Association of Wearable Activity Monitors With Assessment of Daily Ambulation and Length of Stay Among Patients Undergoing Major Surgery

IMPORTANCE

Early postoperative ambulation is vital to minimizing length of stay (LOS), but few hospitals objectively measure ambulation to predict outcomes. Wearable activity monitors have the potential to transform assessment of postoperative ambulation, but key implementation data, including whether digitally monitored step count can identify patients at risk for poor efficiency outcomes, are lacking.

OBJECTIVES

To define the distribution of digitally measured daily step counts after major inpatient surgical procedures, to assess the accuracy of physician assessment and ordering of ambulation, and to quantify the association of digitally measured step count with LOS.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study at Cedars-Sinai Medical Center, an urban tertiary referral center. Participants were patients undergoing 8 inpatient operations (lung lobectomy, gastric bypass, hip replacement, robotic cystectomy, open colectomy, abdominal hysterectomy, sleeve gastrectomy, and laparoscopic colectomy) from July 11, 2016, to August 30, 2017.

INTERVENTIONS

Use of activity monitors to measure daily postoperative step count.

MAIN OUTCOMES AND MEASURES

Operation-specific daily step count, daily step count by physician orders and assessment, and a prolonged LOS (>70th percentile for each operation).

RESULTS

Among 100 patients (53% female), the mean (SD) age was 53 (18) years, and the median LOS was 4 days (interquartile range, 3-6 days). There was a statistically significant increase in daily step count with successive postoperative days in aggregate (r = 0.55; 95% bootstrapped CI, 0.47-0.62; P < .001) and across individual operations. Ninety-five percent (356 of 373) of daily ambulation orders were "ambulate with assistance," although daily step counts ranged from 0 to 7698 steps (0-5.5 km) under this order. Physician estimation of ambulation was predictive of the median step count (r = 0.66; 95% bootstrapped CI, 0.59-0.72; P < .001), although there was substantial variation within each assessment category. For example, daily step counts ranged from 0 to 1803 steps (0-1.3 km) in the "out of bed to chair" category. Higher step count on postoperative day 1 was associated with lower odds of prolonged LOS from 0 to 1000 steps (odds ratio [OR], 0.63; 95% CI, 0.45-0.84; P = .003), with no further decrease in odds after 1000 steps (OR, 0.99; 95% CI, 0.75-1.30; P = .80).

CONCLUSIONS AND RELEVANCE

In this study, digitally measured step count up to 1000 steps on postoperative day 1 was associated with lower probability of a prolonged LOS. Wearable activity monitors improved the accuracy of assessment of daily step count over the current standard of care, providing an opportunity to identify patients at risk for poor efficiency outcomes.

Assessing the Impact of a Novel Smartphone Application Compared With Standard Follow-Up on Mobility of Patients With Knee Osteoarthritis Following Treatment With Hylan G-F 20: A Randomized Controlled Trial

Background

Osteoarthritis (OA) is a leading cause of disability in the United States. Although no disease-modifying therapies exist, patients with knee OA who increase walking may reduce risk of functional limitations.

Objective

The objective of the study is to evaluate the impact of a mobile app (OA GO) plus wearable activity monitor/pedometer (Jawbone UP 24) used for 90 days on the mobility of patients with knee OA treated with hylan G-F 20.

Methods

Patients with knee OA aged 30 to 80 years who were eligible to receive hylan G-F 20 and were familiar with smartphone technology were enrolled in this randomized, multicenter, open-label study. Patients who had a body mass index above 35 kg/m² were excluded. All patients received a single 6-mL injection of hylan G-F 20 and wore the Jawbone monitor. The patients were then randomized 1:1 to Jawbone and OA GO (Group A; n=107) with visible feedback (unblinded) or Jawbone only (Group B; n=104) with no visible feedback (blinded). The primary endpoint was mean change from baseline in steps per day at day 90 between Groups A and B.

Results

Baseline characteristics were similar between groups. There were significant differences between the increases in least squares (LS) mean number of steps per day (1199 vs 467, P=.03) and the mean percentage change (35.8% vs 11.5%, P=.02) from baseline in favor of Group A over Group B. There was a greater reduction in pain from baseline during the 6-minute walk test in Group A versus Group B. (LS mean change: −55.3 vs −33.8, P=.007). Most patients (65.4%) and surveys of physicians (67.3%) reported they would be likely or very likely to use/recommend the devices. Patient Activity Measure-13 scores improved from baseline (LS mean change for Groups A and B: 5.0 vs 6.9), with no significant differences between groups. The occurrence of adverse events was similar in the 2 groups.

Conclusions

Use of a novel smartphone app in conjunction with a wearable activity monitor provided additional improvement on mobility parameters such as steps per day and pain with walking in the 6-minute walk test in patients with knee OA who were treated with hylan G-F 20. Results also highlight the amenability of patients and physicians to using mobile health technology in the treatment of OA and suggest further study is warranted.

The complete blood cell count in a refined cohort of preterm NEC: the importance of gestational age and day of diagnosis when using the CBC to estimate mortality

OBJECTIVE

The value of the white blood cell count (WBC) in necrotizing enterocolitis (NEC) is controversial. One reason for this confusion may be that the various WBC lineages change substantially with increasing gestational age and thereby age of NEC onset. This study postulated that if a data set was large enough and the diagnosis of NEC clean enough, absolute WBC counts would facilitate prediction of NEC mortality. The objective of this study was to determine whether absolute WBC counts enhance the prediction of NEC mortality.

STUDY DESIGN

A de-identified data subset from the Pediatrix national data set specific to the diagnoses of NEC in patients who had a CBC drawn on the day of diagnosis (exclusive of the diagnoses of spontaneous intestinal perforations and congenital anomalies) was the target for analysis. Values of primary interest included: gestation, day of diagnosis, absolute WBC count, platelet count, hematocrit, mortality and the day of diagnosis. Stepwise regression analysis was used to predict mortality.

RESULT

A total of 4059 (79%) survivors and 1107 (21%) infants who died with a diagnosis of medical or surgical NEC were included in the data set. Associations with mortality were found with low gestational age, low platelet count, low hematocrit, high band/segmented neutrophil ratio, earlier day of diagnosis, high birth weight z-score, non-white race, no antenatal steroids in gestations above 24 weeks, absolute lymphocyte count adjusted for gestational age, and absolute monocyte count high and low values. A stepwise regression analysis yielded a receiver-operator curve of 0.819 with a sensitivity of 65% and specificity of 84%.

