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health and health-care by an ICU nurse

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  • September 11, 2011
  • 02:42 PM

Nurses on Sept 11: 'there were no patients'

by CxLxMx in cxlxmxrx

No doubt many nurses today are remembering the attacks on the World Trade Center on September 11, 2001. I wasn't a healthcare professional at the time. I had moved back home and was trying to figure out my next move after a web start-up I had been involved with went belly-up. My father was at the university, my mother was gardening, and my brother was at school. I got up and wandered around the house, read the newspaper. For some reason, I turned on the TV to flip through the channels and came across some live coverage.The towers had already been hit. Not knowing NYC well, I wasn't particularly shocked, mostly just gawking, as you get passing a car accident on the road. I told my mother what was going on, but she wasn't interested enough to stop gardening. So, I road my bike down to the university. My father was teaching a class. Some people in his department office were talking about it casually. But when I went over to the student center, where there was one large projection TV, the students were crowded around and there was a lot distress on faces and in voices. Our university is a popular spot for kids from NYC and Long Island.In the afternoon, I went to the hospital's blood donation center, but there was already a line snaking out the door and down the sidewalk. I was turned away as they had all the volunteers they could handle and were mostly looking for rare blood type donors.Like everyone else, I was riveted to news media for days and even weeks afterward. I briefly considered going down to NYC to see if I could help, but realistically there was nothing I could offer. Some people, like this flight attendant, said they went into healthcare following September 11th. I can't say that, although I do enjoy thinking that if something like the attacks ever happened again, I would be able to help out. (I tried going to Haiti, but was unsuccessful.)Reflections on our responseUnlike most people, I have been unhappy with our response to the devastation. During the initial discussions of what to do with Ground Zero, someone at National Review suggested that we should rebuild the trade towers, only this time with Vulcan cannons on the roof. That about sums up my attitude to the situation: we should have demonstrated that we still had the self-confidence and optimism necessary to rebuild along with the defiance to keep the attacks from happening again; to not rebuild at Ground Zero and move on is a bad omen. I am concerned that our actual response demonstrates our diminishment as a nation. Although many people claim to have felt "united" by the events, I see the widespread focus on negative emotions such as fear and anguish as a socially-directed manifestation of many individuals' obsession with their own problems (as seen across news and entertainment media on a daily basis).Take the National 9-11 Memorial. Prime real estate in NYC has been given over to two large gaping holes in the ground that serve no purpose other than to act as a reminder of the fact that we were dealt pain and death. The memorial has no meaning in the sense that it does nothing to tie the attacks to the broader cultural conflicts or actual physical conflict that preceded or came after September 11th. It isn't, in fact, a memorial in the sense that it commemorates nothing. Horrified as I was to see the jumpers on TV that day, those who died (rescue workers excepted) simply died.Compare the 9-11 Memorial with other memorials: they commemorate actions and actors, not victims. For example, the Gettysburg Memorial commemorates those who gave their lives fighting to change the course of history. The 9-11 Memorial is more like a cross and wreath placed beside a highway where someone died: it doesn't turn our thoughts reverently toward a past that was necessary for some to live through so that we today could have better lives, it turns our thoughts inward as a reminder of personal hurt and the pain of others. The 9-11 Memorial is like a wound that won't heal or a trauma that a person can't leave behind. In 100 years, the Gettysburg Memorial will remind our grandchildren that Americans died for freedom; in 100 years, the 9-11 Memorial will remind our grandchildren that people die senselessly because there is evil in the world. The fact that the pools and fountains are not ones in which children and parents can find delight and relief only reinforces the sense of loss, that the whole site is a monument to death and not to, as the Romans put it, agere.There are those who will say that the 9-11 Memorial commemorates our "unity" on that day. To them, I can say only that it is a sad day when our national monuments in DC are not our symbols of national unity, when people identify with helplessness but not with national aspirations. To a generation that needs to feel fear and anger together to recognize their nationhood, I say it is a sign of your decadence and dysfunction. A generation that scoffs at a "mission accomplished" sign but feels sublimity in empty loss is a sign of the times. In an age of terrorism, what should our cities be? Centers of art and commerce or a pock-marked moonscape of monuments to our enemies' success?Hermeneutic research on nursing narrativesIn the year following 9-11, researchers publishing in the Journal of the New York State Nurses Association conducted interviews with nurses about their experiences of working on that day. They analyzed the narratives using a Heideggerian Hermeneutic approach, looking for thematic commonalities across narratives. The results are interesting in themselves, and also highlight some of the critique of the 9-11 Memorial that I make above.From the findings section of the paper:Seventeen nurses, 2 males and 15 females, comprised the informants. The mean age was 47.7 years (s.d. = 8.4) with a range of 32-64. Ethnicity included 13 white, 2 black, 1 Native American and 1 Asian. Education of the participants included masters (9), baccalaureate (5), associate (2), and diploma (1). Specialty areas included emergency room (4), acute care (2), home care (1), administration (3), pediatric (3), psych/mental health (3), and nursing education (1). The nurses' roles in the disaster included triage (3), coordination (7), care giving and counseling (7). Six themes and one constitutive pattern emerged. The themes are: (a) loss of a symbol, regaining new meaning. (b) disaster without patients. (c) coordinating with and without organizations. (d) rediscovering the pride in nursing. (e) traumatic stress. (f) preparing for the future.In a more detailed explanation of these themes, their fundamental support of my interpretation of the 9-11 Memorial is given some support. One nurse said, "I usually see the towers ...I looked up 14 Street and there were no towers, absolutely no towers, and my body just shuddered, very fearfully," and another, "on my way home that night I would see the towers, and that night, - not seeing them there - still looking - maybe I am not looking in the right place... you can't believe they're not there ... disbelief ... stunned ... not being able to comprehend."Nurses experienced ongoing stress from the trauma of the day:Symptoms of post-traumatic stress were felt by many of the nurses. Some experienced nightmares and flashbacks of victims they cared for. Others described themselves as emotionally fragile and being able "to cry in a New York minute." One nurse has "a lot of pop-up fears that are triggered." Physical symptoms of stress, such as high blood pr... Read more »

Dickerson, Jezewski, Nelson-Tuttle, Shipkey, Wilk, . (2002) Nursing at Ground Zero: Experiences During and After September 11 Word Trade Center Attack. Journal of the New York State Nurses Association, 33(1), 26-33. info:/

  • June 19, 2011
  • 07:32 AM

2 liter bolus of fat: no hemodynamic changes

by CxLxMx in cxlxmxrx

I bring to your attention a case report of a patient who received an accidental overdose of 2 liters intravenous lipid infusion and apparently suffered no ill cardiac effects. That is, the patient received fat directly into the blood stream in a quantity equal to a family-sized bottle of soda and didn't have a "heart attack."Just as certain medications bind to proteins, which binding in the blood stream changes their availability to other tissues, certain medications have an affinity for lipids. This fact has been used as the basis for treating overdoses of these lipid-philic meds. In particular, some medications used for cardiac and cardiovascular disorders have been treated in this manner. For example, Dix et al (2011) report a case of lidocaine toxicity successfully treated with lipids.Although alternative theories of the lipid's beneficial effects exist, the favorite seems to be that lipids in the blood attract and sequester the toxic molecules. The dosing would be weight-based. Smolin (2010) reports a dosing of 1.5mL/kg bolus followed by 0.25mL/kg/min for 30-60 minutes. For a 220 lbs. man, this would be a 150mL bolus followed by 1500mL over 60 minutes.West et al (2010) report the case of a 71-year-old woman who overdosed on a calcium-channel blocker. The emergency room followed a protocol that prescribed she should get 400mL of lipid. However, the infusion pump was not turned off, and the patient received a total of 2000mL, or 5 times the recommended dosage. There was so much lipid in her blood that 22 hours after she got the lipids, the hospital could still not get enough blood out of her veins to run lab work properly. She went on to die from the calcium-channel blocker overdose, but West specifically mentions that the lipid overdose "caused no detectable acute adverse hemodynamic effects."I still hear nurses in the hospital, even in the ICU and cardiac units, talking about having their arteries "clogged" from eating a hamburger. In addition to being incorrect pathophysiology, we can now see that the amount of fat in your burger is not going to kill you.West, P., Mckeown, N., & Hendrickson, R. (2010). Iatrogenic lipid emulsion overdose in a case of amlodipine poisoning Clinical Toxicology, 48 (4), 393-396 DOI: 10.3109/15563651003670843Dix, S., Rosner, G., Nayar, M., Harris, J., Guglin, M., Winterfield, J., Xiong, Z., & Mudge, G. (2011). Intractable cardiac arrest due to lidocaine toxicity successfully resuscitated with lipid emulsion* Critical Care Medicine, 39 (4), 872-874 DOI: 10.1097/CCM.0b013e318208eddfSmollin, C. (2010). Toxicology: Pearls and Pitfalls in the Use of Antidotes Emergency Medicine Clinics of North America, 28 (1), 149-161 DOI: 10.1016/j.emc.2009.09.009... Read more »

