Coexistence of axial spondyloarthritis and thromboangiitis obliterans in a young woman.

A peculiar coexistence of axial spondyloarthritis and ischemia of the feet and the fourth finger of the left hand in a young woman, who was a heavy smoker, is discussed in this report. This picture was considered within the context of thromboangiitis obliterans. Positivity of anti-nuclear antibodies and mild elevation of inflammatory parameters were noted. Computed tomography angiograms of upper and lower limbs showed luminal narrowing and occlusion of the left humeral, left anterior/posterior tibial and right anterior tibial arteries. Daily iloprost perfusions were started, and smoking cessation was strongly recommended. Coldness and rest pain in the distal extremities improved within a few weeks. The possibility that spondyloarthritis might precede the clinical picture of thromboangiitis obliterans should be considered in heavy smokers.

Performance improvement in transfusion medicine. What do nurses need and want?

Transfusion medicine is a complex process dependent on a variety of professionals interacting effectively and efficiently across time and distance. To perform safely, professionals depend on their own knowledge and skills, the knowledge and skills of others, and the overall effectiveness of operating systems. Nursing is an essential link in the process. To be effective, nurses need to practice in environments that recognize the importance of reducing error and improving safety through use of nonpunitive system approaches to analyzing near misses and errors. The "off-with-their-heads" approach must be eliminated. To increase efficiency, pathologists and nurses should collaborate on form development, evaluation, and implementation. Documentation regarding transfusions needs to be simplified and coordinated. Knowledgeable staff is an essential element of safe systems. Basic knowledge should never be assumed. Mechanisms to monitor knowledge of key processes along with ongoing feedback and remediation are necessary to maximize performance. Working together, nursing and transfusion specialists will improve transfusion services.

Developing a culturally competent work force: an opportunity for collaboration.

This article describes a collaborative project formed between three major community systems--education, health care, and the business sector--to respond to the specialized cultural needs of a growing Hispanic population in a large public health care system in Dallas, TX. Two specific strategies, short-term cultural immersion and the development of a nurse exchange program with a "sister" hospital in Mexico, assist health care personnel to learn the language and the culture of Mexico. Findings from process evaluation suggest that these initiatives are essential and beneficial to changing individual views and developing knowledge and skills. Community partnerships requiring a significant commitment to a continuum of efforts from top administrative levels to the individual level facilitate institutional responses to the challenge of developing a culturally skilled health work force.

In-hospital first-responder automated external defibrillation: what critical care practitioners need to know.

Despite the development and widespread implementation of Basic Life Support and Advanced Cardiac Life Support, the percentage of patients who survive in-hospital cardiac arrest has remained stable at approximately 15%. Although survival rates may approach 90% in coronary care units, survival rates plummet outside of these units. The lower survival rates for cardiac arrest that occur outside of the coronary care unit may relate to the time elapsed between the onset of ventricular fibrillation and first defibrillation. The advent of automated external defibrillators has made it possible to decrease the time elapsed before first defibrillation in non-critical care areas of the hospital. First responders need only recognize that the patient is unresponsive, apneic, and pulseless before attaching and activating the automated external defibrillator. Our research shows that, as part of Basic Life Support training, non-critical care nurses can learn to use the device and can retain the knowledge and skill over time. Establishing an in-hospital automated external defibrillator program requires commitment from administration, physicians, and nursing personnel. Critical care practitioners should be aware of this technology and the literature that supports its safety and effectiveness when used by non-critical care first responders. Critical care nurses are in a unique position to effect changes that will decrease the time between the onset of cardiac arrest and first defibrillation.

Resuscitation training: a time for reassessment.

The goal of resuscitation education is to impart the knowledge and skills necessary to successfully resuscitate a victim of cardiopulmonary arrest. This goal can be accomplished only if the interactions among the instructor, learner, and curriculum are optimized. Instructors must have a clear understanding of educational theory and a thorough grasp of the program materials. Learners must be motivated and committed to developing and maintaining a high level of competence. The in-hospital chain of survival for the resuscitation response system must be reorganized to include determination of the appropriateness of resuscitation and provision of first-responder defibrillation capability. Using creativity and flexibility to meet these goals, nurses can improve the practice and potential outcome of resuscitation.

Patient-focused care: a response to the healthcare crisis.

During this time of major challenges and transitions in the healthcare industry, as both healthcare professionals and consumers, nurses are in a pivotal position to become active, informed advocates for reasonable, rational changes within a system in which we have a truly unique perspective. In this environment, it is critical that nurses understand the need for change so that we can critically analyze work redesign initiatives for their likelihood to positively or negatively impact the healthcare system at a global or local level. It will then be possible to explore the transformation of the healthcare delivery system, the concept of patient-focused care, and the impact on the healthcare workforce of the future with particular attention to the practice of intravenous nursing.

Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the in-hospital chain of survival.

