You, on display

Last month, I posted on Freedom, Not Fear Day, October 11. Now Der Spiegel has posted photos of the TSA's new bodyscanning systems. If you peruse the photos at SpiegelOnline, you'll see that it appears they can set the scanning to examine a person's body at different levels of depth. The photo below shows revealed musculature, while other photos show a more superficial view of the body. Should nursing have an opinion on this topic?

If one interpret's Henderson's definition of nursing broadly, it could be taken to include interventional political and legal action for some groups of people. But is there another basis on which nurses should oppose this level of scrutiny? I assume that the scanners have been deemed medically safe. What about a view of fascilitating the integration of the individual vis-a-vis Maslow's hierarchy or another ascending theory of humanism? Actually, I'm unconvinced that nurses should find a professional theoretical basis for opposition to surveillance that does not intrude on a person's health care. However, it's hard to look at the body used in this way without thinking that nursing should have some perspective.

via BoingBoing

Churchill on handwashing

I missed Infection Control week last week (October 19-25). To make up for it, here is a funny anecdote about Sir Winston Churchill and handwashing:

Young man, seeing Churchill leave the bathroom without washing: At Eton they taught us to wash our hands after using the toilet.
Churchill: At Harrow they taught us not to piss on our hands.

Dreamfields pasta

Some of my co-workers are currently engaged in a contest to see who can lose the most weight in 2 months--winner gets a free meal from the losers. So at work the other night, they were comparing notes on food and complaining about whole wheat pasta. And who can blame them?! Whole wheat pasta is awful! Anyhow, that put in mind of the pasta we've been eating lately--low-carb Dreamfields. Actually I've only had the linguini, but it's wonderful (especially if you prefer your pasta al dente) for only 5 grams of carbs.

While I can give a whole-hearted recommendation of this product's edibility, I can't vouch for the nutritional claims. The 5gm/serving measurement is based on a "patent-pending" process, so I wouldn't be surprised if the product is pulled for failing to meet its advertised benefits in the future. That's not stopping me now, though, because it doesn't seem like complete quackery. The product incorporates inulin, which is sort of like a starch that you can't digest efficiently.

If you can find it in your local stores, give it a try. It would be a good recommendation for your diabetic patients who love pasta.

What are you eating this weekend?

Mark Bittman is probably the worst speaker I have every seen give a TED talk, so it should come as no surprise that he's a nutritionist--usually the most boring and moralizing of health care professionals. If you can manage to sit through this, go ahead, but the point I want to make is actually below.


In essence, this is the same talk you've been getting from your hippie health care teacher since grade school. Yet, his message is not as bad as it could be. In nursing, your nutrition class probably taught you all about the "science" behind the government's nutrition recommendations. It's a bunch of hogwash. Amazing how they criticized critics of the former food pyramid, then changed it recently, isn't it?

The fundamental problem with the teaching of nutrition in America today is that it starts with the analogy of the body as an engine, and food as a fuel source. However, this is the wrong analogy to make, especially in a culture where people get almost no activity in the course of making a living. A better analogy is that the body is a machine and food is the parts and upkeep. What's the difference between these?

Body as engine says, you are designed to "burn" carbs, so carbs should be the core of your diet and then there are these other weird things like proteins, minerals and vitamins--we don't know what they all do exactly, but you have to get a minimum of X amount or you'll get sick. Body as machine says, you break down, so you have to fix yourself periodically by replacing the parts that have fallen off. The parts that fall off are proteins, minerals and vitamins.

No matter what kind of "diet" you eat, the real core of your diet is protein, minerals and vitamins. You can live very well without carbs, but you can't live healthy lives without these other things (plus, you need some fats...). That is the fundamental reality of food. The only question is, where do you get your parts from and how many parts?

Mark Bittman wants us to cut out meat and only eat enough to keep from getting sick--back to the old engine analogy. Of course, he says, this is better for us, but is it? Recently, bonobos (the good, peace-loving, matriarchal doppelgangers to chimpanzees) were seen to be eating monkeys. Yes, that's right--not only meateaters, but cannibals as well. Primates are designed to eat meat. (The anthropological record bears this out, too, although I don't have time to go into it here.) And not as a back-up system.

There two fundamental problems that Mark Bittman misses. One is the monism problem--the assumption that if we "ate right" the earth would be in balance is not scientific. The second is that we are eating from the wrong places. Now, Bittman criticizes fast food, but I don't think he sees that fast food is really the core of the problem, not meat-eating. And I'm not talking about McDonalds only, but the grill at your hospital cafeteria, too.

What is the issue? Well, simply that fast food promotes eating only certain cuts of meat and at greater frequency of eating. It's true that ground beef could have hooves in it for all we know, but the point is that a "hamburger" is equivalent in the mind to a "soft steak" not to the "other cow parts," which means that when we eat animals, we've gotten in the habit of expecting only the steak and not extracting enough calories from them. Bittman wants us to eat half as much steak, but the problem is that we're not nibbling on the knuckles, like bonobos. If we got rid of fast food and went back to whole animal consumption (which largely happened in traditional culinary arts), we would reduce the total amount of food we eat, I believe, through less frequent and less savory meals. It might not be enough to save the planet, but that's a different matter. Let's not confuse things with smarmy ideas.

Firefox DOI protocol handler

If you are engaged in any academic or scholarly research, you have probably become familiar with the Digital Object Identifier (DOI), which many publishers are including in their papers' citation information now. The DOI points you toward a stable location on the web where you can find at least the citation information for the article and maybe the abstract or entire article as well.

