Embracing informed learner self-assessment during debriefing: the art of plus-delta.

The healthcare simulation field has no shortage of debriefing options. Some demand considerable skill which serves as a barrier to more widespread implementation. The plus-delta approach to debriefing offers the advantages of conceptual simplicity and ease of implementation. Importantly, plus-delta promotes learners' capacity for a self-assessment, a skill vital for safe clinical practice and yet a notorious deficiency in professional practice. The plus-delta approach confers the benefits of promoting uptake of debriefing in time-limited settings by educators with both fundamental but also advanced skills, and enhancing essential capacity for critical self-assessment informed by objective performance feedback. In this paper, we describe the role of plus-delta in debriefing, provide guidance for incorporating informed learner self-assessment into debriefings, and highlight four opportunities for improving the art of the plus delta: (a) exploring the big picture vs. specific performance issues, (b) choosing between single vs. double-barreled questions, (c) unpacking positive performance, and (d) managing perception mismatches.

Experiments in DNA extraction and PCR amplification from bighorn sheep feces: the importance of DNA extraction method.

Reliability of genotyping is an issue for studies using non-invasive sources of DNA. We emphasize the importance of refining DNA extraction methods to maximize reliability and efficiency of genotyping for such DNA sources. We present a simple and general method to quantitatively compare genotyping reliability of various DNA extraction techniques and sample materials used. For bighorn sheep (Ovis canadensis) fecal samples we compare different fecal pellet materials, different amounts of fecal pellet material, and the effects of eliminating two DNA extraction steps for four microsatellite loci and four samples heterozygous at each locus. We evaluated 192 PCR outcomes for each treatment using indices of PCR success and peak height (signal strength) developed from analysis output of sequencer chromatograms. Outermost pellet material produced PCR results almost equivalent to DNA extracted from blood. Where any inner pellet material was used for DNA extraction, PCR results were poorer and inconsistent among samples. PCR success was not sensitive to amount of pellet material used until it was decreased to 15 mg from 60 mg. Our PCR index provides considerably more information relative to potential genotyping errors than simply comparing genotypes derived from paired fecal and blood or tissue samples. Our DNA extraction method probably has wide applicability to herbivores that produce pelleted feces where samples dry rapidly after deposition.

Recognizing pain in the institutionalized elder with dementia.

Of the approximately 2 million elders residing in nursing homes, experts estimate that 49% to 83% are experiencing pain. Elders in nursing homes have a high incidence of cognitive impairment, possibly as high as 50%. The verbalization of pain can be difficult for those with cognitive impairment, and elders with dementia may be undertreated and unknowingly allowed to suffer. This article summarizes what is known about pain assessment in the cognitively impaired elderly who reside in nursing homes. Clinical practice implications were derived from this summary. Until accurate ways of assessing pain are discovered, nurses must be educated to the prevalence of pain in cognitively impaired elders and the subtle ways in which it might be detected. Nursing practice is about eliminating suffering. Relieving suffering in those most vulnerable and unable to express their needs is critical.

Pain management practices of nurses caring for older patients with osteoarthritis.

Osteoarthritis is a prevalent chronic illness in older people. Management of the ensuing pain is of critical importance in preventing disability and maintaining independence. This qualitative study explored the pain management techniques used by 10 RNs working in home health nursing. Four categories emerged from the interview data: knowing how to assess, knowing about pain treatments, trying but frustrated, and needing more knowledge. These categories were reduced into two constructs: Understanding Pain and Wanting to Provide Good Nursing Care. Clinical implications included supplementing pain management strategies by adding to the assessment base, expanding pain management techniques, and increasing knowledge about aging processes and pain control.

Perspectives from the historic African American medical institutions.

