Psychometric testing of the clinical nurse leader staff satisfaction instrument.

BACKGROUND AND PURPOSE: Patient care is changing rapidly with increased complexity of care, patient volumes, and financial constraints with rising health care costs and limited reimbursements. In response, the clinical nurse leader (CNL) role was developed. No appropriate instrument exists to measure staff satisfaction with the CNL role. This study describes the development and testing of an instrument designed to measure staff satisfaction with implementation of the CNL role. METHODS: The psychometric properties and factor structure of the Clinical Nurse Leader Staff Satisfaction (CNLSS) instrument was examined. RESULTS: A 2-factor solution was discovered for the CNLSS. Cronbach's alpha coefficients were acceptable for the subscales and instrument. CONCLUSION: The CNLSS is a valid and reliable instrument. Future research should focus on establishing test-retest reliability and construct validity.

WIC participation and breastfeeding among White and Black mothers: data from Mississippi.

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower rates of breastfeeding; studies have suggested this relationship may be modified by race. The purpose of this study is to examine the association between WIC participation and breastfeeding behaviors among white and black women in Mississippi. Using data from the 2004-2008 Mississippi Pregnancy Risk Assessment Monitoring System, we calculated multivariable prevalence and hazard ratios to assess the relationships among WIC participation during pregnancy and breastfeeding initiation and duration through 10 weeks postpartum. Stratified analyses were performed for white and black women. 52.2 % of white and 82.1 % of black women participated in WIC. 60.4 % of white and 39.7 % of black women initiated breastfeeding, and 26.5 % and 21.9 %, respectively, were breastfeeding at 10 weeks postpartum. WIC participation was negatively associated with breastfeeding initiation among whites (APR: 0.87; 95 % CI 0.77-0.99), but not blacks (APR: 0.99; 95 % CI 0.28-1.21). WIC participation was not associated with breastfeeding duration for women of either race (white: AHR: 1.05, 95 % CI 0.80-1.38; black: AHR: 0.91, 95 % CI 0.65-1.26). The results among white women suggest that Mississippi WIC might benefit from an in depth evaluation of the program's breastfeeding promotional activities to determine if aspects of the program are undermining breastfeeding initiation. High rates of participation in the WIC program among black women, and the overall low rates of breastfeeding in this population point to the potential the program has to increase breastfeeding rates among blacks.

Cognitive performance of morbidly obese patients seeking bariatric surgery.

Bariatric surgery is efficacious for the treatment of severe obesity; however, little empirical research exists describing the demographic, psychosocial, and cognitive characteristics of patients presenting for the surgery. One hundred and sixty-nine morbidly obese patients seeking bariatric surgery underwent a presurgical psychological assessment, including cognitive testing. Morbidly obese individuals seeking bariatric surgery were similar in education, income status, and IQ compared with normative data. IQ was average, did not correlate with body mass index, and reflected a normal distribution. As a group, bariatric surgery patients endorsed minimal levels of depression and low levels of psychopathology. Obese individuals did demonstrate specific cognitive deficits on tests of executive function (e.g., problem solving and planning) when compared with normative data. This data suggests that bariatric surgery patients differ very little from other surgical populations on most demographic and psychosocial variables. The data does provide evidence for specific cognitive deficits in the area of executive functions at baseline in morbidly obese adults seeking bariatric surgery.

Laparoscopic and open distal pancreatectomy: a comparison of outcomes.

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.

Gastrointestinal symptom improvement after Roux-en-Y gastric bypass: long-term analysis.