Dix, S., Rosner, G., Nayar, M., Harris, J., Guglin, M., Winterfield, J., Xiong, Z., & Mudge, G. (2011) Intractable cardiac arrest due to lidocaine toxicity successfully resuscitated with lipid emulsion*. Critical Care Medicine, 39(4), 872-874. DOI: 10.1097/CCM.0b013e318208eddf  

Smollin, C. (2010) Toxicology: Pearls and Pitfalls in the Use of Antidotes. Emergency Medicine Clinics of North America, 28(1), 149-161. DOI: 10.1016/j.emc.2009.09.009  

  • March 14, 2011
  • 09:58 AM

Open letter to ANA on genetic testing

by CxLxMx in cxlxmxrx

In reporting on the recent March 8-9 meeting of the MCG Panel of the FDA's advisory committee, I find it problematic that I have no recording or minutes of the meeting. Of the five W's of reporting, I am missing the vital Who and hoW components. So, I was taken by surprise yesterday as I was working on my call to nursing organizations to submit comments to federal docket FDA-2011-N-006 in support of patients' rights to view their own genetic information. It turns out the American Nurses' Association has already weighed in on this matter by sending Ann Maradiegue of George Mason University to testify before the panel on March 8th. The ANA has endorsed her testimony, which is available in PDF format from reading Dr. Maradiegue's testimony, I was struck by how much she seems to stay "on message." It leads one to speculate that, as Dan Vorhaus and Daniel MacArthur have suggested, the outcome of the MCGP meeting was pretty much a forgone conclusion. For a fact-finding meeting, Dr. Maradiegue presents little transparency of the assumptions and reasoning underlying her testimony, while the research she presents tells us only that the industry is currently unregulated, which everyone knows. She presents no evidence in support of her implied preference for a "routed through a clinician" standard of regulation. The meeting, indeed, appears to have been an exercise in consensus-building rather than fact-finding.Speaking as a nurse, I cannot endorse or agree with Dr. Maradiegue's testimony. She and the ANA claim to speak for all nurses on this matter. She told the MCGP that, in her testimony, she would inform them "what the nursing profession’s perspective is on the regulation of genetic tests, including Direct to Consumer genetic testing." However, she did not. If she had, her talk would have included statistics on professional opinion research conducted by the ANA. Instead, she has simply reiterated the opinions of select members of the ANA leadership. As the ANA does not license nurses or count them all as members, this is not the "nursing profession's perspective".Therefore, I feel obliged to send Dr. Maradiegue and the ANA the following open letter critiqueing their statements and asking them to revise their position.Ann Maradiegue, PhDSchool of NursingGeorge Mason UniversityFairfax, Virginiaamaradie@gmu.eduDear Dr. Maradiegue:As a nurse, I would like you to know how strongly I disagree with your March 8 testimony for the FDA on direct-to-consumer genetic testing and encourage you and the ANA to submit new comments on federal docket FDA-2011-N-0066.In the coming era of cheap gene sequencing, access to and control of personal genomic data will--and should be--seen as a human right. Your testimony implied that health care professionals should be a protected category of Americans with an exclusive right to order and receive the results of genetic tests. As you must be aware, when whole genome sequencing becomes affordable in the near future, this standard of regulation must result in a denial of access to fundamental information about Americans' personal histories and relationships to our species and its development.Moreover, your implicit suggestion that health care providers' interpretive abilities keep patients safe is disingenuous in multiple ways. First, as Bloss, Schork, and Topol (2011) demonstrated, the available evidence shows no harm to consumers in DTC genetic testing. Second, as you well know, neither APNs nor MDs receive education that specially qualifies them to interpret genetic data. Third, your comments presuppose genetic testing in the context of acutely or chronically ill patients when the FDA is considering regulation of all genetic testing. Fourth, your comments present a false dichotomy between an unregulated industry and clinician control of access to genetic data when a range of regulatory rules are possible that would not restrict Americans' access to their own personal genomes.That genetic testing interpretation is complex and uncertain is due to the fact that genomewide profiling of the type offered in DTC testing is not diagnostic but reflective of risk, risk that is also found in lifestyle choices about exercise, substance use, and nutrition. In these other areas, knowledge of risk (and even advice about risk reduction) is openly available to patients without clinician intervention. Nurses should support a regulatory scheme that would promote testing accuracy but make information about genetic risks as available to Americans as information about lifestyle risks.Your testimony puts you and the ANA, in the words of former President Clinton, "on the wrong side of history." Rather than leading change and advancing health, your testimony promotes social and technological stagnation that will send innovative industries overseas. Rather than promoting patient rights, your testimony acts as a handmaiden to the American Medical Association's docket comments and their misguided guild mentality toward the future of medicine. This guild mentality is reflected in your call for federal funds to educate nurses about genetics when you could have easily called for federal funds to improve science education and increase public knowledge of genetics.I call on you to revise your position on DTC genetic testing. Your testimony's implicit support for the AMA's recommendation of a "routed through a clinician" regulatory standard can be undone by an explicit statement that this standard should be rejected. The FDA has re-opened its comment period for federal docket FDA-2011-N-0066. I encourage you and the ANA to submit comments in support of DTC regulation that would ensure the accuracy of consumer genetic tests while maintaining free and open access to their own genomes for all Americans.Thank you for your attention.Bloss, C., Schork, N., & Topol, E. (2011). Effect of Direct-to-Consumer Genomewide Profiling to Assess Disease Risk New England Journal of Medicine, 364 (6), 524-534 DOI: 10.1056/NEJMoa1011893... Read more »

  • May 8, 2009
  • 12:41 PM

"sane and rational": an approach to swine flu

by CxLxMx in cxlxmxrx

Despite the deaths, the swine flu has not been without its humorous side. For example, in Afghanistan, Kabul Zoo quarantined that nation's only pig. The pig was a gift from China, which has taken the slightly less humorous action of quarantining a number of visitors from the Americas. Where does public health wisdom lie?Writing in Virology Journal, William R. Gallagher of the Louisiana State University Health Sciences Center has reviewed the situation up to the current time and makes recommendations based on a skeptical view of the severity of the current outbreak but a healthy respect for the future of H1N1. The current form of the virus has more animal amino acid sequences than sequences from successfully pathogenic human strains. Nevertheless, the hemagglutinin sequence has shifted 27.2% from its 2008 cousin, and the neuraminidase has shifted 18.2%, leaving open the possibility that new rearrangements might incorporate more pathogenic human sequences along with these new H and N sequences to create a strain with greater pandemic potential.Gallagher takes the sensible positions that shutting public services because of a suspected case, having elected officials override considered public health judgements, or bringing political agendas into the situation are all counterproductive. While I agree in large part, I'm not sure I can accept his argument that there's no sense in a quarantine focused on specific nations due to the fact that the specific H and N sequences arose elsewhere. It's true that some people have made uninformed calls for border closings, but I think the accusatory finger of political agenda should fall on Gallagher as well. The theoretical possibility of a future spontaneous re-arrangement is not an equivalent threat to an existing, spreading re-arrangement, especially when it's not clear, by Gallagher's admission, whether the pandemic nature of the outbreak might have been supressed due to natural seasonal variations, only to expose itself again next season. In any case, the current best course of action would seem to be to start working on a vaccine for this strain for next season.Gallaher, W. (2009). Towards a sane and rational approach to management of Influenza H1N1 2009 Virology Journal, 6 (1) DOI: 10.1186/1743-422X-6-51... Read more »

  • April 19, 2009
  • 11:03 PM

Bum sugar, or why bad ideas persist

by CxLxMx in cxlxmxrx

A few weeks ago, one of my instructors was telling us about the treatments they used to perform in hospitals for ulcers, which included applying sugar and placing the ulcerated part of the patient under a heat lamp. (For those non-nursing types, current treatment is re-positioning patients to relieve the pressure that causes ulcers and prevents them from healing...)I don't know where the idea that putting sugar on an ulcerated rump would make it get better, but really that's not such an interesting question. Even today, there are all kinds of crazy ideas for therapy that crop up. Most of them simply die before reaching the trial stage. A much more interesting question is why nurses and doctors persisted in the idea that a sugary bum was health-promoting long after it must have been obvious to anyone and everyone that it didn't work.In large part, this is the same question that one would ask about traditional medicine in tribal or third-world societies. And Tanaka, Kendal, and Laland determined to answer that question.Writing in PLoS ONE, the researchers have created a mathematical model that seeks to demonstrate the primary factors that contribute to persistence of ineffective treatments throughout the world. Using what seems to be a Bandura-style social cognitive model, the researchers assume that learning is based on observation. Keeping this in mind, it stands to reason that treatments that are performed (or demonstrated) more often will create more learning. Since effective treatments end the conditions for their use, ineffective treatments will be performed more often, resulting in increased learning and greater persistance.The researchers have created a mathematical model that takes into account the factors that contribute to social learning. I'm not qualified to critique their model, but to the extent that I understand it, it makes sense. If you enjoy wading through math, you can read the Methods section of this article yourself.What's the relationship to nursing? If I understand this article properly, it is implying that the way to identify and end ineffective practices is simply to end practices that aren't supported by Evidence-Based research. As nurses, this is difficult to do in the face of medical staff who operate without evidentiary basis for their prescriptions. What IV fluid protocol is best for burn victims? No real consensus, but lots of definitive opinions. The role for hospital practice councils here would be to continue to push for reviews of the literature. On an individual basis, questioning protocols and calling for transparency in publishing the evidentiary basis for protocol adoption would be appropriate.Tanaka, M., Kendal, J., & Laland, K. (2009). From Traditional Medicine to Witchcraft: Why Medical Treatments Are Not Always Efficacious PLoS ONE, 4 (4) DOI: 10.1371/journal.pone.0005192... Read more »

