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PubMed2002

Training, certification, and reimbursement for nephrology procedures.

The field of interventional nephrology is rapidly developing as an important new area of nephrology practice that holds great promise for improved patient care, outcomes, and cost control. This development is contingent on nephrologists acquiring the necessary knowledge and skills through suitable training and experience, and obtaining hospital privileges to perform these interventions. As more training programs are created, and credentialing criteria are established and accepted, it will become more practical for nephrologists to become interventionists. Reimbursement for interventional procedures can be complicated and confusing, with special problems applicable to a nephrology practice involved in the overall care of end-stage renal disease (ESRD) patients. It is essential to become familiar with applicable procedure codes, global periods, and code modifiers to correctly describe these procedures and receive correct reimbursement. Nephrologists work together with vascular access surgeons and interventional radiologists to provide care for dialysis patients. The role of each specialist in the management of vascular access depends on his or her level of interest, knowledge, and technical skill. These roles may vary considerably from one practice to another. There is potential for this area to become highly contentious, especially if one specialist feels threatened by the activities of another. Optimal patient care will be achieved only if all involved physicians take a serious intellectual interest in vascular access, develop superior clinical skills, and maintain cooperative, collegial, relationships.

Certification↗
PubMed2003

An analysis of Simpson's notebook data on the wet nurse.

OBJECTIVE: to understand the meaning of the qualitative data included in the Notebook of wet nurses kept by James Young Simpson. DESIGN: quantitative and qualitative analysis of data in an historical document. SETTING: a list of wet nurses kept by a 'Professor of Midwifery' in mid-19th century Edinburgh. PARTICIPANTS: the Notebook lists the names and other details of 749 women. FINDINGS: the Notebook indicates how the wet nurse was recruited, the implications for her baby, how she negotiated her role and the decision-making around her recruitment. KEY CONCLUSIONS: the ambiguity of this medical pioneer's decision-making is demonstrated. Simpson's scientific credentials may have featured much rhetoric. While in the forefront of many obstetric and medical developments, Simpson was regressive in his support for wet nursing. The social input into the selection of the wet nurse has not been identified previously. IMPLICATIONS FOR PRACTICE: the woman's ability to negotiate her terms of employment emerges. The social determinants of baby feeding decisions, identified in this document, have assumed greater significance since the time that this Notebook was written.

Breast Feeding↗
PubMed2004

A comparison of laparoscopically assisted and open colectomy for colon cancer.

BACKGROUND: Minimally invasive, laparoscopically assisted surgery was first considered in 1990 for patients undergoing colectomy for cancer. Concern that this approach would compromise survival by failing to achieve a proper oncologic resection or adequate staging or by altering patterns of recurrence (based on frequent reports of tumor recurrences within surgical wounds) prompted a controlled trial evaluation. METHODS: We conducted a noninferiority trial at 48 institutions and randomly assigned 872 patients with adenocarcinoma of the colon to undergo open or laparoscopically assisted colectomy performed by credentialed surgeons. The median follow-up was 4.4 years. The primary end point was the time to tumor recurrence. RESULTS: At three years, the rates of recurrence were similar in the two groups--16 percent among patients in the group that underwent laparoscopically assisted surgery and 18 percent among patients in the open-colectomy group (two-sided P=0.32; hazard ratio for recurrence, 0.86; 95 percent confidence interval, 0.63 to 1.17). Recurrence rates in surgical wounds were less than 1 percent in both groups (P=0.50). The overall survival rate at three years was also very similar in the two groups (86 percent in the laparoscopic-surgery group and 85 percent in the open-colectomy group; P=0.51; hazard ratio for death in the laparoscopic-surgery group, 0.91; 95 percent confidence interval, 0.68 to 1.21), with no significant difference between groups in the time to recurrence or overall survival for patients with any stage of cancer. Perioperative recovery was faster in the laparoscopic-surgery group than in the open-colectomy group, as reflected by a shorter median hospital stay (five days vs. six days, P<0.001) and briefer use of parenteral narcotics (three days vs. four days, P<0.001) and oral analgesics (one day vs. two days, P=0.02). The rates of intraoperative complications, 30-day postoperative mortality, complications at discharge and 60 days, hospital readmission, and reoperation were very similar between groups. CONCLUSIONS: In this multi-institutional study, the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.

Adenocarcinoma↗
PubMed2002

A study of the workforce in emergency medicine: 1999.

