Interprofessional simulation training improves knowledge and teamwork in nursing and medical students during internal medicine clerkship

Simulation is effective at improving healthcare students' knowledge and communication. Despite increasingly interprofessional approaches to medicine, most studies demonstrate these effects in isolation. We enhanced an existing internal medicine curriculum with immersive interprofessional simulations. For ten months, third-year medical students and senior nursing students were recruited for four, 1-hour simulations. Scenarios included myocardial infarction, pancreatitis/hyperkalemia, upper gastrointestinal bleed, and chronic obstructive pulmonary disease exacerbation. After each scenario, experts in medicine, nursing, simulation, and adult learning facilitated a debriefing. Study measures included pre- and post-tests assessing self-efficacy, communication skills, and understanding of each profession's role. Seventy-two medical students and 30 nursing students participated. Self-efficacy communication scores improved for both (medicine, 18.9 ± 3.3 pretest vs 23.7 ± 3.7 post-test; nursing, 19.6 ± 2.7 pretest vs 24.5 ± 2.5 post-test). Both groups showed improvement in "confidence to correct another healthcare provider in a collaborative manner" (Δ = .97 medicine, Δ = 1.2 nursing). Medical students showed the most improvement in "confidence to close the loop in patient care" (Δ = .93). Nursing students showed the most improvement in "confidence to figure out roles" (Δ = 1.1). This study supports the hypothesis that interdisciplinary simulation improves each discipline's self-efficacy communication skills and understanding of each profession's role. Despite many barriers to interprofessional simulation, this model is being sustained.

Haematoma in a hydrocele of the canal of Nuck mimicking a Richter's hernia

We report a haematoma in a hydrocele of the canal of Nuck in a 69-year-old female. She presented with a right-sided groin swelling, the differential for which included an irreducible inguinal hernia or haematoma given her aspirin and clopidegrel use. Successful treatment involved evacuation of the haematoma with excision of the sac. Despite a high index of suspicion for a haematoma, these swellings should ideally be explored given the potential for co-existence of a hernia.

THE MULTIPLICATION OF BACTERIOPHAGE IN VIVO AND ITS PROTECTIVE EFFECT AGAINST AN EXPERIMENTAL INFECTION WITH SHIGELLA DYSENTERIAE

1. Anti-Shiga bacteriophage injected into the general circulation can multiply in the brain of mice infected intracerebrally with Shigella dysenteriae. 2. Under proper conditions, the injection of active bacteriophage into the general circulation can protect mice against an otherwise fatal intracerebral infection with Shigella dysenteriae. 3. The protection so induced appears to depend upon the early establishment of a high bacteriophage level in the infected animal.

THE ENHANCING EFFECT OF CONCURRENT INFECTION WITH PNEUMOTROPIC VIRUSES ON PULMONARY TUBERCULOSIS IN MICE

The course of pulmonary tuberculosis in the mouse appears to be accelerated as a result of concurrent infection of the lung with either of two pneumotropic viruses. This effect is obtained with virus inocula sufficiently small as to induce little or no definite viral pneumonia.

INFECTION OF MICE WITH MAMMALIAN TUBERCLE BACILLI GROWN IN TWEEN-ALBUMIN LIQUID MEDIUM

Introduction of the bacilli by the mtravenous route or by feeding gives rise to a disease predominantly localized in the lungs. Following intracerebral infection, the bacilli first multiply rapidly in the brain tissue, and then invade other organs, producing lesions especially in the lungs. Injection of the bacilli by the intraperitoneal route is less effective than by either the intravenous or intracerebral routes; however, admixture of the bacilli with some of the components of egg yolk increases both the infectivity and the pulmonary localization. Different strains of mice differ markedly in their susceptibility to experimental tuberculous infection; the highest susceptibility was observed among the pigmented strains (line 1 dba and C57 black). Greater resistance does not appear to depend on the ability to prevent the establishment of infection, but rather corresponds to a slower rate of progression of the infectious process. It is possible to produce in mice tuberculosis presenting any desired degree of acuteness or chronicity by controlling certain factors which condition the initiation and the progression of the infection.

