The academic-practice gap: Strategies for an enduring problem.

The academic-practice gap in nursing is well documented. Academe is criticized for producing nurses insufficiently prepared to fully participate in patient care. Practice settings are criticized for having unrealistic expectations of new graduates. This article is based on a review of the literature and an exploration of contemporary practices used to bridge academic and practice partnerships. Differences in outcome expectations for new graduates between academe and practice are outlined and consequences of the gap for new graduates, patients, and employers are discussed. Five specific strategies to address the gap are discussed, with the primary realm and responsibility for two falling to education, one to practice, and two to both. Strategies discussed include increased use of simulated learning in nursing education; disruptive innovations in education that promote learner-centered active learning; extended orientation/Transition to Practice Programs for new graduates; dedicated education units; and academic service partnerships. Current literature suggests the viewpoints of academic and practice leaders continue to appear divergent. Closing the gap will require a dedicated and coordinated response from both academe and clinical practice.

An Integrative Analysis of Foot-and-Mouth Disease Virus Carriers in Vietnam Achieved Through Targeted Surveillance and Molecular Epidemiology.

Foot-and-mouth disease (FMD) is a major constraint to transboundary trade in animal products, yet much of its natural ecology and epidemiology in endemic regions is still poorly understood. To address this gap, a multidisciplinary, molecular and conventional epidemiological approach was applied to an investigation of endemic FMD in Vietnam. Within the study space, it was found that 22.3% of sampled ruminants had previously been infected with FMD virus (FMDV), of which 10.8% were persistent, asymptomatic carriers (2.4% of the total population). Descriptive data collected from targeted surveillance and a farm questionnaire showed a significantly lower prevalence of FMDV infection for dairy farms. In contrast, farms of intermediate size and/or history of infection in 2010 were at increased risk of FMD exposure. At the individual animal level, buffalo had the highest exposure risk (over cattle), and there was spatial heterogeneity in exposure risk at the commune level. Conversely, carrier prevalence was higher for beef cattle, suggesting lower susceptibility of buffalo to persistent FMDV infection. To characterize virus strains currently circulating in Vietnam, partial FMDV genomic (VP1) sequences from carrier animals collected between 2012 and 2013 (N = 27) and from FMDV outbreaks between 2009 and 2013 (N = 79) were compared by phylogenetic analysis. Sequence analysis suggested that within the study period, there were two apparent novel introductions of serotype A viruses and that the dominant lineage of serotype O in Vietnam shifted from SEA/Mya-98 to ME-SA/PanAsia. FMDV strains shared close ancestors with FMDV from other South-East Asian countries indicating substantial transboundary movement of the predominant circulating strains. Close genetic relationships were observed between carrier and outbreak viruses, which may suggest that asymptomatic carriers of FMDV contribute to regional disease persistence. Multiple viral sequences obtained from carrier cattle over a 1-year period had considerable within-animal genetic variation, indicating within-host virus evolution.

Heart transplantation in patients with treated breast carcinoma.

Since 1987, five women with end-stage cardiomyopathy and a history of treated breast carcinoma have undergone transplantation at our institution. All patients underwent extensive multidisciplinary pretransplantation evaluation to rule out metastatic disease. Disease-free interval before heart transplantation ranged from 5 to 11 years (mean, 7.6 years). All patients received immunosuppression in accordance with a standard protocol of rabbit antithymocyte globulin, cyclosporine, prednisone, and azathioprine. Mean postoperative follow-up is 49 months. All patients are alive and have no symptoms 18 to 73 months after transplantation. In carefully selected patients with a history of breast carcinoma, heart transplantation can be performed with good functional results and satisfactory late survival.

Coccidioidomycosis and heart transplantation.

Eleven episodes of Coccidioides immits infection (cocci) were documented in nine of 199 heart transplant recipients. Cocci was confirmed by fungal cultures and treated with 1 gram of intravenous amphotericin B, after which all patients were put on ketoconazole 200 mg orally twice a day. Two recurrent cocci episodes were noted, both occurring when ketoconazole maintenance therapy was discontinued. When compared with the group of patients without cocci, actuarial survival at 1 and 5 years was identical. We conclude that cocci does not seem to affect the early and late clinical outcome and that prophylactic use of ketoconazole (or other oral antifungal agents) after successful treatment of the initial infection is recommended.

Incidence and recurrence of gastrointestinal cytomegalovirus infection in heart transplantation.

Cytomegalovirus (CMV) infection of the upper gastrointestinal tract is a major cause of morbidity in heart transplant recipients. Since April 1985, 201 patients underwent heart transplantation at our institution. Immunosuppressive therapy was with a triple drug regimen of cyclosporin A, prednisone, and azathioprine. Fifty-three of these patients had upper gastrointestinal symptoms, which primarily consisted of abdominal pain or nausea and vomiting despite prophylactic treatment with antacids, H2 blockers, or both. A total of 79 esophagogastroduodenoscopies were performed in this group; 15 patients required more than one esophagogastroduodenoscopy for recurrent symptoms. Of these 53 patients with persistent gastrointestinal symptoms, 16 (30.2%) had diffuse erythema or ulceration of the gastric mucosa (14), esophagus (1), and duodenum (1) with biopsy results that were positive for CMV on viral cultures (incidence, 8%). All patients with positive biopsy results were treated with intravenous ganciclovir at a dose of 10 mg.kg-1.day-1 in two divided doses for a period of 2 weeks. Recurrence developed in 6 patients (37.5%) and necessitated repeated therapy with ganciclovir. None of the 16 patients died as a result of gastrointestinal CMV infection. Patients who were seronegative for CMV and received a seropositive heart experienced earlier clinical manifestation of CMV infection. Infection of the upper gastrointestinal tract with CMV is a major cause of morbidity in cardiac transplant patients that may progress to a life-threatening complication if left untreated. Early diagnosis with esophagogastroduodenoscopy and biopsy for viral cultures is essential for documentation and proper management.

Use of the Symbion biventricular assist device in bridging to transplantation.

From 1988 to 1991 13 patients received Symbion biventricular assist devices in attempts to bridge them to cardiac transplantation. All 7 of those who had cardiac transplants survived to hospital discharge. One death occurred 60 days after transplantation because of rejection. All other patients who received transplants are surviving. Implant times in this group varied from 10 to 164 days (mean, 55 days). There were two embolic neurologic events and two significant infections, and 2 of the survivors were dialyzed for reversible renal failure before transplantation. Of those who died on device support, 3 presented on centrifugal pump support. The three other deaths were caused by graft rejection, multiple organ failure, and multiple peripheral emboli. Biventricular assist devices optimally provide cardiac outputs of 4 to 5 L/min, can be quickly inserted often without requiring cardiopulmonary bypass, are easily explanted, and seem best suited for patients weighing less than 80 kg.

Sinoatrial node dysfunction in recipients of domino heart transplants: complication of a surgical harvesting technique.

Two of six domino transplantations performed at our institution required permanent pacemaker implantation as a result of persistent sinoatrial node dysfunction and symptomatic nodal rhythm. Retrospective analysis of several potential etiologic factors showed that the only obvious difference between these two patients and the remaining four domino transplant recipients without this complication was the technique used during harvesting of the cardiac graft. The hearts from the two patients with sinoatrial node dysfunction were harvested using a "right atrial cuff preservation" technique, and the hearts of the remaining four patients were harvested with a standard bicaval division technique. Based on this experience, we think that this right atrial cuff preservation harvesting technique carries a potential risk for sinoatrial node damage, and we do not recommend its use for domino transplantation.