Multidimensional approaches to extending nurse faculty resources without testing faculty's patience

The diminishing number of nurse faculty requires the use of multidimensional strategies to extend faculty resources, especially for clinical courses. Chronic health problems and decreased endurance for demanding clinical courses often forces experienced faculty to retire early, increasing faculty shortages. The use of on-campus, high-fidelity simulation laboratories provides a learning environment that is less physically demanding than the hospital setting, while enabling older faculty to share their experience with students. Using high-fidelity simulations may also attract younger nurses to become educators. In addition to using clinical simulations, faculty resources can be extended through sharing faculty among nursing programs, using graduate teaching assistants in laboratory settings, and having senior nursing students validate underclassmen's competence in performing basic nursing skills.     

Bayesian Information Fusion Networks for Biosurveillance Applications

This study introduces new information fusion algorithms to enhance disease surveillance systems with Bayesian decision support capabilities. A detection system was built and tested using chief complaints from emergency department visits, International Classification of Diseases Revision 9 (ICD-9) codes from records of outpatient visits to civilian and military facilities, and influenza surveillance data from health departments in the National Capital Region (NCR). Data anomalies were identified and distribution of time offsets between events in the multiple data streams were established. The Bayesian Network was built to fuse data from multiple sources and identify influenza-like epidemiologically relevant events. Results showed increased specificity compared with the alerts generated by temporal anomaly detection algorithms currently deployed by NCR health departments. Further research should be done to investigate correlations between data sources for efficient fusion of the collected data.     

Ready or Not,Here They Come: Acting Interns’ Experience and Perceived Competency Performing Basic Medical Procedures

Objective To assess acting interns’ (AI’s) experience with and perceived level of competency performing 6 basic medical procedures. Design Fourth-year medical students at the University of Cincinnati (UCCOM) are required to complete 2 AI rotations in Internal Medicine. All AIs in 2003–2004 (n = 150) and 2004–2005 (n = 151) were asked to complete a survey about whether during each of their rotations they had performed and felt competent performing the following procedures: phlebotomy, intravenous (IV) catheter insertion, arterial blood gas (ABG), nasogastric (NG) tube insertion, lumbar puncture (LP), and Foley catheter insertion. Results Four hundred sixty-seven of 601 possible surveys (across both years and both rotations) were completed (78% response rate). During both rotations, relatively few students performed the procedures, ranging from 9% for Foley catheter insertion (24/208) to 50% for both ABG and NG tube insertion (130/259). The two procedures most often performed were ABG (range 46–50%) and NG tube insertion (range 42–50%). Feelings of competency varied from 12% (LP) to 82% (Foley catheter). Except for LP, if students performed a procedure at least once, they reported feeling more competent (range 85% for ABG to 96% for Foley catheter insertion). Among the students who performed LP during a rotation, many still did not feel competent performing LPs: 23 (74%) in rotation 1 and 20 (40%) in rotation 2. Conclusion Many fourth-year students at UCCOM do not perform basic procedures during their acting internship rotations. Procedural performance correlates with feelings of competency. Lumbar puncture competency may be too ambitious a goal for medical students.     

Weekly rifapentine/isoniazid or daily rifampin/pyrazinamide for latent tuberculosis in household contacts

RATIONALE: Treatment of latent tuberculosis (TB) infection with weekly rifapentine and isoniazid is a potentially effective alternative to current therapies. OBJECTIVES: To compare the efficacy of weekly rifapentine/isoniazid to daily rifampin/pyrazinamide in preventing TB in household contacts of patients with pulmonary TB in Brazil. METHODS: Contacts of patients with TB were randomized to rifapentine 900 mg/isoniazid 900 mg once weekly for 12 wk or rifampin 450-600 mg/pyrazinamide 750-1,500 mg daily for 8 wk and followed for at least 2 yr. MEASUREMENTS: TB rates, adverse events, and adherence to therapy. MAIN RESULTS: A total of 399 household contacts were enrolled, 206 in the rifapentine/isoniazid arm and 193 in the rifampin/pyrazinamide arm. The median age was 34 yr, median weight was 63 kg, 60% of participants were female, and only one patient was HIV infected. Rifapentine/isoniazid was well tolerated, but the trial was halted by the investigators before completion because of unanticipated hepatotoxicity in the rifampin/pyrazinamide arm. Twenty of 193 participants (10%) receiving rifampin/pyrazinamide experienced grade 3 or 4 hepatotoxicity, compared with 2 of 206 participants (1%) on rifapentine/isoniazid (p<0.001). There were no hospitalizations or deaths due to hepatotoxicity, and all participants' liver enzyme levels returned to normal during follow-up. During follow-up, four cases of active TB developed, three in the rifapentine/isoniazid group and one in the rifampin/pyrazinamide group (1.46 vs. 0.52%; difference, 0.94%; 95% confidence interval, -1.6 to 3.7%). CONCLUSIONS: Rifapentine/isoniazid was better tolerated than rifampin/pyrazinamide and was associated with good protection against TB. Rifapentine/isoniazid weekly for 12 wk is likely a promising therapy for latent TB infection.     