The historically African American medical schools have been at the center of medical education for African American physicians in the United States since the Howard University College of Medicine opened in 1868. Although there were more than a dozen African American medical schools established during the next few decades, as propriety or church affiliated schools, only two survived the Flexner Report in 1910. Howard University (1868) and Meharry (1876) survived and trained generations of African Americans. These two schools educated approximately 85% of all African American physicians whereas the majority medical schools educated 15% for more than half of the twentieth century. As the result of a series of lawsuits filed by the National Association for the Advancement of Colored People, civil rights legislation and affirmative action programs, the numbers of the schools that now admitted African Americans increased and the total numbers of African American medical students increased when discrimination was prohibited in 1966. The percentage of African American medical students attending predominantly white institutions increased by 25% in 1948, by 47% in 1968, by 61% in 1983 and to 84% in 1990. Two additional predominantly African American medical schools were established: the Charles R. Drew Medical School, Los Angeles (affiliated with the University of California, Los Angeles) in 1966, and Morehouse Medical School, Atlanta, which admitted its first class in 1978. Recent court decisions prohibiting schools from considering race as factor in admission and the end of affirmative action programs have resulted in a drop in total minority enrollment. The historically African American medical schools, that admitted approximately 15% of the African American medical students during the era of affirmative action programs, will see this percentage decrease as the majority institutions admit fewer African American medical students and minority students. In the United States this trend already has been observed in admission data and graduation data for 1996 and 1997.

Necrotizing fasciitis: a case study.

Necrotizing fasciitis (NF) is a disease characterized by the destruction of the skin, subcutaneous fat, and fascia, with or without inflammation of the muscle tissue. NF carries a mortality rate in excess of 50 percent in neonates. Rapid diagnosis and initiation of antibiotics, along with meticulous nursing care, can provide an acceptable outcome for the neonate. This article reviews the pathophysiology, diagnosis, and treatment of NF; presents a case study; and provides a nursing care plan that supports treatment of this disease process.

Combined ganciclovir and foscarnet in pediatric cytomegalovirus retinitis.

Cytomegalovirus retinitis is the leading cause of blindness in adults and children with acquired immunodeficiency syndrome (AIDS). Although clinical trials on therapy exist for adults, management of cytomegalovirus retinitis in children is not as well-documented. This report describes the clinical course of a 3-year-old child with cytomegalovirus retinitis. After initial failure with single-agent ganciclovir intravenous treatment, early institution of combined treatment with foscarnet and ganciclovir halted progression of the retinitis. This case report highlights the aggressive nature of cytomegalovirus retinitis in children and the consideration of early combined therapy compared to adult patients.

Treatment of IM-9 cells with human growth hormone (GH) promotes rapid disulfide linkage of the GH receptor.

Human GH (hGH) is believed to elicit its signal by promoting dimerization of the hGH receptor (hGHR). In this study, we examined a covalent linkage of receptors induced by hGH treatment of IM-9 cells. hGH induced a time- and concentration-dependent appearance of a disulfide-linked species of 215-230 kilodaltons, designated p215-230, that at 37 C was long-lived (> 1 h). p215-230 was confirmed to contain the hGHR (115-140 kilodaltons) as at least one of its constituents by two-dimensional diagonal sodium dodecyl sulfate-polyacrylamide gel electrophoresis. hGH induction of p215-230 required intact cells and was inhibitable by pretreatment of cells with N-ethylmaleimide (NEM), a sulfhydryl-reactive alkylating agent. NEM pretreatment did not, however, prevent hGH-dependent formation of a nondisulfide-linked p215-230 form, which was detected in NEM-pretreated hGH-stimulated cells by chemical cross-linking of detergent cell extracts. The disulfide-linked form of the hGHR accounted for a substantial fraction of the receptors that became tyrosine phosphorylated early into hGH treatment. However, formation of the disulfide-linked hGHR was not blocked by attenuation of tyrosine kinase activation, in that pretreatment of cells with staurosporine (1.25 microM) prevented detectable hGH-induced tyrosine phosphorylation without preventing the appearance of p215-230. These findings indicate that hGH induces its receptor to form a noncovalently associated complex, which then undergoes a rapid transition to a disulfide-linked form. These processes may have relevance to hGH signaling and/or hGHR trafficking.

Osteomyelitis in patients who have sickle-cell disease. Diagnosis and management.

Fifteen patients who had sickle-cell disease and osteomyelitis (affecting thirty bones) were treated with operative decompression and parenteral administration of antibiotics between 1973 and 1988. Organisms were isolated on culture of specimens of bone from all fifteen patients. Parenteral antibiotic therapy was continued for a minimum of six weeks after operative decompression. The osteomyelitis resolved in twenty-nine (97 per cent) of the thirty affected bones after follow-up ranging from two to fifteen years. With their compromised immune status and poor circulation of blood in bone, patients who have sickle-cell disease and osteomyelitis are prone to have complications. In our series, the complications included an adhesive pericapsulitis of the shoulder in two patients, avascular necrosis of the humeral head in one, and a pathological fracture of the femur in one. In four of the fifteen patients, chronic osteomyelitis persisted, but in three of the four, the infections of bone healed six to fourteen months after the initial operative decompression. Staphylococcus aureus was isolated on culture of specimens of bone from eight to the fifteen patients; Salmonella, from six; and Proteus mirabilis, from one. Although Salmonella has been cited as the principal causative organism of osteomyelitis in patients who have sickle-cell disease, in our experience Staphylococcus aureus was the most common infecting organism. Therefore, Salmonella may not be the most common cause of osteomyelitis associated with sickle-cell disease in all countries or in all areas of a particular country.

