Get With The Guidelines® is a program that helps ensure consistent application of the most recent American Heart Association/American Stroke Association scientific guidelines for patient treatment. The program includes in-hospital modules for heart failure, stroke and resuscitation as well as a program for outpatient practices.

February is American Heart Month

The American Heart Association’s Get With The Guidelines-Outpatient has become The Guideline Advantage™ in collaboration with American Cancer Society and American Diabetes Association.

Mission: Lifeline® is a national, community-based initiative created by the American Heart Association to improve systems of care for patients with ST-elevation myocardial infarction (STEMI). The program focuses on streamlining and coordinating processes to help speed the delivery of appropriate treatment.

Target: Heart Failure is an initiative that provides healthcare professionals with content-rich resources and materials designed to help them advance heart failure awareness, prevention, treatment and recovery.

Target: Stroke is a campaign created to help hospital teams achieve the goal of door-to-needle (DTN) times of 60 minutes or less for ischemic stroke patients that receive thrombolytic therapy by providing evidence-based strategies, clinical decision support, measurement tools and other resources.

More resources for healthcare professionals are available on the American Heart Association’s website.

Source: The American Heart Association

Osteoporosis and heart failure are common, chronic and costly conditions that share common etiologic factors like older age, post-menopausal status and diabetes. Previous studies have suggested that heart failure may predispose a patient to fractures not only because it increases incidence of falling, but because both heart failure itself and its medical treatments can lead to loss of bone mass.

“Our study demonstrates for the first time that heart failure and thinning of bones go hand in hand,” said Sumit Majumdar, MD, of the University of Alberta in Edmonton, Canada, and lead author of the study. “Understanding the mechanism between heart failure and osteoporosis might lead to new treatments for both conditions.”

In this study, researchers conducted a population cohort study consisting of 45,509 adults undergoing bone mineral density testing for the first time and followed them for up to ten years. Of the 45,509 adults included in the study, 1,841 had recent-onset heart failure. After adjusting for traditional osteoporosis risk factors, researchers found that heart failure was associated with a 30% increase in major fractures.

“Part of screening for osteoporosis should involve looking at chest X-rays of patients with heart failure,” said Majumdar. “Heart failure patients get a lot of X-rays and they often incidentally show many fractures of the spine that would automatically provide an indication of severe osteoporosis and need for treatment.”

Other researchers working on the study include: Justin Ezekowitz of the University of Alberta; Lisa Lix of the University of Saskatchewan in Saskatoon, Canada; and William Leslie of the University of Manitoba in Winnipeg, Canada.

The article, “Heart Failure is a Clinically and Densitometrically Independent Risk Factor for Osteoporotic Fractures,” appears in the April 2012 issue of JCEM.

Source: Endocrine Society

Nurses indicated that, despite the implementation of electronic medical records, much of their time away from the bedside is spent documenting orders in multiple places and for regulatory purposes and completing checklists and paperwork.  Less time consuming non-patient care activities include coordinating care between hospital departments and with other caregivers, restocking supplies and preparing medication.

“Our nurses are telling us that while they are now entering orders electronically, they still have to manage many of their activities and records on paper,” said President of Jackson Nurse Professionals, Scott L’Heureux.

His company, along with Care Logistics, partnered with Jackson Healthcare to complete the second biennial study of more than 400 nursing professionals across the country.

In the study, the nurses were asked for recommendations on how to reduce the amount of time spent on indirect patient care.  Solutions frequently offered by study participants include increased staffing resources and more efficient, simplified charting.

“There is a substantial amount of benefit for nurses that can be gained by looking at the processes that support the management and movement of patients within a hospital,” said Karl Straub, President of Care Logistics.

Further details of this survey can be found at www.jacksonhealthcare.com/research.

Findings from this survey are based on data collected from 420 nursing professionals from July to November 2011.  The survey has an error range of +/- 4.8% at the 95% confidence level.

Source: Jackson Healthcare

Oral bisphosphonates are currently taken by some 3 million women in the United States for the prevention or treatment of osteoporosis. In addition, intravenous bisphosphonates are given to thousands of cancer patients each year to control the spread of bone cancer and prevent excess calcium (hypercalcemia) from accumulating in the blood. Bisphosphonates work by binding to calcium in the bone and inhibiting osteoclasts, bone cells that break down the bone’s mineral structure.

