Prevention in the inpatient setting.

PURPOSE: To review the literature on and describe approaches to implementing health promotion and disease prevention practices in the inpatient setting. DATA SOURCES: Comprehensive review of nursing and medical literature, clinical practice guidelines, and U.S. government documents. CONCLUSIONS: Preventive screening has been shown to reduce morbidity and mortality from many diseases. Health promotion and disease prevention activities form the foundation of practice for many nurse practitioners (NPs). As increasing numbers of NPs begin to practice in the acute care setting, it is important they incorporate prevention into the inpatient setting. IMPLICATIONS FOR PRACTICE: Because there are many barriers that impact appropriate preventive screening, health care providers must take advantage of every patient encounter including those in the inpatient setting. Although it may not be feasible to actually perform certain screening exams while a patient is hospitalized, it is feasible in many cases to take a few minutes to review recommended preventive screening.

Neuron-specific expression of the rat gonadotropin-releasing hormone gene is conferred by interactions of a defined promoter element with the enhancer in GT1-7 cells.

Neuroendocrine control of the reproductive cascade is mediated by GnRH, which in mammals is produced by a subset of neurons scattered throughout the hypothalamus and forebrain. Utilizing a cultured cell model of GnRH neurons (GT1-7 cells), two regulatory regions in the rat GnRH 5' flanking DNA were identified as essential for cell-type specificity: a 300-bp enhancer and a 173-bp conserved proximal promoter. Using transient transfections to compare expression in GT1-7 cells to a non-GnRH-expressing cell type (NIH 3T3), we show that the GnRH enhancer and the proximal promoter each play roles in conferring this specificity. Deletion of footprint 2 (FP2; -26 to -76) from the promoter when coupled to the GnRH enhancer diminishes reporter activity in GT1-7 cells more strongly than in NIH 3T3 cells. Furthermore, deletion of FP2 from the promoter when coupled to the heterologous Rous sarcoma virus 5'-long terminal repeat promoter abolishes the difference in reporter activity between GT1-7 and NIH 3T3 cells, suggesting that FP2 of the GnRH promoter is necessary for cell-specific expression. In addition, FP2 alone is sufficient to confer cell-specific expression and can interact with the GnRH enhancer to augment reporter gene expression specifically in GT1-7 cells. Finally, a 31-bp sequence from within FP2 (-63 to -33) synergistically activates transcription when coupled with the GnRH enhancer in GT1-7 cells but not in NIH 3T3 cells. Thus, this 31-bp region contains elements necessary for interaction between the GnRH enhancer and promoter. We show that two of five protein complexes that bind to the -63 to -33 region are GT1-7 cell specific, and both of them appear to be homeodomain proteins. The identification of a cell-specific element in the GnRH proximal promoter significantly advances our understanding of the transcriptional basis for neuron-specific GnRH gene expression.

The Otx2 homeoprotein regulates expression from the gonadotropin-releasing hormone proximal promoter.

The GnRH gene is expressed exclusively in a highly restricted population of approximately 800 neurons in the mediobasal hypothalamus in the mouse. The Otx2 homeoprotein has been shown to colocalize with GnRH in embryonic mouse brain. We have identified a highly conserved bicoid-related Otx target sequence within the proximal promoter region of the GnRH gene from several species. This element from the rat GnRH promoter binds baculovirus-expressed Otx2 protein and Otx2 protein in nuclear extracts of a hypothalamic GnRH-expressing neuronal cell line, GT1-7. Transient transfection assays indicate that the GnRH promoter Otx/bicoid site is required for specific expression of the GnRH gene in GT1-7 cells and that it can confer specificity to a neutral Rous sarcoma virus (RSV) promoter in GT1-7 cells but not in NIH3T3 cells. Overexpression of mouse Otx2 in GT1-7 cells induces expression of a GnRH promoter plasmid, an effect that is dependent upon the Otx binding site. Thus, the GnRH proximal promoter is regulated by the Otx2 homeoprotein. Finally, we have now demonstrated the presence of Otx2 protein in the GnRH neurons of the adult mouse hypothalamus. These data suggest that Otx2 is important in the development of the GnRH neuron and/or in the maintenance of GnRH expression in the adult mouse hypothalamus.

Visual performance after aphakic epikeratoplasty.

While good visual acuity and refractive results after epikeratoplasty for aphakia have been reported, particularly for adults and older children, limited detailed information on the nature of the resulting vision is available. We have evaluated the visual performance of seven aphakic subjects corrected by epikeratoplasty by measuring contrast sensitivity, with and without the presence of glare. These results were compared with those for other aphakic corrections, namely spectacles (n = 5 eyes), contact lenses (n = 5 eyes), or intraocular lens implantation (n = 5 eyes). There were statistically significant differences among these four aphakic correction types (p = 0.0330), with a consistent trend for diminished visual performance after epikeratoplasty. Threshold elevations occurred in the presence of glare, but they were not statistically different between the groups (p = 0.1631). Based on these visual assessments, epikeratoplasty does result in statistically significant visual losses. Despite this, it may still offer an acceptable alternative to other managements of the aphakic patient when those others are contraindicated.