Failure of centralization of the fibula for congenital longitudinal deficiency of the tibia.

Between 1962 and 1983, fourteen patients (twenty knees) had centralization of the fibula for congenital longitudinal deficiency: tibial, complete. Eleven of the twenty index procedures were performed on patients who were one year old or less. A progressive flexion deformity of the knee developed after all twenty index procedures. Twenty-six secondary procedures were needed, including disarticulation at the knee, posterior release, extension osteotomy, femorofibular arthrodesis, and biceps-to-quadriceps transfer, and one patient had a second attempt at centralization of the fibula. The duration of follow-up after the initial centralization of the fibula ranged from four years to twenty-two years and seven months (average, twelve years and four months). Seven patients (eight limbs) in whom the index procedure resulted in failure had a satisfactory result after disarticulation at the knee. The patients who did not have secondary disarticulation at the knee are also considered to have had a failed index procedure because they had a flexion deformity at the latest follow-up. Attempts to reconstruct the knee joint by centralization of the fibula are not warranted for patients who have congenital longitudinal deficiency: tibial, complete. Early disarticulation at the knee and fitting with a prosthesis, with close follow-up, is the treatment of choice.

Proximal femoral focal deficiency: evaluation and management.

Proximal femoral focal deficiency is a rare congenital anomaly characterized by limb malrotation, deficiency of the iliofemoral articulation, and limb length discrepancy. Advances in radiology, such as computed tomography and magnetic resonance imaging, have enhanced the assessment of pelvic-femoral instability prior to ossification of the femoral capital epiphysis. The histopathology of the fetal proximal femoral growth plate has been described, which has increased our knowledge about the etiology of the proximal femoral malformation. Data are now available regarding the long-term functional status of patients with severe acetabular dysplasia (Aitken Class C or Class D deformity) following nonoperative management of the hip. A review of the current knowledge regarding proximal femoral focal deficiency is presented to assist the orthopedic surgeon in evaluation and management.

Differential effect of restraint stress on MHC class II expression by murine peritoneal macrophages.

The effect of restraint stress on the expression of MHC class II glycoproteins by peritoneal macrophages was evaluated. Restraint suppressed the expression of I-A by macrophages from mice that are susceptible to Mycobacterial infection. In contrast, restraint did not affect I-A expression by macrophages from resistant mice. The suppression of MHC class II expression required at least 8 h of restraint and recovered within 4 h after stress. The amount of restraint necessary to suppress I-A expression also resulted in higher levels of plasma corticosterone. Changes in I-A expression were under circadian rhythm control. The differences in the effect of restraint stress on expression of I-A by peritoneal macrophages from resistant and susceptible mice may, in part, be due to differences in the effect of corticosterone in MHC class II expression.

Treatment of hemimelias of the lower extremity. Long-term results.

We used contemporary methods, including early surgical intervention (usually amputation) and prosthetic rehabilitation, to treat tibial or fibular hemimelia in thirty-three patients (forty-four limbs); twenty-four patients (twenty-nine limbs) had adequate follow-up, and their cases are reported here. After an average length of follow-up of sixteen years, all except two of the patients had an excellent or a good result. No patient had migration of the heel pad or a slough or infection of the skin, and only one patient needed a second operation. The Brown procedure was done on three limbs (two patients), but it always had to be supplemented by a corrective operation. We concluded that early surgical treatment and prosthetic rehabilitation yield an excellent result, not only for the short term but also for the long term.

Nonunion of the humerus.

Under certain circumstances, fractures of the humerus may not heal. Some fractures experience delayed union and some develop nonunion despite improved methods of treatment. This chapter discussed nonunion and fracture fixation methods in the proximal, middle, and distal thirds of the humerus. Special circumstances were discussed, such as infection, nerve palsy, comminution, and electrical stimulation.