A. The recent article published in the American Journal of Nursing challenges the predominantly female profession of nursing through the prism of men’s engagement. This literature review analyzes the possibilities of recruiting males into this caring occupation and examines whether stereotypes, predominance and gender discrimination could be overcome.

Article

MacWilliams, B. B., Schmidt, B. & Bleich, M. R. (2013). Men in Nursing. American Journal of Nursing, 113 (1), 38-44. doi: 10.1097/01.NAJ.0000425746.83731.16

Assessment

The literature review by MacWilliams et al. (2013) covered two major databases concerning gender diversities in nursing – the Education Resources Information Center and the Cumulative Index to Nursing and Allied Health Literature over the period from 1996 to 2011. The primary plot of more than 1,000 reviews, articles and dissertations was critically checked and non-relevant papers were excluded. Thus, the initial amount of studies was downsized to some 56 manuscripts that bear insight into the problem of male experience in nursing. The researchers describe in detail the key points of the most significant articles and in doing so, grade the topic into sub-themes: choosing the profession, studying for a nurse, working as a nurse, meeting the institutional polices, sexual stereotypes and national calls for gender diversity in nursing.

Ethical Issues

Although sexual prejudgment in professions is diminishing nowadays, in 2008 only 7% of engaged in nursing were male (MacWilliams et al., 2013). The low percentage may be attributed to ethical barriers in nursing. For example, men students fear obstetrical investigation because it might be perceived as sexual rather than professional. However, stereotypes are diminishing and The American Assembly for Men in Nursing assists in setting a goal of 20% male enrollment in nursing in 2020 (MacWilliams et al, 2013).

Types of Research Used

This is a qualitative research. The authors have collected numerous thoughts regarding the theme from various sources. They collected different observations on how men proceed when applying for nursing educational programs, how they succeed in training, what challenges they meet when negotiating with colleagues, which institutional barriers men overcome, and when sexual stereotypes become unavoidable. The categorization of the theme is logical and coordinates well with the whole study. Thus, this article develops a descriptive research design and makes an attempt to explain the obtained opinions.

Other Types of Research

Quantitative methods if applied would add more strength to the study. The contributors mention some basic statistics regarding proportion of men in the nursing society. However, if appropriate questionnaires were given to a representative number of male students and male nurses and results mathematically analyzed, the general conclusions might be more valid. This type of approach is called mixed.

B. The literature searches on medical treatment (phosphodiesterase-5 inhibitors) of Eisenmenger syndrome in children.

Problem

Congenital heart disease with massive left-to-right shunt (most commonly ventricular septal defect, truncus arteriosus or transposition of the great arteries) if diagnosed beyond the first years of life leads to pulmonary arterial hypertension. This is a devastating condition with poor prognosis and bad morbidity. These children compose a challenging medical problem. Besides high pressure in the pulmonary artery, they suffer from breathleness during physical activity, congestive heart failure, cyanosis, high hemoglobin with subsequent risk of thrombosis (the so-called Eisenmenger syndrome). Phosphodiesterase-5 inhibitors, such as sildenafil and tadalafil, are among the FirstLine Therapy for pulmonary hypertension. FDA approved Sildenafil, a pulmonary vasodilator, for treatment of the Eisenmenger syndrome in the adults. Randomized controlled trials show that this is safe and effective drug to improve their status and prognosis. These results have been applied to children empirically. Some investigations suggest that sildenafil improves symptoms in children effectively and thus, support the idea to treat Eisenmenger syndrome in children with this drug. However, the recent randomized trial shows that sildenafil may provoke sudden heart death if prescribed in high doses. There is a need for the nurse to be aware of the true benefits and potential threats when managing a child with Eisenmenger syndrome.

