Creative thinking in nursing education: preparing for tomorrow's challenges

The present health care environment requires creative change, a thought that evokes both excitement and apprehension and offers a clear challenge for the contemporary nurse. In this era of capitation, re-engineering, and redesign in the health care system, nursing programs must prepare nurses who can successfully perform in an environment that demands innovative problem solving. Integrating creative problem solving into this BSN program has (1) provided students with information and experience in the creative process, (2) fostered the personal creative development of nurses, (3) challenged students to use creative thinking in solving nursing problems, and most important, (4) further established and reinforced a new, higher level of nursing practice--a level that appropriately sees the nurse as a creative and innovative member of the health care team.

Effect of intensive therapy for heart failure on the vasodilator response to exercise

OBJECTIVES

The purpose of the study was to evaluate the lower extremity vascular responsiveness to metabolic stimuli in patients with heart failure and to determine whether these responses improve acutely after intensive medical therapy.

BACKGROUND

Metabolic regulation of vascular tone is an important determinant of blood flow, and may be abnormal in heart failure.

METHODS

The leg blood flow responses were measured in 11 patients with nonedematous class III-IV heart failure before and after inpatient medical therapy and in 10 normal subjects. Venous occlusion plethysmography was used to measure peak blood flow and total hyperemia in the calf after arterial occlusion and also after isotonic ankle exercise. Measurements were repeated following short-term inpatient treatment with vasodilators and diuretics administered to decrease right atrial pressure (18+/-2 to 7+/-1 mm Hg), pulmonary wedge pressure (32+/-3 to 15+/-2 mm Hg), and systemic vascular resistance (1581+/-200 to 938+/-63 dynes.s.cm(-5), all p < 0.02).

RESULTS

Leg blood flow at rest, after exercise, and during reactive hyperemia was less in heart failure patients than in control subjects. Resting leg blood flow did not increase significantly after medical therapy, but peak flow after the high level of exercise increased by 59% (p = 0.009). Total hyperemic volume in the recovery period increased by 73% (p = 0.03). Similarly, the peak leg blood flow response to ischemia increased by 88% (p = 0.04), whereas hyperemic volume rose by 98% (p = 0.1).

CONCLUSIONS

The calf blood flow responses to metabolic stimuli are blunted in patients with severe heart failure, and improve rapidly with intensive medical therapy.

Repeat tear of postoperative meniscus: potential MR imaging signs

PURPOSE

To determine the usefulness of five magnetic resonance (MR) signs of repeat tears of the postoperative meniscus.

MATERIALS AND METHODS

Fat-saturated proton-density-weighted and T2-weighted MR images in 20 patients who had undergone at least two knee surgeries were reviewed. Second-look arthroscopic confirmation of meniscal status was available in all patients. MR images of 39 menisci (10 repeat tears, 11 postoperative menisci without repeat tears, three tears in previously normal menisci, and 15 normal menisci) were evaluated for (a) a linear area of abnormal signal intensity extending to an articular surface on intermediate-weighted images, (b) abnormal meniscal morphology, (c) likelihood of a typical postoperative appearance, (d) fluid extending into the linear area on T2-weighted images, and (e) cartilage defects. Two radiologists rated their confidence on a five-point scale for the presence of these signs and were compared for level of agreement.

RESULTS

The intraclass correlation coefficient (range, 0.75-0.91) indicated a high level of agreement. Areas under the receiver operating characteristic curves were large (range, 0.70-0.87) for all five signs, with a line (grade 3 signal intensity) and fluid within a line having the highest areas. These two signs also had the highest statistical scores (chi 2 = 14.12 and 13.30; P < .002; odds ratio, 1.588 and 1.599 for the line and the fluid within the line, respectively).

CONCLUSION

The two best MR signs of repeat tear of the postoperative meniscus were the presence of a line and fluid within the line extending to an articular surface.

Analysis of Legionella pneumophila serogroup 1 isolates by pulsed-field gel electrophoresis

At a hospital in Halifax, Nova Scotia, Canada, three strains of Legionella pneumophila were detectable based on plasmid content, while the isolates collected at another hospital in Halifax had no plasmids. Genomic DNA was digested with BssHII, SalI, and SpeI and subjected to pulsed-field gel electrophoresis (PFGE). We found no relationship between plasmid profile and PFGE pattern.