STUDY OBJECTIVE: We estimate the total number of physicians practicing clinical emergency medicine during a specified period, describe certain characteristics of those individuals to estimate the total number of full-time equivalents (FTEs) and the total number of individuals needed to staff those FTEs, and compare the data collected with those data collected in 1997. METHODS: Data were gathered from a survey of a random sample of 2,153 hospitals drawn from a population of 5,329 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, and the total number of physicians working during the period from June 6 to June 9, 1999. Demographic data on the individuals were also collected. RESULTS: A total of 940 hospitals responded (a 44% return rate). These hospitals reported that a total of 6,719 physicians were working during the specified period, or an average of 7.85 persons scheduled per institution. The physicians were scheduled for a total of 347,702 hours. The average standard for FTE was 40 clinical hours per week. This equates to 4,346 FTEs or 5.29 FTEs per institution. The ratio of persons to FTEs was 1.48:1. With regard to demographics, 83% of the physicians were men, and 82% were white. Their average age was 42.6 years. As for professional credentials, 42% were emergency medicine residency trained, and 58% were board certified in emergency medicine; 50% were certified by the American Board of Emergency Medicine. CONCLUSION: Given that there are 5,064 hospitals with EDs and given that the data indicate that there are 5.35 FTEs per ED, the total number of FTEs is projected to be 27,067 (SE=500). Given further that the data indicate a physician/FTE ratio of 1.47:1, we conclude that there are 39,746 persons (SE=806) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 31,797. When the 1999 data are compared with those collected in 1997, we note a statistically significant decline in the number of hospital EDs, from 5,126 in 1997 to 5,064 in 1999 (P =.02). The total number of emergency physicians remained the same over the 2-year period, whereas the number of FTEs per institution increased from 5.11 to 5.35. The physician/FTE ratio remained unchanged.

Adult↗
PubMed2002

Advanced practice nurses in emergency care settings: A demographic profile.

INTRODUCTION: Very little is known about clinical nurse specialists and nurse practitioners (advance practice nurses [APNs]) who practice in emergency care settings. The Advanced Practice Committee of the ENA sought to determine a profile of these individuals. METHODS: Surveys were distributed to all registrants at 2 ENA conferences and posted on the ENA Web site. This survey asked 17 questions concerning the demographic characteristics of the APN respondents (eg, education, experience, certification, state recognition, and practice area). The survey was completed by 166 APNs. RESULTS: APNs had considerable experience as ED registered nurses before becoming an APN. They obtained their APN education at the master's degree or post-master's degree level. State recognition was required for 89.2% of the APNs. The majority of APNs (61.4%) obtained their certification through the American Nurses Credentialing Center. Nurse practitioners were predominantly family nurse practitioners (43%), and clinical nurse specialists were either critical care clinical nurse specialists (8.9%) or had other certifications (5.9%). APNs provided services in both the main emergency department and the fast track (45.7%) and were relatively new to their role as an APN. DISCUSSION: Consistent with current educational and certification requirements, the vast majority of APNs held a master's degree. Although relatively new to their role as APNs in emergency care, they were nonetheless very experienced as ED registered nurses. The majority of APNs were certified, even though that is not required for practice in all states. Continued research is needed to identify the most effective utilization of APNs, document their contributions to patient care outcomes, and develop strategies to meet their educational and practice needs.

Certification↗
PubMedDate not supplied

Alternative treatment modalities: the need for a rational response by the nursing profession.

During the last 2 decades, interest in and use of alternative modalities of health care has proliferated. As the public demand for such therapies increased, nursing has been among a few of the health professions to fill this need. Some of these therapies may prove to be valuable, others may be shown to be ineffective, and others may be harmful. Presently, many alternative methods have not been tested by using rigorous scientific methods. In addition, standardization in education and credentialing of practitioners of these modalities is lacking. As health care professionals, nurses have a responsibility to their patients and to their profession to validate the safety and efficacy of their practice. It is incumbent on the recognized bodies of the nursing profession to address these serious issues. The safety of patients and the reputation of the profession of nursing may depend on it.

Complementary Therapies↗
PubMed2001

Carotid angioplasty-stent: clinical experience and role for clinical trials.

