We Solve It! Immersing the Quality Enhancement Plan in a Traditional and Online Baccalaureate Nursing Program.

Problem-solving and critical thinking are essential in nursing; therefore, nurse educators must equip students with these skills. Through a campus-wide initiative to foster problem-solving skills (Quality Enhancement Plan), five school of nursing faculty implemented new pedagogical approaches in face-to-face and online courses. This article discusses the problem-based approaches in nursing education implemented at a state university and their effects on student learning.

Lipophilic statins inhibit growth and reduce invasiveness of human endometrial stromal cells.

PURPOSE: To compare effects of lipid-soluble statins (simvastatin, lovastatin, atorvastatin) and water-soluble statin (pravastatin) on growth and invasiveness of human endometrial stromal (HES) cells. METHODS: Endometrial biopsies were collected during the proliferative phase from five volunteers. HES cells were isolated and cultured in the absence or in the presence of simvastatin, lovastatin, atorvastatin, and pravastatin. Effects of statins on DNA synthesis, cell viability, activity of caspases 3/7 and invasiveness were evaluated. RESULTS: The proliferation of HES cells was significantly decreased by simvastatin (by 47-89%), lovastatin (by 46-78%), and atorvastatin (by 21-48%) in a concentration-dependent manner. Activity of executioner caspases 3/7 was significantly increased by simvastatin (by 10-25%), lovastatin (by 19%) and atorvastatin (by 7-10%) in a concentration-dependent manner. The greatest effects were observed in response to simvastatin. Accounting for the effects of statins on cell number, the invasiveness of HES cells was significantly decreased in cells treated with simvastatin (by 49%), lovastatin (by 54%), and atorvastatin (by 53%). Pravastatin had little or no effects on any of the tested endpoints. CONCLUSIONS: Present findings demonstrate that only lipid-soluble among tested statins were effective in inhibition of growth and invasiveness of HES cells. These findings may have clinical relevance in treatment of endometriosis.

Intramedullary fixation of lateral malleolus using Fibula Rod System in ankle fractures in the elderly.

BACKGROUND: Operative management of ever increasing ankle fractures in the elderly need a reliable system of internal fixation. We present results of one such fixation, Fibula Rod System. METHODS: Patients who underwent Fibula Rod System were included. Fracture union rate, complications, time to weight bearing and patient satisfaction using FAAM score were studied. RESULTS: The mean age of the fifteen patients included was 74 years. Satisfactory reduction was achieved and maintained in all. All fractures united. There were no infections. Complications included lack of purchase of distal AP screw (n=1), fracture of fibula shaft (n=1), failure to insert syndesmotic screws through zig (n=2), delayed secondary wound healing (n=1) and removal of metal ware (n=2). At a mean follow-up of 12 months (n=10 responses), median FAAM score was 91% (Interquartile range of 62%-99%). CONCLUSION: Fibula Rod System providing good stability and union, is a reliable operation for ankle fractures in the elderly.

Markers of physiological stress during exercise under conditions of normoxia, normobaric hypoxia, hypobaric hypoxia, and genuine high altitude.

PURPOSE: To investigate whether there is a differential response at rest and following exercise to conditions of genuine high altitude (GHA), normobaric hypoxia (NH), hypobaric hypoxia (HH), and normobaric normoxia (NN). METHOD: Markers of sympathoadrenal and adrenocortical function [plasma normetanephrine (PNORMET), metanephrine (PMET), cortisol], myocardial injury [highly sensitive cardiac troponin T (hscTnT)], and function [N-terminal brain natriuretic peptide (NT-proBNP)] were evaluated at rest and with exercise under NN, at 3375 m in the Alps (GHA) and at equivalent simulated altitude under NH and HH. Participants cycled for 2 h [15-min warm-up, 105 min at 55% Wmax (maximal workload)] with venous blood samples taken prior (T0), immediately following (T120) and 2-h post-exercise (T240). RESULTS: Exercise in the three hypoxic environments produced a similar pattern of response with the only difference between environments being in relation to PNORMET. Exercise in NN only induced a rise in PNORMET and PMET. CONCLUSION: Biochemical markers that reflect sympathoadrenal, adrenocortical, and myocardial responses to physiological stress demonstrate significant differences in the response to exercise under conditions of normoxia versus hypoxia, while NH and HH appear to induce broadly similar responses to GHA and may, therefore, be reasonable surrogates.