CONCLUSION

Absolute WBC values enhance prediction of NEC survival when used in combination with readily available data on the day of NEC diagnosis.

No conclusive evidence that histologically found granulomas and acute local reactions following hylan G-F 20 injections are related or have clinical significance

Osteoarthritic (OA) knee pain can be successfully treated with hylan G-F 20 (Synvisc, Sanofi Biosurgery, Cambridge, MA) with few local adverse events. However, a few studies have identified hyaluronate positive (HA+) granulomas in the synovial tissue of patients treated with hylan G-F 20 raising the question of their relationship and clinical significance. To understand the potential relationship of HA+ granulomas with the occurrence of acute local reactions (ALRs), we evaluated the synovial tissue of OA patients undergoing total knee replacement that had previously been treated with hylan G-F 20 (n = 101) or had not been treated (n = 20). Granulomas were observed in nine patients, of which eight were in the hylan G-F 20 group (7.9%); HA+ granulomas were identified in six of these eight patients (5.9%). Three of the six patients with HA+ granulomas experienced an ALR within 30 days of administering an injection. Overall, we found no consistent relationship between histologically found HA+ granulomas and the occurrence of an ALR following hylan G-F 20 treatment. These microscopic granulomas were not associated with any symptoms and likely have little clinical significance. The low occurrence of granulomas and/or ALRs should not preclude use of hylan G-F 20 for the treatment of knee pain associated with OA.

Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular-weight heparin

BACKGROUND

Thromboembolic disease is a common complication of total hip arthroplasty. The purpose of this study was to compare a new mobile compression device with low-molecular-weight heparin with regard to their safety and effectiveness for the prevention of venous thromboembolic disease.

METHODS

Patients who had a total hip arthroplasty were randomized to receive prophylaxis with a mobile compression device or low-molecular-weight heparin for ten days. Use of the compression device began intraoperatively, and the patients in this group could receive 81 mg of aspirin daily after the surgery. The first injection of the low-molecular-weight heparin began between twelve and twenty-four hours after the surgery. After ten to twelve days, all patients underwent bilateral lower-extremity duplex ultrasonography to screen for deep venous thrombi in the calf and thigh. Any clinical symptoms of pulmonary embolism were evaluated with spiral computed tomography lung scans. Bleeding events and utilization of (i.e., compliance with) prophylactic treatment in both groups were documented. Clinical evaluation to look for evidence of deep venous thrombi and pulmonary emboli was performed at twelve weeks postoperatively.

RESULTS

Four hundred and ten patients (414 hips) were randomized; 392 of these patients (395 of the hips) were evaluable with regard to the safety of the intervention and 386 patients (389 hips) were evaluable with regard to its efficacy. Demographics were similar clinically between the groups. The rate of major bleeding events was 0% in the compression group and 6% in the low-molecular-weight heparin group. The rates of distal and proximal deep venous thrombosis were 3% and 2%, respectively, in the compression group compared with 3% and 1% in the heparin group. The rates of pulmonary embolism were 1% in the compression group and 1% in the heparin group, and there were no fatal pulmonary emboli. Within the twelve-week follow-up period, two events (one deep venous thrombosis and one pulmonary embolus) occurred in one patient in the compression group following negative findings on duplex ultrasonography on the twelfth postoperative day. There was no difference between the groups with regard to the prevalence of venous thromboembolism.

CONCLUSIONS

When compared with low-molecular-weight heparin, use of the mobile compression device for prophylaxis against venous thromboembolic events following total hip arthroplasty resulted in a significant decrease in major bleeding events.

Basolateral phosphate transport in renal proximal-tubule-like OK cells

It is generally assumed that phosphate (Pi) effluxes from proximal tubule cells by passive diffusion across the basolateral (BL) membrane. We explored the mechanism of BL Pi efflux in proximal tubule-like OK cells grown on permeable filters and then loaded with 32P. BL efflux of 32P was significantly stimulated (P < 0.05) by exposing the BL side of the monolayer to 12.5 mM Pi, to 10 mM citrate, or by acid-loading the cells, and was inhibited by exposure to 0.05 mM Pi or 25 mM HCO3; by contrast, BL exposure to high (8.4) pH, 40 mM K+, 140 mM Na gluconate (replacing NaCl), 10 mM lactate, 10 mM succinate, or 10 mM glutamate did not affect BL 32P efflux. These data are consistent with BL Pi efflux from proximal tubule-like cells occurring, in part, via an electro-neutral sodium-sensitive anion transporter capable of exchanging two moles of intracellular acidic H2PO4- for each mole of extracellular basic HPO4= or for citrate.

Magnesium sulfate and neonatal outcomes of preterm neonates

OBJECTIVE

To determine whether in utero exposure to magnesium sulfate was associated with increased neonatal morbidity and mortality among premature neonates, and secondarily to determine the relationship, if any, between duration of magnesium sulfate exposure and neonatal morbidity and mortality.

METHODS

We studied 401 neonates at our institution who were born between 23 and 34 weeks' gestation following preterm labor or preterm premature rupture of membranes. The population was stratified by exposure to magnesium sulfate and compared by various neonatal outcome variables. Similarly, the magnesium-exposed population was stratified by duration of exposure and compared for various neonatal outcome variables. Student's t test, chi2 test, Fisher's exact test and logistic regression were used for analysis.

RESULTS

A total of 190 neonates were exposed to magnesium sulfate, while 211 neonates were not. The magnesium-exposed neonates were delivered at a significantly lower gestational age compared to the unexposed neonates (28.2 +/- 3.0 vs. 29.3 +/- 3.1 weeks, p = 0.001). Univariate analysis revealed no differences between groups with regard to rates of respiratory distress syndrome, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, patent ductus arteriosus, histological and clinical chorioamnionitis, neonatal sepsis or neonatal death. However, magnesium-exposed neonates were more likely to have received antibiotics (71.6% vs. 45.0%, p = 0.0001) and antenatal steroids (95.8% vs. 61.6%, p = 0.0001), factors known to affect perinatal morbidity and mortality. Controlling for antenatal confounding factors, magnesium sulfate use was not independently associated with neonatal mortality (odds ratio (OR) = 0.66; 95% confidence interval (CI) = 0.28, 1.54; p = 0.34). Seventy-nine neonates were exposed to magnesium sulfate therapy for more than 24 h, while 111 neonates were exposed for 24 h or less. There were no significant differences between groups with respect to neonatal outcomes, with the exception of an increased rate of clinical chorioamnionitis in the group exposed to magnesium for more than 24 h (22% vs. 8.2%, p = 0.005). After adjusting for gestational age at delivery, magnesium sulfate exposure for over 24 h was independently associated with a 2.8-fold increased rate of clinical chorioamnionitis (OR = 2.8, 95% CI = 1.14, 6.90; p = 0.02).