“These drugs have been widely used for years and are generally considered safe and effective,” said study leader Athanasios I. Zavras, DMD, MS, DMSc, associate professor of Dentistry and Epidemiology and Director of the Division of Oral Epidemiology & Biostatistics at the Columbia University College of Dental Medicine. “But the popular literature and blogs are filled with stories of patients on prolonged bisphosphonate therapy who were trying to control osteoporosis or hypercalcemia only to develop osteonecrosis of the jaw.”

Osteonecrosis of the jaw, or ONJ, often leads to painful and hard-to-treat bone lesions, which can eventually lead to loss of the entire jaw. Among people taking bisphosphonates, ONJ tends to occur in those with dental disease or those who undergo invasive dental procedures.

There are no reliable figures on the incidence of ONJ in patients taking oral bisphosphonates. Estimates range from 1 in 1,000 to 1 in 100,000 patients for each year of exposure to the medication, according to the American College of Rheumatology. ONJ is more common among cancer patients taking the intravenous form of the drug, affecting about 5 to 10 percent of these individuals, noted Dr. Zavras.

Studies have suggested that genetic factors play a major role in predisposing patients to ONJ.  Delving deeper into this question, Dr. Zavras and his colleagues performed genome-wide analyses of 30 patients who were taking bisphosphonates and had developed ONJ and compared them with several bisphosphonate users who were disease free.

The researchers found that patients who had a small variation in the RBMS3 gene were 5.8 times more likely to develop ONJ than those without the variation. The study also identified small variations in two other genes, IGFBP7 and ABCC4, that may contribute to ONJ risk.

“Our ultimate goal is to develop a pharmacogenetic test that personalizes risk assessment for ONJ, a test that you could give to people before they start to use bisphosphonates,” said Dr. Zavras. “Those who are positive for this genetic variation would select some other treatment, while those who are negative could take these medications with little fear of developing ONJ.”

“At the moment, many women discontinue or avoid treatment for serious osteoporosis because they are afraid of losing their jaw bones,” added Dr. Zavras. “There even are reports of dentists who have refused to perform certain invasive procedures in patients taking bisphosphonates. So there is a great need for a pharmacogenetic screening test to determine which patients are really at risk for ONJ.”

The current study looked only at Caucasians. Further studies are needed to determine whether the RBMS3 gene variation is seen in other racial groups, according to the researchers.

“Genomewide Pharmacogenetics of Bisphosphonate-Induced Osteonecrosis of the Jaw: The Role of RBMS3,” was published in The Oncologist, and is freely available online.

Source: The Oncologist

New research from the University of North Carolina at Chapel Hill School of Medicine has opened a door to the answer. Researchers led by William E. Goldman, PhD, professor and chair of microbiology and immunology at the University of North Carolina at Chapel Hilland a leading authority on Y. pestis, show that the plague bacteria transform the lungs from a nasty place for microbes into a playground for them to flourish.

The research appears online in the Proceedings of the National Academy of Sciences during the week of Monday January 30, 2012.

Virulent Y. pestis bacteria (red) quickly establish a permissive environment for the growth of non-virulent microbes (green) that would normally be eliminated by lung’s immune mechanisms.

Goldman notes that most other microbes that infect the lungs trigger an antimicrobial response within a few hours after infection. This early inflammatory response is generally sufficient to eliminate microorganisms with no more than mild respiratory symptoms. Not so with Y. pestis; for about 36 hours, the lungs are “quiet,” not inflamed, and symptoms are completely absent.

But in the first 36 hours of infection, plague bacteria are having a field day, growing and reproducing rapidly – 2-fold, 100-fold, 100,000-fold – and all of that without outward disease symptoms or measurable changes in lung tissue.

“And then, rather abruptly, symptoms start to appear,” Goldman says. “They progress rapidly to the point where you realize this is not just a cold, this is not just the flu. But by then the disease has progressed too far for effective medical intervention, and death is likely within the next day or two.”

