Wednesday, March 28, 2012

The Loss of Empathy in Nursing Education

Laurie Scudder, DNP, NP


Posted: 03/12/2012

The Empathy Enigma: An Empirical Study of Decline in Empathy Among Undergraduate Nursing Students
Ward J, Cody J, Schaal M, Hojat M
J Prof Nurs. 2012;28:34-40.

Study Summary
Background: Empathy is central to the nursing role and has been found to be associated with improved patient outcomes and greater satisfaction with care. Empathy is defined here as a cognitive, rather than emotional, skill that includes the ability to understand a patient's experience and communicate in a manner that conveys a recognition of patient concerns and perspectives. The skill of empathy must be integrated into the process of absorbing the social role of the profession that student nurses learn throughout their education. In an increasingly complex and technology-laden healthcare environment, nursing students are so focused on the science of nursing that they might neglect the art, which includes the empathetic communication that is the heart of the nurse-patient relationship. The purpose of this study was to examine changes in empathy during the student experience.

Methodology: This longitudinal cohort study was conducted with 214 undergraduate nursing students drawn from 3 programs at a single institution: an associate degree program, a bachelor's degree program, and a facilitated post-degree program open to students who had earned a previous degree in another discipline. At the beginning of the academic year, students completed a survey containing questions about demographics, academic background, and future career plans. They also completed the Jefferson Scale of Empathy, which was adapted for nursing students from the Jefferson Scale of Physician Empathy. The empathy scale was readministered at the end of the school year.

Results: Participants were predominantly women (84%) and white (74%). Of the one third of the group with a previous undergraduate degree (n = 83), more than half (59%) held a degree in the sciences, with smaller numbers holding degrees in the humanities (29%) or business-related fields (12%). A statistically significant decline in empathy occurred in the total sample from the start to the end of the academic year, a decline that was small and, on the basis of an effect size of -0.16, determined to be of no practical importance. However, the magnitude of the decline was important in some subgroups, including Asian students (effect size of -0.62) and those with previous degrees in business (effect size -1.37) and the sciences (effect size -0.46). Of greater importance, a clinically relevant decline was found in students with more clinical exposure. In other words, as students gained more clinical exposure, they demonstrated a much greater decline in empathy scores over the year than did those with limited clinical experience during that year. This finding extended to students with previous work experiences in the clinical setting, who also evidenced declines in empathy of practical importance, with an effect size of 0.57.

Viewpoint
This study, which captures the experiences of a group of students at a single institution over a single academic year, has important limitations. However, the results echo those of previous studies that found that younger nurses and those with less clinical experience were more empathetic. Research has documented similar reductions in empathy in medical students as they progress through the years of school. Why is this? Although no single factor can likely explain this phenomenon, Ward and colleagues speculate that several factors contribute to this decline, including lack of time (which limits opportunities for empathetic patient communication), anxiety, lack of support from colleagues, an intimidating educational environment, and expanded roles for nurses, which require increased technical skills. It is likely that all are contributing factors. However, the role of education must be examined with its increasing use of technology-driven models such as distance education, which limits opportunities for students to interact with faculty, thus minimizing opportunities for role-modeling. The researchers (all faculty members) suggest a number of commonsense strategies for incorporating empathy training into nursing education, including:

•improved attention to selection of preceptors who will serve as positive role models;
•provision of pseudohospitalization experiences to allow students to see the hospital experience through a patient's eyes;
•use of standardized patients for role-playing;
•recordings of student-patient interactions for later examination and identification of positive and negative behaviors; and
•recognition and reward for empathetic behavior.
Clearly, students must learn the science of nursing. However, until the art of nursing is recognized as a necessary criterion for successful completion of coursework and as important as passing an exam, students will likely continue to demonstrate behaviors that make them good technicians but not necessarily very good nurses.

Medscape Nurses © 2012 WebMD, LLC

Monday, March 26, 2012

Bad aides

We had some students have really negative experiences at clinical this week. (We had some with really great experiences but that's not what I am writing about.)

I won't say where it happened because it doesn't matter and unfortunately it could have been anywhere.

We had two sisters who are white but are fluent in Spanish. They were with aides who spoke Spanish. Both their aides talked about the residents in Spanish while providing care. They called them names, made fun of them and showed a total lack of respect and no compassion. One resident asked if she could go to another floor to see a friend in the facility and the aide said in Spanish to the other aide that she didn't have any friends etc... Then told her no in English. The aide then began talking about the student in Spanish saying she was lazy and thought she was too good for her etc.... The student asked to be changed to another aide (and was). It wasn't until the end of the day that she told the aide she spoke Spanish. I have to admit I would have turned around and said something to her in Spanish very early in the day.

I called the director of the nursing home and relayed this incident today.

Second bad experience last week.
A student had a resident who wanted to go to his room. She was trying to distract him because she knew she wasn't allowed to put him in his bed by herself. He was so insistent that she took him to his room and sat with him. He became increasing agitated and wanted to get in bed. She called for help. An aide came in the room and the resident was slapping the aide’s hands. The aide started to yell at him and the resident tried to bite the aide and the aide SLAPPED HIM IN THE HEAD. Seriously.

If someone will do that in front of a student, doesn't it make you wonder what they will do when no one is watching?

The student told the instructor who talked to the nurse. The nurse talked to the Director who called me later in the day. Today I had the student talk to the Director. The student was concerned because the incident is getting reported to the state and she doesn’t want to be the cause of someone losing their certification. I had to remind her that she didn't cause anything and what happens isn't her call it's the states.

I tried this analogy. I shop at Wal-Mart and I price match and use coupons. Sometimes I annoy the crap out of the cashier. Would it ever be OK for the cashier to scream at me, call me names and slap be upside the head? Of course not. She’d get fired and the police would come. Why is it any different for our frail elderly confined to nursing facilities?

To our ccCNA students that advocate for the residents I say YOU ROCK!!!

You're the best.

Carol

Thursday, March 22, 2012

Connecting the dots: Students gather for Braille challenge

Connecting the dots: Students gather for Braille challenge
Education • Blind students who learn Braille stand a greater chance of landing a career.
By carol lindsay

Special to The Tribune


Published: March 22, 2012 10:49AM


Question: What did the finger say to the Braille dot?

Answer: You tickle me pink.

It was a fitting ice-breaker for Tony Jepson, executive director of the Utah Foundation for the Blind, in kicking off the Utah Regional Braille Challenge.

Blind and visually impaired students from across the state gathered in Salt Lake City this month to participate in a challenge that tested students’ speed and comprehension in Braille.

The competitors — ranging in age from 6 to 18 — used a Perkins Braille Writer to transcribe type and read Braille. The goal: To measure students’ reading comprehension, spelling, graph-reading ability and other academic skills.

The winners now will advance to a national competition in Las Vegas in June.

Nearly two centuries have passed since Louis Braille created the dot-based alphabet in 1824. Although it has been the primary written language for the blind for generations, not all blind students have chosen to learn the technique. That, teachers say, is unfortunate.

Studies show that only 30 percent of blind adults gain full-time employment. Ninety percent of those who beat the odds are Braille readers.

