Integrating Collaborative Interprofessional Simulation into Pre-Licensure Health Care Programs

This interprofessional education activity incorporated National League of Nursing unfolding case studies and patient simulation with nursing, pharmacy, and medical students. Faculty developed a full-day simulation experience; the most unique element was a team meeting where nursing students presented home health findings to an interprofessional team, and students worked together to design a comprehensive plan of care. All students were in their geriatric specialty program rotations. The interprofessional simulation introduced students across disciplines for the purpose of enhancing communication, developing mutual respect, and identifying role clarity through team learning.

Successful establishment of Wolbachia in Aedes populations to suppress dengue transmission

Genetic manipulations of insect populations for pest control have been advocated for some time, but there are few cases where manipulated individuals have been released in the field and no cases where they have successfully invaded target populations. Population transformation using the intracellular bacterium Wolbachia is particularly attractive because this maternally-inherited agent provides a powerful mechanism to invade natural populations through cytoplasmic incompatibility. When Wolbachia are introduced into mosquitoes, they interfere with pathogen transmission and influence key life history traits such as lifespan. Here we describe how the wMel Wolbachia infection, introduced into the dengue vector Aedes aegypti from Drosophila melanogaster, successfully invaded two natural A. aegypti populations in Australia, reaching near-fixation in a few months following releases of wMel-infected A. aegypti adults. Models with plausible parameter values indicate that Wolbachia-infected mosquitoes suffered relatively small fitness costs, leading to an unstable equilibrium frequency <30% that must be exceeded for invasion. These findings demonstrate that Wolbachia-based strategies can be deployed as a practical approach to dengue suppression with potential for area-wide implementation.

Decomposition of nitramine energetic materials in excited electronic states: RDX and HMX

Ultraviolet excitation (8-ns duration) is employed to study the decomposition of RDX (1,3,5-trinitro-1,3,5-triazacyclohexane) and HMX (1,3,5,7-tetranitro-1,3,5,7-tetrazacyclooctane) from their first excited electronic states. Isolated RDX and HMX are generated in the gas phase utilizing a combination of matrix-assisted laser desorption and supersonic jet expansion techniques. The NO molecule is observed as one of the initial dissociation products by both time-of-flight mass spectroscopy and laser-induced fluorescence spectroscopy. Four different vibronic transitions of NO are observed: A (2)Sigma(v(') = 0)<--X (2)Pi(v(") = 0,1,2,3). Simulations of the NO rovibronic intensities for the A<--X transitions show that dissociated NO from RDX and HMX is rotationally cold (approximately 20 K) and vibrationally hot (approximately 1800 K). Another potential initial product of RDX and HMX excited state dissociation could be OH, generated along with NO, perhaps from a HONO intermediate species. The OH radical is not observed in fluorescence even though its transition intensity is calculated to be 1.5 times that found for NO per radical generated. The HONO intermediate is thereby found not to be an important pathway for the excited electronic state decomposition of these cyclic nitramines.

Who is entitled to long-term health care? Emerging policy and moral debate

This paper focuses on emerging British health policy which emphasizes the use of locally determined restrictive criteria to assess access to state provision for long-term health care and the individual's responsibility to plan to meet their own long-term health care needs. Inconsistency in current health policy and ambiguity in the relevant central guidance are explored. This is contextualized in a philosophical framework which seeks to highlight the moral justification underpinning different patterns for the distribution of health care. These issues are of direct relevance to nurse managers because these fundamental changes surface in dilemmas in the management of care and interaction in the multidisciplinary team.