Bilateral Osteonecrosis of the Femoral and Humeral Heads after Short Term Corticosteroid Therapy. A Case Study.

Steroid induced osteonecrosis is a devastating injury that usually requires rebuild of the joint, with the femoral and the humeral head being most commonly affected. Steroid therapy is the most common reported cause of atraumatic osteonecrosis. The Collaborative Osteonecrosis Group Study confirmed that steroids are the primary cause of multi-focal osteonecrosis in 91% of the cases. Osteonecrosis is considered multifocal when three or more joints are involved. We report a rare case of bilateral steroid-induced osteonecrosis of the proximal femora and humeri nine months after a short course of intravenous methylprednisolone for treatment of multiple myeloma. The relationship between development of osteonecrosis and corticosteroid treatment has been extensively investigated. Steroid therapy is the most common reported cause of atraumatic osteonecrosis. Multi-focal osteonecrosis should be highly suspected and thoroughly investigated in patients with persistent pain at typical sites after commencement of steroids.

Atypical Osteomyelitis Caused by Mycobacterium chelonae in a Nonimmunocompromised Patient: A Case Report.

CASE: A previously healthy fifty-seven-year-old woman presented with an acute atypical mycobacterial infection of the first metatarsal bone of the left foot. Despite antimicrobial treatment, the infection was not controlled. First-ray amputation was performed, and antimicrobial treatment was continued for a total of six months. The patient was fitted with an orthotic (insole) and followed for eighteen months; there was no recurrence of infection. CONCLUSION: To the best of our knowledge, this is the first case report describing Mycobacterium chelonae osteomyelitis of the first metatarsal ray in an immunocompetent individual. This diagnosis should be considered in patients with osteomyelitis that persists despite the use of broad-spectrum antibiotics, even in healthy individuals.

Cardiac biomarkers at high altitude.

BACKGROUND: Classically, biomarkers such as the natriuretic peptides (NPs) BNP/NT-proBNP are associated with the diagnosis of heart failure and hs-cTnT with acute coronary syndromes. NPs are also elevated in pulmonary hypertension. High pulmonary artery systolic pressure (PASP) is a key feature of high altitude pulmonary edema (HAPE), which may be difficult to diagnose in the field. We have previously demonstrated that NPs are associated with high PASP and the presence of acute mountain sickness (AMS) in a small cohort at HA. We aimed to investigate the utility of several common cardiac biomarkers in diagnosing high PASP and AMS. METHODS: 48 participants were assessed post-trekking and at rest at three altitudes: 3833 m, 4450 m, and 5129 m. NPs, hs-cTnT and hsCRP, were quantified using immunoassays, PASP was measured by echocardiography, and AMS scores were recorded. RESULTS: Significant changes occurred with ascent in NPs, hs-cTnT, hsCRP (all p<0.001) and PASP (p=0.006). A high PASP (≥40 mm Hg) was associated with higher NPs, NT-proBNP: 137±195 vs. 71.8±68 (p=0.001); BNP 15.3±18.1 vs. 8.7±6.6 (p=0.001). NPs were significantly higher in those with AMS or severe AMS vs. those without (severe AMS: NT-proBNP: 161.2±264 vs. 76.4±82.5 (p=0.008)). The NPs correlated with hsCRP. cTnT increased with exercise at HA and was also higher in those with a high PASP (13.8±21 vs. 7.8±6.5, p=0.018). CONCLUSION: The NPs and hs-cTnT are associated with high PASP at HA and the NPs with AMS.

The effects of exercise at high altitude on high-sensitivity cardiac troponin release and associated biventricular cardiac function.