“Students need to have a way to read and imagine and take in information that is not just read to them,” said Brandon Watts, a teacher of the blind. “They need to create the images and ideas for themselves. Braille is more imaginative. It’s the difference between reading a book and listening to a book. They make up the voices and have a frame of reference. So it’s a lot more enjoyable.”

Watts works with parents who are hesitant to have their students take a Braille class because of concerns that the child will miss the opportunity to take another class such as a foreign language or Advanced Placement class.

“Some parents are intimidated by Braille, “ he said. “They feel like it will interfere with other educational experiences. So we try to fit in what they want, and the Braille.”

Braille is not so much a language as it is a code, according to Jepson.

“The most difficult part is developing tactile stimulation,” he said. “It is much harder for adults to develop that tactile discrimination than children. The younger we start, the better chance that they will become efficient.”

Although technology has additional options for the visually impaired, Jepson doubts that Braille will become obsolete.

“We have kids with low vision who read print, but struggle,” he said. “Braille is a good option. It would make them faster and more efficient. Some want to learn Braille. Some don’t. To learn anything, you have to have motivation. It takes instruction and practice, and that’s part of what the Braille competition is. We want to make it fun.”

Kyerra Limb, a ninth-grader at North Davis Junior High, suffered vision loss at 17 months after having a retinoblastoma in her eye. Kyerra began learning Braille when she was 3. She now works constantly on improving her Braille in case she loses all of her vision.

“The other day she was sitting in the dark reading Harry Potter,” her mother, Kim Limb, recalled. “I told her to flip on the light and she said, ‘Mom, I’m reading Braille.’ ”

One of the younger students at the competition was 8-year-old Sam Williams. Sam, a second-grader at the Utah Schools for the Deaf and the Blind, was born blind. He knows how to use Braille.

“I know the alphabet,” he said.

Jepson hopes the challenge will help kids enjoy practicing their Braille.

“We just try to have fun” he said.

closeup@sltrib.com


--------------------------------------------------------------------------------
© 2012 The Salt Lake Tribune
Connecting the dots: Students gather for Braille challenge
By carol lindsay

Special to The Tribune

Friday, March 16, 2012

Robert P. Krause; 90; engineer for first manned space flights; diabetic for 85 years

Founding member of St. Mary Magdalene Church
By Linda McIntosh

Wednesday, March 14, 2012

On his 90th birthday last year, Bob Krause set a record for being the first known American to live 85 years with diabetes. At his celebration luncheon, he didn’t eat anything because of his strict meal regimen.

That kind of discipline characterized his nearly nine decades of successfully coping with diabetes and went hand in hand with his career in engineering which led him to build rockets for the first manned space flights.

Mr. Krause, who received a medal from the Joslin Diabetes Center in Boston for his longevity, died of acute leukemia March 5 in San Diego, a few months before his 91st birthday.

He was diagnosed with diabetes at age 5 shortly after insulin became readily available and a year after his brother died of the disease. By age 6 he was injecting himself in the arms and legs, and learned early on to stay on top of his condition long before the current medical advancements.


His family recalled stories about how his mother kept him on a strict diet, weighing each piece of food he ate. He continued that regimen for his entire life, carefully monitoring his diet and blood sugar levels.

“He would often say he did not live to eat, he ate to live,” said his daughter, Anne Bowman. When he visited the doctor, he brought charts of his blood sugars along with reams of self-generated data he used to track his condition. “Mr. Krause was successful in living well with type 1 diabetes for over 85 years due to his unfailing diligence in self care,” said Dr. Patricia Wu, his internist at Kaiser Permanente. “He managed his blood sugar by testing 9-10 times daily, meticulously recording every result and using the results to guide his diet and insulin doses.”

Mr. Krause was born May 27, 1921 in Syracuse, N.Y. to Frank and Helen Krause and grew up in Detroit where his father worked for U.S. Rubber. He earned a bachelor of science degree from the University of Detroit and a master’s degree in engineering from the University of Washington in Seattle, serving as engineering professor there from 1947 until 1955, when he joined General Dynamics Convair Division in San Diego. He worked on the Atlas Rocket Program for launching the first Mercury astronauts, such as John Glenn and Alan Shepard during the “space race” years and was also involved in the cruise missile program. “Convair was ramping up a great brain trust of engineers in order to achieve the goal of manned spaceflight, and he was on the forefront of this venture,” Bowman said.

Mr. Krause was a founding member of St. Mary Magdalene Catholic Church in the 1950s, where he served as Eucharistic minister and lector. Bowman said her father had a deep faith in God. “He said God would allow life to throw people a curve in order to not be complacent and to see the greatness of God,” she said. At age 87 he joined the church choir as a baritone; although he was crippled with arthritis and used a walker, he could sing. “He was always prepared with his book marked and music ready; anyone who knew Bob loved him,” said Mary Kay Evanko, director of music and liturgy at St. Magdalene.

He is survived by his wife of 58 years, Kathleen Krause of Clairemont; daughter Anne Bowman of Bellevue Washington; son Tom Krause of San Diego; brother Jim Krause of Kaneohe, Hawaii; and eight grandchildren.

“Even to his last breath his blood sugar was normal and he was checking two days before he died. So you could say he beat diabetes all the way to the end. His life gave hope to so many,” Bowman said.

Services will be held at 11 a.m. on March 15 at St. Mary Magdalene Catholic Church, 1945 Illion St. Interment is at Greenwood Cemetery.


The family suggests donations to Dominican Mission Foundation based in San Francisco.

Monday, March 12, 2012

Coke and Pepsi change manufacturing process to avoid cancer warning

Coca-Cola and Pepsi are changing how they make an ingredient in their drinks to avoid being legally obliged to put a cancer warning label on the bottle.

The new recipe for caramel colouring in the drinks has less 4-methylimidazole (4-MEI) - a chemical which California has added to its list of carcinogens.

The change to the recipe has already been introduced in California but will be rolled out across the US.

Coca-Cola says there is no health risk to justify the change.

'No risk'

Spokeswoman Diana Garza-Ciarlante told the Associated Press news agency they wanted to ensure their products "would not be subject to the requirement of a scientifically unfounded warning".

Continue reading the main story
4-methylimidazole (4-MEI)

Formed naturally in the heating and browning process
Occurs in caramel colouring as well as some roasted and cooked foods
Can be in some cleaning, photographic and agricultural chemicals, dyes and pharmaceuticals
Exposure can be through consumption or during manufacturing process
Source: California Office of Environmental Health Hazard Assessment
The chemical has been linked to cancer in mice and rats, according to one study, but there is no evidence that it poses a health risk to humans, said the American Beverage Association, which represents the wider industry.

The US Food and Drug Administration (FDA) claims a person would need to drink more than 1,000 cans of Coke or Pepsi a day to take in the same dose of the chemical that was given to the animals in the lab test.

Coca-Cola and PepsiCo account for nearly 90% of the US fizzy drink market, according to one industry tracker, Beverage Digest.

The companies say changing their recipes across the whole of the US, not just in California, makes the drinks more efficient to manufacture.

In a statement Coca-Cola added that the manufacturing process across Europe would not change.

It said that apart from California "not one single regulatory agency around the world considers the exposure of the public to 4-MEI as present in caramels as an issue".

