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PubMedDate not supplied

Misdiagnosis of COPD and asthma in primary care patients 40 years of age and over.

Chronic obstructive pulmonary disease (COPD) is often misdiagnosed as asthma, leading to inappropriate treatment and suboptimal patient outcomes. As part of a prospective study of patients with a history consistent with obstructive lung disease, we compared prior diagnostic labels with a study diagnosis based on spirometric results. We enrolled persons 40 years of age or older with prior diagnoses or medications consistent with obstructive lung disease. Patients were recruited via random mailing to primary care practices in Aberdeen, Scotland, and Denver, Colorado. Prior diagnoses of chronic bronchitis or emphysema (CBE) and asthma were reported by the subjects. Participants underwent pre- and post-bronchodilator spirometry. A study diagnosis of COPD was defined using post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV(1)/FVC) < 0.70. Spirometric examination was complete in 597 patients, of whom 235 (39.4%) had a study diagnosis of COPD. Among subjects with a spirometry-based study diagnosis of COPD, 121 (51.5%) reported a prior diagnosis of asthma without concurrent CBE diagnosis, 89 (37.9%) reported a prior diagnosis of CBE, and 25 (10.6%) reported no prior diagnosis of obstructive lung disease. Despite the availability of consensus guideline diagnostic recommendations, diagnostic confusion between COPD and asthma appears common. Increased awareness of the differences between the two conditions is needed to promote optimal patient management and treatment.

Adrenal Cortex Hormones↗

PubMed1999

Behavioral interventions in the diagnosis, treatment and rehabilitation of children with cancer.

Behavioral interventions used to reduce distress and increase cooperation in children undergoing cancer treatment incorporate: contingency management, cognitive/attentional distraction, hypnosis, systematic desensitization, modeling and behavioral rehearsal. In most cases clinical interventions integrate these procedures into a multimodal intervention package. Although in most behavioral interventions the 'therapist' is a nurse, social worker or child psychologist; parents often take an active role in behavioral intervention. Early return to school can 'normalize' the child's life in the midst of coping with cancer and can promote optimal rehabilitation. More research is needed on the integration of behavioral methods with other therapeutic methods (e.g., pharmacologic). Indeed, research in this area of pediatric oncology must be continuously updated as advances in other areas may affect clinical decisions regarding preferred psychosocial intervention methods.

Adaptation, Psychological↗

PubMed2005

Risk factors for delayed discharge home in very-low-birthweight infants:- a population-based study.

AIM: To identify risk factors for delayed discharge home in a population-based cohort of very-low-birthweight (VLBW) infants. METHODS: Demographic, pregnancy, perinatal, and neonatal data were collected in a national population-based database on VLBW infants born from 1995 through 2002. Multivariate analysis determined association with delayed discharge (discharge at a postmenstrual age >42 completed weeks). RESULTS: 882 infants with delayed discharge comprised 9.4% of survivors but accounted for 19.8% of total hospital days utilized until discharge home. Infants with delayed discharge compared to those discharged by term were born at an earlier mean gestational age, at a lower mean birthweight, and had a longer mean hospital stay. Delayed discharge was independently associated with decreasing birthweight (OR 1.25, 95% CI 1.19, 1.31), congenital anomalies (OR 4.80, 95% CI 3.66, 6.28), bronchopulmonary dysplasia (OR 5.88, 95% CI 4.60, 7.57), intraventricular hemorrhage grades 3-4 (OR 1.78, 95% CI 1.34, 2.36), sepsis (OR 1.87, 95% CI 1.54, 2.26), and surgically treated necrotizing enterocolitis (OR 20.20, 95% CI 12.85, 32.03). CONCLUSION: VLBW infants with congenital anomalies or severe complications of preterm birth are at increased risk for delayed discharge home. Early identification of these infants may enable interventions aimed at reducing the detrimental effects of prolonged hospitalization and promoting optimal transition from the hospital to the home environment.

Birth Weight↗

PubMed2005

Determinants of HAART discontinuation among injection drug users.

