Development of vaccines for bio-warfare agents.

There is a recognized need for the development of new vaccines (as well as other biologicals and drugs) to counteract the effects of a potential bio-terrorist or bio-warfare event in the U.S. domestic population and military forces. Regulation of products to protect against potential bio-warfare agents poses unique challenges since the usual measures of efficacy that require exposure to natural disease may not currently be possible, for epidemiological and ethical reasons. To help to address this issue, the FDA has published and requested comments on a proposed animal rule intended to address certain efficacy issues for new agents for use against lethal or permanently disabling toxic substances. Recent product development activity has focused on Bacillus anthracis (anthrax) and variola major (smallpox), agents that are regarded as highest priority in posing a risk to national security. FDA resources exist to assist vaccine developers with regard to the novel challenges posed in the dinical development of these products.

Managing through four decades: a personal reflection.

Achieving quality, compassion and effectiveness in the delivery of health services depends upon managing resources and directing change. Four decades of experience in nursing suggests that managing is the core of all practice areas, clinical or administrative.

Neuronal sensitivity to tetanus toxin requires gangliosides.

Tetanus toxin produces spastic paralysis in situ by blocking inhibitory neurotransmitter release in the spinal cord. Although di- and trisialogangliosides bind tetanus toxin, their role as productive toxin receptors remains unclear. We examined toxin binding and action in spinal cord cell cultures grown in the presence of fumonisin B(1), an inhibitor of ganglioside synthesis. Mouse spinal cord neurons grown for 3 weeks in culture in 20 microM fumonisin B(1) develop dendrites, axons, and synaptic terminals similar to untreated neurons, even though thin layer chromatography shows a greater than 90% inhibition of ganglioside synthesis. Absence of tetanus and cholera toxin binding by toxin-horseradish peroxidase conjugates or immunofluorescence further indicates loss of mono- and polysialogangliosides. In contrast to control cultures, tetanus toxin added to fumonisin B(1)-treated cultures does not block potassium-stimulated glycine release, inhibit activity-dependent uptake of FM1-43, or abolish immunoreactivity for vesicle-associated membrane protein, the toxin substrate. Supplementing fumonisin B(1)-treated cultures with mixed brain gangliosides completely restores the ability of tetanus toxin to bind to the neuronal surface and to block neurotransmitter release. These data demonstrate that fumonisin B(1) protects against toxin-induced synaptic blockade and that gangliosides are a necessary component of the receptor mechanism for tetanus toxin.

Developing patient and family education services. Innovations for the changing healthcare environment.

As the healthcare environment changes, systems that have served hospitals well for many years no longer meet the current needs of patients, families, and communities. This is particularly true with regard to health education. The authors describe an innovative learning center that offers comprehensive health education services and programs designed to empower consumers with the information and skills needed to maintain health or recover from illness or injury.

The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses.

OBJECTIVES: Among the consequences of downsizing and cost containment in hospitals are major changes in the work life of nurses. As hospitals become smaller, patient acuity rises, and the job of nursing becomes more technical and difficult. This article examines the effects of changes in the hospital environment on nurses' job satisfaction and voluntary turnover between 1993 and 1994. METHODS: Data were collected in a longitudinal survey of 736 hospital nurses in one hospital to examine correlates of change in aspects of job satisfaction and predictors of leaving among nurses who terminated in that period. RESULTS: Unadjusted results showed decline in most aspects of satisfaction as measured by Hinshaw and Atwood's and Price and Mueller's scales. Multivariate analysis indicated that the most important determinants of low satisfaction were poor instrumental communication within the organization and too great a workload. Intent to leave was predicted by the perception of little promotional opportunity, high routinization, low decision latitude, and poor communication. Predictors of turnover were fewer years on the job, expressed intent to leave, and not enough time to do the job well. CONCLUSIONS: The authors conclude that although many aspects of job satisfaction are diminished, some factors predicting low satisfaction and turnover may be amenable to change by hospital administrators.

Enhancing support for the graduate nurse.

The authors describe how their new Clinical Entry Nurse Residency Program has helped beginning nurses advance along Benner's path toward expertise.

The Harvard Nursing Research Institute's conference summary.

The Harvard Nursing Research Institute organized a national invitational conference on executive nursing leadership in major teaching hospitals and academic health centers. The conference brought together many of the nation's eminent nurse executives and other prominent individuals in healthcare to analyze the unique and complex challenges facing these organizations, expose participants to other perspectives, and articulate specific aims and strategies that might be taken to increase their effectiveness in leading the nursing profession's efforts to shape the ongoing transformation of the healthcare system.

Provocative exercise maneuver: its effect on nerve conduction studies in patients with carpal tunnel syndrome.

