Advanced practice roles for nurses in tomorrow's healthcare systems.

Advanced practice nurses (APNs) have traditionally been a diverse group in terms of titles, education, credentials, and roles. The classification of APN usually encompasses the nurse practitioner (NP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS). NP, CRNA, and CNM roles have been more clearly delineated than the CNS roles. In light of healthcare reform, the CNS roles have been critically reviewed and analyzed. Attempts have been made to clarify responsibilities and outcomes, and to quantify the financial impact of this role. In this article, seven APN roles clearly defined in terms of minimal qualifications and competencies critical to accomplishment of the duties, responsibilities, and expected outcomes are presented. Comparison of competency requirements are also presented. The roles presented are designed to facilitate healthcare institutions in meeting the demands for serving patients with increasingly complex needs, as well as cost-containment goals.

The efficacy of dexamethasone iontophoresis for the treatment of rheumatoid arthritic knees: a pilot study.

OBJECTIVE: To examine the efficacy of dexamethasone sodium phosphate (DEX) iontophoresis for the treatment of rheumatoid arthritis (RA) of the knee, and to obtain statistical information for a future randomized controlled trial (RCT). METHODS: Ten subjects with RA, ranging in age from 34-75, were randomly assigned to either the experimental or placebo group. Iontophoresis treatments were given to both groups on days 1, 3, and 5. Five subjects in the experimental group received a mixture of 1 ml of DEX (4 mg/ml) and 1 ml of injectable sterile water; those in the placebo group received 2 ml of saline solution. Pain on movement, at rest, and on pressure, active joint count, and active range of motion, were evaluated on days 1, 5, and 20. The patient's global assessment of treatment efficacy was also assessed on days 5 and 20. Mann-Whitney U tests and Friedman two-way analyses of variance were performed for statistical analyses. RESULTS: Pain at rest was found to be statistically different between the two groups (P = 0.0317). Statistical significance was also found over time for pain on movement within the experimental group (P = 0.0224). CONCLUSION: The results suggest that DEX iontophoresis is more effective than placebo in relieving pain at rest and on movement in the RA knee. Based on the study data, a total of 40 subjects will be required for an RCT of a similar nature.

Trophic effect of ciliary neurotrophic factor on denervated skeletal muscle.

The actions and receptor for ciliary neurotrophic factor (CNTF) are largely restricted to cells of the nervous system, although one of the CNTF receptor components, CNTFR alpha, is expressed by skeletal muscle. Here we show that the other CNTF receptor components, LIFR beta and gp130, are also expressed by skeletal muscle and that expression of all three CNTF receptor components is greatly increased in denervated muscle. In vivo, administration of CNTF activates these receptors on skeletal muscle by inducing receptor phosphorylation and immediate-early gene responses. Furthermore, CNTF reduces the denervation-induced atrophy of muscle and attenuates the reduced twitch and tetanic tensions that result from muscle denervation. Our findings reveal that, in addition to its known neurotrophic actions, CNTF exerts myotrophic effects by attenuating the morphological and functional changes associated with denervation of rat skeletal muscle.

Age-dependent changes in acetylcholinesterase activity in the primary somatosensory cortex of the cat.

As cortical reorganization in cat somatosensory cortex has been shown to be age-dependent and acetylcholinesterase and acetylcholine have been implicated in the shaping of sensory responses during the developmental process, we decided to investigate the biochemical changes that occur in acetylcholinesterase during postnatal development of the primary somatosensory cortex in normal cat. Somatosensory cortices were removed from cats at various ages between 4 and 144 postnatal days. Three fractions (total, membrane-bound and soluble) were analyzed for activity (esterase assay and sedimentation analysis) and amount of acetylcholinesterase (electrophoresis). Results indicated that both esterase activity levels and amounts were characterized by 4 distinct phases which included a large step increase in all fractions between postnatal days 10 and 12: a gradual rise between days 12 and 28: a 'dip' during the 42- to 82-day interval, and a subsequent recovery. Results may be attributed to concomitant developmental events. Furthermore, we suggest that the observed changes may relate to age-dependent differences in somatosensory cortex reorganization that occur after spinal cord transection.

Effect of denervation and nerve extract on ultrastructure of muscle.

Changes in denervated skeletal muscle result both from disuse and loss of neurogenic trophic substances. It had been shown that administration of nerve extract intramuscularly in rats or systemically in mice prevented the nondisuse component of atrophy in denervated muscle. Amelioration of atrophy was manifested as reduced losses of weight, protein, and cross-sectional areas of fiber in denervated hind-limb muscles. The present study assessed the effects of nerve extract on ultrastructural changes in different types of fiber (as classified by activity of ATPase) in mouse skeletal muscle denervated for 7 days. Denervated and contralateral innervated muscles of treated and untreated mice were examined by electron microscopy, and morphological parameters were quantitated by stereological techniques. Denervated muscles exhibited smaller reductions of several ultrastructural changes in treated than in untreated mice including sizes of mitochondria, and percentage volume per fiber of mitochondria, sarcoplasmic reticulum, and t-tubules. The magnitude of the myotrophic effects varied in the different types of fiber, with amelioration of between 50 and 95% of the postdenervation changes.