The objective of this study was to identify psychosocial determinants of, and self-reported reasons for, HAART discontinuation among HIV-positive injection drug users (IDUs). We examined correlates between sociodemographic characteristics, drug use and risk behaviors, outcome expectations, adherence self-efficacy, social support and HAART discontinuation among 160 HIV-positive participants in the Vancouver Injection Drug Users' Study (VIDUS). Logistic regression was used to identify the factors independently associated with discontinuation of HAART. Seventy-one (44%) study participants discontinued HAART during the study period. Factors independently associated with discontinuation of HAART included recent incarceration (OR = 4.84, p = 0.022), negative outcome expectations (OR = 1.41, p = 0.001), adherence efficacy expectations (OR = 0.70, p = 0.003) and self-regulatory efficacy (OR = 0.86, p = 0.050). The most frequently cited reasons provided for discontinuing HAART were being in jail (44%) and medication side effects (41%). The results of this study suggest that psychological constructs derived from self-efficacy theory are highly germane to the understanding of HAART discontinuation behavior and interventions that may change it. Incarceration may result in interruptions in HAART among IDUs, and programmatic changes may be needed to promote optimal retention on HAART among incarcerated HIV-infected IDUs.

Adult↗

PubMed2005

Extracellular matrix in bone marrow can mediate drug resistance in myeloma.

Glucocorticoids such as dexamethasone, frequently used for the treatment of multiple myeloma (MM), produce a rapid reduction in tumor mass. However, despite frequent initial complete remission, prolonged dexamethasone treatment results in the appearance of chemoresistant tumor cells and most patients with MM ultimately present relapse of the underlying disease. Accumulating data suggest that bone marrow components such as cytokines, extracellular matrix (ECM) and adjacent stroma cells could cooperate to provide a sanctuary to malignant plasma cells that allow their survival after initial drug exposure. This review focuses on the two major components of the bone marrow ECM that have been identified as mediators for innate or acquired drug resistance in MM, hyaluronan and fibronectin. These two ECM molecules are thought to play a crucial role in the pathogenesis of MM, combining their protective activities to promote optimal conditions for the long life of plasma cells and contribute to de novo drug resistance. They represent promising targets for the development of innovative treatments in order to prevent interactions between tumor cells and their microenvironment and to sensitize cancer cells to chemotherapy before the emergence of acquired mechanisms of chemoresistance.

Apoptosis↗

PubMed2003

Overcoming the barriers for achieving standards of diabetes care: the formation of CADRE.

Diabetes remains one of the leading causes of death and disability in the United States. Despite significant breakthroughs in treatment of diabetes, recent reports suggest a large number of patients are not at target goals for blood pressure, lipids, and glucose levels. Failure to achieve these goals is most likely not due to the unavailability of drugs and innovations, as numerous drugs have been released over the past 10 years, and monitoring of blood glucose is now considered routine. Therefore, other obstacles must exist at the primary care level preventing adherence to suggested targets. Based on the above, the Council for the Advancement of Diabetes Research and Education (CADRE), a membership organization, was launched in an effort to address the problem of understanding diabetes and its treatment. The ultimate goal of CADRE is to expand understanding of diabetes and its treatment by providing educational programs enabling healthcare professionals to manage and empower patients with diabetes. In particular, by focusing on innovations in diabetes care, CADRE hopes to promote optimal therapy for meeting the treatment goals as outlined by governing bodies such as the American Diabetes Association. This article will focus on the formation of CADRE, and, in particular, identification of the problem contributing to the obstacles of care, and review various surveys conducted by CADRE designed in an effort to identify the problem.

Allied Health Personnel↗

PubMed2001

Nutrition and quality of life in older adults.

Good nutrition promotes health-related quality of life (HRQOL) by averting malnutrition, preventing dietary deficiency disease and promoting optimal functioning. However, definitions of quality of life also encompass life satisfaction and both physical and mental well-being. Nutrition and diet have not been a part of mainstream research on quality of life and are not included among key quality of life domains. This article explores connections between diet and nutritional status in relation to HRQOL measures and overall well-being among older adults.

Aged↗

PubMed1987

Effect of beef fat on DMH-induced colon tumorigenesis: influence of rat strain and nutrient composition.