DOI is extremely useful, but has the one drawback that you can't just cut and paste it into your browser address bar like a URL. Instead, you have to type "http://dx.doi.org/" and then paste in the DOI. That's a pain. So, some enterprising person has created a Firefox Add-on that lets you simply cut and paste into the browser address bar like you would want to do. You use Internet Explorer, you say? Well, you're out of luck, I guess.

Wikipedia quoted in nursing textbook

It goes without saying that Wikipedia is old news now, and so are the various controversies surrounding its use as a source for scholarly work. However, I still think of the following as something of a coup...

I was reading my Nur435 textbook the other day--Keltner's Psychiatric Nursing, 5th edition--and noticed that it references Wikipedia at one point. If you have the book, it's pages 397 and 410. Keltner et al reference Wikipedia's "List of people affected by bipolar disorder." The citation on page 410 says it was accessed October 6, 2005. So, the author(s) would have been looking at the October 3, 2005, revision. (I don't know why I find it cool that I can go and look at this revision, but I do.)

Here, we just had Open Access Day, and now I find a hole in the wall of college textbooks, which are inveterate enemies of open access as far as I can tell. "Once more unto the breach, dear friends..."

Page 397:



Page 410:

Medical care refused by duck

"Medical care refused by duck" could be an entire class of humor by itself, but the fact that this from Criggo was really printed in a newspaper makes it even funnier...

RIP, ASA's first president

This came through Androlog yesterday:

Androlog Mail

It is with great sadness that I inform you that Dr. Emil Steinberger died this morning. Dr. Steinberger was the first President of the American Society of Andrology and played an important role in the initiation and development of the ASA. Our field has lost a true renaissance man, talented in many areas beyond just reproductive biology and medicine.

Much of his career focused on the hormonal control of spermatogenesis. His studies of spermatogenesis began in the mid 1950's when he worked together with the famed Dr. Warren O. Nelson. His early research set the stage for work that continues in many andrology laboratories today and included studies of the gonadotoxicity of alkylating agents, in vitro penetration of cervical mucus by sperm, human sperm cryopreservation, effects of heat, ischemia and cryptorchidism on spermatogenesis and the controls of the hypothalamic-pituituary-gonadal axis. In the mid-1970's he published a paper on the frequency distribution of sperm counts of fertile and infertile males, noting that sperm counts, except at the extreme low end of the scale (in the absence of other deficiencies) were not major factors in a couple's infertility setting the stage for the development of sperm function testing. Other clinical work focused on the diagnosis and treatment of the infertile couple (together as a couple) and endocrine manipulation of hyperandrogenic women and those with other causes of ovulatory dysfunction. With his wife, Dr. Anna Steinberger, testicular organ culture and in vitro spermatogenesis were attempted. Together they reported on the presence of an FSH inhibiting protein secreted by Sertoli cells that acted on the pituitary. Today we know this protein is inhibin. Work in his department focused on androgen and FSH regulation of spermatogenesis and Sertoli cell function, Leydig cell steroidogenesis, sexual behavior and other aspects of reproductive biology. Dr. Steinberger was honored for these achievements as the recipient of the Distinguished Andrologist Award in 1987 by the American Society of Andrology. He had served as Professor and Chairman of the Department of Reproductive Medicine and Biology at the University of Texas Health Science Center School of Medicine, before developing the Texas Institute for Reproductive Medicine together with Drs. Keith Smith and Luis Rodriguez- Rigau.

In his later years, Dr. Steinberger became an author and published two books on his life before, during and after the Holocaust. The first, 'Between the Devil and the Deep Blue Sea' tells of his experiences as a young boy growing up before, during and after the Second World War. It is an amazing story chronicling his family's flight from Poland, escape from extermination camps and imprisonment in a Soviet Labor Camp. After the war, he attended Medical School, prior to moving to the United States. His second book, 'The Promised Land: Woes of an Immigrant', relates his experiences beginning with his arrival in the United States with just $20 in his pocket. Ultimately there is much to be learned from his story of perseverance to overcome great obstacles in life to become a leader in our field--A leader who will be missed by all who knew and loved him.

-Dolores J. Lamb, Ph.D.

Happy Open Access Day !

Today, October 14, is the first Open Access Day--a day devoted to broadening awareness and understanding of free and available information. Open Access Day is a joint venture of the Public Library of Science (PLoS), the Scholarly Publishing and Academic Resources Coalition and Students for Free Culture. In response to the call for synchroblogging, I've decided to direct some attention to the issue of open access in nursing.

Although nursing research is promoted in BSN programs and as an ingredient of professionalism, the relationship that research holds to nursing is not the same as the relationship that research holds to medicine or the biological sciences. I think the difference can be seen through the quintessential nursing research project--hand washing. Although much "sexier" and really more complex research has been done in nursing, hand washing is still taught as a model of what nursing research is--a test of and guide for best practice in the clinical setting. Although you might think that the same is true for medicine, it really isn't. A brief perusal of an (open access!) medical journal like PLoS Medicine will reveal that medical research is closely tied to biological research. (Hence, the sometimes-used moniker "biomedical" research.) At first blush, this might seem like a silly truism, but see what it means:

Medical vs. nusing research

Case-based: As we can learn from Foucault, the medical gaze can use the patient as opportunity to isolate pathogenesis. This approach to the patient is totally inimical to the perspective of nursing, and it is no accident that case-based literature is almost absent in nursing publications. In fact, when I asked a question about case-based literature in my Nur427 Nursing Research course, the instructor was momentarily flummoxed in trying to place it in the literature spectrum.