Annotated Bibliography

Balu Vaidyanathan (2008). Drug Therapy: Sildenafil for post-operative pulmonary hypertension and Eisenmenger syndrome – brief review of literature and survey of expert opinion. Ann Pediatr Cardiol, 1(1): 70–74. doi:10.4103/0974-2069.41063

There are no approved recommendations regarding the optimal treatment strategy for Eisenmenger syndrome in children. The author conducted a questionnaire among experts in pediatric cardiology and discussed their opinions. The leading specialists in this area agree that sildenafil should probably be prescribed life-long. The treatment needs to be started after symptoms occur. Most experts feel that this is rather effective therapy, albeit with proper follow-up. The need for well-designed randomized trials is emphasized.

Barst, R. J., Ivy, D. D., Gaitan, G., Szatmari A., et al. (2012). A randomized, double-blind, placebo-controlled, dose-ranging study of oral sildenafil citrate in treatment-naive children with pulmonary arterial hypertension. Circulation, 125: 324-334. doi:10.1161/CIRCULATIONAHA.110.016667

This randomized controlled trial engaged more than 150 children with various congenital heart defects at the stage of pulmonary hypertension and more than 70 with other etiologies. They were prescribed with either sildenafil in different doses (categorized as low, medium and high) or placebo. The investigation group was followed-up for 3 years. At the end of investigation, the improvement was shown in the medium and high doses of sildenafil versus placebo, but no improvement in the low dose group. Increased mortality is associated with high doses of sildenafil. The majority of deaths happened in the non-congenital heart disease group; however, they made a statistically less significant cohort. The authors suggest that the medium dose of sildenafil is preferred in Eisenmenger syndrome in children. The authors expect further investigations.

Beghetti, M. & Galiè, N. (2009). Eisenmenger Syndrome: A clinical perspective in a new therapeutic era of pulmonary arterial hypertension. JACC, 53(9): 733-740. doi:10.1016/j.jacc.2008.11.025

This is a review on Eisenmenger syndrome. The authors describe the key point of pathogenesis that suggests therapeutical approaches. Although patients with Eisenmenger physiology show better patterns than pulmonary hypertension of other etiologies, the overall prognosis is poor. The contributors mention historical attempts, mostly unsuccessful, and emphasize importance of the evidence-based treatments to treat the Eisenmenger syndrome. Severe cases are amenable to the heart-lung transplantation; the latter sometimes gives unsatisfactory results. Sildenafil alone or in combination with other groups of vasodilators alleviates cyanosis and improves the exercise capacity. The authors note large controlled trials concerning that long-term results are still lacking.

Dimopoulos, K., Inuzuka, R., Goletto, S., Giannakoulas, G., et al. (2010). Improved survival among patients with Eisenmenger Syndrome receiving advanced therapy for Pulmonary Arterial Hypertension. Circulation,121:20-25. doi:10.1161/CIRCULATIONAHA.109.883876

This retrospective study followed the natural and modified history of 229 young adult patients with Eisenmenger syndrome. 69 patients received pulmonary vasodilator therapy, and quarter of them took sildenafil. The authors studied 7-year period and learned that when symptomatic patients have no specific therapy their prognosis is extremely poor. Should sildenafil or another vasodilator be added, the survival curve becomes much better, mortality reduces and clinical status improves substantially on vasodilators. However, the authors did not specify which vasodilator is best.

Haworth, S. G. & Hislop, A. A. (2008). Treatment and survival in children with pulmonary arterial hypertension: the UK Pulmonary Hypertension Service for Children 2001-2006. Heart, 95: 312–317. doi: 10.1136/hrt.2008.150086

This article presents the results of retrospective monitoring of children (mean age 12 years at recruiting) with pulmonary hypertension; 49 patients with Eisenmenger syndrome were studied, 37 of them received treatment. There were no deaths in the non-treatment group and two deaths in the pulmonary vasodilator group within the study period. Because this study included other complex diseases with pulmonary hypertension, the Eisenmenger syndrome results looked encouraging in comparison with them. The effects of treatment were also better in Eisenmenger syndrome. The authors agree that pulmonary vasodilators should be started when symptoms occur and symptomatic improvement is the key result of pulmonary hypertension treatment.

