Plasma Aluminum Concentrations in Pediatric Patients Receiving Long‐Term Parenteral Nutrition

Background: Patients receiving long‐term parenteral nutrition (PN) are at increased risk of aluminium (Al) toxicity because of bypass of the gastrointestinal tract during PN infusion. Complications of Al toxicity include metabolic bone disease (MBD), Al‐associated encephalopathy in adults, and impaired neurological development in preterm infants. Unlike the United States, there are no regulations regarding Al content of large‐ and small‐volume parenterals in Canada. We, therefore, aimed to present our data on plasma Al concentration and Al intake from our cohort of pediatric patients receiving long‐term PN. Methods: Plasma Al concentration was retrospectively gathered from the patient charts of all 27 patients with intestinal failure (IF) receiving long‐term PN at The Hospital for Sick Children, Toronto, Canada, and compared with age‐ and sex‐matched controls recruited for comparison. In addition, Al concentration was measured in PN samples collected from 10 randomly selected patients with IF and used to determine their Al intake. Results: The plasma Al concentration of patients with IF receiving long‐term PN was significantly higher than that of control participants (1195 ± 710 vs 142 ± 63 nmol/L; P < .0001). In the subgroup of 10 patients for whom Al intake from their PN solution was determined, mean ± SD Al intake from PN was 15.4 ± 15 µg/kg, 3 times the Food and Drug Administration upper recommended intake level, and Al intake was significantly related to plasma Al concentration (P = .02, r² = 0.52). Conclusion: Pediatric patients receiving long‐term PN for IF in Canada are at risk for Al toxicity.     

Clinical Outcomes in Critically Ill Patients Associated With the Use of Complex vs Weight‐Only Predictive Energy Equations

Background: The energy intake goal is important to achieving energy intake in critically ill patients, yet clinical outcomes associated with energy goals have not been reported. Methods: This secondary analysis used the Improving Nutrition Practices in the Critically III International Nutrition Surveys database from 2007–2009 to evaluate whether mortality or time to discharge alive is related to use of complex energy prediction equations vs weight only. The sample size was 5672 patients in the intensive care unit (ICU) ≥4 days and a subset of 3356 in the ICU ≥12 days. Mortality and time to discharge alive were compared between groups by regression, controlling for age, sex, admission type, Acute Physiology and Chronic Health Evaluation II score, ICU geographic region, actual energy intake, and obesity. Results: There was no difference in mortality between the use of complex and weight‐only equations (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.86–1.15), but obesity (OR, 0.83; 95% CI, 0.71–0.96) and higher energy intake (OR, 0.65; 95% CI, 0.56–0.76) had lower odds of mortality. Time to discharge alive was shorter in patients fed using weight‐only equations (hazard ratio [HR], 1.11; 95% CI, 1.01–1.23) in patients staying ≥4 days and with greater energy intake (HR, 1.19; 95% CI, 1.06–1.34) in patients in the ICU ≥12 days. Conclusion: These data suggest that higher energy intake is important to survival and time to discharge alive. However, the analysis was limited by actual energy intake <70% of goal. Delivery of full goal intake will be needed to determine the relationship between the method of determining energy goal and clinical outcomes.     

Critical appraisal training increases understanding and confidence and enhances the use of evidence in diverse categories of learners

Background

Training in evidence‐based medicine is most commonly offered to physicians, medical students and health‐care decision‐makers.

Setting and participants

We partnered with community organizations to recruit participants and develop trainings for consumers, non‐physician health‐care providers and journalists in California.

Intervention

We conducted half‐day and one‐day workshops in critical appraisal of health evidence. Workshops consisted of didactic presentations, small‐group practice sessions and class discussions.

Outcome measures

We measured knowledge and confidence immediately before and after the workshops and at follow‐up 6 months later. We also asked participants to describe their use of health evidence before the workshops and at follow‐up.

Results

At baseline, 41% of the consumers, 45% of the providers and 57% of the journalists correctly answered questions about health evidence. Scores increased by about 20% (P < 0.05) in all groups at the end of the workshops and remained significantly over baseline at follow‐up. At baseline, 26% of the participants were confident in their understanding of critical appraisal concepts, significantly increasing to 54% after the workshops and sustained (53%) at follow‐up. During discussions, participants’ comments often focused on funding and the potential effects of financial conflicts of interest on study findings. Participants did not use evidence more frequently at follow‐up but said that they applied workshop skills in evaluating research, communicating with others and making decisions about health care.