CONCLUSION

Prenatal exposure to magnesium sulfate was not associated with increased neonatal morbidity or mortality. However, prolonged exposure to magnesium sulfate may be associated with an increased risk of clinical chorioamnionitis.

Israeli nurses' knowledge of health care reforms

OBJECTIVES

This study examines health care reforms' implementation processes from the perspective of nurses' knowledge regarding the reforms. The research has been carried out in the Israeli context, where health care reforms were initiated in 1995. Three specific research questions were formulated: (a) What is the level of nurses' knowledge regarding the recommendations of the Netanyahu committee? (b) What is the level of nurses' knowledge concerning the basic principals of the National Insurance Law? and (c) Are there knowledge differences relating to employment setting (hospital, community, and educational settings), nurses' roles (managerial vs. staff nurses), years of experience, and level and type of education?

METHOD

The stratified nonproportional random sample consisted of a total of 468 nurses. Of these nurses, 206 were employed in community settings (136 in curative care, and 70 in preventive care), 137 were employed in hospital settings, and 125 worked in schools and departments of nursing. Research tools, developed for the purpose of this study, included the nurses' knowledge questionnaire comprised of five subscales, and the knowledge relevancy questionnaire.

RESULTS

Overall, data demonstrated a low to moderate level of knowledge on all knowledge scales. Knowledge level on the criteria questions was particularly low. Contrary to the low level of knowledge, nurses regarded health care reforms' knowledge as highly relevant to their work life. Curative setting, an extensive work experience, managerial position, and non-nursing academic degree were all positively related to higher levels of reforms' knowledge.

CONCLUSION

These findings should encourage both policy makers and managers in various health care organizations to develop programs for informing health care providers on central aspects of health care reforms considered most relevant to the practice setting.

Phosphate depletion in opossum kidney cells: apical but not basolateral or transepithelial adaptions of Pi transport

Monolayers of opossum kidney (OK) cells are widely used as models for the renal proximal tubule. OK cells adapt to phosphate (Pi) depletion by increasing their capacity for apical and basolateral Na+-dependent Pi uptake. Because NMR-visible cell Pi was found to be decreased in Pi-deprived kidney cells, we suggested that up-regulation of basolateral Pi efflux also occurs during adaptation to Pi deprivation [American Journal of Physiol 1994;267:C915-919]. In order to test this hypothesis, we measured the cell Pi pool, basolateral Pi efflux and transepithelial Pi fluxes in OK cells grown on permeable plastic filters, exposed overnight to solutions containing either 0.5 mM (deprived) or 2.0 mM (replete) Pi or 32Pi. Following steady state or acute loading with 32Pi, the specific activity (SA) of cell Pi, the cell Pi pool and the basolateral efflux of 32Pi were measured. In the steady state, a 2-fold increase in Pi uptake sustained the intracellular Pi pool at 85% of the control level (30 +/- 5 nmol/mg) in spite of a decrease in extracellular Pi from 2 to 0.5 mM. When the extracellular Pi was acutely (1 h) reduced to 0.1 mM, the cell Pi pool decreased (to 3 +/- 1 nmol/mg) both in cells previously adapted overnight to either 0.5 or to 2 mM Pi (p >0.3). The rates of absolute and fractional basolateral washout of cell 32Pi after 1 h loading with 0.1 mM 32Pi were similar in cells adapted to 0.5 compared to 2 mM Pi. This indicates that Pi depletion did not affect the effective permeability of the basolateral membranes to Pi. Adaptation for 16 h to 0.5 compared to 2 mM Pi did not alter the rate of net transepithelial transport of 0.1 mM Pi from the apical to the basal compartment but reduced (p < 0.05) the unidirectional fluxes of both 32Pi and 14C-mannitol. An insufficient driving force (unchanged or low Pi concentration in the transport pool, low electrical or coupled-anion gradients) and a constant effective basolateral Pi permeability must have limited basolateral Pi efflux in cells exposed to 0.1 mM Pi. Thus, in OK cells grown on plastic support there are no adaptive increases in either basolateral Pi efflux, or in transcellular and paracellular Pi transport, in response to Pi depletion. Adaptations are limited to increases in apical and basolateral sodium-dependent Pi uptakes that can maintain the cell Pi pool as long as apical Pi is not too low (> or =0.5 mM). The OK cells adapt to low Pi concentrations conserving cell Pi but not increasing basolateral Pi efflux nor transepithelial Pi transport.

Ontogeny of renal phosphate transport and the process of growth

The kidneys of infants and children reabsorb a high fraction of the filtered phosphate (Pi), as appropriate to the needs of a growing organism. This high Pi reabsorptive rate is associated with a high capacity (Vmax) of the Na+-Pi symport system. At the molecular level this high reabsorptive capacity appears to be due to the presence of a growth-specific Na-Pi cotransporter. Several experimental findings support this assumption. Firstly, the expression of NaPi-2 mRNA is, if anything, lower in the renal cortex of young animals than of adult animals. Secondly, polyA RNA obtained from growing animals depleted of NaPi-2 by specific hybridization with an antisense 16-mer induces Na+-Pi transport in oocytes. No induction of Na+-Pi transport was observed in oocytes injected with hybridized polyA RNA obtained from adult animals. Thirdly, polyA RNA derived from young rats, depleted of NaPi-2 by subtractive hybridization with adult animal renal cortical cDNA, retains its ability to encode for Na+-Pi cotransport in oocytes. Adult animal renal cortical polyA RNA, depleted of NaPi-2 by subtractive hybridization, failed to induce Na+-Pi uptake into oocytes. Fourthly, renal cortical polyA RNA from young animals, depleted of NaPi-2, contains a region that is highly homologous (80%-92%) with the corresponding region of other modulated NaPi (type II) transporters. Fifthly, this region is also present in the polyA RNA obtained from the renal cortex of newborn rats (1st week of life), despite the fact that NaPi-2 is absent at this early age. Lastly, Npt2 (-/-) knockout mice, although hypophosphatemic and phosphaturic, filter and reabsorb Pi at rates exceeding those that can be accounted for by the expression of type I and III transporters. Based on these observations it is reasonable to surmise that the high Vmax of the Na+-Pi cotransport system observed in the young is due to a large extent to the presence of a growth-specific NaPi transporter, homologous but not identical to already cloned type II NaPi transporters.