The modulating effect of high levels of dietary fat on chemically induced colon tumorigenesis has been studied in animal models, with conflicting results. The present study was designed to examine the influence of rat strain, stage of tumor development and micronutrient composition of the diet on 1,2-dimethylhydrazine (DMH)-induced intestinal tumorigenesis. Two strains of rats [Sprague-Dawley (SD) and Fischer-344 (F-344)] were fed one of three experimental diets. The diets contained 5 or 20% dietary fat but differed in nutrient composition and nutrient-energy ratio. After receiving the experimental diets for 4 wk, animals were treated with DMH X 2HCl (10 mg/kg body wt) once a week for 20 wk and killed 10 wk after receiving the last dose of carcinogen. Long-term administration of DMH was more toxic to F-344 rats than to SD animals, and the toxicity was potentiated by reductions in the micronutrient composition of the diet. High levels of dietary fat (20%) resulted in a barely significantly higher incidence in colon tumor (but not frequency or size) in SD rats that received the diet promoting optimal growth than did low levels of dietary fat. No effect of 20% beef fat was seen in SD animals fed a diet that produced a slower growth rate or in F-344 animals.

Adenocarcinoma↗

PubMed2003

Micronutrients and the bone mineral content of the mother, fetus and newborn.

The fluxes of the primary bone-forming minerals, calcium, phosphorus, magnesium and zinc, across the placenta and through breast milk place considerable demands on maternal mineral economy. Increases in food consumption, elevated gastrointestinal absorption, decreased mineral excretion and mobilization of tissue stores are several possible biological strategies for meeting these extra mineral requirements. This paper presents a review of the evidence on the extent to which these strategies apply in the human situation, the mechanisms by which they occur, the limitations imposed by maternal diet and vitamin D status and the possible consequences for the growth of the infant and bone health of the mother. On the strength of current evidence it appears that pregnancy and lactation are associated with physiological adaptive changes in mineral metabolism that are independent of maternal mineral supply within the range of normal dietary intakes. These processes provide the minerals necessary for fetal growth and breast milk production without requiring an increase in maternal dietary intake or compromising maternal bone health in the long term. This may not apply to pregnant women whose mineral intakes or sunlight exposure are marginal. As a vehicle for promoting optimal growth and bone mineral content of infants, supplementation of lactating women with minerals or vitamin D is unlikely to prove effective. The situation in pregnancy is less certain. Until more studies have been conducted, a precautionary case can be made for targeted supplementation of pregnant women who have very low intakes of calcium or who are at risk of vitamin D deficiency.

Bone Density↗

PubMed2004

Maternal nutrition and fetal development.

Nutrition is the major intrauterine environmental factor that alters expression of the fetal genome and may have lifelong consequences. This phenomenon, termed "fetal programming," has led to the recent theory of "fetal origins of adult disease." Namely, alterations in fetal nutrition and endocrine status may result in developmental adaptations that permanently change the structure, physiology, and metabolism of the offspring, thereby predisposing individuals to metabolic, endocrine, and cardiovascular diseases in adult life. Animal studies show that both maternal undernutrition and overnutrition reduce placental-fetal blood flows and stunt fetal growth. Impaired placental syntheses of nitric oxide (a major vasodilator and angiogenesis factor) and polyamines (key regulators of DNA and protein synthesis) may provide a unified explanation for intrauterine growth retardation in response to the 2 extremes of nutritional problems with the same pregnancy outcome. There is growing evidence that maternal nutritional status can alter the epigenetic state (stable alterations of gene expression through DNA methylation and histone modifications) of the fetal genome. This may provide a molecular mechanism for the impact of maternal nutrition on both fetal programming and genomic imprinting. Promoting optimal nutrition will not only ensure optimal fetal development, but will also reduce the risk of chronic diseases in adults.

Amino Acids↗

PubMed1978

Physicians' attitudes toward early intervention.

