Canadian oncology nurse work environments: part II

In the aftermath of healthcare restructuring, it is important to pay attention to nurses' perceptions of workplace and professional practice factors that attract nurses and influence their retention. Continuing constraints on cancer care systems make the issue of health human resources an ongoing priority. This paper presents the findings of a follow-up study of a cohort of Canadian oncology nurses that aimed to compare nurses' perceptions of their work environment, job satisfaction and retention over a two-year period. Participants of the follow-up survey represented 65% (397/615) of the initial cohort. Many similar perceptions about the work environment were found over two years; however, at follow-up a larger proportion of nurses reported an absence of enough RNs to provide quality care and a lack of support for innovative ideas. With respect to career status, only 6% (25/397) of the follow-up sample had left oncology nursing. However, the proportion of nurses declaring an intention to leave their current job increased from 6.4% (39/615) on the initial survey to 26% (102/397) on the follow-up survey. Findings suggest that decision-makers need to use both the growing body of workplace knowledge and the input from staff nurses to implement changes that positively influence nurse recruitment and retention. Future research should focus on the implementation and evaluation of strategies that address workplace issues such as nurse staffing adequacy, leadership and organizational commitment.     

Developing an action plan for patient radiation safety in adult cardiovascular medicine: proceedings from the Duke University Clinical Research Institute/American College of Cardiology Foundation/American Heart Association think tank held on February 28, 2011

Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert "think tank" reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community, but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.     

Cor Triatriatum With Partial Anomalous Pulmonary Venous Return: A Rare Case of Parallel Obstruction and Successful Staged Treatment

Cor triatriatum sinister is an uncommon congenital cardiac defect that has rarely been described in association with left-sided partial anomalous pulmonary venous return. We present a case of such rare anatomy with multilevel obstruction that presented in infancy as cardiogenic shock. The patient underwent staged treatment with extracorporeal membrane oxygenation stabilization, catheter-based balloon dilatation of the cor triatriatum and atrial septostomy, followed by definitive surgical repair, with excellent result.     

High maternal vitamin E intake by diet or supplements is associated with congenital heart defects in the offspring

Objective  To study associations between maternal dietary and supplement intake of antioxidants vitamin E, retinol and congenital heart defects (CHDs).
Design  Case–control study.
Setting  Erasmus MC, University Medical Center Rotterdam, the Netherlands.
Population  Participants were 276 case mothers of a child with CHD and 324 control mothers with their children.
Methods  Food frequency questionnaires covering the intake of the previous 4 weeks were filled out at 16 months after the index pregnancy. Data were compared between cases and controls using the Mann–Whitney U test. Risk estimates for the association between CHD and dietary intake of vitamin E and retinol were estimated in a multivariable logistic regression model.
Main outcome measures  Medians (5–95th percentile) and odds ratios with 95% CI.
Results  Dietary vitamin E intake was higher in case mothers than in controls, 13.3 (8.1–20.4) and 12.6 (8.5–19.8) mg/day ( P = 0.05). CHD risk increased with rising dietary vitamin E intakes ( P -trend = 0.01). Periconception use of vitamin E supplements in addition to a high dietary vitamin E intake above 14.9 mg/day up to nine-fold increased CHD risk. Retinol intakes were not significantly different between the groups and not associated with CHD risk.
Conclusions  High maternal vitamin E by diet and supplements is associated with an increased risk of CHD offspring.     

Ligand selectivity of D2 dopamine receptors is modulated by changes in local dynamics produced by sodium binding

We have uncovered a significant allosteric response of the D(2) dopamine receptor to physiologically relevant concentrations of sodium (140 mM), characterized by a sodium-enhanced binding affinity for a D(4)-selective class of agonists and antagonists. This enhancement is significantly more pronounced in a D(2)-V2.61(91)F mutant and cannot be mimicked by an equivalent concentration of the sodium replacement cation N-methyl-D-glucamine. This phenomenon was explored computationally at the molecular level by analyzing the effect of sodium binding on the dynamic properties of D(2) receptor model constructs. Normal mode analysis identified one mode (M(19)), which is involved in the open/closed motions of the binding cleft as being particularly sensitive to the sodium effect. To examine the consequences for D(2) receptor ligand recognition, one of the ligands, L-745,870 [3-{[4-(4-chlorophenyl) piperazin-1-yl]-methyl}-1H-pyrrolo[2,3-b]pyridine or CPPMA, chlorophenylpiperazinyl methylazaindole], was docked into conformers along the M(19) trajectory. Structurally and pharmacologically well established ligand-receptor interactions, including the ionic interaction with D3.32(114) and interactions between the ligand aryl moieties and V2.61(91)F, were achieved only in "open" phase conformers. The docking of (-)-raclopride [3,5-dichloro-N-(1-ethylpyrrolidin-2-ylmethyl)-2-hydroxy-6-methoxybenzamide] suggests that the same binding cleft changes in response to sodium-binding perturbation account as well for the enhancements in binding affinity for substituted benzamides in the wild-type D(2) receptor. Our findings demonstrate how key interactions can be modulated by occupancy at an allosteric site and are consistent with a mechanism in which sodium binding enhances the affinity of selected ligands through dynamic changes that increase accessibility of substituted benzamides and 1,4-DAP ligands to the orthosteric site and accessibility of 1,4-DAPs to V2.61(91)F.     