Correction: This story has been amended to make it clear that it was a manufacturing process that had changed, not the recipe of the drinks themselves.

Getting Flu Shot Tied to Hospital Workers' Beliefs

By Todd Neale, Senior Staff Writer, MedPage Today
Published: March 09, 2012

Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner


Action Points
This meta-analysis found that healthcare workers were twice as likely to get vaccinated against seasonal influenza if they believed that flu prevention is important, that the vaccine is effective, and that influenza is highly contagious.

Other predictors included having a family that is usually vaccinated and being willing to prevent flu transmission.


Among healthcare workers employed in hospitals, the strongest predictor of receiving the seasonal influenza vaccine was a belief in the importance of flu prevention, a meta-analysis showed.

That was one of several factors associated with more than double the likelihood of being vaccinated, Josien Riphagen-Dalhuisen, PhD, of the University of Groningen in the Netherlands, and colleagues reported online in Occupational and Environmental Medicine.

Other factors included a willingness to prevent transmission and believing the vaccine works.

"Future studies could use this information for their interventions and target the predictors that seem to have the most influence on vaccine uptake, and also focus on educating healthcare workers in order to prevent misinformation," the authors wrote.

The CDC, which recommends seasonal flu vaccination for all individuals older than 6 months, has identified healthcare workers as a priority because of the potential to spread infection to vulnerable patients.

And other organizations -- including Association for Professionals in Infection Control and Epidemiology (APIC), the American Academy of Pediatrics (AAP), and the Infectious Diseases Society of America (IDSA) -- have called for requirements for vaccination among healthcare workers.

Influenza vaccine coverage remains low in this group, however, ranging from 2.1% to 62% in the studies included in the current meta-analysis, all conducted before the 2009 H1N1 pandemic. Even after the pandemic, the rate reached only 63.5% in the U.S., according to a CDC survey.

To examine predictors of getting the vaccine, Riphagen-Dalhuisen and colleagues performed a meta-analysis of 13 non-interventional, cross-sectional studies that included a total of 84,880 hospital workers. Ten of the studies assessed vaccine uptake with a questionnaire and the other three used clinical records.

Six studies were conducted in the U.S., three in Europe, two in Canada, one in Australia, and one in several countries. In most of the study, the vaccine was provided for free by the hospitals and immunization was voluntary.

The strongest predictors of receiving the seasonal vaccine were the following:

Believing that flu prevention is important (RR 3.63, 95% CI 2.87 to 4.59)
Having a family that is usually vaccinated (RR 2.32, 95% CI 1.64 to 3.28)
Being willing to prevent influenza transmission (RR 2.31, 95% CI 1.97 to 2.70)
Believing that influenza is highly contagious (RR 2.25, 95% CI 1.66 to 3.05)
Knowing that the vaccine is effective (RR 2.22, 95% CI 1.93 to 2.54)

"We therefore recommend targeting these predictors when developing new influenza vaccination implementation strategies for hospital healthcare workers," the researchers wrote.

Demographic factors associated with vaccination were male gender, an age of 40 years or older, and being a physician (RRs 1.16 to 1.23). Being a nurse was negatively associated with receiving the vaccine (RR 0.90, 95% CI 0.88 to 0.91).

Other negative predictors included a belief that the vaccine transmits influenza (RR 0.67), a belief that vaccination is unpleasant (RR 0.68), and a preference for natural or complementary medicine (RR 0.26).

"Our findings are consistent with the results of previous reviews, which also suggested that raising awareness about vaccine effectiveness and the risks of influenza makes vaccination more likely to be accepted," the authors wrote.

They acknowledged that their study was limited by the inability to address how the predictors interacted with one another using multivariate analysis, and also by the lack of data on vaccine uptake during a pandemic.

"Some reports on pandemic influenza vaccination have shown predictors similar to those described here, although other predictors also might play a role in vaccine uptake," they wrote.

'Pink slime' panic grows online: Are we overreacting?

By Jane Weaver, Deputy health editor
Updated March 9: An online petition urging the government to stop the use of "pink slime" -- the scrape and waste meat products that are treated with ammonium-hydroxide -- in school food has collected almost 20,000 signatures over the last several days.

After reports that school districts around the country were serving kids hamburgers containing up to 15 percent of the processed product known in the meat industry as "Lean Finely Textured Beef', parents and consumers poured online to express their disgust. As of Friday afternoon "pink slime" became the most searched phrase on Google Trends and Twitter users were expressing their disgust on #pinkslime.

Danielle @danzerotti, a self-described "happily married mother of 4, tweeted "Another reason my 4 kids should be glad that I take the time to prepare their lunches at home every day. As much as I complain."

"Pink slime" is bits of meat and muscle salvaged from slaughterhouse floors that are treated with a pink chemical to kill any dangerous pathogens. According to an earlier report by msnbc.com, the unappetizing pink goo is widely used in the food industry as an anti-microbial agent in meats and as a leavener in bread and cake products. It's regulated by the U.S. Agriculture Department, which classifies it as "generally recognized as safe." Nevertheless, McDonald's, have said they are pulling the infamous "pink slime" from their hamburgers.

Although the chemical has been used in ground beef products sold commercially since the 1990s, the sudden concern erupted this week over the USDA's plans to ship 7 million pounds of the processed meat product to schools all over the country. School cafeterias nationwide receive part of the ground beef they serve from the USDA.

The USDA's continued purchase of pink slime for school lunches was first reported Monday by TheDaily.com, which spoke to two former microbiologists at the Food Safety Inspection Service.

"We don't know which districts are receiving what meat, and this meat isn't labeled to show pink slime. They don't have to under federal law," said Bettina Siegal, of TheLunchTray.com earlier this week. Siegal started the petition seeking to ban the ammonia-based waste from school menus. "We should step back and say, 'Why would we feed this to our kid?" said Siegal.

When asked whether the USDA would consider banning "pink slime" from school meat shipments, spokesman Michael Jarvis responded via email: “All USDA ground beef purchases for the National School Lunch Program must meet the highest standards for food safety. This includes stringent pathogen testing and compliance with all applicable food safety regulations. USDA has strengthened ground beef food safety standards in recent years and only allows products into commerce - and especially into schools -- that we have confidence are safe.”

New York nutritionist and msnbc.com contributor Elisa Zied (@elisazied ) said,"people have a right to know what exactly is in their food, so they can make a judgment whether to eat it or not," but shouldn't panic the meat was unsafe just because of the "yuk" factor. "Like with all food, this idea of pink slime in ground beef does speak to the fact that we need to mix up the foods we consume from all the basic food groups to minimize potentially harmful ingredients and maximize nutrient intake," said Zied.

The processed meat reportedly accounts for 70 percent of all ground beef consumed in the U.S.

KPRC contributed to this report
.

Catheter-Related Urinary Tract Infection

Catheter-Related Urinary Tract Infection
Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD
Catheter-related urinary tract infection (UTI) occurs because urethral catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation.[1] The presence of a urinary catheter is the most important risk factor for bacteriuria.

