Publications

Abstract

Nursing interventions - especially education and counseling - can reduce the risk of crisis for women and their families. Here's one model for practice.

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PURPOSE the purposes of this paper are to (1) review the literature on educational interventions for adults with type 2 diabetes; (2) determine what kinds of interventions have been studied; (3) identify which interventions have included cardiac risk factor management; (4) determine how effective these interventions have been on metabolic control, diabetes-related outcomes, and cardiovascular-related outcomes; and (5) make recommendations for further research on combined interventions designed to promote optimal diabetes and cardiac risk factor management in adults with type 2 diabetes. METHODS Using an integrative literature review approach, 64 studies on diabetes education interventions for adults with diabetes published between 1987 and 1998 were reviewed; 44 met these criteria. RESULTS Few studies included cardiac risk factor management, which should be an integral part of diabetes management. Most studies demonstrated a beneficial effect of education on the management of type 2 diabetes but not cardiovascular risk. CONCLUSIONS Identifying strategies that promote effective disease management for improved diabetes control and reduction of cardiac events in adults with diabetes is essential. Further intervention studies focusing on the combined management of diabetes and cardiac risk factors are warranted.

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Evidence linking mutations in ATP-binding-cassette transporter gene 1 (ABC1) to Tangier disease suggests it functions in the active transport of free cholesterol out of cells. Since its mRNA level is regulated in response to cellular cholesterol stores it is of interest to explore its promoter response elements, and to investigate polymorphisms for their contributions to the prevalence of low levels of HDL in the population that promotes premature coronary heart disease. Investigation of the 5' end of the gene by 5' RACE analysis revealed 455 nucleotides additional to published sequences, and predicts another 60 amino acid N-terminal residues, resulting in a 2261-residue protein. Protein sequence analysis predicts a membrane-spanning region and possible signal peptide. The 5' flanking region was located by a Human Research Project BLAST search. This region contains regulatory elements that potentially control ABC1 gene expression. In addition to numerous SP1 binding sites there are four putative sterol regulatory elements (SREs). Our studies uncovered three single nucleotide substitution polymorphisms, one in the promoter region and two in the 5' untranslated region (5' UTR), plus an insertion/deletion polymorphism. (C) 2000 Academic Press.

Abstract

Purpose: With the enactment of the Balanced Budget Act of 1997, American nurse practitioners were granted direct Medicare reimbursement for Part B services. Payment structures in fee-for-service and managed care systems are physician-based, leading to difficulties in constructing payments for other health care professionals. The purpose of this pilot study was to examine the feasibility of using nurse practitioner data for specifying relative work values in the Medicare Fee Schedule for three office-visit codes. Design: An exploratory survey was designed to establish relative work values using magnitude-estimation scaling. Nurse practitioners (N=43) responded to a structured questionnaire in a national mail survey. Physician data (N=46) were obtained from a computerized database from the American Academy of Family Physicians. Methods: The methods used in this study were the same as the process used by the American Medical Association and the Health Care Financing Administration to establish relative work values in the Medicare Fee Schedule. Respondents established relative work values for three Current Procedural Terminology (CPT) codes for office visits (99203, 99213, 99215) commonly billed in primary care practice. Each CPT code descriptor and associated vignette were compared with reference services germane to the practice of nurse practitioners and family physicians, using magnitude-estimation scaling. To establish relative work values for each code, respondents were asked to consider the time to provide the service and intensity of the work involved for each CPT code. Findings: No significant differences between nurse practitioners and family physicians were found in the three CPT codes for relative work values and intensity. Nurse practitioners estimated significantly (p < .01) higher intraservice (face to face) time with patients than did family physicians, and family physicians estimated significantly (p < .05) higher pre-service time for two codes and significantly (p < .05) higher postservice times for three codes. Conclusions: Nurse practitioner relative work values did not differ significantly from family physician relative work values. Although the sample sizes were small, the significance of the findings support the need for further research with large data sets and additional CPT codes. Such studies could then be used as a basis for decisions about Medicare payment and public policy.

