharge depression, and the caregivers of institutionalized CCI patients are at highest risk of long-term negative effects from caregiving.

Trial of a disease management program to reduce hospital readmissions of the chronically critically ill.

BACKGROUND: Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. They are prone to continued morbidity and mortality after hospital discharge and are at high risk for hospital readmission. Disease management (DM) programs have been shown to be effective in improving both coordination and efficiency of care after hospital discharge for populations with single-disease diagnoses, but have not been tested with patients with multiple-disease diagnoses, such as the chronically critically ill. STUDY OBJECTIVES: To test the effect of a DM program on hospital readmission patterns of chronically critically ill patients during the first 2 months after hospital discharge and to estimate the cost-effectiveness of the DM program. DESIGN: Randomized, controlled trial. SETTING: Academic medical center, extended care facilities, and participant homes. PARTICIPANTS: Three hundred thirty-four consenting adults from one academic medical center who underwent > 3 days of mechanical ventilation and survived to hospital discharge. INTERVENTION: Two hundred thirty-one patients in the experimental group received care coordination, family support, teaching, and monitoring of therapies from a team of advanced-practice nurses, a geriatrician, and a pulmonologist for 2 months post-hospital discharge. MEASUREMENTS: Rehospitalization rate, time-to-first rehospitalization, duration of rehospitalization, mortality during rehospitalization, and associated costs. RESULTS: Patients who received DM services had significantly fewer mean days of rehospitalization (11.4; 95% confidence interval [CI], 9.3 to 12.6) compared with the control group (16.7 days; 95% CI, 12.5 to 21.0; p = 0.03). There were no other significant differences between experimental and control groups, although all measures of rehospitalization risk for the experimental group were in a positive direction. Total cost savings associated with the intervention were approximately $481,811 for the 93 subjects who were readmitted to the hospital. CONCLUSIONS: Chronic critical illness may have a natural trajectory of continued morbidity following hospital discharge that is not affected by the provision of additional care coordination services. Nevertheless, given the high cost of rehospitalization and the additional burden it imposes on patients and families, interventions that can reduce the duration of rehospitalization are cost-effective and merit continued testing.

Benefits and challenges in developing a program of research.

The ultimate goals of nursing research are knowledge generation and improvement in nursing practice. Designing studies that provide the evidence needed for practice change and that have clear implications for immediate application to current practice environments is particularly challenging. Research programs that consist of sequential studies, each building on and expanding on the results of the previous work, offer the greatest promise for generating understanding of the human phenomenon relevant to nursing practice. The authors review their experience with a series of studies of inpatient and postdischarge needs and interventions associated with chronic critical illness to illustrate the benefits of developing a longitudinal research program as well as the importance of strategies that will foster application of results. Recommendations for developing such a program are discussed.

Using a virtual patient in an advanced assessment course.

BACKGROUND: A virtual patient, Digital Clinical Experience (DCE), was incorporated into an advanced assessment course. METHOD: Students conducted systems-based physical examinations on the DCE, documenting findings using a standard history format and physical examination skills checklists. Faculty reviewed transcripts generated from the students' history and physical examination to evaluate the logical order and progression of the examination. RESULTS: The nine DCE modules were included as half of the 2-hour weekly laboratory requirement and counted as 17.5% of the course grade. Faculty customized specific components of individual modules, including instructions to students and model documentation, to align with course objectives and faculty preferences. DCE use permitted faculty to provide structured student practice and evaluate essential advanced assessment skills that have not been previously assessed for individual students due to excessive time and cost. CONCLUSION: The potential impact of integrating a virtual patient on students' history taking and physical examination skills in their clinical courses should be explored.

Nurse practitioners and preventive screening in the hospital.

The purpose of this study was to investigate a reminder to discuss cervical cancer screening with hospitalized females. A quasi-experimental design was used to compare the association of a reminder intervention for nurse practitioners with two outcomes: prevalence of cervical cancer screening as documented in patients' charts and patients' self-report of cervical cancer screening 4 months after discharge. Data were collected by chart review and phone survey. The sample consisted of nurse practitioners caring for eligible female patients at a university teaching hospital. Chi-square was used to test all research questions. The rate of documentation of cervical cancer screening increased from 2% to 69% after implementation of the reminder intervention. The reminder intervention did not impact patients actually receiving Pap smears after discharge. The significant increase in documentation of screening associated with the use of the single reminder in the patients' charts support the use of this low-cost intervention.

Interactions among glucose delivery, transport, and phosphorylation that underlie skeletal muscle insulin resistance in obesity and type 2 Diabetes: studies with dynamic PET imaging.

Dynamic positron emission tomography (PET) imaging was performed using sequential tracer injections ([(15)O]H2O, [(11)C]3-O-methylglucose [3-OMG], and [(18)F]fluorodeoxyglucose [FDG]) to quantify, respectively, skeletal muscle tissue perfusion (glucose delivery), kinetics of bidirectional glucose transport, and glucose phosphorylation to interrogate the individual contribution and interaction among these steps in muscle insulin resistance (IR) in type 2 diabetes (T2D). PET imaging was performed in normal weight nondiabetic subjects (NW) (n = 5), obese nondiabetic subjects (OB) (n = 6), and obese subjects with T2D (n = 7) during fasting conditions and separately during a 6-h euglycemic insulin infusion at 40 mU · m(-2) · min(-1). Tissue tracer activities were derived specifically within the soleus muscle with PET images and magnetic resonance imaging. During fasting, NW, OB, and T2D subjects had similar [(11)C]3-OMG and [(18)F]FDG uptake despite group differences for tissue perfusion. During insulin-stimulated conditions, IR was clearly evident in T2D (P < 0.01), and [(18)F]FDG uptake by muscle was inversely correlated with systemic IR (P < 0.001). The increase in insulin-stimulated glucose transport was less (P < 0.01) in T2D (twofold) than in NW (sevenfold) or OB (sixfold) subjects. The fractional phosphorylation of [(18)F]FDG during insulin infusion was also significantly lower in T2D (P < 0.01). Dynamic triple-tracer PET imaging indicates that skeletal muscle IR in T2D involves a severe impairment of glucose transport and additional impairment in the efficiency of glucose phosphorylation.

Using a psychosocial registry as a data source for nurses.

Nurses at the bedside strive to base their practice on the best available information derived from evidence. However, issues related to patient care often arise for which evidence is either difficult to attain or not available. This can be particularly true for nurses who care for patients with diverse diagnoses because most studies focus on patients with a single cancer diagnosis. For example, evidence about quality of life (QOL) as perceived by the patient is a concern for clinicians but is of particular importance to nurses at the bedside. A great deal of study has been performed on the QOL of patients with cancer; however, most of these reports focus on narrow or limited samples, typically one specific cancer type. Having access to a registry that enrolls patients with diverse types of cancer and collects QOL data could be very useful to practicing bedside nurses.

Case histories in the education of advanced practice nurses.

Case histories--rich, anecdotal narratives--are theorized to support the acquisition of cognitive, social, cultural, and emotional knowledge and motor skills through active learning. This manuscript focuses on the value of case histories in teaching and evaluating acute and critical care advanced practice nursing students. Information about the use of case histories in advanced critical care education and clinical practice is limited. Case histories support student-centered learning and development of clinical reasoning. An exemplar of a case history is provided, and application of case histories to both electronic and classroom settings is explored.