Nurse documentation: not done or worse, done the wrong way--Part II

PURPOSE/OBJECTIVES

To focus on nursing documentation and how it can lead to a malpractice lawsuit.

DATA SOURCES

Nursing, non-nursing healthcare and legal journals, case law, and related Internet sources.

DATA SYNTHESIS

To avoid liability for inadequate or inaccurate documentation, nurses must be aware of how their documentation can either lead to a malpractice claim or actually decrease their chances of ever being named in a malpractice lawsuit. Malpractice cases often are decided based on documentation. The only viable way to defend against allegations of professional negligence is accurate and complete patient charting or defensive documentation.

CONCLUSIONS

By examining case law involving inadequate or inaccurate documentation, nurses will be able to effectively adopt documentation practices or policies to decrease potential litigation.

IMPLICATIONS FOR NURSING PRACTICE

Educating nurses about the principles of documentation and the importance of implementing risk-reduction practices will help guard against liability and ultimately improve patient care.

Comparison of exhaust emissions from Swedish environmental classified diesel fuel (MK1) and European Program on Emissions, Fuels and Engine Technologies (EPEFE) reference fuel: a chemical and biological characterization, with viewpoints on cancer risk

Diesel fuels, classified as environmentally friendly, have been available on the Swedish market since 1991. The Swedish diesel fuel classification is based upon the specification of selected fuel composition and physical properties to reduce potential environmental and health effects from direct human exposure to exhaust. The objective of the present investigation was to compare the most stringent, environmentally classified Swedish diesel fuel (MK1) to the reference diesel fuel used in the "European Program on Emissions, Fuels and Engine Technologies" (EPEFE) program. The study compares measurements of regulated emissions, unregulated emissions, and biological tests from a Volvo truck using these fuels. The regulated emissions from these two fuels (MK1 vs EPEFE) were CO (-2.2%), HC (12%), NOx (-11%), and particulates (-11%). The emissions of aldehydes, alkenes, and carbon dioxide were basically equivalent. The emissions of particle-associated polycyclic aromatic hydrocarbons (PAHs) and 1-nitropyrene were 88% and 98% lower than those of the EPEFE fuel, respectively. The emissions of semi-volatile PAHs and 1-nitropyrene were 77% and 80% lower than those from the EPEFE fuel, respectively. The reduction in mutagenicity of the particle extract varied from -75 to -90%, depending on the tester strain. The reduction of mutagenicity of the semi-volatile extract varied between -40 and -60%. Furthermore, the dioxin receptor binding activity was a factor of 8 times lower in the particle extracts and a factor of 4 times lower in the semi-volatile extract than that of the EPEFE fuel. In conclusion, the MK1 fuel was found to be more environmentally friendly than the EPEFE fuel.

Nurse documentation: not done or worse, done the wrong way--Part I

PURPOSE/OBJECTIVES

To focus on nursing documentation and expanding technologies (e.g., facsimile, telephone, e-mail, computer charting) that offer different ways to record, deliver, and receive patient records and avoid nursing liability for inadequate or inaccurate documentation.

DATA SOURCES

Nursing, non-nursing healthcare, legal journals, case law, and related Internet sources.

DATA SYNTHESIS

To avoid liability for inadequate or inaccurate documentation, nurses must be aware of the major issues involved in documentation litigation. New technology is altering how healthcare documentation is done and raising new confidentiality issues.

CONCLUSIONS

Nurses should follow their facility's guidelines and principles for documentation of patient care, especially when using more advanced technologies.

IMPLICATIONS FOR NURSING PRACTICE

Educating nurses about the principles of documentation and the importance of implementing risk-reduction practices will help guard against liability and ultimately improve patient care.

A regulatory hydrophobic area in the flexible joint region of plasminogen activator inhibitor-1, defined with fluorescent activity-neutralizing ligands. Ligand-induced serpin polymerization