Inquisitive: Although you have your occasional Grey's Anatomy doctors, for the most part, students that go into medicine are the geeky kids who spend their time in the bio lab, while students who go into nursing are very average if hard-working. This is reflected in the professional literature by the ongoing interest of medical doctors in knowledge for its own sake.

Exploratory: Building on inquisitiveness, the core of biological and biomedical research is exploratory research. Although undergrad students are taught the hypothesis-confirmation method of research, the reality is different. As we discussed in Bio416 Virology, sometimes papers are constructed backwards--researchers perform some experiments out of curiosity and then try to make a paper out of them by tying them together with a plausible hypothesis. There really isn't exploratory research of this kind in nursing.

Systems-oriented: Science is constantly trying to make facts like symptoms fit into models. Nursing doesn't really care about models. This is the flip-side of case investigation avoidance. Cases and models both make patients into biological objects. Nursing research stays focused on improving the clinical milieu and nurses' posture. This comparison is a little over-generalized, but not completely.

These characteristics of biomedical research are ones that make open access sensible and important for it. Cases and exploratory research reveal occult characteristics that can lie dormant inside inaccessible journals. Free and disseminated information can provide just the right clues to help researchers put the final pieces in a puzzle.

Nursing research is also useless when not accessible, but timliness and particularity are less important. So, the researcher-to-researcher sharing that can come from open access and confer advantages in biomedicine is less relevant to nursing. Instead, open access relates to nursing mostly vis-a-vis three other avenues: (1) integrated self-care, (2) information access in the clinical milieu, and (3) education.

Integrated self-care

Although most synchrobloggers will probably be focusing on the access of synthesizers to research on Open Access Day, we should note that the access issue can be generalized to users and knowledge. The financial resistance to open access in the publishing world can also be generalized to financial resistance in the broader world. Knowledge is not only a commodity in its own right, it's also leverage for decision-making.

Electronic Medical Records (EMRs) are often addressed as a benefit to healthcare professionals, especially doctors, and as a benefit to patients secondary to the increases in efficiency and portability that will assist professionals. However, as Gladwin points out in the June 2007 Nursing Times, giving patients access to their own medical records can improve their care as well. An opinion piece in a 2007 Hospital Home Health titled "...continuation of care not just end of the road: open access could help patients avoid 'terrible choice'" suggests how: open access EMRs could act as loci for patients to re-visit and conceptualize their own care as a continuum across the life span.

Currently, hospitals and primary care offices act as gatekeepers for patients' medical information. In my local hospital, there's bureaucratic process, though no charge, for seeing one's own medical records, but there is a photocopy charge for taking one's own medical records out from the hospital. This combination of restricted access and copy charge models the access issues of the publishing world.

Can it be changed? This question is also asked by Detmer et al. in a paper awaiting publication this month in the open access journal BMC Medical Informatics and Decision Making. They describe several different models for Personal Health Records, but a common theme is the use of technologies. Just as technology has facilitated open access publishing, it can facilitate open access medical records as well. We have seen this already in Google's free Google Health app. But if we are to move toward RFID or other bio-integrated formats, the open source movement will become a necessary ingredient in open access. Proprietary storage and reading formats must not be allowed to predominate in the field of EMRs.

Access in the milieu

My hospital's made great strides in having the Internet available to all nurses through a proliferation of computers at nurses' stations and, now, in rooms and through Computers On Wheels (COWs). Nurses have "ready access" to some clinical information via the MDConsult database. However, this access is paid for by patients and taxpayers, and, in one instance, was disabled by a problem with the hospital's MDConsult account. It is not a true open access system. Moreover, MDConsult is what it says it is--a system geared toward doctors. Where is our RNConsult database to provide up-to-date clinical information specific to nursing or allied health?

My experience is echoed by the nurses in a qualitative study by Tod et al. (2003), who explored nurses' use of the Internet on a clinical ward. Here are some of the participant comments:

I use it more for non-work as I started getting disappointed with there not being much stuff around on practice...

Somehow I don't see how all these so-called models or theories of nursing are going to help... that's one thing I've learnt in this project, don't go to nursing databases, go to Medline or Google.

Morris-Docker et al. (2004) found that use of Internet-based resources was dependent on nurses' capabilities--on their inherent capacity with searches but also the access they were granted in the work place.

More recently, Estabrooks et al. (2008) looked at the organizational context for the clinical application of research at the level of the nursing unit. Besides the predilection of the unit nurses to use research, the next biggest factor was organizational support of research use, such as the authority to integrate findings into care.

These three studies point out issues of access in the use of research by nurses in the clinical milieu. Access is dependent on some factors that are inherent in users, and usability also interacts with access at the level of control. However, all use is fundamentally based on de facto and de jure access to information--availability and freedom, the core tenets of open access. Access in the clinical milieu must include the time and physical resources to use the Internet but also useful information must available to nurses when they go online. Clinical practice guidelines like the AACN's Procedure Manual for Critical Care should no longer reside behind walls of price and print.

