Wednesday, 27 September 2023

Lupine Publishers | Children’s Mouthwash; Commercial Product or Oral Health Guarantor

 Lupine Publishers | Journal of Dentistry and Oral Health Care


Nowadays, when we enter a pharmacy, we come across a variety of healthcare products that come to the market every day. Types of masks, gels, detergents and etc., which may look identical in name and application but claim to be totally different and each has its own user extent. Some of these products are commercial in nature, and some are not so important in maintaining health, and in fact, one’s health is not dependent on them. Perhaps that’s why each of us never consumed some of these health and beauty products, and we do not even know them at all. If the product does not directly interact with our health, we do not need to carefully look at the need to how to consume them and do not curious about them, but when it comes to products that claim to protect our child’s health, the matter becomes more quite critical and worrying. Mouthwash is one of these products which are found at all pharmacies. So many oral health officials have been able to highlight the need to use mouthwashes among people. With the training and information provided in this area, people should use mouthwashes in addition to toothpaste and dental floss. But what is the child’s mouthwash, and do the children really need them to use? Do these products guarantee the health of their teeth or is it more a commercial product to fill the pockets of some of the companies?

Mouthwashes have different types. Some have pharmaceutical uses and should be used in certain cases only with physicians’ prescriptions. Mouthwashes that are on the market for the public use contains fluoride which prevents tooth decay. Many pharmaceutical companies have produced and marketed mouthwashes for children to facilitate the use of mouthwashes for children. These mouthwashes have been manufactured considering the least risk of swallowing fluoride. The proper taste of these mouthwashes is a feature that encourages children to use them. Mouthwash is one of the complementary methods of oral home care. These mouthwashes provide oral and dental care along with tooth brushing and dental floss, but they should never be replaced by each other. In other words, application of none of them alone has the significant effect. Before planning to buy the product, if parents tend to use pediatric mouthwashes, they should have a consultation with the pediatric dentist so that the dentist can select the better of the most appropriate one and the least harmful mouthwash. However, they should be used according to the instructions; these instructions vary from product to product and depending on the content and concentration of fluoride, the application may be different.

In other words, it should be noted that some types of mouthwashes are highly recommended by most dentists in the routine oral care program. This is due to the ease and speed of its use, and its effectiveness. In general, along with toothbrushes and dental flosses, many types of mouthwashes are also produced, each of which has its own interests in the beauty and health of teeth. These mouthwashes can be prescribed by the dentist or can be purchased OTC from the pharmacy. Nonetheless, alcohol-free mouthwash is a product that depends on the individual’s needs. The choice of the mouthwash that meets personal needs is very important. Some mouthwashes on the market contain alcohol, in particular, Ethanol, which can cause burning sensation, unpleasant taste, and dryness in the mouth. It is not recommended for children at all because the burning and spicy tastes force the child to stop using the kid’s mouthwash for future use. Consequently, if the parents intend to choose an appropriate mouthwash, first they should not choose any kinds of mouthwashes, and secondly, it is advisable to have a consultation with the pediatric dentist so that they don’t become bewilderment when choosing the proper mouthwash. To finish this point of view, for some time, fluoridecontaining mouthwash has been commonly used in children. But, in my opinion, some kids do not need to use them at all. That is, if fluoride is adequately contained in fluoride-containing toothpaste, in drinking water, or even the consumption of foods such as seafood or tea which contains this material, then, there is usually no need for fluoride mouthwashes for children.

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Tuesday, 26 September 2023

Lupine publishers | Continuous or Intermittent? Which Regimen of Enteral Nutrition is Better for Acute Stroke Patients? a Systematic Review and Meta-Analysis

 Lupine Publishers | Journal of Neurology and Brain Disorders


Background and purpose: Enteral nutrition via nasogastric tube in acute stroke patients with dysphagia is an important determinant of patient outcomes. It is unclear whether intermittent or continuous feeding is more efficacious. The aim of this review is to examine the current evidence comparing the effectiveness of intermittent versus continuous feeding in stroke patients in terms of nutritional status, gastrointestinal intolerance and other complications.

Methods: A systematic review of randomized controlled studies comparing intermittent with continuous nasogastric feeding in acute stroke patients was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Metaanalyses) guidance using predefined search terms. The search was conducted in MEDLINE and EMBASE up to 1st March 2019. Two independent reviewers assessed study quality using the Joanna Briggs Institute Critical Appraisal Tool. Meta-analyses were conducted, where appropriate, using a random-effects model to pool risk ratio with corresponding 95% CI.

Results: Three studies including a total of 184 patients were identified. All three were medium to low quality. The definition of intermittent enteral nutrition within each study varied considerably in terms of volume, rate and mode of delivery. Achievement of nutritional targets was the same for both feeding patterns in the one study it was reported. Only aspiration pneumonia and diarrhea were measured by all three studies. There was no significant difference in the incidence of aspiration pneumonia (RR 0.91, 95% CI 0.53-1.57, p=0.74, I2=50%) and diarrhea (RR 1.74, 95% CI 0.70-4.30, p=0.23, I2=42%) between the two patterns of feeding. Other outcomes including, vomiting, gastric retention, mortality, pre-albumin and nasogastric tube complications showed no significant differences.

Conclusion: There is very little and low-quality evidence to inform patterns of enteral feeding after stroke. The available evidence shows no significant difference in nutritional achievement and complications between intermittent and continuous nasogastric tube feeding in acute stroke patients.

Keywords: Stroke; Enteral; Nutrition; Nasogastric; Dysphagia


Dysphagia occurs in up to 50% of patients following a stroke [1- 4] and increases the risk of pneumonia almost ten-fold [5]. Strokerelated pneumonia is associated with longer length of hospital stay, worse levels of disability and increased mortality [6-9]. In most dysphagic patients, adaptation of the consistency of diet and fluids is sufficient to ensure that the swallow is safe. However, in a small proportion insertion of a Nasogastric Tube (NGT) is required to ensure safe and adequate nutrition. Despite this, more than twothirds of NGT-fed stroke patients still develop pneumonia [10] Gastric dysmotility is a well-documented phenomenon that occurs in critically ill patients, including acute stroke patients, whereby incomplete gastric emptying results in stasis, heightening the risk of reflux and aspiration of gastric contents [10-13]. NGT bolus feeding was first described by Morrison et al. [14] in 1895 for children with Diphtheria, who received 6-ounce bolus feeds 3 times a day via NGT. However, it wasn’t until 1910s when Morgan et al. [15] and Jones et al. [16] began administering their enteral feeds “drop by drop” rather than as a bolus. Contemporaneously, the regimen most frequently used in most patients requiring enteral feeding is continuous (i.e. low volume pumped feed lasting 16-24 hours without interruption). However, recent attention has been afforded to examining whether a discontinuous feeding strategy - often described as either intermittent or bolus (i.e. high volume of feed administered over a short period multiple times a day) - could reduce patients’ risk of pneumonia and achieve better nutrition and digestive tolerance.

Intermittent feeding reflects normal human feeding patterns more closely than continuous feeding. A period of fasting interrupted by the ingestion of a discrete meal causes gastric distension and subsequent stimulation of gut motility, secretion of digestive enzymes and metabolic responses to nutrient loading [17- 18]. This physiological gastrointestinal response to intermittent feeding has been demonstrated in healthy adults, neonates and intensive care populations [17-20]. While there are good theoretical reasons to assume that intermittent feeding is more physiological, most stroke patients in the UK receive nasogastric feeding continuously, as there are concerns that intermittent feeding may be less well tolerated. Guidance and practice relating to enteral feeding after stroke differs between countries; with the American Heart Association [21] and the Royal College of Physicians [22] not addressing the issue, Australian Guidelines allowing for both options [23] and intermittent feeding described as “traditional” in China [24]. The aim of this systematic review is to determine whether there are differences in the achievement of adequate nutrition, gastrointestinal tolerance, and metabolic stability between intermittent and continuous nasogastric feeding.


This systematic review and meta-analysis were prepared according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [25].

Criteria for Considering Studies for this Review

The inclusion criteria for this review were:
a. Population: Acute stroke patients aged 18 or more with a nasogastric tube receiving enteral nutrition
b. Intervention: Intermittent enteral nutrition: by bolus, gravity systems or infusion pump several times a day with a rest between feeds
c. Control: Continuous enteral nutrition: with gravity systems or infusion pumps, without interruption for a minimum period of 12 hours/day
d. Outcomes: Nutritional status, aspiration pneumonia, diarrhea, vomiting, gastric distension, gastric retention, hyperglycemia, pre-albumin, mortality, length of stay, and NGT complications
e. Study Design: Randomized controlled trials or pseudo-randomised controlled trials (a study without true randomisation) that compared continuous and intermittent enteral feeding methods.