Carotid angioplasty-stenting (CAS) is a relatively new endovascular procedure that has been used increasingly in recent years. Its popularity is due to, at least in part, the perceived advantages of a less invasive treatment for extracranial carotid occlusive disease. However, valid data that contrast the efficacy of CAS and carotid endarterectomy (CEA), the gold standard for the treatment of symptomatic carotid stenosis, are not available. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST) will contrast the relative efficacy of CAS with CEA in the prevention of stroke, myocardial infarction, or death during a 30-day periprocedural period or an ipsilateral stroke thereafter during a follow-up period extending up to 4 years. Stroke events will be verified by an adjudication committee masked to the assigned treatment. Secondary outcomes will (1) describe differential efficacy of CAS and CEA in men and women, (2) contrast periprocedural (30-day) morbidity and postprocedural (after 30-days) morbidity and mortality rates, (3) estimate and contrast the restenosis rates of the two procedures, (4) evaluate the differences in measures of health-related quality of life and cost effectiveness, and (5) identify subgroups of participants at differential risk for CAS and CEA. The primary eligibility criterion is a >50% stenosis of the carotid artery in patients with ipsilateral amaurosis fugax (transient monocular blindness), transient ischemic attack, or nondisabling stroke. Men and women will be eligible for the trial, but patients with medical conditions likely to limit their participation during the follow-up or to interfere with outcome evaluation will be excluded. After a credentialing and training phase, 2500 patients will be randomized to the treatments. Statistical analysis of the primary outcome will use standard survival methods.

Angioplasty↗
PubMed1988

Sustained expression of the human protooncogene MYCN rescues rat embryo cells from senescence.

Amplification of the human gene MYCN may play a role in the malignant progression of human neuroblastomas. In pursuit of this possibility, previous studies have shown that the abundant expression of MYCN in cultured cells can elicit several aspects of the transformed phenotype. We now extend those findings by demonstrating that rat embryo cells transfected with MYCN can proliferate for at least 200 generations. Isolation of established cells was dependent on high expression of MYCN and on biological selection to eliminate untransfected cells. The established cells were not tumorigenic in syngeneic rats or athymic mice, failed to grow in soft agar, and required relatively high concentrations of serum for proliferation in culture. Our results show that enhanced expression of MYCN can rescue normal cells from senescence, add to the credentials of MYCN as an authentic protooncogene, and identify an additional biological activity that can be used in the characterization of MYCN.

Animals↗
PubMed2000

American Board of Clinical Neuropsychology special presentation: The American Board of Clinical Neuropsychology (ABCN), 2000 update.

This paper updates neuropsychologists on the process of obtaining board certification in clinical neuropsychology through the American Board of Clinical Neuropsychology (ABCN), a specialty board operating under the auspices of the American Board of Professional Psychology (ABPP). At this time, the ABPP and ABCN have certified 406 clinical neuropsychologists, which makes it the largest board-certification organization in clinical neuropsychology. This article details the advantages of board certification through the ABCN and the four steps which must be passed in order to obtain board certification. These steps are: credential review, written examination, work sample, and oral examination.

Certification↗
PubMed2005

An update on master's degrees in medical education.

Planning and implementing educational programs in medicine optimally requires a background in educational theory and practice. An avenue of training open to such practitioners is a master's degree in medical education. A single 1998 report lists the programs known at that time and information about them remains scarce. The authors have re-examined all current programs offering master's degrees in medical or health sciences education in the English-speaking world, including the Netherlands. The authors contacted the programs identified in the 1998 report to establish how many were still in operation. The search was extended using Pubmed and other search engines. A further verification targeted a selected sample of 10 prominent US medical schools. Twenty-one currently operating programs were identified: six in the US, eight in the UK, three in Canada, three in Australia and one in Holland. Seven of nine original master's programs were still in existence. URLs, website and other logistical information about each program are tabled. A master's degree in medical or health sciences education is the most specific method for medical faculty to obtain a credentialed grounding in educational theory and practice. The authors provide up-to-date contact information for current programs and summarize other related essential logistical data.

Curriculum↗
PubMedDate not supplied

Application of gene expression profiling for validating models of human breast cancer.