  • March 3, 2009
  • 03:09 PM

Effects of night shift on metabolism

by CxLxMx in cxlxmxrx

Nursing is one of the professions that includes regular shift work. Traditionally, new nurses start off on the night shift and work their way to days as they increase in seniority and skill. In fact, on my floor, there are a number of nurses who work nights by preference. There are advantages that mainly involve different variations of not having management breathing down your neck. However, the night shift tends to be full of people who are overweight and look worn out. It isn't just my imagination, either. Research shows that night shift workers tend to have higher rates of chronic diseases, and now research published in the upcoming version of Proceedings of the National Academy of Sciences examines the metabolic changes that may underlie some of these chronic disease problems.Sheer et al. normalized subjects' sleep patterns over a two-week period and then forced them to live for seven days on a 28-hour-per-day schedule, which rotated them from complete synchronization of their sleep-wake cycle with their biological circadian cycle through complete de-synchronization back to synchronization. Different biometric measurements were taken througout the day. Results demonstrated that metabolic cycles did not follow the sleep-wake patterns, as demonstrated by this graph of leptin, showing how its levels were synchronized, then desynchronized and synchronized again.Results of other measurements such as epinephrine, norepinephrine, glucose, etc. demonstrated essentially stressful and adverse reactions to the shift work.Although my intuition from having worked nights for a while is that this research is pretty much on the money, there were a few possible problems. For example, subjects seem to have been sequestered from sunlight (so that they wouldn't know where in a 24-hour cycle they were), and they were given food rather than being allowed to eat what they wanted. Were they given tasks to perform during their "days"? It doesn't say. Most problematically, they weren't allowed to exercise. From what I can tell, the exercising night shift workers are able to deal with the stress of working night much more easily than the non-exercising workers.Of particular interest to me from the results was the fact that de-synchronized shifts created pre-diabetic states in 30% of the subjects, but not all of them. It would be interesting to follow night shift workers now and see if similar epidemiological results could be found by controlling for weight and eating habits.Anyhow, I think this report justifies the $1.25 per hour shift differential that I received on nights.F. A. J. L. Scheer, M. F. Hilton, C. S. Mantzoros, S. A. Shea (2009). Adverse metabolic and cardiovascular consequences of circadian misalignment Proceedings of the National Academy of Sciences DOI: 10.1073/pnas.0808180106... Read more »

F. A. J. L. Scheer, M. F. Hilton, C. S. Mantzoros, & S. A. Shea. (2009) Adverse metabolic and cardiovascular consequences of circadian misalignment. Proceedings of the National Academy of Sciences. DOI: 10.1073/pnas.0808180106  

  • February 24, 2009
  • 12:20 PM

Xigris : how does it work, really?

by CxLxMx in cxlxmxrx

Xigris, or "recombinant human activated Protein C," is an anticoagulant used to treat septic shock. How does Xigris work?What does Protein C do?Protein C is a key component of the body’s natural negative feedback loop for the coagulation cascade. The final steps in coagulation are the conversion of Prothrombin to Thrombin by Factor X and Factor V. Factor X is activated by Factor VIII.Thrombin produces Fibrin, which is the building block of blood clots, but it also activates Protein C (PC) by converting it to activated Protein C (aPC). Activated Protein C (aPC) is an enzyme that breaks down Factor V and Factor VIII. By breaking down these factors, Factor X is inhibited and Factors X and V are inhibited from producing Thrombin. Hence the negative feedback loop: as Factors V and VIII increase the production of Thrombin, Thrombin increases the production of aPC, which then decreases the production of Factors V and VIII.Figure: Coagulation cascade.How does this apply to septic shock?In inflammation, blood vessels are exposed to chemicals of inflammation like Interleukins (IL) and Tumor Necrosis Factor (TNF). Inflammation makes the blood vessels "leaky," which exposes the outside of the blood vessels to blood. (Normally, only the inside of the blood vessel is exposed to blood.)When the cells on the outside of blood vessels are exposed to blood, they release a chemical called Tissue Factor. Also, the cells on the inside of blood vessels release Tissue Factor if they are damaged by inflammation. Tissue Factor starts the coagulation cascade.Normally, the coagulation cascade started by Tissue Factor is kept in check by the Protein C negative feedback loop.However, in sepsis, the inflammation response occurs systemically in the body. Because it is occurring everywhere at the same time, Protein C begins to get used up. When there is no Protein C left, the coagulation cascade's negative feedback loop stops. Without the negative feedback loop, coagulation occurs systemically in the body, since the inflammation is systemic.Systemic coagulation causes micro-blood clots in the body's small blood vessels. These micro-clots can stop blood flow to some tissues, which causes systemic tissue damage and helps lead to multiple organ failure.By giving activated Protein C (aPC), we can artificially maintain the coagulation cascade's negative feedback loop, which helps prevent tissue damage from systemic micro-clots.Why don't we use warfarin to treat septic shock?Since warfarin (Coumadin) is a relatively cheap anti-coagulant, it would seem logical to use it instead of activated Protein C. However, because of warfarin's specific pharmacodynamics, it actually decreases the body's Protein C before its anti-coagulant effect starts. In patients with A-Fib or other relatively harmless conditions, a temporary decrease in Protein C has no ill effects. However, it could be dangerous in patients with septic shock.Why don't we use heparin to treat septic shock?Since heparin is a relatively cheap anti-coagulant, it would seem logical to use it, too, instead of activated Protein C. However, think back to the coagulation cascade for a moment. Remember that there is an "extrinsic pathway" and an "intrinsic pathway" that lead to coagulation. What do these terms extrinsic and intrinsic mean?Essentially, the intrinsic pathway is coagulation that is started due to conditions intrinsic to the body. Think of an MI. The blood clotting that leads to an MI is started by the body's response to the conditions of its blood vessels.On the other hand, the extrinsic pathway is coagulation that is started due to conditions outside, foreign, or extrinsic to the body. Think of a cut. The blood clotting that is produced by a cut occurs when trauma damages blood vessels."Heparin" is actually a collection of different molecules that work on different parts of the coagulation cascade. Some heparin molecules work on the common pathway, but the others work on the intrinsic pathway, although coagulation that occurs due to septic shock is through the extrinsic pathway.(In fact, research on whether heparin could help in sepsis is unclear. Because many patients are already receiving heparin for DVT prophylaxis, it is hard to create a robust trial of heparin for sepsis treatment. It does appear that it is safe to give Xigris and heparin together.)Does activated Protein C do anything else?Besides its role in the coagulation cascade's negative feedback loop, activated Protein C also inhibits some Interleukins, which helps to decrease the systemic inflammation occurring during shock. Both the body's natural aPC and Xigris have this property. And they both also inhibit the body's PAI-1, a chemical that helps to stop blood clots from breaking up. (That's an inhibitor of an inhibitor--i.e., aPC essentially increases the body's natural tPA.)Does Xigris treat anything else besides septic shock?Choi et al. (2007) tried to determine whether Xigris would be effective in a single-organ treatment. Citing research showing Xigris was especially effective in the treatment of sepsis occurring from pneumonia, they tried to determine whether Xigris would have a protective effect for the lung in treating ventilator-associated pneumonia. Taking samples from several human patients, they inoculated rats with P. aeruginosa and then treated them with either aPC, tPA, or heparin and had a control group treated with saline.Interestingly, the results indicated that while Xigris had an anti-coagulant effect, it did not have the anti-inflammatory effect described above, as measured by neutrophil density in the lung tissue. As the authors indicate, this rat model of pneumonia cannot determine effects in people either for pneumonia or for sepsis. However, citing evidence that anti-inflammatories and anti-coagulants failed to improve mortality in sepsis, the authors imply the mechanisms by which Xigris actually works (as I have described above) may not actually explain its efficacy in improving outcomes.How is Xigris made?Mammalian cells are genetically modified to produce Protein C. They are then grown in lab cultures. The cells excrete the Protein C (PC) into the cultures, where the culture medium converts it to activated Protein C (aPC). The activated Protein C is then purified from the culture medium. Therefore the name "recombinant [i.e., genetic recombination] human activated Protein C," or rhAPC.MDConsult article on Xigris. Retrieved February 23, 2009, from article on pathogenesis of septic shock. Retrieved February 23, 2009, from (2009). Wikipedia. Retrieved February 24, 2009, from C. (2008). Wikipedia. Retrieved February 24, 2009, from Choi, Jorrit-Jan H. Hofstra, Joris J. T. H. Roelofs, Sandrine Florquin, Paul Bresser, Marcel Levi, Tom van der Poll, Marcus J. Schultz (2007). Recombinant human activated protein C inhibits local and systemic activation of coagulation without influencing inflammation during Pseudomonas aeruginosa pneumonia in rats Critical Care Medicine, 35 (5), 1362-1368 DOI: 10.1097/01.CCM.0000261888.32654.6DM. Levi, M. Levy, M. D. Williams, I. Douglas, A. Artigas, M. Antonelli, D. Wyncoll, J. Janes, F. V. Booth, D. Wang, D. P. Sundin, W. L. Macias (2007). Prophylactic Heparin in Patients with Severe Sepsis Treated with Drotrecogin Alfa (Activated) American Journal of Respiratory and Critical Care Medicine, 176 (5), 483-490 DOI: 10.1164/rccm.200612-1803OCFabián Jaimes, Gisela De La Rosa, Clara Arango, Fernando Fortich, Carlos Morales, Daniel Aguirre, Pablo Patiño (2006). A randomized clinical trial of unfractioned heparin for treatment of sepsis (the HETRASE study): design and rationale [NCT00100308] Trials, 7 (1) DOI: 10.1186/1745-6215-7-19Marcel Levi, Tom van der Poll (2004). Coagulation in sepsis: all bugs bite equally Critical Care, 8 (2) DOI: 10.1186/cc2816Warfarin necrosis. (2009). Wikipedia. Retrieved February 24, 2009, from Read more »