BACKGROUND: Obese patients have a multitude of gastrointestinal symptoms that differ from their nonobese counterparts. The published data remain scant on changes in gastrointestinal symptoms among this cohort before and after Roux-en-Y gastric bypass (RYGB). The aim of this study was to quantify these symptoms and understand the changes that occur after bariatric surgery. METHODS: A total of 1724 gastrointestinal symptom surveys were prospectively administered to 763 consecutive patients who underwent laparoscopic RYGB. The patients rated each symptom on a 0-100-mm Liekert scale: 0, absence of symptoms; 33, occasional occurrence; 67, frequent occurrence; 100, continuous. The surveys were administered preoperatively and yearly thereafter. The data are presented as the mean + or - standard error of the mean. RESULTS: Of the 763 patients, 137 were black, 610 were white, and 16 were Hispanic; 83% were women and 17% were men. Their age was 40.8 + or - 0.34 years. The body mass index was 48.4 + or - 0.27 kg/m(2). The American Society of Anesthesiologists class was 2 for 31%, 3 for 68%, and 4 for 1%. Of the 763 patients, 63% underwent short-limb RYGB and 37% underwent long-limb RYGB. The preoperative symptom rating was as follows: abdominal pain, 24.3 + or - 0.7; heartburn, 41.0 + or - 0.8; acid regurgitation, 30.9 + or - 0.9; gnawing epigastric sensation, 26.5 + or - 0.9; nausea/vomiting, 18.8 + or - 0.7; borborygmus, 26.2 + or - 0.8; abdominal distension, 30.3 + or - 0.9; eructation, 28.0 + or - 0.8; increased flatus, 38.9 + or - 0.8; decreased passage of stool, 14.8 + or - 0.8; increased passage of stool, 16.4 + or - 0.7; loose stools, 22.1 + or - 0.8; hard stools, 20.5 + or - 0.9; urgent need for defecation, 23.2 + or - 0.8; incomplete evacuation, 22.2 + or - 0.8; difficulty falling asleep, 42.0 + or - 1.1; insomnia, 38.4 + or - 1; feeling rested, 60.1 + or - 1; and difficulty swallowing, 13.5 + or - 0.67. At 1, 2, 3, 4, and 5 years after RYGB, 99.5% 84.2%, 68.4%, 57.9% and 47.4% of these symptoms had improved significantly (P < .05). CONCLUSION: Laparoscopic RYGB significantly improves the gastrointestinal symptoms experienced by morbidly obese patients without adversely affecting any of the measured parameters. This improvement in symptoms proved durable in the long term.

Pharmacologic prophylaxis against venous thromboembolic complications is not mandatory for all laparoscopic Roux-en-Y gastric bypass procedures.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of postoperative mortality in bariatric surgical patients. The aim of this study is to report the rate of VTE and bleeding complications using no prophylactic pharmacologic anticoagulation among patients undergoing laparoscopic Roux-en-Y gastric bypass. STUDY DESIGN: Nine hundred fifty-seven consecutive patients who were older than 18 years, had no history of VTE, and had laparoscopic Roux-en-Y gastric bypass by a single surgeon (RHC) between January 2000 and October 2008 were included. Outcomes, including deep vein thrombosis and pulmonary embolism, were prospectively collected and retrospectively analyzed using SAS (version 9.1, SAS Institute Inc). VTE prophylactic regimen consisted of calf-length pneumatic compression devices placed before anesthesia induction and mandatory ambulation beginning on the day of operation. No prophylactic pharmacologic anticoagulation was used. All data presented as mean +/- SEM. RESULTS: Of the 957 patients, 792 were women and 165 were men. Mean age was 41.0 +/- 0.3 years, body mass index (calculated as kg/m(2)) was 49.1 +/- 0.2, and American Society of Anesthesiology scores 2 (29.8%), 3 (69.8%), and 4 (0.4%). Mean operative time was 106.0 +/- 0.8 minutes. Clinically evident deep vein thrombosis developed in three patients (0.31%) and one patient had a pulmonary embolism (0.10%). The one mortality in the cohort was unrelated to VTE. There were seven (0.73%) bleeding complications, of which one resolved without treatment, two required reoperation, and four required blood transfusions. CONCLUSIONS: Adequate VTE prophylaxis is achieved using calf-length pneumatic compression devices, early ambulation, and relatively short operative times. Pharmacologic anticoagulation is not mandatory when these conditions are met in patients who have no earlier history of VTE. There are few bleeding complications requiring reoperation or blood transfusions without the use of anticoagulants.

