The impact of computerization on nursing: an interview study of users and facilitators

When health care settings are computerized, nurses' jobs are affected. Hospitals must understand this important phenomenon in order to develop the best possible implementation strategies that consider the impact nurses may experience. The goals of this study were the following: 1) to explore the personal and job-related effects of computerization on nurses; 2) to determine the factors that helped these nurses cope during the computerization process; and 3) to derive recommendations that could assist hospitals implementing computerization in future. Twenty nurses were identified by their peers as knowledgeable informants for a research interview: 10 staff nurse users and 10 nurse educators or administrators serving as facilitators of the change. The confidential interviews were analyzed using a grounded theory approach with constant comparative analysis of the emerging categories. The investigators developed a visual model showing six themes that have the greatest effect on the nurses: 1) time frame, 2) choice of software, 3) communication, 4) the change process, 5) training, and 6) leadership. These themes were considered within a broad hospital context, in which budget, nurse involvement, policy practice issues, and other concurrent projects also influenced nursing. In addition, personal characteristics of each nurse affected how each nurse experienced the change to computerization. Recommendations from the respondents addressed a wide range of factors that may be useful to other hospitals planning to implement computerization in nursing.

Outbreak of Hantavirus pulmonary syndrome in the southwestern United States. Response of pathologists and other laboratorians

During late spring and early summer of 1993, national and international media called worldwide attention to a cluster of deaths in the southwestern United States. These patients succumbed to a rapidly progressive severe respiratory distress syndrome. After notification of state and national health agencies in mid-May, a major effort was launched to determine the cause of this often fatal respiratory distress syndrome, to advise the public on safety measures, and to determine the method of spread of this "mystery illness." Within weeks of recognition of the early cases, the Centers for Disease Control and Prevention announced the probable agent, a Hantavirus. This report details the response of pathologists, medical technologists, and other laboratory scientists to this new viral epidemic, with emphasis on activities that occurred within New Mexico.

Essential tremor entrains rapid voluntary movements

The effect of essential tremor on the timing of rapid wrist flexion was examined in 10 patients with moderate to severe disability. The mean reaction time and motor time of the patients did not differ from the mean values of 10 healthy age- and sex-matched controls. The latencies of the triphasic agonist and antagonist EMG bursts did not differ between patients and controls. The initiation of movement was time-locked to the tremor cycle in all patients. The initial agonist muscle activation occurred in phase with the rhythmic bursts of EMG, but the onset of rapid wrist flexion occurred when the momentum of essential tremor opposed the volitional movement. Essential tremor has subtle effects on motor control that transcend oscillation per se. These effects probably contribute to the impaired performance of fine motor tasks in patients with advanced disease.

A strategy for the design of membrane-permeable folypoly-gamma-glutamate synthetase inhibitors: "bay-region"-substituted 2-desamino-2-methyl-5,8-dideazafolate analogs

Previous attempts to design inhibitors of mammalian folylpolyglutamate synthetase (FPGS) have resulted in three classes of active compounds, all of which have charged moieties in the side chain, but structural alteration of the rest of the folate molecule has not seemed to be an avenue for drug discovery. However, groups in the side chain of folate analogs that bear charge distributions different from that of glutamic acid appear to prevent efficient transport into mammalian cells on the reduced folate carrier system. We now report that substituents at the 7-, 2'-, or 3'-position of 2-desamino-2-methyl-4-hydroxyquinazoline antifolates decrease or prevent the catalysis of diglutamate formation by FPGS but are compatible with efficient binding to the reduced folate carrier system. Thus, 5,8-dideazafolates with a 3'-alkyl group had a lower Vmax for FPGS than did the corresponding unsubstituted quinazolines, by a factor of 4-12, but these compounds inhibited the reaction of control FPGS substrates, indicating that the 3'-groups had much larger effects on catalytic activity than on binding to enzyme. A 7-methyl substituent affected the Vmax of a series of 5,8-dideazafolate compounds by a factor of 2-8, but this decrease in the catalytic rate was also accompanied by an increase in the Km of the substituted compounds by a factor of 10-100. The extent of the effect of a 7-methyl substituent on Vmax appeared to be dependent on the size of the substituent at N10. Different substituents at the 2'-position affected the kinetics of the FPGS reaction with one of three patterns, i.e., 1) a 2'-fluoro substituent both increased Vmax and decreased Km slightly, 2) either -OH or -NH2 decreased the Vmax without affecting the Km, and 3) 2'-Cl-, -CH3, -CF3, or -OCH3 substituents were found to both decrease Vmax and increase Km. Substitutions at the 7-, 2'-, or 3'-position had only minor effects on the ability of 2-desamino-2-methyl-4-oxoquinazolines to interfere with the transport of [3H]methotrexate into L1210 cells. Hence, these classes of compounds are likely to be efficiently transported by the reduced folate carrier system. We conclude that the region of the folate molecule bounded by the 7-, 6-, 9-, 10-, 3'-, and 2'-positions, the "bay region," is of major importance both for the binding of folates and folate analogs to FPGS and for the assumption of a conformation of the enzyme-substrate complex compatible with catalysis.(ABSTRACT TRUNCATED AT 400 WORDS)

