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TITLE: DIETARY FIBER INTAKE AND INITIAL WEIGHT CHANGE IN THE 'REASONABLE EATING AND ACTIVITY TO CHANGE HEALTH' (REACH) TRIAL. AUTHORS: E. Missik, PhD, RN, K. Baughman, PhD, E. Logue, PhD, [...]

This presentation illustrates the establishment of a College of Nursing, Center for Gerontological Health Nursing and Advocacy through parmering with a federally funded Administration on Aging (AoA) demonstration project. The mission of the Gerontology Nursing Center is to advance knowledge about appropriate and effective health promotion and health care interventions for elders. This goal will be carried out in the AoA project by addressing health care and quality of life for elders in the areas of urinary incontinence and anticipatory guidance for end-of-life care. The presentation highlights the education, research, and service activities that are being carried our in the project and how health care issues and advocacy of elders are addressed. Also presented are expected outcomes for the project that included creation of an online learning environment for education and training of nursing personnel; access to the most recent best practice information for urinary incontinence and end-of-life care; and collaboration and networking between academic and practice settings.

Background: The increasing prevalence of obesity and obesity-related conditions in primary care settings challenges the health care system. Thus, we used available baseline data from an on-going clinical trial to examine the biopsychosocial characteristics of overweight and obese primary care patients. The primary research objective was to ascertain whether theoretically important psychosocial and behavioral variables mediate the empirical relationships between sociodemographic factors and body mass index (BMI).Methods: Overweight or obese primary care patients (n=665) enrolled in an on-going trial of a cognitive-behavioral obesity intervention provided baseline sociodemographic, psychosocial, nutritional, physical activity, and anthropometric data that were analyzed via multiple regression.Results: Lower educational attainment was associated with a higher BMI after controlling for decisional balance, social support, self-efficacy, energy intake, and energy expenditure (P<0.05). In contrast, ethnicity was not associated with BMI after controlling for the psychosocial and behavioral variables. Decisional balance and social support variables were associated with BMI and energy intake, but the directions of some of the associations were not consistent with a priori expectations.Conclusions: Overall, we found some evidence of mediation by the psychosocial and behavioral variables of the relationship between ethnicity and BMI, but not for the relationship between education and BMI. In addition, some of the relationships between the psychosocial variables and BMI were opposite of our expectations. [ABSTRACT FROM AUTHOR]

Introduction: Staphylococcus aureus is one of the most common pathogens in health care facilities and in the community, and can cause invasive infections, sepsis, and death. Despite progress in preventing methicillin-resistant S. aureus (MRSA) infections in health care settings, assessment of the problem in both health care and community settings is needed. Further, the epidemiology of methicillin-susceptible S. aureus (MSSA) infections is not well described at the national level., Methods: Data from the Emerging Infections Program (EIP) MRSA population surveillance (2005-2016) and from the Premier and Cerner Electronic Health Record databases (2012-2017) were analyzed to describe trends in incidence of hospital-onset and community-onset MRSA and MSSA bloodstream infections and to estimate the overall incidence of S. aureus bloodstream infections in the United States and associated in-hospital mortality., Results: In 2017, an estimated 119,247 S. aureus bloodstream infections with 19,832 associated deaths occurred. During 2005-2012 rates of hospital-onset MRSA bloodstream infection decreased by 17.1% annually, but the decline slowed during 2013-2016. Community-onset MRSA declined less markedly (6.9% annually during 2005-2016), mostly related to declines in health care-associated infections. Hospital-onset MSSA has not significantly changed (p = 0.11), and community-onset MSSA infections have slightly increased (3.9% per year, p<0.0001) from 2012 to 2017., Conclusions and Implications for Public Health Practice: Despite reductions in incidence of MRSA bloodstream infections since 2005, S. aureus infections account for significant morbidity and mortality in the United States. To reduce the incidence of these infections further, health care facilities should take steps to fully implement CDC recommendations for prevention of device- and procedure-associated infections and for interruption of transmission. New and novel prevention strategies are also needed., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Approaches to controlling emerging antibiotic resistance in health care settings have evolved over time. When resistance to broad-spectrum antimicrobials mediated by extended-spectrum β-lactamases (ESBLs) arose in the 1980s, targeted interventions to slow spread were not widely promoted. However, when Enterobacteriaceae with carbapenemases that confer resistance to carbapenem antibiotics emerged, directed control efforts were recommended. These distinct approaches could have resulted in differences in spread of these two pathogens. CDC evaluated these possible changes along with initial findings of an enhanced antibiotic resistance detection and control strategy that builds on interventions developed to control carbapenem resistance., Methods: Infection data from the National Healthcare Safety Network from 2006-2015 were analyzed to calculate changes in the annual proportion of selected pathogens that were nonsusceptible to extended-spectrum cephalosporins (ESBL phenotype) or resistant to carbapenems (carbapenem-resistant Enterobacteriaceae [CRE]). Testing results for CRE and carbapenem-resistant Pseudomonas aeruginosa (CRPA) are also reported., Results: The percentage of ESBL phenotype Enterobacteriaceae decreased by 2% per year (risk ratio [RR] = 0.98, p<0.001); by comparison, the CRE percentage decreased by 15% per year (RR = 0.85, p<0.01). From January to September 2017, carbapenemase testing was performed for 4,442 CRE and 1,334 CRPA isolates; 32% and 1.9%, respectively, were carbapenemase producers. In response, 1,489 screening tests were performed to identify asymptomatic carriers; 171 (11%) were positive., Conclusions: The proportion of Enterobacteriaceae infections that were CRE remained lower and decreased more over time than the proportion that were ESBL phenotype. This difference might be explained by the more directed control efforts implemented to slow transmission of CRE than those applied for ESBL-producing strains. Increased detection and aggressive early response to emerging antibiotic resistance threats have the potential to slow further spread., Competing Interests: No conflicts of interest were reported.

