Does intact limb loading differ in servicemembers with traumatic lower limb loss?

BACKGROUND: The initiation and progression of knee and hip arthritis have been related to limb loading during ambulation. Although altered gait mechanics with unilateral lower limb loss often result in larger and more prolonged forces through the intact limb, how these forces differ with traumatic limb loss and duration of ambulation have not been well described. QUESTIONS/PURPOSES: The purpose of this study was to determine whether biomechanical variables of joint and limb loading (external adduction moments, vertical ground reaction force loading rates, and impulses) are larger in the intact limb of servicemembers with versus without unilateral lower limb loss and whether intact limb loading differs between shorter (≤ 6 months) versus longer (≥ 2 years) durations of ambulation with a prosthesis. METHODS: A retrospective review was conducted of all clinical and research gait evaluations performed in the biomechanics laboratory at Walter Reed Army Medical Center and Walter Reed National Military Medical Center between January 2008 and December 2012. Biomechanical data meeting all inclusion and exclusion criteria were obtained for 32 individuals with unilateral transtibial limb loss, 49 with unilateral transfemoral limb loss, and 28 without limb loss. Individuals with unilateral lower limb loss were separated by their experience ambulating with a prosthesis at the time of the gait collection, ≤ 6 months or ≥ 2 years, to determine the effect of duration of ambulation with a prosthesis. RESULTS: Intact limb mean and peak vertical ground reaction force loading rates (median [range; 95% confidence interval]) were larger for transtibial subjects with ≤ 6 months of experience ambulating with a prosthesis versus control subjects (mean: 12.13 body weight [BW]/s [4.45-16.79; 10.18-12.81] versus 9.03 BW/s [4.64-14.47; 8.26-9.74]; effect size [ES] = 0.40; p = 0.003; and peak: 17.23 BW/s [6.58-25.25; 15.46-19.01] versus 13.60 BW/s [9.82-19.51; 12.98-15.05]; ES = 0.43; p = 0.001), respectively. Intact limb mean and peak vertical ground reaction force loading rates were also larger in subjects with transfemoral limb loss with ≤ 6 months and ≥ 2 years of experience ambulating with a prosthesis versus control subjects (mean: 12.67 BW/s [5.88-18.15; 11.06-14.47] and 12.59 BW/s [8.08-17.39; 11.83-13.68] versus 9.03 BW/s [4.64-14.47; 8.26-9.74]; ES ≥ 0.53; p < 0.001; peak: 19.82 BW/s [11.93-29.43; 18.35-23.05] and 21.33 BW/s [16.68-36.69; 20.66-24.26] versus 13.60 BW/s [9.82-19.51; 12.98-15.05]; ES ≥ 0.68; p < 0.001, respectively). Similarly, intact limb vertical ground reaction force impulses (0.63 BW·s [0.53-0.81; 0.67-0.69] and 0.62 BW·s [0.55-0.74; 0.60-0.63] versus 0.57 BW·s [0.50-0.66; 0.55-0.58]; ES ≥ 0.53, p < 0.001) were also larger among both groups of transfemoral subjects versus control subjects, respectively. Limb loading variables were not statistically different between times ambulating with a prosthesis within groups with transtibial or transfemoral limb loss. CONCLUSIONS: Larger intact limb loading in individuals with traumatic transtibial loss were only noted early in the rehabilitation process, but these variables were present early and late in the rehabilitation process for those with transfemoral limb loss. Such evidence suggests an increased risk for early onset and progression of arthritis in the intact limb, especially in those with transfemoral limb loss. CLINICAL RELEVANCE: Interventions should focus on correcting modifiable gait mechanics associated with arthritis, particularly among individuals with transfemoral limb loss, to potentially mitigate the development and progression in this population.

Quality and safety in graduate nursing education: Cross-mapping QSEN graduate competencies with NONPF's NP core and practice doctorate competencies.

To ensure that nurse practitioners are prepared to deliver safe, high-quality health care, the National Organization of Nurse Practitioner Faculties (NONPF) publishes documents that outline the expected competencies for nurse practitioner (NP) practice (Domains and Core Competencies of Nurse Practitioner Practice and Practice Doctorate Nurse Practitioner Entry-Level Competencies). Having participated in the development of the Quality and Safety Education for Nurses (QSEN) competencies for graduate education, NONPF convened a task force to compare NONPF competencies with QSEN competencies for graduate education. This paper reports the first step of that cross-mapping process, comparing NONPF competencies with the QSEN knowledge objectives. Overall findings indicate close congruence across the 2 sets of competencies; however there are areas in which gaps are noted or for which clarification is required.

Positioning advanced practice registered nurses for health care reform: consensus on APRN regulation.