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Familial combined hyperlipidemia (FCH) is a common genetic lipid disorder with a frequency of 1-2% in the population. In addition to the hypercholesterolemia and/or hypertriglyceridemia that affected individuals exhibit, small, dense LDL particles and decreased HDL-cholesterol levels are traits frequently associated with FCH. Recently, we reported that families with FCH and families enriched for coronary artery disease (CAD) share genetic determinants for the atherogenic lipoprotein phenotype (ALP), a profile presenting with small, dense LDL particles, decreased HDL-cholesterol levels, and increased triglyceride levels. Other studies in normolipidemic populations have shown that the hepatic lipase (HL) gene is linked to HDL- cholesterol levels and that a polymorphism within the HL promoter (-514C→T) is associated with increased HDL-cholesterol levels as well as larger, more buoyant LDL particles. In the present study, we tested whether the HL, gene locus also contributes to ALP in a series of Dutch FCH families using nonparametric sibpair linkage analysis and association analysis. Evidence for linkage of LDL particle size (P < 0.019), HDL-cholesterol (P < 0.003), and triglyceride levels (P < 0.026) to the HL gene locus was observed. A genome scan in a subset of these families exhibited evidence for linkage of PPD (LOD = 2.2) and HDL-cholesterol levels (LOD = 1.2) to the HL gene locus as well. The -514C→T promoter polymorphism was significantly associated (P < 0.0001) with higher HDL-cholesterol levels in the unrelated males of this population, but not in unrelated females. No association was observed between the polymorphism and LDL particle size or triglyceride levels. Our results provide support that ALP is a multigenic trait and suggest that the relationship between small, dense LDL particles, HDL-cholesterol, and triglyceride levels in FCH families is due, in part, to common genetic factors.

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Communication about health issues such as HIV/AIDS is essential for people, especially women, to obtain the social support they need either to prevent illness or manage it. This article compares the kinds of HIV-related issues that HIV positive and HIV negative substance-abusing women (N=211) in New York City talk about with various types of supporters. Despite the stigma associated with AIDS and their unconventional lifestyles, both groups of women talked to a broad spectrum of supporters about a variety of HIV-related issues, though this was more the case for HIV positive women. Although the main topic that both groups discussed with their supporters was their HIV status, the women also talked about risk reduction, their supporters' HIV status, HIV testing, how to live with AIDS, information about H/V/AIDS, and the emotional impact of AIDS (e.g., fear of infection, reactions to learning test results, and the impact of knowing others who have died from the disease).

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The experts concluded that current data show that the average nurse staffing levels (for RNs, LVN/LPNs, and NAs) in nursing homes are too low in some facilities to provide high quality of care. Caregiving, the central feature of a nursing home, needs to be improved to ensure high quality of care to residents. Because detailed time studies have not been conducted on the amount of time that is required to provide high quality of care to residents, expert opinion is currently the best approach to addressing the problem of inadequate staffing. Increases in the education level and training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover rates in nursing homes. These recommendations are designed for consideration by Congress, HCFA regulators, policymakers, nursing home administrators, and nurses. Ideally, Congress would pass legislation establishing these recommendations as minimum standards for all nursing homes or direct HCFA to establish detailed minimum nurse staffing standards to ensure that staffing levels take into account the number and the case-mix of the residents. Alternatively, HCFA could introduce minimum staffing standards through the regulatory process. In 1999 there were a number of efforts at the state level to increase minimum staffing levels. Mohler (1999) surveyed selected states and found that 21 states had either proposed new legislation or were considering proposals for new legislation or new regulations. In California, for example, in 1999 the state budget approved $31 million in new state funds (to be matched with $31 million in federal Medicaid dollars) to increase nursing home staffing minimum requirements from 2.8 to 3.2 hr per resident day and to increase wage rates. Overall, nursing facilities need to be held accountable by HCFA for providing adequate levels and types of staffing to meet the needs of their residents, especially because government is paying for 61% of the expenditures. Adopting these minimum standards will have an important impact on improving the quality of the nation's nursing home care. Additional research is needed to determine appropriate levels and types of staff to provide high quality of care to residents. These studies could test the proposed staffing standards against existing staffing levels to examine the impacts on quality. As new data become available on staffing levels, revisions of staffing standards should be made if necessary to ensure that high standards are maintained.

Abstract

A descriptive design with repeated measures was used to describe patterns of fatigue, emotional stress, and left ventricular (LV) function among 22 patients with myocardial infarction (MI) from day 5 postadmission to day 21 postadmission for the MI. The severity of fatigue in patients with MI during the subacute period ranged from 32 to 44 on the 100-mm Visual Analogue Scale for Fatigue. Severity of fatigue and depression remained the same; however, LV function improved (p < .01) and patients experienced more energy (p < .01) and less anxiety (p < .01) in the third week following MI. Researchers observed five different fatigue patterns: decreasing fatigue, increasing fatigue, unchanged low fatigue, unchanged-high fatigue, and a curvilinear fatigue pattern. The finding of five different fatigue patterns after an MI suggests that all patients with MI should not be treated as a uniform group assumed to have decreasing fatigue with the passage of time.

