Precepting nurse practitioner students: One medical center's efforts to improve the precepting process.

PURPOSE: To describe the challenges shared by schools of nursing and precepting institutions in meeting the clinical rotation requirements for nurse practitioner (NP) students. A formal process was developed to screen students and provide appropriate clinical placement with ongoing evaluations. Detailed description of a preceptor class for NPs is offered. DATA SOURCES: Single institution NP survey, preceptor class participant survey, author experience, and PubMed, CINAHL. CONCLUSIONS: The barriers to precepting are well known, particularly from the viewpoint of schools of nursing. This article describes the barriers from a precepting institution's standpoint. Standardizing processes and expectations for NP students and preceptors improves the overall efficiency, effectiveness, and safety of the clinical experiences. IMPLICATIONS FOR PRACTICE: Highlights of an NP preceptor class and efforts to streamline precepting arrangements are described. Lessons learned, including the need to minimize paperwork burden on students during the preclinical period and the continued need for improvement of evaluation tools, are discussed. Recommendations for ways to blend specialty rotations with primary care rotations are made.

An unusual case of infective endocarditis: extension of a tricuspid valve vegetation into the left atrium through a patent foramen ovale.

Tricuspid valve endocarditis frequently occurs in the setting of intravenous drug use. A case of tricuspid valve endocarditis in a 37-year-old woman with a history of intravenous cocaine use is described. Transthoracic echocardiography showed extension of the tricuspid valve mass through a patent foramen ovale and into the left atrium. One week after intravenous antibiotic treatment, the mass no longer traversed the patent foramen ovale, and only two smaller tricuspid valve vegetations remained. The present case demonstrates the value of performing a complete and thorough transthoracic echocardiography to visualize and evaluate both the right- and left-sided consequences of infective endocarditis in intravenous drug users. It also serves as a useful reminder to physicians caring for such patients that right sided endocarditis can have important left-sided complications.

Secondary hyperparathyroidism in primary osteoporosis and osteopenia: optimizing calcium and vitamin D intakes to levels recommended by expert panels may not be sufficient for correction.

OBJECTIVE: To compare biochemical variables, renal function and calcium and vitamin D intakes in euparathyroid and hyperparathyroid patients with primary osteoporosis and osteopenia and describe the measures necessary to normalize serum PTH in the patients with secondary hyperparathyroidism. DESIGN AND PATIENTS: We reviewed the charts of normocalcemic patients with primary osteoporosis and osteopenia first seen during the years 1991-2003 and identified 75 with elevated serum PTH levels at baseline. These patients were compared to all the 143 euparathyroid patients first seen in 1998 and 1999. Patients were restudied after 1 year and we attempted to follow patients with secondary hyperparathyroidism until PTH levels became normal. MEASUREMENTS: At baseline serum PTH, ionized calcium, inorganic phosphate, alkaline phosphatase, creatinine, a complete blood count and serum 25 hydroxy vitamin D were measured in the early morning fasting state. These tests were repeated at follow up. RESULTS: In one-third of the hyperparathyroid patients, the standard baseline treatment failed to correct the secondary hyperparathyroidism necessitating extraordinary measures including unusually large doses of vitamin D (i.e. 50 000 IU vitamin D(2) twice weekly) or the substitution of calcium citrate for calcium carbonate as a calcium supplement. CONCLUSION: Large doses of vitamin D are frequently necessary to suppress secondary hyperparathyroidism in patients with primary osteoporosis and osteopenia. This suggests that vitamin D metabolism may be altered in some of these patients.