Comparison of fixed-ratio versus variable-ratio regular and NPH semisynthetic human insulin in insulin-requiring diabetic patients

The efficacy and safety of a fixed combination of semisynthetic human insulin (Novolin) providing a 70:30 ratio of NPH to regular insulin versus a varying ratio of semisynthetic human insulin, regular and NPH (control group), were compared in adult insulin-dependent and noninsulin-dependent diabetic patients whose glycemic control had been stable on customized split-mix regimens of animal insulin. Seventy-eight patients were enrolled, of whom 72 were evaluated for efficacy of the respective regimens. Although the baseline fasting serum glucose concentrations were significantly higher in the fixed-ratio group than in the control group, mean serum glucose and glycosylated hemoglobin values throughout the 12 weeks of experimental treatment were not significantly different between groups. The mean serum glucose and glycosylated hemoglobin values in the fixed-ratio group also did not differ significantly from baseline; however, statistically significant increases were observed in the control group at weeks 4 and 8, but not at week 12. Total daily insulin dosages were comparable between the two groups, and body weight did not change significantly in either group. At the end of the study, the investigators judged 90% of the patients in the fixed-ratio group and 88% of the patients in the control group to be either improved or unchanged with respect to glycemic control. The frequency of hypoglycemic episodes and other clinical events did not change significantly from baseline in either group or differ significantly between the two groups at any time. The results of this study suggest that stable diabetic patients receiving animal insulin can safely be transferred to semisynthetic human insulin and that the majority of patients can maintain acceptable glycemic control with a fixed 70:30 ratio of NPH to regular semisynthetic human insulin.

Quantification of insulin secretion and in vivo insulin action in nonobese and moderately obese individuals with normal glucose tolerance

Insulin secretion and in vivo insulin action were quantified in nonobese and moderately obese subjects (approximately 35% above desirable body weight) with normal glucose tolerance. Insulin secretion was estimated by determining plasma insulin responses to a 75-g oral challenge, and in vivo insulin-stimulated glucose uptake by the euglycemic clamp technique. Plasma glucose levels of the two groups were identical during the glucose tolerance test, but the plasma insulin response was significantly greater (P less than 0.01) in the obese subjects. However, insulin-stimulated glucose utilization by the two groups was equal during the euglycemic clamp studies. These results were supported by the fact that degree of obesity correlated significantly with insulin response (r = 0.61, P less than 0.005), but not with insulin-stimulated glucose utilization (r = -0.25, P greater than 0.2). Thus, indirect evidence that moderately obese subjects were more insulin-resistant based on measurement of plasma insulin response was not supported by direct quantification of insulin action. One explanation for these findings is that the height of the plasma insulin response bears no relationship to loss of in vivo insulin action, but that seems unlikely in view of the fact that there was a significant correlation (r = -0.52, P less than 0.01) between these two variables in the group as a whole. Therefore, it appears that the hyperinsulinemia seen in obese individuals may not be a simple function of insulin resistance, and that ability of insulin to stimulate glucose utilization is not significantly impaired in moderately obese subjects with normal glucose tolerance. Alternatively, the degree of impairment in insulin action seen in these individuals is insufficient to be detected by the euglycemic clamp technique.

Diurnal variation in specific insulin binding to erythrocytes

We studied the insulin binding to erythrocytes during a 24-h period in 11 normal subjects. Compared with 0800 and 1600 h the specific 125I-insulin binding decreased significantly at midnight. These changes were mainly due to alterations in insulin binding affinity rather than a decrease in receptor number. An inverse finding was obtained concerning the plasma insulin levels. In fact, the highest insulin concentrations were observed at midnight. The results suggest that diurnal variations in insulin receptor function occur in response to fluctuations of plasma insulin levels.

Insulin receptor binding and insulin-mediated glucose uptake in type-II-diabetics

A 5-hour insulin clamp was performed in 7 normal subjects (N) and 6 type-II-diabetics. After a 10-min-priming insulin infusion, a constant infusion of 1.813 micrograms/m2 s.a./min was given to all subjects. Glycemia was kept at fasting levels by a variable glucose infusion. Under these conditions the amount of metabolized glucose (M) has been calculated and served as a measure of insulin-stimulated glucose disposal. M differed markedly between N (35.6 +/- 3.11 mumol glucose/kg b.w./min and diabetics (17.8 +/- 1.17 mumol glucose/kg b.w./min; p less than 0.01) indicating a diminished insulin sensitivity in the latter group. However, M increased slightly but significantly until the end of the study in both groups. Under fasting conditions the mean percent 125I-insulin specifically bound to 3.5 X 10(9) erythrocytes/ml at tracer concentrations was 12 +/- 1.2% and 8.9 +/- 0.9% in N and diabetics, respectively. During insulin infusion specific insulin binding decreased significantly in both groups by 34% and 41%. Thus, the downregulation of insulin binding was similar in both groups and was due to changes in receptor affinity. Assuming that insulin binding to red blood cells mimic that to target cells we conclude that the cause of reduced glucose utilization in type-II-diabetes lies mainly in changes of postreceptor events rather than in receptor binding.

