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In this article, two clinical nurse researchers describe experiences with integrating a program of nursing research, including the use of the findings and methods of research and the conducting and disseminating of research, into two acute care hospitals. Strategic and contextual factors are specified in relation to targets within and outside of the hospitals.
A pilot program followed patients who were recovering from coronary artery bypass graft procedures. A cardiac surgery nurse visits patients in their homes to provide physical assessments, reinforce discharge teaching and answer questions. Because of the pilot's success, the program was integrated with the transitional open heart unit.
PURPOSE OF REVIEW: The demand for peripheral nerve blocks and neuroaxial blocks from both patients and surgeons has increased over the last few years. This change in attitude towards regional anesthesia is prompted by the insight that adequate perioperative pain management leads to earlier ambulation, shorter hospital stay, reduced cost and increased patient satisfaction. To avoid serious complications of these techniques structured residency programs need to be available. RECENT FINDINGS: Until 2004, the Residency Review Committee for Anesthesiology in the United States required a minimum of 50 epidurals, 40 spinals and 40 peripheral nerve blocks during residency. Similarly, the German Society for Anesthesia and Intensive Care required 100 neuroaxial blocks and 50 peripheral nerve blocks. In 2004 the American Society of Regional Anesthesia and Pain Medicine endorsed standardized guidelines for regional anesthesia fellowships which regulate the administrative, equipment and educational demands. SUMMARY: This review introduces the reader to the different teaching methods available, including cadaver workshops, three-dimensional videoclips, video filming, ultrasound guidance and acoustic assist devices as well as demonstrating their advantages and disadvantages. Moreover, an overview is given of future residency training programs, which integrate administrative, material and educative demands as well as the teaching means into the daily clinical routine.
OBJECTIVE: Our objective was to examine our hypothesis that the transmission of parentally shared human leukocyte antigen (HLA) alleles to offspring increases the risk of preterm delivery. METHODS: A population-based family study with participating children and their parents was conducted in Kaiser Permanente Medical Care Program, an integrated healthcare delivery system, in the Northern California Region. A total of 234 participants from 78 families with early preterm deliveries (35 weeks of gestation or greater) and 60 participants from 20 families with full-term births were included in the study. Buccal cells were collected from the first-born preterm cases and their parents to determine HLA-B (class I) and DRB1 (class II) types and the transmission of parental alleles to the offspring. The buccal samples were also collected from full-term deliveries to rule out possible segregation distortion at the studied HLA loci. RESULTS: Compared with the expected transmission probability based on Mendel's laws (25%), transmission of parentally shared HLA-B or DRB1 alleles from both heterozygous parents to offspring (48% of 23 heterozygous parents) was associated with a more than 5-fold increased risk of preterm delivery (odds ratio 5.5; 95% confidence interval 1.2-51). Transmission of parentally shared HLA alleles from heterozygous mothers (83%) appears to be more important in the etiology of preterm delivery than transmission from fathers (57%). The transmission pattern of parentally shared HLA alleles in our full-term controls was almost identical to the expected pattern based on Mendel's laws and demonstrated no segregation distortion at those HLA loci. CONCLUSION: Our findings provide evidence that the transmission of parentally shared HLA alleles may be an underlying mechanism for preterm delivery.
Osteogenesis Imperfecta (OI) is characterized by bone fragility. At least seven discrete types have been described ranging from mild disease to a lethal form. In a large number of cases, mutations in one of the two genes encoding type I collagen have been found. In forms recently described (types V, VI, VII), such mutations have been excluded. In two other forms, (Bruck, and osteoporosis - pseudoglioma syndromes) defects in other proteins have been characterized. In OI, bone fragility stems from: decreased bone mass, disturbed organization of bone tissue, and altered bone geometry (size and shape). Histologic studies have shown that increased bone turnover is the rule in OI bone. This justifies using bisphosphonates in order to reduce osteoclast mediated bone resorption. Initial results are encouraging. Cyclical intravenous pamidronate administration reduces bone pain and fracture incidence, and increases bone density and level of ambulation, with minimal side effects. Effects on bone include increase in size of vertebral bodies and thickening of cortical bone. These results allow for more efficacious corrective surgery using intramedullary rodding of the long bones and paravertegral instrumentation. Specific occupational and physiotherapy programs are integral parts of the treatment protocol. This multidisciplinary approach will prevail until strategies aiming at the correction of the basic defect(s) will have come to fruition.
