Preben Ulrich Pedersen

Cognitive Outcomes in Elderly High-Risk Patients After Off-Pump Versus Conventional Coronary Artery Bypass Grafting A Randomized Trial

Background— It has been suggested that the risk of cerebral dysfunction is less with off-pump coronary artery bypass grafting (OPCAB) than with conventional coronary artery bypass grafting (CCAB). However, evidence for this statement is preliminary, and additional insight is needed. Methods and Results— The study was a substudy of the randomized Best Bypass Surgery trial that compared OPCAB with CCAB treatment with respect to intraoperative and postoperative mortality and morbidity in patients with a moderate to high level of predicted preoperative risk. The outcome was cognitive function. A total of 120 elderly patients (mean age 76 years, SD 4.5 years) underwent psychometric testing before surgery and at a mean of 103 (SD 15) days postoperatively with a neuropsychological test battery that included 7 parameters from 4 tests. Cognitive dysfunction was defined as the occurrence of at least 2 of the 7 possible deficits. Secondary analysis was performed on the basis of the definition of a 20% decline in cognitive scores compared with baseline, and with z score analysis. Cognitive dysfunction was identified in 4 of the 54 patients (7.4%, 95% confidence interval [CI] 2.1% to 17.9%) in the OPCAB group and 5 of the 51 patients (9.8%, 95% CI 3.3% to 21.4%) in the CCAB group. We found no difference in incidence of cognitive dysfunction between the groups regardless of the definition applied. Conclusions— In elderly high-risk patients, no significant difference was found in the incidence of cognitive dysfunction 3 months after either OPCAB or CCAB.

Comprehensive cardiac rehabilitation improves outcome for patients with implantable cardioverter defibrillator. Findings from the COPE-ICD randomised clinical trial

Aims: The aim of this randomised clinical trial was to assess a comprehensive cardiac rehabilitation intervention including exercise training and psycho-education vs ‘treatment as usual’ in patients treated with an implantable cardioverter defibrillator (ICD). Methods: In this study 196 patients with first time ICD implantation (mean age 57.2 (standard deviation (SD)=13.2); 79% men) were randomised (1:1) to comprehensive cardiac rehabilitation vs ‘treatment as usual’. Altogether 144 participants completed the 12 month follow-up. The intervention consisted of twelve weeks of exercise training and one year of psycho-educational follow-up focusing on modifiable factors associated with poor outcomes. Two primary outcomes, general health score (Short Form-36 (SF-36)) and peak oxygen uptake (VO2), were used. Post-hoc analyses included SF-36 and ICD therapy history. Results: Comprehensive cardiac rehabilitation significantly increased VO2 uptake after exercise training to 23.0 (95% confidence interval (CI) 20.9–22.7) vs 20.8 (95% CI 18.9–22.7) ml/min/kg in the control group (p=0.004 (multiplicity p=0.015)). Comprehensive cardiac rehabilitation significantly increased general health; at three months (mean 62.8 (95% CI 58.1–67.5) vs 64.4 (95% CI: 59.6–69.2)) points; at six months (mean 66.7 (95% CI 61.5–72.0) vs 61.9 (95% CI 56.1–67.7) points); and 12 months (mean 63.5 (95% CI 57.7–69.3) vs 62.1 (95% CI 56.2–68.0)) points (p <0.05). Explorative analyses showed a significant difference between groups in favour of the intervention group. No significant difference was seen in ICD therapy history. Conclusion: Comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves VO2-uptake and general health. Furthermore, mental health seems improved. No significant difference was found in the number of ICD shocks or anti-tachycardia pacing therapy.

COPE-ICD: A randomised clinical trial studying the effects and meaning of a comprehensive rehabilitation programme for ICD recipients -design, intervention and population

BackgroundGrowing evidence exists that living with an ICD can lead to fear and avoidance behaviour including the avoidance of physical activity. It has been suggested that psychological stress can increase the risk of shock and predict death. Small studies have indicated a beneficial effect arising from exercise training and psychological intervention, therefore a large-scale rehabilitation programme was set up.Methods/DesignA mixed methods embedded experimental design was chosen to include both quantitative and qualitative measures. A randomised clinical trial is its primary component. 196 patients (power-calculated) were block randomised to either a control group or intervention group at a single centre. The intervention consists of a 1-year psycho-educational component provided by two nurses and a 12-week exercise training component provided by two physiotherapists. Our hypothesis is that the COPE-ICD programme will reduce avoidance behaviour, sexual dysfunction and increase quality of life, increase physical capability, reduce the number of treatment-demanding arrhythmias, reduce mortality and acute re-hospitalisation, reduce sickness leading to absence from work and be cost-effective. A blinded investigator will perform all physical tests and data collection.DiscussionMost participants are men (79%) with a mean age of 58 (range 20-85). Most ICD implantations are on primary prophylactic indication (66%). 44% is NYHA II. Mean walk capacity (6MWT) is 417 m. Mean perception of General Health (SF-36) is PCS 42.6 and MCS 47.1.A large-scale ICD rehabilitation trial including psycho-educational intervention and exercise training has been initiated and will report findings starting in 2011.Trial RegistrationClinicalTrials.gov: NCT00569478