First-responder automated external defibrillation (AED) in the hospital is consistent with the American Heart Association's (AHA) early defibrillation standard or care. With trained personnel and automated external defibrillators immediately available, early defibrillation should have a greater impact on survival than early cardiopulmonary resuscitation (CPR). Therefore, in our hospitals we modified basic life support to include automated external defibrillation (BLS-AED) for all personnel who are expected to respond to a cardiac arrest, with rapid defibrillation taking priority over CPR. We describe how we organized and implemented this hospital-wide first-responder BLS-AED program. Planning the process includes gaining support from key leaders who are responsible for resuscitation practice, and identifying the target audience of the training program. Hospital unit needs for AED or conventional defibrillation and equipment must be identified, the training program developed, and existing policies and procedures modified. Several barriers to implementation may exist. Education about the efficacy and safety of AED and experience once the BLS-AED program is in place can overcome attitudes and bias. Concerns about the cost of equipment and training must be addressed. Program evaluation may include patient issues such as measuring the time to the first defibrillation and patient outcome; as well as training and retention issues.

Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues.

STUDY OBJECTIVE: To determine whether staff outside critical care areas who were proficient in basic life support (BLS) could be easily trained to use automated external defibrillators (AEDs) and whether they would retain these skills. DESIGN: Prospective, longitudinal cohort series. SETTING: Two university teaching hospitals. PARTICIPANTS: One hundred forty nurses who had previously learned BLS and constituted the staff from three medical/surgical nursing units from each study hospital. INTERVENTIONS: The nurses were taught how to use the Heartstart 1000s, a lightweight portable shock-advisory AED, in a 2-hour class with an instructor and manikin-to-student ratio of 1:5. The course emphasized hands-on practice of the BLS-AED algorithm on a computerized manikin. RESULTS: Using a similar scenario, each nurse was evaluated on the computerized manikin immediately after training (posttest). At 1 to 3, 4 to 6, and 7 to 9 months after the initial training, convenience samples of the cohort in three different groups were evaluated for retention. Satisfactory performance was defined as delivery of the first AED shock within 2 minutes of recognition of the arrest. At the posttest after training, 139 of 140 nurses (99%) demonstrated satisfactory performance. Of 77 nurses evaluated, 31 of 32 at 1 to 3 months, 18 of 18 at 4 to 6 months, and 24 of 27 at 7 to 9 months after initial training (95% overall) performed satisfactorily. CONCLUSION: As has been demonstrated with prehospital emergency personnel, nurses outside critical care areas who are proficient in BLS can easily learn and retain the knowledge and skills to use AEDs. Automated external defibrillation, a BLS skill, should be incorporated into BLS programs (BLS-AED) for all hospital personnel expected to respond to a patient in cardiac arrest, with rapid defibrillation taking priority over CPR.

The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner or the curriculum.

Many studies (several even before American Heart Association recommended in 1973 that lay public be trained in cardiopulmonary resuscitation (CPR] have documented that retention of CPR skills is poor, unaffected by modifications in curriculum or whether the students are lay or professional. We chose to investigate what actually occurs during a CPR course, and gained the following insights: despite clearly defined curricula, we found that instructors did not teach in a standardized way. Practice time was limited and errors in performance were not corrected. Instructors consistently rated the students' overall performance as acceptable; at the same time, using the same checklist, we consistently rated performance as unacceptable. The checklist is an inaccurate tool for evaluating CPR performance. Despite the poor performance that we documented, students and instructors were satisfied with the courses and believed that the level of performance was high. As a result of these studies, we discovered that the problem of poor retention of CPR skills may lie not with the learner or the curriculum, but with the instructor. But, since lives are being saved with bystander CPR, does this documented poor retention matter? Perhaps the solution is not only to improve instructor training to make certain that students receive adequate practice time and accurate skill evaluation, but also to modify the criteria for correct performance when testing for retention. These criteria should be based on the minimum CPR skills that are required to sustain life for the critical 4-8 min before defibrillation and other advanced cardiac life support are delivered.

Effect of crush lesion on ganglioside radiolabelling patterns in rat sciatic nerve.

Left sciatic nerves in rats were crushed and allowed to regenerate for variable periods of time up to 14 days; uncrushed right nerves from the same animals were used as controls. Two days before killing the rats, both L-5 dorsal root ganglia (DRG) were injected with 100 microcuries [3H]glucosamine. Gangliosides were purified separately from sciatic nerve (SN) distal to the crush site, lumbosacral trunk (LST) proximal to the crush site, and the injected DRG. Changes in major glycoconjugate classes were previously reported; in this study total gangliosides were separated by high performance thin layer chromatography, located by autofluorography and radioactivity was measured by liquid scintillography. In control DRG, major radiolabelled gangliosides were GM3 and LM1; in control LST and SN, GD1b and GT1b were the major ones. During day two and four following crush, GM3 and LM1 decreased in DRG, but at one and two weeks were at normal and elevated levels, respectively; there were inverse changes in GD3, GT1b and GQ1b. GD1b, GT1b and GQ1b were lower in crushed than in control LST and SN between days zero and four. In LST, GM3 and LM1 remained constant for four days, but were elevated at one and two weeks, whereas GD1a was elevated at all times. Indeed, GD1a is the major recently synthesized ganglioside that is transported into LST and SN two to four days after trauma, suggesting that it may play an important role in regeneration. Indices of oligosaccharide complexity and degree of sialylation indicated that between two and four days following crush, gangliosides in DRG had more complex oligosaccharides and more sialic acid residues than in either controls or in DRG of crushed nerves at one and two weeks post-crush. The degrees of ganglioside sialylation and oligosaccharide complexity in crushed LST and SN were lower than in control specimens between one and seven days after crush. Changes in the ganglioside composition of peripheral nerve following trauma may be important for axonal regeneration.