Our evolution toward a more integrative approach toward healing will accelerate if we can alter the different perspectives that patients and physicians bring to their relationship. This article reviews lessons that have been acquired using alternative approaches to facilitate the recovery of patients undergoing invasive procedures. After identifying that most of our patients use alternative therapies but prefer not to discuss these therapies with their surgeons, we began to routinely refer our patients to a coordinator trained in this field. The resulting integrative medicine program offers massage, yoga, audiotapes, and additional customized treatments. The coexisting research laboratory designs and conducts well-organized research endeavors evaluating the efficacy of therapies being offered. By mixing clinical practice with conventional research, we seek to emulate the successful formula used in allopathic medicine.
According to Healthy People 2010, 95% of employers with more than 50 employees reported that they offered at least one health promotion activity by 1999. Employment-based health promotion/disease prevention (hp/dp) programs have significantly increased in frequency and scope since 1985. Yet, 20 years later, the reported results for employee health lag behind the literature documenting the impact of lifestyle-related health risks on morbidity, healthcare utilization, and costs. In this article, we consider the key stakeholders involved-employers, health plans, and employees-and explore their legitimate and feasible roles in employment-based hp/dp programs, including the incentives and barriers they face to program participation. We argue for the integration of hp/dp programs into the traditional health protection mission of occupational health and safety professionals.
The postgenomic era of large-scale gene expression studies is inundating drug abuse researchers and many other scientists with findings related to gene expression. This information is distributed across many different journals, and requires laborious literature searches. Here, we present an interactive database that combines existing information related to cocaine-mediated changes in gene expression in an easy-to-use format. The database is limited to statistically significant changes in mRNA or protein expression after cocaine administration. The Flash-based program is integrated into a Web page, and organizes changes in gene expression based on neuroanatomical region, general function, and gene name. Accompanying each gene is a description of the gene, links to the original publications, and a link to the appropriate OMIM (Online Mendelian Inheritance in Man) entry. The nature of this review allows for timely modifications and rapid inclusion of new publications, and should help researchers build second-generation hypotheses on the role of gene expression changes in the physiology and behavior of cocaine abuse. Furthermore, this method of organizing large volumes of scientific information can easily be adapted to assist researchers in fields outside of drug abuse.
The characteristics of sorbitol and sucrose export out of mature leaves in seedlings of peach (Prunus persica L. Batsch cv GF 305) were investigated by simulating carbon fluxes through the leaf. Three treatments were employed: a control treatment and two treatments modifying leaf export, the latter using either shading or girdling. Photosynthesis and 14C partitioning into sorbitol and sucrose were measured during carbohydrate pool buildup at the beginning of the photoperiod, and the export rate of sorbitol and sucrose was modeled using a PSPICE (Simulation Program with Integrated Circuit Emphasis) simulator. The simulation allowed prediction of the resulting sorbitol and sucrose contents, which were compared to experimental carbohydrate contents. The apparent Km for sorbitol and sucrose phloem loading, estimated by carbon flux modeling, was 6.6 and 4 mol m-3, respectively. The predicted export capacity of the leaf, characterized by the estimated Vmax values for phloem loading of sorbitol and sucrose, was similar to the photosynthetic carbon flux measured under the leaf growth conditions. This export capacity was enhanced in plants in which all leaves except those studied were shaded. The mature leaf had a higher storage capacity for sorbitol than for sucrose in control plants, especially in the girdled treatment. Sucrose content appears to be tightly regulated.
Collecting optimum X-ray diffraction data involves a number of choices and compromises, including choice of crystal, source, rotation range, exposure time and programs for integration and scaling. This paper presents a series of questions which should be considered in planning a data-collection experiment.