Search Strategy

A literature search was performed using MEDLINE (1966 – 1st March 2019) and EMBASE (1974– 1st March 2019). Studies were searched for using the terms enteral, nutrition, nasogastric, gastrointestinal, feeding as Medical Subject Heading (MeSH) and free text terms. These were combined with the set operator “AND” with following terms: intermittent, continuous as both MeSH and free text terms. Publications were restricted to those studying adult populations, defined as greater than 18 years old, with a documented diagnosis of stroke according to accepted international criteria [26]. This search strategy is described in Appendix 1. The reference lists of all eligible studies that were identified were also comprehensively searched for studies not identified using the initial search strategy. This search was performed independently by two reviewers.

Selection of studies

Two reviewers (GDP and ET) assessed the studies independently for inclusion using the title and abstract. In cases where relevance could not be determined solely from the abstract, the full text was consulted. Any disagreements were resolved by consensus with a third reviewer (CR).

Data extraction and management

Data extraction was done manually by two reviewers (GDP and ET). Differences were discussed and adjudicated in faceto- face meetings. Foreign language papers were translated, and descriptions of each study were derived. This included authors, year of publication, type of participant, location, study design, sample size, age and gender of participants, exclusion criteria, when feeding was started, monitoring period, nasogastric tube size, type of feed and definitions of each intervention. In addition, data was extracted for definition and results of each outcome from all studies.

Assessment of risk of bias in included studies

Methodological quality of the studies was assessed using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (MAStARI) Critical Appraisal tool for experimental studies [27].

Data synthesis

The studies presented in this review all fitted the conceptual definitions of intermittent and continuous enteral nutrition, as outlined in the inclusion criteria. However, there were differences in the volume, rate and temperature of nutrient delivered. In addition, two of the studies did not use true randomisation. Taking into consideration these limitations, a meta-analysis has been carried out with the outcome’s diarrhea and aspiration pneumonia, as these were the outcomes assessed by all studies. Narrative synthesis was used where outcomes did not allow meta-analysis. The meta-analysis was performed using Review Manager (RevMan) Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014. Data was extracted from all three studies for the outcome’s diarrhea and aspiration pneumonia. We calculated risk ratios (RR) and 95% CIs using the Mantel–Haenszel model. Statistical heterogeneity among trials was assessed by the I2 test, with I2 >50 representing possible substantial heterogeneity. The meta-analysis was performed with a random‐effects model irrespective of the level of heterogeneity as the included trials varied considerably in a number of methodological features.


Study selection

Figure 1: PRISMA flowchart for study selection process.

The PRISMA flow-chart for study selection is shown in Figure 1. Following the removal of duplicates the number of potentially relevant studies identified from this search was 1,377. Four studies met the criteria of relevance and no studies were added following a secondary manual search. On review of the full-texts, one study [28] was excluded due to a cross-over study design with no washout period and the outcomes reported were not clinically relevant to this review. Three studies [25] [29,30] remained including a total of 184 patients.

Study characteristics

Table 1 shows the characteristics of the included studies and patients. Two studies were conducted in China [24,25,29] and one in Turkey [30]. Population sizes (52-69) and age (mean 61-69 years) were similar in all three. A summary of the studies is given in Appendix 2.

Table 1: Characteristics of included studies. SD: Standard Deviation; M: Male; F: Female; NG: Nasogastric; BMI: Body Mass Index.

Risk of bias and quality of the evidence

Appendix 3 shows details of the quality assessment with moderate risk of bias (9/13 quality criteria fulfilled by Wang, and 6/13 by Chen and Gungor respectively). Only one study (Wang) was truly randomized (random numbers table), while Chen used alternate assignment for allocation of treatment groups, and Gungor randomized patients into two groups taking into account the age and gender, with no more detail has been given regarding how they randomised. Wang randomised patients using a random number table. Blinding of participants and assessors was not feasible due to the nature of the intervention and the outcomes measured. Only Chen commented on removal of patients from the study for clinical reasons. Four patients were excluded within three days of enrolment because of left ventricular failure, cerebral herniation, gastrointestinal haemorrhage, and respiratory failure respectively. It was not reported whether these patients were included in an intention to treat analysis. The other two studies did not refer to removal of patients after allocation to treatment groups. Chen was the most comprehensive in demonstrating similar baseline characteristics using age, gender, Glasgow Coma Scale, [31] the Acute Physiology, Age, Chronic Health Evaluation- II scale, [32] the National Institutes for Health Stroke Scale, [22] and the Barthel index [33]. Gungor used age, gender and a stroke subscale, and Wang only used age, gender and the Glasgow Coma Scale. The only outcome measure that is likely to be unreliable is the assessment of gastric distension in Wang’s study. This was ascertained by palpation combined with measurement of abdominal circumference, a method which is not validated and has no defined criteria.

Delivery of the feeds

Feed was given via wide bore NGTs (16 and 14 F for Wang and Gungor respectively). Details of administration given in Appendix 4. Continuous enteral nutrition was delivered via an infusion pump in all three studies, initially at less than 50 ml/h increasing to 75-100 ml/h as tolerated. Gungor started at a slower rate (10 ml/h) than the other two studies and increased feeding rates more gradually. Two studies (Wang and Gungor) continued feeding overnight without a period of rest, while Chen discontinued the feed for a period of 7 hours overnight. Intermittent regimens were considerably different between the studies. Wang delivered each feed (200-300 ml) over 10-15 minutes at a rate of 800-1800 ml/h, while Gungor infused a smaller volume of feed (120 ml) over a longer period of time (30-60 min) at a much slower rate of 300-600 ml/h. Wang administered the feed manually with a 50 ml syringe, which may have resulted in an even quicker administration time by the nurses than appreciated by the assessors of the study.


The effects of intermittent and continuous feeding on clinically relevant outcomes are given in Table 2. Definitions for key outcomes are detailed in Appendix 5.

Table 1: Comparative effects of intermittent and continuous enteral nutrition on clinically relevant outcomes. g/L: grams per litre.

Achievement of nutritional targets

This was only reported in one study [29]. There was no significant difference in achievement of the nutritional target and in levels of pre-albumin between intermittent and continuous feeding.

Complications of nasogastric feeding

One of the three studies (Chen) showed a significantly higher incidence (58.3%) of pneumonia with continuous feeding than with intermittent feeding (33.3%), with no difference in the other two studies. Diarrhea was significantly more frequent with intermittent feeding (64.0% vs. 14.3%) in Wang, but not in the other two studies. Wang also reported significantly more hyperglycaemia with intermittent feeding. No significant differences were found for vomiting (Gungor), gastric retention (Gungor, Wang), and NGT complications (Gungor).

Other outcomes

One study (Gungor) reported mortality and length of stay. No significant differences were identified between feeding patterns.


Figure 1: Meta-analysis of intermittent compared with continuous enteral nutrition on the incidence of aspiration pneumonia and diarrhea in acute stroke patients.

CI: Confidence interval; Chi2: Chi-squared test; Tau: Tau test

Only aspiration pneumonia and diarrhea were assessed by all three studies and could be included in the meta-analysis. There was no significant difference between intermittent and continuous feeding in either incidence of aspiration pneumonia (RR 0.91, 95% CI 0.53-1.57, p=0.74, I2=50%) or diarrhea (RR 1.74, 95% CI 0.70- 4.30, p=0.23, I2=42%). A funnel plot is not presented here as there were only 3 trials. This is analysis is displayed in Figure 2.


The systematic review identified three studies comparing intermittent and continuous nasogastric feeding including 184 acute stroke patients. There was no significant difference between feeding regimes for most outcomes in individual studies with the exception of pneumonia, which was higher with continuous feeding in one study [29] and diarrhea, gastric distension and hyperglycemia, which were seen more frequently in another study [24]. The only outcomes which were assessed by all three studies and could be included in the meta-analysis were aspiration pneumonia and diarrhea, neither of which were significantly different in the two feeding regimens. Intermittent feeding would be expected to improve achievement of nutritional goals, as it is closer to normal feeding patterns allowing for more physiological gastrointestinal and metabolic responses. There is insufficient evidence to determine the effect of feeding pattern on the achievement of nutritional goals in this patient group. In the one study [29], where nutritional goals were addressed, no significant difference was found. Studies in intensive care patients found that calorific objectives were more likely to be achieved with intermittent than with continuous enteral nutrition [34,35] and this was confirmed through systematic review [21]. Furthermore, studies examining these two methods of administering enteral nutrition in older adults on general wards also found no discernible difference in the calories achieved [36,37] This was in keeping with the results observed from this review.