Nursing education

Anyone in nursing school today or who has graduated recently will probably be familiar with the HESI preparatory exam and integrated textbook websites such as Elsevier's eVolve sites. Digital resources such as university extranets are spreading in popularity, but their use is limited by the imagination of nursing instructors. In my own school, nursing students are forced to communicate and download instructions and lecture notes through the college's ANGEL system, but access to resources inside the system is limited and access to resources outside the system is discouraged. Gibbon (2006) found similar disposition when reviewing literature for an article on the UK's open access SONIC system: "Reproducing lecturers' notes can be meaningless... Savin-Baden (2003) acknowledges that some resources that are used for web-based education do not enhance PBL, such as the provision of lecturer notes online."

Perhaps this failure on the part of instructors is a result of the generational gap. Floor nurses in my hospital resist every technological innovation for difficulty in adaptation, and Cole and Brunk (1999) identified unease with computer education as an impediment to obtaining advanced nursing degrees.

The under-usage of the Internet's ability to disseminate free information in nursing education is partly the fault of nursing faculty, but there is also a large component of publisher manipulation. The NIH already provides a large number of free medical texts online--but online nursing textbooks and educational resources remain behind pay walls. And, as I have noted previously on this blog, rather than moving toward open access models, textbook publishers are trying hard to create systems that lock students into continuing to make purchases (such as the bundling of books with online passwords) and that seduce faculty into using proprietary websites (such as providing online assessment services with protected educational material).

There is simply no excuse for nursing students to be spending hundreds of dollars on disposable nursing textbooks anymore. Textbooks are not pieces of literature that are enhanced by the ability to become physically connected with the printed material. Textbooks are only repositories and are subject to rapid change. The failure of the nursing educational system to move toward open access models of educational materials is wasteful and keeps students behind the information envelope unnecessarily.

Nursing culture

Nursing culture is a mixed bag. On the one hand, threatened, mean, controlling nurses and nursing instructors are common and characteristic enough that almost any nurse can recognize sayings like "the instructor is always right" and "nurses eat their young." On the other hand, nursing is also full of progressives and pseudo-hippies who will believe in the benefit of almost any intervention. In actuality, both these types are threats to improved patient care because both refuse to recognize the objective superiority of evidence-based care.

Of course, there are exceptions (Brennan, Ripich, and Moore (1991) were using a "free, public-access computer network" to develop their own computer-based home-care system back before "the Interwebs" became popular), but for the most part, nursing needs to be lead and is most comfortable when it has a institution impetous for change. The current model for this observation is Keeping Patients Safe. Rather than a grass-roots effort at improving conditions in individual hospitals, this is a top-down program from the Institute of Medicine (IOM).

So, what about open access? Open access publishing is currently flying under the radar in nursing. In a CINAHL database search, the most comprehensive treatment was an essentially informational article describing what open access is (Schloman, 2007). Position statements and comments from publishers were found in a few journals, but for the most part open access publishing has not been discussed within the literature.

Of current journals, one can count the number of serious attempts at open access publishing on the fingers of one hand:

• BMC Nursing: Published by Biomed Central, this is one of only a few usable open access nursing journals affiliated with a serious publisher.
• Online Journal of Issues in Nursing: Published by the ANA, this journal has good content, but the interface makes it difficult to use.
• Online Journal of Rural Nursing and Health Care: Published by the University of Alabama.
• Topics in Advanced Practice Nursing: Medscape publishes this journal and makes it available online along with selections from a number of other journals.

The Directory of Open Access Journals lists 25 nursing journals, most of which are in Spanish and some of which do not contain the degree of publishing standards needed for them to be taken seriously.

Creating open access culture

Although BMC has a good service going, I generally regard PLoS as the flagship of open access academic and research publishing. (At one point a year or so ago, I even e-mailed PLoS to find out if they were going to expand into general health fields, but the editor who wrote back said they were planning to stick to biological sciences.) So, it seems appropriate that the Policy Forum column in PLoS Medicine should address the promotion of open access publishing in academia and health care.

Piwowar et al. (2008) recommend that Academic Health Centers take a lead role in promoting open access publishing. They recommend an institution-wide approach to help change the culture of AHCs to embrace open access. Recommendations include formally committing to opening access to data, funding the infrastructure and human resources needed, rallying AHC members through recognition and education, and developing the community by working on standards and social networking.

In nursing, Casida and Pinto-Zipp (2008) identified a strong correlation between organizational cultural change and transformational leadership behaviors by nurse managers. These behaviors are in many ways similar to the recommendations of Piwowar et al. for AHCs.

The time is right for nursing leaders to make a push to create a culture of open access for nursing as well. Just as the importance of open access to nursing is different from its importance to biomedicine, the open access culture needed in nursing is different from the open access culture needed in biomedical research. Nursing needs to shrug off some of its heavily authority-oriented cultural baggage.

Nurses need education in basic economics and principles of software development to understand how open access can impact patient consumption of health care.
The infrastructure and intellectual resources necessary to utilize research should be supported by health care institutions, including ongoing education.
Nursing educators should disentangle themselves from the large publishing houses and start teaching more from primary literature, review papers, and reliable online resources.
Most importantly, nursing leaders in practice and instruction at all levels of institutions should avoid squelching dissent and support independent initiatives to improve the dissemination and application of research. Inspiring and engaging leadership practices are proven to have an impact in changing the cultural in health care.

1. Gladwin, J. (2007) Opinion: Giving patients open access to medical records would help nurses improve care. Nursing Times, 103(25), 14. Abstract retrieved from CINAHL database.


2. n.a. (2007) Hospice as continuation of care not just end of the road: open access could help patients avoid 'terrible choice'. Hospital Home Health, 24(6), 66-68. Abstract retrieved from CINAHL database.