VIRULENCE AND MORPHOLOGICAL CHARACTERISTICS OF MAMMALIAN TUBERCLE BACILLI

Experimental infection of the mouse can be used for the determination of virulence of cultures of mammalian tubercle bacilli. The relative virulence of such cultures for the mouse is approximately the same as for the guinea pig. Cultures of virulent and avirulent variants of mammalian tubercle bacilli grown in the depth of Tween 80-albumin liquid medium, on the surface of solid agar modifications of this medium, and on the surface of a liquid modification of this medium exhibit consistent morphological differences. All virulent cultures tend to form microscopically demonstrable serpentine cords of varying thickness and length consisting of highly acid-fast bacilli oriented in parallel along the long axis of the cord. The formation of cords appears to be an important factor in conditioning the ability of cultures to spread on the surface of liquid and solid media. It can be inhibited by the addition to the medium of the surface-active water-dispersible oleic acid ester, Tween 80. Avirulent variant bacilli grow in a more or less non-oriented fashion. They have never been observed to form cords under any condition of growth and are much less acid-fast than the virulent cultures when grown in Tween-albumin medium. Two strains of mammalian tubercle bacilli which are intermediate in degree of virulence between the fully virulent and the avirulent variants also exhibit intermediate morphological characteristics.

Life-threatening hypernatraemic dehydration in breastfed babies

We describe five babies, who were exclusively breast fed, with life-threatening complications of hypernatraemic dehydration secondary to inadequate breast feeding. An increased awareness among health professionals is required so that this potentially devastating condition can be prevented.

Crossover by line length and spatial location

It is well known that line length has a systematic influence on line bisection error in neglect. Most patients with neglect misbisect long lines on the same side of true center as their brain lesion but then cross over on short lines, misbisecting them on the opposite side (i.e., crossover by line length). What is less recognized is that the spatial location of lines relative to the viewer can similarly induce a crossover effect when one considers line bisection error scores that have been averaged across individual line lengths. Patients with right hemisphere injury and neglect classically make averaged line bisection errors that fall right of true center on lines located either at midline or to the left of the viewer; however, we observed that the averaged line bisection error can fall left of true center when lines are located to the right of the viewer (i.e., crossover by spatial location). We hypothesized that crossover by both line length and spatial location stem from systematic errors in magnitude estimation, i.e., perceived line length. We tested predictions based on this hypothesis by examining how the crossover effect by line length is altered by the spatial location of lines along a horizontal axis relative to the viewer. Participants included patients with unilateral lesions of the right and left cerebral hemispheres and age-appropriate normal subjects. All groups demonstrated a crossover effect by line length at the midline location but the effect was altered by placing lines to the right and left of the viewer. In particular, patients with right hemisphere injury and neglect crossed-over across a broader range of line lengths when the lines were located to the right of the viewer rather than at either midline or left of the viewer. It is proposed that mental representations of stimulus magnitude are altered in neglect, in addition to mental representations of space, and that traditional accounts of neglect can be enhanced by including the psychophysical concept of magnitude estimation.

A systematic review of the associations between dose regimens and medication compliance

BACKGROUND

Previous reviews of the literature on medication compliance have confirmed the inverse relationship between number of daily doses and rate of compliance. However, compliance in most of these studies was based on patient self-report, blood-level monitoring, prescription refills, or pill count data, none of which are as accurate as electronic monitoring (EM).

OBJECTIVE

In this paper, we review studies in which compliance was measured with an EM device to determine the associations between dose frequency and medication compliance.