Effect of age on glucose tolerance, insulin secretion, and in vivo insulin action

The effect of age on glucose tolerance, insulin secretion, and in vivo insulin action (insulin clamp) was studied in 48 nonobese subjects, all of whom were fully ambulatory and in good general health. The observed age-related increase in fasting plasma glucose (r = 0.35, P less than 0.01) was not due to an increase in relative body weight (RBW). Plasma insulin levels, both fasting and postprandial, tended to rise with age, but these changes were not significant. There was a marginally significant correlation (r = -0.21) between age and insulin-stimulated glucose utilization, which fell to -0.13 when controlled for RBW. However, steady-state insulin levels during the insulin-clamp period were higher in the older subjects, suggesting that age leads to an impairment in insulin catabolism; thus it is likely that the impairment of in vivo insulin action with age was underestimated. The variation in in vivo action between individuals was much greater among the older subjects. It was concluded that the glucose intolerance associated with aging is of relatively minor magnitude when ambulatory, generally healthy, nonobese, and nondiabetic subjects are studied. The cause of the glucose intolerance associated with aging seems to be loss of normal in vivo insulin action. On the other hand, this defect is not shared by all older persons, and in many over the age of 70, glucose transport is as efficient as in persons in their 20s.

Effects of moderate increases in dietary polyunsaturated: saturated fat on plasma triglyceride and cholesterol levels in man

1. The effects of two isoenergetic diets differing only in the values for polyunsaturated: saturated fat (P:S values of 0.2 v. 2.0) were studied in twenty adult human volunteers. 2. A period of 14 d on the high P:S diet failed to produce significant changes in fasting triglyceride levels, though there were individual variations. On the other hand, fasting cholesterol levels dropped by 10% (P less than 0.005). High-density-lipoprotein-cholesterol concentrations were not influenced by changes in the P:S value. 3. Investigations into the mechanism by which changes in the P:S value might affect plasma triglyceride values revealed no consistent effects on very-low-density-lipoprotein kinetics, insulin secretion, insulin sensitivity or free fatty acid concentrations. 4. The results of this study suggest that the largest increase in dietary P:S values that is likely to be obtained on a long-term basis may have only a small effect on plasma triglyceride and cholesterol concentrations.

Relationship between insulin resistance, insulin secretion, very low density lipoprotein kinetics, and plasma triglyceride levels in normotriglyceridemic man

We have previously postulated that resistance to insulin-mediated glucose uptake was the basic metabolic abnormality in patients with endogenous hypertriglyceridemia. In this situation, glucose tolerance would tend to deteriorate, and could only be maintained by the increased secretion of insulin. Although the ensuing hyperinsulinemia might prevent the development of glucose intolerance, we suggested that it would also lead to increased hepatic very low density (VLDL) triglyceride (TG) synthesis and secretion. In the current study we have quantified these four metabolic variables in 16 nonobese human subjects with plasma TG concentrations less than 175 mg/dl. The results demonstrate the following degree of correlation: insulin resistance (Formula: see text) insulin response to food (Formula: see text) VLDL-TG secretion rate (Formula: see text) plasma TG concentration. These data indicate that nonobese subjects with normal TG levels have the same relationship between degree of insulin sensitivity, insulin response to food, VLDL-TG secretion, and TG concentration previously described in patients with endogenous hypertriglyceridemia.