  • February 10, 2009
  • 06:42 AM

Comin' to America: Marburg Hemorrhagic Fever

by CxLxMx in cxlxmxrx

I like this understated headline from the RockyMountainNews: "Rare Marburg hemorrhagic fever shows up in Denver". Well, golly gee! Of all the fevers you don't want to just show up on your doorstep, Marburg hemorrhagic is one of the rarest. In fact, this is the first reported case in the United States. The CDC's Dr. Pierre Rollin (seen here and here doing field work in Africa... and by the way, you don't expect the first search hit for an infectious disease doctor to be IMDB...) says the patient recovered fully. Apparently, the case was unconfirmed until just days ago (my guess is that since the incubation period isn't longer than two weeks, the CDC was waiting to make sure the infection was contained before making an announcement).Maramagambo Python CaveThe AP article says the unidentified patient had been visiting the "python cave" of Maramagambo Forest in Uganda and had come in contact with fruits bats. If you have any interest in hemorrhagic fevers, you will recognize that fruit bats are also the reservoir for Ebola, Marburg's cousin in the Filoviridae family, and the cave connection has been a feature of pop virology since at least The Hot Zone, which featured Kitum Cave. So why is it called the python cave, anyway?Flickr user Simian, a resident of The Netherlands, visited the cave several years ago and has posted some great photos in his bat cave set. He writes that "the noise and smell in the cave were overpowering, as was the sight of thousands of [bats] whirling about, and to top it all off there were two huge African Rock Pythons and a Black Forest Cobra in there snacking on the occasional unlucky bat."[click to enlarge]Unlucky bat, but stupid people! Actually, it's hard to imagine, but the photos in Simian's set were potentially taken within a few feet of a virus that could kill thousands or millions of people throughout America or Europe. In fact, the international community recognized this, and Uganda closed down tourism to the python cave after another tourist from The Netherlands brought Marburg back to Europe and died last summer.Lutheran Medical CenterThe patient was cared for at Lutheran Medical Center in Wheat Ridge, CO, a 400-bed hospital employing about 500 Registered Nurses and 5 Nurse Practitioners. As part of a protocol for an unknown infection, they followed standard contact precautions, including gowns and gloves. I was just thinking that at my hospital "standard precautions" really just means gloves and actually gloves only when making certain types of patient contact. Maybe this patient's symptoms were such that they took more precautions with him. The CDC has posted guidelines for US health care workers dealing with viral hemorrhagic fevers and linked to it from their Marburg page.A 2003 study in Emerging Infectious Diseases could identify only two risk factors for contracting Marburg. One was working as a miner and the other was receiving an injection. So, as long as a nurse doesn't have a needle-stick incident, contraction probably isn't too big a worry. In fact, of the all health care workers who were enrolled in the study, none had antibodies for Marburg: "Types of patient contact included administering injections (38%); cleaning up blood, vomitus, urine, or feces (28%); washing bed clothes (7%); washing corpses (6%); and receiving a needlestick injury (2%)."VSV-G vaccines and tetherinBut what if you were a nurse who had a needle-stick incident? Well, right now you'd be screwed, I think. But maybe in the near future, there will be a prophylactic. Feldmann et al. (2007), working with the related Ebola virus, were able to protect monkeys from lethal doses of virus by using a post-exposure dose of vaccine created by integrating an Ebola glycoprotein into a vesicular stomatitis virus: "treatment is particularly suited for use in accidentally exposed individuals and in the control of secondary transmission during naturally occurring outbreaks or deliberate releases." And although Feldmann et al. were working with Ebola, Daddario-DiCaprio et al. (2006) produced a similar experiment using the Marburg glycoprotein. This 2006 study looked at the efficacy of this antigenic delivery method as a preventive vaccine, but since the 2007 study uses the same essential methodology in a post-exposure context, it seems highly likely that a post-exposure treatment for Marburg could be created as well.An emerging treatment option that has just been published in February and March issues of Journal of Virology involves the use of tetherin (formerly CD317), a cellular component that keeps new virions from detaching from infected cells. (See some great photos of budding Ebola virus at PLoS Pathogens.) Two teams (Sakuma et al & Jouvenet et al) found that tetherin has specific action on a spectrum of viruses including Marburg. However, Vincent Racaniello over at virology blog recently blogged a PNAS article showing that Ebola glycoprotein inhibits tetherin activity on the cell surface.The announcement of this whole Marburg episode occurs just shortly after a Filipino man contracted Ebola from pigs...Bausch DG, Borchert M, Grein T, Roth C, Swanepoel R, Libande ML, et al. (2003). Risk Factors for Marburg Hemorrhagic Fever, Democratic Republic of the Congo Emerging Infectious Diseases, 9 (12)K. M. Daddario-DiCaprio (2006). Cross-Protection against Marburg Virus Strains by Using a Live, Attenuated Recombinant Vaccine Journal of Virology, 80 (19), 9659-9666 DOI: 10.1128/JVI.00959-06Heinz Feldmann, Steven M. Jones, Kathleen M. Daddario-DiCaprio, Joan B. Geisbert, Ute Ströher, Allen Grolla, Mike Bray, Elizabeth A. Fritz, Lisa Fernando, Friederike Feldmann, Lisa E. Hensley, Thomas W. Geisbert (2007). Effective Post-Exposure Treatment of Ebola Infection PLoS Pathogens, 3 (1) DOI: 10.1371/journal.ppat.0030002N. Jouvenet, S. J. D. Neil, M. Zhadina, T. Zang, Z. Kratovac, Y. Lee, M. McNatt, T. Hatziioannou, P. D. Bieniasz (2008). Broad-Spectrum Inhibition of Retroviral and Filoviral Particle Release by Tetherin Journal of Virology, 83 (4), 1837-1844 DOI: 10.1128/JVI.02211-08T. Sakuma, T. Noda, S. Urata, Y. Kawaoka, J. Yasuda (2008). Inhibition of Lassa and Marburg Virus Production by Tetherin Journal of Virology, 83 (5), 2382-2385 DOI: 10.1128/JVI.01607-08... Read more »

Heinz Feldmann, Steven M. Jones, Kathleen M. Daddario-DiCaprio, Joan B. Geisbert, Ute Ströher, Allen Grolla, Mike Bray, Elizabeth A. Fritz, Lisa Fernando, Friederike Feldmann.... (2007) Effective Post-Exposure Treatment of Ebola Infection. PLoS Pathogens, 3(1). DOI: 10.1371/journal.ppat.0030002  