METHODS

Articles included in this review were identified through literature searches of MEDLINE, PsychInfo, HealthStar, Health & Psychosocial Instruments, and the Cochrane Library using the search terms patient compliance, patient adherence, electronic monitoring, and MEMS (medication event monitoring systems). The review was limited to studies reporting compliance measured by EM devices, the most accurate compliance assessment method to date. Because EM was introduced only in 1986, the literature search was restricted to the years 1986 to 2000. In the identified studies, data were pooled to calculate mean compliance with once-daily, twice-daily, 3-times-daily, and 4-times-daily dosing regimens. Because of heterogeneity in definitions of compliance, 2 major categories of compliance rates were defined: dose-taking (taking the prescribed number of pills each day) and dose-timing (taking pills within the prescribed time frame).

RESULTS

A total of 76 studies were identified. Mean dose-taking compliance was 71% +/- 17% (range, 34%-97%) and declined as the number of daily doses increased: 1 dose = 79% +/- 14%, 2 doses = 69% +/- 15%, 3 doses = 65% +/- 16%, 4 doses = 51% +/- 20% (P < 0.001 among dose schedules). Compliance was significantly higher for once-daily versus 3-times-daily (P = 0.008), once-daily versus 4-times-daily (P < 0.001), and twice-daily versus 4-times-daily regimens (P = 0.001); however, there were no significant differences in compliance between once-daily and twice-daily regimens or between twice-daily and 3-times-daily regimens. In the subset of 14 studies that reported dose-timing results, mean dose-timing compliance was 59% +/- 24%; more frequent dosing was associated with lower compliance rates.

CONCLUSIONS

A review of studies that measured compliance using EM confirmed that the prescribed number of doses per day is inversely related to compliance. Simpler, less frequent dosing regimens resulted in better compliance across a variety of therapeutic classes.

Is leukocytosis a predictor of mortality in severe pertussis infection?

Bordetella pertussis causing severe respiratory failure in infants that is unresponsive to treatment is well described. Pulmonary hypertension is a prominent feature of such cases. In this series of 13 critically ill infants with B. pertussis, hyperleukocytosis ( > 100 x 10(9)/l) was an independent predictor of death. We suggest that such extreme leukocytosis may contribute to disease severity via the formation of aggregates in the pulmonary vasculature.

Laparoscopic Colon Resections: A Five-Year Retrospective Review

In recent years, laparoscopic surgery has become a matter of growing interest. It has been shown that laparoscopic colectomy is well tolerated and safe for benign disease. However, there is some uncertainty about using this method for malignant disease when curative resection is the aim. These uncertainties mainly consist of spread of cancer to port site, long-term survival, and adequacy of resection. The majority of laparoscopic colectomies are technically assisted procedures in which anastomosis is performed outside the abdomen. However, some surgeons are now performing this surgery totally laparoscopically with the anastomosis performed inside the abdomen. Laparoscopic colectomy is currently practiced with great frequency by general surgeons. Its performance requires a steep learning curve and a large number of cases to obtain proficiency. The indications for laparoscopic colectomy are different from one institution to another. In some institutions all patients with colorectal disease are candidates for laparoscopic colectomy and in others it may be limited to benign disease only. The purpose of this review is to analyze all laparoscopic colectomies performed at our medical center since 1992. We conducted a retrospective chart review of both hospital and clinic charts of patients who underwent colectomies at our hospital. A total of 338 patient charts were reviewed. In a comparison of both laparoscopic (n = 285) and converted (n = 53) methods, the age and operative time were about the same. Age average and operating room time average were similar for both groups. With laparoscopy, there was a 3-day drop in length of hospital stay as well as a 1-day-earlier regaining of bowel function. Hospital cost dropped $5000 average for the laparoscopic colectomy. The conversion rate at our center was 15 per cent. Complication rates were lower in the laparoscopic group. Recurrence of cancer at the port site (0.7%) was no higher than in the converted group (incisional recurrence, 1.8%). We conclude that laparoscopic colectomy does show an improvement in return of bowel function, hospital cost, and shorter hospital stay. Long-term follow-up will be necessary to determine the effectiveness of laparoscopic colon resection for colorectal cancer.

