2. Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiacsurgery. J Cardiovasc Nurs 2006; 21(3): 194-200. 3. Bauer BA, Cutshall SM, Wentworth LJ, Engen D, Messner PK, Wood CM, et al. Effect of massage therapy on pain,
anxiety, and tension after cardiacsurgery: a randomized study. Complement Ther Clin Pract 2010; 16(2): 70-5. 4. Montazer R. Not necessary surgeries or jobber surgeries. [Online]. 2012. Available from:
In the present study, qualitative content analysis technique was used to determine primiparous women’s perception of comfortableresources on labor pain. Information providers were 18 primiparous women from those who referred to a health center for screening tests of thyroid of their newborns within 3–5 days after childbirth. It means that after interviewing 18 participants, we reached data saturation. They had vaginal delivery without complications and using assistive device for childbirth, and born alive and healthy babies. These women expressed interest and ability to recall and describe their delivery processes. The participants were selected using purposive sampling. Researchers, after introducing themselves, explained the objectives of the project and tried to win the participants’ trust and confidentiality concerning safe interview in compliance with ethical issues. The participants were free to withdraw from the study at any time. The participants were interviewed with open questions in a quiet and private place in the health center for 45–90 min.
sought by parents at varying times, and through multiple sources, a formal exchange of information occurred at time point 2, during discussion with the surgeon and anaesthetist. Quantitative studies exploring patient experiences of information exchange with clinicians present conflicting findings between information volume and patient satisfaction. 37 This apparent contradiction is explored in the qualitative literature where findings suggest a trusting clinician-parent/patient relationship forms the basis of ensuring patients feel that their information needs have been met. 37 A UK wide study, examining information requirements of parents whose children underwent cardiacsurgery, highlighted that consistency of information giving was of primary importance in reducing anxiety; however, almost two-thirds of parents questioned suggested they had received different information from different people, leaving them confused and anxious. 38 The ‘one stop shop’ approach as experienced by this cohort, where a surgeon, anaesthetist and specialist nurse worked together to provide co- ordinated information, supported the delivery of a consistent message. Overall, the trend in responses from the parents reflected a drop in the median perception of risk and distribution of scores following discussions with surgeons and anaesthetists. Rather than assuming the information provided offered reassurance, evidence suggests that the opportunity to meet the surgeons prior to admission provided space to build the parent-surgeon relationship.
a cast at the hospital and then he went home. He didn’t know there was a DVT, and soon he died of pulmonary embolism” (Participant 1); “My sister suffered from serious varicose veins in her lower limbs. After having an operation, her doctor told us it was important to prevent DVT, which could lead to PE and death” (Partici- pant 6); and “During hospitalization, the medical staff talked to me about VTE. I know VTE includes two types: DVT and PE. My surgery increases the risk of DVT, and DVT may cause PE; it’ s a disaster” (Participant 8). The other five participants mistook cerebral thrombosis for VTE; they described the following: “I’ve heard of some elderly people with cerebral thrombosis” (Participant 2); “ My father had a cerebral thrombosis ” (Participant 4); “ I have high blood pressure and coronary heart disease. I’m afraid that I might get a cerebral thrombosis” (Participant 5); and “ The medical staff told me, but I don ’ t think it ’ s important, and now I’m not very sure what VTE is” (Participant 7).
Results: A total of twenty-one diabetes patients between the ages 35–67 years with physical disability (P1–P21) were interviewed. The cohort of participants was dominated by males (n = 12) and also distribution pattern showed major- ity of participants were Malay (n = 10), followed by Chinese (n = 7) and rest Indians (n = 4). When the participants were asked in their opinion what was the preferred method of recording blood glucose tests, several participants from low socioeconomic status and either divorced or widowed denied to adapt telemonitoring instead preferred to record manually. There were mixed responses about the barriers to control diet/calories. Even patients with high eco- nomic status, middle age 35–50 and diabetes history of 5–10 years were influenced towards alternative treatments. Conclusions: Study concluded that patients with physical disability required extensive care and effective strategies to control glucose metabolism.
Postoperative delayed complications would be depend- ent on many factors. However, this raises a crucial ques- tion: What is the reason for different increase of PCT in patients? As shown in Table 1, comorbidity and intraop- erative parameters were different and could explain more postoperative complications. However, after surgery the patients showed no clinical signs of complications. Nevertheless, it is known that increased PCT levels are associated with many inflammatory diseases (e.g., blood stream infection, pneumonia, renal failure or heart fail- ure) [11, 27–30], all known to possibly occur after car- diac surgery. It can be summarized that it seems that increased PCT levels are associated with worse global health condition. We hypothesize that the raise of PCT after surgery is an early warning signal of upcoming com- plications associated with proinflammatory states.