Blood Pressure Control in Diabetes: Temporal progress yet persistent racial disparities: national results from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

OBJECTIVE

Despite widespread dissemination of target values, achieving a blood pressure of <130/80 mmHg is challenging for many individuals with diabetes. The purpose of the present study was to examine temporal trends in blood pressure control in hypertensive individuals with diabetes as well as the potential for race, sex, and geographic disparities.

RESEARCH DESIGN AND METHODS

We analyzed baseline data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal cohort study of 30,228 adults (58% European American and 42% African American), examining the causes of excess stroke mortality in the southeastern U.S. We calculated mean blood pressure and blood pressure control rates (proportion with blood pressure <130/80 mmHg) for 5,217 hypertensive diabetic participants by year of enrollment (2003–2007) using multivariable logistic regression models.

RESULTS

Only 43 and 30% of European American and African American diabetic hypertensive participants, respectively, demonstrated a target blood pressure of <130/80 mmHg (P < 0.001). However, a temporal trend of improved control was evident; the odds of having a blood pressure <130/80 mmHg among diabetic hypertensive participants of both races enrolled in 2007 (as compared with those enrolled in 2003) were ∼50% greater (P < 0.001) in multivariate models.

CONCLUSIONS

These data suggest temporal improvements in blood pressure control in diabetes that may reflect broad dissemination of tighter blood pressure control targets and improving medication access. However, control rates remain low, and significant racial disparities persist among African Americans that may contribute to an increased risk for premature cardiovascular disease.In 2003, the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure published (1) revised recommendations (JNC 7) on the management of hypertension that recommended a lower target for patients with diabetes (130/80 mmHg) than for the general population with uncomplicated essential hypertension (140/90 mmHg). This differential target was originally based on early studies (2,3), suggesting a benefit from further blood pressure reduction in helping to offset higher renal and cardiovascular risk. Subsequent evidence from the UK Prospective Diabetes Study (UKPDS) (4), the Hypertension Optimal Treatment (HOT) (5) Study, the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) (6) Study, and the Stop Atherosclerosis in Native Diabetics Study (SANDS) (7) all demonstrated improved outcomes in patients assigned to tighter blood pressure control. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) (8) Study, despite discontinuation of an intensive glucose reduction arm in February 2008 (9), is investigating the value of reducing blood pressure to ≤120 mmHg, and results will be available soon.Published goal values for blood pressure in patients with diabetes of <130 mmHg for systolic blood pressure and <80 mmHg for diastolic blood pressure represent a differential and more aggressive target for diabetic patients when compared with uncomplicated nondiabetic patients with essential hypertension. However, the extent to which this differential goal has been effectively achieved in routine practice has not been sufficiently examined, especially in large national samples. Wang (10) examined the effect of this guideline change on hypertension control in diabetic patients during the time period 1995 through 2005 and demonstrated only a modest differential improvement in blood pressure control in diabetic subjects. However, this physician office–based study was insufficient to examine the population-level impact of the 2003 JNC 7 guideline change. Population-level data from National Health and Nutrition Examination Survey 1999 through 2004 (11) suggest more substantial improvement in blood pressure control in patients with diabetes; however, the timing of these observations does not allow examination of the longitudinal effects of the 2003 guideline change. Additionally, investigators have not sufficiently examined the potential for racial and geographic differences in the extent to which blood pressure control has improved in a population-based sample in response to these guideline changes. Because of differential risks for diabetic complications by race, such studies are of critical importance. Therefore, the purpose of the present study is to examine temporal trends in blood pressure control in hypertensive individuals with diabetes as well as the potential for race, sex, and geographic disparities. To meet these goals, the primary analysis herein is to compare mean systolic and diastolic blood pressure values and the proportion of hypertensive diabetic subjects with guideline-recommended blood pressure values by race, sex, and region across different time points over the time period 2003 through 2007.     