Laparoscopic colon resections: a five-year retrospective review

In recent years, laparoscopic surgery has become a matter of growing interest. It has been shown that laparoscopic colectomy is well tolerated and safe for benign disease. However, there is some uncertainty about using this method for malignant disease when curative resection is the aim. These uncertainties mainly consist of spread of cancer to port site, long-term survival, and adequacy of resection. The majority of laparoscopic colectomies are technically assisted procedures in which anastomosis is performed outside the abdomen. However, some surgeons are now performing this surgery totally laparoscopically with the anastomosis performed inside the abdomen. Laparoscopic colectomy is currently practiced with great frequency by general surgeons. Its performance requires a steep learning curve and a large number of cases to obtain proficiency. The indications for laparoscopic colectomy are different from one institution to another. In some institutions all patients with colorectal disease are candidates for laparoscopic colectomy and in others it may be limited to benign disease only. The purpose of this review is to analyze all laparoscopic colectomies performed at our medical center since 1992. We conducted a retrospective chart review of both hospital and clinic charts of patients who underwent colectomies at our hospital. A total of 338 patient charts were reviewed. In a comparison of both laparoscopic (n = 285) and converted (n = 53) methods, the age and operative time were about the same. Age average and operating room time average were similar for both groups. With laparoscopy, there was a 3-day drop in length of hospital stay as well as a 1-day-earlier regaining of bowel function. Hospital cost dropped 5000 dollars average for the laparoscopic colectomy. The conversion rate at our center was 15 per cent. Complication rates were lower in the laparoscopic group. Recurrence of cancer at the port site (0.7%) was no higher than in the converted group (incisional recurrence, 1.8%). We conclude that laparoscopic colectomy does show an improvement in return of bowel function, hospital cost, and shorter hospital stay. Long-term follow-up will be necessary to determine the effectiveness of laparoscopic colon resection for colorectal cancer.

Surgical technologists advance practice and profession at Indiana Hospital

The surgical technologist can be a cost-effective staff member in the OR. Techs work with RNs as part of the important team of perioperative and intraoperative patient care providers. All who work in the OR, including techs, are responsible for its cost effectiveness.

The impact of the standards for pediatric immunization practices on vaccination coverage levels

OBJECTIVE

To assess the impact on clinic-specific vaccination coverage of implementing the Standards for Pediatric Immunization Practices.

DESIGN

A nonrandomized intervention trial conducted for 1 year.

SETTING

Two public health clinics in Albuquerque, NM: 1 intervention site and 1 control site, each serving 1 of 4 city quadrants.

PARTICIPANTS

All children enrolled in the 2 city public health clinics.

INTERVENTIONS

Implementation of the Standards for Pediatric Immunization Practices.

OUTCOME MEASURES

Assessment of up-to-date vaccination coverage levels prior to and at the conclusion of the project. The impact on the proportion of children who dropped out of vaccination services after receiving 1 dose by 3 months of age.

RESULTS

At the intervention site, up-to-date coverage at 12 months of age rose from 57.5% to 80.4%, while levels at the control site decreased from 42.1% to 41.9%. Before the intervention, 24% of children at the intervention site who received the first dose of diphtheria and tetanus toxoids and pertussis vaccine (DTP 1) by 3 months of age failed to receive the third dose of DTP (DTP 3) by 12 months of age vs 5% after the intervention. At the control site, the proportion of children who received DTP 1 by 3 months of age, but not DTP 3 by 12 months of age, increased from 39% to 51%.

CONCLUSION

Implementation of the Standards for Pediatric Immunization Practices in a public health clinic was associated with important increases in vaccination coverage levels and a reduction in the proportion of children who dropped out of vaccination services.