However, the claim to provide safe and effective treat- ment resulting from pull and push factors is not always true. Furthermore, there is the potential for herb toxicity and herb-drug interactions, and patients may even dis- continue conventional treatment in favor of CAM. The risk of hemorrhage may increase when certain cardiac drugs such as aspirin, clopidogrel, and warfarin are taken together with ginkgo  or garlic (Allium sativum L) supplements , though this risk has not been found in other studies [34-36]. Many cardiacpatients experience allergies, toxic reactions, mutagenic effects, and even death with CAM use [20,37]. Paul and Seaforth  found that the continued popularity of folk remedies in Trinidad potentially exposes people to dangerous toxins. Our present findings are consistent with those of White et al. , who found that patients perceived CAM as less harmful and conventional medicine as ineffective and with other reports in which patients perceived CAM as natural and safe  or cost-effective . The attrac- tiveness of CAM arises from its perceived ability to pre- vent and treat illness with minimal adverse effects while decreasing complications caused by conventional medi- cations . Despite the overall positive attitudes and acceptance of CAM by patients, conventional medicine was not generally condemned, although many patients felt that conventional therapies did not meet their thera- peutic goals. This attitude likely indicates that patients do not completely trust CAM to perform all the roles served by conventional therapy. It therefore comple- ments the role of conventional medicine. This dichoto- mous and complementary role encourages and expands the use of CAM. Patients are aware of the limitations of conventional medicine and therefore seek alternative treatments. This is well recognized for cardiac diseases especially with patients with a history of atherosclerosis where there no cure. Patients welcome and embrace CAM because it fills the void left by conventional medi- cine. CAM promises to alleviate and even prevent cor- onary artery blockage.
The categories information, communication, breach of the patient’s wishes or patient’s advance care directives and not perceived as an informed patient touch the topics of autonomy. Autonomy at the end of life, especially considering decision-making is con- troversially discussed . A large number of pallia- tive care physicians in the world do not inform their patients about the terminal stage of their illness . Palliative Care patients identified knowing what to expect about their physical condition as a major need when they were asked about preferences regarding end of life preparations . Supporting these find- ings, the lack of honest information about physical condition and prognosis as well as shared decision- making was described as an error in palliative care in our interviews.
are not discharged too early potentially leading to ICU- readmission and/or prolonged hospital stay, both of which are associated with higher mortality rates [25,26]. The good prognostic abilities of SOFA and CASUS in this study suggest they could be used to identify high- risk patients, enabling certain precautions to be put into place, such as daily monitoring of physiological dysfunc- tion , and allowing prognoses and therapeutic choices, including withdrawal of therapy, to be dis- cussed and reconsidered . Nevertheless, no scoring system can replace clinical evaluation at a patient’s bed- side; they can only serve as an objective tool in decision making. Although scoring systems may provide an indi- cation of disease severity and prognosis in individual patients and assist in overall patient assessment along with full clinical evaluation and other available para- meters, they are designed for use in groups of patients and should never be the sole basis for therapeutic decisions .
The only other study, a small randomized study among 20 patients undergoing cardiacsurgery, however, found no marked differences in hemodynamic parameters according to treatment with dobutamine or milrinone . The study provided no information on clinical outcomes. Earlier trials comparing the efficacy of early- generation phosphodiesterase inhibitors (maranon and enoximone) with dobutamine similarly lack data on effect on major clinical outcomes . Recent meta-analyses of randomized clinical trials with milrinone for cardiac dysfunction conclude that the use of milrinone is neither to be recommended nor refuted due to risk of bias and random error in current evidence. None of the included studies in these meta-analyses used dobutamine as a single comparator [32, 33]. One study using network meta- analytic data including indirect comparisons suggested no big differences between milrinone and dobutamine in cardiacsurgery . To date, the only randomized trial sufficiently powered to establish the safety and efficacy profile of milrinone was the OPTIME-CHF trial enrolling 951 patients with nonsurgical acute exacerbation of chronic heart failure. The results of this trial suggested that milrinone might be harmful in patients with ischemic heart failure with LVEF < 40%. However, data are difficult to interpret as the study allowed cointerventions with dobutamine in randomized patients [35, 36].