N. Jouvenet, S. J. D. Neil, M. Zhadina, T. Zang, Z. Kratovac, Y. Lee, M. McNatt, T. Hatziioannou, & P. D. Bieniasz. (2008) Broad-Spectrum Inhibition of Retroviral and Filoviral Particle Release by Tetherin. Journal of Virology, 83(4), 1837-1844. DOI: 10.1128/JVI.02211-08  

T. Sakuma, T. Noda, S. Urata, Y. Kawaoka, & J. Yasuda. (2008) Inhibition of Lassa and Marburg Virus Production by Tetherin. Journal of Virology, 83(5), 2382-2385. DOI: 10.1128/JVI.01607-08  

  • January 29, 2009
  • 05:58 PM

Genotype linked to longer ICU admission

by CxLxMx in cxlxmxrx

This article is still only in a provisional state, and there isn't much in it to relate to nursing practice, but I thought it was fascinating as an example of the type of issue health care, hospital administration, and the nursing professional are going to be faced with in the near future.Researchers have discovered that patients with two T alleles at 9545 in the gene that codes for Interleukin 18 have higher levels of TNF-alpha and stay in the ICU longer after cardiac surgery.Because of the whole diagnostic-related groups payment scheme, it would be interesting to know if hospitals are eating more costs for these patients' longer stays. If that turns out to be the case, can the situation be solved pharmacologically or will these patients be in danger of being rejected for cardiac surgeries?I wonder if there will be genetic predispositions to the big nosocomial infections (foley-related UTI, ventilator-associated pneumonia, and central line blood infections) discovered as well? As these account for large health care costs, will insurance companies be forced to pay more for admitting these patients to ICU due to the increased risk the ICU takes on? Or will these people just be bumped from insurance, or what?David M Shaw, Ainsley M Sutherland, James A Russell, Samuel V Lichtenstein, Keith R Walley (2009). Novel polymorphism of interleukin-18 associated with greater inflammation after cardiac surgery Critical Care, 13 (1) DOI: 10.1186/cc7698... Read more »

David M Shaw, Ainsley M Sutherland, James A Russell, Samuel V Lichtenstein, & Keith R Walley. (2009) Novel polymorphism of interleukin-18 associated with greater inflammation after cardiac surgery. Critical Care, 13(1). DOI: 10.1186/cc7698  

  • December 29, 2008
  • 01:09 AM

Thought & Action: multitasking, the civil class, and the scholarly voice

by CxLxMx in cxlxmxrx

2008 is drawing to a close, but not before I could read the autumn'08 issue of Thought & Action, the National Education Association's journal of higher education. This issue contains three articles related to technology (or at least modern life) and education. Although they're not presented as such, all three seem related to me.You Say Multitasking Like It's a Good ThingIn the first article1, Professor Charles J. Abaté reviews with a skeptical eye the issue of "multitasking." He identifies three myths related to multitasking that he refutes with evidence from psychology: (1) multitasking saves time, (2) learning while multitasking is as good as learning while single tasking, and (3) the young have an advantage at multitasking. At least the first two clearly have something to say to nursing and nursing education.Sources that I don't have time to re-find and cite here have suggested that multitasking is a skill at which women excel (or at least are better at than men) and is a professional characteristic of nursing. As Abaté suggests, this is likely not true. What's more, the suggestion that multitasking is a skill rather than a necessary evil of nursing changes the terms of the issue in a way that is likely not good for patients. The necessity for mutlitasking is something that should be reduced or rooted out systemically at the health institution level, not something that students should be indoctrinated with at the educational level. For example, at my hospital, those on the 7pm-7am shift have to do shift assessments at 7pm and again at 11pm. Charting is something that is necessarily done in snatches of time here and there. Since multitasking nurses are not actually saving time, it's an efficiency reducer and administrators should seek to reduce its incidence.Multitasking indoctrination occurs in nursing school mostly in relation to clinicals. I have often thought that the idea of learning medications by researching patients is a bad idea, and Abaté seems to agree with me. My personal thoughts on patient research and learning medications (and lab values, pathophys, etc) have had more to do with the half-life of information and repeated sustained study, but the multitasking issue adds its own dimension--learning while multitasking does not support analytical thinking. Abaté's evidence here is a study from the 2006 Proceedings of the National Academy of Sciences. It's an interesting study with regard to the clinical learning design of nursing school and something I'll return to in a future post.The Civil Classroom in the Age of the 'NetIn the second article2, Professor P.M. Forni addresses the problems educators face with kids these days. Just at the end of this last semester, one of the faculty at my school was describing to me how the graduating class below mine complains that all the requirements imposed on them are too stringent and should be reduced. While I have a lot of complaints of my own about nursing school, I have simpathy with things like the required 73 test average for passing and penalties for absence and tardiness. The way students act these days is preposterous, although to try to be fair, I often also feel the anxiety and anger that they seem to feel free to express. Forni makes several suggestions with, in my opinion, mixed usefulness:Establish a climate of relaxed formality. Control in nursing education is a problem, but formality is not control. Nursing is quite different from other undergraduate programs in the degree of time spent together, whether students all taking the same courses or faculty spending hours at a time with students multiple days per week. The authority gap can disappear, and establishing formalized boundaries can help with this. Also, as an instructor, informality leaves you open to manipulation. If you need to be called by your first name to feel younger, a little bastard can start calling you Mrs. X to tear you down a little. I did that.Train students to distinguish the trivial from the valuable. Forni suggests that the web-based equality of valuable and trivial material means each course should start from the philosophical perspective of why we are engaged in this study and, having established value, show students how to differentiate good and bad web sources.Sell your product and yourself. Forni distinguishes the cultures of knowledge retention and knowledge retrieval. This is actually a really big deal, and I confess to being one of the "bad" students in this regard. I depend on lab values and medication information being available at my fingertips. Forni makes the point that knowledge retention is necessary for future learning. In order to make analytical connections, you have to actually remember. I agree.However, Forni fails to note that this point does not solve the problem of why the student has to sit in a class. Retained knowledge can be tested remotely and gleaned from books and the web without classroom attendance. What is the professor's role? Forni doesn't say exactly.Let's face it. The modern education system was designed in a time when knowledge was passed from person to person. That time is passed. Either professors bring something extra to the classroom or they are obsolete. Bad professors bring props and humor. Good professors bring illustrative anecdotes and try to identify the areas where these specific students are having trouble.Stipulate a fair covenant. I think this suggestion is rather poor. I had a nursing professor who did this and then felt she couldn't make a change in the syllabus that both she and the class wanted--duh!A mixed bag for the road. Here, Forni implies that instructors should seek to diminish the digital divide between themselves and students. I have mixed feelings about this. It's all right as long as two things are kept in mind: (a) making things fancy won't cut it and (b) web-based material still needs to be structured. Filling up PowerPoints with nice backgrounds and ClipArt is not learning how to use PowerPoint effectively. Putting up an extranet site for a course that's full of broken links and files too large to view quickly is taking a step back, not forward.More on civility from Forni at Johns Hopkins website.Scholarly Voice and Professional Identity in the Internet AgeProfessor Douglas Harrison [LinkedIn] teaches English and also blogs on Southern gospel music. In the third article3, he addresses working in "mixed modes" on his blog (posting things with an academic, critical voice and also trivial and personal things) and suggests that academic blogging should no longer be seen as something to undermine a professional academic career. The points here about niche audiences, forming new intellectual communities, and personal enrichment will be familiar to those who have used the Interwebs since about 2000. The one thing that really strikes me, though, is the reference to an academic who says blogging takes up more of the time he used to spend watching TV and reading mystery novels. Spending all one's time thinking about one's academic field does not strike me as a good thing.Charles Abaté (2008). You say multitasking like it's a good thing. Thought & Action, 24, 7-15P.M. Forni (2008). The civil classroom in the age of the Net. Thought & Action, 24, 15-22D. Harrison (2008). Scholarly oice and professional identity in the Internet age. Thought & Action, 24, 23-34... Read more »

Charles Abaté. (2008) You say multitasking like it's a good thing. Thought , 7-15.

P.M. Forni. (2008) The civil classroom in the age of the Net. Thought , 15-22.