While classical histopathologic approaches are invaluable in classifying tumors and understanding aspects of cellular interactions, genomic approaches provide a means to molecularly dissect tumorigenesis. The relationship of gene expression to the development of neoplasia remains an area of intensive research. With the advent of large-scale genomic platforms, alterations in gene expression can be related to the morphological development of cancer. The feasibility of using large-scale genomic analysis platforms has dramatically changed the landscape of biological sciences, as cellular processes must be considered in the context of complex networks. Alterations in gene expression must now be understood in a systems approach in which the relationships between genes expression changes are studied by considering the interplay of multiple regulatory networks. Ultimately, such changes must be understood at the protein level. We have begun to apply this technology to determine changes in gene expression that differentiate various types of mammary cancers that arise in mouse models that have been initiated by different genetic alterations. Ultimately, a molecular catalogue of similarities and differences between rodent and human tumors can be created which will serve to validate or credential particular models for specific experimental purposes, such as preclinical testing. These approaches have led to new insights into molecular pathways involved in oncogenesis, new classifications of human breast cancer, and the identification of new genes that may be relevant to understanding and treating human cancer.

Animals↗
PubMed2004

Snapshot of the substance abuse treatment workforce in 2002: a synthesis of current literature.

Substance abuse among adolescents and adults continues to be a major public health concern. Given the prevalence of substance use, abuse, and dependence in the United States, the treatment needs of the population who abuse substances are great. Adolescents and adults who abuse substances need competent, knowledgeable, and qualified staff to provide services to meet their treatment needs. However, providers of substance abuse treatment services are varied, ranging from those who have minimal formal training to those who have specialized degrees and credentials in the field. In addition, substance abuse professionals represent a variety of fields (social work, psychiatry, psychology, etc) as opposed to a single unifying discipline. Few studies have been conducted examining the background, qualifications, and professional development needs of treatment staff. This article represents an attempt to lay the groundwork for future research. It summarizes information on staff demographics, level of competency, training, recruitment, and retention. In addition, recommendations are made for the advancement of research.

Adolescent↗
PubMed2002

Radiation oncology--linking technology and biology in the treatment of cancer.

Technical advances in radiation oncology including CT-simulation, 3D- conformal and intensity-modulated radiation therapy (IMRT) delivery techniques, and brachytherapy have allowed greater treatment precision and dose escalation. The ability to intensify treatment requires the identification of the critical targets within the treatment field, recognizing the unique biology of tumor, stroma and normal tissue. Precision is technology based while accuracy is biologically based. Therefore, the intensity of IMRT will undoubtedly mean an increase in both irradiation dose and the use of biological agents, the latter considered in the broadest sense. Radiation oncology has the potential and the opportunity to provide major contributions to the linkage between molecular and functional imaging, molecular profiling and novel therapeutics for the emerging molecular targets for cancer treatment. This process of 'credentialing' of molecular targets will require multi disciplinary imaging teams, clinicians and basic scientists. Future advances will depend on the appropriate integration of biology into the training of residents, continuing post graduate education, participation in innovative clinical research and commitment to the support of basic research as an essential component of the practice of radiation oncology.

Biology↗
PubMed1999

Research misconduct in clinical research--the American experience and response.

Research misconduct in the United States has occurred sporadically since 1961 in the laboratories of some of our most distinguished scientists. In view of the enormous number of research grants funded, cases of this kind are relatively uncommon, but have none the less attracted governmental supervision and calls for reform. The scientific community, universities and government have addressed the issue in various ways and changes have been proposed and some actually instituted. In view of human nature, no one seriously believes that dishonesty in research can be prevented to any greater extent than in any other human activity. However, some practices may discourage and mitigate such occurrences. These include: education in sound laboratory research practices, a fair distribution of authorship assignment, and adequate supervision of research personnel including appropriate reviewing of primary data. Other measures which might be considered include: an adequate check of the credentials of all new personnel, audits for clinical research, especially for those involving significant numbers of patients and multiple institutions, and the introduction of quality control concepts into research procedures. The hope is that the senior individual scientist responsible for the quality and integrity of the research will institute such measures as needed, and that institutional and government supervision will not interfere with the creative process.

Humans↗
PubMed2001

Undergraduate oncology nursing education in the Balkans and the Middle East.

BACKGROUND: The levels of undergraduate oncology nursing education in the Balkans and the Middle East had not been determined. METHODS: The authors used a questionnaire to survey representatives of nine Balkan and Middle East countries about the oncology nursing education available in undergraduate nursing programs in their countries. Admission criteria, the educational requirements for teachers providing the education, and the levels of nursing credentials in the country were investigated. RESULTS: Years of schooling needed for admission ranged from eight to 12. Requirements for teachers varied widely, from none to academic degrees and experience, as did levels of nurses in the countries. Israel, Slovenia, and Greece had fairly substantial oncology nursing education programs, while some countries, especially in the Balkans, offered none at all. CONCLUSIONS: There is a need for routine inclusion of required oncology training in the nursing programs of these countries.