3. Don E. Detmer, Meryl Bloomrosen, Brian Raymond, Paul Tang (2008). Integrated personal health records: Transformative tools for consumer-centric care BMC Medical Informatics and Decision Making, 8 (1) DOI: 10.1186/1472-6947-8-45


4. Tod AM, Harrison J, Docker SM, Black R, & Wolstenholme D. (2003) Information technology. Access to the internet in an acute care area: experiences of nurses. British Journal of Nursing, 12(7), 425-434.


5. Morris-Docker SB, Tod A, Harrison JM, Wolstenholme D, & Black R. (2004) Nurses' use of the Internet in clinical ward settings. Journal of Advanced Nursing, 48(2), 157-166.


6. Carole A Estabrooks, Shannon Scott, Janet E Squires, Bonnie Stevens, Linda O'Brien-Pallas, Judy Watt-Watson, Joanne Profetto-McGrath, Kathy McGilton, Karen Golden-Biddle, Janice Lander, Gail Donner, Geertje Boschma, Charles K Humphrey, Jack Williams (2008). Patterns of research utilization on patient care units Implementation Science, 3 (1) DOI: 10.1186/1748-5908-3-31


7. Gibbon C. (2006) Enhancing clinical practice through the use of electronic resources. Nursing Standard, 20(22):, 41-46.


8. Cole BH & Brunk Q. (1999) Six rules for computers and other stumbling blocks to obtaining an advanced degree. Journal of Continuing Education in Nursing, 30(2), 66-70.


9. Brennan PF, Ripich S, & Moore SM. (1991) The use of home-based computers to support persons living with AIDS/ARC. Journal of Community Health Nursing, 8(1), 3-14.


10. n.a. (2004) American Nurses Association commends House Patient Safety Bill aimed at open access to information on nurse staffing practices. Nevada RNformation, 13(4), 11.


11. Schloman, B. (2007). Open access: The dust hasn’t settled yet. Online Journal of Issues in Nursing, 12 (1)


12. Baggs JG. (2006) Open access. Research in Nursing & Health, 29(1), 1-2.


13. Paquette M. (2005) The public-access movement. Perspectives in Psychiatric Care, 41(2), 49-50.


14. Harington R. (2005) Commentary on the public-access movement. Perspectives in Psychiatric Care, 41(3), 97-98.


15. Lawson L. (2006) Research dissemination, open access, and the cost of doing business. Journal of Forensic Nursing, 2(2), 57-58.


16. Heather A. Piwowar, Michael J. Becich, Howard Bilofsky, Rebecca S. Crowley (2008). Towards a Data Sharing Culture: Recommendations for Leadership from Academic Health Centers PLoS Medicine, 5 (9) DOI: 10.1371/journal.pmed.0050183


17. Casida, J, Pinto-Zipp, G (2008). Leadership-Organizational Culture relationship in nursing units of acute care hospitals Nursing Economic$, 26 (1), 7-13

HIPAA and blogging

Along with my slightly revised design and new about page, I thought it would be a good idea to revisit my anxiety over this blog--especially that associated with HIPAA regulations, which could get me thrown out from school or de-licensed. The blog Clinical Cases and Images has a good post that lays out the 18 patient identifiers that a doctor must remove from a case report in order to be in HIPAA compliance. I would assume that these apply to nursing as well.

Most of the 18 identifiers are no-brainers (like a patient's name) or wouldn't normally apply to a nurse wanting to blog (like a medical device serial number). However, two gave me pause: you can't say a patient's age if the patient is over the age of 89; and you can't mention a geographical subdivision smaller than a State.

The first of these makes sense to me--there are so few people over the age of 89 that I suppose it would really be quite simple to sift through those patients and identify someone from a description of their medical condition. The second of these really doesn't make sense, though, unless it applies only to a patient's personal addresses. Consider for a moment that you are a doctor who is writing a case report. If you have to obscure the location of the patient's treatment, how hard is it to find out where a doctor has a practiced? In fact, articles usually mention an author's institutional affiliation right at the top of the page. This rule would be so constricting as to make case reporting impossible in many situations. Therefore, I have to assume that the rule only applies to a patient's personal home or business addresses.

There is a third identifier, which is dates specific to the patient, that I am a little leary of as well. Say you have a clinical rotation and come home and blog about it. You haven't mentioned a specific admission or discharge date, but does a "date during a period of care" count? I choose to think not.

Anyhow, be careful, student nurse bloggers, for there are overzealous instructors around every corner, and you have no power!

A new look, slightly

I've revised the design of this blog slightly and added a new about page. I supposed what this really means is that I am anticipating possibly failing one of my classes this semester (Nur428 Management) and starting to withdraw from identifying as a nurse. De-socialization. I considered the above design, which would have made the background here white, since a white-on-black design seems less serious and less professional than a black-on-white design, but frankly, I find the white background harder to read.

A bad thing happened at work

A bad thing happened at work tonight. There is a man who has been in and out of the hospital for months, and whenever his wife sees me, she really talks up a storm about how he's doing.

At first this was confusing for me since she acted as though everyone on the floor knew about his condition already, which I didn't. I tried hard to pay attention since she seemed to be really nervous about him and also because I think she is a "good" family member--i.e., she has educated herself a little, been involved in his care, and assesses his condition separately from the nursing and medical staff--but, you know, I have work to do and whatnot.