Aspiration pneumonia is a major complication of dysphagic stroke and may be affected by the pattern of feeding. Our metaanalysis did not find a significant difference in pneumonia between intermittent and continuous feeding. In all three studies the minimum incidence of aspiration pneumonia in acute stroke patients fed by NGT was regardless of intervention. Chen was an outlier with almost twice the incidence of aspiration pneumonia in the continuous group, and this difference might have been due to chance. However, this was the only study to specify that they recruited patients within 7 days of admission, and this could have ensured that patients hadn’t had a significantly long starvation period in which gastric dysmotility would have developed. Interestingly, it was the only study which discontinued feeding during the night, a practice usually considered to reduce the risk of pneumonia. Studies of intermittent versus continuous feeding in other settings give mixed results with a reduction of pneumonia with intermittent feeding in intensive care,38 but no difference in older people nursed on general wards [37]. Gastrointestinal tolerance is a major determinant of choice of feeding pattern. There was no significant difference in the incidence of diarrhea in our meta-analysis. Looking at individual studies, Wang consistently reported more gastrointestinal and metabolic adverse effects in the intermittent feeding group than with continuous feeding with a significantly higher incidence of diarrhoea, gastric distension, and hyperglycaemia. While this might have been a chance effect, it could have been due to differences in the delivery of the feeds. They gave intermittent feeding manually via a 50 ml syringe rather than by pump and at a much higher rate (200-300 ml over 10-15 minutes). Wang was the only study to warm their feed to body temperature (37 degrees in the intermittent group and 40 degrees in the continuous group to allow for slower infusion rates).

This would be expected to improve tolerance [39-41] especially with the larger volumes in the intermittent feeding group [42]. Both gastric distention and retention are known to be affected by gastric motility/emptying, which has been shown to be improved by the use of intermittent enteral nutrition in healthy adults[17,18]. However, in intensive care patients, where gastric dysmotility is common, studies have consistently demonstrated no difference between intermittent and continuous nutrition [43-48]. Several previous studies, largely conducted in intensive care, demonstrated that gastrointestinal tolerance was similar with intermittent and continuous enteral nutrition. However, [36] 1992 found a very high frequency of diarrhea in older adults on intermittent compared with continuous feeding (96% v 66%, p <0.008).36 Not to the same extent, this finding was also reported by Hiebert et al 1981 in adult patients with burns.44 However, in a systematic review in intensive care patients by Martinez 2014 [20] there was no significant difference between intermittent and continuous enteral nutrition with regards to gastrointestinal tolerance. This is corroborated by our results, which has also shown no significant difference in incidence of diarrhoea when comparing intermittent with continuous enteral nutrition.

The measurement of gastric residual volume (GRV) is not standard practice for acute stroke patients admitted in the UK, although it is carried out in patients on intensive care units. Two of the studies used GRV to assess gastric retention as an outcome measure; this will have required large bore NGT (French 14- 16 as described in Wang and Gungor). These size NGT are not normally required for standard feeding regimens and would have facilitated the faster rates of feeding seen in these studies. Glycaemic responses to feeding were only assessed in one study (Wang), where hyperglycaemia was found to significantly more common with intermittent feeding. In this study, blood glucose was measured every 4 hours and a blood glucose of more than 8.0 mmol/L was documented as an episode of hyperglycaemia. It has previously been shown that increasing gastric emptying heightens postprandial glycaemic excursions, [49] which is likely to be the case in intermittent feeding. In an of itself, hyperglycaemia potentiates the slowing of gastric emptying [50,51] which is an important factor considering its sequential impact on gastric retention. However, this may not mean that the overall glycaemic control is worse than with continuous feeding, which would be better assessed through 24-hour blood glucose monitoring. The limitations of the review are the small number of studies, the limited number of participants, and the moderate quality of the evidence. There is a risk of bias which was evident when significant findings in individual studies were no longer evident in systematic review. While the interventions and populations where comparable, there were variations in the definition of intermittent and continuous feeding and delivery of feeds which may have accounted for some of the differences observed between individual studies.


In conclusion, there are only few studies comparing intermittent with continuous feeding in stroke patients, and these are of low quality with small sample sizes. The definitions of intermittent enteral nutrition varied, and the findings were inconsistent. Based on this review, no definitive conclusion can be made as to which method of delivery of nutrition by nasogastric tube is safer and more effective in acute stroke patients. Further research is warranted to address this.

Monday, 25 September 2023

Lupine Publishers | The Cone of Events in Anthropokinetics

 Lupine Publishers | LOJ Medical Sciences


The author presents the physical structure of the light cone, which divides the space-time into two parts. The information and events in the first one is connected with each other and may form the cause-effect chains. The information and events in the other one (dubbed “elsewhere”) cannot influence the run of events under consideration. The same general philosophy might be applied to the motor operation patterns in humans (and other living beings) while taking into consideration temporal constraints of various rungs of the modalities’ ladder. The latter is a mental structure originated in N.A. Bernstein’s “brain skyscraper”. Author shows at the practical manifestations of the application of the mental model termed events’ cone.

Keywords: Anthropokinetics; Modalities’ ladder; Light cone; Events’ cone


Let us start from three simply banal statements:

A. Firstly: The only manifestation of any mental activity, and the only way to affect the environment, is the movement. Consequently, there are no other behaviors than the motor ones.

B. Secondly: The main task of the Science (with great “S”) probably most consciously has been expressed by Auguste Comte in the words “To know in order to predict; to predict in order to can” [1]. The first element of this statement may be substituted with the word “understand”. If one wants to predict, it is not enough to simply know; it is necessary to understand the essence of phenomena and processes under consideration and their mutual relations. The accurate prediction causes-nearly directly-the potentiality of realization of actions reliably resulting with desired effects. In general, “to understand” (or, may be, more precisely- “to grasp”) might be regarded as a product of philosophy, “to predict”-a product of science, and “can”-a product of technology.

C. Thirdly: Let us remember that mathematics is the science on relations, which facilitate understanding. In the non-living world, where the things passively obey the laws external against them, establishing of the net of such laws enables predicting the behavior of such things also in the future. On the other hand, in the living world the laws are not external against the entities (no longer “things”!). In biology, just these entities contribute to creation of such relations. More, in psychological processes, where various relations are being actively and sometimes “online”, i.e., consciously shaped by living entities. Not rarely such relations act only in very short periods. Therefore, it is not possible to establish a universal net of relations, reliably governing the behavior of living entities. Therefore mathematics-being the science on relations, which may be described with a “stiff” formalism-is not eligible for description of biological phenomena, where the evolution destroys any “stiffness” of a formalism (or any “formalism-like” structure). The same concerns, more, the psychological processes, which are not prone to any “formalism-like” constraints, external against entities being described and taking no into consideration their internal determinants [2,3].

The term “anthropokinetics” from the title of this paper should be described more precisely. The position of this discipline in the general system of sciences on human motor behavior has been shown in the Table 1. It is worth noting that specific disciplines, which in such a system have been termed “sub-disciplines”, in other systems may play the function of supra-disciplines. Such a flexibility makes one of the aspects of beauty and usefulness of a system. However, in the system of sciences on motor behavior such an order seems to be the most effective.

Table 1: The system of sciences on motor behavior of living beings, especially humans (Petryński, 2019, in print).


The physical light Cone

In physics there is known the notion of “light cone” (Figure 1). It is “a surface in space-time that marks out the possible directions for light rays passing through a given event” [4]. Let us look closer at this cone. The basic rule of its construction is the fact that “nothing can move faster than light” [4]. Therefore, if anything lies in the distance greater than that, which during observation might be travelled by light, is located “elsewhere”, i.e., in the space, from which no information may be received by observer. Accordingly, such an information cannot influence the run of events in the spacetime region encompassed by the light cone. And vice-versa. If a given event starts a cause-effect chain, it may act only inside the light cone (Figure 1). Therefore, such a representation of reality divides the whole space-time of events into two parts. Inside the cone, there are some mutually related cause-effect chains, which shape the run of events, but the information from outside the cone (“elsewhere”) cannot influence such a run. On the other hand, the actions inside the cone have no effect on what is going on outside it. The light cone is no doubt a mathematical structure. Therefore, according to earlier statements, it should not be useful in the description of psychical processes underlying human motor behavior.

Figure 1: The light cone. The events from “elsewhere” cannot influence the events inside the cone. It would be possible only when the information from this region would be able to travel faster than light. After time “t” from the moment of event, the light will reach the distance “r” from the place of event.


Anthropokinetics and physics

However, the anthropokinetics is still young discipline, which searches for its scientific identity. Therefore, it is forced to adopt what might be termed the “Foraminifera-strategy”. The Foraminifera are one-cellular organisms, which build around their bodies the shells of sand. However, they select only such grains that under microscope their tests look as if they were polished [5]. Anthropokinetics should take any suitable “grains of knowledge”, no matter, where they come from, either. Accordingly, let us listen to novelist Jo Nesbø, who wrote: “You can discover new things by changing your perspective and your location (in science their equivalent is the methodology-WP). You can compensate for any blind spots” [6]. Accordingly, let us try to look at anthropokinetics from slightly different perspective. Already in 19th century philosopher, Auguste Comte has divided the whole science into two parts: “physique organique” and “physique inorganique” [7]. The former might be-roughly-identify with the biology, whereas the latter-with physics. The common element is the “physics”. Hence, one may perceive it no as a sum, but as a system. In such a situation justified seems to be the presumption that-may be-some relations are active in both these regions, but in “physique inorganique” they are better visible, whereas in “physique organique” are hidden deeper. In such a context highly illustratively sounds the statement by Niels Bohr that “It is wrong to think that the task of physics is to find out how Nature is. Physics concerns what we say about Nature”.