Constipation and defecation pattern the first 30 days after thoracic surgery

INTRODUCTION In clinical practice constipation is often an overlooked aspect of patient care and first gains attention when it has become a severe problem for the patients. Constipation increases the risk for postoperative complications, can prolong hospital stay, increase financial cost, and staff nursing care time. MATERIAL AND METHOD A prospective descriptive design was used. One hundred and thirty nine patients participated in the study from February to June 2006. On admission, day of discharge, and 30 days after surgery patients normal and actual defecation pattern, stool consistency, and if they experienced problems with defecation was assessed by a structured interview. North America Nursing Diagnosis Associations (NANDAs) general definition of constipation was used as a frame of reference for this study. The Bristol Stool Scale was used to measure stool consistency. Prolonged and difficult evacuation and defecation pattern was recorded on a self-composed scale. RESULTS Fifty per cent of patients developed constipation during the first postoperative period and their normal pattern of defecation was re-established 17 days after discharge. Nearly one third of the patients reported that their daily life was affected by constipation after discharge. CONCLUSION The results imply that further studies are needed to prevent constipation and to help patients to cope with this side effect of surgery after discharge. The results of this study also suggest that acute and chronic constipation might be two different disorders.

COPE-ICD: patient experience of participation in an ICD specific rehabilitation programme.

Purpose: Evaluating rehabilitation programmes from the patient’s perspective is much needed, as the patients are the most important stakeholders in the health care system. A comprehensive rehabilitation programme, COPE-ICD programme, consists of exercise training and nursing consultations during a one year period post ICD implantation. The purpose of this paper is to describe the experience and meaning of participating in a comprehensive ICD-specific rehabilitation programme. Methods: Qualitative interviews were conducted with 10 patients representing the participating population, and later transcribed. The analysis was inspired by Ricoeur’s theory of interpretation, which consists of three levels: naive reading, structured analysis and critical interpretation and discussion. Results: The overall concept was that participating in the COPE-ICD programme meant feeling inspired and secure through individualized care. Four themes emerged: Knowledge: patients gained much needed understanding; Physical attention: patients interpreted body signals and adjusted their exercise behaviour; Trust: patients regained trust, felt secure and dared to live again; Strategies of living: patients’ coping was supported through reflection and professional dialogue, and they dealt with the risk of shock or death. Conclusion: Participating in an ICD-specific rehabilitation programme can make patients feel inspired and secure through individualized care. They discover that they have to rethink some of their strategies of living and they gain support in the reflection and coping needed for that. Patients gain insight and they develop a special physical attention whereby they continue healthy activities through interpreting body signals and adjusting exercise behaviour. They learn to trust their body again.

Sexual concerns and practices after ICD implantation: findings of the COPE-ICD rehabilitation trial

Background: Studies show that patients with implantable cardioverter defibrillators (ICD) frequently experience sexual dysfunction. These experiences are often linked to exercise intolerance, side-effects of medication, and psychological problems. Objective: To describe (a) the level of information given about sexual activity, (b) the areas of patient concerns related to sexual function and the ICD, and (c) changes in sexual behavior. Methods: A randomized controlled trial including 196 patients (1:1) was designed, including 12 weeks of exercise training and 1 year of psycho-educational follow-up focusing on modifiable factors associated with poor outcomes, including sexual functioning. The Sex After ICD Survey was administered 6 months after the randomization as part of the planned explorative outcomes. 141 patients responded. Results: The analyses showed that 37 of the 69 (55.2%) patients of the intervention group and 16 of the 72 (24.6%) patients of the control group received information (p<0.001). The areas of greatest concern reported by many patients were: lack of interest in sex, erectile dysfunction, and an over-protective partner. Fewer patients were sexually active 6 months after the ICD implantation than before the ICD implant: 51.8% versus 66.7%. In the intervention group, patients had sexual intercourse a mean of 4.9 times during the previous 2 months versus 4.0 in the control group (p=0.4). Conclusion: Despite having received more information, no interventional effect was found between groups in terms of sexual concerns or activity.