Visual losses after myopic epikeratoplasty.

The vision of seven patients who had undergone epikeratoplasty for myopia was evaluated by measuring their contrast sensitivity functions without and with the presence of a glare source. Compared with findings for a normal control population, these epikeratoplasty patients were found to have statistically significant contrast sensitivity losses. To evaluate the clinical relevance of these losses, the results were also compared with those for two other patient groups with abnormal corneal optics, seven radial keratotomy patients and seven keratoconus patients wearing rigid contact lenses. Contrast thresholds for the epikeratoplasty and keratoconus patients were similar and usually statistically indistinguishable, and their losses were far more profound than those of the radial keratotomy patients. The addition of glare did not alter this pattern of losses. The results document the extent of vision losses in these patients and suggest that increased intraocular light scattering is not a major contributor to the observed contrast sensitivity decrements.

Contact lens related corneal ulcers at the Ohio State University Hospitals 1983-1987.

We reviewed the records of patients with ulcerative keratitis associated with contact lens wear admitted to The Ohio State University Hospitals from January 1, 1983 through December 31, 1987. Of 127 cases of infectious ulcerative keratitis, 25 (19%) were associated with the use of contact lenses. Of these 25, 21 cases (84%) were associated with the use of soft lenses (40% aphakic, 40% cosmetic). Seventy-six percent (19 of 25) were culture-positive; Pseudomonas was the most common isolate (12 of 19, 63% of culture-positive cases). When compared with daily wear soft contact lenses, cosmetic and aphakic extended wear contact lens related ulcers were associated with a delay in definitive diagnosis and a worse prognosis. Patching and steroid use were associated with more severe ulcers. Gram stain findings were of value only when gram-negative rods were noted. The findings emphasize the need for patients to understand: 1) the risks of extended wear; 2) the necessity of removing the lenses at the first sign of irritation; and 3) the importance of having prompt, intensive care readily available.

Epikeratophakia for pediatric aphakia.

We used epikeratophakia for rehabilitation in 11 contact lens-intolerant aphakic children aged 9 months to 14 years. Minimum follow-up was five months; the longest was 12 months. There were no graft failures, and no patients were unavailable for follow-up. Objective postoperative overrefractions on all patients revealed that an average of 93% of the desired correction was obtained. Residual corrections ranged from -3.75 diopters spherical equivalent to +2.87 D. Nine of the 11 children were of verbal age; their spectacle visual acuities averaged 20/50, with a range of 20/20 to 20/80. Preverbal children all tolerated occlusive therapy, although accurate visual acuities could not be obtained. Our early results with this modality as therapy for monocular aphakia in the pediatric population have demonstrated improvement in visual function in all patients to date.

Surgical management of peripheral fungal keratitis (keratomycosis).

Keratomycosis often follows ocular trauma caused by vegetable matter. Medical management sometimes is unsuccessful, and surgical intervention is required. Débridement, penetrating keratoplasty, and lamellar keratoplasty in conjunction with an inlay conjunctival flap have all been proved effective. Three case reports illustrate the usefulness of lamellar keratoplasty and conjunctival flaps in the management of peripheral corneal fungal ulcers.

A primate model of human corneal transplantation.

Human donor corneas were used for penetrating keratoplasty in one eye of each of 12 rhesus monkeys. In six animals, a 9.5-mm cornea was sutured into a 9.0-mm recipient bed by means of interrupted 10-0 nylon sutures. Six other animals received a 6.5-mm cornea in a 6.0-mm bed. Biomicroscopy, pachymetry, and specular microscopy revealed two distinct healing patterns. Of the six eyes receiving the smaller grafts, five showed prompt, stable clearing and thinning of the grafts with endothelial cell densities ranging from 850 to 1600 cells/mm2 Two of the six animals receiving larger grafts developed fibrinous reactions in the immediate postoperative period, and the grafts never cleared. Three showed a satisfactory early course, but after 10-16 days, developed endothelial keratic precipitates, anterior chamber reaction, and progressive graft edema. The sixth graft remained technically satisfactory 1 year later. This study indicates that the application of small human donor grafts in monkey eyes can provide a useful, clinical model for the future exploration of the response of human corneal transplants to materials such as epidermal growth factor and for the study of surgical manipulation of postkeratoplasty astigmatism.

Regional specular microscopy.

It was originally assumed that endothelial damage associated with radial keratotomy occurred at the time of surgery. However, Yamaguchi and his associates suggested that there is an ongoing loss of endothelial cells related to repetitive stretching of the posterior cornea. Endothelial cell densities can be monitored by specular microscopy of the central cornea, but it is possible that regional endothelial cell losses occur in the peripheral areas near the incisions, and that these changes are not reflected in the central areas until some time after surgery.