Developing military nursing research priorities

Congress established the TriService Nursing Research Program (TSNRP) in 1992 to serve the nursing research needs of the military. The TSNRP advances the science of military nursing to support mission readiness and deployment, improves the health and quality of life of military personnel, and provides optimal nursing care in settings worldwide. In 1995, the TSNRP Advisory Council commissioned the Institute of Medicine to make recommendations on management, research funding areas, resource allocation, and objectives. In 1996, the committee issued its report, The Program for Research in Military Nursing: Progress and Future Direction. A principal recommendation was that the TSNRP hold regular research priority-setting conferences. In response, since 2000, the TSNRP has held three conferences. This article follows up the Institute of Medicine report and summarizes the results of those conferences. The article describes conference processes, constituents, and conclusions and outlines future TSNRP research directions.     

Voxel-based analysis of MTR images: a method to locate gray matter abnormalities in patients at the earliest stage of multiple sclerosis

PURPOSE: To determine whether voxel-based analysis of magnetization transfer ratio (MTR) maps can provide evidence of a coherent pattern of gray matter (GM) macroscopic and microscopic tissue damage in patients at the earliest stage of multiple sclerosis (MS). MATERIALS AND METHODS: We acquired GM MTR maps in 18 patients with clinically isolated syndrome suggestive of MS (CISSMS), and 18 sex- and age-matched healthy controls. We evaluated the clinical status of the patients using the MS functional composite score and the expanded disability status scale. A two-sample t-test (P <0.0001, k=20, uncorrected for height threshold) was used to compare GM MTR maps from patients and controls on a voxel-by-voxel basis. We then extracted data from regions with t-values above the statistical threshold to verify the significance of differences using a nonparametric Mann-Whitney U-test. RESULTS: A between-groups comparison of GM maps revealed large abnormalities in the basal ganglia, including the bilateral thalamus, bilateral lenticular nucleus, bilateral head of caudate, and protuberance, and smaller abnormalities in the right insula, right BA 4, and left BA 40. The MTR measured in the left caudate and right insula was inversely correlated with duration following the first clinical event. CONCLUSION: These results suggest that although MS is a multifocal demyelinating disease that affects white matter (WM), a pattern of tissue damage is present inside the GM involving predominantly basal ganglia at the earliest stage of the disease.     

The effect of opening wedge thoracostomy on thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis

BACKGROUND: Thoracic insufficiency syndrome is the inability of the thorax to support normal respiration or lung growth and is seen in patients who have severe congenital scoliosis with fused ribs. Traditional spinal surgery does not directly address this syndrome. METHODS: Twenty-seven patients with congenital scoliosis associated with fused ribs of the concave hemithorax had an opening wedge thoracostomy with primary longitudinal lengthening with use of a chest-wall distractor known as a vertical, expandable prosthetic titanium rib. Repeat lengthenings of the prosthesis were performed at intervals of four to six months. Radiographs were analyzed with respect to correction of the spinal deformity, as indicated by a change in the Cobb angle, and lateral deviation of the spine, as indicated by the interpedicular line ratio. Spinal growth was assessed by measuring the change in the length of the spine. Correction of the thoracic deformity and thoracic growth were assessed on the basis of the increase in the height of the concave hemithorax compared with the height of the convex hemithorax (the space available for the lung), the increase in the thoracic spinal height, and the increase in the thoracic depth and width. The thoracic deformity in the transverse plane was measured with computed tomography, and the scans were analyzed for spinal rotation, thoracic rotation, and the posterior hemithoracic symmetry ratio. Clinically, the patients were assessed on the basis of the relative heights of the shoulders and of head and thorax compensation. Pulmonary status was evaluated on the basis of the respiratory rate, capillary blood gas levels, and pulmonary function studies. RESULTS: The mean age at the time of the surgery was 3.2 years (range, 0.6 to 12.5 years), and the mean duration of follow-up was 5.7 years. All patients had progressive congenital scoliosis, with a mean increase of 15 degrees /yr before the operation. The scoliosis decreased from a mean of 74 degrees preoperatively to a mean of 49 degrees at the time of the last follow-up. Both the mean interpedicular line ratio and the space available for the lung ratio improved significantly. The height of the thoracic spine increased by a mean of 0.71 cm/yr. At the time of the last follow-up, the mean percentage of the predicted normal vital capacity was 58% for patients younger than two years of age at the time of the surgery, 44% for those older than two years of age (p < 0.001), and 36% for those older than two years of age who had had prior spine surgery. In a group of patients who had sequential testing, all increases in the volume of vital capacity were significant (p < 0.0001), but the changes in the percentages of the predicted normal vital capacity were not. There was a total of fifty-two complications in twenty-two patients, with the most common being asymptomatic proximal migration of the device through the ribs in seven patients. CONCLUSIONS: Opening wedge thoracostomy with use of a chest-wall distractor directly treats segmental hypoplasia of the hemithorax resulting from fused ribs associated with congenital scoliosis. The operation addresses thoracic insufficiency syndrome by lengthening and expanding the constricted hemithorax and allowing growth of the thoracic spine and the rib cage. The procedure corrects most components of chest-wall deformity and indirectly corrects congenital scoliosis, without the need for spine fusion. The technique requires special training and should be performed by a multispecialty team.     

