Effectiveness of a clinical ladder program

A 5-hospital system shares results of the evaluation of a clinical ladder program. Improvements were noted in overall satisfaction with the program, nurse retention of those who participated in the program, and costs savings due to decreased turnover. The authors point out the importance of evaluating the effectiveness of advancement programs for nurses. The analysis of a clinical ladder program in relation to costs, financial impact, and benefits helps to justify the salary increments for the ladder programs. This article provides the nurse executive with appropriate justification and outcome data to effectively champion these programs.     

Health effects of garlic

Garlic has long been used medicinally, most recently for its cardiovascular, antineoplastic, and antimicrobial properties. Sulfur compounds, including allicin, appear to be the active components in the root bulb of the garlic plant. Studies show significant but modest lipid-lowering effects and antiplatelet activity. Significant blood pressure reduction is not consistently noted. There is some evidence for antineoplastic activity and insufficient evidence for clinical antimicrobial activity. Side effects generally are mild and uncommon. Garlic appears to have no effect on drug metabolism, but patients taking anticoagulants should be cautious. It seems prudent to stop taking high dosages of garlic seven to 10 days before surgery because garlic can prolong bleeding time.     

The familial Mediterranean fever (MEVF) gene as a modifier of Crohn's disease

OBJECTIVES: Crohn's disease (CD) has been reported to be more frequent among non-Ashkenazi Jewish patients suffering from familial Mediterranean fever (FMF). Interestingly, functional similarities between the CD susceptibility gene (NOD2/CARD15) and the FMF gene (MEFV) have been described: both belong to the death domain containing protein family, important in the regulation of apoptosis, cytokine processing and inflammation. AIMS: To investigate the prevalence of MEFV mutations in Jewish non-Ashkenazi CD patients and its putative effect on CD presentation. METHODS: Germline DNA of 105 Israeli CD patients of non-Ashkenazi and mixed Ashkenazi-non-Ashkenazi ethnic background was analyzed for three most common MEFV mutations: M694V, V726A, and E148Q. Five patients (4.7%) with a clinical diagnosis of FMF were included. Data obtained from each patient included: age of onset, disease location, and behavior, the presence of extraintestinal manifestations of CD and therapeutic regimens. RESULTS: The overall prevalence of mutation carriers among non-FMF-CD patients was 13% (13/100). A stricturing disease pattern was observed in 56% (10/18) of all carriers, FMF-CD, and non-FMF-CD patients, and in 25% (22/87) of noncarriers (OR: 3.7, 95% CI: 1.3-10.5, p= 0.015). The prevalence of fistulas was comparable in both groups. Extraintestinal manifestations were significantly more frequent among carriers than noncarriers (65%vs 32%, OR 3.9, 95% CI = 1.3-11.5, p= 0.015). No differences were observed in disease location and disease severity. CONCLUSIONS: MEFV mutations are not associated with CD susceptibility, yet the presence of these mutations appears to be associated with a stricturing disease pattern and extraintestinal disease manifestations of CD.     

Effects of conjugated equine estrogen on health-related quality of life in postmenopausal women with hysterectomy: results from the Women's Health Initiative Randomized Clinical Trial

BACKGROUND: The Women's Health Initiative (WHI) clinical trial of conjugated equine estrogens (CEEs), involving 10,739 postmenopausal women with hysterectomy, aged 50 to 79 years, was stopped early owing to lack of overall health benefit and increased risk of stroke. Because CEE is still prescribed for treatment of menopausal symptoms and prevention of osteoporosis, it is important to understand the overall impact of this therapy on health-related quality of life (HRQOL). METHODS: All participants completed 6 specific measures of quality of life at baseline and 1 year, and a subsample (n = 1189) also completed the questions 3 years after randomization. Changes in scores were analyzed for treatment effect. RESULTS: Randomization to CEE was associated with a statistically significant but small reduction in sleep disturbance at year 1 compared with baseline (mean benefit, 0.4 points on a 20-point scale) and a statistically significant but small negative effect on social functioning (mean effect, -1.3 points on a 100-point scale). There were no significant improvements due to CEE in the areas of general health, physical functioning, pain, vitality, role functioning, mental health, depressive symptoms, cognitive function, or sexual satisfaction at year 1. A subgroup examined 3 years after baseline had no significant benefits for any HRQOL outcomes. Among women aged 50 to 54 years with moderate to severe vasomotor symptoms at baseline, CEE did not improve any of the HRQOL variables at year 1. CONCLUSION: In this trial of postmenopausal women with prior hysterectomy, oral CEE did not have a clinically meaningful effect on HRQOL.     