We have characterized the neutralization of the inhibitory activity of the serpin plasminogen activator inhibitor-1 (PAI-1) by a number of structurally distinct organochemicals, including compounds with environment-sensitive spectroscopic properties. In contrast to latent and reactive center-cleaved PAI-1 and PAI-1 in complex with urokinase-type plasminogen activator (uPA), active PAI-1 strongly increased the fluorescence of the PAI-1-neutralizing compounds 1-anilinonaphthalene-8-sulfonic acid and 4,4'-dianilino-1,1'-bisnaphthyl-5,5'-disulfonic acid. The fluorescence increase could be competed by all tested nonfluorescent neutralizers, indicating that all neutralizers bind to a common hydrophobic area preferentially accessible in active PAI-1. Activity neutralization proceeded through two consecutive steps as follows: first step is conversion to forms displaying substrate behavior toward uPA, and second step is to forms inert to uPA. With some neutralizers, the second step was associated with PAI-1 polymerization. Vitronectin reduced the susceptibility to the neutralizers. Changes in sensitivity to activity neutralization by point mutations were compatible with the various neutralizers having overlapping, but not identical, binding sites in the region around alpha-helices D and E and beta-strand 1A, known to act as a flexible joint when beta-sheet A opens and the reactive center loop inserts as beta-strand 4A during reaction with target proteinases. The defined binding area may be a target for development of compounds for neutralizing PAI-1 in cancer and cardiovascular diseases.

Tuberculosis notifications in Australia, 1998

Since the inception of the National Mycobacterial Surveillance System (NMSS) in 1991, annual crude notification rates for tuberculosis have remained stable at between 5 and 6 per 100,000 population. In 1998, there was a total of 923 TB notifications in Australia of which 884 were new TB cases, and 39 relapsed cases. The corresponding annual crude notification rate for new and relapsed TB was 4.72 and 0.21 per 100,000 respectively. Seventy-seven percent of notifications that had a country of birth reported were overseas born. In keeping with trends observed over recent reporting years, the populations for which notified TB rates are highest include the overseas born from high prevalence countries and Indigenous Australians. The lowest rates of disease have continued to be reported in the non-Indigenous, Australian born population. Surveillance reports over the last seven years indicate that the rate of disease in this population is gradually declining.

8-Substituted cAMP analogues reveal marked differences in adaptability, hydrogen bonding, and charge accommodation between homologous binding sites (AI/AII and BI/BII) in cAMP kinase I and II

cAMP analogues, systematically substituted at position 8 of the adenine moiety (C8), were tested quantitatively for binding to each cAMP interaction site (A and B) of the regulatory subunits of cAMP-dependent protein kinase type I (RI) and II (RII). Site AII did not accommodate cAMP analogues with any bulk at position 8, whereas site AI accepted even bulky 8-substituents. This implies that the narrow, buried pocket of site AI facing position C8 of cAMP in the RI-cAMP crystal [Su, Y., Dostmann, W. R., Herberg, F. W., Durick, K., Xuong, N. H., Ten Eyck, L., Taylor, S. S., and Varughese, K. I. (1995) Science 269, 807-813] must undergo considerable conformational change and still support high-affinity cAMP analogue binding. The B sites of RI and RII differed in three respects. First, site BI had a lower affinity than site BII for cAMP analogues with hydrophobic, bulky 8-substituents. Second, site BI had a preference for substituents with hydrogen bonding donor potential close to C8, whereas site BII had a preference for substituents with hydrogen bonding acceptor potential. This implies that Tyr(371) of RI and the homologous Tyr(379) of RII differ in their hydrogen bonding preference. Third, site BI preferred analogues with a positively charged amino group that was an extended distance from C8, whereas site BII discriminated against a positive charge. The combined results allow refinement of the cAMP binding site geometry of RI and RII in solution, and suggest design of improved isozyme-specific cAMP analogues.

[Antibiotic resistance of blood culture isolates in Buskerud in 1994 and 1998]

BACKGROUND

The increase of antimicrobial resistance has caused general concern world-wide. There is a high risk that this development will also occur in Norway. Several efforts have been made to prevent the emergence of antimicrobial resistance. A national surveillance programme for antimicrobial resistance has been started, and new legislation has made resistance surveillance programmes compulsory in every Norwegian hospital. Local surveillance of resistance is among the most important measures.

MATERIAL AND METHODS

We have undertaken surveillance of all blood culture isolates from the County of Buskerud in 1994 and 1998. Detection of antibiotic resistance-patterns were undertaken for all blood culture isolates in the two years using disc diffusion method (Rosco diagnostics, Taastrup, Denmark). We also looked at the consumption of antimicrobial agents in Buskerud Central Hospital in 1998. A total of 628 isolates from 572 patients were included in the study, 279 isolates from 1994 and 349 from 1998.