  • November 25, 2008
  • 12:00 AM

Fibers in the skin, but still no Morgellons explanation

by CxLxMx in cxlxmxrx

Morgellons disease is characterized by skin lesions that contain fibers of unknown origin. Morgellons is often dismissed as delusional parasitosis or Munchausen's syndrome by proxy (now boringly re-named FII, fabricated or induced illness), although the fibers represent an objective finding and their origin is contested if not unknown. Critics insist the fibers are placed or at least synthetic in origin (fabric-induced illness?), while proponents of the disease point to a number possible origins such as production by the Argobacterium or some fungus.In a provisionally-published paper by Almarestani, Longo, and Ribeiro-da-Silva, chronic inflammation was shown to induce the growth of sympathetic nervous system fibers in the dermis. The researchers injected complete Freund's adjuvant into the paws of rats and subsequently stained tissues after several weeks. Nerves were shown to change typical innervation of the lower dermis to innervation of the upper dermis as well.Of course, nerve fibers don't really correspond to the fibers present in Morgellons as the images in the PDF demonstrate. My best guess is that Morgellons represents a few legitimate unrelated cases of pathology of unknown origin combined with a lot of DP and FII. It would be interesting, though, to discover a real pathological process at work in Morgellons.Lina Almarestani, Geraldine Longo, Alfredo Ribeiro-da-Silva (2008). Autonomic fiber sprouting in the skin in chronic inflammation Molecular Pain, 4 (1) DOI: 10.1186/1744-8069-4-56... Read more »

Lina Almarestani, Geraldine Longo, & Alfredo Ribeiro-da-Silva. (2008) Autonomic fiber sprouting in the skin in chronic inflammation. Molecular Pain, 4(1), 56. DOI: 10.1186/1744-8069-4-56  

  • October 14, 2008
  • 05:38 AM

Happy Open Access Day !

by CxLxMx in cxlxmxrx

Today, October 14, is the first Open Access Day--a day devoted to broadening awareness and understanding of free and available information. Open Access Day is a joint venture of the Public Library of Science (PLoS), the Scholarly Publishing and Academic Resources Coalition and Students for Free Culture. In response to the call for synchroblogging, I've decided to direct some attention to the issue of open access in nursing.Although nursing research is promoted in BSN programs and as an ingredient of professionalism, the relationship that research holds to nursing is not the same as the relationship that research holds to medicine or the biological sciences. I think the difference can be seen through the quintessential nursing research project--hand washing. Although much "sexier" and really more complex research has been done in nursing, hand washing is still taught as a model of what nursing research is--a test of and guide for best practice in the clinical setting. Although you might think that the same is true for medicine, it really isn't. A brief perusal of an (open access!) medical journal like PLoS Medicine will reveal that medical research is closely tied to biological research. (Hence, the sometimes-used moniker "biomedical" research.) At first blush, this might seem like a silly truism, but see what it means:Medical vs. nusing researchCase-based: As we can learn from Foucault, the medical gaze can use the patient as opportunity to isolate pathogenesis. This approach to the patient is totally inimical to the perspective of nursing, and it is no accident that case-based literature is almost absent in nursing publications. In fact, when I asked a question about case-based literature in my Nur427 Nursing Research course, the instructor was momentarily flummoxed in trying to place it in the literature spectrum.Inquisitive: Although you have your occasional Grey's Anatomy doctors, for the most part, students that go into medicine are the geeky kids who spend their time in the bio lab, while students who go into nursing are very average if hard-working. This is reflected in the professional literature by the ongoing interest of medical doctors in knowledge for its own sake.Exploratory: Building on inquisitiveness, the core of biological and biomedical research is exploratory research. Although undergrad students are taught the hypothesis-confirmation method of research, the reality is different. As we discussed in Bio416 Virology, sometimes papers are constructed backwards--researchers perform some experiments out of curiosity and then try to make a paper out of them by tying them together with a plausible hypothesis. There really isn't exploratory research of this kind in nursing.Systems-oriented: Science is constantly trying to make facts like symptoms fit into models. Nursing doesn't really care about models. This is the flip-side of case investigation avoidance. Cases and models both make patients into biological objects. Nursing research stays focused on improving the clinical milieu and nurses' posture. This comparison is a little over-generalized, but not completely.These characteristics of biomedical research are ones that make open access sensible and important for it. Cases and exploratory research reveal occult characteristics that can lie dormant inside inaccessible journals. Free and disseminated information can provide just the right clues to help researchers put the final pieces in a puzzle.Nursing research is also useless when not accessible, but timliness and particularity are less important. So, the researcher-to-researcher sharing that can come from open access and confer advantages in biomedicine is less relevant to nursing. Instead, open access relates to nursing mostly vis-a-vis three other avenues: (1) integrated self-care, (2) information access in the clinical milieu, and (3) education.Integrated self-careAlthough most synchrobloggers will probably be focusing on the access of synthesizers to research on Open Access Day, we should note that the access issue can be generalized to users and knowledge. The financial resistance to open access in the publishing world can also be generalized to financial resistance in the broader world. Knowledge is not only a commodity in its own right, it's also leverage for decision-making.Electronic Medical Records (EMRs) are often addressed as a benefit to healthcare professionals, especially doctors, and as a benefit to patients secondary to the increases in efficiency and portability that will assist professionals. However, as Gladwin points out in the June 2007 Nursing Times, giving patients access to their own medical records can improve their care as well. An opinion piece in a 2007 Hospital Home Health titled "...continuation of care not just end of the road: open access could help patients avoid 'terrible choice'" suggests how: open access EMRs could act as loci for patients to re-visit and conceptualize their own care as a continuum across the life span.Currently, hospitals and primary care offices act as gatekeepers for patients' medical information. In my local hospital, there's bureaucratic process, though no charge, for seeing one's own medical records, but there is a photocopy charge for taking one's own medical records out from the hospital. This combination of restricted access and copy charge models the access issues of the publishing world.Can it be changed? This question is also asked by Detmer et al. in a paper awaiting publication this month in the open access journal BMC Medical Informatics and Decision Making. They describe several different models for Personal Health Records, but a common theme is the use of technologies. Just as technology has facilitated open access publishing, it can facilitate open access medical records as well. We have seen this already in Google's free Google Health app. But if we are to move toward RFID or other bio-integrated formats, the open source movement will become a necessary ingredient in open access. Proprietary storage and reading formats must not be allowed to predominate in the field of EMRs.Access in the milieuMy hospital's made great strides in having the Internet available to all nurses through a proliferation of computers at nurses' stations and, now, in rooms and through Computers On Wheels (COWs). Nurses have "ready access" to some clinical information via the MDConsult database. However, this access is paid for by patients and taxpayers, and, in one instance, was disabled by a problem with the hospital's MDConsult account. It is not a true open access system. Moreover, MDConsult is what it says it is--a system geared toward doctors. Where is our RNConsult database to provide up-to-date clinical information specific to nursing or allied health?My experience is echoed by the nurses in a qualitative study by Tod et al. (2003), who explored nurses' use of the Internet on a clinical ward. Here are some of the participant comments:I use it more for non-work as I started getting disappointed with there not being much stuff around on practice...Somehow I don't see how all these so-called models or theories of nursing are going to help... that's one thing I've learnt in this project, don't go to nursing databases, go to Medline or Google.Morris-Docker et al. (2004) found that use of Internet-based resources was dependent on nurses' capabilities--on their inherent capacity with searches but also the access they were granted in the work place.More recently, Estabrooks et al. (2008) looked at the organizational context for the clinical application of research at the level of the nursing unit. Besides the predilection of the unit nurses to use research, the next biggest factor was organizational support of research use, such as the authority to integrate findings into care.These three studies point out issues of access in the use of research by nurses in the clinical milieu. Access is dependent on some factors that are inherent in users, and usability also interacts with access at the level of control. However, all use is fundamentally based on de facto and de jure access to information--availability and freedom, the core tenets of open access. Access in the clinical milieu must include the time and physical resources to use the Internet but also useful information must available to nurses when they go online. Clinical