004 静脉注射Dofetilide迅速终止心房纤颤与心房扑动的疗效和安全性

研究心房纤颤/心房扑动[(atrial fibrillation;AF)/(atrial flutter;AFI)]患者69例,男46、女23,平均年龄60岁(25～75岁),随机分成4组(即输注Dofetilide 2μg/kg组、4μg/kg组、8μg/kg组和安慰剂对照组)。 研究结果,转律的成功率分别为：2μg/kg组为25％(4/16)、4μg/kg组为29％(5/17)、8μg/kg组为39％(7/18);对照组为6％(1/18)。 AF/AFI持续时间决定着转律的成功率,持续时间＜24小时者,成功率为67％(4/6)、1～7天者为36％(4/11)、7天以上者为24％(8/34)。 输注Dofetilide总的转律成功率,单剂一次输注为31％(16/51;p=0.03;95％CI 19～46);二次输注为38％(26/68;p=0.009;95％CI 27～51)。安慰剂对照组则为6％(1/18;95％CI0～27)。转为窦律的平均时间是从开始输注起的22分钟(5-49分钟)。     

Histologic evaluation of fetal brains following maternal pneumoperitoneum

Background: The purpose of this study was to determine if maternal pneumoperitoneum with carbon dioxide (CO2) produces evidence of central nervous system (CNS) injury in preterm fetal guinea pigs. Methods: Thirty pregnant guinea pigs at gestational day (GD) 45 were assigned at random to one of three treatment groups: anesthesia only, CO2 pneumoperitoneum (5 mmHg), or laparotomy. Dams were killed 3 or 5 days postprocedure and fetal brains (83 total) harvested and fixed for subsequent histopathologic evaluation. For comparative purposes, histologic features of fetal guinea pig brain injury were defined from examination of fetal brains harvested from an additional dam that underwent laparotomy with 20 min of uterine arterial occlusion. Results: Carbon dioxide pneumoperitoneum did not increase maternal/fetal morbidity. No evidence of brain injury was found in fetuses from any of the treatment groups. Conclusion: Carbon dioxide pneumoperitoneum at 5 mmHg for 40 min in the pregnant guinea pig does not produce evidence of fetal brain injury.     

Endodermal cyst of the oculomotor nerve

Endodermal cysts are rare congenital intracranial lesions. Although histologically benign, they can become symptomatic as a result of mass effect and cause neurological deficits. We report a 30-year-old woman who presented with paresis of her right oculomotor nerve. Magnetic resonance imaging showed a 13 x 8-mm cystic lesion originating from the right oculomotor nerve at its exit from the mesencephalon. She underwent craniotomy, biopsy, slit resection, and drainage of the cyst. To our knowledge, endodermal cysts have not been previously described in relation to the oculomotor nerve.     

Screening for Diabetic Retinopathy in Rural Areas: The Potential of Telemedicine

Diabetic retinopathy is a common cause of blindness, and screening can identify the disease at an earlier, more treatable stage. However, rural individuals with diabetes may have limited access to needed eye care. The objective of this project was to demonstrate the feasibility of a diabetic retinopathy screening program using a state-of-the-art nonmydriatic digital fundus imaging system. The study involved a series of patients screened in primary care and public health locations throughout seven predominantly rural counties in eastern North Carolina. Images of each fundus were obtained and sent to a retinal specialist. The retinal specialist reviewed each image, recorded image quality, diagnosed eye disease and made recommendations for subsequent care. Of 193 volunteers with a history of diabetes mellitus, 96.3 percent reported that they were very comfortable or comfortable with the camera. Eighty-five percent of images were rated as good or fair by the retinal specialist. The retinal specialist also reported being very certain or certain of the diagnosis in 84 percent of cases. Image quality correlated highly with the certainty of diagnosis (Spearman's rank order correlation coefficient = 0.79; P < 0.001). The average time since the previous examination by an eye care specialist for diabetic subjects was two years. Approximately 62 percent of diabetic patients had diagnosable eye conditions, the most common of which was diabetic retinopathy (40.9 percent). In this convenience sample, African Americans, despite similar age and disease duration, were more likely to have retinopathy. Digital imaging is a feasible screening modality in rural areas, may improve access to eye care, and may improve compliance with care guidelines for individuals with diabetes mellitus.