Anyhow, I saw her again tonight and she talked, but I was on my way to get dinner and I was hungry and focused on food. I listened momentarily but I was so "un-present" that I don't even remember how I extricated myself from that conversation. I may have just walked away while she was talking to me!!

That's not a good thing. I must try to stay in the moment more when patients and their family members are involved.

BP quite high; me sad

My (cute) PA put me on Benicar and Lipitor, and I added them to my regimen of ASA, vitamins, fish oil, and antioxidants. I've been quite regimented about taking the Benicar, but my BP today was 140/91. It's better than having the SBP in the 160's, but still not good enough. I missed yesterday and the day before, so that might have been the cause. I could go back to trying HCTZ in combination with the Benicar, but last time I tried HCTZ, I got cramps everywhere and headaches, so we'll see.

I really need to go back to the gym and get regular exercise. For me, I think that means changing gyms. One of the big drawbacks I've found is that I am often wrapping up my work around 11:30-11:45, and my gym closes at midnight. Another gym closeby is open 24hrs, but it's more expensive, and I hate it. But if I would use it...

MRSA with linezolid tolerance

I came across an article the other day that describes an infection of S. aureus that could not be cured with Linezolid. It was a 68-year-old woman who remained febrile throughout her hospital stay and died from massive PE on day 18. From the abstract:

Antimicrobial “tolerance” is defined as a wide discrepancy between the minimal inhibitory concentration and the minimal bactericidal concentration of an isolate. Tolerance was first described in S. aureus and has since been described with streptococci and enterococci. Despite apparent in vitro susceptibility, infections caused by “tolerant” strains are not cured by appropriate antimicrobial therapy. The lack of bactericidal activity of the antibiotic becomes apparent when minimal bactericidal concentrations are determined for “tolerant” strains, and there is a great discrepancy between the minimal inhibitory concentration being used. Antibiotic tolerance to S. aureus has been described with a variety of antibiotics. To the best of our knowledge, this is the first case of continuous, high-grade methicillin-resistant S. aureus bacteremia due to a linezolid-tolerant strain.

1. B CUNHA, N MIKAIL, L EISENSTEIN (2008). Persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia due to a linezolid “tolerant” strain Heart & Lung: The Journal of Acute and Critical Care, 37 (5), 398-400 DOI: 10.1016/j.hrtlng.2007.12.001

Getting the beatdown

Let's see--I was up all night Sunday night and last night. There's a ridiculous amount of work for almost no payoff this semester. There's something seriously wrong with nursing schools, I think. The work-to-learning ratio is so, so high.

Nevermind

Pay no attention to that last post. IE still stinks (does the PNG below look blue to you?), but the JPEG looks okay.

Re-inoculation from the appendix and recurrent C. difficile infection (CDI)

Trying to find a topic to write a review article in Bio416 Virology, I came across a post on enzyme evolution in the Discount Thoughts blog that led me to a post on the possible functionality of the appendix. Bollinger et al., writing in Journal of Theoretical Biology, propose that the appendix is a tool for creating probiotic biofilms in the large intestine as well as re-inoculating the large intestine in the event of its defloration by, for example, diarrhea. Their argument rests mostly on recent evidence they cite suggesting that the immune system does not operate antagonistically with normal intestinal bacteria. They present an interesting idea. Although from a developmental view Clarkson points out the authors' limited conception of vestigiality, this view is less relevant to the proposed current functions of the appendix.

(One thing I didn't quite follow was the authors' statement that "receptors for secretory IgA that are important for biofilm formation are up-regulated by the presence of secretory IgA." I take this to mean that IgA is a positive feedback loop in the gut. This interpretation would make sense with regard to IBD and Crohn's. It would also help explain the connection between antibiotics and Clostridium difficile infection--if antibody production were partly dependent on the presence of antibodies, immunity would be partly dependent on the presence of bacteria. However, based on the abstracts for the relevant citations, the statement seems like a non-sequitur. Wold and Adlerberth (2000) conclude that mother's IgA results in less gut immune stimulation and lower salivary IgA, while Friman et al. (1996) refer to IgA's role in capturing probiotic E. coli but not IgA receptors. Peterson et al. (2007) agree with Wold and Adlerberth in finding that IgA attenuates the gut inflammatory response.)

Mongolian nomadic herders

The issue raised by Bollinger et al. of re-inoculating the intestines from the appendix put me in mind of a speaker who came to my nursing school last year. Sas Carey, RN, has traveled to Mongolia on several occasions to help build a health database of nomadic reindeer herders as well as to record their indigenous medical practices. Her travels resulted in the creation of a documentary film as well as a non-profit group called Nomadicare.



In her talk, I remember quite distinctly that she spoke about the herders treating chronic appendicitis by drinking liquified animal stool. My thinking at the time was that it makes sense if the intestinal bacteria from the stool compete with the inflammatory bacteria. In the context of Bollinger et al.'s theory, perhaps it is simply a re-balancing of similar gut flora that keeps appendicitis in check rather than allowing it to become acute.

Chronic appendicitis

You may be thinking that you haven't heard of chronic appendicitis, and it's true that in this country we as nurses are taught RLQ pain-appendicitis-surgery. And even as recently as 1998, Van Winter et al. was asking whether it really existed. However, a breif review of the literature shows that it's been accepted: Konstantinidis et al. (2008) found 6.1% of appendectomy cases from chronic symptoms; and Roumen et al. (2008) found that elective appendectomy relieved chronic RLQ pain.

