VISCERAL FAT AND HYPERTENSION
Among Japanese Americans, the connection may be significant.
Recently analyzed data of the Japanese-American Community Diabetes Study demonstrate a strong association between greater amounts of visceral fat and the risk of having hypertension, independent of factors such as obesity and insulin resistance.
Of 658 second- and third-generation Japanese Americans enrolled in the major study, 300 met the criteria for eligibility to participate in the data analysis--at study entry, their systolic blood pressures were lower than 140 mmHg, their diastolic blood pressures were lower than 90 mmHg, and they were not taking antihypertensive or oral hypoglycemic medications or insulin. Blood pressure was measured three times during a single visit, and the last two measurements were averaged in order to determine the final reported reading. Visceral fat was calculated from intraabdominal fat as shown on a computed tomographic (CT) scan, and measurements of many other factors involved in the metabolic syndrome, such as central and total adiposity, insulin resistance, and blood lipids, were taken. Patients were followed up after five to six years and after 10 to11 years, and the same measurements were taken again each time. It was revealed that 92 of 300 participants (30%) had developed hypertension over the 10-to-11-year study period.
A complex statistical analysis was performed to examine the relationship between a particular element of the metabolic syndrome and hypertension. In univariate logistic regression, every risk factor seemed to be associated to some degree with the development of hypertension. When visceral fat was isolated from the other factors and several different kinds of statistical tests were performed, visceral adiposity and age emerged as the only risk factors consistently associated with hypertension.
In this prospective, longitudinal study, the strong association between visceral adiposity and the development of hypertension was believed to indicate a causal relationship; however, the study was not designed to investigate why visceral adiposity might cause hypertension. The authors call attention to the recent awareness that adipocytes function as an endocrine gland, secreting various compounds (such as plasminogen-activator inhibitor), some of which are thought to elevate blood pressure. There is some evidence that visceral adipocytes are more active than other adipocytes are in terms of endocrine functioning.
The limitations of this study include the taking of blood pressure measurements at a single visit, the estimation of total visceral adiposity from one CT scan - taken at the umbilicus, and a lack of generalizability to other ethnic groups. Nurses can educate this patient population on the cardiovascular risks associated with total visceral adiposity. -FM
Hayashi T, et al. Ann Intern Med 2004; 140(12):992-1000.
MANAGING CANCER SYMPTOMS WITH MASSAGE THERAPY
Large study reveals benefits for several common symptoms.
Patients with cancer who are bothered by symptoms of pain, fatigue, anxiety, nausea, or depression, and who receive massage therapy as inpatients or outpatients, report reductions in symptom severity by approximately 50%.
Over a period of three years, 1,290 patients at Memorial Sloan-Kettering Cancer Center in New York City received massage therapy (through provider, self-, or family referral) by one of 12 licensed massage therapists. Patients were allowed to request the type of massage they desired: standard Swedish massage, light-touch massage, foot massage, or a combination. Prior to and soon after the session, patients were asked to rate from 0 to 10 their level of pain, fatigue, stress or anxiety, nausea, depression, and other symptoms. Inpatient sessions lasted approximately 20 minutes, whereas outpatient sessions lasted approximately 60 minutes. Only data from the initial massage sessions for each patient were analyzed.
Most patients received standard Swedish massage (43%) or foot massage (45%), with more hospitalized patients receiving foot massage than other massage techniques; the majority of out-patients received standard Swedish massage. Anxiety was the most common presenting symptom (that is, symptom with the highest score at baseline), followed by pain and fatigue (31%, 28%, and 24%, respectively). The severity of the presenting symptom was reduced by a mean of 54.1%, but all symptoms showed improvements after massage therapy. Anxiety showed the greatest reduction, even in patients whose baseline scores started off as "moderate" severity (fatigue had the smallest reduction in this group of patients). Outpatients showed a 10% greater improvement in symptom scores than did inpatients. Standard Swedish massage and light-touch massage were associated with better outcomes than foot massage. The effects of standard Swedish massage and light-touch massage didn't differ significantly. Follow-up of 25% of outpatients and 25% of inpatients showed that although the effects of massage therapy for inpatients were short lived, the effects for outpatients lasted 48 hours (duration of the study).