Advanced practice registered nurses (APRNs) have positioned themselves to serve an integral role in national health care reform. This article addresses both the policy and the process to develop this policy that has placed them in a strategic position. A successful transformation of the nation's health system will require utilization of all clinicians, particularly primary care providers, to the full extent of their education and scope of practice. APRNs are highly qualified clinicians who provide cost-effective, accessible, patient-centered care and have the education to provide the range of services at the heart of the reform movement, including care coordination, chronic care management, and wellness and preventive care. The APRN community faces many challenges amidst the opportunities of health reform. However, the APRN community's triumph in reaching consensus on APRN regulation signifies a cohesive approach to overcoming the obstacles. The consensus model for APRN regulation, endorsed by 44 national nursing organizations, will serve as a beacon for nursing, as well as a guidepost for consumers and policymakers, on titling, education, certification, accreditation, and licensing for all four APRN roles.

Effect of drug type on the degradation rate of PLGA matrices.

We compare the rate of drug release through the degradation of 50:50 polylactic-co-glycolic acid polymer pellets, for six different drugs: Thiothixene, Haloperidol, Hydrochlorothiozide, Corticosterone, Ibuprofen, and Aspirin. Despite using the same polymer matrix and drug loading (20% by weight), we find that the rate of polymer degradation and the drug release profile differ significantly between the drugs. We conclude that the design of biodegradable polymeric drug carriers with high drug loadings must account for the effect of the drug on the polymer degradation and drug release rate.

State-resolved collisional quenching of vibrationally excited pyrazine (E(vib) = 37,900 cm(-1)) by D35Cl(v = 0).

Supercollision relaxation of highly vibrationally excited pyrazine (E(vib) = 37,900 cm(-1)) with D35Cl is investigated using high-resolution transient IR diode laser absorption spectroscopy at 4.4 microm. Highly excited pyrazine is prepared by pulsed UV excitation at 266 nm, followed by rapid radiationless decay to the ground electronic state. The rotational energy distribution of the scattered DCl (v = 0,J) molecules with J = 15-21 is characterized by T(rot) = 755+/-90 K. The relative translational energy increases as a function of rotational quantum number for DCl with T(rel) = 710+/-190 K for J = 15 and T(rel) = 1270+/-240 K for J = 21. The average change in recoil velocity correlates with the change in rotational angular momentum quantum number and highlights the role of angular momentum in energy gain partitioning. The integrated energy-transfer rate for appearance of DCl (v = 0,J = 15-21) is k(2)(int) = 7.1x10(-11) cm3 molecule(-1) s(-1), approximately one-eighth the Lennard-Jones collision rate. The results are compared to earlier energy gain measurements of CO2 and H2O.

Moving forward together: the practice doctorate in nursing.

Societal drivers, as well as trends in education and health care, are advancing the practice doctorate in nursing. For nurse practitioner preparation, the current resurgence of interest in the practice doctorate could precipitate change that mimics the evolution from post-basic certificate to Master's level education. The National Organization of Nurse Practitioner Faculties (NONPF) is a resource for the study of the practice doctorate relative to quality nurse practitioner education. This article will offer some insights into the movement toward the practice doctorate by describing, from the NP perspective, the societal impetus for change, the historical perspective of NP and doctoral education, the 4 Ws (why, what, where, and when) of the movement, and some of the myths and realities about the practice doctorate.

Clinical Prevention and Population Health Curriculum Framework: the nursing perspective.

The Clinical Prevention and Population Health Curriculum Framework (Curriculum Framework) was developed by the Healthy People Curriculum Task Force comprised of representatives from allopathic and osteopathic medicine, dentistry, nursing and nurse practitioners, pharmacy and physicians assistants. This multidiscipline Task Force was covened to address the Healthy People 2010 objective of increasing the health promotion/prevention content in health professional education. A focus on clinical prevention and population health activities is central to the goal of improving the health status of the nation and offers the greatest potential to reduce many leading causes of death and improve quality of life across diverse populations. The Curriculum Framework provides a set of 4 components (evidence base for practice, clinical preventive services, health systems/health policy and community aspects of practice) and 19 domains for organizing and implementing the curriculum. The title "Clinical Prevention and Population Health" includes both individual and population focused health promotion and prevention efforts. The role of nursing in developing the Curriculum Framework, and the tailoring and implementation of the Curriculum Framework for undergraduate and graduate programs in nursing is discussed.

Clinical prevention and population health: curriculum framework for health professions.

The Clinical Prevention and Population Health Curriculum Framework is the initial product of the Healthy People Curriculum Task Force convened by the Association of Teachers of Preventive Medicine and the Association of Academic Health Centers. The Task Force includes representatives of allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. The Task Force aims to accomplish the Healthy People 2010 goal of increasing the prevention content of clinical health professional education. The Curriculum Framework provides a structure for organizing curriculum, monitoring curriculum, and communicating within and among professions. The Framework contains four components: evidence base for practice, clinical preventive services-health promotion, health systems and health policy, and community aspects of practice. The full Framework includes 19 domains. The title "Clinical Prevention and Population Health" has been carefully chosen to include both individual- and population-oriented prevention efforts. It is recommended that all participating clinical health professions use this title when referring to this area of curriculum. The Task Force recommends that each profession systematically determine whether appropriate items in the Curriculum Framework are included in its standardized examinations for licensure and certification and for program accreditation.