Endocrine therapy is a cornerstone of medical treatment for estrogen receptor-positive breast cancer. The discovery of selective estrogen receptor modulators (SERMs) > 40 years ago represented a revolutionary advance in the treatment of breast cancer. As a therapeutic class, SERMs have either estrogenic or antiestrogenic activity, depending on the target tissue and the hormonal environment. In breast tissue, SERMs are antiestrogenic, making them a major treatment option for women with hormone-sensitive breast cancer. Toremifene citrate was developed > 20 years ago with the goal of achieving efficacy similar to that of tamoxifen and with an improved safety profile. Although studies to date have not confirmed a clear safety advantage or disadvantage for toremifene, clinical data support the efficacy and safety of toremifene for the treatment of breast cancer in postmenopausal patients. Toremifene also has a pharmacokinetic profile and metabolic pathway different from that of tamoxifen, which may provide a therapeutic advantage in certain patients. In addition, because of the selective estrogenic effects of SERMs in bone and on lipid levels along with a different side effect profile compared with the aromatase inhibitors (AIs), toremifene is a viable option to the AIs for some patients. Despite a number of clinical trials and over 500,000 patient years of use, many oncologists have limited familiarity with toremifene data. This article will examine the rationale for the use of toremifene in the treatment of women with breast cancer and review data from 20 years of clinical experience with this agent., (Copyright © 2014 The authors. Published by Elsevier Inc. All rights reserved.)

Objective: To compare health benefits achieved in a transtheoretical model-chronic disease (TM-CD) minimal intervention for obesity vs. augmented usual care (AUC)., Research Method and Procedures: This was a 2-year, randomized clinical trial with overweight or obese men and women from 15 primary care sites. AUC (n = 336) included dietary and exercise advice, prescriptions, and three 24-hour dietary recalls every 6 months. TM-CD care (n = 329) included AUC elements plus "stage of change" (SOC) assessments for five target behaviors every other month, mailed SOC and target behavior-matched workbooks, and monthly telephone calls from a weight-loss advisor. Weight change was the primary outcome., Results: Repeated measures models under the missing at random assumption yielded nonsignificant adjusted differences between the AUC and TM-CD groups for weight change, waist circumference, energy intake or expenditure, blood pressure, and blood lipids. The pattern of change over time suggested that TM-CD participants were trying harder to impact target behaviors during the first 6 to 12 months of the trial but relapsed afterward. Sixty percent of trial participants maintained their baseline weights for 18 to 24 months., Discussion: A combination of mailed patient materials and monthly telephone calls based on the transtheoretical model and some elements of chronic disease care is not powerful enough, relative to AUC, to alter target behaviors among overweight primary care patients in an obesogenic environment. AUC may be sufficient to maintain weights among at-risk primary care patients.

Objective: According to the Transtheoretical Model (TM), tailoring interventions to patients' readiness to change can enhance patient progress and help patients use therapeutic resources more effectively. However, tailoring an intervention depends on accurate assessment of patients' stage of change (SOC). This study describes a multi-item algorithm of SOC (M-SOC) for weight loss-related behaviors that attempts to overcome some of the conceptual and methodological difficulties encountered in previously SOC assessments., Research Methods: Data were collected from participants randomly assigned to the treatment arm of a clinical trial comparing a TM-based, cognitive-behavioral intervention with enhanced usual care for weight loss., Results: The stair-step relationships hypothesized by the TM between assessed SOC and key behavioral measures were found for all algorithms (p < 0.05), indicating that the M-SOC algorithm performs as well as single item algorithms. However, 50% fewer patients were classified in action or maintenance for dietary fat intake and portion control (p < 0.05) by the multiple-item algorithms, providing staging more consistent with the clinical presentation of obese individuals. In addition, logistic regression analyses indicated that the single-item algorithms were not sufficient predictors of these behavioral domains., Discussion: To the extent that treatment is guided by assessed SOC, there is potential for a considerable variability in interventions with different approaches to staging. For weight-loss interventions that target portion control and decreased fat intake, the multi-item SOC algorithms seem to be better guides for matching treatments to SOC.