Conclusion

It is possible to successfully conduct critical appraisal workshops to aid health‐related decision making for groups who have previously not had access to this kind of training.     

Ontologies of nursing in an age of spiritual pluralism: closed or open worldview?

North American society has undergone a period of sacralization where ideas of spirituality have increasingly been infused into the public domain. This sacralization is particularly evident in the nursing discourse where it is common to find claims about the nature of persons as inherently spiritual, about what a spiritually healthy person looks like and about the environment as spiritually energetic and interconnected. Nursing theoretical thinking has also used claims about the nature of persons, health, and the environment to attempt to establish a unified ontology for the discipline. However, despite this common ground, there has been little discussion about the intersections between nursing philosophic thinking and the spirituality in nursing discourse, or about the challenges of adopting a common view of these claims within a spiritually pluralist society. The purpose of this paper is to discuss the call for ontological unity within nursing philosophic thinking in the context of the sacralization of a diverse society. I will begin with a discussion of secularization and sacralization, illustrating the diversity of beliefs and experiences that characterize the current trend towards sacralization. I will then discuss the challenges of a unified ontological perspective, or closed world view, for this diversity, using examples from both a naturalistic and a unitary perspective. I will conclude by arguing for a unified approach within nursing ethics rather than nursing ontology.     

Citizen minds,citizen bodies: the citizenship experience and the government of mentally ill persons

The concept of citizenship is becoming more and more prominent in specific fields, such as psychiatry/mental health, where it is constituted as a solution to the issues of exclusion, discrimination, and poverty often endured by the mentally ill. We argue that such discourse of citizenship represents a break in the history of psychiatry and constitutes a powerful strategy to counter the effects of equally powerful psychiatric labelling. However, we call into question the emancipatory promise of a citizenship agenda. Foucault's concept of governmentality is helpful in understanding the production of the citizen subject, its location within the ‘art of government’, as well as the ethical and political implications of citizenship in the context of mental health.     

Jamesian pragmatism: a framework for working towards unified diversity in nursing knowledge development

Nursing is frequently described as practical or pragmatic and there are many parallels between nursing and pragmatism, the school of thought. Pragmatism is often glancingly referenced by nursing authors, but few have conducted in‐depth discussions about its applicability to nursing; and few have identified it as a significant theoretical basis for nursing research. William James's pragmatism has not been discussed substantially in the nursing context, despite obvious complementarities. James's theme of pluralism fits with nursing's diversity and plurality; his emphasis on social conscience in our actions matches nursing's fundamental purpose of improving the lives of others; his continuous testing of pluralistic truths in critically reflective practice pairs well with nursing's focus on developing best‐available, holistic evidence; and his conceptualization of truth as being born in practice and becoming an instrument in practice is entirely compatible with nursing's theory–practice identity. The oft‐discussed theory–practice gap is seen to hinder the development of nursing knowledge. If nursing is to find its identity in knowledge development and potentiate the knowledge developed, it is imperative to identify and address that which is impeding progress. By way of the pragmatic tenets of William James, I will argue that a significant part of the theory–practice gap lies in how nursing knowledge development is operationalized, creating a false dichotomy between practice and research. I will also argue that the research–practice schism has been widened by continued philosophical and methodological infighting in the research community. I will describe how Jamesian pragmatism can be ‘what works’ for rebuilding relationships and supporting an engaged plurality within nursing research and bring research and practice together into a collaborative and iterative process of developing nursing knowledge.     

Phenomenology as research method or substantive metaphysics? An overview of phenomenology's uses in nursing

In exploring phenomenological literature, it is evident that the term ‘phenomenology’ holds rather different meanings depending upon the context. Phenomenology has been described as both a philosophical movement and an approach to human science research. The phenomenology of Husserl, Heidegger, Gadamer, and Merleau‐Ponty was philosophical in nature and not intended to provide rules or procedures for conducting research. The Canadian social scientist, van Manen, however, introduced specific guidelines for conducting human science research, which is rooted in hermeneutic phenomenology and this particular method has been employed in professional disciplines such as education, nursing, clinical psychology, and law. The purpose of this paper is to explore the difference between the phenomenological method as described by van Manen and that of other philosophers such as Husserl, Heidegger, Gadamer, and Merleau‐Ponty. In so doing, the author aims to address the blurred boundaries of phenomenology as a research method and as a philosophical movement and highlight the influence of these blurred boundaries on nursing knowledge development.