Determination of in vitro susceptibility of ocular Fusarium spp. isolates from keratitis cases and comparison of Clinical and Laboratory Standards Institute M38-A2 and E test methods

We evaluated the susceptibility of 85 Fusarium spp. isolates from cases of fungal keratitis with 8 antifungal drugs using the standard Clinical and Laboratory Standards Institute broth microdilution and E test methods. Members of the Fusarium solani species complex showed consistently higher MICs to the triazole drugs itraconazole, voriconazole, and posaconazole than did members of other species complexes (Fusarium oxysporum and other minor species). High MICs to amphotericin B, natamycin, and echinocandins were consistently obtained with no discrimination based on species or method. Further work is required to determine any potential correlation between MIC and clinical outcome in keratitis.     

Outcomes of gynecologic oncology patients undergoing robotic-assisted laparoscopic procedures in a university setting

This study evaluated intraoperative complications and postoperative outcomes of gynecologic oncology patients undergoing robotic-assisted (RA) laparoscopic procedures in a university setting. A retrospective chart review evaluated all gynecologic oncology patients at the University of Alabama at Birmingham who underwent attempted RA procedures between August 2006 and October 2011. Patient demographics, medical/surgical history, intraoperative complications, postoperative outcomes, conversion rates, readmission rates, and length of stay were examined. Total complication rates were assessed over time for each surgeon. 681 patients underwent planned RA procedures by seven gynecologic oncologists. The mean body mass index was 33.5 kg/m² (range 16.6–71.0 kg/m²). 61.4 % were diagnosed with malignancy. The most common procedure was RA hysterectomy with unilateral/bilateral salpingo-oophorectomy (37.2 %). Robotic staging was performed in 291 patients (45.1 %). Mean estimated blood loss was 75 ml (range 5–700 ml). 36 patients (5.3 %) were converted to laparotomy. The most common reason for conversion was adhesions (30.1 %), followed by uterine size (22.2 %). In 107 cases, a surgical modification was required for specimen removal including mini-laparotomy (24), extension of accessory port (36), morcellation (9), and difficult vaginal delivery (38). 3.7 % had intraoperative complications; 6 patients had a cystotomy and 5 had a vascular injury. Postoperatively, 20 patients had a febrile episode, 9 had wound complications, and 3 had a vaginal cuff dehiscence. 27 (4.2 %) patients were readmitted within 30 days. Complication rates and conversion rates were similar per surgeon. Total complication rates for evaluable surgeons were similar between the first 10 cases and subsequent 50 cases. Although patients undergoing RA procedures in a university setting are high risk, the conversion rate to laparotomy is low and intraoperative and postoperative complications are acceptable. Total complication rates for each surgeon were not impacted by the number of cases performed.     

Biofeedback: its role in the treatment of chronic constipation.

Constipation accounts for more than 2.5 million physician visits a year. Treatment of constipation has been a long-standing and costly problem. Affecting approximately 4.5 million Americans, predominantly women and the elderly, constipation can be persistent and difficult to manage. With the great number of laxative products available, more than $350 to $400 million is spent on over-the-counter laxatives each year. In addition to a complete history and physical examination, tests of anorectal function are useful in the assessment of defecation disorders. Approximately 50% of patients exhibit uncoordinated or dyssynergic defecation patterns. Biofeedback therapy may improve the symptoms of these patients. Biofeedback therapy is labor-intensive, expensive, and available only at a few centers. Although the concept of dyssynergic defecation has existed for only a few years, its therapy, based on neuromuscular conditioning, is gaining recognition. The biofeedback program from one Midwestern tertiary care center is described. Although much still needs to be learned regarding the etiology and pathophysiology of dyssynergic defecation, its management with biofeedback is shown to be efficacious and may prove to be the treatment of choice for patients with this dysfunction of the pelvic floor.     

A program to educate school nurses about mental health interventions.

Concerned with the increasing incidence of mental health problems in children and adolescents and the impact of these problems on students' school success and predisposition to self- and other-directed violence, the Multnomah Education Service District Department of School Health Services determined to become proactive by providing preventive interventions for students experiencing actual or potential mental health problems. An educational program was designed to assist school nurses in the identification of potential mental health problems. In addition, information about appropriate interventions for students at risk for aggression, violence, and other mental health pathology was presented. The program involved education on mental health assessment and intervention, as well as expert psychiatric clinical support for the development of student support groups. School nurses were then challenged to develop practice improvement projects incorporating this knowledge for a group of students in their work setting. This introductory article describes the project's general rationale and implementation process. The four articles following in this issue of The Journal of School Nursing describe the goals, implementation, and outcomes of the practice improvement projects developed for early intervention with students exhibiting attention disorders, school absenteeism, social withdrawal, and depression.     

Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study

Objective To evaluate the specificity, sensitivity, and accuracy of pain intensity assessments (0–10) conducted by registered nurses (RN) and clinical nurse assistants (CAN) as compared to those conducted by the palliative care consultant (PCC).Patients and methods We performed a retrospective review of charts of patients who had received palliative care consult between April 2002 and August 2002. Data on patient demographic, date of palliative care consult, and date and intensity of pain assessment were collected. A numerical rating scale from 0 (no pain) to 10 (worst pain) was used to assess pain intensity. The data were included for analysis if the pain intensity assessment was performed during the same shift by all three care providers (RN, CNA, and PCC).Results Forty-one charts were found to include a complete pain assessment performed by the RN, CNA, and PCC. The agreement of pain intensity between the PCC and both the RN and CNA was poor. For a diagnosis of moderate-to-severe pain, the RNs intensity assessment had a specificity of 90% but a sensitivity of 45%, and the CNAs intensity assessment had a specificity of 100% but a sensitivity of only 30%. The Spearman correlation coefficient between the intensity assessments performed by the PCC and the RN was 0.56 (p=0.00) and between those by the PCC and the CNA 0.22 (p=0.15).Conclusion Lack of agreement between pain intensity assessments performed by the PCC and bedside nurse suggests possible inconsistencies in the way the assessments were performed. Better education on how to perform standard pain intensity assessment is needed.     

Evaluating and monitoring analgesia and sedation in the intensive care unit

Management of analgesia and sedation in the intensive care unit requires evaluation and monitoring of key parameters in order to detect and quantify pain and agitation, and to quantify sedation. The routine use of subjective scales for pain, agitation, and sedation promotes more effective management, including patient-focused titration of medications to specific end-points. The need for frequent measurement reflects the dynamic nature of pain, agitation, and sedation, which change constantly in critically ill patients. Further, close monitoring promotes repeated evaluation of response to therapy, thus helping to avoid over-sedation and to eliminate pain and agitation. Pain assessment tools include self-report (often using a numeric pain scale) for communicative patients and pain scales that incorporate observed behaviors and physiologic measures for noncommunicative patients. Some of these tools have undergone validity testing but more work is needed. Sedation-agitation scales can be used to identify and quantify agitation, and to grade the depth of sedation. Some scales incorporate a step-wise assessment of response to increasingly noxious stimuli and a brief assessment of cognition to define levels of consciousness; these tools can often be quickly performed and easily recalled. Many of the sedation-agitation scales have been extensively tested for inter-rater reliability and validated against a variety of parameters. Objective measurement of indicators of consciousness and brain function, such as with processed electroencephalography signals, holds considerable promise, but has not achieved widespread implementation. Further clarification of the roles of these tools, particularly within the context of patient safety, is needed, as is further technology development to eliminate artifacts and investigation to demonstrate added value.     

Facilitating writing for publication

In order to develop physiotherapy practice and interventions, it is essential that both service development and research be brought into the public domain. Writing for publication requires a high level of writing skills, and clinicians facing competing demands for their time need strategies for productive writing. These skills and strategies are not always developed in undergraduate or postgraduate courses. This study assessed a writing for publication course for allied health professionals. It explored the writing skills and strategies that participants developed during the course. It also assessed whether these skills and strategies were sustained in clinical workplaces after the course. Clinical professionals, including physiotherapists, who had attended the 6-month course were identified. Semi-structured interviews were conducted with 12 of the 14 participants (four males, 10 females), including six physiotherapists. The results show that course participants reported a range of benefits, which included improved skills and increased confidence. They also increased their published output. However, participants also identified the need for ongoing support. This paper identifies the main issues in establishing writing for publication as part of the allied health professional role.     

Peeling the layers: a grounded theory of interprofessional co-learning with residents of a homeless shelter

Clients, patients, families, and communities must be conceived as partners in care delivery, not just as recipients (D'Amour, D. & Oandasan, I. (2005). Journal of Interprofessional Care, 19(Suppl.), 8-20). Health-care students need an opportunity to understand community member self-determination, partnership, and empowerment (Scheyett, A., & Diehl, M. ( 2004 ). Social Work Education, 23(4), 435-450), within the frame of interprofessional education (IPE) where community members are involved as teachers and learners. The aim of this grounded theory research was to determine the conditions that support health-care students to learn with, from, and about community members. This study took place in a shelter for the homeless where nursing and social work students learned interprofessionally along with residents and clients of the shelter. Data were gathered through 7 months of participant observation, interviews, and focus groups. The interprofessional co-learning theory that emerged introduces the three phases of entering, engaging, and emerging, which co-learners experienced at different levels of intensity. This article outlines the conditions that support each of these phases of the co-learning process. This interprofessional co-learning theory provides a basis for further development and evaluation of IPE programs that strive to actively include community members as teachers and learners, experts, and novices together with service providers, students, and faculty members.