Education, Nursing, Baccalaureate↗
PubMed1991

Impact of the Cancer Education Program on career paths of students.

A questionnaire sent to former University of North Carolina students who participated in the Cancer Education Program, a National Cancer Institute sponsored program designed to provide integrated educational opportunities in oncology for students in the health science schools, ascertained the career paths taken by students and elicited opinions regarding the impact of the program on those decisions. One hundred five surveys were returned. The opportunity to be involved in cancer research was the most common reason given for participation in the program (65 respondents). The opportunity to work with a specific faculty member (48) and improving academic credentials (44) were also important. Twenty-three individuals changed their career goals after participation in this program, 20 decided to pursue cancer-related careers, and 3 decided to avoid this field. One hundred three individuals were currently in health professions, 58 in academic, and 45 in community-based practice. Twenty-seven were not involved with cancer, while 56 spent up to 25% of their professional time, 8 spent 25%-50%, and 9 spent over 50% of their professional time in cancer-related activities.

Career Choice↗
PubMedDate not supplied

Predicted utilization of emergency medical services telemedicine in decreasing ambulance transports.

OBJECTIVE: To determine predicted utilization, decrease in ambulance transports, and target population for emergency medical services (EMS) if telemedicine capabilities were available to the medic units in the field. METHODS: A retrospective chart review of 345 consecutive ambulance transports to four hospitals (Level I urban trauma center, urban tertiary care center, children's hospital and suburban community hospital) was performed by a panel of three board-certified emergency medicine physicians experienced and credentialed in emergency telemedicine. They independently reviewed the emergency department (ED) and EMS records and were asked to determine whether patients required ambulance transport for evaluation or whether disposition could be made following paramedic and emergency physician assessment via telemedicine. A five-point Likert scale was used to grade feasibility of telemedicine disposition (definitely yes, probably yes, maybe, probably no, definitely no). Other variables analyzed included age, sex, race, chief complaint, phone, private medical doctor, and call location by patient zip code, call site, and receiving hospital. RESULTS: In 14.7% of cases (6% definitely yes and 8.7% probably yes), disposition could be made without transport using telemedicine. The age range for eliminating transport was 2 weeks through 92 years, with mean age of 26.6 years. Under the age of 50 years, 46 out of 238 patients (19.3%) could have possibly been managed by telemedicine. CONCLUSION: Use of EMS telemedicine could result in an approximately 15% decrease in ambulance transports when it alone is added to the prehospital care provider's armamentarium. Emphasis for implementation should be placed on younger patients and an identified subset of chief complaints conducive to management using telemedicine.

Adolescent↗
PubMedDate not supplied

Resident perspectives of EMS as a subspecialty.

OBJECTIVE: Emergency medical services (EMS) is frequently considered to be a subspecialty of emergency medicine (EM) despite the unavailability of subspecialty certification. An assessment of future interest in EMS subspecialization and the perceived educational needs of potential EMS physicians was performed in order to provide data to leaders responsible for development of this subspecialty area. METHODS: A survey concerning EMS subspecialization issues was distributed to 2,464 members of the Emergency Medicine Residents Association (EMRA). Questions addressed demographic information, interest in EMS, educational issues, and desired credentials. The response rate was 30% (n = 737). All surveys were analyzed by the Pearson chi-square probability and Mantel-Haenszel tests for linear association. RESULTS: A moderate to very high interest in EMS medical direction was expressed by 84% of the respondents, with 14% interested in full-time EMS positions. This interest increased with years of training (p < 0.0001). Almost 89% believed that EMS physicians should have special preparations prior to practice beyond EM residency training. Fewer than half (44%) thought that an EM residency provided sufficient preparation for a significant role in EMS, and this perception increased in intensity with years of training (p < 0.0052). Interest in EMS fellowships (24%) would increase to 36% if subspecialty certification were available (p < 0.0001). Thirty-nine percent believed subcertification should be required of all EMS medical directors if available. CONCLUSIONS: Many EM residents have an interest in active participation in EMS on either a part-time or a full-time basis. Most respondents think EMS is a unique area requiring focused education beyond an EM residency. Interest in EMS fellowships would greatly increase if subspecialty certification were available.

Adult↗