Navy fleets have a defined overall objective for mission readiness impacted by the health of personnel aboard the ships. Medical treatment facilities on the ships determines the degree of mission readiness. This paper describes the concepts and technologies necessary to establish a Naval telemedicine system, which can drastically improve health care delivery. It consists of various combinations of the following components: Fleet Naval Medical Consultation and Diagnostic Centers, Shipboard Naval Medical Consultation and Diagnostic Centers (hospital ship or combatant ships with medical specialists on board), and Remote Medical Referring Centers such as a ship, a small Naval station annex, or a field hospital. This Naval telemedicine architecture delivers clinical medicine and continuing medical education (CME) by means of computers, video-conferencing systems, or telephony to enhance the quality of care through improved access to research, medical and nonmedical imaging, remote consultations, patient clinical data, and multimedia medical education programs. It integrates the informatics infrastructure and provides a medical telepresence among participants.
As the largest cancer killer of women around the globe, breast cancer adversely impacts countries at all levels of economic development. Despite major advances in the early detection, diagnosis, and treatment of breast cancer, health care ministries face multitiered challenges to create and support health care programs that can improve breast cancer outcomes. In addition to the financial and organizational problems inherent in any health care system, breast health programs are hindered by a lack of recognition of cancer as a public health priority, trained health care personnel shortages and migration, public and health care provider educational deficits, and social barriers that impede patient entry into early detection and cancer treatment programs. No perfect health care system exists, even in the wealthiest countries. Based on inevitable economic and practical constraints, all health care systems are compelled to make trade-offs among four factors: access to care, scope of service, quality of care, and cost containment. Given these trade-offs, guidelines can define stratified approaches by which economically realistic incremental improvements can be sequentially implemented within the context of resource constraints to improve breast health care. Disease-specific "vertical" programs warrant "horizontal" integration with existing health care systems in limited-resource countries. The Breast Health Global Initiative (BHGI) Health Care Systems and Public Policy Panel defined a stratified framework outlining recommended breast health care interventions for each of four incremental levels of resources (basic, limited, enhanced, and maximal). Reallocation of existing resources and integration of a breast health care program with existing programs and infrastructure can potentially improve outcomes in a cost-sensitive manner. This adaptable framework can be used as a tool by policymakers for program planning and research design to make best use of available resources to improve breast health care in a given limited-resource setting.
This paper describes the integrated postgraduate programmed recently introduced by the University of Ulster which includes the first Doctor of Nursing Science (DNSc) programme in Europe. It has three exist points: with a Postgraduate Diploma in Advanced Nursing or Midwifery, a Master of Science in Advanced Nursing or Midwifery or the DNSc. It aims to develop nurses who have the necessary knowledge and skills to function as advanced practitioners and, concurrently, to prepare nurses able to undertake high quality research which will contribute to the knowledge and theoretical base of nursing. Some of the issues which influenced the planning are discussed and demographic characteristics, expectations of the course, and comments of the first two cohorts of students are presented. Anticipated benefits for nursing knowledge and practice as well as potential difficulties with such a programmed are identified.
OBJECTIVE: To describe the epidemiology of urban malaria, an emerging problem in sub-Saharan Africa. METHOD: Cross-sectional surveys of communities in Accra and Kumasi, Ghana, determining risk factors for malaria infection and anaemia in children aged 6-60 months. RESULTS: Malaria prevalence rates ranged from 2% to 33% between urban communities. 47.1% of children were anaemic (Hb<11.0 g/dl). Factors associated with malaria prevalence were low socio-economic status, age and anaemia. The attributable risks of anaemia and severe anaemia (Hb<8.0 g/dl) caused by malaria were 5% and 23% respectively. CONCLUSIONS: Malaria in urban areas displayed a heterogeneity and complexity that differed from the rural environment, which has important implications for malaria control. Marked intra-city variation indicates the importance of targeting specific areas or districts. The most vulnerable group, the urban poor, should be prioritized when designing control measures. This would require careful assessment of the malaria risk pattern in any city to guide an integrated control program.