While coming out from such a “starting point”, one might put a question, whether the physical-mathematical structure of the light cone (or, more precisely, the philosophy underlying its mental construction) might be useful also in description of any psychological processes (in general) and anthropokinetical ones (in particular)? In other words-whether in anthropokinetics we have to do with relations independent of an individual, which executes a motor operation, which are able somehow “from outside” impose specific constraints on potentialities of performing by this individual specific motor actions? And whether to description of such a relation one might-even marginally-use a physical model?

Brain skyscraper and modalities ladder

The questions put above may be answered positively. Such external (against, e.g., an individual human) system of constraints is the “brain skyscraper”, shaped by evolution. It has been invented by Nikolai A. Bernstein [8-10], and its “intellectual daughter” is the modalities’ ladder [2,3]. The latter is fully coherent with the “skyscraper”, but devoid of evolutionary and neurophysiological components; it is mainly information-processing structure. Both are hierarchic, systemic structures. The former has five levels, the latter–five rungs. One if the main rules by Bernstein states that each motor operation has its main level of control (“master”), where the attention of the executor is being focused, and the lower ones (“slaves”) play the function of “background” (not “subconsciousness”, whatever this term might mean) and their action does not need attention concentration. Let us emphasize: the main criterion is not a division into “consciousness” and “subconsciousness”, but into elements, which need attention focusing and such ones, which do not need such a concentration. Before comparing the “brain skyscraper” and the modalities’ ladder, let us remember that one and only manifestation of each mental, psychical process in living beings-including humans-is the movement. This is why philosopher Andrzej Wohl wrote: “All that we dispose of, all what constitutes the resource of our culture, all the pieces of art, science and technology-all that results from motor activities” [11]. In short, there are no other conducts than the motor ones. The basis of such a behavior is the consciousness. Before further considerations, let us formulate the two definitions:

A. Motor operation: Motor action of a living being aimed at solving of a given task in environment; it may be evoked either by extrinsic stimulus (trigger; in such a case it is the motor response), or by intrinsic motivation without any contact with environment [12].

B. Consciousness: A dynamically changing component of a quasi-static whole; the multimodal knowledge of an individual, activated at given moment by perception directed by attention, aimed at dealing with a task at hand [3].

Let us add that the consciousness is a multifaceted phenomenon. Knowledge might be described with various codes-e.g., haptic, visual or verbal-but the general term “consciousness” encompasses all these modalities of information processing. It seems worth remembering that the term “modality” includes a specific code of information storing and processing, a logic specific to them, certain scale of phenomena and processes, the definite time period and depth of information processing. The characteristics of the “brain skyscraper” and modalities’ ladder, as well as the phenomena related to them, have been presented in Table 2. In short, the brain skyscraper has been built on structural, whereas the modalities’ ladder-on functional basis.

Table 2: Bernstein’s “brain skyscraper” and the modalities’ ladder.


As one can see, the divisions in both these structures are not identical. The equivalent of the single A-level in “brain skyscraper” are two sub-rungs (A1 and A2) in the modalities’ ladder. A single C-rung in the modalities’ ladder has two sub-levels (C1 and C2) in the brain skyscraper. Some comment needs the function of the tonus (sub-rung A1) in the structure of any motor operation in a human. The skeleton of Homo sapiens amounts to about 200 bones. Each of them may move against other ones; such movements may be described with the term “degrees of freedom”. In sum, human skeleton disposes of very many degrees of freedom. However, if a muscle should to move a given bone lever, then one its end has to be fixed relatively stiffly. In other words, all bones in a kinematic chain ending with this “stiffly fixed” end of the muscle should be properly immobilized; Bernstein dubbed this process “reduction of freedom degrees”. It makes the main task for the muscle tonus. Thanks to it, non-controllable system has been transformed into a controllable one. Hence, the muscle tonus makes a basis for the all other motor operations. Therefore, Bernstein termed it “background of all backgrounds”. In the modalities’ ladder, the notion of “degree of freedom” has been generalized and encompasses the abstract “information chunks”, related to movements or set of movements, specific to higher rungs of the modalities’ ladder.

The anthropokinetic events cone

The modality of each rung of the modalities’ ladder includes a specific type of coding, logics of information processing and temporal limits of the phenomena under consideration. Therefore, facing angry grizzly bear somewhere in Alaska, I would prefer company of experienced trapper with Winchester rather, and not ingenious Albert Einstein. Just the temporal limits, peculiar to rungs, may make a structure similar to the physical light cone. Let us term it “events’ cone” (for the sake of simplicity, because it should be named “the cone of abstract representation of real events”). A given modality may effectively “deal” with events, which belong to a specific period. Hence, the events lying beyond these limits should be categorized as being “elsewhere” (Figure 1). Consequently, they cannot influence the information processing inside the events’ cone. It is possible, then, to use the general rule of construction of the physical light cone, i.e., the division of the space of events into two parts. One of them includes such events, which may make parts of cause-effect chain shaping the future, and the other, which are to be found “elsewhere” and cannot influence the run of events (Figure 2).

The structure of the light cone differs essentially from that of events’ cone. In the former the time axis is positioned vertically (Figure 1), whereas in the latter-horizontally (Figure 2). However, the general philosophy-division of events and information into potentially active and unable to any activity-remains the same. It is worth noting that the time axis in Figure 2 should be perceived as a logarithmic scale, and not a linear one. Nevertheless, clearly visible are time periods specific to rungs, and the fact that the higher the rung, the longer the time period for analysis of events and information processing (thinking).

As a result, one might consider the space inside the events’ cone (bold dashed line) makes the room for analyses and information processing, whereas the space outside the cone represents the “elsewhere”. In short, the temporal constraints-specific to rungs of the modalities’ ladder-disable the events from “elsewhere” and make them ineffective in shaping of a given motor operation. The higher rung, the longer “working” period. The price, which inevitably must be paid for its extension, is higher and higher level of abstraction, i.e., getting further and further from reality. Therefore, the processes and phenomena at distant to the “tangible” reality highest rungs of the modalities’ ladder cannot be tested experimentally. Therefore, at those rungs the only tools for scientific description are hypotheses and theories. The techniques of intellectual work, which may be applied in this region of abstraction, are, e.g., the logic of loops by Michał Heller [13] or “inference to the best explanation” (IBE) by Gilbert Harman (Harman, 1965). Otherwise, both of them are nearly identical. Such a “moonshine” way of science creation evokes almost contempt of “genuine scientists”, i.e., the worshippers of arithmetical average and standard deviation. Nevertheless, the science is being composed of theories, and not “new, original experimental data”. Their amorphous ashes may merely fertilize the intellectual ground, on which the theories should grow. This has succinctly expressed by biologist (Nobel Prize winner) Peter Medawar with the words “theories destroy facts” [14]. Unfortunately, as its physicist Edward Teller aptly stated, “A fact is a simple statement that everyone believes. It is innocent, unless found guilty. A hypothesis is a novel suggestion that no one wants to believe. It is guilty, until found effective.”

However, let us look once more at the Figure 2. Let the symbols A, B, C, D and E symbolize rungs of the modalities’ ladder, tightly related to Bernstein’s brain skyscraper levels. The grasping of time is possible only at C-level-at that level appear remote sensory organs, which enable observation of motion in the environment; it is the only phenomenon, which makes possible to shape the notion of time-but it does not mean that it cannot be used to description of phenomena also from the lower rungs. The bold dashed line symbolizes the anthropokinetic events’ cone, including rungs of the modalities’ ladder. Not without reason the borders between rungs are marked with the dotted line. In fact, they symbolize not sharp limits, but fluid zones rather. The information may cross them, indeed, but in the zone between the rungs, its modality is being transformed. This is a non-linear process, i.e., elements from one rung are differently amplified in the other one. This phenomenon is probably responsive, to the main extent, for unpredictable, qualitatively new system effect produced by such a system. Let us notice that such a structure is generally coherent with division of memory into short-term sensory store (STSS), short-term memory (STM) and long-term memory (LTM) by Richard Atkinson and Richard Shiffrin. Roughly, STSS might be associated with the lowest rungs of the modalities’ ladder, STM-with the middle ones, and LTMwith the highest rungs. The vertical relations make the system. The horizontal extension, limited by dashed line, represents the period specific to the information processing modality at a given rung.