Severely compromised quality of life in women and those of lower socioeconomic status waiting for joint replacement surgery

OBJECTIVE: To determine health-related quality of life (HRQOL), psychological distress, physical function, and self efficacy in persons waiting for lower-limb joint replacement surgery. METHODS: A total of 214 patients on a waiting list for unilateral primary total knee or hip replacement at a large Australian public teaching hospital completed questionnaires after entry to the list. HRQOL and psychological distress were compared with available population norms. RESULTS: Average HRQOL was extremely poor (mean +/- SD 0.39 +/- 0.24) and much lower (>2 SD) than the population norm. Near death-equivalent HRQOL or worse than death-equivalent HRQOL were reported by 15% of participants. High or very high psychological distress was up to 5 times more prevalent in the waiting list sample (relative risk 5.4 for participants ages 75 years and older; 95% confidence interval 3.3, 9.0). Women had significantly lower HRQOL, self efficacy, and physical function scores than men. After adjusting for age and sex, significant socioeconomic disparities were also found. Participants who received the lowest income had the poorest HRQOL; those with the least education or the lowest income had the highest psychological distress. Low self efficacy was moderately associated with poor HRQOL (r = 0.49, P < 0.001) and more strongly associated with high psychological distress (r = -0.55, P < 0.001). CONCLUSION: Patients waiting for joint replacement have very poor HRQOL and high psychological distress, especially women and those from lower socioeconomic backgrounds. Lengthy waiting lists mean patients can experience extended and potentially avoidable morbidity. Interventions to address psychological distress and self efficacy could reduce this burden and should target women and lower socioeconomic groups.     

Gender differences and predictors of mortality in spontaneous coronary artery dissection: a review of reported cases

Spontaneous coronary artery dissection (SCAD) is a rare clinical event with little available information on etiology, treatment, or outcomes. Two cases of SCAD are presented and identified cases from the literature with complete data (n = 222) are reviewed and analyzed. Female patients (71.9%) were younger (40.4 versus 46.7; p < 0.001), less likely to have coronary artery disease (3.7 versus 20.6%; p = 0.01), more likely to have left anterior descending artery (46.4 versus 25.4%; p = 0.004) and left main artery involvement (14.9 versus 3.2%; p = 0.01), and less likely to survive (50.9 versus 22.2%; p < 0.001) compared to their male counterparts. Thirty percent were in the peripartum state. Multivariate predictors of death included female sex (OR 4.27; 95% CI 1.50 to 12.2), non-treatment (OR 35.5; 95% CI 10.7 to 118.1), and earlier decade of diagnosis (OR 0.28 per increase in decade after 1980; 95% CI 0.16 to 0.49). Survival was no different by treatment type and did improve over time.     

Crossing cultures: the lived experience of Jordanian graduate students in nursing: a qualitative study

This qualitative phenomenologic study explores the meaning of crossing cultures as experienced by Jordanian graduate students in nursing. Seven male and female students participated in conversations and journals regarding their experiences in the academic, social and professional realms of an American culture at a private, mid-Atlantic university. An analysis of the text revealed an overarching theme, "metamorphosis of self." Events leading to the metamorphosis included being chosen, experiencing a time full of memories, feeling bombarded with stimuli and "looking to do something" as professional nurses in Jordan.     