BACKGROUND: It has been consistently shown that heavy exercise leads to cardiac troponin (cTn) release and variable changes in post exercise cardiac function. This relationship has not been explored at increasing or significant high altitude (HA). This study assessed the effects of exercise at progressively increasing HA on high-sensitivity (hs)-cTnT levels and their relationship to biventricular cardiac function and severity of acute mountain sickness (AMS). METHODS: Transthoracic echocardiograms, hs-cTnT levels and AMS scores were measured at rest at 1,300 m then repeated post exercise and 12 h later after progressive trekking to 3,440, 4,270 m and at 5,150 m (after trekking to 5,643 m) on 19 healthy subjects (age 35.4 ± years, 52.6 % males). RESULTS: There was a detectable increase (>5 ng/L) in post exercise hs-cTnT with exercise at HA which became significant at 5,150 m (5.84 % at 3,440 m, 5.2 % at 4,270 m and 56.3 % at 5,150 m; p = 0.0005). Compared with baseline, HA to 5,150 m led to a significant rise in post exercise Lake Louis AMS scores (p < 0.001) pulmonary artery systolic pressure (PASP) (23.7 ± 3.8 vs 37.9 ± 11.7 mmHg: p < 0.001), cardiac output (5.2 ± 1.2 vs 7.5 ± 1.3 l/min; p < 0.001) and a fall in SpO2 (96.1 ± vs 77.4 ± 12.0 %; p < 0.001). There was no change in stroke volume (p = 0.10) or estimated filling pressures (E/E') of the left (p = 0.50) and right ventricles (p = 0.4). On multivariate analysis increasing cardiac output (p = 0.02) and PASP (p = 0.04) and decreasing SpO2 (p = 0.01) were the only independent predictors of increasing cTnT levels (overall R (2) = 0.23, p < 0.0001). CONCLUSIONS: Moderate intensity exercise at significant HA influences the post exercise increase in hs-cTnT without overt deleterious effects on cardiac function.

The use of standardized exit examinations in baccalaureate nursing education.

To improve pass rates on the NCLEX-RN, many nursing programs have implemented progression policies that require a minimal passing score on a commercial standardized exit examination. In this article, the authors provide an overview of the controversy surrounding the use of these examinations in nursing education, including ethical, legal, cultural, socioeconomic, and technological considerations, as well as discuss their program's exit examination policy, pass rates, and recommendations for the use of exit examinations.

Renal impairment after high-dose flucloxacillin and single-dose gentamicin prophylaxis in patients undergoing elective hip and knee replacement.

BACKGROUND: Following advice from the Scottish Antimicrobial Prescribing Group, we switched our antibiotic prophylaxis for elective hip and knee replacement surgery from cefuroxime to flucloxacillin with single-dose gentamicin in order to reduce the incidence of Clostridium difficile associated diarrhoea (CDAD). A clinical impression that more patients subsequently developed acute kidney injury (AKI) led us to examine this possibility in more detail. METHODS: We examined the incidence of AKI in 198 consecutive patients undergoing elective hip or knee surgery. These patients were given the following prophylactic antibiotics: cefuroxime (n = 48); then high-dose (HD) flucloxacillin (5-8 g) with single-dose gentamicin (n = 52); then low-dose (LD) flucloxacillin (3-4 g) with single-dose gentamicin (n = 46) and finally cefuroxime again (n = 52). RESULTS: Patients receiving HD flucloxacillin required more vasopressors during surgery (P = 0.02); otherwise, there were no statistically significant differences in pre- and peri-operative characteristics between the four groups. The proportion of patients with any form of AKI by RIFLE criteria was first cefuroxime (8%), HD flucloxacillin with gentamicin (52%), LD flucloxacillin with gentamicin (22%) and second cefuroxime (14%; P < 0.0001). Odds ratios for AKI derived from a multivariate logistic regression model, adjusted also for sex and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, with the first cefuroxime group as a reference category were: HD flucloxacillin with gentamicin 14.53 (4.25-49.71); LD flucloxacillin with gentamicin 2.96 (0.81-10.81) and second cefuroxime 2.01 (0.52-7.73). Three patients required temporary haemodialysis. Biopsies in two of these showed acute tubulo-interstitial nephritis. All three patients belonged to the HD flucloxacillin with gentamicin group. None of the patients developed CDAD. CONCLUSIONS: We have shown an association between the prophylactic antibiotic regimen and subsequent development of AKI following primary hip and knee arthroplasty that appeared to be due to the use of HD flucloxacillin with single-dose gentamicin. We found no evidence to suggest that this association was confounded by any of the co-variates we measured.