Laparoscopic versus open approach for implantation of the peritoneal catheter during ventriculoperitoneal shunt placement.

BACKGROUND: Ventriculoperitoneal shunt (VPS) is the mainstay of therapy for hydrocephalus. The aim of this study is to compare outcomes of laparoscopic (LVPS) versus open (OVPS) techniques for placement of distal VPS catheters. METHODS: All patients undergoing new VPS placement at a tertiary care center between January 2004 and August 2007 were included. Univariate analysis was performed. Wilcoxon rank-sum, chi-square, and Fisher's exact tests were used to make comparisons between LVPS and OVPS groups. Stepwise backward logistic regression was performed to predict complications requiring operative intervention. A Kaplan-Meier estimate of the survival function was calculated for shunt survival. All data is presented as median and range unless otherwise specified. RESULTS: Five hundred thirty-five consecutive patients underwent 579 VPS (258 LVPS, 321 OVPS). Median age (52.0 years) and American Society of Anesthesiologists (ASA) score (3) were similar in LVPS and OVPS groups. Body mass index (BMI) [27.8 (17.0-64.9) kg/m(2) versus 25.9 (12.3-44.4) kg/m(2), p = 0.007], previous operations [0.8 +/- 0.9 versus 0.6 +/- 0.7, p = 0.004 (mean +/- standard deviation)], estimated blood loss (EBL) [20 (0-175) ml versus 25 (0-500) ml, p < 0.001], operating room (OR) time [37.5 (17.0-152.0) min versus 52.0 (20.0-197.0) min, p < 0.001], and length of stay (LOS) [11 (1-77) days versus 14 (1-225) days, p = 0.016] were statistically different between the LVPS and OVPS groups, respectively. LVPS abdominal complication rate of 5.8% and OVPS rate of 6.9% were similar (p = 0.611). Previous abdominal operation [odds ratio (OR) 1.673, 95% confidence interval (CI) 1.100-2.543, p = 0.016] and previous VPS (OR 1.929, 95% CI 1.147-3.243, p = 0.016) were significant predictors of complications requiring operative intervention. Kaplan-Meier analysis demonstrated no difference in survival between LVPS and OVPS groups (p = 0.538), with overall shunt survival of 86.4% at 6 months and 83.0% at 1 year. CONCLUSIONS: LVPS is associated with decreased OR time, less blood loss, and shorter LOS with no difference in complication rate when compared OVPS. The laparoscopic approach for VPS is a safe, effective, and readily reproducible alternative to the traditional open approach.

Hyperparathyroidism and vitamin D deficiency after laparoscopic gastric bypass.

Hyperparathyroidism (HPT) can occur after gastric bypass because of the alteration in vitamin D and calcium absorption. Adequate serum vitamin D concentrations have not been clearly defined in this patient population. Vitamin D (Vit D) and parathyroid hormone (PTH) were assessed 1 year after laparoscopic gastric bypass (LGB). The prevalence of HPT and Vit D deficiency were determined and their association was evaluated using Fisher's exact test. Ninety-three patients (aged 44 +/- 1.1 years, 49.6 +/- 0.67 Kg/m2 body mass index, 79.6% female, 69.6% white) were evaluated. The prevalence of Vit D deficiency (less than 20 ng/mL) and HPT (greater than 65 pg/mL) was 23.6 per cent (n = 22) and 25.7 per cent (n = 28), respectively. Among patients with HPT, only eight of 28 (28.6%) had Vit D deficiency, and of those with Vit D deficiency, only eight of 22 (36.4%) had HPT. There was a weak inverse correlation (r = -0.37) between PTH and Vit D. Blacks are at higher risk for Vit D deficiency. There was no significant association between Vit D deficiency and HPT, Vit D deficiency and Roux limb length, or HPT and Roux limb length. After LGB, Vit D deficiency and hyperparathyroidism occur commonly. Body mass index and Roux limb length are not associated with these two conditions, but racial differences do exist. There is a weak inverse correlation between Vit D and PTH. Further research is needed to elucidate the causes, treatments, and significance of HPT after LGB.