The manganese stabilizing protein of photosystem II modifies the in vivo deactivation and photoactivation kinetics of the H2O oxidation complex in Synechocystis sp. PCC6803

Dark deactivation and photoactivation of H2O-splitting activity were examined in a directed mutant (delta psbO) of Synechocystis sp. PCC6803 lacking the extrinsic manganese-stabilizing protein of the photosystem II (PSII) reaction center complex. Rapid (t1/2 = 10 min) losses of H2O-splitting activity were observed for delta psbO cells kept in the dark, but not for wild-type cells. The loss of H2O-splitting activity by delta psbO cells was suppressed by maintaining the cells under illumination and dark losses were rapidly (t1/2 < 1 min) reversed by light. Photoactivation kinetics of delta psbO and wild-type cells were compared following hydroxylamine extraction of PSII Mn. Photoactivation of delta psbO cells under continuous illumination occurs at an intrinsically faster rate (about 4-fold) than the wild-type. Virtually all of the increase in the rate of photoactivation can be accounted for by a corresponding 4-fold increase in the relative quantum yield of photoactivation as indicated by the yield of photoactivation as a function of flash number. The flash frequency dependence of photoactivation indicates a multi-quantum process in the mutant resembling the wild-type, but with significant increases in yields at all flash frequencies examined. The higher quantum yield of photoactivation in delta psbO cells occurs in the absence of large changes in the kinetics of the rate-limiting dark rearrangement. The results are consistent with increased accessibility (or affinity) and photooxidation of Mn2+ at one or both of the two binding sites involved in the initial stages of the photoactivation mechanism. In the context of previous results, it is proposed that MSP regulates the binding/photooxidation of the second Mn2+ of the photoligation sequence, but not the first.

Assessing the role of the Blues plans' all-payer clearinghouses

A growing number of the nation's 67 Blue Cross and Blue Shield plans, many of which are dominant health insurers in their markets, are attempting to expand their electronic health care transactions business. At least a dozen plans have created claims clearinghouses designed to handle claims and other electronic transactions destined for any payer.

An interview with: Charlie Pierce on the use of covert CCTV

Charlie Pierce is the founder and president of LRC Electronics Company and LTC Training Center, Davenport, IA. He has 18 years of field, office, seminar, and shop experience in the closed-circuit television industry and frequently lectures about CCTV issues. In this interview, he discusses the use of CCTV technology for covert surveillance applications, the available technology, and the legal ramifications.

Reference period analysis of vaginal bleeding with triphasic oral contraceptive agents containing norethindrone or levonorgestrel: a comparison study

The World Health Organization recommends the use of fixed reference periods for quantification of the incidence and severity of vaginal bleeding when patients use various forms of contraception. Ninety- and 110-day reference periods were used in the analysis of data from daily menstrual diaries kept by 72 healthy women in a one-year study of oral contraceptive agents containing ethinyl estradiol and either norethindrone or levonorgestrel. Analysis of bleeding patterns reported during both 90-day and 110-day periods revealed fewer days of bleeding and/or spotting overall with norethindrone than with levonorgestrel (e.g., a mean of 16.06 vs. 19.55 days, respectively, over the first 90-day period; P = .013) and significantly shorter bleeding and/or spotting episodes with the norethindrone preparation. This trend persisted when data were adjusted for a day-1 pill start. Using either method of analysis, duration of bleeding episodes was shorter among subjects taking norethindrone than levonorgestrel. Pills were missed in both study groups, but more women in the LNG/EE group missed from 1 to 3 pills in at least one cycle (31 vs. 21 in the NET/EE group). The between-group difference in bleeding events may be due to intrinsic hormonal differences in regimens or to the greater number of pills missed among levonorgestrel users.

Standardization of ELISA for the detection of anti-cardiolipin antibodies--effect of non-specific IgG binding

Various frequencies of anti-cardiolipin antibodies reported in patients with systemic lupus erythematosus and other autoimmune and infectious diseases necessitates the need for standardization of the immunoassay. We report here the usefulness of "no-antigen" control for each serum in determining the actual value of the anti-phospholipid antibodies. This non-specific "no-antigen" binding was quite variable from serum to serum and in general was higher in the patient population than in healthy individuals which served as controls. This non-specific binding may be associated with the increased IgG content of the sera as shown by the linear association of the absorbance of the back-ground readings to increases in IgG concentration (correlation coefficient 0.98).