Fixation of 3- and 4-part proximal humerus fractures using the PHILOS plate: mid-term results.

Treatment of unstable, displaced, and comminuted fractures of the proximal humerus remains challenging, and optimal treatment continues to be controversial. Fifty-six patients with displaced 3- and 4-part fractures of the proximal humerus had open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate (Synthes, Stratec Medical Ltd, Mezzovico, Switzerland). Data were collected retrospectively, and clinical and radiological outcomes were assessed. Mean follow-up was 40 months (range, 18-62 months). The study shows that the PHILOS plate gives good results in the treatment of displaced 3- and 4-part fractures of the proximal humerus. Good fracture stability can be achieved early, allowing early mobilization without compromising fracture union. Most importantly, it requires minimal soft tissue dissection, does not need contouring, and gives good stability. No differences were observed in the functional outcomes of patients younger and older than 65 years. Few complications were associated with the plate, and the number of ≥2 surgeries was minimal. The complications noted were 1 case each of superficial wound infection, failure of the plate, and persistent stiffness. One patient had screw perforation of the humeral head articular surface, and 1 had subacromial impingement. Of the 32 patients who had been in active employment before the injury, 28 returned to their previous occupation.

Rapid recovery from spontaneous and simultaneous bilateral quadriceps tendon rupture in an active, healthy individual.

Bilateral spontaneous quadriceps rupture is an uncommon injury that is usually seen in association with multiple medical conditions and is frequently misdiagnosed. It is rarely seen in healthy, active individuals. This article presents a case of bilateral simultaneous and spontaneous rupture of the quadriceps tendon in a healthy, athletic, active and highly motivated patient with rapid recovery from injury and return to full sport activity within a relatively short period of time. A 65-year-old healthy man felt both knees give way while walking down stairs at home and collapsed, unable to bear weight. He was fit and well, not on any medications and basic laboratory screening was within normal limits. He was an active sportsman, horse rider, swimmer, and long-distance cyclist, and had completed a half marathon 1 month before his injury. He was diagnosed with bilateral quadriceps tendon ruptures. An ultrasound of both knees confirmed the diagnosis of full-thickness rupture. Surgical repair of both quadriceps tendons was performed 3 days after the injury. Bilateral locking brace in 10 degrees of flexion was used to immobilize both knees and protect the repair for 6 weeks. The patient remained nonweight bearing for 2 weeks, then gradual weight bearing was commenced, with full weight bearing at 6 weeks. Intensive isometric quadriceps exercises were started on the second postoperative day. Immobilization of both knees was maintained for 6 weeks, after which full active range of motion (ROM) was initiated. At 16 weeks after the injury he had bilateral ROM from 0 degrees to 120 degrees flexion, with no extension lag. He was horse riding, playing golf, swimming, and walking distances up to 2 miles at that time.

Parents' evaluation of adoption success: a follow-up study of intercountry and domestic adoptions.

Parents of 165 children adopted from Romania and 52 children adopted from within the United Kingdom rated the success of the adoptions when the children were 11 years old. As was the case at two earlier study waves, satisfaction was found to be extremely high. Both positive and negative assessments were generally stable between ages 6 and 11, although for the children who had more problems there was an increase in negative evaluation, albeit within an overall positive picture. Parents' evaluations were somewhat more negative for this group of children; however, parents reported that having the child as part of their family was very rewarding. Negative evaluation was not directly related to age at placement, but appeared to be a reflection of the later-placed children's higher rates of problem behavior. As found at earlier assessment waves, child factors, in particular conduct problems and inattention or overactivity, were key in predicting parental evaluations at age 11, as were four domains closely associated with institutional deprivation, namely cognitive impairment, quasi-autistic patterns, inattention or overactivity, and disinhibited attachment. The findings emphasize the need for early intervention for children in severely deprived conditions, and for access to postadoption services that target the particular problem behaviors the children may exhibit.

