Multidisciplinary treatment for functional neurological symptoms: a prospective study.

Although functional neurological symptoms are often very disabling there is limited information on outcome after treatment. Here we prospectively assessed the short- and long-term efficacy of an inpatient multidisciplinary programme for patients with FNS. We also sought to determine predictors of good outcome by assessing the responsiveness of different scales administered at admission, discharge and follow-up. Sixty-six consecutive patients were included. Assessments at admission, discharge and at 1 year follow-up (55%) included: the Health of the Nation Outcome Scale, the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire-15, the Revised Illness Perception Questionnaire, the Common Neurological Symptom Questionnaire, the Fear Questionnaire and the Canadian Occupational Performance Measure. At discharge and at 1 year follow-up patients were also asked to complete five-point self-rated scales of improvement. There were significant improvements in clinician-rated mental health and functional ability. In addition, patients reported that their levels of mood and anxiety had improved and that they were less bothered by somatic symptoms in general and neurological symptoms in particular. Two-thirds of patients rated their general health such as "better" or "much better" at discharge and this improvement was maintained over the following year. Change in HoNOS score was the only measure that successfully predicted patient-rated improvement. Our data suggest that a specialized multidisciplinary inpatient programme for FNS can provide long-lasting benefits in the majority of patients. Good outcome at discharge was exclusively predicted by improvement in the HoNOS which continued to improve over the 1 year following discharge.

Time series analysis of emergency department length of stay per 8-hour shift.

INTRODUCTION: The mean emergency department (ED) length of stay (LOS) is considered a measure of crowding. This paper measures the association between LOS and factors that potentially contribute to LOS measured over consecutive shifts in the ED: shift 1 (7:00 am to 3:00 pm), shift 2 (3:00 pm to 11:00 pm), and shift 3 (11:00 pm to 7:00 am). SETTING: University, inner-city teaching hospital. PATIENTS: 91,643 adult ED patients between October 12, 2005 and April 30, 2007. DESIGN: For each shift, we measured the numbers of (1) ED nurses on duty, (2) discharges, (3) discharges on the previous shift, (4) resuscitation cases, (5) admissions, (6) intensive care unit (ICU) admissions, and (7) LOS on the previous shift. For each 24-hour period, we measured the (1) number of elective surgical admissions and (2) hospital occupancy. We used autoregressive integrated moving average time series analysis to retrospectively measure the association between LOS and the covariates. RESULTS: For all 3 shifts, LOS in minutes increased by 1.08 (95% confidence interval 0.68, 1.50) for every additional 1% increase in hospital occupancy. For every additional admission from the ED, LOS in minutes increased by 3.88 (2.81, 4.95) on shift 1, 2.88 (1.54, 3.14) on shift 2, and 4.91 (2.29, 7.53) on shift 3. LOS in minutes increased 14.27 (2.01, 26.52) when 3 or more patients were admitted to the ICU on shift 1. The numbers of nurses, ED discharges on the previous shift, resuscitation cases, and elective surgical admissions were not associated with LOS on any shift. CONCLUSION: Key factors associated with LOS include hospital occupancy and the number of hospital admissions that originate in the ED. This particularly applies to ED patients who are admitted to the ICU.

Leadership in doctoral nursing research programs.

The expansion of U.S. doctoral nursing research programs and transitions based on demographic distribution of the nursing academic workforce raises questions about the preparation for leadership transition planning. The purpose of this study was to describe the program leaders, job conditions, and status of transition efforts. A survey of U.S. nursing research doctoral programs (N = 105) was conducted in 2008. The response rate was 84.8%. A Web search of nonresponding schools provided some data from all programs. Most research doctoral program leaders hold additional responsibilities (mean = 4.2). The mean budgeted leadership time was 32.9% (SD = 21.4). Among programs in which the director's age was at least 60 years, 59% had no succession plan. Continuing improvement of the quality of doctoral nursing research programs could be compromised by leadership transition issues. To produce research-competitive graduates, continued support and attention to leadership of these programs is essential.

Defining and describing capacity issues in US doctoral nursing research programs.

The expansion of US doctoral research programs raises questions about mentorship capacity, program quality, and decisions about future expansion. To describe capacity issues and, when possible, compare findings to those of an earlier study, a survey of US nursing research doctoral programs (n = 105) was conducted in 2008. The response rate was 84.8%. The Web sites of non-responding schools were reviewed providing some data from all programs. The mean ratio of students per current externally funded grant was 6.9 (SD 7.5) to 1. The mean ratio of student to ever-funded faculty was 8.3 (SD 8.3) to 1. The mean number of research activities required (out of 5 possible) was 1.8 (SD 1.4), and the most common was a research practica (77%), followed by attendance at a research meeting external to the school (37%), and submitting an article for publication (32%). The quality of many programs may be compromised by capacity issues. Attention to existing programs' requirements and capacities and determination of the roles of these variables in producing research competitive graduates is needed.

Targeting cytokine expression in glial cells by cellular delivery of an NF-kappaB decoy.