Figure 2: The events’ cone in anthropokinetics. White field inside – consciousness; grey field outside – unconsciousness (“elsewhere”); bold dashed line – half-consciousness.


Consciousness, half-consciousness and unconsciousness

At that moment of our analyses appears the space for mental construction of what might be associated with the phenomenon commonly termed “sub-consciousness”. This term seems to be incorrect, because it not describes the essence of the phenomenon under consideration. It may be regarded as a specific “black box”, where one may put all, what scientists are not able to properly describe scientifically. In such a situation, the item put into black box termed “sub-consciousness” remains not understandable, indeed, but marvelously gains the attribute of “scientificity”. However, one might imagine that the borders of the events; cone are not sharp as the cut of Japanese sword, but they make rather some fluid zones. While approaching the inside of the cone, the image of a given phenomenon or process becomes more and more pronounced, and inside the cone are completely clear. In such a model, each of the rungs-which dispose of its “own” modality of information processing and temporal limits of abstract representations of phenomena and processes-has also its own “zone of twilight of perception”. Such a model would enable description of the phenomenon of gradual forgetting of a particular event. It would transfer from the inside of the events’ cone-in this region, its abstract representation is immediately accessible-to the “twilight zone”. Its retrieving from this zone is possible indeed, but it is more difficult and time consuming. Finally, when it goes out from the zone of “twilight”, it becomes completely forgotten. Such a “twilight zone” from the side of future one might dub “precognition”, and that from the side of past- “shadows of oblivion”. The representations of events in this zone exist, indeed, but they are not precise and indistinct. Therefore, the interior of the events’ cone may be identified with the consciousness, the border zone-with half-consciousness, and the region of “elsewhere”-the unconsciousness.

To avoid creation of a “moonshine” term (like “subconsciousness”), let us try to invent a rationale for what has been roughly dubbed “precognition”. Motor operations are always faced towards future-closer or farther, according to the rung of the modalities’ ladder. The main “processor”, which produces the abstract, mental pattern of a motor operation is the intellect. It may be perceived, roughly as a system consisting of three mechanisms of information processing: intelligence, intuition, and instinct. Intelligence makes the “armed forces” of the intellect. It is responsible for final shape of the motor operation pattern. However, to produce such a pattern, it needs full information necessary to given task solution and knowledge of all the rules of such information processing. We are very rarely in such a luxurious situation; we have not such a complete knowledge. Hence, if an information lacks, it must be guessed to get intelligence going. This makes the task for intuition. Finally, the instinct directs the searching for lacking information towards these regions of memory, where its finding seems to be most probable. The half-consciousness zone faced towards future cannot include the full information about a given task; otherwise, it would be the full consciousness. Hence, the intelligence itself cannot be effective in this region. As a result, here opens the wide field of action for intuition. The term “precognition” might be described, then, as a way of processing of not complete information, where the main tool is the intuition (“I don’t know, but I suppose”), and only marginal role plays the intelligence.

The Events’ cone in practice

The system presented in the Figure 2 may make sense only when the time period, assigned to a given rung, is sufficiently long to enable practical realization of the task related to this rung. Therefore, the lower rung, the simpler operation and the swifter its execution. And vice-versa: the higher rung, the more time-consuming preparation and execution of a specific motor operation. Let us imagine such a situation. During a solemn, international scientific conference, I am presenting my work. I am moving freely in the room and using a pilot for changing slides remotely. Suddenly, I take a pin, hidden in my sleeve, and acutely sting the buttock of a dignified, gray-haired scientist. What will happen? No doubt, the scientist will jump. It is natural reaction in such a situation: to take a distance from the source of pain. Does s/he realize immediately, what happened? For sure-not! Such an event would be so astonishing, so improbable, without any equivalents in the past, to which it might be related. The scientist would have to build the abstract model of the event, what inevitably must be time-consuming. Hence, at the contact B-rung the stimulus is received, response-prepared and executed, before at the verbal D-rung the stimulus is barely identified. However, if it happens, I would be far away.

The content of events’ cone depends not only on information processing modality, but also on the level of pre-preparation of a needed operation pattern. In this respect instructively sound the words by Ben Johnson-mysterious racing driver “Stig” from the BBC program “Top Gear”. In the interview, he stated: What defines a good driver? What attribute is necessary, and what merely useful? The anticipation. Racing driver is a person, who does not look for solutions of the problems that occur in a race. S/he knows those solutions, and when the situation comes, when the reaction becomes necessary, s/he simply performs the operations leading to its successful solving [15]. While seen from the perspective of the modalities’ ladder, in this case we have to do with the D-rung depth of information processing being “pushed down” to the C-rung temporal constraints. In daily language, such a process may be identified with what is commonly termed “experience”. It has been described by Nikolai A. Bernstein [10,16].

On the other hand, if an individual has to his/her disposition C-rung time, one cannot expect the information processing with depth specific to D-rung. In such a situation suitable information processing should be located in the region of “elsewhere”. For example, the analysis of car accident or ships’ collision at sea, where the teams of expert witnesses have plenty of time for D-rung calculations and analyses, cannot be compared to the situation of a driver or captain, who was able to make only C-rung assessments, basing on previous experience, and had to his/her disposal merely seconds or minutes. Such a situation has been brilliantly presented in the movie by Clint Eastwood “Sully”, about landing on 15th January 2009 on the Hudson River of the Airbus 320, in charge of the captain Chesley “Sully” Sullenberger.


Well, is it possible-based on the presented analyses-to formulate the conclusion that the laws of physics in their “pure” form may be applied also in anthropokinetics? For sure-no! One might merely assume that some mental structures, invented by physicists, may be used-after specific modifications-also in anthropokinetics. However, such an analogy reminds the similarity of the shark and the dolphin rather, and not a common law being in force in both these disciplines. It is not possible, then, to perceive it as a rule. In science there are no any well-worn, simple templates-like, e.g., calculations (not mathematics!) or any other commonly accepted methodologies”-which would release scientists from thinking. In this respect highly instructively sound the words by Niels Bohr: “You are not thinking; you are just being logical.”

Philosopher Paul Feyerabend has invented an image of knowledge built by Truth and Freedom. The former has its feet firmly on the ground; the latter flies freely in the sky. Where they meet, the Science (with great “S”) is being born. However, the Truth is harnessed with the stiff constraints; hence, it cannot for long remain in union with the unhampered Freedom. Hence, sooner or later, they must part their ways. Until next meeting. Analogously, also the similarity of the light cone and the events’ cone should be treated as a result of a momentary meeting of the Feyerabend’s Truth and Freedom, and not as a basis for formulation of more general theories.

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Saturday, 23 September 2023

Lupine Publishers | A Worksite Health Promotion Project in The University Setting A Doctor of Nursing Practice Project

 Lupine Publishers | Journal of Nursing & Healthcare


Non-communicable diseases (NCD) have become the leading cause of death and disability worldwide. This public health issue has driven the development of innovative solutions, one of which has been implementing wellness programs at work. Historically, the university has been characterized as a low physical activity setting, which made it the perfect place to test the potential benefits of a workplace wellness program. This Doctor of Nursing Practice (DNP) project was designed to improve health behaviors in a satellite university faculty. The project implemented a 10-week worksite wellness program intervention comprised of education and walking. The intervention effectiveness was evaluated with American Heart Association My Life Check® (AHA MLC) online tool. Although there was not a significant difference between the pre-intervention heart scores (M=6.04, SD=1.66) and post-intervention heart scores (M=6.31, SD=1.57); t (19) =1.47, p=0.159), this project demonstrated improvements in several independent areas of the AHA MLC, which included weekly activity levels, overall cholesterol, increased fruit, and grain intake, and decreased sugary beverage intake. This project contributed to research by offering an example of how an innovative web-based wellness program could impact faculty health behaviors in a satellite university setting. Future studies are needed to identify types of wellness programs that yield positive results in various workplace settings.

Keywords: worksite wellness program; workplace wellness program; wellness program wellness program in the university setting


Background and Significance

Non- communicable diseases (NCDs), rather than infectious agents, have become the primary source of illness among Americans. While these diseases have not been infectious or transmittable, they have been considered chronic and preventable. Diabetes, cardiovascular disease, cancer, and chronic lung disease have emerged as the most common NCDs [1] (World Health Organization [WHO], 2017). NCDs have been directly related to increased mortality rates of 88% in the United States (US) and 70% across the globe [2] (WHO, 2014). The macro and microeconomic impact associated with NCDs has been substantial. Macroeconomic issues have included increased health care expenditures and lost labor and productivity for businesses and employers. Microeconomic issues have included increased personal costs associated with disease treatment, work-related absenteeism, and lost personal independence [3] (WHO, 2009). Risk factors for developing NCDs have included a sedentary lifestyle, obesity, stress, as well as alcohol and tobacco use. The American way of life has changed substantially since the 1950s, when more than 50% of the workforce was employed in physically demanding jobs (Centers for Disease Control and Prevention [4] [CDC], 2016b). Today, less than 20% of workers are in positions requiring physical labor. Technological advances have shifted labor from physically demanding jobs to service-oriented jobs requiring minimal strenuous activity. Occupations necessitating minimal physical activity have been classified as sedentary. Over the last half-century, there has been an 83% increase in sedentary work environments (American Heart Association [5] [AHA], 2015b). Both sedentary jobs and lifestyles have contributed to the development of NCDs.