Once a catheter is placed, the daily incidence of bacteriuria is 3-10%. Between 10% and 30% of patients who undergo short-term catheterization (ie, 2-4 days) develop bacteriuria and are asymptomatic. Between 90% and 100% of patients who undergo long-term catheterization develop bacteriuria. About 80% of nosocomial UTIs are related to urethral catheterization; only 5-10% are related to genitourinary manipulation.

The presence of potentially pathogenic bacteria and an indwelling catheter predisposes to the development of a nosocomial UTI. The bacteria may gain entry into the bladder during insertion of the catheter, during manipulation of the catheter or drainage system, around the catheter, and after removal.

Enteric pathogens (eg, Escherichiacoli) are most commonly responsible, but Pseudomonas species, Enterococcus species, Staphylococcus aureus, coagulase-negative staphylococci, Enterobacter species, and yeast also are known to cause infection. Proteus and Pseudomonas species are the organisms most commonly associated with biofilm growth on catheters.

Risk factors for bacteriuria in patients who are catheterized include longer duration of catheterization, colonization of the drainage bag, diarrhea, diabetes, absence of antibiotics, female gender, renal insufficiency, errors in catheter care, catheterization late in the hospital course, and immunocompromised or debilitated states.

Guidelines for Catheter Use
Guidelines for Catheter Use
The 2009 Centers for Disease Control and Prevention (CDC) guidelines for prevention of catheter-associated urinary tract infections (UTIs) recommends catheter use only for appropriate indications. Catheter use and duration should be minimized in all patients, especially those at higher risk for catheter-associated UTI (eg, women, elderly persons, and patients with impaired immunity).[2]

Catheters should be kept in place only for as long as needed. Indwelling catheters placed in patients undergoing surgery should be removed as soon as possible postoperatively. The use of urinary catheters for treatment of incontinence in patients and nursing home residents should be avoided.[2]

The 2009 CDC guidelines recommend that clinicians avoid using systemic antimicrobials routinely to prevent catheter-associated UTI in patients requiring either short- or long-term catheterization.[2]

The 2009 Infectious Diseases Society of America (IDSA) guidelines for catheter-associated UTIs state that an indwelling catheter may be used at the patient’s request in exceptional cases and when other approaches to incontinence management have been ineffective.[3]

Long-term catheterization increases patient satisfaction but also increases mechanical complications. Contraindications include bleeding disorders, previous lower abdominal surgery or irradiation, and morbid obesity. Intermittent catheterization is an option, but most patients become bacteriuric within a few weeks; the incidence of bacteriuria is 1-3% per insertion.

According to the 2009 IDSA guidelines, if an indwelling catheter has been in place for more than 2 weeks at the onset of catheter-associated UTI and remains indicated, the catheter should be replaced to promote continued resolution of symptoms and to reduce the risk of subsequent catheter-associated infection.[3]

Improved management of catheter-related UTIs was approved as a National Patient Safety Goal for 2012.[4]
Diagnosis
Symptoms of catheter-related urinary tract infection (UTI) generally are nonspecific; most patients present with fever and leukocytosis. Significant pyuria is generally represented by more than 50 white blood cells (WBCs) per high-power field (HPF). Colony counts on a urine culture range from 100-10,000/mL.

Infections may be polymicrobial. Pyuria and elevated bacterial colony counts are seen in all patients in whom a catheter has been in place for more than a few days. In this situation, their presence is not synonymous with a UTI.

The 2009 Infectious Diseases Society of America (IDSA) guidelines define catheter-related UTI in patients whose urinary (urethral, suprapubic, or condom) catheter has been removed within the previous 48 hours by the presence of symptoms or signs compatible with UTI with no other identified source of infection along with 1000 or more colony-forming units (CFU)/mL of 1 or more bacterial species.[3]

If catheterization can be discontinued, the culture can be obtained in a voided midstream urine specimen. If an indwelling catheter has been in place for longer than 2 weeks at the onset of the UTI and is still indicated, it should be replaced, and the urine culture should be obtained from the freshly placed catheter.

Guidelines for Catheter Use
Treatment & Management
In some patients with bacteriuria, removal of the catheter suffices. To reduce the risk of urinary tract infection (UTI), antibiotic treatment may be considered in patients with asymptomatic bacteriuria that persists 48 hours after removal of a short-term indwelling catheter. A specimen for urine culture should be obtained before initiation of antibiotic therapy, because of the wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance.[3]

In patients whose symptoms resolve promptly, 7 days is the recommended duration of antibiotic treatment. In those with a delayed response or with bacteremia, 10-14 days of treatment is recommended. In patients who are not severely ill, a 5-day regimen of levofloxacin may be considered. In women older than 65 years who develop a UTI after removal of an indwelling catheter and who have no upper urinary tract symptoms, a 3-day antimicrobial regimen may be considered.[3]

Guidelines for Catheter Use
Prevention
Best practices should be followed for the prevention of healthcare-associated infections. Urinary tract infections (UTIs) are the most common hospital-acquired infections, with most attributed to the use of an indwelling catheter.[5] Healthcare providers should first ensure that there is a justifable indication for placement of a urinary catheter.[6]

Aseptic indwelling catheter insertion, a properly maintained closed-drainage system (with ports in the distal catheter for needle aspiration of urine), and unobstructed urine flow are essential for prevention of UTI. Because many of these infections occur in clusters, good hand washing before and after catheter care is essential.

Urinary catheters coated with silver alloy also reduce the risk of infection.[7] An alternative is to use the Lubricath (Bard Medical, Covington, GA), which has a hydrophilic coating that decreases tissue irritation and nosocomial UTIs. It is reasonable to use these more expensive catheters in patients who are at highest risk.

Systemic antimicrobial drug therapy has repeatedly been shown to lower the risk of UTI in catheterized patients; the greatest benefit was observed in those catheterized for 3-14 days. Most hospitalized patients already are receiving antibiotics for other reasons. Disadvantages include creating resistant organisms.

The 2009 Infectious Diseases Society of America (IDSA) guidelines advise against the routine addition of antimicrobials or antiseptics to the drainage bag of patients who are catheterized in an effort to reduce the risk of catheter-associated bacteriuria or catheter-associated UTI.[3]

One adult neurological intensive care unit implemented an evidence-based "UTI bundle" focused on the avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal. In a 30-month period, catheter-associated UTIs signficantly decreased (from 13.3 to 4.0 infections per 1000 catheter days), with a linear relationship between catheter use rate and catheter-associated UTIs

Contributor Information and DisclosuresAuthorJohn L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Chief EditorMichael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation

Additional ContributorsFrancisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

decubitus ulcer

Decubitus Ulcers
Author: Don R Revis Jr, MD; Chief Editor: John Geibel, MD, DSc, MA

The terms decubitus ulcer and pressure sore often are used interchangeably in the medical community. Decubitus, from the Latin decumbere, means "to lie down." Decubitus ulcer, therefore, does not adequately describe ulceration that occurs in other positions, such as prolonged sitting (eg, the commonly encountered ischial tuberosity ulcer). Because the common denominator of all such ulcerations is pressure, pressure sore is the better term to describe this condition.

