An Innovative Approach to a Multitrack Advance Practice Registered Nurse Program: The Integration of Psychiatric Mental Health and Primary Care Cohorts.

ABSTRACT: We describe how an online graduate nurse practitioner program combined psychiatric mental health nurse practitioner and primary care advanced practice registered nurse (AGNP/FNP/PNP) tracks into an integrated curriculum. Student evaluations and assessments, along with board certification scores, demonstrated improvement in identifying and managing behavioral health problems, as well as increased competence and collaboration with other nurse practitioner students. Details of the integrated curriculum are provided.

Consumer detection and acceptability of reduced-sodium bread.

OBJECTIVE: Bread is the largest contributor of Na to the American diet and excess Na consumption contributes to premature death and disability. We sought to determine the Na level at which consumers could detect a difference between reduced-Na bread and bread with typical Na content, and to determine if consumer sensory acceptability and purchase intent differed between reduced-Na bread and bread with typical Na content. DESIGN: Difference testing measured ability to detect differences in control bread and reduced-Na bread using two-alternative forced choice testing. Acceptability was measured using a nine-point hedonic scale and purchase intent was measured using a five-point purchase intent scale. SETTING: Difference and acceptability testing were conducted in Portland, OR, USA in January 2013. SUBJECTS: Eighty-two consumers participated in difference testing and 109 consumers participated in acceptability testing. RESULTS: Consumers did not detect a difference in saltiness between the control bread and the 10 % reduced-Na bread, but did detect a difference between the control bread and bread reduced in Na content by 20 % and 30 %. Na reductions had no effect on consumer acceptability of sensory characteristics, including overall liking, appearance, aroma, flavour, sweetness, salt level and texture, or purchase intent. CONCLUSIONS: Reducing Na levels by up to 30 % in the sandwich bread tested did not affect consumer liking or purchase intent of the product. These results support national recommendations for small, incremental Na reductions in the food supply over time and assure bread manufacturers that sensory characteristics and consumer purchase intent of their products will be preserved after Na reductions occur.

A decision-making tool to determine economic feasibility and break-even prices for artisan cheese operations.

Artisan cheese makers lack access to valid economic data to help them evaluate business opportunities and make important business decisions such as determining cheese pricing structure. The objective of this study was to utilize an economic model to evaluate the net present value (NPV), internal rate of return, and payback period for artisan cheese production at different annual production volumes. The model was also used to determine the minimum retail price necessary to ensure positive NPV for 5 different cheese types produced at 4 different production volumes. Milk type, cheese yield, and aging time all affected variable costs. However, aged cheeses required additional investment for aging space (which needs to be larger for longer aging times), as did lower yield cheeses (by requiring larger-volume equipment for pasteurization and milk handling). As the volume of milk required increased, switching from vat pasteurization to high-temperature, short-time pasteurization was necessary for low-yield cheeses before being required for high-yield cheeses, which causes an additional increase in investment costs. Because of these differences, high-moisture, fresh cow milk cheeses can be sold for about half the price of hard, aged goat milk cheeses at the largest production volume or for about two-thirds the price at the lowest production volume examined. For example, for the given model assumptions, at an annual production of 13,608kg of cheese (30,000 lb), a fresh cow milk mozzarella should be sold at a minimum retail price of $27.29/kg ($12.38/lb), whereas a goat milk Gouda needs a minimum retail price of $49.54/kg ($22.47/lb). Artisan cheese makers should carefully evaluate annual production volumes. Although larger production volumes decrease average fixed cost and improve production efficiency, production can reach volumes where it becomes necessary to sell through distributors. Because distributors might pay as little as 35% of retail price, the retail price needs to be higher to compensate. An artisan cheese company that has not achieved the recognition needed to achieve a premium price may not find distribution through distributors profitable.

Start-up and operating costs for artisan cheese companies.