Hormonal regulation of sodium-dependent phosphate transport in opossum kidney cells

There are multiple regulators of renal proximal tubule sodium-dependent phosphate (Na(+)-Pi) transport, including 1,25-dihydroxyvitamin D (1,25-Vit. D), parathyroid hormone (PTH), insulin-like growth factor 1 (IGF-1), and arachidonic acid (AA) and/or its metabolites. The purpose of our studies was to determine whether the effect of these factors on Pi transport is synergistic or antagonistic. The control solution or the substances were added independently or coincidentally to opossum kidney (OK) cells before incubation for 4 h. 1,25-Vit. D (10(-8) M) had no significant effect on Pi transport ( upward arrow6.8%; p = 0.8). PTH (10(-7) M) significantly inhibited Pi transport by 39.6% (p < 0.0001). IGF-1 (10(-8) M) stimulated Pi transport by 19.6% (p < 0.0001). The AA metabolite 20-HETE (10(-7) M) had no significant impact on Pi transport ( downward arrow6.4; p = 0.3). The combined effect of 1,25-Vit. D and PTH was no different from PTH alone (p = 0.2). Likewise, addition of either 1,25-Vit. D or 20-HETE to IGF-1 failed to affect the magnitude of the increase on Pi transport induced by IGF-1 alone (p = 0.4, p = 0.6, respectively). The combination of 20-HETE and PTH was not different from that observed with PTH alone (p = 0.9). We conclude that in OK cells, PTH inhibits whereas IGF-1 stimulates Pi transport into OK cells. The effects of each of these hormones are independent and unaffected by either 1,25-Vit. D or 20-HETE.

From bedside nursing to managerial roles: changing occupational perceptions of nursing students

This longitudinal study examined changes in the occupational perceptions of nursing students studying in a non-traditional undergraduate nursing program. The respondents, 210 first- and second-year nursing students, completed a questionnaire measuring the perceived importance of traditional and non-traditional nursing interventions and values. Questionnaires were administered at the beginning and at the end of the academic year. Students studying in a more traditional program comprised the control group. The results show that certain traditional nursing activities and values are perceived as more important by first-year students compared with second-year students in both programs, whereas the perceived importance of non-traditional activities is higher among second-year students. The preference for non-traditional interventions is stronger among students in the non-traditional nursing program. The results are discussed with regard to the gradual effect of nursing education on students' occupational perceptions.

Activating mineralocorticoid receptor mutation in hypertension exacerbated by pregnancy

Hypertension and pregnancy-related hypertension are major public health problems of largely unknown causes. We describe a mutation in the mineralocorticoid receptor (MR), S810L, that causes early-onset hypertension that is markedly exacerbated in pregnancy. This mutation results in constitutive MR activity and alters receptor specificity, with progesterone and other steroids lacking 21-hydroxyl groups, normally MR antagonists, becoming potent agonists. Structural and biochemical studies indicate that the mutation results in the gain of a van der Waals interaction between helix 5 and helix 3 that substitutes for interaction of the steroid 21-hydroxyl group with helix 3 in the wild-type receptor. This helix 5-helix 3 interaction is highly conserved among diverse nuclear hormone receptors, suggesting its general role in receptor activation.

Evaluation of an innovative curriculum: nursing education in the next century

The present research focused on an interim evaluation of a new nursing curriculum made by first- and second-year undergraduates. Study 1 examined the assessments made by 90 students of the new, actual programme of their studies, as well as an ideal one, on 21 bipolar criteria reflecting the developing changes in health care practices and higher educational processes in western society. The results of study 1 indicated that students perceived the actual programme as compatible with health care changes, but lacking in terms of the learning process. Study 2 investigated the same assessments among 105 registered nurses who evaluated the traditional nursing programme under which they were trained as well as an ideal one. The results of study 2 showed that registered nurses perceived past curricula as lower than the ideal on both health care and process of learning. The results of this interim evaluation imply that the new nursing curriculum follows health care trends, but a shift in the educational process is required.

Multiple arachidonic acid metabolites inhibit sodium-dependent phosphate transport in OK cells

The cytochrome P450-dependent monoxygenase pathway represents a major route for the metabolism of arachidonic acid (AA) in the kidney. In turn, AA metabolites have been shown to affect renal electrolyte metabolism, including sodium transport. Specifically AA, 20-HETE and 12-HETE inhibit sodium-dependent (Na+-Pi) uptake into renal culture cells, and both 12-HETE and 14,15 EET have been shown to reduce renin release from renal cortical slices. Since the bulk of Pi transport occurs in the proximal tubule (PT), and the PT is a major site of AA metabolism, we studied the effect of AA and several of its metabolites on Na+-Pi uptake into PT-like opossum kidney (OK) cells. Incubation of OK cells in AA (10(-8) M) resulted in 17% inhibition of Pi uptake. Three metabolites of omega-hydroxylation of AA induced significant decreases in Pi uptake: 19R-HETE (10(-8) M) by 36% (P=0.008), 19S-HETE (10(-8) M) by 24% (P=0.002) and 20-COOH-AA (10(-8) M), a metabolite of 20-HETE, by 25% (P<0.0001). 14,15 EET (10(-8) M), a breakdown product of AA by the epoxygenase pathway, had the greatest effect on Pi uptake in OK cells. It decreased Pi uptake by 47% (P < 0.0001). Addition of the P450 inhibitor, 7-ER (10(-8) M), to OK cells resulted in a significant stimulation (28%) of Pi uptake (P=0.016). These results indicate that these AA metabolites have a significant inhibitory effect on Na+-Pi uptake in OK cells.