Advanced sacral pressure ulcer shows the effects of pressure, shearing, and moisture.
Heel pressure ulcer.
Recent studies
A study by Howard and Taylor found the incidence of pressure sores in nursing home residents in the southeastern United States to be higher in black patients than in white ones. The authors examined data from 113,869 nursing home residents, none of whom had pressure sores at nursing home admission. They determined that 4.7% of black residents developed postadmission ulcerations, compared with 3.4% of white residents. In addition, the racial differences in pressure sore incidence displayed a sex predilection based on patient characteristics. The variation in incidence between black and white males occurred in residents who were dependent in mobility, while in females, such variation occurred in black and white residents who were bedfast and living in nursing homes with fewer than 200 beds.

History of the Procedure
Pressure sores have probably existed since the dawn of our infirm species. They have been noted in unearthed Egyptian mummies and addressed in scientific writings since the early 1800s. Presently, treatment of pressure sores in the United States is estimated to cost in excess of $1 billion annually.

Problem
Pressure is exerted on the skin, soft tissue, muscle, and bone by the weight of an individual against a surface beneath. These pressures are often in excess of capillary filling pressure, approximately 32 mm Hg. In patients with normal sensitivity, mobility, and mental faculty, pressure sores do not occur. Feedback, conscious and unconscious, from the areas of compression leads individuals to change body position. These changes shift the pressure prior to any irreversible tissue damage.

Individuals who are unable to avoid long periods of uninterrupted pressure over bony prominences—a group of patients that typically includes elderly individuals, persons who are neurologically impaired, and patients who are acutely hospitalized—are at increased risk for the development of necrosis and ulceration. These individuals cannot protect themselves from the pressure exerted on their body unless they consciously change position or have assistance in doing so. Even the most conscientious patient with an extensive support group and unlimited financial resources may develop ulceration resulting from a brief lapse in avoidance of the ill effects of pressure.
Two thirds of pressure sores occur in patients older than 70 years. The prevalence rate in nursing homes is estimated to be 17-28%.

Among patients who are neurologically impaired, pressure sores occur with an annual incidence of 5-8%, with lifetime risk estimated to be 25-85%. Moreover, pressure sores are listed as the direct cause of death in 7-8% of all paraplegics.

Patients hospitalized with acute illness[4] have a pressure sore incidence rate of 3-11%. In a study of 658 patients aged 65 years or older who underwent surgery for hip fracture, Baumgarten et al found that 36.1% developed an acquired pressure sore within 32 days after hospital admission.[5] (The authors defined an acquired pressure sore as one that arose after hospital admission and had reached stage II or higher.) Although the 32-day period included time spent by patients in rehabilitation facilities and nursing homes, the highest incidence rate for pressure sores occurred during the patients' acute hospital stays.

Disturbingly, even with current medical and surgical therapies, patients who achieve a healed wound have recurrence rates of as high as 90%.

Etiology
Many factors contribute to the development of pressure sores, but pressure leading to ischemia is the final common pathway. Tissues are capable of withstanding enormous pressures when brief in duration, but prolonged exposure to pressures slightly above capillary filling pressure initiates a downward spiral towards ulceration.
Impaired mobility is an important contributing factor. Patients who are neurologically impaired, heavily sedated, restrained, or demented are incapable of assuming the responsibility of altering their position to relieve pressure. Moreover, this paralysis leads to muscle and soft-tissue atrophy, decreasing the bulk over which these bony prominences are supported.

Contractures and spasticity often contribute by repeatedly exposing tissues to pressure through flexion of a joint. Contractures rigidly hold a joint in flexion, while spasticity subjects tissues to considerable repeated friction and shear forces.

Sensory loss also contributes to ulceration, by removing one of the most important warning signals, pain.

Paralysis and insensibility also lead to atrophy of the skin with thinning of this protective barrier. The skin becomes more susceptible to minor traumatic forces, such as friction and shear forces, exerted during the moving of a patient. Trauma causing deepithelialization leads to transdermal water loss, creating maceration and adherence of the skin to clothing and bedding, which raises the coefficient of friction for further insult.

Malnutrition, hypoproteinemia, and anemia reflect the overall status of the patient and can contribute to vulnerability of tissue and delays in wound healing. Poor nutritional status certainly contributes to the chronicity often observed with these lesions. Anemia indicates poor oxygen-carrying capacity of the blood. Vascular disease also may impair blood flow to the region of ulceration.

Bacterial contamination from improper skin care or urinary or fecal incontinence, while not truly an etiological factor, is an important factor to consider in the treatment of pressure sores and can delay wound healing.

Pathophysiology
The inciting event for a pressure sore is compression of the tissues by an external force, such as a mattress, wheelchair pad, or bed rail. Other traumatic forces that may be present include shear forces and friction. These forces cause microcirculatory occlusion as pressures rise above capillary filling pressure, resulting in ischemia. Ischemia leads to inflammation and tissue anoxia. Tissue anoxia leads to cell death, necrosis, and ulceration.

Irreversible changes may occur after as little as 2 hours of uninterrupted pressure.

Presentation
Clinical presentation of pressure sores can be quite deceiving to the inexperienced observer. Soft tissues, muscle, and skin have a differential resistance to the effects of pressure. Generally, muscle is the least resistant and will necrose prior to skin breakdown. Also, pressure is not equally distributed from the bony surface to the overlying skin. Pressure is greatest at the bony prominence, decreasing gradually towards the periphery. Once a small area of skin breakdown has occurred, one may be viewing only the tip of the iceberg, with a large cavity and extensive undermining of the skin edges.

Many classification systems for staging pressure ulcers have been presented in the literature.[8] The most widely accepted system is that of Shea, which has been modified to represent the present National Pressure Ulcer Advisory Panel classification system. This system consists of 4 stages of ulceration but is not intended to imply that all pressure sores follow a standard progression from stage I to stage IV. Nor does it imply that healing pressure sores follow a standard regression from stage IV, to stage I, to healed wound. Rather, it is a system designed to describe the depth of a pressure sore at the specific time of examination, in order to facilitate communication among the various disciplines involved in the study and care of such patients.

Stage I represents intact skin with signs of impending ulceration. Initially this would consist of blanchable erythema from reactive hyperemia that should resolve within 24 hours of the relief of pressure. Warmth and induration also may be present. Continued pressure creates erythema that does not blanch with pressure. This may be the first outward sign of tissue destruction. Finally, the skin may appear white from ischemia.

Stage II represents a partial-thickness loss of skin involving epidermis and possibly dermis. This lesion may present as an abrasion, blister, or superficial ulceration.

Stage III represents a full-thickness loss of skin with extension into subcutaneous tissue but not through the underlying fascia. This lesion presents as a crater with or without undermining of adjacent tissue.

Stage IV represents full-thickness loss of skin and subcutaneous tissue and extension into muscle, bone, tendon, or joint capsule. Osteomyelitis with bone destruction, dislocations, or pathologic fractures may be present. Sinus tracts and severe undermining commonly are present.

Other important characteristics of the wound should be noted in addition to depth. One should note the presence or absence of foul odors, wound drainage, eschar, necrotic material, and soilage from urinary or fecal incontinence. This provides information regarding the level of bacterial contamination and the need for d├ębridement or diversionary procedures.

The overall state of health, comorbidities, nutritional status, mental status, and smoking history also should be noted. Presence or absence of contractures and spasticity also are important in the formulation of a treatment plan. One should note where the patient normally resides and the extent of his or her support structure. Examining the support surfaces present on the patient's bed or wheelchair also is important.