Is the construction of an ileoanal pouch associated with the development of arthritis?

The construction of an ileoanal pouch in patients who have undergone total colectomy for ulcerative colitis is claimed to be associated with the development of arthritis. The pattern and prevalence of reported musculoskeletal symptoms in the 15 patients with ileoanal pouches attending our hospital was not significantly different to a control group of 60 patients with an ileostomy for inflammatory bowel disease. There was no clinical or serological evidence of arthritis in the eight patients from the study group reporting symptoms. We conclude that the majority of symptoms occurring following pouch construction are not attributable to an inflammatory arthropathy.

Impact of computerization on nursing: automated order entry, care planning, and implications for recruitment

Very few empirical studies have been completed which verify the actual benefits of automation for nursing. This article provides an overview of the results and implications of five research studies undertaken at a Canadian Hospital to ascertain the impact of computerization on selected aspects of nursing. These studies found that nurses perceived few positive benefits for direct care givers when order entry, results reporting and care planning were automated. This article will be of particular interest to nurse administrators who are embarking on automation within their hospitals.

A computerized system for morphometric analysis of digitized images of histologically prepared arterial cross sections

A method is described for computerized, operator-assisted, morphometric measurement of histologically prepared arterial cross sections. The system is composed of an image cytometer equipped with a one power lens and a digitizing camera interfaced with an imaging board residing in a PC computer. Algorithms were developed for automated segmentation of the areas of interest. The method is rapid, objective, accurate and requires minimum operator intervention. It gives reliable and reproducible results in the measurement of all elements of the cross section including circumference, area of the media, circumference of the internal elastic lamina, area of the lumen and percent occlusion of the lumen by the intimal thickening. While manual measurements using computerized planimetric methods give similar results, this method is an order of magnitude faster (1-2 min vs. 10-20 min per cross section) thus facilitating the study of large numbers of specimens. A blinded re-measurement of 284 sections of artery for reproducibility yielded r values of 0.86-0.97.

Peer Group Interactions and the Student-Perceived Climate for Caring

Using the descriptive mode of qualitative inquiry, this study was conducted with 10 junior nursing students at five baccalaureate schools of nursing to describe a climate for caring as it is experienced within the context of peer group interactions. The findings from this study indicate that a climate for caring is experienced through peer group behaviors that are perceived as caring, and during peer group interactional episodes that are characterized by giving assistance. Based on the data from these participants, student vulnerability and personal knowledge of peers are suggested as factors that mediate the ability of junior nursing students to experience a climate for caring during peer group interactions.

Discrimination between forms of vitamin E by humans with and without genetic abnormalities of lipoprotein metabolism

To study the mechanisms of discrimination between various forms of vitamin E, four normal subjects, one patient with lipoprotein lipase deficiency, and three patients with abnormal apolipoprotein B-100 production were given an oral dose containing three tocopherols labeled with differing amounts of deuterium (2R,4'R,8'R-alpha-(5,7-(C2H3)2)tocopheryl acetate (d6-RRR-alpha-tocopheryl acetate), 2S,4'R,8'R-alpha-5-(C2H3)tocopheryl acetate (d3-SRR-alpha-tocopheryl acetate), and 2R,4'R,8'R-gamma-(3,4-2H)tocopherol (d2-RRR-gamma-tocopherol). The tocopherol contents of plasma, red cells, and lipoproteins were measured up to 76 h after the dose. In normal subjects all three tocopherols were absorbed and secreted in chylomicrons with equal efficiencies. Both d2-gamma- and d3-SRR-alpha-tocopherols peaked at similar concentrations in the other lipoprotein fractions, then decreased similarly, but 2-4 times more rapidly than did d6-RRR-alpha-tocopherol. A lipoprotein lipase-deficient patient and a patient with prolonged production of chylomicrons with absent apolipoprotein B-100 also demonstrated the lack of discrimination between tocopherols during absorption. Despite abnormal apolipoprotein B-100 production in two patients, the "VLDL" was preferentially enriched in d6-RRR-alpha-tocopherol. Our results show that there is no discrimination between the three tocopherols during absorption and secretion in chylomicrons, but subsequently there is a preferential enrichment of very low density lipoprotein (VLDL) with RRR-alpha-tocopherol. Catabolism of this VLDL results in the maintenance of plasma RRR-alpha-tocopherol concentrations.