Effect of source of dietary carbohydrate on plasma glucose and insulin responses to test meals in normal subjects

Plasma glucose and insulin responses were measured in 22 subjects after two meal tolerance tests that varied only in the food source of carbohydrate. Each meal contained 45% carbohydrate, 15% protein, and 40% fat and provided 40% of calculated daily caloric requirement. The meals elicited a similar glucose response; however, the insulin response was significantly lower when rice and corn supplied the carbohydrate as compared to potato and gelatin. The total insulin response, calculated as area under the response curve, was 60% (P less than 0.001) greater in the meal with potato and gelatin versus the rice and corn meal.

Mechanism of hypertriglyceridaemia in diabetic patients with fasting hyperglycaemia

Several aspects of lipid metabolism were studied to define the mechanism of hypertriglyceridaemia in insulin-independent diabetic patients with fasting hyperglycaemia. Patients with insulin-independent diabetes were more obese (p < 0.001) and had a significantly (p < 0.001) higher mean (+/- SEM) fasting plasma triglyceride concentration (387 +/- 66 mg/dl) than did either insulin-dependent diabetics (133 +/- 11 mg/dl) or normal (73 +/- 1 mg/dl) subjects. Very low density lipoprotein secretion rate was also significantly (p < 0.01 - < 0.001) higher in patients with insulin-independent diabetes (14.65 +/- 1.37 mg/kg/h) as compared to 7.64 +/- 0.60 mg x kg/h and 9.86 +/- 0.75 mg/kg/h in normal subjects and patients with insulin-dependent diabetes, respectively. However, the relationship between plasma triglyceride concentration and very low density lipoprotein-triglyceride secretion was similar in diabetics and in normals. The diabetic groups had equivalent degrees of fasting and postprandial hyperglycaemia, and comparable elevations of fasting plasma nonesterified free fatty acid levels (insulin-independent = 0.72 +/- 0.07 mmol/L, insulin-dependent = 0.63 +/- 0.08 mmol/L). Postprandial plasma insulin concentrations, however, reached normal levels in insulin-independent diabetics and were higher (p < 0.001) than in insulin-dependent diabetics. Thus, hypertriglyceridaemia in insulin-independent diabetics with fasting hyperglycaemia was associated with increased hepatic very low density lipoprotein-triglyceride secretion, and normal plasma insulin levels. The lower triglyeride levels in the insulin-dependent diabetics is assumed to be due to their relative hypoinsulinaemia.

Effect of a high carbohydrate diet on insulin binding to adipocytes and on insulin action in vivo in man

We studied the effects of short-term (5 days) and long-term (2 wk) high carbohydrate (75%) feedings on insulin binding to isolated adipocytes and insulin sensitivity in vivo in normal subjects. Ingestion of the high carbohydrate diet led to daylong hyperinsulinemia in both short- and long-term groups. Insulin binding to isolated adipocytes was decreased in both groups; in the short-term groups this decrease in insulin binding was caused by a decrease in the receptor affinity, whereas in the long-term group it was caused by a decrease in receptor number. On the other hand, despite this decrease in insulin binding, total in vivo insulin sensitivity was markedly improved in both groups. In conclusion, (1) the short-term adaptive response of the insulin receptor is a decrease in binding affinity whereas the long-term response is a decrease in receptor number, (2) sustained and chronic hyperinsulinemia can lead to a decrease in the number of cellular insulin receptors, (3) high carbohydrate diets lead to a general increase in insulin's ability to promote glucose removal from plasma, and (4) the paradox of enhanced insulin sensitivity in the face of decreased insulin binding can be explained if high carbohydrate diets also lead to an increase in the activity of steps in glucose metabolism distal to the insulin receptor.

