Using simulations and standardized patients in intervention research

Caregiving is both an art and a science; both knowledge and skills are necessary to improve the quality of care that professionals provide. Researchers are often limited in their assessment of skill performance due to inadequate and unrealistic measurement options. Simulation using standardized patients offers researchers an objective method to evaluate skill performance. This article describes the use of simulations by researchers in their quest to measure changes in violence prevention skills after an intervention program given to nurse assistants working in long-term care facilities.     

Hepatic duct confluence injury in blunt abdominal trauma: case report and synopsis on management

Injuries of the extra hepatic biliary tree following blunt trauma to the abdomen are rare. We present here a case of injury to the confluence of the hepatic ducts and a brief synopsis on diagnosis and management of blunt injury to the extrahepatic biliary system.     

Genomewide linkage analysis to presbycusis in the Framingham Heart Study

OBJECTIVE: To identify chromosomal regions that show evidence of linkage to age-associated hearing impairment (presbycusis) in humans. DESIGN: We evaluated the genetic linkage between quantitative measures from audiometric examinations and markers from a genomewide scan in a population-based sample ascertained without respect to hearing status. PARTICIPANTS: Audiometric examinations were conducted on 2263 original cohort members and 2217 offspring cohort members of the National Heart, Lung, and Blood Institute's Framingham Heart Study. Of these, 1789 individuals were members of 328 extended pedigrees used for linkage analysis. The outcome traits for linkage analysis were pure-tone average at medium (0.5, 1.0, and 2.0 kHz) and low (0.25, 0.5, and 1.0 kHz) frequencies adjusted for cohort, sex, age, age squared, and age cubed. RESULTS: We found heritability (proportion of variance due to genes) of age-adjusted pure-tone average at medium and low frequencies to be 0.38 and 0.31, respectively. Genomewide linkage analysis identified several locations with suggestive evidence of linkage. Of particular interest are the regions 11p (maximum multipoint logarithm of odds [MLOD], 1.57), 11q13.5 (MLOD, 2.10), and 14q (MLOD, 1.55), which overlap with genes known to cause congenital deafness. CONCLUSIONS: There is evidence that genetic and environmental factors contribute to hearing loss in the mature human population. Several of the chromosomal locations identified overlap with loci known to cause congenital hearing loss. Further studies are needed to determine whether the same genes cause presbycusis and congenital hearing loss.     

Ventilation is greater in women than men, but the increase during acute altitude hypoxia is the same

We wished to determine whether the previously reported lower arterial or alveolar P(CO2) in women than men, and in luteal (LUT) compared with follicular (FOL) menstrual cycle phase would persist during normal oral contraceptive use and during early altitude exposure. Ventilation and blood gases were measured at baseline (636 mmHg approximately 5400 ft, 1650 m) and during simulated altitude at 426 mmHg ( approximately 16000 ft, 4880 m), after 1 h (A1) and during the 12th h (A12), in 18 men (once) and in 19 women twice, during LUT and FOL and in 20 women twice while on placebo (PLA) or highest progestin dose (PIL) oral contraceptives. At baseline, Pa(CO2) was significantly higher in men than all women by 3.3 mmHg. When progesterone-progestin (PRO) was elevated in women, Pa(CO2) was significantly lower than in FOL and PLA, but the latter were still significantly lower than men. At altitude the P(CO2) differences between men and women and PRO levels persisted, with PA(CO2) falling by 3.6 and 7.3 mmHg at A1 and A12 in all, indicating an equivalent increase in alveolar ventilation. The mean arterial-end tidal P(CO2) difference was never >2 mmHg in the groups, indicating no VA/Q mismatch related to gender, PRO levels or altitude. All women had higher breathing frequency than men, resulting in greater deadspace ventilation. At altitude, the mean Pa(O2) was approximately 44 mmHg (Sa(O2) approximately 79%) for all, indicating equivalent oxygenation, but alveolar-arterial P(O2) differences were greater in women than men and higher when PRO was elevated. These results show that, relative to men, women have a compensated respiratory alkalosis, accentuated with elevated PRO. However, the ventilation response to acute altitude is the same in women and men.     