practice guidelines like the AACN's Procedure Manual for Critical Care should no longer reside behind walls of price and print.Nursing educationAnyone in nursing school today or who has graduated recently will probably be familiar with the HESI preparatory exam and integrated textbook websites such as Elsevier's eVolve sites. Digital resources such as university extranets are spreading in popularity, but their use is limited by the imagination of nursing instructors. In my own school, nursing students are forced to communicate and download instructions and lecture notes through the college's ANGEL system, but access to resources inside the system is limited and access to resources outside the system is discouraged. Gibbon (2006) found similar disposition when reviewing literature for an article on the UK's open access SONIC system: "Reproducing lecturers' notes can be meaningless... Savin-Baden (2003) acknowledges that some resources that are used for web-based education do not enhance PBL, such as the provision of lecturer notes online."Perhaps this failure on the part of instructors is a result of the generational gap. Floor nurses in my hospital resist every technological innovation for difficulty in adaptation, and Cole and Brunk (1999) identified unease with computer education as an impediment to obtaining advanced nursing degrees.The under-usage of the Internet's ability to disseminate free information in nursing education is partly the fault of nursing faculty, but there is also a large component of publisher manipulation. The NIH already provides a large number of free medical texts online--but online nursing textbooks and educational resources remain behind pay walls. And, as I have noted previously on this blog, rather than moving toward open access models, textbook publishers are trying hard to create systems that lock students into continuing to make purchases (such as the bundling of books with online passwords) and that seduce faculty into using proprietary websites (such as providing online assessment services with protected educational material).There is simply no excuse for nursing students to be spending hundreds of dollars on disposable nursing textbooks anymore. Textbooks are not pieces of literature that are enhanced by the ability to become physically connected with the printed material. Textbooks are only repositories and are subject to rapid change. The failure of the nursing educational system to move toward open access models of educational materials is wasteful and keeps students behind the information envelope unnecessarily.Nursing cultureNursing culture is a mixed bag. On the one hand, threatened, mean, controlling nurses and nursing instructors are common and characteristic enough that almost any nurse can recognize sayings like "the instructor is always right" and "nurses eat their young." On the other hand, nursing is also full of progressives and pseudo-hippies who will believe in the benefit of almost any intervention. In actuality, both these types are threats to improved patient care because both refuse to recognize the objective superiority of evidence-based care.Of course, there are exceptions (Brennan, Ripich, and Moore (1991) were using a "free, public-access computer network" to develop their own computer-based home-care system back before "the Interwebs" became popular), but for the most part, nursing needs to be lead and is most comfortable when it has a institution impetous for change. The current model for this observation is Keeping Patients Safe. Rather than a grass-roots effort at improving conditions in individual hospitals, this is a top-down program from the Institute of Medicine (IOM).So, what about open access? Open access publishing is currently flying under the radar in nursing. In a CINAHL database search, the most comprehensive treatment was an essentially informational article describing what open access is (Schloman, 2007). Position statements and comments from publishers were found in a few journals, but for the most part open access publishing has not been discussed within the literature.Of current journals, one can count the number of serious attempts at open access publishing on the fingers of one hand:BMC Nursing: Published by Biomed Central, this is one of only a few usable open access nursing journals affiliated with a serious publisher.Online Journal of Issues in Nursing: Published by the ANA, this journal has good content, but the interface makes it difficult to use.Online Journal of Rural Nursing and Health Care: Published by the University of Alabama.Topics in Advanced Practice Nursing: Medscape publishes this journal and makes it available online along with selections from a number of other journals.The Directory of Open Access Journals lists 25 nursing journals, most of which are in Spanish and some of which do not contain the degree of publishing standards needed for them to be taken seriously.Creating open access cultureAlthough BMC has a good service going, I generally regard PLoS as the flagship of open access academic and research publishing. (At one point a year or so ago, I even e-mailed PLoS to find out if they were going to expand into general health fields, but the editor who wrote back said they were planning to stick to biological sciences.) So, it seems appropriate that the Policy Forum column in PLoS Medicine should address the promotion of open access publishing in academia and health care.Piwowar et al. (2008) recommend that Academic Health Centers take a lead role in promoting open access publishing. They recommend an institution-wide approach to help change the culture of AHCs to embrace open access. Recommendations include formally committing to opening access to data, funding the infrastructure and human resources needed, rallying AHC members through recognition and education, and developing the community by working on standards and social networking.In nursing, Casida and Pinto-Zipp (2008) identified a strong correlation between organizational cultural change and transformational leadership behaviors by nurse managers. These behaviors are in many ways similar to the recommendations of Piwowar et al. for AHCs.The time is right for nursing leaders to make a push to create a culture of open access for nursing as well. Just as the importance of open access to nursing is different from its importance to biomedicine, the open access culture needed in nursing is different from the open access culture needed in biomedical research. Nursing needs to shrug off some of its heavily authority-oriented cultural baggage.Nurses need education in basic economics and principles of software development to understand how open access can impact patient consumption of health care.The infrastructure and intellectual resources necessary to utilize research should be supported by health care institutions, including ongoing education.Nursing educators should disentangle themselves from the large publishing houses and start teaching more from primary literature, review papers, and reliable online resources.Most importantly, nursing leaders in practice and instruction at all levels of institutions should avoid squelching dissent and support independent initiatives to improve the dissemination and application of research. Inspiring and engaging leadership practices are proven to have an impact in changing the cultural in health care.Gladwin, J. (2007) Opinion: Giving patients open access to medical records would help nurses improve care. Nursing Times, 103(25), 14. Abstract retrieved from CINAHL database.n.a. (2007) Hospice as continuation of care not just end of the road: open access could help patients avoid 'terrible choice'. Hospital Home Health, 24(6), 66-68. Abstract retrieved from CINAHL database.Don E. Detmer, Meryl Bloomrosen, Brian Raymond, Paul Tang (2008). Integrated personal health records: Transformative tools for consumer-centric care BMC Medical Informatics and Decision Making, 8 (1) DOI: 10.1186/1472-6947-8-45Tod AM, Harrison J, Docker SM, Black R, & Wolstenholme D. (2003) Information technology. Access to the internet in an acute care area: experiences of nurses. British Journal of Nursing, 12(7), 425-434.Morris-Docker SB, Tod A, Harrison JM, Wolstenholme D, & Black R. (2004) Nurses' use of the Internet in clinical ward settings. Journal of Advanced Nursing, 48(2), 157-166.Carole A Estabrooks, Shannon Scott, Janet E Squires, Bonnie Stevens, Linda O'Brien-Pallas, Judy Watt-Watson, Joanne Profetto-McGrath, Kathy McGilton, Karen Golden-Biddle, Janice Lander, Gail Donner, Geertje Boschma, Charles K Humphrey, Jack Williams (2008). Patterns of research utilization on patient care units Implementation Science, 3 (1) DOI: 10.1186/1748-5908-3-31Gibbon C. (2006) Enhancing clinical practice through the use of electronic resources. Nursing Standard, 20(22):, 41-46.Cole BH & Brunk Q. (1999) Six rules for computers and other stumbling blocks to obtaining an advanced degree. Journal of Continuing Education in Nursing, 30(2), 66-70.Brennan PF, Ripich S, & Moore SM. (1991) The use of home-based computers to support persons living with AIDS/ARC. Journal of Community Health Nursing, 8(1), 3-14.n.a. (2004) American Nurses Association commends House Patient Safety Bill aimed at open access to information on nurse staffing practices. Nevada RNformation, 13(4), 11.Schloman, B. (2007). Open access: The dust hasn’t settled yet. Online Journal of Issues in Nursing, 12 (1)Baggs JG. (2006) Open access. Research in Nursing & Health, 29(1), 1-2.Paquette M. (2005) The public-access movement. Perspectives in Psychiatric Care, 41(2), 49-50.Harington R. (2005) Commentary on the public-access movement. Perspectives in Psychiatric Care, 41(3), 97-98.Lawson L. (2006) Research dissemination, open access, and the cost of doing business. Journal of Forensic Nursing, 2(2), 57-58.Heather A. Piwowar, Michael J. Becich, Howard Bilofsky, Rebecca S. Crowley (2008). Towards a Data Sharing Culture: Recommendations for Leadership from Academic Health Centers PLoS Medicine, 5 (9) DOI: 10.1371/journal.pmed.0050183Casida, J, Pinto-Zipp, G (2008). Leadership-Organizational Culture relationship in nursing units of acute care hospitals Nursing Economic$, 26 (1), 7-13... Read more »