Preoperative variables expected to be associated with the development of preoperative malnutrition were obtained during a preoperative interview with the patients and using chart records. These variables included the questions asked in the ESPEN recom mended nutrition risk screening questionnaires, Nutritional Risk Screening 2002 (NRS2002), Mal nutrition Universal Screening Tool (MUST) and Mini Nutritional Assessment (MNA), and various clinical parameters and comorbidities presented in Table 1 (26). These variables were divided into three clinically relevant groups of malnutrition risk factors: psychosocial and lifestyle factors, labora tory findings and diseaseassociated factors (31). The psychosocial and lifestyle factors encompassed the intake of food and weight loss, the presence of depresssion and neurophysiological problems, the severity of the chronic disease, mood disorders and impaired mobility as defined in the latter ques tionnaires. The laboratory values tested were those indicating chronic inflammation, impaired haemo poiesis and other most clinically relevant parame ters for cardiacsurgerypatients. The diseaseasso ciated factors group was generated by employing all of the most prevalent comorbidities for the pa tients in question and by adding the hospitalisation and demographic parameters (32).
NIRS is a relatively new tissue oxygenation monitoring technology, and its use for monitoring brain oxygena- tion with INVOS may be a useful tool in an attempt to improve outcomes in carotid and cardiacsurgery. Pub- lished data suggest that significant intraoperative reduc- tion of INVOS values correlates with adverse outcomes (cognitive dysfunction, hospital length of stay), and pre- liminary data suggest that prompt interventions in epi- sodes of reduced INVOS values may contribute to improved outcomes. However, in order to better under- stand the role of INVOS brain tissue oxygenation moni- toring in clinical practice, more data are needed to establish baseline values and identify factors influencing INVOS measurement in different patient populations. Relevant data have already been published: baseline INVOS values in cardiacsurgery were 58.6% ± 10.2% in the Yao study , and transient cerebral ischemia dur- ing carotid or cardiacsurgery seemed to correlate with adverse neurologic outcomes. Our small study is an attempt to evaluate factors that could influence baseline INVOS values in patients undergoing cardiac or carotid
In a previous study done in the sub-group of diabetic patients, significant distortions in self-perceived body weight have been found. In fact, this increased signifi- cantly with the increase in BMI weight status . This is similar to the observations made in cardiacpatients in the current study. Only 12 % of overweight and obese patients in a group of hypertensive patients correctly identified that they had higher than normal weight . In the present group, only around 14 % of both over- weight and obese patients managed to accurately state their weight status. These similarities observed between these patient groups, in contrast to the general popula- tion, could be expected, as the diseases themselves are most of the time inter-related or co-existent and there are similarities in the exposure of patients to health- related information.
Patients with diabetes mellitus undergoing pri- mary CABG surgery performed on cardiopulmonary bypass were included in the study. This study was con- ducted in the department of Cardiothracic Anesthesia PGMI/LRH from April 2012 to December 2014. A total number of 100 patients were randomly assigned in one of the two groups, i-e 50 in GIK and 50 patients in control group. Approval to use GIK solutions in human subjects was obtained from Institutional Resarch and Ethical board Post Graduate Medical Institute, Lady Reading Hospital, Peshawar. An informed consent was obtained from each patient enrolled in the study.
No significant impairments in respiratory muscle strength were found two months after cardiacsurgery, as compared to preoperative values. This is the first study to describe respiratory muscle strength after dis- charge in patients undergoing cardiacsurgery. Riedi et al.  has reported an 11 % reduction in MIP five days after surgery, and Morsch et al.  a 36 % reduc- tion in MIP six days after surgery. Reduced respiratory muscle strength in the early postoperative period after cardiacsurgery might be due to sternal pain that affects the possibility of performing the respiratory muscle tests properly. It is still unclear whether muscle strength is as- suredly affected by surgery, or whether it is masked by pain or patients ’ motivation and skills to perform the test postoperatively, which might be challenging after surgery. After median sternotomy, distortion of the chest wall configuration reduces chest wall compliance and the ability to breath. Altered respiratory movements, dis- tortion of the chest wall configuration and the reduction of the chest wall compliance might be one explanation for the decreased lung function found two months after surgery.
The magnitude of tissue damage in connection of routine surgery varies from small superficial incisions to large operations. Accordingly, local and systemic biochemical and cellular responses may be negligible or most extensive. Open cardiacsurgery with cardiopulmonary bypass (CPB) belongs clearly to major procedures. Additional strengths are the uniform location, length and depth of the presternal skin incisions. CPB may activate the inflammatory response fol- lowing exposure of blood to the foreign surfaces, through the ischemia-reperfu- sion injury and endotoxemia . Hence in this study local individual inflam- matory changes are strong enough to be detected.