Modern technological conveniences have resulted in decreased physical job requirements, altered eating habits, and increased sedentary leisure time. Improved access to public and private transportation has reduced the amount of time people spend walking to everyday activities, contributing to decreased daily movement [5] (AHA, 2015b). The 1970s heralded a shift in eating patterns. Readily available food options, in the form of processed and fast food, have replaced home-cooked, home-grown meal preparation. Additionally, food consumption volume has doubled, and overall levels of nourishment have decreased. This flip-flop in nutrition has resulted in obesity, vitamin and mineral deficiencies, and immune system dysfunction [6]. While activity and nutrition have decreased, the average American is suffering from an increase in stress. Job stress has contributed to missed days at work and could lead to other unhealthy behaviors, including increased substance abuse, decreased physical activity, and unhealthy eating trends (Center for Disease Control and Prevention [7] [CDC], 2016a). For decades, Americans have been educated on the poor health outcomes associated with tobacco and alcohol consumption. Multiple forms of tobacco use have been linked to cardiovascular disease and different types of cancer. Heavy alcohol intake, classified as more than eight drinks a week for females and ten for males, has been linked with cardiovascular disease, liver impairment, highrisk sexual behaviors, accidents, and if consumed during pregnancy, can cause fetal harm [7] (CDC, 2016a). These changes have affected the population across all socioeconomic levels. Unfortunately, these evolutionary alterations have not improved physical and mental health, but have contributed to decreased physical activity, increased stress, poor nutrition, and continued alcohol and tobacco use [8] (AHA, 2015a). The burden of chronic disease has inspired the nation to examine innovative health improvement strategies. One solution has been the incorporation of worksite health promotion programs. These programs have been encouraged to offer onsite health-related activities to promote physical activity, proper nutrition, relaxation techniques, and tobacco and alcohol cessation for employees [9].

Sedentary work environments have unintentionally become poor health behavior breeding grounds. Less than ideal working conditions characterized by low activity levels, limited nutritional choices, and increased stress have contributed to poor health choices. Unfortunately, the university setting has been one such environment, defined by desk jobs, vending machines, and high-stress deadlines [10]. Nursing education jobs have long been considered sedentary, associated with mostly deskbound clerical tasks such as computer use, grading papers, and course development. As health promoters, an integral part of the nurse’s role has been to recognize negative health habits and develop programs to improve the health of individuals and society [11] (American Association of Colleges of Nursing [AACN], 2006).

Purpose and Significance

This project aimed to evaluate the effect of a worksite wellness program on faculty health behaviors at a satellite university campus. This study intended to determine if a workplace wellness program could improve health behaviors. Additionally, the project provided data to illuminate how employers could offset adverse health outcomes by implementing workplace health programs. This project helped university employees establish a worksite wellness program with the intent of increasing participants’ overall health. The project included evidence-based interventions and provided health and productivity research directed at satellite university faculty, which was generalizable to other similar professions. A needs assessment was conducted to determine the facility baseline wellness status using the CDC Health Scorecard (HSC). Each section of the HSC tool gave the facility a score based on the presence or absence of specific health activities. Categories with a low numerical rating identified areas of need. The results were as follows: tobacco control 11/19, nutrition 1/21, physical activity 6/24, weight management 0/12, stress management 10/14, depression 7/18, elevated blood pressure 2/10, cholesterol 0/15, diabetes 2/15, signs and symptoms and response plans for heart attacks, strokes, and occupational safety 22/22, and vaccine-preventable disease 6/18. According to the CDC HSC results, the lowest scores were in nutrition, physical activity, weight management, hypertension, hyperlipidemia, and diabetes. The employee wellness needs assessment focused on these areas and determined the best worksite wellness intervention for the project.

Method and Design


Expedited approval for this quality improvement project was obtained from the Institutional Review Board at Northwestern State University of Louisiana and Southeastern Louisiana University prior to initiation. Approval was based on the probability of no greater than minimal risk to the participants.

Participants and Setting

Convenience sampling was used for participant recruitment by campus email. The naturalistic study setting was the university satellite campus. The campus was comprised of classrooms, offices, and a library. Classrooms were rectangular with desks and chairs and short carpet. The campus outside was flat, even pavement conducive for an activity intervention. The intervention and data collection settings varied from individual and small groups to indoor and outdoor campus areas.


Phase one of the study was the administration of the Alliance for a Healthier Generation EWIS to assess current wellness behaviors in employees and identify areas of need [12] (Alliance for a Healthier Generation, 2015). The EWIS survey was chosen because it was specifically designed to determine the needs and wants of employees in a school setting [13] (Alliance for a Healthier Generation, 2016). The survey examined healthy activities, including various types of exercise, health screening interest, weight and stress management, and nutritional education. Survey specifics have been discussed under the outcomes measured section. The results of the study were calculated and used to formulate a relevant intervention. The results of the EWIS revealed that employees were interested the most in dietary and nutritional education, followed by physical activity and stress management. This information was used to develop a 10-week wellness intervention that focused on nutrition and physical activity. The purpose of phase two was to deliver the wellness intervention to a group of 20 participants. Identification of one set day and time was impossible due to faculty schedule variations. Creating an intervention that offered participants flexibility was a project goal. Therefore, after researching various web-based tools, the DNP student created a centralized project content delivery area, where invited participants could access information on their own time. The university’s Microsoft Office 365 account was used to create a group site, upload content, and interact with study participants.

Each week participants had various videos and educational content they were asked to review. The educational content focused on Life’s Simple 7 and healthy eating videos from the Physicians Committee for Responsible Medicine (PCRM). Life’s Simple 7 detailed seven steps that were associated with improved health. The seven steps were: managing blood pressure, controlling cholesterol, reducing blood sugar, getting physically active, eating healthier, losing weight, and smoking cessation [14] (AHA, 2017c). PCRM was comprised of healthy eating videos that encouraged a diet high in fruits and vegetables to improve overall heart and health status. In addition to the weekly educational information, participants were asked to walk half a mile twice weekly. Although participants were not required to submit proof of weekly walking at the end of the study, they were asked to identify if they completed this part of the project. Indoor and outdoor walking routes were mapped and provided for subjects. Subjects were expected to have the physical ability to complete the one-half-mile distance during the project timeframe. The AHA MLC was used, both pre and post intervention, to assess intervention effectiveness. The AHA MLC tool was developed specifically to evaluate WWP, making it appropriate for this project.

Outcome Measures and Instruments

All study participants completed the EWIS and MLC assessment tools. The EWIS was an anonymous two-part survey administered through Survey Monkey. The EWIS measured individual healthy activities and health behavior interests. The first part included 16 questions regarding healthy activities. The healthy activity list was comprised of the following: fitness plan development, exercise classes, dancing, team sports, walking, bicycling, yoga, etc., and also health screening, weight and stress management, and nutritional education. Participants indicated their level of interest by choosing one of the following: “very interested,” “might be interested,” or “not interested.”

The subsequent 12 questions evaluated participant interest in the following categories: health promotion programs, healthy snack options, and preferred physical activity types and times. These 12 questions were scored with a four to one Likert scale: “4=very likely,” “3=somewhat likely,” “2=not very likely,” and “1=not likely at all” [15] (Healthier Generation, 2016). The EWIS tool was offered as a free assessment from the Alliance for a Healthier Generation, which was founded by the American Heart Association and the Clinton Association [16] (American Heart Association, 2017a). The results of the EWIS were used to determine participant interest and develop a tailored wellness intervention. Although the validity and reliability of the EWIS survey were not available, the EWIS survey was supported by the AHA and used by the Wellness Council of America, The California Department of Public Health, and The United States Department of Agriculture as a recommended wellness assessment tool [17] (Healthier Generation, 2013). The MLC was an innovative science-based tool created by the AHA specifically for WWP. The MLC assessment tool evaluated seven behaviors associated with good health, also known as Life’s Simple 7. The key outcome measured by the MLC was an overall heart score, also known as an overall heart health score. The heart score was a valid and reliable measurement [18] (American Heart Association, 2017c). The original research study by [19] reported the Heart Score demonstrated good discrimination (Harrell’s c-index, 0.72; 95% confidence interval [CI], 0.71, 0.74 [females]; 0.77; 05% CI, 0.76, 0.79 [males]), fit, and calibrated.