Sgourakis et al. (2008) identified lack of bowel movement as a factor in chronic appendicitis but not blockage, which is interesting since blockage is the usual explanation for acute appendicitis. Do they have a different etiology? If Mongolian reindeer herders spend a lot of time in the saddle or going without food, could this lead to intestinal stasis and inflammation?

Also, if chronic appendicitis comes from stasis rather than blockage, could the infectious bacteria be different? The theory with acute appendicitis is that normal bacterial flora get trapped in the appendix by a blockage and start to infect the appendix wall. Perhaps in chronic appendicitis, it is the abnormal gut bacteria that get into the appendix. This would explain why the appendicitis is not acute (normal and abnormal bacteria are competing) as well as why the reindeer herders' techniques worked (adding more normal gut bacteria as a probiotic to compete with the infection).

And in fact acute appendicitis is not always caused by blockage, either. Brown et al. (2007) report the case of a man who developed appendicitis after Clostridium difficile infection. From a literature review, they conclude this etiology is rare but may be under-diagnosed since mild forms of appendicitis would be treated by antibiotics along with the C.diff while severe C.diff infections of the entire colon might obscure appendicitis.

The appendix and re-current C. difficile infection

If, as Bollinger et al. suggest, the appendix is involved in re-inoculating the intestine with normal intestinal bacterial, could it not also be a factor in re-current cases of C.diff infection? Maroo and Lamont (2006) state that the reasons some patients have recurrent C.diff infections while others do not is not known: stool samples of recovering patients indicate that spores are present in both patients who have re-current infection and those that do not. Reinfection through the fecal-oral route is a best guess. However, if C.diff infection can occur through die-off of normal bacteria, perhaps the appendix can also lose its normal flora, to be replaced by C. difficile and its spores, which subsequently re-infect the intestine.

As Maroo and Lamont show in their review, stool transplant, which they gingerly call fecal bacteriotherapy, is more effective than pure antibiotics for the treatment of C.diff infection. (The route of stool transplant does not seem to be a decisive factor.) As well, pulsed antibiotic treatment is more effective than daily dosing to prevent re-currence. Both these modalities would allow increased growth of competitive bacteria, which suggests that there is still a source of infection to be competed with.

Stool transplant off the steppe

Aas et al. (2003) performed one of the stool transplants reviewed by Maroo and Lamont. In their retrospective study, of 16 patients suffering from re-curring C.diff infections and multiple antiobiotic treatments, only 1 experienced a re-currence of infection following a nasogastric stool transplant.

The procedure used in this study was as follows:

Obtain stool sample less than 6 hrs before the transplantation procedure
Select a stool specimen (preferably a soft specimen) with a weight of 30 g or a volume of 2 cm3
Add 50–70 mL of sterile 0.9 N NaCl to the stool sample and homogenize with a household blender. Initially use the low setting until the sample breaks up; then, advance the speed gradually to the highest setting. Continue for 2–4 min until the sample is smooth.
Filter the suspension using a paper coffee filter. Allow adequate time for slow filtration to come to an end.
Refilter the suspension, again using a paper coffee filter. As before, allow adequate time for slow filtration.
Treat with omeprazole capsules (20 mg po) on the evening before and on the morning of the stool transplantation
Immediately before the stool transplantation, a nasogastric tube is placed. Radiography should be used to verify that the tube tip position is in the gastric antrum.
A total of 25 mL of the transplantation stool suspension is aspirated into a syringe and instilled into the recipient via the nasogastric tube
After the stool instillation, the nasogastric tube is flushed with 0.9 N NaCl. The nasogastric tube is then withdrawn.
The patient is permitted to resume a normal diet and all customary physical activities immediately after discharge from the gastroenterology clinic.

This is a lot more expensive than I imagine the Mongolian herders' method is, but I suspect it is also a lot more pleasant for the patient.

Anyhow, to sum up: one theory of the appendix is that its purpose is to re-inoculate the intestines after a pathologic (or possibly pathogenic) event like diarrhea; appendicitis (including or especially chronic appendicitis) may be caused by inoculation of the appendix with pathogens; re-current C.diff infection is not explained, but the effectiveness of probiotic treatment suggests a source of re-infection; and, finally, Mongolian herders' traditional treatment of chronic appendicitis with methods proven to be effective in treating re-current C.diff infection suggests a possible connection between the appendix and C.diff.

1. R RANDALBOLLINGER, A BARBAS, E BUSH, S LIN, W PARKER (2007). Biofilms in the large bowel suggest an apparent function of the human vermiform appendix Journal of Theoretical Biology, 249 (4), 826-831 DOI: 10.1016/j.jtbi.2007.08.032
   
2. Wold AE & Adlerberth I. (2000) Breast feeding and the intestinal microflora of the infant—implications for protection against infectious diseases, Adv. Exp. Med. Biol. 478 (2000), pp. 77–93. Abstract from Scopus.
   
3. Friman et al. (1996) V. Friman, I. Adlerberth, H. Connell, C. Svanborg, L.A. Hanson and A.E. Wold, Decreased expression of mannose-specific adhesins by Escherichia coli in the colonic microflora of immunoglobulin A-deficient individuals, Infect. Immun. 64 (1996), pp. 2794–2798. Abstract from Scopus.
   
4. Peterson DA; McNulty NP; Guruge JL; Gordon JI (2007). IgA response to symbiotic bacteria as a mediator of gut homeostasis. Cell Host & Microbe [Cell Host Microbe] 2007 Nov 15; Vol. 2 (5), pp. 328-39. Abstract from Medline.
   