Targeting bacteriophage to mammalian cell surface receptors for gene delivery

Filamentous bacteriophages represent one of nature's most elegant ways of packaging and delivering DNA. In an effort to develop novel methods for ligand discovery via phage gene delivery, we conferred mammalian cell tropism to filamentous bacteriophages by attaching basic fibroblast growth factor (FGF2), transferrin, or epidermal growth factor (EGF) to their coat proteins and measuring CMV promoter-driven reporter gene expression in target cells. In this system, FGF2 was a more effective targeting agent than transferrin or EGF. The detection of green fluorescent protein (GFP) or beta-galactosidase (beta-Gal) activity in cells required FGF2 targeting and was phage concentration dependent. Specificity of the targeting for high-affinity FGF receptors was demonstrated by competing the targeted phage with FGF2, by the failure of FGF2-targeted bacteriophage to transduce high-affinity FGF receptor-negative cells, and by their ability to transduce these same cells when stably transfected with FGFR1, a high-affinity FGF receptor. Long-term transgene expression was established by selecting colonies for G418 resistance, suggesting that with the appropriate targeted tropism, filamentous bacteriophage can serve as a vehicle for targeted gene delivery to mammalian cells.

The effects of noncontingent and contingent attention for self-injury, manding, and collateral responses

To date, most functional analysis studies have focused on the effects of treatment contingencies on specific targeted aberrant and alternative responses. In the current investigation, the main and collateral effects of the assessment and treatment of attention-maintained self-injury were assessed. Specifically, we evaluated the effects of noncontingent and contingent social attention on four categories of behavior: self-injury, a novel mand, preexisting prosocial responses (e.g., babbling and reaching out), and other aberrant responses (i.e., aggression and destruction). Results suggested that self-injury, prosocial responses, and other aberrant behaviors were within the same functional response class. Possible impact of these results when selecting mands for functional communication training is discussed.

Salmonella typhimurium DT104: a virulent and drug-resistant pathogen

Salmonella typhimurium phage type (PT) or definitive type (DT) 104 is a virulent pathogen for humans and animals, particularly cattle. It has been isolated increasingly from humans and animals in the United Kingdom and several other European countries and, more recently, in the United States and Canada. Humans may acquire the infection from foods of animal origin contaminated with the infective organism. Farm families are particularly at risk of acquiring the infection by contact with infected animals or by drinking unpasteurized milk. The symptoms in cattle are watery to bloody diarrhea, a drop in milk production, pyrexia, anorexia, dehydration and depression. Infection may result in septicemic salmonellosis and, upon necropsy, a fibrinonecrotic enterocolitis may be observed. The infection occurs more commonly in the calving season than at other times. Feedlot cattle and pigs may also be affected. Prolonged carriage and shedding of the pathogen may occur. Symptoms in humans consist of diarrhea, fever, headache, nausea, abdominal pain, vomiting, and, less frequently, blood in the stool. Salmonella typhimurium DT104 strains are commonly resistant to ampicillin, chloramphenicol, streptomycin, sulfonamides, and tetracycline.

Establishing the level of digitization for wrist and hand radiographs for the third National Health and Nutrition Examination Survey

In the third National Health and Nutrition Examination Survey (NHANES III) conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention, radiographs of the hands and knees were taken of participants 60 years and older as part of the study of arthritis and musculoskeletal conditions. The purpose of the study was to decide the digitizing resolution to be used for these radiographs. A set of wrist and hand radiographs (N = 49) was graded by two radiologists for degree of bone erosions and served as a "gold standard." The radiographs were then digitized at three resolution levels; low-resolution 150 microns (2001 x 1634 x 12 bit matrix); intermediate-resolution 100 microns (3000 x 2400 x 12 bit matrix); and high-resolution 50 microns (4900 x 3000 x 12 bit matrix). A comparison of the digital images versus the gold standard reading was made at the three resolutions by two radiologists. Kappa statistics suggested fair (K > .4) to excellent (K > .75) agreement between the gold standard and the images at all levels. Intraclass correlation coefficient suggested high agreement between readers (ICC > .5), with minimal individual reader effect. Variance component estimates showed that the major contribution (78-83%) to scoring came from variability in the images themselves, not from the readers. The 100 microns resolution was selected over the 150 and 50 microns on the basis of practical considerations such as storage requirements, display time, and easier manipulation of the digital images by the readers.

The effect of a curfew on pediatric out-of-hospital EMS responses

OBJECTIVE

The purpose of a curfew is to decrease the amount of crime inflicted on minors during the late hours of the night. On June 1, 1994, a city curfew was instituted in New Orleans, requiring all persons 17 years of age or younger to be off the streets from 9 PM to 6 AM Sunday through Thursday, and from 11 PM to 6 AM on Friday and Saturday. This study evaluated the effect of the curfew on emergency medical services (EMS) transports for patients who were 17 years old or younger (pediatric).