Fourteen pediatricians serving Boston neighborhood health centers and fourteen pediatric neurologists in the greater Boston area were interviewed in order to determine their attitudes toward early intervention for infants with developmental disorders. The two groups differed significantly over the potential of early treatment for promoting optimal motor, cognitive, and affective development in the disadvantaged infant. Both groups viewed prevention of musculoskeletal deformities as appropriate for physically handicapped children and supported early intervention for the parents. When referral for treatment was delayed or withheld, the prime reasons given were an expression of a maturationist viewpoint, a desire for a definitive diagnosis prior to initiating treatment, the assumption that an adequate family can function without professional involvement, and misinterpretation of professional roles.

Attitude of Health Personnel↗

PubMed2002

Complete osseous regeneration of a large skull defect in a patient with cutis aplasia: a conservative approach.

Cutis aplasia (or aplasia cutis congenita) is a congenital absence of all skin layers, often extending through bone. This defect usually occurs in the scalp and can be extensive, exposing the dura mater, and deeper meninges. Treatment regimens for cutis aplasia have included early operative intervention, including skin and bone grafts, local scalp flaps, or free flaps to close the defect. In addition to the significant perioperative risks, these invasive procedures may inhibit the osteogenic potential of the dura to initiate and sustain bony closure of the defect. We report a case of an infant with Adams-Oliver syndrome and cutis aplasia involving a large portion of the skull that was treated conservatively with topical Silvadene dressings. No surgical treatment of bone or soft tissue reconstruction was necessary. This case report is the first to our knowledge to document complete bony restoration of the cranial vault through serial three-dimensional CT scans. The intensive therapeutic intervention in this case report allowed early discharge from the hospital, a gradual amelioration of the patient's alopecia as the hair-bearing scalp slowly covered the defect, and precluded the need for any subsequent bony reconstruction of the cranial vault. We hypothesize that conservative treatment of cutis aplasia maintains dural induction of osseous regeneration, and any treatment plan for bony defects of cutis aplasia should consider maintenance of dural integrity. Although further investigation is warranted, an initial trial of antimicrobial dressing care might optimally promote secondary closure of the cranial vault without the need for surgical intervention.

Administration, Cutaneous↗

PubMed1996

Proving that less is more: linking resources to outcomes.

Advocates of inpatient managed care employing clinical pathways are confident that this patient management strategy reduces cost while promoting optimal patient outcomes. Other health care professionals are concerned that cost reductions place patients at higher risk for adverse health events. Research is needed to demonstrate the true impact of cost-containment strategies on clinical outcomes. The article describes a study in progress comparing patients conventionally managed by their physicians with similar patients whose overall management involved a nurse case manager. This study explores the issue of resource costs that can be linked to clinical and financial outcome measures.

Case Management↗

PubMed1979

Discrepancies between knowledge and use of diagnostic studies in asymptomatic patients.

The value of educational programs designed to promote optimal use of laboratory tests by physicians remains unsolved. To assess the effects of level of training and knowledge of test characteristics in determining laboratory ordering habits, physicians' use of laboratory tests as applied to asymptomatic patients was surveyed and their knowledge of four specific procedures was tested. The survey included 148 physicians both in training and in practice in Rochester, New York. Increased selectivity in the use of tests occurred during residency training, but selectivity correlated poorly with knowledge of test characteristics. These data underline the need for additional studies to determine the role of factors other than knowledge which contribute to the use of laboratory tests. Planners of cost containment programs and educational strategies will need to direct attention to these factors.

Clinical Laboratory Techniques↗

PubMed1994

Applying Benner's model to school nursing of multiple handicapped children.

The role of the school health nurse has become more complex in recent years due to public policy changes. The focus of this article is on changes in school health nursing since enactment of Public Law 94-142, the Education for All Handicapped Children Act, which places medically complex and multiply handicapped children in the public school system. The changing character of school health nursing increases the need for the advanced practice nurse (APN) to use nursing theories to guide nursing decisions. In this article, Benner's Model of Expert Practice is used by the APN in the challenging setting of school health nursing. A case study is included to describe how an APN can use this model to promote optimal functioning in a child with multiple handicaps while helping the child and family transition through developmental stages.

Child↗

PubMedDate not supplied

Postoperative arm massage: a support for women with lymph node dissection.