Lack of valid economic data for artisan cheese making is a serious impediment to developing a realistic business plan and obtaining financing. The objective of this study was to determine approximate start-up and operating costs for an artisan cheese company. In addition, values are provided for the required size of processing and aging facilities associated with specific production volumes. Following in-depth interviews with existing artisan cheese makers, an economic model was developed to predict costs based on input variables such as production volume, production frequency, cheese types, milk types and cost, labor expenses, and financing. Estimated values for start-up cost for processing and aging facility ranged from $267,248 to $623,874 for annual production volumes of 3,402 kg (7,500 lb) and 27,216 kg (60,000 lb), respectively. First-year production costs ranged from $65,245 to $620,094 for the above-mentioned production volumes. It is likely that high start-up and operating costs remain a significant entry barrier for artisan cheese entrepreneurs.

Advancing the Role of the Doctor of Nursing Practice in Palliative Care.

Doctor of nursing practice-prepared nurses are well suited to provide high-quality palliative care to patients with serious illness and their caregivers. Their rigorous education and expertise prepare them for the complexity often associated with chronic disease and end of life. There are clear and strong recommendations from multiple national organizations supporting palliative care education for nurses and tools available for nurses to implement palliative care into practice. This article is from the perspective of the doctor of nursing practice nurse. It reviews the limited evidence on palliative care integration into the doctor of nursing practice role, the barriers to palliative care education and implementing palliative care into practice, and the potential roles that a doctor of nursing practice palliative care nurse may fill in health care.

Pulmonary function testing for the primary care nurse practitioner.

ABSTRACT: Knowledge of which pulmonary function tests are commonly performed in primary care and interpretation of their results is integral for the diagnosis, care, and management of those with pulmonary symptoms. This article provides an overview of the most common pulmonary function tests and interpretation of their results.

The therapeutic versatility of antihistamines: A comprehensive review.

Antihistamines are common and readily available medications for primary care patients and those seeking over-the-counter treatments. This article provides an overview of available antihistamines, their mechanisms of action, safety concerns in specific populations, and their therapeutic uses in several common conditions.

Safety of Over-the-Counter Medications in Pregnancy.

Approximately 90% of pregnant women use medications while they are pregnant including both over-the-counter (OTC) and prescription medications. Some medications can pose a threat to the pregnant woman and fetus with 10% of all birth defects directly linked to medications taken during pregnancy. Many medications have documented safety for use during pregnancy, but research is limited due to ethical concerns of exposing the fetus to potential risks. Much of the information gleaned about safety in pregnancy is collected from registries, case studies and reports, animal studies, and outcomes management of pregnant women. Common OTC categories of readily accessible medications include antipyretics, analgesics, nonsteroidal anti-inflammatory drugs, nasal topicals, antihistamines, decongestants, expectorants, antacids, antidiarrheal, and topical dermatological medications. We review the safety categories for medications related to pregnancy and provide an overview of OTC medications a pregnant woman may consider for management of common conditions.

Consumer Response to Tomato Pomace Powder as an Ingredient in Bread: Impact of Sensory Liking and Benefit Information on Purchase Intent.

This study evaluated consumer acceptance and purchase intent (PI) for bread formulated with dried tomato pomace powder (DTPP). DTPP was used to substitute 5 or 10% by weight for a 50/50 mix of white and whole-wheat flour used in a control bread. Consumers (n = 231) evaluated sensory attributes and PI on the breads, which were produced and presented as slices from a typical commercial sandwich loaf. Before answering PI questions, panelists were presented with information regarding the DTPP ingredient. Some received information on nutritional quality, some on sustainability impact, some both, some neither. This approach allowed the impacts of those messages on PI to be tested, along with impact of liking, price, and other factors. PI was analyzed using a fractional logistic model. Statistically significant differences were observed in several sensory attributes, some favoring the DTPP ingredient with overall liking very similar for the 5% DTPP and control bread samples. Price and overall liking were highly significant variables effecting PI. DTPP proved to be an excellent ingredient to replace a portion of wheat flours to improve nutritional value of bread products. PRACTICAL APPLICATION: This study shows that dried tomato pomace powder (DTPP) has potential application as an ingredient, since it improved nutritional content, appearance, and color appeal of wheat bread. Furthermore, food producers who are considering the use of byproducts in their product formulations should be encouraged by the finding that informed consumers were as willing to purchase the bread with the ingredient, as they were to purchase a typical comparable sandwich bread without it. Furthermore, both a nutrition message and a sustainability message can increase PI for the bread containing the byproduct relative to their PI toward the control bread.