METHODS

Data from all pediatric transports were included from the months before (5/94) and after (6/94) the institution of the curfew, and from the same two months one year earlier (5/93 and 6/93). A chi-square test was used to evaluate comparisons.

RESULTS

The city EMS transports 48,000 patients per year in a one-tiered system (paramedic only) that acts as the sole provider of emergency EMS transport in the city. Approximately 10% of all transports are pediatric, and 40% of the pediatric transports are for trauma. A total of 1,642 transports were found that fit the inclusion criteria. In May 1993, there were 415 total pediatric transports; 234 were pediatric trauma. In June 1993, there were 406 total pediatric transports; 250 were pediatric trauma. In May 1994, there were 447 total pediatric runs; 243 were pediatric trauma. During the postcurfew month, June 1994, there were a significant decrease in pediatric transports to 370 (p < 0.01) and a significant decrease in pediatric trauma transport to 189 (p < 0.01).

CONCLUSION

The institution of a curfew may lead to a drop in pediatric EMS runs during curfew hours. Another value of the curfew may be in the secondary effects of the curfew in preventing childhood injury during noncurfew hours.

Sensitivities and specificities of premier E. coli O157 and premier EHEC enzyme immunoassays for diagnosis of infection with verotxin (Shiga-like toxin)-producing Escherichia coli. The SYNSORB Pk Study investigators

This study describes the performance of two rapid enzyme immunoassays, Premier E. coli O157 and Premier EHEC (Meridian Diagnostics Inc., Cincinnati, Ohio) for the detection in stools of Escherichia coli O157 and verotoxins (Shiga-like toxins), respectively. Both tests were performed on stools from 876 children presenting to eight emergency departments with diarrhea. Standard culture, including E. coli O157:H7 isolation, was performed, and paired sera were taken for anti-O157-lipopolysaccharide antibody determination. Stools from patients enrolled in the study, and those yielding discordant results, were sent to a reference laboratory for repeat testing and further investigation, including cytotoxicity and non-O157 verotoxin-producing E. coli culture. Results were classified as field results (obtained in the eight site laboratories) and resolved results (obtained after repeat testing in the central laboratory). The "gold standard" for sensitivity of both tests and for specificity of Premier E. coli O157 was isolation of E. coli O157:H7 or a fourfold anti-O157 antibody rise. Specimens positive by the Premier EHEC test and negative for E. coli O157 culture were examined for non-O157 verotoxin-producing E. coli. The field sensitivity of Premier E. coli O157 was 86%, that of Premier EHEC was 89%, and the specificity of Premier E. coli O157 was 98%. Ten of 13 discordant Premier E. coli O157 results were reassigned as true results after repeat testing. Ten non-O157 verotoxin-producing E. coli isolates were recovered from Premier EHEC-positive, E. coli O157 culture-negative stools. Only one specimen gave an unequivocally false-positive Premier EHEC result. Both tests are highly sensitive and are specific if correctly performed. The Premier EHEC test will be particularly valuable as a practical routine test for the detection of non-O157 verotoxin-producing E. coli.

The thyroid hormone receptor variant alpha2 is a weak antagonist because it is deficient in interactions with nuclear receptor corepressors

The thyroid hormone receptor splice variant, alpha2, is unable to bind thyroid hormone (T3) and has been proposed to function as an endogenous inhibitor of T3 action. In this report, we examined further the DNA sequence requirements for alpha2 binding to thyroid hormone response elements (TREs) in an attempt to identify response elements that mediate potent inhibition by alpha2. Heterodimers of alpha2 and retinoid X receptor were found to bind to a subset of TREs (DR4, direct repeats spaced by 4 bp) in which selected flanking and spacer sequences enhanced interactions with the AGGTCA core binding sequence. Despite the optimization of the TRE-binding sites, alpha2 remained a weak dominant negative inhibitor of TRE-driven transcription. A promoter interference assay was also developed for testing inhibition by alpha2. In these studies, alpha2 blocked gene transcription, but it required cotransfected retinoid X receptor, and it was not as potent as unliganded thyroid hormone receptors. These results led to the hypothesis that alpha2 might be deficient in interactions with nuclear receptor corepressors. Consistent with this view, alpha2 did not silence basal transcription in its native form or when linked to Gal4. Alpha2 also failed to interact with corepressors (NCoR and SMRT) in both gel shift assays and mammalian two-hybrid assays. We conclude that alpha2 is a weak antagonist of thyroid hormone action because it binds weakly to a limited repertoire of response elements, and it does not interact with corepressors. Thus, alpha2 may be able to compete with thyroid hormone receptors for binding to a limited group of target sites, but it is not able to actively inhibit transcription.