Surgical aortic valvuloplasty using the Cavitron Ultrasonic Surgical Aspirator: an invasive hemodynamic follow-up study

Valve repair and calcium debridement in patients with calcific aortic stenosis, using the Cavitron Ultrasonic Surgical Aspirator (CUSA), results in a reduction in the aortic valve gradient while potentially avoiding long-term problems inherent to prosthetic valves. Invasive followup data in these patients has not previously been reported. Ten patients in whom CUSA debridement was performed underwent cardiac catheterization prior to and 8.0 +/- 2.5 months following the procedure. Compared to baseline, the aortic valve area significantly increased from 0.75 +/- 0.2 to 1.1 +/- 0.3 cm2 (p = 0.009) and the mean gradient was significantly reduced from 54 +/- 21 to 27 +/- 21 mmHg (p = 0.02) at followup. No significant change was noted in cardiac output, ejection fraction, left ventricular end systolic or diastolic volumes or left ventricular end diastolic pressure. However, 6 patients were found to have at least one grade worsening of aortic regurgitation. The development of increased aortic insufficiency in many patients after CUSA aortic valve debridement will likely limit this procedure's clinical utility.

Determinants of one-year outcome from balloon aortic valvuloplasty

Balloon aortic valvuloplasty (BAV) has been a therapeutic alternative treatment for severe symptomatic aortic stenosis. Previous studies have been unable to predict 1-year outcome because of limited acute and follow-up clinical, invasive and echocardiographic data. The purpose of this study was to predict long-term outcome based on comprehensive data obtained at the time of valvuloplasty and at 3 and 6 months after the procedure. Of 170 consecutive patients undergoing BAV, 108 (mean age 78 years) were at least 1 year from their procedure. Prospective clinical, micromanometer hemodynamic, digital ventriculographic and echocardiographic/Doppler data were collected at baseline and immediately after the procedure. Echocardiographic data were also obtained at 3 and 6 months. With use of Cox model analysis, major events (defined as cardiac death [n = 30], aortic valve replacement [n = 21] or repeat BAV [n = 13]) were predicted by advanced age, baseline heart failure class, and baseline echocardiographic-determined diastolic left ventricular diameter. Only baseline left ventricular ejection fraction proved to be a significant predictor of cardiac death (p = 0.002) in a multivariate model. Absolute values after BAV (stroke work, first derivative of left ventricular pressure, valve area, end-systolic volume, Fick cardiac output, transvalvular gradient) and acute changes measured by catheterization or echocardiography did not provide additional predictive information over that of post procedure ejection fraction. Similarly, echocardiographic valve area and transvalvular gradient at 3 months added no further prognostic data. With an ejection fraction greater than or equal to 45% (n = 63), cardiac survival at 1 year was 80%, irrespective of age, sex, congestive heart failure class or severity of coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-phospholipid antibody profiles of different specificities in syphilis and systemic lupus erythematosus

Controversies exist as to the differences in the specificities of phospholipid antibodies in SLE and syphilis. We report an ELISA assay that could distinguish phospholipid antibodies associated with SLE and syphilis based on their differential reactions with phosphatidyl choline and VDRL antigens. Antibodies to phospholipid from patients with SLE reacted equally well when tested with these two antigens in the ELISA assay whereas phospholipid antibodies present in syphilis patients exhibited little or no binding to phosphatidyl choline. There were no differences in the binding of phospholipid antibodies to other phospholipids such as cardiolipin and phosphatidyl serine. In addition, there was no association of anti-phospholipid antibodies with the presence of either DNA or RPR antibodies suggesting their distinctness from each other.