Don E. Detmer, Meryl Bloomrosen, Brian Raymond, & Paul Tang. (2008) Integrated personal health records: Transformative tools for consumer-centric care. BMC Medical Informatics and Decision Making, 8(1), 45. DOI: 10.1186/1472-6947-8-45  

Carole A Estabrooks, Shannon Scott, Janet E Squires, Bonnie Stevens, Linda O'Brien-Pallas, Judy Watt-Watson, Joanne Profetto-McGrath, Kathy McGilton, Karen Golden-Biddle, Janice Lander.... (2008) Patterns of research utilization on patient care units. Implementation Science, 3(1), 31. DOI: 10.1186/1748-5908-3-31  

Casida, J, & Pinto-Zipp, G. (2008) Leadership-Organizational Culture relationship in nursing units of acute care hospitals. Nursing Economic$, 26(1), 7-13.

  • September 24, 2008
  • 05:11 PM

Re-inoculation from the appendix and recurrent C. difficile infection (CDI)

by CxLxMx in cxlxmxrx

Trying to find a topic to write a review article in Bio416 Virology, I came across a post on enzyme evolution in the Discount Thoughts blog that led me to a post on the possible functionality of the appendix. Bollinger et al., writing in Journal of Theoretical Biology, propose that the appendix is a tool for creating probiotic biofilms in the large intestine as well as re-inoculating the large intestine in the event of its defloration by, for example, diarrhea. Their argument rests mostly on recent evidence they cite suggesting that the immune system does not operate antagonistically with normal intestinal bacteria. They present an interesting idea. Although from a developmental view Clarkson points out the authors' limited conception of vestigiality, this view is less relevant to the proposed current functions of the appendix.(One thing I didn't quite follow was the authors' statement that "receptors for secretory IgA that are important for biofilm formation are up-regulated by the presence of secretory IgA." I take this to mean that IgA is a positive feedback loop in the gut. This interpretation would make sense with regard to IBD and Crohn's. It would also help explain the connection between antibiotics and Clostridium difficile infection--if antibody production were partly dependent on the presence of antibodies, immunity would be partly dependent on the presence of bacteria. However, based on the abstracts for the relevant citations, the statement seems like a non-sequitur. Wold and Adlerberth (2000) conclude that mother's IgA results in less gut immune stimulation and lower salivary IgA, while Friman et al. (1996) refer to IgA's role in capturing probiotic E. coli but not IgA receptors. Peterson et al. (2007) agree with Wold and Adlerberth in finding that IgA attenuates the gut inflammatory response.)Mongolian nomadic herdersThe issue raised by Bollinger et al. of re-inoculating the intestines from the appendix put me in mind of a speaker who came to my nursing school last year. Sas Carey, RN, has traveled to Mongolia on several occasions to help build a health database of nomadic reindeer herders as well as to record their indigenous medical practices. Her travels resulted in the creation of a documentary film as well as a non-profit group called Nomadicare.In her talk, I remember quite distinctly that she spoke about the herders treating chronic appendicitis by drinking liquified animal stool. My thinking at the time was that it makes sense if the intestinal bacteria from the stool compete with the inflammatory bacteria. In the context of Bollinger et al.'s theory, perhaps it is simply a re-balancing of similar gut flora that keeps appendicitis in check rather than allowing it to become acute.Chronic appendicitisYou may be thinking that you haven't heard of chronic appendicitis, and it's true that in this country we as nurses are taught RLQ pain-appendicitis-surgery. And even as recently as 1998, Van Winter et al. was asking whether it really existed. However, a breif review of the literature shows that it's been accepted: Konstantinidis et al. (2008) found 6.1% of appendectomy cases from chronic symptoms; and Roumen et al. (2008) found that elective appendectomy relieved chronic RLQ pain.Sgourakis et al. (2008) identified lack of bowel movement as a factor in chronic appendicitis but not blockage, which is interesting since blockage is the usual explanation for acute appendicitis. Do they have a different etiology? If Mongolian reindeer herders spend a lot of time in the saddle or going without food, could this lead to intestinal stasis and inflammation?Also, if chronic appendicitis comes from stasis rather than blockage, could the infectious bacteria be different? The theory with acute appendicitis is that normal bacterial flora get trapped in the appendix by a blockage and start to infect the appendix wall. Perhaps in chronic appendicitis, it is the abnormal gut bacteria that get into the appendix. This would explain why the appendicitis is not acute (normal and abnormal bacteria are competing) as well as why the reindeer herders' techniques worked (adding more normal gut bacteria as a probiotic to compete with the infection).And in fact acute appendicitis is not always caused by blockage, either. Brown et al. (2007) report the case of a man who developed appendicitis after Clostridium difficile infection. From a literature review, they conclude this etiology is rare but may be under-diagnosed since mild forms of appendicitis would be treated by antibiotics along with the C.diff while severe C.diff infections of the entire colon might obscure appendicitis.The appendix and re-current C. difficile infectionIf, as Bollinger et al. suggest, the appendix is involved in re-inoculating the intestine with normal intestinal bacterial, could it not also be a factor in re-current cases of C.diff infection? Maroo and Lamont (2006) state that the reasons some patients have recurrent C.diff infections while others do not is not known: stool samples of recovering patients indicate that spores are present in both patients who have re-current infection and those that do not. Reinfection through the fecal-oral route is a best guess. However, if C.diff infection can occur through die-off of normal bacteria, perhaps the appendix can also lose its normal flora, to be replaced by C. difficile and its spores, which subsequently re-infect the intestine.As Maroo and Lamont show in their review, stool transplant, which they gingerly call fecal bacteriotherapy, is more effective than pure antibiotics for the treatment of C.diff infection. (The route of stool transplant does not seem to be a decisive factor.) As well, pulsed antibiotic treatment is more effective than daily dosing to prevent re-currence. Both these modalities would allow increased growth of competitive bacteria, which suggests that there is still a source of infection to be competed with.Stool transplant off the steppeAas et al. (2003) performed one of the stool transplants reviewed by Maroo and Lamont. In their retrospective study, of 16 patients suffering from re-curring C.diff infections and multiple antiobiotic treatments, only 1 experienced a re-currence of infection following a nasogastric stool transplant.The procedure used in this study was as follows:Obtain stool sample This is a lot more expensive than I imagine the Mongolian herders' method is, but I suspect it is also a lot more pleasant for the patient.Anyhow, to sum up: one theory of the appendix is that its purpose is to re-inoculate the intestines after a pathologic (or possibly pathogenic) event like diarrhea; appendicitis (including or especially chronic appendicitis) may be caused by inoculation of the appendix with pathogens; re-current C.diff infection is not explained, but the effectiveness of probiotic treatment suggests a source of re-infection; and, finally, Mongolian herders' traditional treatment of chronic appendicitis with methods proven to be effective in treating re-current C.diff infection suggests a possible connection between the appendix and C.diff.R RANDALBOLLINGER, A BARBAS, E BUSH, S LIN, W PARKER (2007). Biofilms in the large bowel suggest an apparent function of the human vermiform appendix Journal of Theoretical Biology, 249 (4), 826-831 DOI: 10.1016/j.jtbi.2007.08.032Wold AE & Adlerberth I. (2000) Breast feeding and the intestinal microflora of the infant—implications for protection against infectious diseases, Adv. Exp. Med. Biol. 478 (2000), pp. 77–93. Abstract from Scopus.Friman et al. (1996) V. Friman, I. Adlerberth, H. Connell, C. Svanborg, L.A. Hanson and A.E. Wold, Decreased expression of mannose-specific adhesins by Escherichia coli in the colonic microflora of immunoglobulin A-deficient individuals, Infect. Immun. 64 (1996), pp. 2794–2798. Abstract from Scopus.Peterson DA; McNulty NP; Guruge JL; Gordon JI (2007). IgA response to symbiotic bacteria as a mediator of gut homeostasis. Cell Host & Microbe [Cell Host Microbe] 2007 Nov 15; Vol. 2 (5), pp. 328-39. Abstract from Medline.Van Winter, Wilkinson, Goerss, & Davis (1998). Chronic appendicitis: does it exist? J Fam Pract, 46, 507-509. From KM; Anastasakou KA; Vorias MN; Sambalis GH; Georgiou MK; Xiarchos AG (2008). Journal Of Laparoendoscopic & Advanced Surgical Techniques, 18 (2), 248-258. Abstract from Medline.Roumen RM; Groenendijk RP; Sloots CE; Duthoi KE; Scheltinga MR; Bruijninckx CM. (2008). Randomized clinical trial evaluating elective laparoscopic appendicectomy for chronic right lower-quadrant pain. The British Journal Of Surgery, 95 (2), 169-174. Abstract from Medline.Sgourakis G; Sotiropoulos GC; Molmenti EP; Eibl C; Bonticous S; Moege J; Berchtold C. (2008). Are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coproliths? World Journal Of Gastroenterology: WJG, 14 (20), 3179-3182. Abstract from Medline.Brown TA; Rajappannair L; Dalton AB; Bandi R; Myers JP; Kefalas CH. (2007). Acute appendicitis in the setting of Clostridium difficile colitis: case report and review of the literature. Clinical Gastroenterology And Hepatology, 5 (8), 969-671. Abstract from Medline.S MAROO, J LAMONT (2006). Recurrent Clostridium Difficile Gastroenterology, 130 (4), 1311-1316 DOI: 10.1053/j.gastro.2006.02.044Johannes Aas, Charles E. Gessert, Johan S. Bakken (2003). Recurrent Colitis: Case Series Involving 18 Patients Treated with Donor Stool Administered via a Nasogastric Tube Clinical Infectious Diseases, 36 (5), 580-585 DOI: 10.1086/367657... Read more »

  • February 6, 2008
  • 12:00 AM

Dyspnea & cadence

by CxLxMx in cxlxmxrx

I recently purchased a CD of Navy SEAL cadences to try listening to while running. For the past year or so, I've been trying to listen to mp3's of internet talk radio shows, but it doesn't do much to help. I also tried listening to Bach (I was intending to go through his whole repertoire on the treadmill), but I discovered that Bach actually inhibits athletic performance.

So, yesterday, I put on my radio shows and interspersed them with the SEAL cadences, and I had a very interesting experience... At one point, I was nearing the end of one of the radio shows and nearing a point of breathing exertion that usually makes me slow down--it's the point where your breathing starts getting irregular and shallow and your footfalls lose their pacing. Then the show ended and a cadence started and all of sudden my breathing became deeper, more regular, more productive, and my running regained its pace.

I know that there have been quite a few nursing studies done on the effects of music on patients, but I wonder if there are any studies on cadences...... Read more »

Hill et al. (1998) Short-term entrainment of ventilation to the walking cycle in humans. Journal Of Applied Physiology, 65(2), 570-578.

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