The need and ability to achieve cognitive structuring: individual differences that moderate the effect of stress on information processing

The authors examined the hypothesis that the interaction between the need for cognitive structure (NCS) and the ability to achieve cognitive structure (AACS) moderates the effect of stress on information processing. NCS is the preference for using cognitive structuring, as opposed to piecemeal processes, as a means to achieve certainty. AACS is the extent to which individuals are able to apply information processes that are consistent with their levels of NCS. The hypothesis was validated in 4 studies, which showed that stress increased high-AACS participants' use of cognitive structuring if they had high NCS and reduced it if they had low NCS. An opposite effect was found for low-AACS participants. The implications of these results for the understanding of the mechanisms responsible for the effect of stress on information processing are discussed.

The effect on coping of monitoring, blunting, and the ability to achieve cognitive structure

The effects of monitoring and blunting on individuals' choices of coping strategies and their effectiveness were examined. In addition, the authors explored the effect of the ability to achieve cognitive structure (AACS), defined as either or both of the following: (a) the ability to avoid information that either cannot be categorized or clashes with the individual's existing knowledge; (b) the ability to organize knowledge to fit an already existing cognitive structure. The results showed that in addition to the main effects of monitoring on problem-focused coping and social support seeking behaviors and of blunting on the use of wishful thinking, AACS was found to moderate blunting's influence on problem-focused coping as well as the effectiveness of distancing and avoidance coping. Finally, the results showed that the combination of high monitoring and high blunting sometimes contributes to coping effectiveness.

The need and ability to achieve cognitive structuring: individual differences that moderate the effect of stress on information processing

The authors examined the hypothesis that the interaction between the need for cognitive structure (NCS) and the ability to achieve cognitive structure (AACS) moderates the effect of stress on information processing. NCS is the preference for using cognitive structuring, as opposed to piecemeal processes, as a means to achieve certainty. AACS is the extent to which individuals are able to apply information processes that are consistent with their levels of NCS. The hypothesis was validated in 4 studies, which showed that stress increased high-AACS participants' use of cognitive structuring if they had high NCS and reduced it if they had low NCS. An opposite effect was found for low-AACS participants. The implications of these results for the understanding of the mechanisms responsible for the effect of stress on information processing are discussed.

[The assessment of sudomotor function for diagnosis of autonomic diseases. Principles and methods]

Thermoregulatory and emotional sweating can be distinguished in humans. While the first is organized via feed back mechanisms involving thermoreceptors, thermoregulatory centers in the brain and the effector system (sympathetic nervous system and sweat glands), the latter is generated directly by cortical and limbic mechanisms without any feed back. Sweat glands on the hairy skin can be stimulated by thermoregulatory mechanisms (rising body temperature), the emotional sweating on the glabrous skin as a result of an arousal reaction and they can be stimulated by peripheral acting cholinergic agents, which initiate direct or axon reflex mediated sweating. To evaluate sweating there are qualitative methods that visualize the sweat response or indirect methods like the registration of skin potentials. Alternatively sweat output can be quantified by evaporative measurement. For best results these methods should be combined. In this way autonomic dysfunction e.g. after nerve lesions, in polyneuropathies, central lesions and certain pain disorders can be assessed. The sudomotor function tests complete the conventional electrophysiological methods.

Cardiac sympathetic denervation in early stages of amyotrophic lateral sclerosis demonstrated by 123I-MIBG-SPECT

Involvement of the autonomic cardiac nervous system in early stages of amyotrophic lateral sclerosis (ALS) was evaluated in 40 patients. I-123-metaiodobenzylguanidine-single photon emission computed tomography (MIBG-SPECT) and heart rate variability (HRV) yielded information about sympathetic and parasympathetic innervation of the heart. MIBG-SPECT is a sensitive diagnostic method for demonstration of early cardiac sympathetic denervation. Both sympathetic and parasympathetic dysfunction was observed in 16 (40%) out of 40 patients. Mean cardiac MIBG uptake as demonstrated by the heart/mediastinum ratio was significantly reduced in all ALS patients in comparison with controls (P<0.01). The global MIBG-SPECT score was clearly abnormal in 29% and slightly abnormal in 22% of patients. HRV was diminished in 6 of 38 patients, 4 of whom having an abnormal MIBG-SPECT score as well. The presented results indicate that ALS patients with mild to moderate impairment may have evidence of postganglionic sympathetic adrenergic cardiac or cardiovagal denervation. To our knowledge, this is the first study indicating possible postganglionic sympathetic denervation in ALS. The original concept of ALS as an isolated degeneration of motor neurons seems to extend to a more widespread understanding of the disease which possibly represents different entities.

Moving into the information era: does the current nursing paradigm still hold?

The transition into the information era is characterized by society's passage through three crossroads representing a change from: (a) technology to post-technology; (b) rigid jobs and hierarchies to dejobbing and vanishing hierarchies; and (c) limited competition to competition dominating all markets. These transitions have caused dramatic changes in the health care system at large and escalating problems that cannot be solved within the current paradigm of nursing. Among the nursing problems that were identified are those including difficulties in: (a) defining the relative contribution of nursing vis a vis other health professions; (b) the scope and dimensions of nursing authority; (c) implementing all aspects of the nursing intervention; (d) actualizing caring in nursing intervention; and (f) implementing the nursing process as a major thinking process in the profession. The analysis of the state of nursing suggests that the current clinical paradigm fails to consolidate the economic and quality issues into the core of nursing. It is not capable of solving central professional problems and emerging dilemmas. Considering that under the current paradigm, nursing has difficulties in highlighting to clients and the system alike where nursing can make a difference, it is questionable whether such a paradigm can ensure the existence of nursing in the future.

Nursing in the health care system of the postmodern world: crossroads, paradoxes and complexity

Entering the postmodern world in which society is confronting crossroads, paradoxes, and complexity, the health care system is encountering a transformation more comprehensive and revolutionary than has ever been seen before. Analysis of the state of nursing vis a vis these transformations indicates that the current paradigm does not ensure the existence of the profession in the postmodern health care system. That is because of increased difficulties in consolidating the economic and quality issues into the core of nursing, and in understanding the complexity inherent in health related situations.

Sudden infant death syndrome rates subsequent to the American Academy of Pediatrics supine sleep position

OBJECTIVES

In April 1992, the American Academy of Pediatrics (AAP) recommended that healthy infants be positioned for sleep on their side or back to reduce the risk of Sudden Infant Death Syndrome (SIDS). The authors hypothesized three different forms of the intervention to examine the impact of the recommendation according to theory such as technology diffusion. Seasonality was included in the models to control its effect when testing.