Kim, H. W., Kim, G. B., Je, H. J., Beak, J. S., et al. (2008). Pulmonary arterial hypertension in children: A single center experience. Korean Circ J, 38: 644-650. doi:10.4070/kcj.2008.38.12.644

This paper presents a single center experience of 10 children with Eisenmenger syndrome. Sildenafil was stopped in one patient due to adverse effect – skin rash. Clinical improvement was reported in all. Overall, the investigators conclude that no matter how effective the initial response to vasodilator is, the overall survival still remains poor. Albeit this general conclusion was based on the entire cohort of patients who suffered from other complex disorders.

Mukhopadhyay, S., Sharma, M., Ramakrishnan, S., Yusuf J. et al. (2006). Phosphodiesterase-5 inhibitor in Eisenmenger syndrome: a preliminary observational study. Circulation, 114:1807-1810. doi: 10.1161/CIRCULATIONAHA.105.603001

In this trial tadalafil was administered to 16 young patients with Eisenmenger syndrome for 12 weeks. Thirteen of them responded to the drug and improved significantly immediately after prescription and 12 weeks later. No significant hemodynamic abnormalities were observed, neither in the response, nor in the non-response group. The authors conclude that a single day dose of tadalafil may improve the quality of life of those who suffer from Eisenmenger syndrome. Overall, this study is in agreement with other trials in patients treated with sildenafil.

Singh, T. P., Rohit, M., Grover, A., Malhotra, S. & Vijayvergiya R. (2006). A randomized, placebo-controlled, double-blind, crossover study to evaluate the efficacy of oral Sildenafil therapy in severe pulmonary artery hypertension. Am Heart J, 151: 851.e1 - 851.e5. doi:10.1016/j.ahj.2005.09.006

In this randomized trial 10 patients of the mean age 10 years old were enrolled to investigate the effectiveness of sildenafil in improving their clinical condition. After a 6-week period of sildenafil intake the walking capacities, metabolic tests and clinical conditions improved significantly. No major side effects were detected. The dose of sildenafil in this trial was as high as the patient’s hemodynamic could tolerate within the pharmaceutical prescriptions. The major limitation of this study is its short duration, so survival advantages or disadvantages have not been shown.

Takatsuki, S., Calderbank, M. & Ivy, D. D. (2012). Initial experience with tadalafil in pediatric pulmonary arterial hypertension. Pediatr Cardiol, 33:683-688. doi:10.1007/s00246-012-0180-4

This is a retrospective study that encompassed children who took sildenafil. 29 children were switched to tadalafil because of its daily administration regimen. The doses were medium. All children improved clinically. Nearly half of them underwent heart catheterization that showed hemodynamic improvement. In most cases the side effects were minor, but in two of them migraine and allergy required discontinuation of tadalafil. The author’s opinion is that this is safe and perspective drug in pediatrics.

Zhang, Z., Jiang, X., Zhang, R., Li, X., Wu, B., et al. (2011). Oral Sildenafil treatment for Eisenmenger syndrome: a prospective, open-labeled, multicentred study. Heart, 97(22):1876-1881. doi:10.1136/heartjnl-2011-300344.

This article reports a 12-month trial conducted on 84 patients aged 14 to 56 years old with Eisenmenger physiology. Sildenafil at medium doses was prescribed to the diseased. Both hemodynamical and clinical improvements occurred. During the investigation period, no major adverse effects were detected, but complaints of headache and flushing were common. The weakest point in this study is that this is not a placebo-controlled trial, so the results must be taken with care.