5. Van Winter, Wilkinson, Goerss, & Davis (1998). Chronic appendicitis: does it exist? J Fam Pract, 46, 507-509. From http://findarticles.com/p/articles/mi_m0689/is_n6_v46/ai_20842646
   
6. Konstantinidis KM; Anastasakou KA; Vorias MN; Sambalis GH; Georgiou MK; Xiarchos AG (2008). Journal Of Laparoendoscopic & Advanced Surgical Techniques, 18 (2), 248-258. Abstract from Medline.
   
7. Roumen RM; Groenendijk RP; Sloots CE; Duthoi KE; Scheltinga MR; Bruijninckx CM. (2008). Randomized clinical trial evaluating elective laparoscopic appendicectomy for chronic right lower-quadrant pain. The British Journal Of Surgery, 95 (2), 169-174. Abstract from Medline.
   
8. Sgourakis G; Sotiropoulos GC; Molmenti EP; Eibl C; Bonticous S; Moege J; Berchtold C. (2008). Are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coproliths? World Journal Of Gastroenterology: WJG, 14 (20), 3179-3182. Abstract from Medline.
   
9. Brown TA; Rajappannair L; Dalton AB; Bandi R; Myers JP; Kefalas CH. (2007). Acute appendicitis in the setting of Clostridium difficile colitis: case report and review of the literature. Clinical Gastroenterology And Hepatology, 5 (8), 969-671. Abstract from Medline.
   
10. S MAROO, J LAMONT (2006). Recurrent Clostridium Difficile Gastroenterology, 130 (4), 1311-1316 DOI: 10.1053/j.gastro.2006.02.044
    
11. Johannes Aas, Charles E. Gessert, Johan S. Bakken (2003). Recurrent Colitis: Case Series Involving 18 Patients Treated with Donor Stool Administered via a Nasogastric Tube Clinical Infectious Diseases, 36 (5), 580-585 DOI: 10.1086/367657
    

NCLEX and neuroscience... testing what?

I suppose many nursing students complain about the NCLEX-style questions they are forced to answer in nursing school. Today, purely by chance, I witnessed an interesting little correlation that I suspect sheds light on the nature of nursing exams.

In my Nursing Management/Leadership course this afternoon, we did an exercise where we were asked to come up with as many words as possible using the letters from "teamwork." For example, the words "team" and "work" are in "teamwork" as well as the words "tea" and "am." We had a time limit, and the most number of words one person came up with was 19. We then went around and added the words everyone else had come up with to make a total of 50-something words.

At the end of adding everyone else's words, the dry-erase board was a series of columns of mostly two- and three-letter words, with the exception of two columns that contained mostly words of four letters or more. These columns belonged to myself and one other student. She and I thought up mostly four-letter words, and almost all the four-letter words in the class were from the two of us. Interestingly enough, we two are the only older students in the class and the only ones with previous educations--I with an aborted almost-degree in humanities and she with an MA.

We two were very much in the middle of the group as far as the total number of words we thought up, but the type of words we were trying to produce involved a different level of anagrammatization (or whatever you call it).

Now, what's really interesting is that earlier in the day we had a post-test review in Psych Nursing, and on one particular question, this other student and I chose the "wrong" answer because we interpreted the question in a similar way that was different from the professor and the other students. When I tried to explain what I thought the question was asking, she looked at me confusedly like she thought I was crazy, and I guarantee I was thinking "you know, I'm not crazy."

I think--and I have always thought--that nursing exams really don't test knowledge (very well) or critical thinking skills (as they supposedly do) but, rather, whether or not you think the same way as the instructor.

Of course, you would guess that thinking like the instructor was "getting at the right answer," but I often don't feel that way. In fact, on more than one occasion, the "correct" answer on a test has also been the foolish or illogical interpretation in my view. (In this case, illogical means poorly thought out, not intuitive.)

Now, if I had just asserted my opinion, I suspect you wouldn't give it a second thought before dismissing it. However, given the difference in style demonstrated in the word test, you should consider whether the NCLEX questions don't just test the ability to sink up with the nursing instructors.

"Sink up" isn't a very rigorous concept, but I know that women who live together do sink up in other ways, such as their endocrine processes. I don't think it's out of the realm of possibility that women sink up in their neuro processes as well. Does this constitute "education"? I don't think so, but what does that matter since the whole field is dominated by women?

Participate in research

One thing I think is that nursing, and health care in general, does not make enough connections with the fitness industry and sports medicine.

Think of all those older people lying in bed who you, as a nurse, are encouraging to use the Incentive Spirometer in order to prevent pneumonia. How often do you witness people with feeble breathing capacity who are unable to move the IS even close to the goal?

Now think of all those fitness commercials advertising "core" fitness. Do you think there is any connection between youthful core fitness and elderly ability at IS? Of course, you would have to study this to find out, but I would be willing to bet on it.

If you're interesting in making the nursing-fitness connection, you can start now by participating in research on the effect of stretching on exercise. Although stretching before exercise to prevent injury is a gospel on many sports teams and among personal trainers, the evidence is actually not very good, and there is some thought that stretching before exercise actually increases the possibility of injury. (I only warm up now.) For better flexibility, stretching after exercise is definitely preferable.

www.stretchingstudy.nokc.no

Depression and heart attack

Right now on RN radio's The Health Report, listen to a podcast [download mp3 here] about depression and heart attack.