RESULTS

We still have low occurrence of resistance in Buskerud, and there has been no significant increase during the four-year period.

INTERPRETATION

The low prevalence of antibiotic resistance reflects the restrictive antibiotic policy in Norway. Therefore, we find it important to continue this policy and to continue close surveillance of the development of antibiotic resistance.

Integrative behavioral couple therapy: an acceptance-based, promising new treatment for couple discord

Although traditional behavioral couple therapy (TBCT) has garnered the most empirical support of any marital treatment, concerns have been raised about both its durability and clinical significance. Integrative behavioral couple therapy (IBCT) was designed to address some of these limitations by combining strategies for fostering emotional acceptance with the change-oriented strategies of TBCT. Results of a preliminary clinical trial, in which 21 couples were randomly assigned to TBCT or IBCT, indicated that therapists could keep the 2 treatments distinct, that both husbands and wives receiving IBCT evidenced greater increases in marital satisfaction than couples receiving TBCT, and that IBCT resulted in a greater percentage of couples who either improved or recovered on the basis of clinical significance data. Although preliminary, these findings suggest that IBCT is a promising new treatment for couple discord.

Integrative behavioral couple therapy: an acceptance-based, promising new treatment for couple discord

Although traditional behavioral couple therapy (TBCT) has garnered the most empirical support of any marital treatment, concerns have been raised about both its durability and clinical significance. Integrative behavioral couple therapy (IBCT) was designed to address some of these limitations by combining strategies for fostering emotional acceptance with the change-oriented strategies of TBCT. Results of a preliminary clinical trial, in which 21 couples were randomly assigned to TBCT or IBCT, indicated that therapists could keep the 2 treatments distinct, that both husbands and wives receiving IBCT evidenced greater increases in marital satisfaction than couples receiving TBCT, and that IBCT resulted in a greater percentage of couples who either improved or recovered on the basis of clinical significance data. Although preliminary, these findings suggest that IBCT is a promising new treatment for couple discord.

Demonstration of expression of six proteins of the mammalian cell entry (mce1) operon of Mycobacterium tuberculosis by anti-peptide antibodies, enzyme-linked immunosorbent assay and reverse transcription-polymerase chain reaction

Polyclonal rabbit antibodies were generated to synthetic peptides corresponding to predicted B-cell epitopes of six proteins of the mce1 operon of Mycobacterium tuberculosis. Antipeptide antibodies reacted with Mce1A and Mce1E fusion proteins in sonicates of recombinant Escherichia coli as well as with distinct bands in sonicates, but not in culture fluids of M. tuberculosis and M. bovis bacillus Calmette-Guérin (BCG). Polyvalent rabbit antibodies generated by immunization with sonicates of BCG bacilli reacted with synthetic peptides from the six Mce1 proteins on the solid phase in enzyme-linked immunosorbent assay (ELISA), albeit with different frequencies. The Mce1A peptide (p124-140) reacted most frequently, with seven of the nine antibodies tested, while the Mce1F peptide (p329-343) reacted with two. Used as a control, 20 polyclonal rabbit antibodies to 12 isolated proteins of M. tuberculosis and M. bovis BCG did not react with any of the six synthetic peptides, except in one case. mRNA expression of the six mce1A-mce1F genes of M. tuberculosis was demonstrated by reverse transcription-polymerase chain reaction (RT-PCR). These data indicate that all Mce1A-Mce1F proteins of the mce1 operon are expressed by in vitro-grown M. tuberculosis and M. bovis BCG.

[Cryptococcal meningitis in a patient without known predisposing disease]

Cryptococcal meningitis is a rare disease. It may occur as a superinfection in AIDS patients or other immunosuppressed patients. We describe a case of cryptococcal meningitis in a non-immunosuppressed patient. Initial symptoms were fatigue, depression and headache. A correct diagnosis was made after two weeks based on microscopic examination of cerebrospinal fluid. The patient died after six days on antimycotic therapy. Cryptococcosis is a difficult diagnosis, as our case illustrates. Psychiatric symptoms are often the first clinical manifestations. Early diagnosis is crucial for the outcome. A short overview on cryptococcosis is given.