Relevant Anatomy
The hip and buttock regions account for 67% of all pressure sores, with ischial tuberosity, trochanteric, and sacral locations being most common. The lower extremities account for an additional 25% of all pressure sores, with malleolar, heel, patellar, and pretibial locations being most common.

The remaining 10% or so of pressure sores may occur in any location that experiences long periods of uninterrupted pressure. Nose, chin, forehead, occiput, chest, back, and elbow are among the more common of the infrequent sites for pressure ulceration. No surface of the body can be considered immune to the effects of pressure.

CNA Blog CNA Students Salt Lake City

There are always really funny anecdotes in our circle game and I think I should remember them then I forget so I decided to start recording some of the funniest in this blog.
1. Saved a choking llama (she fed the llama cauliflower and he started to choke which made her two year old cry, "the llama is going to die." She put her hand down his throat and pulled out the cauliflower. Pretty smart, I'd of been trying to figure out how to give that thing abdominal thrust:)
2. like coke with raw egg
3. had a baby ten days before mom
4. six kids under six
5. ran 37 miles
6. pants fell off doing cpr

Funny "group" things
1. We hate the word moist (really??? That's funny)
2. We think Brad Pitt is smokin hot


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Tuesday, March 6, 2012

Hospitals Demand Payment Upfront From ER Patients With Routine Problems

Next time you go to an emergency room, be prepared for this: If your problem isn't urgent, you may have to pay upfront.

Last year, about 80,000 emergency-room patients at hospitals owned by HCA, the nation's largest for-profit hospital chain, left without treatment after being told they would have to first pay $150 because they did not have a true emergency.

Led by the Nashville-based HCA, a growing number of hospitals have implemented the pay-first policy in an effort to divert patients with routine illnesses from the ER after they undergo a federally required screening. At least half of all hospitals nationwide now charge upfront ER fees, said Rick Gundling, vice president of the Healthcare Financial Management Association, which represents health-care finance executives.

"It has been a successful part of helping to reduce crowding in emergency rooms and to encourage appropriate use of scarce resources," HCA spokesman Ed Fishbough said.

But emergency-room doctors and patient advocates blast the policy as potentially harmful to patients, and they say those with mild illnesses such as sore throats and ear infections do little to clog ERs and do not require CT scans or other pricey technologies.

Kim Bailey, research director for the consumer group Families USA, said the tactic lets hospitals turn away uninsured patients who often fail to pay their bills and are a drag on profits. While the uninsured pay upfront fees as high as $350, depending on the hospital, those with insurance pay their normal co-payment and deductible upfront.

"This is certainly a concern to us," Bailey said.

'A Real Problem'

Physicians worry that sick people will forgo treatment. There is no data on how many who leave the ER without treatment follow up with visits to doctors' offices or clinics.

"This is a real problem," said Dr. David Seaberg, president of the American College of Emergency Physicians, who estimated that 2 to 7 percent of patients screened in ERs and found not to have serious problems are admitted to hospitals within 24 hours.

"After you've done the medical screening, it makes little sense to not go ahead and write a patient a prescription," said Dr. Michael Zappa, a Boca Raton, Fla., hospital consultant and former president of the Florida College of Emergency Physicians.

Patient advocates say the strategy could discourage patients from going to the ER for true emergencies.

"It seems the point of the policy is to put a financial barrier between the patient and care," said Anthony Wright, executive director of Health Access California, a consumer advocacy group.

The U.S. Centers for Disease Control and Prevention says that about 8 percent of ER visits are for non-urgent problems that could be treated less expensively in a doctor's office or clinic; others put the number of non-emergency visits much higher. A 2010 Health Affairs study found that 27 percent of those visiting ERs could be treated more cost-effectively at doctors' offices or clinics.

Reducing Bad Debt

Hospital officials say the upfront payments are a response to mounting bad debt caused by the surge in uninsured and underinsured patients and to reduced reimbursements by some private and government insurers for patients who use the ER for routine care.

In the past year, for instance, Iowa, Tennessee and Washington state reduced or eliminated Medicaid reimbursements for those visiting ERs for specified non-urgent conditions, such as sore throats or warts.

In an annual report filed last year with the Securities and Exchange Commission, HCA officials wrote that "we are taking proactive measures to reduce our provision for doubtful accounts by, among other things, screening all patients, including the uninsured, through our emergency screening protocol, to determine the appropriate care setting in light of their condition, while reducing the potential for bad debt."

HCA says it complies with federal requirements to screen and stabilize anyone with an emergency. Of more than 6 million ER visits to HCA hospitals last year, 314,000, or about 5 percent, were determined not to be emergencies, Fishbough said. About 230,000 of those patients paid and remained in the emergency room for treatment. The other 80,000 or so left. The HCA payment policy excludes children 5 and younger, pregnant women and those 65 and older.

"This helps ensure that the sickest patients get treated quickly and those who do not have an emergency have access to more efficient, less costly care settings," Fishbough said.

HCA officials declined to say which of its hospitals use the practice, but the company owns more than 160 hospitals in 20 states, including Virginia, California, Alaska, Georgia, Missouri, Kentucky, Idaho and South Carolina.

Following HCA's lead

Other large chains that have followed HCA's example include Naples, Fla.-based Health Management Associates and Franklin, Tenn.-based Community Health Systems.

"These policies are beneficial because they help patients understand their financial responsibilities and make informed decisions about where to utilize services," said Tomi Galin, a spokeswoman for Community Health Systems. "These practices help reduce costs for both the patient and the hospital."

John Merriweather, vice president at Health Management Associates, said the 66-hospital system has seen a decline in wait times since it implemented upfront payments.

"We think this is appropriate, given that some people use the ER in a way it was not intended: as a source for routine care," he said.

The upfront payments for non-urgent ER visits are also used by nonprofit hospitals.

In May, Halifax Health in Daytona Beach, Fla., began asking adult patients to pay their co-payment or $350 before treatment for a non-emergency in its ER, spokesman Byron Cogdell said. Like other hospitals, Halifax applies that fee to the patient's bill.

Paying To Get Prescriptions

In December, Skaggs Regional Medical Center in Branson, Mo., began asking ER patients to pay $40 or their insurance co-payment before receiving a prescription.

"If they don't pay . . . they won't be given their prescription," hospital spokeswoman Michelle Leroux said.

The strategy is designed to help the hospital deal with spiraling, unpaid ER bills. About a third of the 120 patients treated daily in the hospital's ER are uninsured. The change was implemented after the ER reported $1.3 million in bad debt for August.

"This amount of bad debt is unsustainable for our operation," Skaggs chief executive William Mahoney said.

Midland Memorial Hospital in Midland, Tex., implemented a $150 upfront ER fee in 2009 as part of a cost control effort. In 2008 the nonprofit hospital lost $14 million, partly because of millions of dollars in unpaid bills from ER patients.

Since the change, the 320-bed hospital has seen a 10 percent drop in people visiting the ER with non-emergencies and a big drop in bad debt, said Stephen Bowerman, Midland's chief financial officer.