And once people have pneumonic plague, the bacteria can spread via respiratory droplets to others who have close contact with them. The US Centers for Disease Control and Prevention notes that during the delay between being exposed to Y. pestis and becoming seriously sick, people could travel over a large area, possibly infecting others, which could make the infection more difficult to control.

“Here’s the question we wanted to answer: Is the organism avoiding detection or is it actually suppressing the immune responses of the lung?” Goldman said. “The paper is really about the experiments designed to distinguish between these possibilities. And the answer we found suggests the latter.”

In their “co-infection” experiments, the UNC study team mixed together a fully virulent Y. pestis strain and a mutant strain known not to be infectious in that it lacked the components essential for it to be a pathogen. The mix was then given to a single laboratory animal.

“The expectation would be that the virulent strain would do an excellent job of infecting the host. And the non-virulent strain would get killed by the host,” Goldman said. “But in our experiments, the non-virulent strain would actually grow very well, almost as well as the virulent strain, and we would see this with any non-virulent strain of Y.pestis.”

And then the study team tried other microbes, different lung pathogens and an assortment of random microbes – “including the sort of organisms you inhale all the time and that are disposed of easily by the lungs’ standard defense mechanisms. But as long as the virulent bacteria were present, the non-virulent organisms would grow,” Goldman said.

“There is no other microbe that does that, no other inhaled organism that in a matter of minutes or hours transforms the lung into such a permissive environment for microbial proliferation,” he added.

Goldman points out that not much evolutionary distance exists between Yersinia pestis and its closest ancestor, Yersinia pseudotuberculosis, which causes a much milder disease.

“Our work shows that of these two species, only Y. pestis has the ability to transform the lung into an environment that permits an extended period of unrestricted microbial proliferation with no symptoms. Looking at the genetic differences between these two species may reveal the mechanism responsible for this phenomenon exclusive to Y. pestis, and that may lead to new therapeutic strategies for pneumonic plague.”

UNC study coauthors were graduate student Paul A. Price, and Jianping Jin, PhD, of the UNC Center for Bioinformatics.

Source: University of North Carolina at Chapel Hill School of Medicine

“Our military personnel and their dependents deserve the best anesthesia care, and CRNAs are privileged to provide it to them,” said Debra Malina, CRNA, MBA, DNSc, president of the American Association of Nurse Anesthetists (AANA).  “We commend the Air Force for making these policy improvements, which were developed collaboratively within the Air Force by CRNAs, nurses and physicians. Formal recognition of the outstanding care our military CRNAs provide, through an unencumbered scope of practice policy, is based on existing scientific evidence and current best practices.”

Photo Source: www.aana.com

CRNAs provide the majority of anesthesia services to the US armed forces at home and abroad, including the USAF.  They are often the only anesthesia professionals deployed in front-line military facilities. In 2011, 142 active duty CRNAs served in the Air Force.

The updated policy, Air Force Instruction 44-102, was publicly issued on January 20 by the Secretary of the Air Force and replaces regulations dating to 2006.  A collaborative process involving USAF physicians, nurse anesthetists, and other healthcare professionals led to the following important changes:

• The USAF’s new Anesthesia Policy, Practice and Services demonstrates a commitment to professional collaboration among CRNAs and physician anesthesiologists in the interest of patient safety and access to care. Significantly, the policy states “Traditionally, ACT [anesthesia care team] referred to a CRNA working in a medical directed environment with an Anesthesiologist. However, in the [new policy], ACT refers to any combination of Anesthesiologist or CRNA working as a team…. The ACT concept is thus collaboration among anesthesia providers in the delivery of anesthesia and its related services.”
• The new policy authorizes directors of USAF treatment facilities to name either a CRNA or anesthesiologist as chief of anesthesia.
• The new policy closely mirrors similar policies in place in the U.S. Navy, promoting consistent patient care by advancing joint, common healthcare delivery and practice rules across military healthcare facilities worldwide.