Low-dose leptin reverses skeletal muscle, autonomic, and neuroendocrine adaptations to maintenance of reduced weight

Maintenance of a reduced body weight is accompanied by decreased energy expenditure that is due largely to increased skeletal muscle work efficiency. In addition, decreased sympathetic nervous system tone and circulating concentrations of leptin, thyroxine, and triiodothyronine act coordinately to favor weight regain. These "weight-reduced" phenotypes are similar to those of leptin-deficient humans and rodents. We examined metabolic, autonomic, and neuroendocrine phenotypes in 10 inpatient subjects (5 males, 5 females [3 never-obese, 7 obese]) under 3 sets of experimental conditions: (a) maintaining usual weight by ingesting a liquid formula diet; (b) maintaining a 10% reduced weight by ingesting a liquid formula diet; and (c) receiving twice-daily subcutaneous doses of leptin sufficient to restore 8 am circulating leptin concentrations to pre-weight-loss levels and remaining on the same liquid formula diet required to maintain a 10% reduced weight. During leptin administration, energy expenditure, skeletal muscle work efficiency, sympathetic nervous system tone, and circulating concentrations of thyroxine and triiodothyronine returned to pre-weight-loss levels. These responses suggest that the weight-reduced state may be regarded as a condition of relative leptin insufficiency. Prevention of weight regain might be achievable by strategies relevant to reversing this leptin-insufficient state.     

Human breast cancer resistance protein: interactions with steroid drugs, hormones, the dietary carcinogen 2-amino-1-methyl-6-phenylimidazo(4,5-b)pyridine, and transport of cimetidine

The breast cancer resistance protein (BCRP/ABCG2) is an ATP-binding cassette drug efflux transporter that extrudes xenotoxins from cells, mediating drug resistance and affecting the pharmacological behavior of many compounds. To study the interaction of human wild-type BCRP with steroid drugs, hormones, and the dietary carcinogen 2-amino-1-methyl-6-phenylimidazo(4,5-b)pyridine (PhIP), we expressed human BCRP in the murine MEF3.8 fibroblast cell line, which lacks Mdr1a/1b P-glycoprotein and Mrp1, and in the polarized epithelial MDCKII cell line. We show that PhIP was efficiently transported by human BCRP in MDCKII-BCRP cells, as was found previously for murine Bcrp1. Furthermore, we show that six out of nine glucocorticoid drugs, corticosterone, and digoxin increased the accumulation of mitoxantrone in the MEF3.8-BCRP cell line, indicating inhibition of BCRP. In contrast, aldosterone and ursodeoxycholic acid had no significant effect on BCRP. The four most efficiently reversing glucocorticoid drugs (beclomethasone, 6alpha-methylprednisolone, dexamethasone, and triamcinolone) and 17beta-estradiol showed a significantly reduced BCRP-mediated transepithelial transport of PhIP by MDCKII-BCRP cells, with the highest reduction of PhIP transport ratio for beclomethasone (from 25.0 +/- 1.1 to 2.7 +/- 0.0). None of the tested endogenous steroids or synthetic glucocorticoids or digoxin, however, were transported substrates of BCRP. We also identified the H(2)-receptor antagonist drug cimetidine as a novel efficiently transported substrate for human BCRP and mouse Bcrp1. The generated BCRP-expressing cell lines thus provide valuable tools to study pharmacological and toxicological interactions mediated by BCRP and to identify new BCRP substrates.     

Participatory action research to understand and reduce health disparities

Participatory action research (PAR) is an excellent way to systematically learn about the conditions under which people experience health disparities, what it is like from the perspective of those experiencing such disparities and, even more importantly, how to ameliorate this major public health problem and create a more equitable and effective health care system. This article describes the method of PAR, supports the appropriateness of PAR to learn about and reduce health disparities, and then presents some specific examples of research projects that have employed or are planning to employ PAR. These examples are from the work of several authors of this article, who are members of an interdisciplinary working group that serves as a forum for discussion of issues related to qualitative research methods and facilitates the development of qualitative studies. All of the authors of this article are part of a task force of this working group that is focusing specifically on community outreach with the goal of reducing health disparities within specific communities.