Pancreatic resection with islet cell autotransplant for the treatment of severe chronic pancreatitis.

Pancreatic resection can alleviate pain in properly selected patients with severe chronic pancreatitis (CP), although the apancreatic state causes "brittle" diabetes. Islet auto-transplantation (IAT) after resection can decrease diabetes-related morbidity. Twenty-six consecutive patients with CP who underwent 27 pancreatic resections with IAT from April 2005 to December 2007 were evaluated in this retrospective case control study. Data were collected by chart and operative note reviews and query of hospital databases. Subgroup analysis was performed on 21 cases of total pancreatectomy and six cases of pancreaticoduodenectomy (PD). Mean age was 43.8 years and 46.2 per cent of patients were female. The most common etiology of CP was alcoholism (34.6%), followed by idiopathic causes (30.8%) and pancreatic divisum (23.1%). There was no mortality and the complication rate was 56 per cent. Islet equivalents infused and islet equivalents/gram of pancreas were 82,094 and 2,739 respectively. Mean discharge insulin dose was 10.7 units/day. Mean follow-up was 6.5 months. At 6 months, 80 per cent of patients reporting had decreased or eliminated their use of narcotic medication and all total pancreatectomy patients required insulin (mean 23 units/day). In appropriately selected patients, pancreatic resection with IAT is safe and effective for the treatment of intractable pain associated with CP.

Organizational culture: the silent political force.

Organizational cultures are affected by, and affect, organization politics. Underlying all cultures is the values of the individuals in the organization. These need to be identified and understood by anyone who seeks to influence or change behaviors. This article describes a series of studies done to increase the understanding of values of professional nurses. The results point out differences between specialties, organizations, and communities that can help leaders make better decisions in areas ranging from staffing to leadership styles, while assisting colleagues in the expression of their authentic selves.

Borrelia burgdorferi intercepts host hormonal signals to regulate expression of outer surface protein A.

The Borrelia burgdorferi infectious cycle requires that the organism adapt to vast differences in environmental conditions found in its tick and mammalian hosts. Previous studies have shown that B. burgdorferi accomplishes this accommodation in part by regulating expression of its surface proteins. Outer surface protein A (OspA) is a borrelial protein important in colonization of the tick midgut. OspA is up-regulated when the organism is in its tick host and down-regulated when it is in a mammalian host. However, little is known about how it is up-regulated again in a mammalian host in preparation for entry into a feeding tick. Here, we report that the host neuroendocrine stress hormones, epinephrine and norepinephrine, are specifically bound by B. burgdorferi and result in increased expression of OspA. This recognition is specific and blocked by competitive inhibitors of human adrenergic receptors. To determine whether recognition of catecholamines, which are likely to be present at the site of a tick bite, may play a role in preparing the organism for reentry into a tick from a mammalian host, we administered a beta-adrenergic blocker, propranolol, to infected mice. Propranolol significantly reduced uptake of B. burgdorferi by feeding ticks and decreased expression of OspA in B. burgdorferi recovered from ticks that fed on propranolol-treated mice. Our studies suggest that B. burgdorferi may co-opt host neuroendocrine signals to inform the organism of local changes that predict the presence of its next host and allow it to prepare for transition to a new environment.

Shared governance: making the transition in practice and perception.

The shared governance literature contains numerous examples of how to design and implement nursing shared governance models. However, there is a major gap between design/implementation and a change in culture. A change in nursing culture will support viability of this governance model. The authors detail the steps taken by a shared governance transition team to help a large nursing organization make changes in governance process and perception as well as to incorporate a maintenance plan.