PURPOSE/OBJECTIVE: To evaluate the usefulness of arm massage from a significant other following lymph node dissection surgery. DESIGN: Randomized clinical trial with a pretest-posttest design. Data were collected prior to surgery, within 24 hours post surgery, within 10 to 14 days post surgery, and 4 months post surgery. SAMPLE: 59 women, aged 21 to 78 undergoing lymph node dissection surgery and who had a significant other with them during the postoperative period. METHODS: Subjects were randomly assigned to intervention and control groups. Subjects' significant others in the intervention group were first taught, then performed arm massage as a postoperative support measure. RESEARCH MAIN VARIABLES: Variables included postoperative pain, family strengths and stressors, range of motion, and health related costs. FINDINGS: Participants reported a reduction in pain in the immediate postoperative period and better shoulder function. CONCLUSION: Arm massage decreased pain and discomfort related to surgery, and promoted a sense of closeness and support amongst subjects and their significant other. IMPLICATION FOR NURSING PRACTICE: Postoperative massage therapy for women with lymph node dissection provided therapeutic benefits for patients and their significant other. Nurses can offer effective alternative interventions along with standard procedures in promoting optimal health.

Activities of Daily Living↗

PubMedDate not supplied

Nursing care of donor site wounds.

The list of ideal donor site characteristics includes many items related to nursing care such as the ability of the dressing to minimize pain, permit patient mobility, and simplify postoperative care. Biobrane must adhere to the donor site wound bed and be allowed to dry without fluid accumulation. Coarse-mesh gauze wraps applied over the Biobrane in the operating room help maintain contact between Biobrane and the wound bed, protect the donor site from traumatic dislodgment in the early postoperative period, and serve to wick wound drainage in the first 24 hours. Twenty-four hours after surgery the nurse removes the outer dressing. The Biobrane is usually adherent to the wound, and the site is left open to dry. The primary goal of nursing care is to maintain sufficient airflow around the site. Nursing care of Biobrane-covered donor sites is uncomplicated but requires adherence to certain procedures to promote optimal donor site healing.

Biocompatible Materials↗

PubMed1999

International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: IV. Therapeutic dose dependence and abuse liability of benzodiazepines in the long-term treatment of anxiety disorders.

Despite decades of relevant basic and clinical research, active debate continues about the appropriate extent and duration of benzodiazepine use in the treatment of anxiety and related disorders. The primary basis of the controversy seems to be concern among clinicians, regulators, and the public about the dependence potential and the abuse liability of benzodiazepines. This article reports systematically elicited judgments on these issues by a representative panel of 73 internationally recognized experts in the pharmacotherapy of anxiety and depressive disorders, a panel which was constituted by a multistage process of peer nomination. The criterion for inclusion at each stage was the nomination by at least two peers as one of the "professionally most respected physicians of the world with extensive experience and knowledge in the pharmacotherapy of anxiety and depressive disorders." Sixty-six respondents (90%) completed a comprehensive questionnaire covering a wide range of topics relevant to the therapeutic use of benzodiazepines and other medications that might be used for the same purposes. Overall, the expert panel judged that benzodiazepines pose a higher risk of dependence and abuse than most potential substitutes but a lower risk than older sedatives and recognized drugs of abuse. There was little consensus about the relative risk of dependence and abuse among the benzodiazepines. Differences between benzodiazepines with shorter and longer half-lives in inducing withdrawal symptoms are much less clear during tapered than during abrupt discontinuation. There was little agreement about the most important factors contributing to withdrawal symptoms and failure to discontinue benzodiazepines. The pharmacologic properties of the medication may be the most important contributors to withdrawal symptoms. In contrast, the clinical characteristics of the patient may be the most important contributors to failure to discontinue medication. The experts' judgment seems to support the widespread use of benzodiazepines for the treatment of bona fide anxiety disorders, even over long periods. The experts generally viewed dependence and abuse liability as clinical issues amenable to appropriate management, as for other adverse events related to therapy. However, more definitive clinical research on the remaining controversial issues is urgently needed to promote optimal patient care.

Anti-Anxiety Agents↗