In conjunction with the new ER policy, Midland set up a 24-hour telephone nurse triage system so people in the community can call a nurse to help decide whether to go to the ER or a nearby clinic.

Bowerman said the policy is helping to change behavior. He estimated that about 75 percent of patients with non-emergencies left the facility instead of paying the upfront fee.

"More people now know our ER is not a walk-in clinic or a primary care office," he said.

Soft-Surface Contamination

Soft-Surface Contamination
A look at all the unexpected places contamination exists in a patient's room.
Within 1 week of being laundered, 92 percent of hospital privacy curtains studied were contaminated.

By Bill O'Neill


What's wrong with this picture: a nurse enters a hospital room, does a thorough handwashing, pulls back the privacy curtains and attends to a patient?


The hard-to-spot flaw in this scenario is that the nurse's conscientious efforts at hand hygiene are compromised by one simple, everyday act - touching the privacy curtains after washing her hands.


According to a growing body of published, peer-reviewed evidence, those curtains may often harbor infectious microorganisms, such as MRSA and vancomycin-resistant Enterococcus (VRE) - and these opportunistic bacterial strains can hitch a ride on the hands of nurses.
This unwitting transfer of pathogens could potentially increase the incidence of HAIs (healthcare-associated infections),1 which currently afflict approximately one out of every 20 hospitalized patients and can lead to dire consequences. HAIs cause 100,000 deaths annually in the U.S. - more than deaths due to car crashes and HIV/AIDs combined.


The speed with which soft surfaces in the hospital environment can become contaminated was revealed in a recently reported study at the University of Iowa Hospitals in Iowa City. The results of the study were sobering: within 1 week of being laundered, 92 percent of hospital privacy curtains studied were contaminated.2

More on Infection Control


Nursing's Dirty Laundry
In one study, more than 60 percent of nurses' scrubs had MRSA on them.


Those results echo findings from an earlier study conducted at the Cleveland VA Medical Center, which showed that 42 percent of hospital privacy curtains studied were contaminated with VRE; 22 percent with MRSA and 4 percent with Clostridium difficile.


Meanwhile, a report from researchers at the Hospital of Saint Raphael in New Haven, CT, confirmed that, when healthcare workers touch contaminated environmental surfaces, they are likely to transmit pathogens to patients.3


Results from a just released study presented at the 2011 annual meeting of the Infectious Disease Society of America have made an explicit link between a reduction in bioburden on hospital surfaces and reduced infection rates.4


Research Implications


While further research is needed, there are a number of implications for nurses and hospitals nationally.


•Since privacy curtains are one of the most commonly touched soft surfaces in the patient environment, nurses need to heighten their awareness about the possible pathogens hiding in these fabrics, and many healthcare workers may have to change long-ingrained habits.

•As the University of Iowa Hospital study suggests, nurses should wash their hands after touching privacy curtains and before touching patients. Such a protocol can be time-consuming, however, at a time when hospital administrators and managers are already grappling with scheduling and staffing constraints.


•While healthcare facilities have long focused on disinfecting hard surfaces, such as bed rails, over-bed tables and door knobs, and sterilizing medical devices (catheters for example), they will face increasing pressures to address the condition of the entire patient environment. That means hospitals may need to expand their multi-layered attack on HAIs to fighting contamination on soft surfaces such as bedding and scrubs, as well as privacy curtains and other materials.



•The rapid rate at which soft surfaces can become contaminated in a hospital setting poses a challenge to conventional approaches to managing privacy curtains, including schedules for laundering and/or replacement. Some hospitals clean their curtains every few months, while others may only do so when they are obviously soiled; but all healthcare facilities will need to re-examine their approach to cleaning and maintaining these textiles.



Strategic Considerations

When it comes to reducing bioburden in the patient environment, there is, unfortunately, no "silver bullet." Microbial contamination is endemic in the hospital setting, in spite of the Herculean efforts made by both clinicians and environmental services staff over the past several years.


Consider the challenge: whether colonized or infected, many patients bring pathogens with them when they enter the hospital. The environment can be further compromised by visitors, delivery people, service technicians and even clinicians who may carry unwelcome microbial guests with them as they move through the hospital.


In such a scenario, the robust and consistent application of proper hand hygiene is top priority. That said, healthcare workers and hospital management should also consider every available tool and approach to reducing bioburden on soft surfaces. The options are many, ranging from the use of hydrogen peroxide mists to intense exposure to ultraviolet light to fabrics and textiles that incorporate one or more antimicrobial elements.


All have their positive qualities as well as their limitations. With budgets tight, how should institutions evaluate their options? Here are some questions nursing directors and administrators should ask themselves and potential vendors about their solutions:



•Is there clinical evidence that the solution reduces bioburden specifically on soft surfaces?


•Are there any harmful side effects or unintended consequences associated with the solution?


•What are the incremental costs of implementing the solution?


•Does the solution require additional staff training or education?


•What impact does the approach have on bed or room availability? Does it increase "down time" between patients?


Every institution will need to determine which approach, or group of approaches, is right for their particular situation. The above questions, however, may provide a useful analytical framework for those decisions.


As with most subjects in healthcare, more published, peer-reviewed clinical data is needed on the transmission of pathogens from soft surfaces to patients in hospitals. While that research is under way, healthcare workers involved in patient care must continue their multi-pronged attack on HAIs by making the patient environment as clean and healthy as possible.




Bill O'Neill is vice president of infection control applications for PurThread Technologies Inc., Princeton, NJ.

Artificial pancreas gives girl a vacation from diabetes

Portsmouth, New Hampshire (CNN) -- At 3:30 a.m., Stefany Shaheen awoke to a feeling of uneasiness. Something was not quite right with her daughter, Elle.

Creeping into her bedroom, Shaheen removed a lancet from its wrapper and poked her diabetic daughter's finger.

Putting the blood onto the testing strip, she saw the results: dangerously low blood sugar. Shaheen woke Elle up and gave her orange juice to keep her from slipping into unconsciousness.

Shaheen was relieved her motherly intuition had told her something was wrong with Elle that night, but she wished she didn't have to rely on it. She yearned for an automatic way of knowing when Elle was dipping into a dangerously high or low blood sugar -- and not just at night, but at school, where the 12-year-old is largely responsible for monitoring her own blood sugar.

Elizabeth Cohen is a senior medical correspondent for CNN.Then last week, Shaheen got her wish.

Elle was selected to try out an experimental device called an artificial or "bionic" pancreas. During the three-day study, Elle didn't have to poke her finger every few hours to find out her blood sugar level because the "bionic" pancreas recorded it automatically and adjusted her insulin accordingly.

Shaheen didn't have to set her alarm to wake up every three hours at night because the device was designed to catch a dangerously high or low blood sugar and treat it.

"For the first time since she was diagnosed, I didn't have to worry," says Shaheen, who lives in Portsmouth, New Hampshire.

Medical device companies are racing to be the first to market an artificial pancreas, which takes over the work of the diabetic's malfunctioning organ. The device could potentially be used for Type 1 diabetics or Type 2 diabetics who use insulin.

"It's transformative technology," says Aaron Kowalski, assistant vice president for treatment therapies research at JDRF, a research foundation for juvenile diabetes.