Gathering the following information generated the overall score: smoking status, nutrition, activity, weight, blood pressure, cholesterol, and blood glucose. MLC obtained information such as age, height, weight, gender, and ethnicity, as well as seven additional questions, which included three questions on blood components such as cholesterol and blood glucose and four questions on daily activities such as fruit and vegetable intake and activity levels that impact health. The information was entered into the MLC online tool, and an individual heart score along with an action plan was generated. One feature of the MLC tool was that participants could access it multiple times, enabling them to track improvements over time.

Data Analysis

Demographic data were collected on the AHA MLC but not the EWIS. The demographic data and characteristics obtained, provided in Table 1, included gender, age, race, pregnant/breastfeeding status, smoking status, diabetes status, and BMI. Of the 20 study participants, 10% (n=2) were male and 90% (n=18) female and the age ranges in years were as followed 15% (n=3) were 25-34, 30% (n=6) were 35-44, 20% (n=4) were 45-54, 30% (n=6) were 55-64, and 5% (n=1) was 65-74. The study participants were Caucasian 80% (n=16) followed by African Americans 15% (n=3), and Hispanic 5% (n=1). None of the study participants reported being pregnant or breastfeeding. Ninety percent (n=19) of participants denied having diabetes; 10% (n=2) were self-reported diabetics. Regarding smoking status, 80% (n=16) identified as “never been a smoker,” and the remaining 20% (n=4) reportedly quit over 12-months ago. Finally, the sample study participants’ BMI was as follows: 30% (n=6) were 18.5- 24.9 normal, 25% (n=5) were 25.0-29.9 overweight, 10% (n=2) were 30.0-34.9 obese, and 35% (n=7) were classified as extremely obese. In summary, the majority of participants were female, age 35-44 or 55-64 years, Caucasian, never smoked, without diabetes, and classified as extremely obese.

Table 1: My Life Check® Demographic Characteristics.

American Heart Association My Life Check®

The AHA MLC online tool was used to calculate each participant’s overall heart score. The AHA MLC heart score was computed using participant demographics, underlying cardiovascular disease presence, blood pressure, glucose, total cholesterol, exercise, and dietary habits. All 20 participants completed the pre-intervention AHA MLC. The result of the pre-intervention AHA MLC has been reported in Table 2. The mean systolic blood pressure (SBP) was 124 mmHg, and the mean diastolic blood pressure (DBP) was 77 mmHg. The mean total cholesterol was 189 mg/dL, with the highest at 245 mg/dL and the lowest at 145 mg/dL. The mean glucose was 111 mg/dL, with the highest glucose recorded being 213 mg/dL, and the lowest was 74 mg/dL. Dietary habits were assessed in regard to sugary beverages, fish servings, fruits, vegetables, and grain consumption. The average number of sugary beverages consumed in a week was 4.1. The average number of fish serving was 1.25 per week. The average number of daily servings of fruits, vegetables, and whole grains was 0.925, 2.15, and 1.93, respectively. The preliminary data used to calculate the heart score also reported participant exercise activity as 73.25 minutes a week of moderate exercise and 15.00 minutes a week of vigorous exercise. This data, along with the demographic characteristics, were used to calculate participants’ heart scores. The mean pre-intervention heart score was 6.0, with the highest heart score being 9.3 and the lowest at 3.6 on a 0-to-10-point scale, with 10 representing the lowest risk for cardiovascular disease.

The AHA MLC online assessment tool was used to calculate each participant’s pre and post-intervention heart score. All 20 participants completed the post-intervention AHA MLC. The result of the post-intervention AHA MLC was reported in Table 2. The mean SBP was 128 mmHg, and the mean DBP was 78 mmHg. The mean total cholesterol was 186 mg/dL, with the highest total cholesterol at 264 mg/dL and the lowest at 135 mg/dL. The mean glucose was 97 mg/dL, with the highest glucose recorded being 158 mg/dL, and the lowest was 68 mg/dL. Dietary habits were re-assessed regarding sugary beverages, fish servings, fruits, vegetables, and grain consumption. The average number of sugary beverages consumed in a week was 1.95. The average number of fish servings was 1.15 per week. The average number of daily servings of fruits, vegetables, and whole grains was 1.32, 1.92, and 2.15. The final data used to calculate the heart score also reported participant exercise activity as 119 minutes a week of moderate exercise and 24.50 minutes a week of vigorous exercise. The mean post-intervention heart score was 6.31, with the highest heart score being 9.3 and the lowest at 3.6 on a 0-to-10-point scale, with 10 representing the lowest risk for cardiovascular disease.

Table 2: Pre and Post Intervention My Life Check® Data.



When comparing the pre and post-AHA MLC Mean (M) data (n=20), improvements were noted in several areas. In regard to nutritional intake Means: the weekly sugary beverage intake decreased from 4.1 to 1.95 servings, and the daily fruit serving intake increased from 1.93 to 2.15. Increases were seen in the Mean scores of both average weekly minutes of exercise from 73 to 119 and vigorous weekly minutes of exercise from 15 to 245. The average glucose and cholesterol decreased from 111mg/dL to 97 mg/dL, and 189mg/dL to 186 mg/dL, respectively. Finally, the Mean heart score increased from 6.0 pre-intervention to 6.3 post intervention. The project intervention was delivered in a flexible format where participants could access information at their leisure. This non-traditional design forced participants to be self-directed. Therefore, the post-intervention data also collected a response from each participant to assess study compliance, presented in Table 3. Compliance was defined as completing 80% of both the weekly intervention information sessions and the weekly walking. Of the 20 participants, 75% (n=15) reported study compliance, 5% (n=1) reported non-compliance, and 20% (n=4) did not answer the question.

A paired t-test was used to compare the heart scores for participants’ pre and post-workplace wellness intervention for both the entire group (n=20) and separately for the group who reported study compliance (n=15); see Table 4. There was not a significant difference between the pre-intervention heart scores (M=6.04, SD=1.66) and post-intervention heart scores (M=6.31, SD=1.57); t (19) =1.47, p=0.159) for the total group; t (14) =2.14, p=0.051 for the compliant group. The Shapiro-Wilk test of normality (n=20) was performed and showed a significance of p=0.018 (α 0.05) which indicated data did not follow a normal distribution. Consequently, the Wilcoxon signed-rank test was used for comparison. However, the Wilcoxon signed-rank test (n=20) also showed no statistical significance (W=14; p=0.227). Tables 4, 5, and 6 have been provided with the statistical data information.

Table 3: Self-Reported Intervention Compliance.


Table 4: Statistical Analysis of Heart Scores.


Table 5: Shapiro-Wilk Tests.


Table 6: Wilcoxon Signed-Rank.


For several decades non-communicable diseases (NCDs) were responsible for the majority of deaths and disabilities worldwide [7] (CDC, 2016a). The impact of NCDs in the United States matched this disturbing trend. One of the most shocking features of common NCDs was the fact they have been considered preventable. Each year the NCD related death toll has continued to rise, which has made the issue a public health priority. Despite advances in NCD prevention, the number of people affected has continued to rise. The two main reasons for this increase were attributed to decreased activity and poor nutrition. Technological growth has altered the occupational environment, changing the way people work, leading to less daily physical movement. Compounding this activity issue has been the proliferation of processed and fast food consumption. These two major shifts in modern society have contributed to an increase in cardiovascular disease, the number one NCD associated with increased morbidity and mortality [7] (CDC, 2016a). The growing realization that declining employee health has become a global health concern has sparked employers to utilize the workplace as a wellness intervention site. Higher education settings, especially those focused on health education like nursing, have had a unique opportunity to foster collaboration between disciplines and departments to promote workplace wellness programs. Furthermore, higher education settings where faculty jobs are considered sedentary have provided an optimal setting for this project.

The main result of this DNP project, which consisted primarily of nutrition and activity interventions, was a mean heart score increase from 6.0 to 6.3 on a 0-to-10 point scale. The American Heart Association (AHA) My Life Check® (MLC) online total heart score tool evaluated intervention success. The AHA MLC was a recommended tool to evaluate overall health in the workplace [9]. In addition, key findings included improvements in total cholesterol, weekly sugary beverage intake, daily fruit, and grain intake, and weekly moderate and vigorous exercise. Improvements in inactivity and nutrition were consistent with the previous studies from [20,21]. There were no participants who dropped out of the study. The final data collection tool added a question on program compliance. Compliance was described as subjects completing 80% of weekly information sessions and the twiceweekly one-half mile walks. According to the final data collection tool, 75% of participants self-reported project compliance. Among the 20 program participants, the majority were Caucasian (80%) and female (90%). Furthermore, 70% of participants were classified either as overweight, obese, or extremely obese, showing that wellness programs aimed at improving weight loss through nutrition and activity were relevant for this population. Although the purpose of this study was not aimed at weight loss per se, healthy eating and nutrition are known contributors to a healthy weight. The five participants who did not self-report study compliance were all classified as extremely obese. A second statistical analysis was completed on the compliant participants. Interestingly, the AHA MLC score was still not statistically significant even after the non-compliant group was removed from the analysis (p=0.051).