Postoperative patients in Cardiac Intensive Care Unit (CICU) have more complexities compared to their condition before the operation. Complexities that discussed here is in terms of postoperative complications and data management. Postoperative complications related to cardiac function have a wide variation in rate of severity and progression. In addition to this, the increase in number of patients and the amount of data recorded, make it unfeasible for clinicians to accurately analyze those huge amounts of data and predict the patients’ state in response to the devised therapeutic interventions. These complexities in patients’ condition and data management can lead to lack of adequate continuity of care to the patients by the clinicians, hence increase the rate of patient readmission to the hospital. Looking at these problems, it is foreseen that there is a need for a computerized model that can utilize patients’ hemodynamic data and predict the patients’ state in order to assist clinicians in patients monitoring and clinical care. This research is aimed to develop a mapping system that can predict the patients' state based on changes in different hemodynamic parameters of patients after cardiacsurgery. Previously developed physiological model which is also known as cardiovascular system (CVS) model has been used to produce data for different patients' condition after cardiacsurgery such as hypertension (related to high blood pressure), hypervolemic (related to blood loss) and vasodilation (related to widening of blood vessel). This physiological model has been comprehensively validated and therefore can be effectively used to simulate the physiological profiles of the patients. The proposed method for predicting the state of these patients is using Computational Intelligence (CI) models, whereby the logical constructs used in this system is easy to describe and closely approximate the thinking processes used in clinical decision making. The availability of this CI has been recognized to perform as intelligent assistants to clinicians providing constantly monitoring electronic data streams for important trends.
It is not surprising that the need of inotropes prior to surgery is the strongest predictors of mortality. Chronic kidney disease and COPD are well known risk factors for both short- and long-term morbidity and mortality after cardiacsurgery [44–47]. Our findings clearly show how these conditions acquire an even more considerable relevance in patients who also have a reduced LV function. In the present study the rate of postoperative complications is higher than previously reported in literature. In particular compared with data from recent large studies led in a general cardiac surgical population [48, 49], in this high risk population with low EF we found a higher rate of postoperative AKI, AF and LCOS [36, 37]. On the contrary, we observed a lower rate of myocardial infarction. A possible explanation is that postoperative myocardial infarction after cardiacsurgery may be related to inaccurate myocardial protection peri- operative hemodynamic instability, a post-operative pro- thrombotic state complexity of coronary revasculariza- tion, surgical technical skills rather than LVEF itself . The following limitations have to be considered: first the retrospective design of the study ; second it covers a relatively long period during which both the indications to surgery and the perioperative care may have changed; third the lack of a long-term follow-up. The study is monocentric and a validation group was not available. The performance of the two models is not optimal and they might be further improved in larger multicentric studies; however, the cut-offs for analyses were based on relevant clinical parameters and were chosen according to international guidelines . We are aware that LVEF remains among the strongest predictors of clinical outcome after cardiacsurgery, and we cannot exclude that other parameters, that were not taken into consideration in the present study, might play a relevant role. Finally, in some cases, isolated CABG surgery was performed, although mitral valve disease was also present: as we cannot provide the rate of occurrence of this phenomenon, we can- not exclude that it might have influenced our results.
For peer review only
24 participants here viewed the surgery as a physical tool to change eating rather than relying on their will power or eating decisions. This suggests naivety regarding post- operative lifestyle change. The potential of positive outcomes following surgery are reduced if patients do not accept the need to modify their eating behaviours. Unrealistic expectations regarding the perceived level of effort required indicates the need for additional interventions pre-and post-surgery. There is the potential to learn from behavioural, self-management interventions in other conditions, for example the Expert Patient Programme in long term conditions, and the DESMOND programme for newly diagnosed type 2 diabetes. Many such behaviour change interventions are routed in psychological theory and aim to improve psychological wellbeing as well as promote behaviour change. This study indicates such an approach may be appropriate with in the bariatric surgery population. The findings here raise the question of whether similar interventions such as DESMOND could be developed for people referred for bariatric surgery. Such services could be introduced prior to surgery to prepare people more effectively but be continued post-surgery to promote sustained self-management and behaviour change. Further research is required to inform the development of such interventions and evaluate their impact on behaviour change, self-management and achieving positive outcomes.
reexploration for bleeding. The wound complication was comparatively low. Respiratory complications, such as pul- monary infection and hypoxemia, can be also seen, because postoperative acute renal failure and hemofiltration mainly depend on the preoperative renal function and the degree of damage during the simultaneous surgery. What matters is that surgeons must take into account every single operative risk related to every single problem. They must decide in the first place whether there is a necessity for simultaneous surgery or whether there is contraindication. In order to select the best surgical strategy for each patient, a complete preoperative examination and an accurate estimation of combined risks should be carried out before treatment planning.