METHODS

Box and Tiao time-series intervention methodology was used to examine the effect of the AAP recommendation on SIDS rates. Sudden Infant Death Syndrome mortality data from Philadelphia and Chicago were examined separately for white and nonwhite populations over 32 quarters.

RESULTS

Overall SIDS rates dropped significantly according to an abrupt effect from the intervention. However, the effect appeared to be gradually declining in Philadelphia but permanent in Chicago. In Philadelphia, a decline of 62.3% was estimated in whites in the first quarter after the intervention but decreased to only 5% in the last quarter of 1994. A decline of 35.8% was estimated in nonwhites in the first quarter after the intervention but decreased to only 9.4% in the last quarter of 1994. An abrupt and permanent decrease of 26.7% and 16.5% was found in Chicago for whites and nonwhites, respectively.

CONCLUSIONS

Evidence of an abrupt adoption of the recommendation can be explained by the authority innovation decision made by the AAP. Some evidence was found that the effect is temporary, perhaps because physicians are reversing earlier decisions. The demonstrated methodology provides a powerful way to test naturally occurring interventions from quasiexperimental designs to test the impact of policy guidelines.

Psychometric evaluation of the Russian Language version of the Resilience Scale

The Resilience Scale (RS) was developed by Wagnild and Young (1993) to measure a personality characteristic or coping resource that facilitates adaptation. The RS, however, has not been evaluated with foreign-born populations. Therefore, the purpose of this study was to report the factor structure, internal consistency, and concurrent validity of a Russian language version of the RS in a sample of 450 recent former Soviet immigrants. The 25-item 2-factor solution obtained by Wagnild and Young (1993) was not supported by the Russian data. However, a modified 12-item Russian language version of the RS was, for the most part, reliable and valid: The standardized factor loadings and goodness of fit indices obtained from confirmatory factor analysis were acceptable, the internal consistency of one of the two subscales was very good, and the correlations between scores from the RS subscales and various measures of constructs that are theoretically linked with adaptation were in the expected direction and statistically significant.

The NMDA receptor antagonist amantadine reduces surgical neuropathic pain in cancer patients: a double blind, randomized, placebo controlled trial

Neuropathic pain is often severe, persistent, and responds poorly to analgesic medications. Recent evidence suggests that N-methyl-D-aspartate (NMDA) receptor antagonists may be effective in the treatment of neuropathic pain. The present trial was designed to test the efficacy of acute administration of the NMDA receptor antagonist amantadine in relieving surgical neuropathic pain in patients with cancer. The study sample consisted of 15 cancer patients with the diagnosis of surgical neuropathic pain. Two 500 ml infusions of either 200 mg amantadine or placebo were administered over a 3 h period, in a randomized order, 1 week apart from each other. Spontaneous and evoked pain were measured for 48 h before treatment, during treatment, and for 48 h following treatment. An average pain reduction of 85% was recorded at the end of amantadine infusion vs. 45% following placebo administration. The difference in pain relief between the two treatments was statistically significant (P = 0.009). Mean pain intensity remained significantly lower during the 48 h following amantadine treatment as compared with the 48 h prior to treatment (31% reduction; P = 0.006), whereas no such effect was found with the placebo (6% reduction; P = 0.40). Amantadine, but not the placebo, also reduced 'wind up' like pain (caused by repeated pinpricking) in four patients. We conclude that amantadine infusion is a safe and effective acute treatment for surgical neuropathic pain in cancer patients. Further trials with long-term oral or parenteral amantadine treatment should be conducted.

20-HETE mediates the effect of parathyroid hormone and protein kinase C on renal phosphate transport

Parathyroid hormone (PTH) is a major inhibitor of renal proximal tubule (PT) sodium-dependent phosphate (Na+-Pi) cotransport. PTH is thought to exert its effect on Pi transport in the PT via the protein kinase A (PKA) and C (PKC) intracellular signalling pathways. PKC-dependent phosphorylation of phospholipase A2 stimulates arachidonic acid (AA) release, the latter a potent inhibitor of Pi transport. In turn, AA is metabolized to 20-hydroxyeicosatetraenoic acid (20-HETE) in the PT. In addition, 20-HETE production is stimulated by PTH. We therefore explored the possibility that 20-HETE may mediate the PTH/PKC inhibition of renal Na+-Pi cotransport. To this end, we tested the effect of 20-HETE on Na+-Pi cotransport in proximal tubule-like cells. Exposure of opossum kidney (OK) cells for 4 h to 20-HETE (10(-7) M) decreased Na+-dependent uptake of 32Pi (from 0.26 +/- 0.02 to 0.19 +/- 0.01 nmol/mg protein.min) by approximately 25% (P < 0.001). The inhibition was due to a reduction in Vmax. 20-HETE had no significant effect on either the apical amiloride-sensitive and insensitive 22Na uptakes or on basolateral ouabain-sensitive 86Rb uptake, and was specific for Pi. These results indicate that 20-HETE specifically inhibits Na+-dependent Pi transport in OK cells and that it may be a mediator of PTH action in the PT.

A putative growth-related renal Na(+)-Pi cotransporter

The mRNA that encodes for NaPi-2, the renal Na(+)-Pi cotransporter that is upregulated by Pi depletion in the adult rat, is low in the young animal. Yet, renal Na-Pi cotransport rates are higher in rapidly growing than in fully grown rats. The aim of this study was to unravel the molecular basis of this apparent discrepancy. Poly(A) RNA obtained from the renal cortex of young animals induced higher rates of Na(+)-Pi cotransport in oocytes than equal amounts of poly(A) mRNA obtained from the renal cortex of mature rats. Moreover, poly(A) RNA obtained from renal cortex of rapidly growing animals treated with antisense NaPi-2 oligomers or depleted of NaPi-2 transcripts by subtractive hybridization with cDNA generated from the renal cortex of adult rats retained its ability to induce Na(+)-Pi cotransport in oocytes. In addition, renal poly(A) RNA of the young subjected to subtraction hybridization generated a 379-base pair reverse transcriptase-polymerase chain reaction product common to all known type II Na(+)-Pi cotransporters. These observations permit us to surmise that the high rates of Na(+)-Pi cotransport prevailing during growth are due, at least in part, to the expression of a specific mRNA that is only partially homologous to that of NaPi-2.