Phase resetting and frequency entrainment of essential tremor

Step and sinusoidal forcings were delivered to the wrists of 10 patients with advanced essential tremor using a computer-controlled torque motor. Consistent (type 0) phase resetting was produced in only 5 patients, whereas all 10 patients exhibited harmonic and 2:1 subharmonic entrainment of essential tremor. These results indicate that the oscillator of essential tremor is coupled to the stretch-reflex arc. Irregularity in the tremor rhythm and postperturbation mechanical-reflex oscillations obscured the phase of essential tremor, thereby impeding the computation of phase resetting curves. Sinusoidal forcings circumvented these problems, but frequency entrainment was produced only by forcings at frequencies within +/- 1 Hz of the tremor frequency and its second harmonic. Resonance accompanied frequency entrainment and probably plays a role in the clinical expression of tremor.

Faculty-student interactions and the student-perceived climate for caring

The identification of caring as a core value for nursing practice elaborates the need to investigate the educational processes through which caring can be learned by those who will assume primary caregiver roles. Using qualitative inquiry, this study was conducted to describe a climate for caring as perceived by 10 junior nursing students and to identify faculty behaviors and faculty-student interactional episodes through which these students experience a climate for caring. Consistent with one researcher's conceptualization of the components of a moral education, the findings from this study suggest that modeling, dialogue, practice, and confirmation are the faculty-student interactional processes through which these students experienced a climate for caring.

The syndrome of senile gait

Infrared computed stroboscopic photometry was used to quantify the kinematic profiles of walking in 10 elderly patients with symmetrical neurological disturbances of gait and in 19 age-matched neurologically healthy people. Clinical examination of the patients revealed similar profiles of walking even though their diagnoses were vascular dementia (2), normal pressure hydrocephalus (2), Alzheimer dementia with possible normal pressure hydrocephalus (2), mixed Alzheimer and vascular dementia (1), peripheral neuropathy (1), Alzheimer dementia with parkinsonian features (1), and undetermined (1). Quantitatively, the patients' gait kinematics deviated greatly from control values, but these deviations were statistically attributable to reductions in stride. We suggest that many gait disturbances in elderly people are similar, regardless of etiology, because the characteristics of these gait disturbances are heavily veiled by nonspecific stride-dependent changes that comprise the syndrome of senile gait.

Longitudinal study of essential tremor

We measured wrist tremor and forearm EMG in 18 patients with essential tremor on two occasions separated by periods of 4 to 8 years. The frequency of tremor decreased 0.28 Hz to 3.21 Hz in 10 patients and changed less than 0.25 Hz in the remaining eight patients. Thus, the frequency of essential tremor may decrease over time.

Part-time Residency Training in Psychiatry

Part-time training in psychiatry has largely remained informaland has been utilized only by about 1% of psychiatry residents. This is puzzling considering the large number of women who have children during residency. In addition to aiding residents with child care needs, part-time training is also of potential value to dual-career families, handicapped residents with mobility problems, physicians seeking mid-career changes, and as a solution to those with funding problems. In this article, we present the case for systematic planning for part-time training based on experience in our program and a survey of other programs. We address the practical issues of arranging inpatient and outpatient clinical experiences, on-call arrangements, didactic programs, funding dilemmas, supervision, and evaluation.

Impairment, disability, handicap and medical expenses of persons aging with spinal cord injury

Data from 205 Craig Hospital patients with spinal cord injuries (SCI) were analysed with regard to level of injury, age, length of time since SCI, disability (as measured by the Functional Independence Measure), handicap (as measured by the Craig Handicap Assessment and Reporting Technique), and average annual costs for services relating to the SCI. Differences in disability, handicap, and costs of care were analysed by chronological age and length of time since injury. Older individuals showed significant increases in disability and handicap. When chronological age was added to the number of years post-injury, significant increases in disability, handicap, and costs of care were noted at all neurological levels.