These results suggest that massage therapy can reduce the severity of symptoms that patients with cancer often experience. Outpatients in particular can benefit longer from a single session. The results also suggest that light-touch therapy could be used more frequently for inpatients, as it seems to be more effective than foot massage. -JC
Cassileth B, Vickers, AJ. J Pain Symptom Manage 2004;28(3):244-9.
CARE PLANS ASSOCIATED WITH DNR ORDERS
Documentation is less than optimal.
In a cross-sectional study of medical inpatients with do-not-resuscitate (DNR) orders at two large urban medical centers, researchers found that the care plans often didn't explicitly document the limits of life-sustaining therapies.
At Georgetown University Medical Center in Washington, DC, and St. Vincent Catholic Medical Centers, St. Vincent's Hospital-Manhattan in New York City, researchers reviewed the medical charts of 189 consecutively admitted patients (mean age, 71.6 years) to assess for the attention or absence of attention to 11 patient care needs, within two days of the DNR order, using a validated chart review technique called "concurrent care concerns" (CCCs). The CCCs criteria included the assessment of the use of intubation, dialysis, blood products, antibiotics, vasopressors, artificial hydration, and artificial nutrition; consideration of the need for analgesia and sedation and for hospice and spiritual care; and consideration of the decrease in the number of times that vital signs are measured.
The results showed that in only slightly more than half of the charts (55%) the reason for the DNR order was documented, whereas documentation of a conversation with the patient or surrogate concerning consent was present in 69% of cases, suggesting that the quality of documentation of DNR orders was inadequate. In most cases, at least one CCC per DNR order (mean, 1.55) was attended to (one or less indicating a low level of attention and two or more indicating a high level). The limiting of intubation was documented most often after cardiopulmonary resuscitation (in 42% of the charts). Attention to analgesic needs was documented in only 37% of the charts (according to data collected in 1998 and 1999, before the Joint Commission on Accreditation of Healthcare Organizations issued its pain-management standards), to spiritual needs in 7% of them, and to decreasing frequency of the measurement of vital signs in 1%. Greater severity of illness was associated with attention to a greater number of CCCs-among patients with cancer 2.08 CCCs were considered per DNR order, whereas among those with dementia 0.67 CCCs were attended to.
Although the generalizability of the results is limited, they show that documentation of the plan of care in patients with DNR orders is less than optimal. Although that has not been linked to patient outcomes, the authors suggest that the CCCs are important parameters in end-of-life care and that nurses and other members of the health care team receive continued training and education in attending to the CCCs. -JC
Sulmasy DP, et al. Arch Intern Med 2004;164(14):1573-8.
CONTINUOUS VERSUS INTERMITTENT BOLUS INFUSION OF FUROSEMIDE
A comparison of hemodynamic and biochemical effects.
Furosemide administered by either continuous infusion or by intermittent bolus infusion in critically ill patients is effective in reducing fluid overload. But continuous infusion in patients who have significant fluctuations in hemodynamic variables and electrolyte levels may produce a more stable diuresis.
Patients in need of diuresis with furosemide were randomly assigned to receive either continuous infusion (n = 11) or intermittent bolus infusion (n = 11) of the drug for 36 hours according to a protocol after being initially divided according to serum creatinine level. After an initial bolus infusion of furosemide 20 mg IV, the drug was titrated to a maximal dose of 0.75 mg/kg/hr in the continuous infusion group and 320 mg (per dose) in the bolus group.
Intermittent bolus infusions were associated with greater increases in heart rate and greater decreases in potassium ion concentration in relation to baseline, compared with continuous infusion. Further, a greater mean increase in PaO2/FIO2 was achieved in the continuous infusion group, compared with the bolus intermittent infusion group.
Continuous infusion of furosemide not only produces less deviation in hemodynamic and biochemical variables during diuresis, it may be the more efficient means of administration, from the nurse's perspective, according to the researchers. -JC
Mojtahedzadeh M, et al. J Infus Nurs 2004;27(4):255-61.