Visualization and attentive behavior for pain reduction during radiofrequency ablation of atrial fibrillation

Radiofrequency (RF) ablation of atrial fibrillation (AF) can be accompanied by pain and anxiety when light conscious sedation is used. We sought to determine how visualization and structured attentive behavior during ablation of AF could reduce pain intensity, spontaneously expressed pain, the amount of analgesics, anxiety, and adverse events.

Evaluation of a multi-modal grounded theory approach to explore patients’ daily coping with breathlessness due to chronic obstructive pulmonary disease

Conventional methods have not yet succeeded in capturing the complexity of how people with chronic obstructive pulmonary disease (COPD) cope with breathlessness during daily living. We used a multi-modal grounded theory (GT) approach to investigate coping. In this paper, we describe and evaluate the multi-modal GT approach, which encompasses videos of daily life activity, interviews, medical history, demographics, self-rated sensation of breathlessness, and physiological measurements. A formative evaluation was conducted according to the criteria that the data collection should strengthen the participants’ ability to remember and narrate how they cope with breathlessness; capture the multidimensional aspects involved in coping with breathlessness; encompass tools for collecting both qualitative and quantitative data, providing the opportunity to generate, synchronize, and combine data; and be ethically justifiable. The approach should also be consistent with the GT methodology of generating a theory. Striving to develop and perfect the multi-modal GT approach was time-consuming. Apart from this practical challenge, the multimodal GT approach met all evaluation criteria. This approach has the potential to generate new knowledge and may become an important methodological contribution towards understanding the multidimensionality of coping with breathlessness.

Physical health problems experienced in the early postoperative recovery period following total knee replacement

BACKGROUND The length of stay in hospital following total knee replacement is markedly shortened due to fast-track programmes. Patients have to be responsible for their recovery at a very early stage. The aim of this study was to investigate the prevalence of physical health problems and the level of exercising in the early recovery period after discharge from hospital following total knee replacement. METHOD A cross-sectional survey was conducted using a questionnaire. A total of 86 patients were included following first-time elective total knee replacement. Descriptive statistics were used. RESULTS The majority of the patients experienced leg oedema (90.7%). Secondary to this were pain (81.4%), sleeping disorders (47.7%) problems with appetite (38.4%) and bowel function (34.9%) were the most frequently identified physical health problems. In total, 69.8% of the patients indicated that they did not exercise or only partly exercise as recommended, but without associated experience of pain. CONCLUSION Patients experienced a wide range of physical health problems following total knee replacement and deviation from recommended self-training was identified. These findings are valuable for health professionals in regard to improve treatment as well as patient education and information.

A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care.

AIMS AND OBJECTIVES To identify the effect of early rehabilitation of patients with post-traumatic amnesia in patients with traumatic brain injury, to review and critically assess evidence related to the timing of intervention and to identify the effect on outcome of a specific neurological rehabilitation in acute care. BACKGROUND Up to 70% of patients with traumatic brain injury will experience post-traumatic amnesia. Although duration of post-traumatic amnesia is correlated negatively with outcome for patients with traumatic brain injury, there is limited evidence relating to what influence timing and effect may have on enhancing early rehabilitation patient outcomes. DESIGN A critical literature review. METHODS Searches for systematic reviews were undertaken in Medline, CINAHL, Cochrane, PSYC INFO and Neurotraume databases. The efficacy of intervention and timing was classified based on a hierarchy of study designs for questions about health care interventions based on soundness of design. RESULTS Six reviews and 11 original studies were included and comprised the review. Many studies used weak designs and small sample size, thus limiting their ability to control confusing variables and outcomes. Few studies included papers with the information about timing and effect of early post-traumatic amnesia intervention. Only one study showed an effect of a reality orientation programme in acute care. Although there was no significant detail reported on the possibility of reducing the post-traumatic amnesia period, the study showed clinical relevance. CONCLUSION This review highlights the limited evidence of the effect of early rehabilitation of patients with post-traumatic amnesia. Future research should be conducted to identify the effectiveness of early intervention. RELEVANCE TO CLINICAL PRACTICE Although nurses are treating patients with post-traumatic amnesia without systematic assessment, the limited evidence available does little to direct nurses as to the best approach to start early rehabilitation of post-traumatic amnesia to promote good outcomes.