Fibrinogen, factor VII clotting activity and coronary artery disease severity

To asses the relationship between fibrinogen, factor VII coagulant (VIIc) activity and extent of coronary artery disease, we studied 43 white males shown to have greater than 50% stenosis of at least one major coronary artery. Thirty six had a definite history of myocardial infarction at least 3 months earlier and were classified as having 1, 2 or 3 vessel disease while 7 had 2 or 3 vessel disease, but no prior infarction. Groups were similar with regard to age, body mass index and blood pressure. In those with documented prior infarction, there was a significant relationship between the extent of atheroma and coagulation variables factor VIIc and fibrinogen. However, given a similar degree of atheroma, patients with prior infarction had significantly higher levels of factor VIIc activity compared with patients without such a history. These results corroborate those from prospective studies confirming a significant role for the coagulation system in the clinical manifestation of coronary artery disease.

Sequestrated meningoceles of scalp: extracranial meningeal heterotopia

Sequestrated meningocele of the scalp has seldom been reported and is difficult to diagnose. Clinically it resembles dermoid cyst, hemangioma, or alopecia; radiographs and computed tomographic scans reveal no cranial bone defect, and surgery discloses no communication with the cranial cavity. Histologically, the lesion is characterized by a loose arrangement of connective tissue in dermis and subcutis, associated with flattened cells around collagen fibers (meningothelial cells). Most examples are very vascular, sometimes mimicking angioma, and about one third contain small necrotic foci. The meningothelial nature of the lesion is shown by its architectural similarity to communicating meningocele, and its identical immunoperoxidase reactions with vimentin and epithelial membrane antigen. In the 12 cases reported herein, most lesions were small (1 to 1.5 cm), and all but one were noted at birth but usually not resected until the patient had reached age 1 to 4, and one not until the patient was 31 years of age. Five lesions were not midline. We have been unable on histologic grounds to determine whether meningoceles are communicating or sequestrated. Compared with 20 communicating meningoceles, the sequestrated lesions were usually smaller, found in slightly older patients, and much less likely to be associated with hydrocephalus. The local excision of scalp lesions in children should include a search for a small intracranial connection.

Examination of vascular anastomoses during liver transplantation by intraoperative Doppler duplex scanning

Intraoperative examination of the arterial and portal vein anastomoses was performed in 16 liver transplant patients using duplex scanning. Two major defects and three minor defects were found in 5 arterial anastomoses. Major defects were defined as those associated with an audibly abnormal Doppler signal, a defect greater than 3 mm in length or greater than 50% luminal narrowing. Minor defects were defects visible by ultrasound but not meeting the above criteria. The major defects were repaired and scans following repair were without evidence of defects. The three minor defects were ignored. A nearly occluding thrombus was found in the portal vein of one patient. A thrombectomy was performed successfully. All patients have done well postoperatively. This report suggests that intraoperative duplex scanning may be of value in detecting technical imperfections in the vascular anastomoses during liver transplantation. Detection of a major defect intraoperatively allows immediate repair.

Further studies of a new vitamin E analogue more active than alpha-tocopherol in the rat curative myopathy bioassay

The bioactivities of the acetates of 2R,4'R,8'R- and 2S,4'R,8'R-2,4,6,7-tetramethyl-2-(4',8',12'-trimethyltridecyl)-5-h ydroxy-3,4- dihydrobenzofuran (RRR- and SRR-1-Ac) have been measured in the rat curative myopathy bioassay and compared with the RRR and SRR stereoisomers of alpha-tocopheryl acetate (RRR- and SRR-2-Ac). Each stereoisomer of 1 is only slightly more active than the corresponding stereoisomer of 2(RRR-1-Ac/RRR-2-Ac = 1.10; SRR-1-Ac/SRR-2-Ac = 1.16). This finding contrasts with our earlier finding [(1986) FEBS Lett. 205, 117-120], confirmed in the present study, that all-rac-1-Ac is 1.5-1.9 as active as all-rac-2-Ac. We suggest that the stereochemistry (S vs R) at the 4' and 8' tail carbons is of less biological importance in 1 than in 2.