This study examined the influence of a provocative dynamic exercise maneuver on nerve conduction studies (NCS) in three study groups: Group A, controls (n = 10); Group B, patients with clinical carpal tunnel syndrome (CTS), but normal NCS (n = 10); and Group C, patients with clinical CTS and abnormal NCS (n = 10). A wrist flexion-extension exercise was designed to increase pressure on the median nerve within the carpal tunnel to aid diagnosis by revealing latent nerve conduction slowing in patients presenting with clinical CTS but normal NCS. The exercise protocol was sufficient to evoke symptom exacerbation in 50% of the patients. The results showed that 4 minutes of this active provocative maneuver revealed a significant (p < .05) difference in the sensory distal latency (median) for digit IV; however, this was not clinically significant inasmuch as the change in latency was insufficient to meet the a priori criteria for NCS abnormality required for the electrodiagnosis of median nerve abnormality. There was no increase in the distal sensory latencies of those patients whose symptoms were exacerbated, when compared with those patients whose symptoms remained unchanged. There appears little diagnostic value in adding this particular active provocative wrist maneuver to the routine electrodiagnostic evaluation for carpal tunnel syndrome.

Successful management of chronic pain syndrome.

Managing patients with chronic pain syndrome can be frustrating and unrewarding. Much of the difficulty experienced when managing these patients stems from an incomplete understanding of pain, especially the difference between acute and chronic pain. Pain theory and treatment of chronic pain syndrome are reviewed. An alternative management strategy for chronic pain syndrome is presented and the literature is reviewed.

An interview with Joyce C. Clifford. Interview by Carmella A. Bocchino.

Various professional practice models have been used to advance nursing. The primary nursing model at Boston's Beth Israel Hospital has continued to be successful for over 15 years and has gained the respect of both the nursing community and the hospital industry. Joyce C. Clifford, MSN, RN, FAAN, Vice-President for Nursing and Nurse-in-Chief at Beth Israel, discusses the development and implementation of this practice model and her strategies--continuity and accountability--to advance nursing.

Electrodiagnosis of mild carpal tunnel syndrome.

Electrophysiologic tests have been reported to detect mild carpal tunnel syndrome (CTS). Such tests include (i) absolute palmar latency of median wrist segment; (ii) comparison of median and radial distal sensory latencies in digit I; (iii) comparison of median and ulnar distal sensory latencies in digit IV; (iv) comparison of median and ulnar palmar latencies; (v) comparison of median and ulnar sensory potential amplitudes in digits II and V. To clarify the clinical utility of these tests, the parameters of all five tests were determined across four carefully established patient subgroups: group A, controls; group B, CTS referrals with normal nerve conduction studies (NCS) and normal needle electromyography (EMG); group C, CTS referrals with abnormal NCS and normal EMG; group D, CTS referrals with abnormal NCS and abnormal EMG. Special attention was focused on patients in group B who represent the diagnostic dilemma. In group B, tests ii and iii each yielded abnormal results in 44% of hands, while the combination of tests ii and iii yielded abnormal results in 51% of hands.

What DRGs mean to the patient and the provider.

What are the effects of DRGs on patients and providers? I have attempted to provide some insights from my own experience and that of others. But I think we must not lose sight of the fact that it is very difficult to determine the specific effects of DRGs in light of all the other environmental factors that contribute to the intensity of patient services and care provider stress and work load. To what extent does the general aging of the population itself contribute to these issues? People would still be getting older, and chronic disease would continue to increase, even if a prospective payment system using DRGs was not in place. Medical technology has not been capped and the explosion of knowledge still directs much of the medical practice related to increased intensity of care. A financially driven health care system was put into place shortly after the implementation of Medicare, when it became obvious how quickly the costs of health care were rising. In many ways it is impossible to say what the specific effects of the DRG system have been on the patient and the provider. Perhaps it is only a little, but, quite frankly, it does not really feel that way to those who are in the mainstream of providing care.

Plasma 11-deoxycortisol and cortisol following dexamethasone in psychiatric patients.

As it has been suggested that calculating the ratio of cortisol to its biosynthetic precursor, 11-deoxycortisol, may enhance the sensitivity of the dexamethasone suppression test (DST) for depression, cortisol and 11-deoxycortisol were measured in 90 subjects undergoing this test. Among these subjects, post-dexamethasone cortisol and 11-deoxycortisol levels were significantly correlated (r = 0.65, P less than 0.001) and evaluating the ratio of cortisol to 11-deoxycortisol decreased rather than enhanced sensitivity of the DST.

Managing disability from stroke.

Strokes are the single greatest neurological cause of disability, yet many stroke patients do not ever reach a specialized stroke rehabilitation unit. For those remaining in the hospital to which they were first admitted, active medical involvement may decline dramatically once the diagnosis has been made. However, the family physician can play an active role in managing post-stroke patients, enhancing their functional recovery and achieving successful discharge back into the community. This article describes post-diagnosis management of stroke, discharge planning, and post-discharge follow-up.

Working together: a positive experience in service-education collaboration.

The participants in this interview agree that university schools of nursing must maintain realistic and relevant programs in administration. There is a need for active involvement of practicing administrators in the design of nursing administration curricula. Administrators must also learn to involve faculty in identifying the roles of nursing care organizations in a changing health care delivery system. Directors of nursing must be willing to "open the door" to educators seeking practice opportunities. The result can be positive relationships that mutually benefit both nursing education and the delivery of care.