The 360-degree evaluation model: A method for assessing competency in graduate nursing students. A pilot research study.

BACKGROUND: The 360 Degree Evaluation Model is one means to provide a comprehensive view of clinical competency and readiness for progression in an online nursing program. OBJECTIVES: This pilot project aimed to evaluate the effectiveness of implementing a 360 Degree Evaluation of clinical competency of graduate advanced practice nursing students. DESIGN: The 360 Degree Evaluation, adapted from corporate industry, encompasses assessment of student knowledge, skills, behaviors and attitudes and validates student's progression from novice to competent. SETTINGS: Cohort of advanced practice nursing students in four progressive clinical semesters. PARTICIPANTS: Graduate advanced practice nursing students (N = 54). METHODS: Descriptive statistics and Jonckheere's Trend Test were used to evaluate OSCE's scores from graded rubric, standardized patient survey scores, student reflection and preceptor evaluation. RESULTS: We identified all students passed the four OSCEs during a first attempt or second attempt. Scaffolding OSCE's over time allowed faculty to identify cohort weakness and create subsequent learning opportunities. Standardized patients' evaluation of the students' performance in the domains of knowledge, skills and attitudes, showed high scores of 96% in all OSCEs. Students' self-reflection comments were a mix of strengths and weaknesses in their self-evaluation, demonstrating themes as students progressed. Preceptor evaluation scores revealed the largest increase in knowledge and learning skills (NONPF domain 1), from an aggregate average of 90% in the first clinical course, to an average of 95%. CONCLUSIONS: The 360 Degree Evaluation Model provided a comprehensive evaluation of the student and critical information for the faculty ensuring individual student and cohort data and ability to analyze cohort themes.

It's All in the Wrist: Diagnosis and Management of Carpal Tunnel Syndrome.

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy accounting for 90% of similar disorders, occurring in 3.8% of the population, common in adults aged 40-60 years, and is associated with an average 32 lost days of work and lost productivity. In addition to occupational exposure, there are several common chronic disorders that can preclude CTS, obesity, diabetes mellitus, rheumatoid arthritis, pregnancy, metabolic syndrome, and thyroid disorder, to name a few. Therefore, it is important for the primary care provider to have knowledge in this syndrome. The purpose of the article is to inform the provider about the etiology, presentation, diagnosis, and treatment of CTS, as well as the implications for job-associated CTS.

Adult asthma: Diagnosis and treatment.

Adult asthma is a prevalent chronic medical condition that is associated with high morbidity, mortality, and cost. Early identification, evidence-based diagnosis, and step-wise management can lead to improvements in patient outcomes, decrease exacerbations, and eliminate respiratory function decline as the patient ages.

Diagnosis and management of impetigo.

Impetigo, a bacterial skin infection that involves the superficial layers of the skin, is one of the most common skin infections in children ages 2 to 5 but can occur in individuals across the lifespan. This article discusses the diagnosis and management of impetigo in primary care.

Evaluating a college student's urethritis.

Gonorrhea is the second most common sexually transmitted infection (STI) after chlamydia. After a significant decrease from 1975 to 2009, trends reveal that gonorrhea is on the rise. NPs need to review the latest CDC guidelines regarding STIs, as treatment guidelines are regularly changing.

Pain management in patients with rheumatoid arthritis.

Rheumatoid arthritis (RA) is one of the most common inflammatory conditions in the United States affecting approximately 1 million adults. This article briefly reviews the evidence-based diagnosis of RA, mainstays of treatment to prevent joint destruction, and pain management.