Among the scientific evidence considered by the USAF was the landmark 2010 Institute of Medicine report titled “The Future of Nursing: Leading Change, Advancing Health,” and a 2010 research study published in the preeminent health policy journal Health Affairs titled “No Harm Found when Nurse Anesthetists Work Without Supervision by Physicians.” The publications underscored the patient safety, access to care, and cost-effectiveness benefits associated with policies promoting the use of CRNAs and other advanced practice registered nurses (APRNs) to their full scope of practice.

• A summary of the Institute of Medicine “Future of Nursing” recommendation
• The Health Affairs paper

Source: American Association of Nurse Anesthetists

Lead researcher, Thoralf Liebs, theorized that the pressure of the water helps reduce fluid buildup in the knee joint, thereby resulting in less pain. AquaHab Physical Therapy – a multi-clinic practice serving the Greater Philadelphia area – saw similar positive outcomes for a patient who had undergone a TKR in both knees, according to a recent case study documented by Tate Rice, Director of AquaHab Physical Therapy.

The subject of the AquaHab Physical Therapy case study was referred to the clinic in October 2011, after having a TKR of the right knee earlier in the month. He subsequently underwent a TKR of the left knee at the beginning of November. His past medical history included a total hip replacement in 2009 and a lumbar laminectomy in 2008, as well as hypertension and Multiple Sclerosis (MS). While AquaHab Physical Therapy offers both aquatic and land therapies, the patient’s therapist determined that he would be best served by an aquatics-based program due to his high subjective report of pain, history of severe back pain, and MS-related balance issues. The referring surgeon was consulted and approved the treatment plan.

Among the goals of the treatment were improving the patient’s strength, endurance, and range of motion while minimizing his pain. His movements were affected by the severity of his pain, so he was submerged in chest-deep water to minimize the force of gravity and his own body weight while focusing on proper gait technique. As his strength improved and pain decreased, he was able to transition to four-foot deep water to increase the joint load, and was eventually able to walk on land without difficulty. He followed a similar process for stairs, beginning by climbing up and down steps in deeper water and progressing to four-foot deep water over time. Upon completion of his physical therapy, he was able to manage the full flight of stairs in his home without pain – an important achievement given that his bedroom and bathroom were located on the second floor.

The treatment plan devised by AquaHab Physical Therapy also addressed other deconditioning and balance issues. The patient had been inactive for more than a year due to osteoarthritis of the knee and chronic back pain, and had become deconditioned. By exercising in the pool, he was able to complete 15 to 30 minutes of continuous aerobic exercise without pain, thereby building up his activity endurance. He was also able to work on his MS-related balance issues in the pool without the risk of falling or injury. His physical therapist started him out with the aid of assistive equipment, which was phased out as the patient’s balance improved. In addition, the therapist performed manual stretching after each aquatic session, which helped to increase the patient’s range of motion, and developed a home exercise program that helped the patient maintain his progress and momentum between visits.

“By the time this patient completed physical therapy for both the left and right knees, his outcomes were excellent,” said Rice. “In my professional opinion, the use of aquatic physical therapy allowed this patient to progress much faster than he would have otherwise. His compliance with physical therapy and an extensive home exercise program, along with hands-on treatment by his therapist, also played significant roles. Aquatic therapy allowed the patient to work on his range of motion, balance, cardiovascular endurance, and functional abilities while taking advantage of water’s natural buoyancy to control joint compression and mediate pain. A traditional land-based program would not have been able to deliver results like these within the same timeframe.”

Source: AquaHab Physical Therapy

The DSM, from the American Psychiatric Association, is the standard reference for the diagnosis of mental disorders and has an important influence on insurance coverage and access to educational support and therapeutic services, as well as research.

The new, more restrictive criteria would combine three subgroups on the autism spectrum into one category and require a child to display more pronounced symptoms to qualify for a diagnosis. The effect may be that it is harder for some more mildly affected children to qualify for insurance to cover therapeutic and educational support services.

Jennifer A Pinto-Martin, PhD, MPH Viola MacInnes/Independence Professor of Nursing, Chair, Department of Biobehavioral Health Sciences

Rather than debate about whether changes in diagnostic criteria are warranted or wise, the focus should be on the effects such a change would have, says Dr. Pinto-Martin, who directs the Center for Autism and Developmental Disabilities Research and Epidemiology (CADDRE) at Penn Nursing. CADDRE is one of six centers funded by the Centers for Disease Control (CDC) to study the prevalence and causes of autism spectrum disorders.