JDRF is funding artificial pancreas trials at 13 sites worldwide, including Yale University, Stanford University, the University of Virginia and the University of Colorado. Device companies also are funding several other studies.



Artificial pancreas a 'game changer' "It's looking incredibly promising," Kowalski says. "I hope very much we'll have a system on the market within four years, and I'll be very disappointed if we don't."

'Pale and pasty ... and all by herself'

It was Elle who urged her mother to enroll her in an artificial pancreas study.

The Shaheens first heard about the artificial pancreas shortly after Elle was diagnosed with diabetes at age 8, but she had to be 12 years old to enroll. So the day she turned 12 this past September, she started bugging her parents.

"She was constantly reminding me, 'Mom, you need to call, you need to call,'" Shaheen remembers.

Her mother was only too happy to comply. There had been several middle-of-the-night close calls, plus some desperate situations at school where the staff nurse was responsible for 450 children and "ill-equipped," Shaheen says, to handle the needs of a diabetic child.

"I got a call from Elle one morning. She was in the school office and her voice was trembling, and she said 'Mom, I need you to come quick. I don't know what's wrong,'" Shaheen says. "I got there and her blood sugar was dropping like a rock. She was pale and pasty and sweating profusely and all by herself."

A glimpse of the dream

Elle Shaheen tests her blood sugar levels while her mother watches. In January, Elle walked into Massachusetts General Hospital to start the trial.

Doctors fitted her for an artificial pancreas. In the future, the device will be the size of a cell phone, but for now Elle is hooked up to a laptop.

For three days, the device did the work Elle's pancreas can no longer do.

"It went very smoothly -- her blood sugar control was really very, very good," said Dr. Steven Russell, an instructor at Harvard Medical School. "We were really very pleased by what we saw with Elle."

Russell's research partner, Edward Diamano, an associate professor of biomedical engineering at Boston University, says the device learned Elle's blood sugar patterns and made changes accordingly.

"It's making adjustments every five minutes," he says.

For that one weekend, Elle didn't have to draw blood, and she could eat foods she hadn't eaten in large quantities for four years.

"She ate Spaghetti-O's and grilled cheese and french fries and hamburgers," Shaheen says. "She ate between 67 and 100 grams of carbs [every meal], and usually she can only eat between 40 and 50."

Then, after the experiment, Elle had to leave the artificial pancreas behind, and it was back to counting carbs and poking herself every couple of hours. Her mother reset the nighttime alarm clock.

"We're extraordinarily impatient for access to the device," Shaheen says. "I think it will revolutionize the way she lives."

"That was really hard," Elle says. "I just hope one day I can use it at home."

Baby steps

I think it will revolutionize the way she lives.

Stefany ShaheenLast week, Russell and Damiano visited the Food and Drug Administration offices in Silver Spring, Maryland, to show regulators a prototype for the artificial pancreas.

The device itself can be worn in a pocket or clipped to a belt. Two tiny pieces go under the skin, one to detect glucose levels in the blood and another to deliver insulin and glucagon, a drug used to raise very low blood sugar.

Algorithms determine how much insulin and Glucagon the patient needs, and if necessary the patient can manually override the device.

So far, the FDA has required doctors to keep patients inside the hospital while their using the device.

The potential benefits are enormous, Dr. Charles Zimliki, who chairs the FDA's Artificial Pancreas Critical Path Initiative, testified before a Senate committee last year. But "if not properly designed, use of an artificial pancreas device in an outpatient setting can place patients at significant risk."

Russell said he hopes that by the fall, the FDA will give him permission to allow adult diabetic patients to leave the building and walk the grounds of the Massachusetts General Hospital campus accompanied by a nurse, eating as they like and using the hospital's gym.

Then by the summer of 2013, he hopes to give the artificial pancreas to children attending a summer camp.

"These are all baby steps towards what we ultimately want to do, which is give them the device and say, 'Go home and check back with us in a week,'" Russell says.

Shaheen is closely watching the proceedings at the FDA, with the help of her mother, Sen. Jeanne Shaheen, D-New Hampshire, who co-chairs the Senate Diabetes Caucus.

"We're extraordinarily impatient for access to the device," she says. "I think it will revolutionize the way she lives."

HPV Vaccine Recommended for Boys in New AAP Guidelines

February 27, 2012 — The American Academy of Pediatrics (AAP) has published new guidelines for the use of the human papillomavirus (HPV) vaccine and, for the first time, has specifically recommended use of the vaccine in adolescent boys as well as girls.

The recommendations were published online February 27 and in the March print issue of Pediatrics.

The vaccine was recommended for girls in 2006, but even though at that time the AAP said the vaccine could be used in boys, it was not specifically recommended for that population.

The new recommendations were spurred in part by mounting evidence that the HPV vaccine is effective as prophylaxis against genital warts in both males and females. HPV infection has been associated with increased risk for cervical cancer, anal cancer, and oropharyngeal cancer.

The AAP recommends that the vaccine be administered at 11 to 12 years of age in both boys and girls. Their rationale is 2-fold: First, the vaccine is most effective if it is administered before the individual begins engaging in sexual activity, mainly because the vaccine is inactive against HPV strains acquired before vaccination. Second, children mount the most robust antibody responses to the vaccine when they are between the ages of 9 and 15 years, the AAP says.

Two HPV vaccines are currently available in the United States, but there are differences in their approved indications. Quadrivalent HPV vaccine (HPV4, Gardasil, Merck) is the only vaccine approved for use in boys. Bivalent HPV vaccine (HPV2, Cervarix, GlaxoSmithKline) is only approved for use in girls; HPV4 is also approved for girls.

Among the AAP's updated recommendations are that:

•Girls aged 11 to 12 years should be routinely immunized using 3 doses of the HPV4 or HPV2 vaccine, administered intramuscularly at 0, 1 to 2, and 6 months.
•Girls and women aged from 13 to 26 years who have not been previously immunized or who have not completed their vaccinations should finish the series.
•Boys aged 11 to 12 years should be routinely immunized with HPV4, using the same schedule as for girls.
•Boys and men aged from 13 to 21 years who have not already been immunized or who have not completed their vaccines should finish the series.
•Men aged from 22 to 26 years who have not already been immunized or who have not finished the full series may be administered the recommended vaccine. (The AAP guidelines note that "cost-efficacy models do not justify a stronger recommendation in this age group.")
•Special efforts should be made to target use of the vaccine in gay or bisexual men up to 26 years of age who have not previously received the vaccine.
•People infected with HIV should be vaccinated or complete their series of vaccinations.
•The vaccine is not recommended during pregnancy, nor should it be administered to individuals with a known immediate hypersensitivity to yeast. However, it may be administered during lactation, as well as to those who are immunocompromised from either illness or medication
The AAP recommends that because the HPV vaccine will not prevent infection from all types of HPV types, cervical screening should continue after HPV vaccination.

The organization also says that administration of the vaccine should not alter physicians' recommendations regarding use of barrier methods for preventing HPV and other sexually transmitted diseases.

The AAP urges that use of the vaccine be covered by all public and private health insurance.

More information on implementing the guidelines, including guidance on supply, payment, coding, and liability issues, is available on the AAP's Web site.