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OBJECTIVE: To search for novel genes contributing to adiposity in familial combined hyperlipidemia (FCH), a disorder characterized by abdominal obesity, hyperlipidemia and insulin resistance, using a 10 cM genome-wide scan. DESIGN: Plasma leptin and soluble tumor necrosis factor receptor superfamily members 1A and 1B (sTNFRSF1A and sTNFRSF1B, also known as sTNFR1 and sTNFR2) were analyzed as unadjusted and adjusted quantitative phenotypes of adiposity, in addition to body mass index (BMI), in multipoint and single-point analyses. In the second stage of analysis, an important chromosome 1 positional candidate gene, the leptin receptor (LEPR), was studied. SUBJECTS: Eighteen Dutch pedigrees with familial combined hyperlipidemia (FCH) (n=198) were analyzed to search for chromosomal regions harboring genes contributing to adiposity. RESULTS: Multipoint analysis of the genome scan data identified linkage (log of odds, LOD, 3.4) of leptin levels to a chromosomal region defined by D1S3728 and D1S1665, flanking the leptin receptor (LEPR) gene by approximately 9 and 3 cM, respectively. The LOD score decreased to 1.8 with age- and gender-adjusted leptin levels. Notably, BMI also mapped to this region with an LOD score of 1.2 (adjusted BMI: LOD 0.5). Two polymorphic DNA markers in LEPR and their haplotypes revealed linkage to unadjusted and adjusted BMI and leptin, and an association with leptin levels was found as well. In addition, the marker D8S1110 showed linkage (LOD 2.8) with unadjusted plasma concentrations of soluble TNFRSF1A. BMI gave a LOD score of 0.6. Moreover, a chromosome 10q-ter locus, AFM198ZB, showed linkage with adjusted BMI (LOD 3.3). CONCLUSION: These data provide evidence that a human chromosome 1 locus, harboring the LEPR gene, contributes to plasma leptin concentrations, adiposity and body weight in humans affected with this insulin resistant dyslipidemic syndrome. Novel loci on chromosome 8 and 10qter need further study.

Abstract

During the past two decades, the drive to rein in rising health care costs has shifted some of the power in health care policy making from professional groups, government agencies, and not-for-profit health care organizations to large for-profit corporations (1-4). This has been a worldwide phenomenon, as the provision and financing of health care services is shifted from governments to private health care organizations (5,6). In the United States, the shift in power is manifested in profound ways. Market competition and bottom-line economics have permeated the health care system, creating powerful new incentives for mergers, other corporate restructuring, and the shift to for-profit status by formerly not-for-profit insurance companies and providers. Private sector health care is now increasingly influenced by for-profit organizations (3). Moreover, the health insurance industry has been transformed as traditional indemnity insurance is replaced by versions of managed care. The role of government, or the public sector, in setting parameters for health care financing and standards for the delivery of health care services is increasingly outpaced in cost cutting by organizations that directly face the bottom line. In addition, private foundations, many of which are under the auspices of managed care organizations, now fund a large proportion of health care research and demonstration projects, a task once largely within the realm of the government. Through education and experience, nurses have developed political sophistication and understanding of policy making in the public sector (7). The challenge now is to educate nurses to adapt their political and policy strategies to the new health care milieu. This challenge is particularly crucial for advanced practice nurses, who must survive in a managed care environment.

Abstract

PURPOSE The purpose of this study was to assess the health-promoting practices of young black women at risk for type 2 diabetes. METHODS The sample consisted of 30 black women from an urban area who had a history of gestational diabetes and/or a first-degree relative with diabetes. Participants completed the Health-Promoting Lifestyle Profile II Survey and an interview. Both were used to categorize health-promoting practices, exercise, diet, knowledge of diabetes prevention, and general health. RESULTS Demographic information and interview revealed a propensity towards obesity, despite education and income levels. The results for the Lifestyle II Survey showed a higher average total score for healthy nutrition than physical activity, which were inconsistent with the qualitative data obtained by interview. Fifty percent stated that they exercised as a general health-promoting behavior. Self-reported daily caloric, fiber, and fat intake was high to moderate; 60% reported initiating diet modifications secondary to a desire to lose weight or for medical problems; and 26% reported receiving information on diabetes prevention from a healthcare provider. CONCLUSIONS A systematic approach of planning and actively incorporating health-promoting activities into one's lifestyle as a young adult may protect or delay the onset of diabetes and prevent complications.