Service as a form of scholarship of application is examined from the perspectives of academic and practice experiences of professional nurses. Emphasis is placed on the evolution of services. Data and case studies are provided to illustrate varied ways in which nurses are expertly providing service to the profession and community. The need to explore further the innovative contributions nurses make through scholarly service is stressed.

The provision of pharmacokinetics services in Veterans Affairs (VA) medical centers was studied. In October 1992 a questionnaire was mailed to the chief of pharmacy at each of the nation's 160 VA medical centers. The survey was designed to determine the percentage of centers providing pharmacokinetics services, the general characteristics of pharmacokinetics services provided, and whether the presence of these services was associated with specific characteristics of the medical centers. Of the 160 questionnaires mailed, 148 (93%) were returned and analyzed. Pharmacokinetics services were provided by 104 (70%) of the respondents. Of the 104 services, 58 (56%) had existed for less than five years. Of the 44 VA medical centers without a pharmacokinetics service, almost two thirds planned to start one in the future. Aminoglycosides, vancomycin, and theophylline were the drugs most frequently monitored. Fifty-four percent of the pharmacokinetics services evaluated 1-24 patients per month, and another 24% evaluated 25-49 patients monthly. VA medical centers with a pharmacy residency program were more likely to have a pharmacokinetics service than centers without such a program; an association with geographic region was also identified. Nearly three fourths of responding VA medical centers indicated that they provided pharmacokinetics services.

This article discusses issues that are relevant for the delivery of culturally appropriate psychiatric care to African-Americans. The conceptual model of Cultural Competence in Psychiatric Mental Health Nursing is used as the organizer of information presented, however, the model is also critiqued. Suggestions for the provision of culturally competent psychiatric care are provided.

Objective: To evaluate the frequency with which current loading and maintenance vancomycin dosages achieve target serum concentrations based on pharmacokinetic parameters obtained after the initial dose. Also, to identify the daily vancomycin dosage necessary to achieve target serum concentrations at steady-state and to determine if any relationships exist between vancomycin pharmacokinetic parameters and various patient characteristics., Setting: Neonatal intensive care unit (NICU) at Georgia Baptist Medical Center., Patients/methods: Twenty-three infants with suspected or documented gram-positive infection who received intravenous vancomycin between July 1990 and November 1991 were included in this retrospective analysis. Gestational age range from 23 to 41 weeks and postconceptional age (PCA) at the time of the study ranged from 26 to 46 weeks. Vancomycin therapy was initiated with a loading dose of 15 mg/kg, followed by a maintenance dosage of 20-30 mg/kg/d, which was usually given as 10 mg/kg q8-12h. All vancomycin doses were administered using a syringe pump. Peak and trough serum concentrations were obtained following the first dose. Vancomycin pharmacokinetic parameters were determined using a one-compartment model. Infants receiving indomethacin within two weeks prior to study were analyzed separately (group 2, n = 4). All other infants were included in group 1 (n = 19)., Results: For group 1, vancomycin clearance (Cl), volume of distribution (Vd), and half-life were (mean +/- 1 SD) 0.072 +/- 0.032 L/kg/h, 0.52 +/- 0.08 L/kg, and 5.6 +/- 1.6 hours, respectively. For both groups, loading doses provided 1-hour postinfusion peak concentrations of 25-35 mg/L in one of every two infants studied, whereas only three percent of initial maintenance doses were projected to provide desired peak and trough concentrations at steady-state. For group 1, the mean daily dosage necessary to provide target peak (25-35 mg/L) and trough (5-10 mg/L) concentrations at steady-state was larger than that initially prescribed (29.6 +/- 13.1 vs. 22.2 +/- 4.7 mg/kg/d). For group 2, the mean daily dosage required to achieve target peak and trough concentrations at steady-state was smaller than that initially prescribed (14.8 +/- 4.3 vs. 20.0 +/- 0.1 mg/kg/d) and was exactly half of that required for group 1. Excellent correlations were observed between PCA and vancomycin Cl (L/h) (r = 0.92; p < 0.0001), body weight and Vd(L) (r = 0.94; p < 0.0001), body weight and vancomycin Cl (L/h) (r = 0.85; p < 0.0001), PCA and Vd (L) (r = 0.89; p < 0.0001), and body surface area and Vd (L) (r = 0.93; p < 0.0001) for group 1. Moderate correlations were also noted between PCA and Cl relative to body weight (L/kg/h), postnatal age and Cl (L/kg/h), and PCA and vancomycin dosage requirements (mg/kg/d). No linear correlation was observed between any patient characteristic and Vd standardized for body weight., Conclusions: Our data demonstrate the need for a more accurate method of estimating initial vancomycin dosage requirements in this NICU population. Although some of the relationships revealed in this study could be used to determine vancomycin dosage for infants in the range of approximately 30-36 weeks PCA, we hesitate to suggest this approach presently because of the potential limitations of our study design. Further prospective study is needed to confirm these observations. In addition, further study is necessary to describe the time course of the interaction between vancomycin and indomethacin in infants with successful and unsuccessful closure of their patent ductus arteriosus.