Consistent with previous research, the study found that workplace wellness can positively impact employee health behaviors [21,22,23]. This DNP project’s contribution to the literature was an example of a workplace wellness program delivered in a non-traditional style to sedentary university faculty employees. However, the best type of WWP in this setting will still need additional investigation and planning. The project provided information on the effects of a workplace wellness program on faculty health behaviors. This was important because as health educators, nursing faculty should have opportunities and resources to promote personal health. This project also depicted faculty health characteristics like weight, body mass index, physical activity levels, and basic eating habits. Although the final heart score change was not statistically significant, several areas of improvement were seen in various participant health behaviors, including increased weekly activity and daily fruit consumption. These results were consistent with the previous WWP studies by [20,21]. Moreover, this project provided detailed employee interest information for facility future wellness adventures. Employers might be inspired to invest in workplace wellness programs if they view the investment as beneficial. As stated previously by [22], successful WWP needs leadership involvement, including policies that promote a culture of health. The sustainability plan of establishing a workplace wellness committee, including a human resource person, could improve long-term wellness opportunities for the university. Workplace wellness programs have been linked to positive outcomes, but the question then becomes which program is the best fit for various facilities. This question should be best answered individually by organizations. Similar to the study by [24,25,26], the internetbased WWP approach was doable by most participants. Embracing innovative approaches to wellness that encourage employee input may have improved the chances of successful wellness program implementation and sustainability.

Strengths and Limitations

Several limitations were related to the sample. First, a sample of 20 participants is considered small (Faber & Fonseca, 2014).

Secondly, the project participants were from a satellite university campus concentrated in a Southern region, with the majority of participants being Caucasian and female. Therefore, the study group may not be reflective of the larger population and may limit generalizability. Another limitation of the project was the time of year that it was implemented. This project took place during the fall and ended the week after the Thanksgiving holiday. Participants may have found it challenging to maintain healthy eating habits during a holiday known for eating in abundance. The main strength of the project as it provided the needs assessment and employee interest of a specific facility. This site-specific comprehensive exploration could be used to develop current and future university health practices. Additionally, the recommendation of developing a wellness committee could improve the future health of employees.

Future studies should target more generalizable samples from various regions of the United States. Research focusing on WWP intervention time length, specific program measurement tools, and various seasonal influences would also be beneficial. Finally, specific studies evaluating types of wellness programs yielding effective for university faculty will also be needed.

Discussion and Conclusion

The findings of this study suggested that workplace wellness programs can positively impact faculty health behaviors. Seventyfive percent of the study participants acknowledged that a onceweekly time commitment to wellness activities was both acceptable and sustainable. While the total participants’ group findings were not statistically significant, the author notes that the small sample size and further lack of compliance by some subjects may have impacted the outcomes. A larger sample would have yielded a more reliable result. Workplace wellness programs benefit both employees and employers by improving worker health. More research needs to be conducted to determine if workplace wellness programs could be used to halt the progression of NCDs in an increasingly sedentary world.

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Friday, 22 September 2023

Lupine Publishers | Ultrafiltration and Reinfusion of Ascites to Treat Pregnancy Complicated with Severe Ovarian Hyper-Stimulation

 Lupine Publishers | Journal of Clinical & Community Medicine


Background: Ovarian hyper-stimulation syndrome (OHSS) is one of the most serious iatrogenic complications during in vitro fertilization-embryo transfer (IVF-ET). How to treat OHSS has attracted the attention of many scholars. Here we reported a case treated with reinfusion of ascites after concentration and ultrafiltration in hope of providing a new option in clinics.

Case presentation: The patient experienced severe OHSS demonstrated by severe electrolyte disorder, blood concentration, hypercoagulability and loss of protein. The symptom aggravated even with symptomatic treatment. After treat with reinfusion of ascites after concentration and ultrafiltration, the above-mentioned symptoms were significantly relieved. The patient was discharged with two alive embryos and low hospital expense.

Conclusion: We inferred reinfusion of ascites after ultrafiltration and concentration could achieved a good curative effect and can be further used in clinical practice.

Keywords: Ascites; Ultrafiltration; IVF-ET; OHSS; Reinfusion


In recent years, the incidence of infertility due to anovulatory is getting higher and higher, which results to the boom of assisted reproductive technology (ART). OHSS mainly occurs in the patients with infertility, who experiences the treatment of ovulation induction. The incidence of OHSS ranges from 1% to 10% in IVF-ET cycle[1,2]. The main clinical manifestations of OHSS are enlargement of ovarian volume, increased permeability of capillary leading to the formation of local or systemic tissue edema [3-5]. Liver and kidney failure may be induced by hypovolemic shock, oliguria or even anuria due to decreased blood flow [6]. Here we report a case of pregnancy with severe OHSS treated by reinfusion of ascites after ultrafiltration and concentration, in hope of providing a new insight for the treatment of OHSS. This study was undertaken with ethical approval of the Human Ethics Committee of JiNan University, which was in accord with the Declaration of Helsinki. The enrolled patients have signed the informed consents.

Case Presentation

A 40-year-old woman was admitted to our hospital for “vomiting and abdominal distention for 8 days after embryo transplantation”. Ultrasonography showed a large amount of ascites and increased bilateral ovary. The patient was supposed to experience OHSS. Laboratory tests demonstrated Total Protein 51.0g/L, Albumin 27.8g/L, HGB 184.40g/L, Hct 56.79%, PLT 499.0*109/L, WBC 32.85*109/L, Potassium 4.26mmol /L, Sodium 127.3mmol/L, Chlorine 95mmol/L, Plasma D-dimer quantification 2780ng/ml. All those index showed disordered electrolyte, blood concentration, hypercoagulability and loss of protein. To correct the disordered state, we adopted low molecular weight heparin to prevent thromboembolism, administration of human albumin, crystal and colloid supplementation to maintain osmotic pressure, diuresis and other symptomatic treatment. Unfortunately, the ascites continued to increase, Albumin and total protein continued to decrease. Two weeks later, ultrasonography demonstrated even larger ovary and increased ascites in the liver and kidney crypt and the intestinal lacunae. To relieve the symptom, we performed reinfusion of ascites after ultrafiltration and concentration. WLFHY-500 computer ascites ultrafiltration and concentration system were adopted. The patients experienced the treatment twice every week, during which 2000-3000ml of ascites was filtered every time. After two times of treatment, the symptoms of abdominal distension were significantly relieved. The volume of urine was increased without further use of diuretic. Laboratory test indicators, such as blood routine and electrolyte examination fluctuated in the normal range. Also, the hypercoagulable state was corrected. Ultrasonography showed transplanted embryos were alive and the ascites was significantly decreased. The patient was discharged with good prognosis after 10 times of treatment.


The pathogenesis of OHSS is complex and diverse, which is mainly related to the increased permeability of ovarian blood vessels and peritoneal epithelial cells [7]. Up to now, about 25 factors have been proved to be involved in the regulation of vascular permeability, such as renin-angiotensin-aldosterone system (RAS) [8], human chorionic gonadotropin beta subunit [9], estradiol [10], luteinizing hormone [9],vascular endothelial growth factor. Among all of these factors, the role of vascular endothelial growth factor is particularly critical [11]. With the widespread development of assisted reproductive technology, the incidence of OHSS has gradually increased. About 2% to 6% of women who experiences ART experienced severe OHSS [12]. About 16% of OHSS patients were accompanied with a large amount of ascites, leading to abdominal distension, dyspnea and even acute abdominal symptoms [13]. Therefore, it is very important to treat ascites actively. At present, the clinical treatment of traditional abdominal puncture and drainage is generally adopted, but it is easy to cause the loss of a large number of protein [13]. Comparing with traditional abdominal puncture and drainage, reinfusion of ascites after ultrafiltration and concentration has the following advantages [14], such as effective relieve of abdominal compression, reuse of autologous albumin, and rapid increment of plasma albumin concentration. Also, reinfusion of ascites after ultrafiltration and concentration can alleviate the economic burden of patients and avoid the risk of infection some contagious disease when using blood-derived products. In our case, the disordered conditions of the patients were significantly ameliorated after two times of treatment and the patient was discharged with low expense. In a word, reinfusion of ascites after concentration and ultrafiltration is an effective treatment for a large number of ascites, dyspnea and oliguria induced by severe OHSS in pregnancy. It can rapidly improve the symptoms and shorten the period of the disease. It is worth further promotion and application in clinical practice.

Conflict Of Interest

The authors declare that they have no conflict of interests.


Not applicable.


The National College Students Innovation and Entrepreneurship Training Program (CX18024).

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