Correlations between acetone in milk and milk production during the first nine weeks postpartum were calculated in ten individual cows and for a whole herd. The decrease in milk production due to ketonaemia was evaluated using a mathematical model of the KaleidaGraph integrate area program. For determination of milk components, a milk sample was obtained twice a week from one to nine weeks postpartum. Milk yield was negatively correlated with acetone concentration in milk. In non-clinical ketotic cows the calculated loss of milk yield due to elevation of milk acetone was 2-9% and in clinical ketotic cow it was as high as 26%. The correlation between milk components and acetone level varied at different stages of ketosis. Thus the stage of lactation and of ketosis should be taken into consideration when the correlation between milk parameters and milk production is evaluated. Prior to clinical ketosis, milk acetone was negatively correlated with milk yield, percentage of protein and percentage of lactose, whereas it was positively correlated with percentage of fat and urea concentration. In addition, high levels of acetone tended to be associated with high cell count. It is concluded that 1) ketotic cows do not achieve the maximum potential milk yield and 2) high levels of milk acetone are harmful to the udder. For high milk production, the concentration of acetone in milk should not exceed 0.05 mmol/l at any stage of lactation.
Crisis reactions, a stressful environment, infant care practices, and nurse behavior may cause difficulties in entering the natural parental role for parents of infants who are admitted to a neonatal intensive care unit (NICU). In connection with discussions in the Uppsala NICU on what constitutes good care, a philosophy of care, based on Callista Roy's adaptation model, was formulated for the purpose of providing developmentally supportive, family-centered care, and for defining good care and the professional nurse role. The philosophy describes the infant's needs and environment. Caring activities focus on support of the infant's and his parent's roles and self-concept in their progress towards independence from professional assistance. The philosophy is an essential component in the introductory program which integrates newly recruited personnel from different disciplines into the unit. It is presented as a suggestion of how a model-based philosophy of care can be formulated by operationalization of the theoretical concepts of a nursing model.
BACKGROUND: The incidence of diabetes mellitus (DM) has increased persistently in recent years and is becoming an epidemic. Some have estimated that 4.4% of the world's population will be diabetic by the year 2030. The increase incidence of DM has been accompanied by an increased incidence in diabetic nephropathy (DN), the main cause of end-stage renal disease. METHODS AND RESULTS: In 1996, a pharmaco-economic study estimated that 162,000 people in Spain had type 1 DM and 1,354,900 had type 2 DM. More recent studies have estimated that 6% to 10% of the Spanish population might be diabetic. This percentage is higher in some autonomous communities, such as Canarias, in which 12% of the population is thought to have DM. Based on these studies, we estimate that more than 33,000 residents of Canarias have DN associated with type 1 DM, and more than 405,000 have DN associated with type 2 DM. The percentage of diabetic patients starting renal replacement therapy each year is currently around 21% in Spain but much higher (35%) in Canarias, which equates to 78 patients per million population (pmp) per year. In Catalonia, the number of DM patients entering renal replacement therapy has increased from 8.6 pmp per year in 1984 to 32.4 pmp per year in 2003. We estimate that the systematic application of converting enzyme inhibitors or angiotensin receptor blockers could save more than 2.690 million over 15 years in Spain. CONCLUSION: This epidemic could be prevented, or its impact reduced, through multifactorial and multidisciplinary early intervention, under the observance of guides, Spanish consensus documents, and clinical practice recommendations, together with an integrated educational program aimed at people with diabetes and the improvement of the standard of medical care.
It is vital that teachers, parents, and health professionals recognize the major educational problems that affect students with epilepsy. Children with epilepsy should be placed in the least restrictive schooling environment so that social, emotional, and educational requirements can be met in a setting best suited to the individual's present needs and future development. Personal assessment and monitoring of progress form an equally important part of a child's educational program in integrated schools, but there is a need to develop suitable instruments to assist teachers in their assessments and decision making. In Australia, the National Epilepsy Association has developed an "Alert Kit" based on the Epilepsy Foundation of Americas "School Alert Kit" to provide basic medical information on epilepsy to teachers and pupils.