Measuring cardiopulmonary resuscitation performance: a comparison of the Heartsaver checklist to manikin strip.

Both checklists and recording manikin strips (strips) are used for evaluation of cardiopulmonary resuscitation (CPR) performance. To examine their relationship, we simultaneously evaluated single rescuer CPR of 255 subjects using both checklists and strips. For Group 1 (N = 192; general public tested in Heartsaver course) we compared the total number of initial ventilations and compressions judged to be correct by checklists with those judged to be correct by strips. For Group II (N = 63; physicians, nurses, general public tested in retention studies) we compared each subjects checklist with their own strip for evaluation of correct ventilations and compressions. In Group I, CPR was judged to be correct two to four times more frequently by checklists than by strips. In Group II, all correlations were poor. The most common disagreements were with performances evaluated as correct by checklist but not by strip. Therefore, the current checklist may be a poor instrument for measuring CPR. More accurate evaluation should improve learning and therefore improve outcome following cardiac arrest.

Specialty nursing council: a peer support group for nurses in independent roles.

As nurses move into more nontraditional, expanded roles, they sometimes lack a social and professional support group within the work setting. Feeling isolated and lacking support, several clinical nurse specialists (CNSs) at a large county institution began the Specialty Nursing Council. The Specialty Nursing Council provides a means of networking and support for nurses in specialty roles in a three institution health care campus. Monthly meetings are conducted to bring members together and for continuing education programs. The keys to success in forming this type of council are: 1) a dedicated group that plans, organizes, and distributes informational material; 2) common goals and objectives; 3) direct benefits to members.

Effect of crush lesion on radiolabelling of ganglioside in rat peripheral nerve.

Left sciatic nerves of adult male Sprague-Dawley rats were crushed and allowed to recover for 0, 1, 2, 4, 7, or 14 days. At each of these times both L-5 dorsal root ganglia were injected with 100 microCi of [3H]glucosamine. Two days later, dorsal root ganglia, lumbosacral trunks, and sciatic nerves were removed bilaterally. The amounts of radiolabelled ganglioside in crushed lumbosacral trunks were consistently higher than in the controls, with the largest difference occurring within 2 days from simultaneous crush and injection to killing (specimens labelled day 0). The largest difference in the amount of radiolabelled ganglioside between crushed and control sciatic nerve (4-9 days from crush to killing) occurred later than that of lumbosacral trunk, but no significant difference occurred within the first 3 days following crush. There was only a slightly higher radioactivity in gangliosides totalled from all three anatomical specimens of crushed than in control nerves. The neutral nonganglioside lipid and acid-precipitable fraction followed patterns of synthesis and accumulation similar to those of the gangliosides. These findings indicate that after nerve crush gangliosides, glucosamine-labelled neutral nonganglioside lipids, and glycoproteins accumulate close to the proximal end of the regenerating axon. This accumulation could serve as a reservoir to increase the ganglioside concentration in the growth cone membrane.

Advanced cardiac life support refresher course using standardized objective-based Mega Code testing.

The American Heart Association (AHA) recommends that those whose daily work requires knowledge and skills in advanced cardiac life support (ACLS) not only be trained in ACLS, but also be given a refresher training at least every 2 yr. However, AMA offers no recommended course for retraining; no systematic studies of retraining have been conducted on which to base these recommendations. In this paper we review and present our recommendation for a standardized approach to refresher training. Using the goals and objectives of the ACLS training program as evaluation criteria, we tested with the Mega Code a sample population who had previously been trained in ACLS. The results revealed deficiencies in ACLS knowledge and skills in the areas of assessment, defibrillation, drug therapy, and determining the cause of an abnormal blood gas value. We combined this information with our knowledge of other deficiencies identified during actual resuscitation attempts and other basic life-support and ACLS teaching experiences. We then designed a refresher course which was consistent with the overall goals and objectives of the ACLS training program, but which placed emphasis on the deficiencies identified in the pretesting. We taught our newly designed refresher course in three sessions, which included basic life support, endotracheal intubation, arrhythmia recognition and therapeutic modalities, defibrillation, and Mega Code practice. In a fourth session, using Mega Code testing, we evaluated knowledge and skill learning immediately after training. We similarly tested retention 2 to 4 months later. Performance immediately after refresher training showed improvement in all areas where performance had been weak.(ABSTRACT TRUNCATED AT 250 WORDS)