Inhibition of nuclear factor (NF)-kappaB has emerged as an important strategy for design of anti-inflammatory therapies. In neurodegenerative disorders like Alzheimer's disease, inflammatory reactions mediated by glial cells are believed to promote disease progression. Here, we report that uptake of a double-stranded oligonucleotide NF-kappaB decoy in rat primary glial cells is clearly facilitated by noncovalent binding to a cell-penetrating peptide, transportan 10, via a complementary peptide nucleic acid (PNA) sequence. Fluorescently labeled oligonucleotide decoy was detected in the cells within 1 h only when cells were incubated with the decoy in the presence of cell-penetrating peptide. Cellular delivery of the decoy also inhibited effects induced by a neurotoxic fragment of the Alzheimer beta-amyloid peptide in the presence of the inflammatory cytokine interleukin (IL)-1beta. Pretreatment of the cells with the complex formed by the decoy and the cell-penetrating peptide-PNA resulted in 80% and 50% inhibition of the NF-kappaB binding activity and IL-6 mRNA expression, respectively.

Car seat or car bed for very low birth weight infants at discharge home.

OBJECTIVE: To compare the incidence of apnea, bradycardia, or desaturation in a car seat with that in a car bed for preterm very low birth weight (< or = 1500 g) infants. STUDY DESIGN: Infants were studied for 120 minutes in a car seat and in a car bed. Apnea (> 20 seconds), bradycardia (heart rate < 80/min for > 5 seconds), desaturation (SpO2 < 88% for > 10 seconds), and absent nasal flow were monitored. RESULTS: We assessed 151 infants (median birth weight, 1120 g [range, 437 to 3105]; median birth gestational age, 29 weeks [24 to 34]) in both devices. Twenty-three infants (15%) had > or = 1 event in the car seat compared with 29 (19%) in the car bed (P = .4). Time to first event was similar in the car seat and car bed (mean, 54 to 55 minutes). In logistic regression analyses, bronchopulmonary dysplasia was a significant predictor for a car seat event and a lower gestational age at birth was a risk factor for a car bed event. CONCLUSIONS: We found no evidence that an event is less likely in a car bed than in a car seat. Whichever device is used, very low birth weight infants require observation during travel.

Time series analysis of variables associated with daily mean emergency department length of stay.

STUDY OBJECTIVE: We measure the effect of various input, throughput, and output factors on daily emergency department (ED) mean length of stay per patient (daily mean length of stay). METHODS: The study was a retrospective review of 93,274 ED visits between April 15, 2002, and December 31, 2003. The association between the daily mean length of stay and the independent variables was assessed with autoregressive moving average time series analysis (ARIMA). The following independent variables were measured per 24-hour period: number of elective surgical admissions, ED volume, number of ED admissions, number of ED ICU admissions, number of ED clinical attending hours, hospital medical-surgical occupancy (hospital occupancy), and day of the week. RESULTS: Three factors were independently associated with daily mean length of stay in time series analysis: number of elective surgical admissions, number of ED admissions, and hospital occupancy. The daily mean length of stay increased by 0.21 minutes for every additional elective surgical admission, 2.2 minutes for every additional admission, and 4.1 minutes for every 5% increase in hospital occupancy. Elective surgical admissions were associated with a maximum of 35 hours of additional ED dwell time. The model accounted for 31.5% of the variability in daily mean length of stay. The final model parameters for the ARIMA analysis were autoregressive term (1) moving average (1). CONCLUSION: Hospital occupancy and the number of ED admissions are associated with daily mean length of stay. Every additional elective surgical admission prolonged the daily mean length of stay by 0.21 minutes per ED patient. Autocorrelation exists between the daily mean length of stay of the current day and the previous day.

Psychological intervention in fluid management.

BACKGROUND: Hemodialysis is a palliative treatment for patients with established renal failure (ERF), and volume overload is a common problem for hemodialysis patients with low urinary output. Volume overload is thought to be mostly attributable to interdialytic fluid intake by the patient and is associated with an increased symptom burden and the development of serious medical complications. Repeated episodes of volume overload may adversely affect staff-patient relationships and the perception of care in this patient population. The aim of this case series study was to evaluate the effect and experience of a psychological intervention on interdialytic weight gain in a small group of patients. METHODS: Five patients were treated. The intervention involved using techniques derived from both cognitive behavior therapy and motivational interviewing. The main outcome measures were interdialytic weight gain and patient perception of the intervention. RESULTS: Three of the five patients reduced both mean interdialytic weight gain and the frequency with which they gained in excess of 3% of their dry weight during the intervention phase. The intervention was found to be acceptable to patients. SIGNIFICANCE OF RESULTS: The intervention was effective in helping three of the five patients to reduce both the frequency and the severity of volume overload, and two of these patients maintained this for at least 6 months post intervention. The intervention used actively engaged the patients and appeared to be experienced positively. The methods used to mobilize patient resources and optimize staff-patient relationships as vehicles of change are discussed. Both may have implications for treatment concordance and the perception of care delivered.

beta-Amyloid and interleukin-1beta induce persistent NF-kappaB activation in rat primary glial cells.