Ligand binding properties of the very low density lipoprotein receptor. Absence of the third complement-type repeat encoded by exon 4 is associated with reduced binding of Mr 40,000 receptor-associated protein

The very low density lipoprotein receptor (VLDLR) binds, among other ligands, the Mr 40,000 receptor-associated protein (RAP) and a variety of serine proteinase-serpin complexes, including complexes of the proteinase urokinase-type plasminogen activator (uPA) with the serpins plasminogen activator inhibitor-1 (PAI-1) and protease nexin-1 (PN-1). We have analyzed the binding of RAP, uPA.PAI-1, and uPA.PN-1 to two naturally occurring VLDLR variants, VLDLR-I, containing all eight complement-type repeats, and VLDLR-III, lacking the third complement-type repeat, encoded by exon 4. VLDLR-III displayed approximately 4-fold lower binding of RAP than VLDLR-I and approximately 10-fold lower binding of the most C-terminal one of the three domains of RAP. In contrast, the binding of uPA.PAI-1 and uPA.PN-1 to the two VLDLR variants was indistinguishable. Surprisingly, uPA.PN-1, but not uPA.PAI-1, competed RAP binding to both VLDLR variants. These observations show that the third complement-type repeat plays a crucial role in maintaining the contact sites needed for optimal recognition of RAP, but does not affect the proteinase-serpin complex contact sites, and that two ligands can show full cross-competition without sharing the same contacts with the receptor. These results elucidate the mechanisms of molecular recognition of ligands by receptors of the low density lipoprotein receptor family.

INTERVENTIONS FOR COUPLES

A substantial body of empirical research has documented both the promise and the shortcomings of psychological interventions for preventing or ameliorating marital distress. Couple therapy reduces relationship distress and may affect individual psychopathology, such as depression. However, some couples are unresponsive and others improve but relapse later. Interventions to prevent marital distress usually produce short-term changes in behavior and relationship satisfaction, but little evidence exists demonstrating a longer-term prevention effect. Furthermore, these interventions have yet to be examined on a diverse population of couples or with a diverse set of outcome criteria (e.g. effects on children). Concern about the negative impact of marital discord and divorce will continue to provide the impetus for research on more effective means of intervening with couples. Future research could benefit from a focus on a more diverse population of couples, treatment in natural settings, the development of more powerful interventions, and the examination of those interventions over longer periods of time and with more comprehensive outcome measures.

Acceptance versus change interventions in behavioral couple therapy: impact on couples' in-session communication

Integrative Behavioral Couple Therapy (IBCT) attempts to improve Traditional Behavioral Couple Therapy (TBCT) by incorporating an emphasis on promoting acceptance into TBCT's emphasis on behavioral change. This study examined changes in couples' communication over the course of IBCT and TBCT. Early, middle, and late sessions were coded to measure couples' communication of acceptance. Results showed that IBCT couples expressed more nonblaming descriptions of problems and more soft emotions than TBCT couples during late stages of therapy. IBCT couples significantly increased their nonblaming description of problems and significantly decreased their expressions of hard emotions and their problematic communication over time. Results support the hypothesis that structural differences between the therapies affect initial levels of emotional expression in session. Increases in nonblaming descriptions of problems were significantly correlated with increases in marital satisfaction.

The enhancement of traditional behavioral couples therapy: consideration of individual factors and dyadic development

There has been little effort by behavior therapists to develop couple interventions that view marriage from a content-relevant or developmental perspective. Consequently, we have delineated ways in which a perspective of intimate relationships including individual factors and dyadic development might guide the enhancement of traditional behavioral couples therapy (TBCT) with novel and improved techniques that will ultimately allows us to reach a wider range of distressed couples than our current interventions allows. Specifically, we examined the potential benefits to intervention that could occur by considering the impact of individual factors on relationship quality, using the literature on attachment patterns as an example. Further, we have discussed the potential gains to couple interventions that could occur by considering the impact of dyadic development on relationship satisfaction. We first addressed gradual changes in marriage, using intimacy as an example. Next we examined "stage of marriage" issues, using child behavior problems as an example. Finally, we considered whether or not a problem was chronic. Throughout, we have proposed utilizing TBCT as a starting point, and considering ways to enhance TBCT specifically, as it is the marital therapy for which we have the most information and empirical support.

