Nancy J. Finch

Recipients' of implanted cardioverter-defibrillators actual and perceived adaptation: a review of the literature.

Purpose: To identify qualitative studies that have examined actual and perceived adaptation of patients to an implanted cardioverter‐defibrillator (ICD). The question explored was do recipients of ICDs experience real or perceived physical or psychological adaptation distress? Do themes expressed indicate a need for intervention that will facilitate postimplantation adjustment? Data sources: A systematic search of the scientific literature uncovered 153 studies of which 12 met the following inclusion criteria: qualitative English research of psychological adaptation to the implantable defibrillator or qualitative research literature reviews. Exclusion criteria included unpublished studies, studies involving cardiac pacemaker devices without defibrillator, and quantitative research studies. Conclusion: Multiple themes pertaining to adjustment to ICD therapy were identified, which warrants further study for potential therapeutic interventions. Themes identified by ICD recipients and their partners include perception of fear, anxiety, and dependence, and the desire for enhanced support and information. Increasing awareness of the complex adaptation issues related to ICD implantation should be a priority of primary care clinicians who provide follow‐up care for these patients. Implications for Practice: ICD recipients have reported multiple physical and psychological adjustment issues that require further study to determine gravity and duration. Clinicians must be familiar with adjustment difficulty expressed by ICD recipients in order to facilitate appropriate tailored interventions. The findings of this literature review emphasize a need for support groups for ICD recipients and their partners; behavioral and sexual counseling; continued education after discharge; and a supportive healthcare provider who is knowledgeable in device adjustment issues. The research indicates a need for a post‐ICD implantation plan, and data are available for the design testing of tailored interventions.

A Randomized Controlled Trial to Evaluate the Effect of Glycemic Control on Renal Transplantation Outcomes

CONTEXT Outcomes from intensive glycemic control postrenal transplant have not been studied. OBJECTIVE Our objective was to observe the optimal management of hyperglycemia in patients with diabetes or impaired glucose tolerance receiving renal transplantation. DESIGN, SETTING, AND PATIENTS We conducted a randomized controlled trial with patients undergoing renal transplantation randomized to either i.v. insulin therapy (intensive) or standard s.c. insulin therapy while the patients were admitted to the hospital. INTERVENTIONS The study consisted of a 3-day postrenal transplant group treated with intensive i.v. insulin [blood glucose (BG) = 70-110 mg/dl] or a control group treated with s.c. insulin (BG = 70-180 mg/dl). MAIN OUTCOME MEASURE The primary endpoint was delayed graft function (DGF). Secondary endpoints were glycemic control, graft survival, and acute rejection episodes. RESULTS A total of 104 patients were screened and randomized to either the intensive or control condition; however, the intention-to-treat analysis set consisted of only the 93 participants (n = 44 intensive, n = 49 control) that underwent a renal transplant. DGF was present in 18% (eight of 44) of the intensive group and 24% (12 of 49) of the control group (P = 0.46). The occurrence of severe hypoglycemia (BG < 40 mg/dl) and severe hyperglycemia (BG > 350 mg/dl) were the primary safety outcome measures. There were nine participants with hypoglycemia identified, seven of which (78%) were in the intensive treatment group (P = 0.08). There were 30 instances of hyperglycemia with five participants (11%) in the intensive group and 12 participants (24%) in the control group having at least one hyperglycemic event (P = 0.10). For the 11 rejection episodes, nine were in the intensive treatment group (P = 0.013). CONCLUSIONS The primary outcome measure of DGF was not statistically different for the two treatment groups. Regarding longer-term rejection and graft survival, the intensively treated participants were at higher risk for a rejection episode.

Driving with an internal defibrillator: legal, ethical, and quality-of-life issues

Patients with internal cardioverter-defibrillators experience many issues after implantation. One issue is operating a motor vehicle. This issue has many ethical, legal and quality-of-life concerns that must be addressed by the patient, health care providers, and society. The legal and ethical issues surrounding patients with internal cardioverter-defibrillators will be explored using an ethically based theoretical framework.

Disparities in preferences for receiving support and education among patients with implantable cardioverter defibrillators.

Background: The implantable cardioverter‐defibrillator (ICD) is the established treatment for patients with a history of or at risk for sudden cardiac arrest. Patients receiving an ICD are diverse, and little is known regarding their preferences for support and education postimplantation. The purpose of this study was to examine race, gender, and age preferences for receiving support and education (e.g., written, verbal).

Inflammatory biomarkers, glycemic variability, hypoglycemia, and renal transplant outcomes: results of a randomized controlled trial.

Background We previously reported that compared to standard glycemic control [blood glucose (BG): 70–180 mg/dL], patients randomized to intensive glycemic control (BG: 70–110 mg/dL) were at increased risk of graft rejection in renal transplantation. However, the underlying mechanisms that associate the effect of intensive glycemic control with renal transplant outcomes have not been identified. Methods A secondary data analysis of 93 participants (n=44 intensive, n=49 control) was conducted using data from a previous randomized controlled clinical trial. We examined inflammatory biomarkers, glycemic variability, hypoglycemia, and hyperglycemia as potential contributing etiologies by assessing the effect of intensive glycemic control on these characteristics, and evaluate the association of these variables with graft rejection. Results Intensive glycemic control had no appreciable effect on highly sensitive C-reactive protein, interleukin (IL)-6, tumor necrosis factor alpha, IL-1&bgr;, or IL-10 levels at all time points after transplantation. Moreover, neither inflammatory biomarkers nor increased glycemic variability were associated with graft rejection. However, intensive treatment increased the risk of hypoglycemia (BG <70 mg/dL, 84% vs. 25%, P<0.001). In sub-analysis, compared to non-rejecters, rejecters demonstrated higher rates of blood glucose below 70 mg/dL (90% vs. 49%, P=0.02). Conclusion Inflammatory biomarkers and increased glycemic variability lack correlation with clinical outcomes in renal transplant, but importantly, increased perioperative hypoglycemic episodes (BG <70mg/dL) may be a salient etiology that contributed to the increased risk for acute allograft rejection related to intensive glycemic control. Further research is needed to confirm a causal association.

Quality of life when living with heart failure

Heart failure is a chronic condition and consumes a huge portion of health care expenditures. Increased life expectancy combined with increasingly effective treatments for coronary artery disease and hypertension will increase the number of patients with heart failure. Efforts are aimed at helping patients better care for themselves. Nurses can design interventions that focus on education and self-management of complex treatments, spiritual support, and clinical relationships based on trust. It is essential that health care providers direct and evaluate interventions that promote improved QOL for patients and families. Nurses also need to continue to study the effects of education and self-care interventions so that care for heart failure patients is evidence based.