Predicting blood loss and transfusion requirements during radical prostatectomy: the significant negative impact of increasing body mass index

PURPOSE: Radical retropubic prostatectomy (RRP) has been associated with significant blood loss and/or transfusion requirement. While still a concern, routine autologous blood donation has not been standard at our institution for more than a decade. We assessed recent blood loss and transfusion requirements in contemporary patients undergoing RRP and examined the possible predictive impact of preoperative variables. MATERIALS AND METHODS: A retrospective review of 436 consecutive patients who underwent RRP between July 1999 and December 2001 was performed with the primary purpose of analyzing estimated blood loss (EBL) and blood transfusion requirements as well as possible preoperative risk factors, including clinical demographic characteristics, body mass index (BMI), defined as weight in kg/height in m, comorbidities, American Society of Anesthesiologists classification and Charlson index score. RESULTS: A total of 436 consecutive patients with a mean age of 60 years (range 39 to 78) underwent RRP under general anesthesia. Mean American Society of Anesthesiologists class was 2.3 (range 1 to 3) and the mean BMI was 27.7 (range 18.2 to 44.3). Mean preoperative and postoperative hematocrit was 43.9% and 32.5%, respectively. Overall mean EBL was 603 cc (range 100 to 3500) and the transfusion rate was 4.8%. On multivariate analysis the only significant correlative predictor of EBL was BMI. There was a significantly lower EBL in patients with an acceptable BMI (less than 25) vs overweight (25 to 30) and obese (greater than 30) patients (p = 0.021). Likewise the rate of transfusion was significantly higher in the overweight (6.9%) and obese (5.6%) groups compared to the normal BMI group (1.9%) (p = 0.009). CONCLUSIONS: Our series demonstrates that blood loss during RRP continues to decrease. The respectable blood loss and low transfusion rates in this series were due to refinements in surgical technique rather than to perioperative modifications. To our knowledge the identification of BMI as a predictor of blood loss and transfusion is novel. These data serve as a benchmark for future comparisons and argue for continued refinements in techniques to decrease blood loss, particularly in overweight and obese patients.     

Nonpeptide alphavbeta3 antagonists. Part 11: discovery and preclinical evaluation of potent alphavbeta3 antagonists for the prevention and treatment of osteoporosis

3-(S)-Pyrimidin-5-yl-9-(5,6,7,8-tetrahydro-[1,8]naphthyridin-2-yl)-nonanoic acid (5e) and 3-(S)-(methylpyrimidin-5-yl)-9-(5,6,7,8-tetrahydro-[1,8]naphthyridin-2-yl)-nonanoic acid (5f) were identified as potent and selective antagonists of the alpha(v)beta(3) receptor. These compounds have excellent in vitro profiles (IC(50) = 0.07 and 0.08 nM, respectively), significant unbound fractions in human plasma (6 and 4%), and good pharmacokinetics in rat, dog, and rhesus monkey. On the basis of the efficacy shown in an in vivo model of bone turnover following once-daily oral administration, these two compounds were selected for clinical development for the treatment of osteoporosis.     

Imaging cocaine-induced changes in the mesocorticolimbic dopaminergic system of conscious rats

Functional magnetic resonance imaging (fMRI) was used to assess the effects of cocaine on brain activation in fully conscious rats. Methods were developed to image cocaine-induced changes in blood-oxygen-level-dependent (BOLD) signal without the peripheral cardiac and respiratory complications associated with psychostimulant administration. Using spin echo planar imaging (EPI), conscious rats were imaged in a 4.7 T spectrometer prior to and following the intracerebroventricular injection of cocaine (20 microg) in artificial cerebrospinal fluid (10 uL). Within 5 min of injection, there was a significant increase in BOLD signal intensity in the substantia nigra, ventral tegmental area, nucleus accumbens, dorsal striatum and prefrontal cortex, as compared to vehicle controls. Minimal negative BOLD signal changes were observed in response to cocaine and no significant perturbations in normal cardiovascular and respiratory function. These findings demonstrate the technical feasibility of studying psychostimulant-induced brain activity using functional MRI in conscious rats.     

Control of aedes vectors of dengue in three provinces of Vietnam by use of Mesocyclops (Copepoda) and community-based methods validated by entomologic,clinical, and serological surveillance

We describe remarkable success in controlling dengue vectors, Aedes aegypti (L.) and Aedes albopictus (Skuse), in 6 communes with 11,675 households and 49,647 people in the northern provinces of Haiphong, Hung Yen, and Nam Dinh in Vietnam. The communes were selected for high-frequency use of large outdoor concrete tanks and wells. These were found to be the source of 49.6-98.4% of Ae. aegypti larvae, which were amenable to treatment with local Mesocyclops, mainly M. woutersi Van der Velde, M. aspericornis (Daday) and M. thermocyclopoides Harada. Knowledge, attitude, and practice surveys were performed to determine whether the communities viewed dengue and dengue hemorrhagic fever as a serious health threat; to determine their knowledge of the etiology, attitudes, and practices regarding control methods including Mesocyclops; and to determine their receptivity to various information methods. On the basis of the knowledge, attitude, and practice data, the community-based dengue control program comprised a system of local leaders, health volunteer teachers, and schoolchildren, supported by health professionals. Recycling of discards for economic gain was enhanced, where appropriate, and this, plus 37 clean-up campaigns, removed small containers unsuitable for Mesocyclops treatment. A previously successful eradication at Phan Boi village (Hung Yen province) was extended to 7 other villages forming Di Su commune (1,750 households) in the current study. Complete control was also achieved in Nghia Hiep (Hung Yen province) and in Xuan Phong (Nam Dinh province); control efficacy was > or = 99.7% in the other 3 communes (Lac Vien in Haiphong, Nghia Dong, and Xuan Kien in Nam Dinh). Although tanks and wells were the key container types of Ae. aegypti productivity, discarded materials were the source of 51% of the standing crop of Ae. albopictus. Aedes albopictus larvae were eliminated from the 3 Nam Dinh communes, and 86-98% control was achieved in the other 3 communes. Variable dengue attack rates made the clinical and serological comparison of control and untreated communes problematic, but these data indicate that clinical surveillance by itself is inadequate to monitor dengue transmission.