[Iodine content of Bavarian consumer milk]

Over a period of one year the iodine content of the milk of 28 bavarian dairies was determined monthly by a gaschromatographical method. The annual mean value was 115 micrograms/l. In March, April and November, December, respectively a distinct increase of the concentration was observed. In the southern part of Bavaria the iodine contents were below 100 micrograms/l in contrast to the region Oberpfalz and Franken where contents up to 150 micrograms/l could be determined. Compared with concentrations in different tables the iodine content in bavarian milk could increase the iodine uptake up to 6%.

Acquired renal cystic disease in children and young adults on maintenance dialysis

Acquired renal cystic disease (ARCD) is a well-known complication of end-stage renal disease (ESRD). We studied 24 patients, aged 8-27 years (mean 19.8 +/- 5.3 years), on chronic maintenance dialysis in our service. The duration of dialysis ranged between 13 and 192 months (mean 77.8 +/- 44.3 months). High-resolution ultrasonography revealed ARCD in 11 (45.8%) patients. No cysts were seen in 7 (29.1%) patients and solitary cysts in one or both kidneys were seen in 6 (25%) patients. Renal malignancy was diagnosed in 2 patients. One, 15 years old, had renal cell carcinoma after being on dialysis for 6 years. She did well after bilateral nephrectomy, left salpingo-oophorectomy, and regional lymphadenectomy. The second patient, 23 years old, had been on dialysis for 16 years when she developed renal oncocytoma. She died of congestive cardiomyopathy 6 months later. We conclude that ARCD is common in children and young adults with ESRD. Neoplastic transformation, although rare, is a potential complication. Annual follow-up with ultrasonography with selective use of computed tomography or magnetic resonance imaging is advised.

Cardiac autonomic involvement and peripheral nerve function in patients with diabetic neuropathy

The aim of our study was to investigate the relationship between cardiac autonomic neuropathy and dysfunction of myelinated and unmyelinated nerve fibres in the peripheral nerve. We measured nerve conduction velocities, warmth/cold perception thresholds at the foot dorsum, sympathetic skin response (SSR), and performed the quantitative sudomotor axon reflex test (QSART). Forty-three diabetic patients with distal-symmetric polyneuropathy were included. According to the results of heart rate variation, 20 patients had cardiac autonomic neuropathy (CAN+). Apart from motor nerve conduction velocities, all tests were more often abnormal in CAN+ patients. Warmth thresholds (afferent C-fibres) and reduced compound muscle action potentials (CMAPs) of the tibial and peroneal nerve, indicating axonal damage, were more often abnormal in CAN+. Cold threshold and sural nerve conduction velocity were indicators of involvement of myelinated small and large nerve fibres, but not of the cardiac autonomic system. Ninety-four percent (94%) of patients with absent SSR and 78% of patients with abnormal QSART had CAN+. SSR and QSART may be useful for assessment of autonomic neuropathy in diabetic patients with cardiac arrhythmia where direct measurement of heart rate variability is not possible. In the majority of our patients with CAN+, the vagal-cardiac and the sudomotor-sympathetic systems were involved simultaneously, although two entirely different systems were tested. This may reflect a C-fibre directed selectivity of the pathological process in autonomic diabetic neuropathy. In conclusion our results show that diabetics with and without cardiac autonomic neuropathy have a different profile of involvement of peripheral nerve fibres.

Sudomotor function in sympathetic reflex dystrophy

Sudomotor functions were studied in 27 patients suffering from reflex sympathetic dystrophy (RSD) according to the criteria established by Bonica (18 women, 9 men; mean age 50 +/- 12.3 years; median duration of disease 8 weeks, range 2-468 weeks). To measure local sweating rates, two small chambers (5 cm2) were affixed to corresponding areas of hairy skin on the affected and unaffected limbs. Dry nitrogen gas was passed through the chambers (270 ml/min) and evaporation was recorded at both devices with hygrometers. Thermoregulatory sweating (TST) was induced by raising body temperature (intake of 0.5 1 hot tea and infra-red irradiation). Local sweating was also induced through an axon reflex (QSART) by transcutaneous iontophoretic application of carbachol (5 min, 1 mA). In addition, skin temperature was measured on the affected and unaffected side by infra-red thermography. Mean skin temperature was significantly higher on the affected side (P < 0.003). In spite of the temperature differences, there was no difference in basal sweating on the affected and unaffected side. However, both methods of sudomotor stimulation lead to significantly greater sweating responses on the affected compared to the unaffected side (TST: P < 0.05, QSART: P < 0.004). Latency to onset of sweating was significantly shorter on the affected side under both test conditions (P < 0.04 and P < 0.003, respectively). Sweat responses were not correlated to absolute skin temperature but were probably related to the increased blood flow on the affected side. Our findings imply a differential disturbance of vasomotor and sudomotor mechanisms in affected skin. Whereas vasoconstrictor activity is apparently lowered, sudomotor output is either unaltered or may even be enhanced.

Family stress and support among former Soviet immigrants

The purpose of this qualitative descriptive study was to investigate types of family support and stress among former Soviet immigrants. Forty-two immigrants (14 males and 28 females) were interviewed about their immigration experiences, including description of current relationships with family in the resettlement country. Content analysis of interview data documented that immigrant families can be a valuable source of emotional and/or instrumental support. Immigrant families, however, can also be too overwhelmed by their own immigration demands to provide support or can generate additional stress for its members. Types of family stress included conflict from differing values and opinions, increased responsibility for family members who could not manage resettlement on their own, family members' emotional distress over immigration experiences, unmet expectations for family members' adjustment, and changes in household composition and living arrangements upon arrival in the United States.

Learning About Another Culture: Project and Curricular Reflections

Over the past two years, an innovative collaborative project in the care of Ethiopian Jews who immigrated to Israel has been carried out. In this project, both students and faculty joined in activities of research and practice through a clinic at a trailer court that houses 96 Ethiopian immigrant families. This project brought about several favorable changes: a) Health of the underprivileged and underserved was enhanced through bi-weekly services provided to the poor and sick trailer court inhabitants; b) An educational program for learning in a cross-cultural community setting was developed. This curricula advanced recognition of the growing cultural and racial diversity of both individual and family lifestyles, as well as allowed for learning events that are based on substantive contact with, or participation by, persons at health risk; c) An educational milieu that fosters the use of research-based interventions was developed. This article describes the cross-cultural educational project which was designed as a pilot for a new baccalaureate program in nursing, and critiques it based on the criteria of the five major concepts--primacy of the teacher-student relationship, social responsibility, centrality of caring, interpretive stance and theoretical pluralism, proposed by the promoters of the "curriculum revolution."