Breast carcinoma epithelial cells express a very low-density lipoprotein receptor variant lacking the O-linked glycosylation domain encoded by exon 16, but with full binding activity for serine proteinase/serpin complexes and Mr-40,000 receptor-associated protein

Very-low density lipoprotein receptor (VLDLR) belongs to the low-density lipoprotein receptor family of endocytosis receptors. It binds a variety of different ligands, including apolipoprotein E, Mr-40,000 receptor-associated-protein (RAP), and some serine proteinase/serpin complexes. We previously demonstrated the occurrence of two forms of VLDLR in SDS/PAGE, migrating with Mr 105,000 and Mr 130,000, respectively [Heegaard, C. W., Simonsen, A. C. W., Oka, K., Kjøller, L., Christensen, A., Madsen, B., Ellgaard, L., Chan, L. & Andreasen, P. A. (1995) J. Biol. Chem. 270, 20,855-20,869]. We now demonstrate that these two forms correspond to forms with the absence (type-II) and presence (type-I) of the O-linked glycosylation domain encoded by exon 16, respectively. We show that the two forms have the same binding affinity to RAP and serine proteinase/serpin complexes. Using reverse transcription and PCR, we demonstrate that the splice variation giving rise to the two forms is highly cell specific. In particular, we demonstrate that human breast carcinomas express predominantly or exclusively the variant lacking exon 16. By immunohistochemistry, we demonstrate that VLDLR is mainly expressed by the epithelial cancer cells in these carcinomas. The VLDLR variant expressed by epithelial cancer cells could function in the clearance of cell-surface-associated serine proteinase/serpin complexes in breast carcinomas.

Specificity of serine proteinase/serpin complex binding to very-low-density lipoprotein receptor and alpha2-macroglobulin receptor/low-density-lipoprotein-receptor-related protein

Very-low-density lipoprotein receptor (VLDLR) and alpha2-macroglobulin receptor/low-density-lipoprotein-receptor-related protein (alpha2MR/LRP) are multifunctional endocytosis receptors of the low-density lipoprotein receptor family. Both have been shown to mediate endocytosis and degradation of complex between plasminogen activators and type-1 plasminogen-activator inhibitor (PAI-1) by cultured cells. We have now studied the specificity of binding and endocytosis by VLDLR and alpha2MR/LRP among a variety of serine proteinase/serpin complexes, including various combinations of the serine proteinases urokinase-type and tissue-type plasminogen activators, plasmin, thrombin, human leukocyte elastase, cathepsin G, and plasma kallikrein with the serpins PAI-1, horse leukocyte elastase inhibitor, protein C inhibitor, C1-inhibitor, alpha2-antiplasmin, alpha1-proteinase inhibitor, alpha1-antichymotrypsin, protease nexin-1, heparin cofactor II, and antithrombin III. Binding was estimated with radiolabelled ligands in ligand blotting analysis and microtiter well assays. Endocytosis was estimated by measuring receptor-associated protein (RAP)-sensitive degradation of radiolabelled complexes by Chinese hamster ovary cells transfected with VLDLR cDNA and by COS-1 cells, which have a high endogenous expression of alpha2MR/LRP. We found that the receptors bind with high affinity to some, but not all, combinations of plasminogen activators and thrombin with PAI-1, protease nexin-1, protein C inhibitor, and antithrombin III, while complexes of many serine proteinases with their primary inhibitor, i.e. plasmin/alpha2-antiplasmin complex, do not bind, or bind with a very low affinity. Both the serine proteinase and the serpin moieties contribute to the binding specificity. The binding specificities of VLDLR and alpha2MR/LRP are overlapping, but not identical. The results suggest that VLDLR and alpha2MR/LRP have different biological functions by having different binding specificities as well as by being expressed by different cell types.

Studying the effectiveness of psychotherapy. How well can clinical trials do the job?

Although there has been much discussion of the recent Consumer Reports (CR) study (1995) on the effectiveness of psychotherapy, there is little new information reported either in the CR article or in M. E. P. Seligman's (1995) discussion of the findings. The findings that are new are hard to interpret because of serious methodological problems. In fact, the CR study is similar in many ways to H. J. Eysenck's (1952) controversial report on the effectiveness of psychotherapy, a study that has been rejected by the field despite the fact that it avoided some of the methodological shortcomings of the CR study. It would be a mistake to put forth a design rejected in the 1950s as an exemplar of good effectiveness research, especially when better alternatives exist. Clinical trials, despite many limitations, can answer all of the questions regarding the effectiveness of psychotherapy posed by M. E. P. Seligman, without the interpretive ambiguities and other methodological problems inherent in surveys such as the one published in CR.