An increasing body of evidence suggests that beta-amyloid (Abeta) and activated glial cells play a crucial part in the pathogenesis of Alzheimer's disease (AD). Activated glial cells surrounding the senile plaques, formed by Abeta peptides, have been proposed to promote neurodegeneration by producing putatively toxic factors, including the inflammatory cytokine interleukin-1beta (IL-1beta). Elevated levels of both IL-1beta and activated nuclear factor kappaB (NF-kappaB), a key transcription factor regulating a wide variety of inflammatory genes, have been found in the brains of AD patients. In this study, we have investigated the ability of the Abeta(25-35) peptide and IL-1beta, either alone or together, in activating NF-kappaB in glial cells. Mixed primary glial cells from rat were treated with IL-1beta and/or Abeta(25-35), and NF-kappaB binding activity was analyzed by electophoretic mobility shift assay. We observed that the induction of NF-kappaB binding activity induced by either IL-1beta or Abeta(25-35) showed a peak at 30 min, and significantly declined after 2 h. The induced NF-kappaB activation persisted after 24 h and even seemed to increase in cells treated with Abeta(25-35). The activation of NF-kappaB by Abeta(25-35) was shown to be dose-dependent. In addition, Abeta(25-35) potentiated the effect of IL-1beta in a dose-dependent manner when co-stimulating the cells. The potentiating effect of Abeta(25-35) on IL-1beta-induced NF-kappaB binding activity was observed after 30 min, 2 h and 24 h, and did not significantly differ over time. A possible explanation is that when glial cells are stimulated by inflammatory factors in the presence of Abeta peptides or senile plaques, the NF-kappaB negative feedback regulation is no longer functional.

Achieve emergency department restraint reduction.

Reduce restraint episodes without compromising safety by implementing process-oriented, behaviorally based practice tools. Learn how one trauma center minimized restraint use with intensive process management.

Childhood experiences of illness and parenting in adults with chronic fatigue syndrome.

OBJECTIVE: There are many similarities between chronic fatigue syndrome (CFS), the somatoform disorders and problems otherwise known as "medically unexplained symptoms." There is some evidence to suggest that a combination of inadequate parenting and early illness experience may predispose the individual to develop medically unexplained symptoms in adult life. The aim of this investigation was to compare the contributions of childhood experiences of illness and parenting in adults with CFS with a fracture clinic control group. METHOD: A retrospective case control design was used. Thirty patients with a diagnosis of CFS and 30 patients attending a fracture clinic in an inner London teaching hospital completed questionnaires measuring parental care and protection and were interviewed about childhood experiences of illness. RESULTS: There were no differences in childhood experience of illness in the two groups. However, logistic regression revealed that maternal overprotection and depression were associated with the diagnosis of CFS. CONCLUSION: The findings may represent risk factors for the development of CFS in adult life. It is possible that maternal overprotection in particular is related to the formation of belief systems about avoiding activity that operate to adversely influence behaviour in patients with CFS.

Achieve ED restraint reduction.

Reduce restraint episodes without compromising safety by implementing process-oriented, behaviorally based practice tools.

Comparison of specialty referral patterns of primary care providers.

Difficulty, perceived by 17 treatment facilities, of obtaining specialty referral appointments at Dwight David Eisenhower Army Medical Center (DDEAMC), a major referral center, prompted this study that utilizes provider profiling as a tool to answer three questions that examine the problem: (1) Is the difficulty in obtaining referral appointments real or perceived? (2) Are the referral patterns of the providers contributing factors in the perceived inability to meet the demand for specialty appointments? (3) If the providers' referral patterns are a contributing factor, which provider behaviors need to be modified? Major findings of the study included: 1. the referral rate of the primary care providers was 8 percent, compared to the national average of 7.5 percent; 2. interns and residents were provider outliers with referral rates of 11.7 percent and 13.5 percent, respectively; and 3. of the 32,182 referral appointments requested during Fiscal Year 1999, slightly less than 2.4 percent were disengaged. Data analysis indicates opportunities for improvement of referral rates in DDEAMC's department of primary care by addressing the referral practices of residents and interns, which will therefore decrease the number of disengaged patients. By decreasing the number of referrals, the organization will more effectively control internal costs in an era of shrinking budgets.

Multi-Market Impacts of Market-Based Recycling Initiatives.

In 1995 the average tipping fee in the state of New York was $70/ton, with some landfills charging as high as $100.1 In New Jersey, fees reached prices as high as $165/ton.2 With budget crises occurring at all levels of government, economists, environmental scientists, policy-makers, and others are scrambling to find alternatives to waste disposal. Recycling as a solution has risen to the forefront, most likely because it both saves landfill space and may use fewer resources than virgin material processing. At every level of government, policies are being set that encourage recycling. Unfortunately, some of these programs may be resulting in unintended and undesirable side effects. To understand these effects, a broader view of the many factors involved in materials use, waste generation, and disposal is necessary. Within this paper, the broader view is considered, including a discussion of the externalities that exist in the markets affected by waste and an analysis of the effects on all alternatives to recycling, including composting and reuse. Through use of mathematical optimization, this paper shows that a recycling subsidy, or the more complicated tax/subsidy scheme, does not necessarily provide greater environmental benefits compared with disposal taxes.