Educating nurses in Rhode Island: a lot of diversity in a little place

Faculty at a baccalaureate nursing program at a state college discuss a multifaceted approach to meeting the needs of a very diverse student population. These students reflect the changing demographics of the state and their education contributes to providing a racially, ethnically, and culturally diverse nursing workforce. The program addresses multiple issues which may impede academic performance. These measures have enhanced and promoted graduates' success on NCLEX-RN. Creative and varied strategies are presented and their implementation and evaluation described.     

Kawasaki disease: a ride for little girls too!

Kawasaki disease is the leading cause of acquired heart disease in children. Little is known about the origin; however, speculation exists that the disease is associated with the use of carpet cleaner or stagnate water. The disease can have devastating lifelong effects on the heart and cardiovascular system. Early recognition of the clinical manifestations by the health care provider may lead to early treatment and prevention of long-term cardiovascular disease. This article presents a case study, with discussion about the prevalence, incidence, pathophysiology, clinical features, and collaborative clinical management of Kawasaki disease.     

Energy healing: a complementary treatment for orthopaedic and other conditions

Complementary and alternative therapies continue to grow in popularity among healthcare consumers. Among those modalities is energy healing (EH) (Eisenberg et al., 1998). EH is an adjunctive treatment that is noninvasive and poses little downside risk to patients. Well more than 50 major hospitals and clinics throughout the United States offer EH to patients (DiNucci, research table on healthcare facilities that offer Reiki, unpublished data, 2002). The National Institutes of Health is funding numerous EH studies that are examining its effects on a variety of conditions, including temporomandibular joint disorders, wrist fractures, cardiovascular health, cancer, wound healing, neonatal stress, pain, fibromyalgia, and AIDS (National Institutes of Health, 2004a). Several well-designed studies to date show significant outcomes for such conditions as wound healing (Grad, 1965) and advanced AIDS (Sicher, Targ, Moore, & Smith, 1998), and positive results for pain and anxiety (Aetna IntelliHealth, 2003a; Wardell, Weymouth, 2004), among others (Gallob, 2003). It is also suggested that EH may have positive effects on various orthopaedic conditions, including fracture healing, arthritis, and muscle and connective tissue (Prestwood, 2003). Because negative outcomes risk is at or near zero throughout the literature, EH is a candidate for use on many medical conditions.     

Natural polypill Xuezhikang: its clinical benefit and potential multicomponent synergistic mechanisms of action in cardiovascular disease and other chronic conditions

Polypill has been a hot issue since it was first advanced in 2003. This new concept immediately spurred a worldwide discussion. Xuezhikang is a partially purified extract of fermented red yeast rice (Monascus purpureus). It is composed of 13 kinds of natural statins, unsaturated fatty acids, ergosterol, amino acids, flavonoids, alkaloid, trace element, and other substances, and thus could be regarded as a natural lipid-lowering polypill. Interestingly, Xuezhikang in the China Coronary Secondary Prevention Study trial lowered lipid levels less as compared with provastatin in the Cholesterol and Recurrent Events trial, but seemed to gain more benefit in reducing the cardiovascular events and the risk of death from cancer. In recent years, Xuezhikang has been further demonstrated to have additional health benefits and thus raised great interest. This article reviews the clinical benefits of Xuezhikang and the potential multicomponent synergetic mechanism. The authors hold that polypill is anticipated to be a more effective and feasible way to treat complicated diseases.     

Photoacoustic tomography: a potential new tool for prostate cancer

The feasibility of photoacoustic tomography (PAT) for noninvasive imaging of prostate cancer was explored through the study on a canine model in vivo. Imaging of blood-rich lesions mimicking prostate tumors was achieved using a commercial medical ultrasound (US) system without affecting its original imaging functions. Based on the optical contrast between hemoglobin and other tissues, PAT has demonstrated good sensitivity and high contrast-to-noise ratio in visualizing deep lesions; while US has presented the morphological features including the boundary and the urethral of the prostate. PAT of prostate cancer may facilitate improved tumor localization, staging of disease, and detection of recurrences.     

Vaccine therapy for a patient with androgen-insensitive prostate cancer without evidence of measurable disease on scans

Androgen ablation therapy is the mainstay treatment of patients who have failed local therapy for prostate cancer. PSA is a serum marker commonly used to monitor patients who have undergone primary therapy for evidence of disease progression. However, there currently is no standard therapy for patients once they have demonstrated disease progression. We report a case of a 65-year-old man with castrate testosterone levels but a rising serum PSA level without radiographic evidence of metastasis. After failing prior antiandrogen therapy, he enrolled on a clinical trial comparing a PSA-based vaccine with nilutamide. When his PSA level rose on nilutamide, he commenced treatment with the vaccine therapy. He has continued to have a PSA response with the vaccine treatments with no radiographic evidence disease for >20 months.     

Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective

The current scientific literature relevant to the use of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions was reviewed and critically analyzed to determine a clinical effect. Three randomized, controlled studies were found studying the use of dextrose/glycerine/phenol prolotherapy for chronic low back pain; however, they were inconclusive due to the lack of adequate controls, heterogeneity in patient diagnoses, and variations in solutions injected. Two randomized, controlled studies were found that provide some evidence supporting the use of 10% dextrose prolotherapy for osteoarthritis. The sample size of the study (n = 13) involving osteoarthritic thumbs and fingers may have been too small to be strongly conclusive; however, it provides preliminary data to support future studies. Two studies involving osteoarthritic knees report an improvement in anterior cruciate ligament laxity; however, they did not have control groups for comparison. Only case reports were found supporting the pursuit of controlled clinical studies of prolotherapy for chronic neck pain. On the basis of the scarce body of literature critically reviewed to date, the clinical efficacy of prolotherapy in treating osteoarthritis, low back pain, and other musculoskeletal conditions remains inconclusive.     

Lower limit of assay sensitivity: an under-recognised and significant problem in von Willebrand disease identification and classification

von Willebrand disease (VWD) is the most common inherited bleeding ailment, and is characterised by low levels of, or abnormal function in, the plasma protein von Willebrand factor (VWF). However, the laboratory testing process is problematic because of both the heterogeneity of VWD and the limitations in the tests used to identify reduced or abnormal VWF. OBJECTIVE: This study reports on the lower levels of sensitivity for the different assays used in the diagnostic process for VWD and their significance in the diagnostic identification and classification ofVWD. METHODS: The RCPA Haematology QAP is an international external quality assurance (EQA) program that includes VWF/VWD testing within one of its special haemostasis modules. Over the past 10 years, over 50 samples have been distributed to participants, including five samples devoid of VWF and derived from either true Type 3 VWD patients or else from commerciallypurchased VWF deficient plasma. Samples were tested blind by study participants, who report back both numerical values (for VWF and Factor VIII:C) and an interpretation regarding whether or not VWD is suggested by laboratory findings, and if so, the probable VWD subtype. RESULTS: Returned data indicates that the lower level of sensitivity (LLS) tends to be around 5-10U/dL for Factor VIII:C, VWF antigen(VWF:Ag), VWFcollagen binding (VWF:CB), and VWF 'activity' (VWF:Act), but canreach 20U/dL or more for VWF ristocetin cofactor (VWF:RCo). There does not appear to be any improvement over the past decade despite ongoing automation of methodology, and indeed, automation does not seem to provide better LLS performance. CONCLUSIONS: Limitations in the LLS of VWD testing have significant implications in terms of the identification and classification of an individual's VWD, given that these laboratory assays are used to identify VWD andhelp characterise functional VWF discordance, and that the majority of severe VWD subtypes have levels of VWF below 20U/dL. Thus, laboratories will sometimes be unable to distinguish whether VWF deficient samples derive from Type 3 VWD or severe Type 1 VWD or even Type 2 VWD.     

Epidemiology of Chagas disease in Europe: many calculations, little knowledge

Chagas disease and its causative agent Trypanosoma cruzi are endemic in almost all countries in South and Middle America. Currently, there are more than 10 million affected people. It is the most common reason for heart failure and a frequent cause of intestinal problems in Latin America. The phenotype of the Chagas cardiomyopathy is varying. Dilative cardiomyopathy, often accompanied by an apical aneurysm is the most common finding in the end stage heart failure, but rhythm disorders like conduction blocks, ventricular or supraventricular forms of tachycardia or repolarization changes occur as well, mainly in the early stages. Migration of infected people leads to a distribution from the endemic countries to North America and Europe. Although more than 500,000 people of Latin American origin are currently living in Europe, Chagas disease is not considered as a public health problem, yet. Cases of transmission via blood donation, organ transplantation or from mother-to-child are reported for several European countries but there is no database for Germany. Current epidemiological data are mostly available from regional surveys from other countries or are extrapolated. Hence, there is a large variation in the estimated numbers on the incidence of Chagas. Robust and reliable data are lacking. This review gives an overview on the currently available data and calls for a German Chagas surveillance.     