Is sub-nutrition necessary for a poor outcome following early institutional deprivation?

Institutional deprivation is multifaceted and includes adverse psychosocial and nutrition-related components. In this study we partitioned these risks in relation to cognitive impairment and mental ill health, and explored the mediating role of reduced head/brain size. There were 138 participants (61 males, 77 females) in the study. Participants were Romanian adoptees who had experienced at least 2 weeks of early institutional deprivation. The sample was stratified on the basis of duration of deprivation (high risk >6 mo in institutions) and sub-nutrition (i.e. 1.5 SD below UK age-related norms for weight at UK entry). UK children adopted before 6 months of age and a group of non-institutionally deprived Romanian children constituted the comparison groups. Duration of deprivation was associated with smaller head circumference, lowered IQ, and increased mental heath problems, independently of effects found for sub-nutrition on head circumference and IQ. The mediating role of head circumference was limited to either sub-nourished (IQ) or non-sub-nourished (inattention/overactivity and disinhibited attachment) subgroups. Many negative effects of early deprivation, including stunted brain growth, occur without sub-nutrition: psychosocial deprivation plays a major role in neurodevelopmental effects of deprivation. Further studies of functional and structural neuroanatomy following institutional deprivation are required to delineate the role of brain development in its effects.

Knowledge-based inferences across the hemispheres: domain makes a difference.

Language comprehension occurs when the left-hemisphere (LH) and the right-hemisphere (RH) share information derived from discourse [Beeman, M. J., Bowden, E. M., & Gernsbacher, M. A. (2000). Right and left hemisphere cooperation for drawing predictive and coherence inferences during normal story comprehension. Brain and Language, 71, 310-336]. This study investigates the role of knowledge domain across hemispheres, hypothesizing that the RH demonstrates inference processes for planning knowledge while the LH demonstrates inference processes for knowledge of physical cause and effect. In experiment 1, sixty-eight participants completed divided-visual-field reading tasks with 2-sentence stimuli that relied on these knowledge areas. Results showed that readers made more planning inferences from the RH and more physical inferences from the LH, indicating inference processes occur from each hemisphere dependent upon the knowledge domain required to support it. In experiment 2, sixty-four participants completed the same reading task with longer, story-length stimuli to demonstrate the effect in a more realistic setting. Experiment 2 results replicated the findings from experiment 1, extending previous findings, specifying that hemispheric differences for inferences rely on knowledge domains.

Emotional difficulties in early adolescence following severe early deprivation: findings from the English and Romanian adoptees study.

The study assessed conduct and emotional difficulties in a group of Romanian adoptees at age 11, and serves as a follow-up to assessments made when the children were 6 years old. It was found that there was a significant increase in emotional difficulties, but not conduct problems, for the Romanian sample since age 6. It was also found that emotional difficulty was significantly more prevalent at age 11 in the Romanian group than in a within-UK adoptee group. Emotional difficulties in the Romanian adoptee group were found to be significantly and strongly related to previous deprivation-specific problems (disinhibited attachment, cognitive impairment, inattention/overactivity and quasi-autism); however, the presence of such early problems did not account fully for the onset of later emotional problems. Five contrasting hypotheses concerning possible mediators for later onset of emotional difficulties for the Romanian group were examined. No links were found to duration of deprivation or other deprivation-related indices, stresses/difficulties in the postadoption family environment, or educational attainment and self-esteem. There was some evidence that emotion recognition might play a role in the emergence of these problems, but other measures of social competence and theory of mind showed no associations with the onset of emotional problems.

Do theory of mind and executive function deficits underlie the adverse outcomes associated with profound early deprivation?: findings from the English and Romanian adoptees study.