Pediatric developmental screenings: a primary care approach.

Early recognition of developmental delay is critical to providing comprehensive pediatric primary care. Advanced practice nurses must be aware of the guidelines for surveillance and developmental screening in children. This article discusses guidelines for screening, examples of screening tools, information for follow up, and referral for positive screenings.

Teaching dual-process diagnostic reasoning to doctor of nursing practice students: problem-based learning and the illness script.

Accelerating the development of diagnostic reasoning skills for nurse practitioner students is high on the wish list of many faculty. The purpose of this article is to describe how the teaching strategy of problem-based learning (PBL) that drills the hypothetico-deductive or analytic reasoning process when combined with an assignment that fosters pattern recognition (a nonanalytic process) teaches and reinforces the dual process of diagnostic reasoning. In an online Doctor of Nursing Practice program, four PBL cases that start with the same symptom unfold over 2 weeks. These four cases follow different paths as they unfold leading to different diagnoses. Culminating each PBL case, a unique assignment called an illness script was developed to foster the development of pattern recognition. When combined with hypothetico-deductive reasoning drilled during the PBL case, students experience the dual process approach to diagnostic reasoning used by clinicians.

Use of nonsteroidal anti-inflammatory drugs in the older adult.

PURPOSE: Annually, approximately 90 million prescriptions are filled for nonsteroidal anti-inflammatory drugs (NSAIDs) with the number prescribed for older adults approximately three times higher than for younger adults. This article examines the benefits and risk of NSAID use in older adults. DATA SOURCES: Electronic data collection of research studies, evidence-based reviews, consensus statements, and guidelines related to the purpose of this article were analyzed if published between 2000 and 2013 in English from Ovid, MEDLINE, and PubMed databases. CONCLUSIONS: While NSAIDs are commonly used to treat pain and inflammation in older adults, strong consideration must be given to the potential adverse effects. A lack of consistency in the guidelines regarding NSAID use poses further challenges for clinicians in the selection of the best pharmacological approach. When prescribing NSAIDs, adverse events, polypharmacy, comorbidities, and treatment guidelines must be considered. NSAIDs are an appropriate option for pain management in select older adults, often after a trial of acetaminophen and if benefits outweigh risks. Alternative pharmacological and nonpharmacological therapies may be more appropriate in many older adults. IMPLICATIONS FOR PRACTICE: The challenge for clinicians prescribing NSAIDs in the treatment of pain in older adults is to utilize safe, individualized, and evidenced-based pain management regimens.

Effects of water, sodium hypochlorite, peroxyacetic acid, and acidified sodium chlorite on in-shell hazelnuts inoculated with Salmonella enterica serovar Panama.

Recent foodborne disease outbreaks involving minimally processed tree nuts have generated a need for improved sanitation procedures. Chemical sprays and dips have shown promise for reducing pathogens on fresh produce, but little research has been conducted for in-shell hazelnuts. This study analyzed the effectiveness of 3 chemical sanitizers for reducing Salmonella on in-shell hazelnuts. Treatments of water, sodium hypochlorite (NaOCl; 25 and 50 ppm), peroxyacetic acid (PAA; 80 and 120 ppm), and acidified sodium chlorite (ASC; 450, 830, and 1013 ppm) were sprayed onto hazelnut samples inoculated with Salmonella enterica serovar Panama. Hazelnut samples were immersed in liquid cultures of S. Panama for 24 h, air-dried, and then sprayed with water and chemical treatments. Inoculation achieved S. Panama populations of approximately 8.04 log CFU/hazelnut. Surviving S. panama populations were evaluated using a nonselective medium (tryptic soy agar), incubated 3 h, and then overlaid with selective media (xylose lysine deoxycholate agar). All of the chemical treatments significantly reduced S. Panama populations (P ≤ 0.0001). The most effective concentrations of ASC, PAA, and NaOCl treatments reduced populations by 2.65, 1.46, and 0.66 log units, respectively. ASC showed the greatest potential for use as a postharvest sanitation treatment.