Caring demands and delay in seeking care in African American women newly diagnosed with breast cancer: an ethnographic, photographic study

PURPOSE/OBJECTIVES: To describe the caring behaviors and demands of African American women newly diagnosed with breast cancer and to consider the influence of caring on the women's decision to delay prompt diagnosis and maintain continuing treatment. DESIGN: Focused ethnographic design using photography. SAMPLE/SETTING: 13 African American women (ages 30-66) purposefully selected from two oncology clinics in the mid-South. METHODS: Ethnographic interviews (transcribed verbatim), observations at informant-selected sites, field notes, and snapshots of caring taken by the women where caring occurred were analyzed using Lelninger's phases of ethnographic analysis. FINDINGS: Major themes were (a) generic caring for others and self as meaningful and as promoting continued commitment to diagnosis and treatment, (b) generic and professional caring from others as supportive to the women in "going on," and (c) noncaring related to a "wait and see" attitude of healthcare providers and of women in delaying early diagnosis. CONCLUSIONS: African American women's caring both for and from others was supportive in seeking and continuing diagnosis and treatment. The women with cancer viewed ensuring early diagnosis and continued treatment for other women as their "mission." Delay by providers and women requires further research. IMPLICATIONS FOR NURSING PRACTICE: Nurses must advocate assertiveness for African American women in seeking help for breast cancer symptoms and in challenging providers who adopt a "wait and see" attitude when symptoms are present. Taking snapshots, in addition to fostering the research process, is suggested as a potentially helpful intervention for women as they work through their experiences during treatment for breast cancer.     

Effect of venesection on bone mineral density in an eugonadal woman with haemochromatosis

BACKGROUND: A 41-year-old premenopausal woman with newly diagnosed haemochromatosis was found to have osteopenia on screening bone mineral densitometry. METHODS AND RESULTS: Liver biopsy showed grade 3 haemochromatosis with an hepatic iron index of 4. Investigation for secondary factors for osteopenia revealed no cause. The patient was clinically and biochemically eugonadal. Following venesection of 8 L blood (4 g iron) over 17 months and calcium supplementation, her bone density rose significantly. Neck of femur bone density increased by 6.0% over 13 months and lumbar vertebral bone density increased by 7.2%. There are no previous reports of response of bone density to venesection in eugonadal patients or in women with haemochromatosis.     

The use of cyanoacrylate in transsphenoidal hypophysectomy

In an attempt to find a better technique for immediate control of CSF rhinorrhea following transsphenoidal hypophysectomy, a tissue adhesive, ethyl 2-cyanoacrylate, has been used in 28 consecutive operations. The physical properties of the adhesive, its theoretical advantages, and our results are discussed.     

Factors affecting the clinical value of microscopy for acid-fast bacilli

In order to assess the clinical value of microscopy for acid-fast bacilli (AFB), the results of 3,207 clinical specimens submitted for mycobacterial smear and culture were analyzed. Mycobacteria grew from 176 (5.5%) of the specimens, 95 (54%) of which were Mycobacterium tuberculosis. Although the overall sensitivity of the smear was low (33%), 65% of respiratory specimens yielding M. tuberculosis had positive AFB smears. Furthermore, 96% of patients with pulmonary tuberculosis from whom more than one specimen was processed had at least a single positive AFB smear. Smear sensitivity correlated well with quantitative growth; 89% of specimens yielding greater than or equal to 50 colonies per slant were smear positive. Specificity of the AFB smear was high; 89% of smear-positive specimens had positive cultures. After the results from culture-negative patients known to have active tuberculosis were eliminated from the analysis, the specificity of a positive smear rose to 98.3%. When the results of all specimens from each patient were considered in toto, the AFB smear had a predictive value of greater than or equal to 96%.