The effect of ten days of fasting on various aspects of carbohydrate metabolism in obese diabetic subjects with significant fasting hyperglycemia

Patients with nonketotic diabetes mellitus, who were both obese and had significant fasting hyperglycemia (mean plasma glucose = 310 mg/100 ml), were fasted for 10 days. There was a prompt drop of plasma glucose levels as the result of the caloric deprivation with a mean fall of approximately 200 mg/dl at the end of the fast. The drop in plasma glucose level that occurred during the fast was associated with a drop in plasma insulin level. Fasting plasma glucose concentration rose immediately after food intake was resumed and stabilized within 3--4 days at levels halfway between the initial and the lowest value. At this time, the patients also seemed capable of disposing of an oral glucose load more efficiently. The apparent improvement in carbohydrate homeostasis observed after the fast could not be attributed to an increase in insulin response, but was associated with some amelioration of the insulin resistance that characterizes these patients. Unfortunately, the beneficial effects of the 10-day period of caloric deprivation were transitory and fasting plasma glucose values had returned to prefast levels in most patients within a few months.

Development of Bragg diffraction imaging for medical use

Experience gained in developing a real-time acoustical imaging system using Bragg diffraction is presented. Particular emphasis has been placed on medical applications. We have studied the difficulties in assembling a system capable of producing high-quality images. Engineering data on the optical mounting and on the design of the transducer along with representative images are presented and discussed.

Effect of simultaneous potassium and saline loading on plasma aldosterone levels

To assess the relative importance of the renin-antiotensin system and potassium in the acute regulation of aldosterone secretion in the salt depleted state, normal subjects were infused with an asotonic saline solution containing potassium chloride (KCl) and the responses compared to the infusions of isotonic saline (500 ml/h) and KCl alone (20 mEq K+/h). Subjects were studied recumbent in balance on a 10 mEq sodium/100 mEq potassium diet. The rates of infusing saline and potassium were selected to produce comparable but opposite effects on the levels of plasma aldosterone. As plasma renin activity (PRA) declined and plama potassium increased during the combined saline-KCl infusions, plasma aldosterone levels appeared to be the arithmetic sum of the changes in these parameters. In fact, the calculated changes in aldosterone levels per unit change in PRA or potassium from each infusion alone, correlated well with the observed levels, further supporting an additive relationship. These data support the concept that in the salt depleted state the renin-angiotensin system and potassium are equally important in the acute regulation of plasma levels of aldosterone.

A delayed suppression of the renin-aldosterone axis following saline infusion in human hypertension

The purpose of this study was to compare the acute suppressibility of the renin-angiotensin-aldosterone (RAA) axis in normotensive (n = 23) and essential hypertensive (n = 62) subjects. Only those hypertensive subjects with normal plasma renin activity (PRA) levels (sodium restricted, upright) were included in the study. Acute suppression of the RAA axis was determined by measuring PRA, plasma angiotensin II (A II), and plasma aldosterone (PA) at frequent intervals during the infusion of isotonic saline (500 ml/hour for 6 hours). Although all parameters fell significantly from control levels by 20-30 minutes in the normotensive subjects, we found that 60% of the hypertensive subjects showed no significant decline in PRA or PA until 120-240 minutes after beginning the infusion. The other hypertensive subjects showed normal RAA suppression. In addition, while there were no significant differences between the three groups in control PRA or PA levels, we found that the PA levels from 30 to 240 minutes during the saline were significantly higher (P less than 0.01) in the hypertensive subjects with delayed suppression. That there were two distinct populations in the hypertensive group was suggested by the bimodality of the frequency response curve, with peaks occurring at 30 and 240 minutes. These studies indicate an abnormality in the acute suppression of the RAA axis in a substantial proportion of subjects with normal renin essential hypertension. Since previous studies in normal subjects have reported that the early phase of response to saline infusion is related to the sodium ion per se and not to intravascular volume expansion, we have come to the conclusion that the present data are consistent with the hypothesis that the delayed suppression hypertensive group has a diminished ability to respond to the sodium ion.

Hospital libraries: focal point in the continuing education crisis

The Proposed Requirements for Professional Libraries in Hospitals to be Licensed in the Commonweath of Pennsylvania are presented and discussed. Indication is given of current trends in the development of hospital libraries as the single most important factor in continuing medical education and as the least-developed factor.