Efficacy

Pulmonary hypertension in the congenital heart disease (Eisenmenger syndrome) carries poor outcome (Kim et al., 2008). Phosphodiesterase-5 inhibitors are generally indicated when devastating symptoms occur. All researchers state that sildenafil is an effective pulmonary vasodilator (Vaidyanathan, 2008). Its hemodynamic effects result in the clinical immediate and remote consequences: the physical capacities improve (Barst et al., 2012), walking abilities become better (Singh et al, 2006) and cyanosis decreases (Kim, 2008). One might expect improvement in survival. However, the long-time results are still lacking. One of the first long-lasting studies conducted by Barst et al. (2008) suggests that there may be serious adverse effects that preclude using high doses of sildenafil in children. Tadalafil, another potent vasodilator, may be a reasonable option for medical treatment of Eisenmenger syndrome. In conclusion, symptomatic relief for children with pulmonary hypertension can be provided, but evidence for long-term prognosis is still lacking.

Tools

Because there are so many articles collected in this research, various tools have been applied in the assessment. Some use quantitative experimental methods (Barst et al., 2012; Zhang et al., 2011) in their studies. These are randomized trials when the scientists conduct surveys with accurate mathematical management of the obtained data. Others (Vaidyanathan, 2008) use qualitative approach collecting opinions from different experts worldwide to work out a coordinated approach. All studies are close to strong evidence base in their attempt to develop recommendations how to treat children with Eisenmenger syndrome.

Effect on Results

The results of the studies seem to be valid enough because the methodologies were accurate and adequate. All papers describe in detail the methodology and statistical techniques used to evaluate their conclusions. However, only a few of them are long-term observations, thus the key limits of the tools lie in their time limits. The conclusions might be less optimistic if other research groups detected long-term major adverse effects of Sildenafil as in the Barst et al. (2012) survey.

Evidence Summary

It is generally accepted that improvement of well-being in a diseased person has positive impact on his/her long-term outcome. However, this has not been proved for Eisenmenger syndrome treatment yet. The evidence base for Sildenafil treatment group is convincing in its symptomatic positive effect and supporting hemodynamic changes. Statistical data strongly suggest that as long as phosphodiesterase-5 inhibitors are prescribed symptoms diminish. Nevertheless, the current state of the problem cannot suggest that this improves survival to the general level. The presented results validate hypothesis of positive impact of Sildenafil on pulmonary hypertension in the young in the short and medium-time periods. Annex 2 summarizes the articles in terms of objectives, methodology and analytical framework.

Recommendation

Strategy to manage sick children with congenital heart disease and pulmonary hypertension must include thorough knowledge of pharmacology. In the 21st century, many medical issues can be managed successfully. However, to treat a disease promptly, both the physician and the nurse need to be aware of all possible pitfalls of the drugs, which sometimes are sophisticated, medical interventions or care approaches. The evidence-based statement is that symptomatic children with Eisenmenger syndrome should be prescribed with a phosphodiesterase-5 inhibitor (sildenafil, or maybe tadalafil) to improve symptoms. These drugs often provoke minor adverse effects, which the health caregiver must be ready to explain to the parents. Usually complaints of heart failure and cyanosis will diminish and physical activity would improve. However, when sildenafil is taken in large doses, the nurse must provide education about cardio-cerebral resuscitation to the parents. Nurses who work with children with Eisenmenger syndrome should be ready to explain the possible sequel to the relatives.

Theoretical Model

Any health care worker gains unique experience throughout his/her career. Howsoever, the experience itself is of doubtful value when disorganized or in a chaotic order. Only professional experience that is properly organized into a logical outlook system is worth. This is so because should a proper working system of thinking develop, the framework will serve an adequate theoretical model to assess challenges in the future. The evidence-based model serves special tasks because this experience of others is organized and critically appraised by colleagues. However, what is most important, this theoretical model has already been examined and verified by life.

The evidence-based research integrates experience and paradigms into a practically-oriented system. It takes into account the numerous natural influencing factors that serve the best recommendations for health care providers. I am deeply convinced that all within the medical community must use the evidence-based research results in their everyday work.

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