“The proposed changes raise important issues for both the parents of children on the autism spectrum and researchers focused on understanding the trends and risk factors for autism,” says Dr. Pinto-Martin. She is the lead researcher in the first large-scale study to find a link between low birthweight and children diagnosed with autism. Dr. Pinto-Martin’s work, supported by a $3 million grant from the National Institute of Mental Health, showed that premature infants are five times more likely to have autism than children born at a normal weight. The study appeared in the journal Pediatrics in October.

For families, the change provides an opportunity to seek educational support and therapeutic services that are tailored to the specific needs of their child rather than the one-size-fits-all approach so common today, says Dr. Pinto-Martin. By separating children into more homogeneous groups with respect to their needs and challenges, therapies can be designed to target the specific needs of each group.

“The challenges faced by children who function at the higher end of the spectrum would not diminish with a change in diagnostic criteria,” says Dr. Pinto-Martin. “Seeking ways to better address therapy and educational support needs of all children with autism must be a commitment and a goal in the face of changing eligibility.”

For autism researchers, she says, the proposed changes are both good and bad. The search for the cause of autism has been hampered by the heterogeneity of those who fall under the umbrella of the autism spectrum. Many researchers believe that the various sub-types of autism may have differing causes, just as there are different causes for the numerous types of cancer.

Refining the diagnostic criteria could help to sort those with the disorder into a more homogeneous group by requiring greater clarity and consistency in symptom presentation, says Dr. Pinto-Martin. This would enhance research efforts focused on uncovering risk factors for autism by refining the group under consideration. This is the strategy researchers follow for uncovering risk factors for cancer, sorting patients by the specific type of cancer and then looking for risk factors in that group. While there are some common risk factors across cancer types, there are also risk factors that are specific to each type. Researchers expect the same will be true for the sub-types of autism such as autistic disorder, pervasive developmental delay, and Asperger disorder.

Monitoring changes in the prevalence of autism over time, another important, ongoing research initiative, could be hampered by changes in the way children are labeled, Dr. Pinto-Martin explains. Tracking prevalence is one of the major tools in epidemiologic investigations because it gives important clues about etiology. Autism researchers may be faced with a decrease in prevalence due to a change in the way the diagnosis is defined. Sorting out any actual change in risk from an artificial increase or decrease due to a change in the size of the diagnostic umbrella will be made more difficult.

Says Dr. Pinto-Martin: “We must be cognizant of the potential effect of a decrease in reported prevalence using the new DSM criteria from research and clinical perspectives, and pay careful attention to the real and ongoing needs of children and families who are coping with autism, no matter the criteria used to make the diagnosis.”

Source: University of Pennsylvania School of Nursing

According to the Centers for Disease Control and Prevention, approximately 74% of the adult US population age 20 years and older is either overweight or obese, and that percentage is expected to increase. The new Lockton report, “Ten Safety Steps to Enhance Bariatric Patient Care,” suggests ways for organizations can adjust to accommodate a heavier population. Lockton is the world’s largest privately held insurance broker and a leading safety and risk management advisor to healthcare providers.

Said Lockton’s Lori Severson, co-author of the report, “Training employees how to lift and move heavier patients and how to communicate respectfully with them are vitally important skills.”

The report also recommends incorporating bariatric design guidelines from the Facility Guidelines Institute (GFI) and incorporating state-of-the-art lifts, for example.

Healthcare organizations that adopt these suggestions will differentiate themselves in the healthcare marketplace, distinguishing themselves as the experts on providing dignified care to bariatric patients.

The report is written by Lori Severson, Lockton Loss Control Consultant, and Dr. Ian Chuang, MD, Lockton Medical Director.  The American Society of Safety Engineers recently honored Severson as its Healthcare Practice Specialty Safety Professional of the Year in 2011.

“Healthcare facilities can define themselves as experts in providing dignified bariatric care, and this can mean greater customer satisfaction, efficiency, profitability, and professional standing,” said Dr. Chuang.

Source: Lockton