FDG-PET status following chemoradiotherapy provides high management impact and powerful prognostic stratification in oesophageal cancer

Purpose The purpose of this study was to evaluate the impact of FDG-PET following chemoradiotherapy (CRT) on treatment planning and survival in patients with oesophageal cancer (OC). Methods Fifty-three consecutive OC patients had a post-treatment PET scan to evaluate tumour response to CRT prior to possible surgery. Baseline pre-CRT PET was performed in 33 patients. Prospectively recorded post-CRT management plans were compared with post-PET treatment. High impact was defined as a change in treatment intent or modality. Survival was analysed using the Kaplan-Meier product limit method and Cox proportional hazards regression model. Results After completion of CRT, 23/53 patients (43%) achieved complete metabolic response (CMR), as compared with only four (8%) with complete response on computed tomography. High PET impact was observed in 19 patients (36%). CMR was strongly predictive of survival (p<0.008) on multivariate analysis. CMR patients in whom resection was not performed had comparable survival to those (CMR and non-CMR) who underwent resection. Conclusion The use of post-treatment FDG-PET for assessment of tumour response after CRT changed the clinical management of more than one-third of OC patients. CMR status as assessed by PET powerfully stratified prognosis. Even in the absence of a baseline study, normalisation of uptake at all sites of known tumoral involvement carries a good medium-term prognosis. Data from this study were presented at the American Society of Surgical Oncology (plenary session), New York, March 2004, and the Royal Australasian College of Surgeons’ Annual Scientific Congress, Melbourne, May 2004.     

Reducing Drug Costs at a Veterans Affairs Hospital by Increasing Market-share of Generic Fluoxetine

We previously showed that a multifaceted intervention designed to contain costs of prescribing selective serotonin reuptake inhibitors (SSRIs) at a Veterans Affairs hospital resulted in substantial projected savings. Intervention components included clinician education and pharmacy and computer information process changes. We now report on effects of altering the intervention to promote prescribing of generic fluoxetine. Over 30 months, fluoxetine’s market-share increased from 12 to 32% of all SSRIs prescribed. A total of $2,500,000 in cost avoidance resulted from substituting generic for brand fluoxetine, and $600,000 resulted from increases in market-share of fluoxetine. The results highlight the robustness and flexibility of the intervention approach. Steven K. Dobscha is affiliated with the Behavioral Health and Clinical Neurosciences Division, Portland VA Medical Center, Portland, OR, USA and Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA. Lisa M. Winterbottom is affiliated with the Division of Hospital and Specialty Medicine, Portland VA Medical Center, Portland, OR, USA and Department of Medicine, Oregon Health & Science University, Portland, OR, USA. Lisa M. Winterbottom and LeAnn S. Snodgrass are affiliated with the Portland Center for the Evaluation of Clinical Services, Portland, OR, USA. Address correspondence to Steven K. Dobscha, M.D., Behavioral Health and Clinical Neurosciences Division, Portland VA Medical Center, P. O. Box 1034 (P3MHDC), Portland, 97207 OR, USA; e-mail: steven.dobscha@med.va.gov     

Advanced glycation end-product accumulation and associated protein modification in type II skeletal muscle with aging

One mechanism that may influence the quality of skeletal muscle proteins, and explain the age-related decline in contractility, is protein damage. Advanced glycation end-products (AGE) in vivo are useful biomarkers of damage. In this study, comparison of extensor digitorum longus (EDL) muscles from young (8 months), old (33 months), and very old (36 months) Fischer 344 Brown Norway F1 (F344BNF1) hybrid rats shows that muscles from the very old rats have a significantly higher percentage of myofibers that immunolabel intracellularly for AGE-antibody 6D12 compared to the younger age group. The AGE-modified proteins, determined in the semimembranosus muscles from young (9 months) and old (27 months) F344 rats, identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry include creatine kinase, carbonic anhydrase III, beta-enolase, actin, and voltage-dependent anion-selective channel 1. Moreover, there is a significant increase in AGE modification of beta-enolase with age. These results identify a common subset of proteins that contain AGE and suggest that metabolic proteins are targets for glycation with aging.     

Avian Influenza: Mixed Infections and Missing Viruses

A high prevalence and diversity of avian influenza (AI) viruses were detected in a population of wild mallards sampled during summer 2011 in California, providing an opportunity to compare results obtained before and after virus culture. We tested cloacal swab samples prior to culture by matrix real-time PCR, and by amplifying and sequencing a 640bp portion of the hemagglutinin (HA) gene. Each sample was also inoculated into embryonated chicken eggs, and full genome sequences were determined for cultured viruses. While low matrix Ct values were a good predictor of virus isolation from eggs, samples with high or undetectable Ct values also yielded isolates. Furthermore, a single passage in eggs altered the occurrence and detection of viral strains, and mixed infections (different HA subtypes) were detected less frequently after culture. There is no gold standard or perfect reference comparison for surveillance of unknown viruses, and true negatives are difficult to distinguish from false negatives. This study showed that sequencing samples prior to culture increases the detection of mixed infections and enhances the identification of viral strains and sequences that may have changed or even disappeared during culture.