Reliability of photographic analysis in determining change in scar appearance

Photographs frequently are used to document change in the management of hypertrophic scars. The purpose of this study was to design a scale for the analysis of photographs of hypertrophic scars and to test its reliability. The subjects were four occupational and physical therapists, (two novices and two experts), in scar management. Existing scales were modified to produce a new scale. The subjects twice rated four slides from each of ten patients' scars, in random order. They used a Latin Square design. Interrater and test-retest reliabilities were calculated using a weighted kappa statistic. The newly developed scale demonstrated interrater reliability, which ranged between 0.66 and 0.90 for all items. The test-retest reliability ranged between 0.73 and 0.89 for all items. The new scale had substantial reliability (using a single rater) and was at least as reliable when used by novice therapists. This indicated that training had no effect.

Shear bond strength of immediately repaired light-cured composite resin restorations

The goal of this study was to examine the extent to which the state of the surface of newly placed restorations made of one of two commercial formulations of composite resin (Pertac-Hybrid and Z-100) affects the interfacial bond strength when such restorations are immediately repaired with the same resin. Three groups of specimens for each material were prepared: one group in which there was an air-inhibited film on the surface of the initial layer of the restoration, another in which that film was prevented from being formed, and a third in which that surface was abraded prior to placement of the repair layer. All specimens were stored for 6 weeks in water at 23 degrees C before being loaded to fracture in shear at a rate of 5 mm/min. The shear bond strength results were treated using the three-parameter Weibull equation and a clearly defined index of performance (I), which is a measure of both the magnitude and variability of the shear bond strength. It was found that, for two states of the surface of the initial layer, I for Pertac-Hybrid specimens is about the same as that for Z-100 specimens. For specimens made of either material, there was a demonstrable difference in I between specimens with or without an air-inhibited film on the initial layer, while abrading the surface of that layer severely degraded I.

Proteolipid protein is necessary in peripheral as well as central myelin

Alternative products of the proteolipid protein gene (PLP), proteolipid protein (PLP) and DM20, are major components of compact myelin in the central nervous system, but quantitatively minor constituents of Schwann cells. A family with a null allele of PLP has a less severe CNS phenotype than those with other types of PLP mutations. Moreover, individuals with PLP null mutations have a demyelinating peripheral neuropathy, not seen with other PLP mutations of humans or animals. Direct analysis of normal peripheral nerve demonstrates that PLP is localized to compact myelin. This and the clinical and pathologic observations of the PLP null phenotype indicate that PLP/DM20 is necessary for proper myelin function both in the central and peripheral nervous systems.

Regulation of the human chorionic gonadotropin alpha- and beta-subunit promoters by AP-2

Production of the placental hormone, chorionic gonadotropin (CG), increases dramatically as cytotrophoblasts fuse to form syncytiotrophoblasts. The CG alpha- and beta-promoters are both responsive to cAMP, although the kinetics of cAMP stimulation are different. In an effort to understand the mechanisms of coordinate induction of these genes, AP-2 binding sites were identified in the promoter regions of the alpha and CGbeta genes. AP-2 bound to the upstream regulatory element (-186 to -156 base pairs (bp)) in the alpha-promoter and to several different regions of the CGbeta promoter, including footprints 2 and 4B (FP2, -311 to -279 bp; FP4B, 221 to -200 bp). AP-2 antibodies induced supershifts of these complexes, confirming the identity of the protein-DNA complex. In JEG-3 cells, which contain abundant AP-2, mutations in these CGbeta AP-2 sites reduced basal activity and decreased cAMP stimulation. In AP-2-deficient Hep-G2 cells, co-transfection of AP-2 stimulated expression of the CGbeta promoter 10-20-fold, and the alpha-promoter was induced by 3-6-fold. Mutations that eliminate AP-2 binding to CGbeta FP4B reduced AP-2 stimulation by more than 80%, whereas mutations in FP2 reduced AP-2 stimulation by less than 50%. Analyses of AP-2 mutants revealed a requirement for the DNA binding/dimerization domain and the amino-terminal proline-rich and acid-rich transactivation domains for stimulation of the CGbeta promoter. Primary cultures of placental cytotrophoblasts were differentiated into syncytiotrophoblasts in vitro to examine AP-2 expression by reverse transcriptase-polymerase chain reaction. AP-2 mRNA levels increased by day 2 and continued to rise in parallel with a marked increase in alpha and CGbeta gene expression. We conclude that both the alpha and CGbeta promoters contain binding sites for AP-2 and suggest that this transcription factor provides a mechanism for coordinating the induction of these genes during placental cell differentiation.