One of the major goals of any medical center is to provide safe, cost-effective drug therapy. To ensure rational antimicrobial therapy and control hospital drug costs, a criteria-based antibiotic surveillance program was developed. This method of antibiotic restriction provided exceptional cost savings in our institution. Clinical pharmacy interventions resulted in physician education and an 18% increase in compliance with the program criteria producing in a one-year period a $43,000 cost avoidance for antibiotic expenditures.

Respiratory diseases are major causes of morbidity and mortality in premature neonates. Theophylline has been utilized as an adjunct in facilitating ventilator weaning and in the management of apnea with or without bradycardia. Patient characteristics associated with improved outcome from theophylline have not been determined. The purpose of this study was to evaluate parameters associated with improved outcome in neonates with respiratory diseases receiving theophylline. The study population consisted of premature neonates that were studied retrospectively. Criteria for entry into the study were (1) less than 40 weeks gestation, (2) a diagnosis of respiratory distress syndrome (RDS), apnea of prematurity, hyaline membrane disease (HMD), or bronchopulmonary dysplasia (BPD), (3) dependence on intermittent mandatory ventilation, (4) failure to wean from the ventilator 24 h or more before the study, or (5) receiving theophylline. In this study, we found no correlations between time to wean from the ventilator and postnatal age at the time theophylline was initiated, 5-min APGAR score, and final theophylline serum concentration before complete weaning from the ventilator. However, there were significant negative correlations between birthweight and gestational age with respect to time to wean from the ventilator. The average theophylline serum concentration before weaning from the ventilator for this population of neonates was approximately 5-10 micrograms/ml, indicating that theophylline is not beneficial as an aid to ventilator weaning at serum concentrations < 10 micrograms/ml.

A survey of pharmacokinetic service (PKS) provision and characteristics of the service was conducted in Georgia's 223 hospitals. The survey's questionnaire, returned by 133 (59.6%) institutions, showed that 23.3% currently had a PKS and that 47% of those without a PKS had plans to establish one in the future. Services were primarily provided by pharmacists (93%) who were certified to provide the consultations in only 40% of the institutions and the PKS was run through either the pharmacy (93%) or pathology laboratory. All services used calculators and/or computers with a variety of software programs to assist in pharmacokinetic evaluations. Patients were charged for the service in 38% of the institutions.

How do you choose and plan for the implementation of a conceptual model for professional nursing practice? This article discusses one institution's experience with the Neuman Systems Model. The process discussed in this article will serve as a guide for other nursing administrators considering this significant undertaking.

Healthy, mature, spontaneously contracting muscle was cultivated from explants of 13-day chick embryos for periods up to 4 months in the multipurpose chamber (Rose, 1954) using cellophane-strip technique (Rose et al., 1958) with silicone gaskets, Eagle's medium including 10 per cent horse serum reinforced with 300 mg-per cent of glucose, and the teased type of explant. This method provided optically ideal conditions for the study of muscle fibers with oil immersion, phase contrast time-lapse cinematography at 1 frame per minute without apparent damage for periods as long as 10 days. In no case was mitosis, amitosis, or nuclear "budding" observed in the course of muscle development. Multinuclear muscle fibers have been shown with cine technique to result from both myoblast fusion and polar extension of preformed (explanted) muscle tissue. Myoblast fusion was the only demonstrable way of giving rise to multinucleation. Nuclear membrane "wrinkling" was shown to be merely a temporary distortion that occurred during nuclear migration and rotation. It is suggested that this phenomenon may be responsible for numerous reports of amitosis in the genesis of muscle fibers. The histological development of new straps resulted from an orderly sequence of events. Included in these were polar extension, nuclear migration, rotation, and fixation. Following these events there was increased mitochondrial activity, myofibril formation, and cross-banding. Spontaneous contractions were seen throughout the entire course of differentiation in vitro but became more regular and stronger in the later stages.