Trichloroethylene: Mechanistic,epidemiologic and other supporting evidence of carcinogenic hazard

The chlorinated solvent trichloroethylene (TCE) is a ubiquitous environmental pollutant. The carcinogenic hazard of TCE was the subject of a 2012 evaluation by a Working Group of the International Agency for Research on Cancer (IARC). Information on exposures, relevant data from epidemiologic studies, bioassays in experimental animals, and toxicity and mechanism of action studies was used to conclude that TCE is carcinogenic to humans (Group 1). This article summarizes the key evidence forming the scientific bases for the IARC classification. Exposure to TCE from environmental sources (including hazardous waste sites and contaminated water) is common throughout the world. While workplace use of TCE has been declining, occupational exposures remain of concern, especially in developing countries. The strongest human evidence is from studies of occupational TCE exposure and kidney cancer. Positive, although less consistent, associations were reported for liver cancer and non-Hodgkin lymphoma. TCE is carcinogenic at multiple sites in multiple species and strains of experimental animals. The mechanistic evidence includes extensive data on the toxicokinetics and genotoxicity of TCE and its metabolites. Together, available evidence provided a cohesive database supporting the human cancer hazard of TCE, particularly in the kidney. For other target sites of carcinogenicity, mechanistic and other data were found to be more limited. Important sources of susceptibility to TCE toxicity and carcinogenicity were also reviewed by the Working Group. In all, consideration of the multiple evidence streams presented herein informed the IARC conclusions regarding the carcinogenicity of TCE.     

Carotid Doppler: low velocity as a sign of significant disease

Hemodynamically significant stenosis of the internal carotid artery (ICA) is usually diagnosed by elevated velocities in a region of luminal narrowing. Many other significant diagnoses can be made based upon lower-than-normal velocities. Analysis of the combinations of low ICA velocity, abnormal ICA waveform, and abnormal velocities and waveforms in ipsilateral or contralateral ICA, common carotid artery, and vertebral arteries can allow diagnosis of significant vascular or valvular disease from the heart to the brain.     

An overview of atopic eczema in children: a significant disease

Atopic eczema is a significant disease, being the most common skin disorder in children, affecting 12-15% of all school-age children (Emerson et al, 1998). It is an inflammatory skin condition, which is genetic in origin but is triggered by many factors, such as detergents, emotional distress or dust mites (Buxton, 1998) and often starts in the first year of life. It is characterised by dry and itchy skin. This often breaks down and becomes infected, partly as a result of the close relationship of atopic eczema and the organism Staphylococcus aureus, which is found on the skin of most children with atopic eczema (Goodyear, 1993).     

Rehabilitation for Parkinson's disease: a systematic review of available evidence

OBJECTIVE: To systematically review the available evidence on the effectiveness of nonpharmacological rehabilitation interventions for people with Parkinson's disease, and identify future research needs. DESIGN: Electronic searches of four databases (CINAHL, Cochrane Library, MEDLINE, PsychLIT) 1980-2002; examination of reference lists of relevant papers. Controlled trials and observational studies were included. Data extraction and quality assessment of papers by two independent reviewers. A narrative review. SETTING: Rehabilitation interventions delivered either in subjects' own homes, or in clinical settings as outpatients. SUBJECTS: Community-living adults with Parkinson's disease. INTERVENTIONS: Physiotherapy, occupational therapy, speech and language therapy, psychological counselling and support, and education. MAIN MEASURES: A range of outcomes: mobility, functional status, speech, swallowing, psychological well-being, as determined by the studies included in the review. RESULTS: Forty-four different studies (reported in 51 papers) were included (25 physiotherapy, 4 occupational therapy, 10 speech and language therapy, 3 psychological counselling, 1 educational, 1 multidisciplinary). All studies, except one, reported improvements on at least one outcome measure. CONCLUSIONS: Findings may reflect publication bias, but suggest interventions can affect patients' lives for the better in a variety of ways. It is difficult to interpret the clinical importance of statistically significant improvements reported in most studies. There is a need for methodologically more robust research with meaningful follow-up periods, designed in a manner that separates specific and nonspecific effects. Cost-effectiveness evidence is required to provide clear guidance on service extensions.     

Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners

BACKGROUND: It is not clear if good methodologic quality in current practice guidelines necessarily leads to more valid recommendations, i.e., those that are supported with consistent research evidence or, when evidence is conflicting or lacking, with sufficient consensus among the guideline development team. To help clarify this issue, we assessed whether there is a link between methodologic quality and recommendation validity in practice guidelines for the use of laboratory tests in the management of patients with non-small cell lung cancer (NSCLC). METHODS: We conducted a systematic review of data on laboratory tests in NSCLC published in English or in French within the last 10 years and retrieved 11 practice guidelines for the use of these tests. The guidelines were critically appraised and scored for methodologic quality and recommendation validity based on the Appraisal of Guidelines Research and Evaluation (AGREE) criteria and on the systematic review. RESULTS: Overall, these 11 guidelines had considerable shortcomings in methodologic quality and, to a lesser extent, in recommendation validity. Practice guidelines with the best methodologic quality were not necessarily the most valid in their recommendations, and conversely. CONCLUSIONS: Poor methodologic quality and lack of recommendation validity in laboratory medicine call for methodologic standards of guideline development and for international collaboration of guideline development agencies. We advise readers of guidelines to critically evaluate the methods used as well as the content of the recommendations before adopting them for use in practice.