Protein kinase C in intracellular pH regulation in alveolar type II cells

The Na+/H+ exchanger and Na(+)-HCO3- cotransporter have been implicated in regulation of intracellular pH (pHi) in alveolar type II cells. This study demonstrates that activation of protein kinase C (PKC) stimulates both of these ion transporters in type II cells. Treatment of type II cells with 80 nM phorbol 12-myristate 13-acetate (PMA) increased the resting pHi in a time-dependent manner. Compared with control cells, the rates of recovery from an acid load increased with PMA treatment, reaching a maximum at 15 min, and returned to control levels by 3 h. The PMA-stimulated changes in recovery rate were sensitive to H-7, a PKC inhibitor. For PMA treatment up to 2 h, these recoveries were also sensitive to dimethylamiloride (DMA), an inhibitor of Na+/H+ exchanger activity, and to HCO3-, suggesting activation of both the Na+/H+ exchanger and the Na(+)-HCO3- cotransporter. After prolonged (3 h) treatment with PMA, however, the recovery was insensitive to DMA but was sensitive to HCO3-, suggesting that the Na+/H+ exchanger was no longer active and that most of the recovery was mediated by the Na(+)-HCO3- cotransporter. PMA treatment also altered the Na+ kinetics of the recovery from an acid load with respect to the Michaelis constant (Km) and maximal ion flux (Vmax), suggesting protein modifications of each transporter. We suggest that PKC activation in type II cells results in acute and long-term changes in pHi regulatory mechanisms mediated by the Na+/H+ exchanger and by the Na(+)-HCO3- cotransporter.

Pregnancy and delivery practices and beliefs of Ethiopian immigrant women in Israel

This exploratory, qualitative study compared traditional and biomedical pregnancy and delivery practices from the perspective of Ethiopian immigrant women in Israel. Findings documented that certain beliefs, such as the belief that nonmedical factors (i.e., moral behavior, God, and proper nutrition) were responsible for pregnancy outcomes, were relatively unaffected by immigration. After immigration to Israel, Ethiopian women, however, chose to deliver their babies in the hospital rather than import traditional home delivery practices from their homeland. Despite many negative aspects of labor and delivery in Israel, Ethiopian immigrant women felt that it was worth enduring negative Israeli health care practices in order to have "clean," "safe," and expert deliveries. Findings from this study assist health care professionals to provide more culturally sensitive care to this immigrant group.

Mechanism of renal phosphate retention during growth

We have previously demonstrated that the retention of phosphate required for growth is due to a a high Vmax of the Na(+)-Pi cotransport system located in the brush border membrane of the proximal tubule. Because of this and other similarities between adaptation of the kidney to a high Pi demand (growth) and that to low Pi supply, we measured the levels of NaPi-2 mRNA and cDNA present in kidney cortex of 3- and > 12-week-old rats. Like in Pi depletion, Western blots revealed that a 80 to 85 kDa protein recognized by a polyclonal antibody directed against the N-terminal region of the NaPi-2 protein was 2.3-fold more abundant in renal microvilli of the young than of adult animals. However, unlike in Pi depletion, Northern blot analysis failed to reveal a significant difference between mRNA levels at the two ages. Furthermore, suppression of NaPi-2 mRNA activity by annealing with antisense oligomers, or removal of the NaPi-2 transcripts by subtractive hybridization did not affect the rate of Na(+)-Pi cotransport induced in oocytes by polyA RNA of rapidly growing animals, while abolishing the ability of the renal cortical polyA RNA of adult rats to encode for Na(+)-Pi cotransport. RT-PCR of subtracted polyA RNA using primers specific for a region conserved in NaPi type II (Pi modulated) cotransporters yielded a product that was 98% homologous with that region, despite the absence of NaPi-2 cDNA. The results of these experiments demonstrate that the polyA RNA from kidneys of young animals contains unique mRNA transcripts able to encode for a NaPi protein homologous to, but distinct from NaPi-2.

The moderating effect of age on self-care

The study examined the moderating effect of age on the relations between symptom severity, self-care and others' care, patients' perception of the extent of problem solution, their satisfaction with the solution, and their perception of control over their health. Participating in the study were 121 female and 167 male chronically ill patients. Results indicated that age did play a major role in the relations between self-care and others' care and self-care outcomes. The young population sought maximum relief of symptoms with minimum effort from the self. The elderly, in contrast, could be said fo maximize control because what was important for them was not to depend on others but to be self-sufficient in solving their health problems.

The current approach to the assessment of fetal renal function: fact or fiction?

The wide use of ultrasonography during pregnancy has led to the identification of a relatively large number of renal and urinary tract abnormalities, particularly hydronephrosis. Uncertainty, however, exists regarding the indications for surgical intervention. Prominent among the variables currently used to assess fetal renal function and predict the long-term outcome are measurements of urinary concentration of electrolytes and low molecular weight proteins. It has become, therefore, imperative to examine the evidence on which the selection of these variables is based, before they become entrenched in medical practice. The analysis reveals that single measurements of any of these variables is unlikely to be reliable. Sequential measurements, albeit more dependable, are impractical due to the narrow window of opportunity for useful surgical intervention. It is therefore necessary to search for new, innovative approaches aimed at detecting changes in the kidney or urine that reflect the biological response of the developing kidney to injury. Such markers may be represented by renal metabolites or peptides involved in the maintenance of renal function under conditions of stress.

Internal body perceptions of Ethiopian Jews who emigrated to Israel

Previous research regarding knowledge about internal organs among school-age children tied this knowledge to the development of cognitive capabilities. Studies have rarely considered the impact of culture on this knowledge. The purpose of this study was to examine internal body perceptions among Ethiopian Jews who emigrated to Israel. A total of 65 children (stratified according to age) and 19 adults were interviewed. Findings indicated that Ethiopian children reported fewer body organs than did Western children. Further, Ethiopian children and adults, unlike people from Western societies, did not think about the body in terms of different biophysical functions. Rather, they perceived the body as a holistic system in which a divine providence was responsible for body organs working together harmoniously. Implications of the differing perceptions about internal body organs, health, illness, and treatment are discussed.