Theory of Mind (ToM) and Executive Function (EF) have been associated with autism and with attention-deficit hyperactivity disorder (ADHD), and hence might play a role in similar syndromes found following profound early institutional deprivation. In order to examine this possibility the current study included a group of 165 Romanian adoptees, of whom 144 were adopted into the UK from deprived institutional settings before 43months of age, and a group of 52 within-UK adoptees, all adopted before 6months of age. Both groups were assessed at 6 and 11years. The Strange Stories task was used to assess ToM and the Stroop task was used to assess EF, both at age 11. The Romanian adoptees displayed deficits in both ToM and EF compared with the within-UK adoptee group. The degree of deficit was greater for children who had experienced more than 6months of institutional deprivation. Deficits in both domains (ToM and EF) were associated with each of the three apparently deprivation-specific problems, namely quasi-autism, disinhibited attachment and inattention/overactivity. Statistical analyses indicated a mediating role for both ToM and EF with respect to quasi-autism; possibly a partial mediating role for EF with respect to inattention/overactivity; and probably no mediating role for either ToM or EF in the case of disinhibited attachment. In conclusion, there is evidence for a possible mediating role for ToM and EF in the development of some apparently deprivation-specific difficulties in institution-reared Romanian adoptees, but neither accounts for the overall pattern of deprivation-related difficulties.

Inattention/overactivity following early severe institutional deprivation: presentation and associations in early adolescence.

The current study examined the persistence and phenotypic presentation of inattention/overactivity (I/O) into early adolescence, in a sample of institution reared (IR) children adopted from Romania before the age of 43 months. Total sample comprised 144 IR and 21 non-IR Romanian adoptees, and a comparison group of 52 within-UK adoptees, assessed at ages 6 and 11 years. I/O was rated using Rutter Scales completed by parents and teachers. I/O continued to be strongly associated with institutional deprivation, with continuities between ages 6 and 11 outcomes. There were higher rates of deprivation-related I/O in boys than girls, and I/O was strongly associated with conduct problems, disinhibited attachment and executive function but not IQ more generally, independently of gender. Deprivation-related I/O shares many common features with ADHD, despite its different etiology and putative developmental mechanisms. I/O is a persistent domain of impairment following early institutional deprivation of 6 months or more, suggesting there may be a possible pathway to impairment through some form of neuro-developmental programming during critical periods of early development.

Normality and impairment following profound early institutional deprivation: a longitudinal follow-up into early adolescence.

Longitudinal analyses on normal versus impaired functioning across 7 domains were conducted in children who had experienced profound institutional deprivation up to the age of 42 months and were adopted from Romania into U.K. families. Comparisons were made with noninstitutionalized children adopted from Romania and with nondeprived within-U.K. adoptees placed before the age of 6 months. Specifically, the validity of the assessment, the degree of continuity and change in levels of functioning from 6 to 11 years, and the factors in the pre- and postadoption environment accounting for heterogeneity in outcome were examined. Pervasive impairment was significantly raised in children experiencing institutional deprivation for > or =6 months of life, with a minority within this group showing no impairment. There was no additional significant effect of duration of deprivation beyond the 6-month cutoff, and few other predictors explained outcome. The pattern of normality/impairment was mainly established by 6 years of age, with considerable continuity at the individual level between 6 and 11 years. The findings are discussed in terms of the possibility of a sensitive period for development.

Scholastic attainment following severe early institutional deprivation: a study of children adopted from Romania.

The relationship between severe early institutional deprivation and scholastic attainment at age 11 in 127 children (68 girls and 59 boys) adopted from institutions in Romania was compared to the attainment of 49 children (17 girls and 32 boys) adopted within the UK from a non-institutional background. Overall, children adopted from Romania had significantly lower attainment scores than those adopted within the UK; the children within the Romanian sample who had spent 6 months or more in an institution had significantly lower attainment scores than those who had spent less than 6 months in an institution, but there was no additional risk of low attainment associated with longer institutional care after 6 months. The lower scholastic attainment in the children adopted from Romanian institutions, as compared with domestic adoptees, was mediated by IQ, and to a lesser degree, inattention/overactivity. When these factors were taken into account, only small between-group differences in attainment remained.