Alvin C. York VA Medical Center

The treatment of tuberculosis requires at least two drugs to retard the development of drug resistance. Unfortunately, patients may take only one drug (monotherapy) when more than one is prescribed. Fixed-dose combinations with two or more antituberculous drugs in one capsule or tablet are available to prevent this. In the United States, these drugs are Rifamate (Marion Merrell Dow), which contains isoniazid plus rifampin, and Rifater (Marion Merrell Dow), which contains isoniazid plus rifampin and pyrazinamide. Because these preparations make monotherapy impossible, they are clearly preferable to individual drugs. In the United States in 1993, however, only 15% to 18% of rifampin was sold in the form of fixed-dose combinations. To correct this deficiency, fixed-dose combinations should be widely promoted and accepted as a primary way to prevent drug-resistant tuberculosis. There are two caveats regarding these preparations. First, many fixed-dose combinations, especially those in developing countries, achieve inadequate blood levels of one or more of the component drugs, especially rifampin. Our recommendations apply only to preparations with proven bioavailability. Second, because the name Rifamate is similar to the name rifampin, mistakes in prescribing and dispensing can result in the patient receiving rifampin alone when Rifamate is intended. A name change from Rifamate to a highly distinctive name such as Rif-Isoniazid is needed to prevent such occurrences.

Elderly persons of today are survivors of a time when most adults were infected with tuberculosis. Although many people died at that time, others survived the initial infection but continued to harbor viable bacilli in dormant caseous and calcified lesions. This article discusses the tuberculin test in the elderly, transmission and risk of infection in nursing homes, clinical manifestations, diagnosis, management considerations, preventive therapy, and surveillance of tuberculosis in nursing homes.

OBJECTIVE: To describe the association between the use of the fluoroquinolone ofloxacin in an elderly man and an unusual acute encephalopathy with characteristics suggestive of Tourette's syndrome. CASE SUMMARY: An unusual syndrome was observed in a 71-year-old man temporally related to the initiation of ofloxacin therapy that resolved completely after discontinuation of the drug. The most remarkable phenomena were spitting and profuse swearing; other features were echolalia, echopraxia, orofacial and limb automatisms, hypersalivation, and amnesia for the episode on recovery. The clinical syndrome had several features in common with Tourette's syndrome and possibly with frontal lobe onset complex partial seizures. The electroencephalographic, neuroradiologic, and cerebrospinal fluid examinations were normal. DISCUSSION: The reported neurotoxic effects of the fluoroquinolones include insomnia, seizures, delirium, and psychosis, best explained by the gamma-aminobutyric acid-antagonistic properties of this class of drugs. This is the first reported case of a Tourette-like syndrome associated with the use of any quinolone, suggesting a possible interaction with central dopaminergic neurotransmitter systems. CONCLUSIONS: Use of drugs such as ofloxacin that have improved central nervous system penetration, disease- or age-related reductions in renal function, concomitant use of drugs such as theophylline and nonsteroidal antiinflammatory drugs, and possibly increased pharmacodynamic sensitivity place the elderly at special risk for quinolone neurotoxicity. Dosing modifications and an awareness of possible central nervous system adverse effects are warranted.

Objectives: To explore the possible association of childhood residence, education levels, and occupation with declining incidence rates of dementia in 2 cohorts of elderly African Americans. Methods: African Americans residing in Indianapolis without dementia were enrolled in 1992 and 2001 and evaluated every 2-3 years. The cohorts consist of 1,440 participants in 1992 and 1,835 participants in 2001 aged 70 years and older. Cox proportional hazard regression models were used to compare cohort differences in dementia and Alzheimer's disease (AD) risk. Results: The 2001 cohort had significantly decreased risk of both incident dementia and AD (hazard ratio [HR]: 0.62/0.57 for dementia/AD). Years of education was associated with decreased risk of dementia (HR = 0.93; p = .0011). A significant interaction (p = .0477) between education and childhood rural residence was found for the risk of AD that higher education level is significantly associated with reduced AD risk (HR = 0.87) in participants with childhood rural residence, but no association in those with urban upbringing. The cohort difference for dementia rates were attenuated by adjusting for the 3 risk factors but remained significant (HR = 0.75; p = .04). Discussion: These results emphasize the importance of early life factors including rural residence and education for the risk for dementia later in life.

The interaction of lithium with sulindac and naproxen was studied in six sulindac-treated and seven naproxen-treated patients admitted to a geropsychiatry ward. Patients under a steady state lithium level received lithium for 3 days, then lithium + sulindac (300 mg/day) or naproxen (750 mg/day) for 6 days, and then lithium alone for 5 days. Sulindac failed to affect serum lithium levels and lithium clearance. The results with naproxen showed marked interindividual variations ranging from no increase to a 41.9% increase in serum lithium levels within 5 days. There was a corresponding decrease in lithium clearance in naproxen-treated patients. Patients undergoing lithium therapy might need a reduction of their lithium dosage following naproxen administration. More frequent serum lithium level determinations are required following initiation of naproxen therapy until the magnitude of the lithium-naproxen drug interaction can be adequately assessed in a given individual.

This study tests a set of hypotheses that predict self-esteem and anxiety in adults infected with human immunodeficiency virus (HIV). The analysis is motivated by the following question: Is the level of perceived coherence, i.e., the extent to which individuals derive meaning and purpose in their lives despite their HIV-illness, related to their levels of self-esteem and anxiety? Data were obtained from one of three HIV care and referral centers in the Midsouth. The results demonstrate that clients who experienced a greater sense of derived meaning and purpose (perceived coherence) from their situations and those with more confidants (social support) reported higher self-esteem and lower anxiety than other HIV-infected adults seeking counseling and maintenance services. Implications are drawn for strategies to meet HIV-related mental health care needs.

In this article, the author presents a model that demonstrates that viscosity is an important variable in all aspects of the dysphagia evaluation and management. Data are presented that show that clinicians do not provide close control of this important variable. As a consequence, clinicians are at risk for producing diagnostic and management errors. The author summarizes the “dilution curve” method for creating viscosity‐accurate test materials and reviews the status of research for developing viscosity standards for thickened liquids.

Posttraumatic stress disorder (PTSD) is a major health concern among veterans, specifically African American veterans, and is commonly comorbid with other negative mental health outcomes including substance use disorders (SUD) and symptoms of depression. The current study examined intolerance of uncertainty as a mediator of the relationship between PTSD and depression symptoms in a sample of African American veterans with a dual diagnosis of PTSD and SUD. Participants included 113 African American veterans who were in treatment for PTSD and SUD at a Veterans Affairs Medical Center. Five mediation analyses were conducted to examine the mediational effect of intolerance of uncertainty on the relationship between PTSD symptom clusters (i.e., total, hyperarousal, numbness, avoidance, and intrusion) and depression symptoms. Findings indicated that intolerance of uncertainty mediated the relationship between four of the five mediation models (i.e., total symptoms, hyperarousal, numbness, and intrusion). These results imply that for African American veterans, higher levels of certain PTSD symptoms were associated with higher levels of intolerance of uncertainty, which in turn were related to increased levels of depression symptoms.

Excess iodine has been associated with an increased incidence of lymphocytic thyroiditis (LT) in the BB/W rat, obese strain chicken, and hamster. The spontaneous incidence of LT in the Buffalo (Buf) rat is increased by neonatal thymectomy. In the present study, the effect of combined thymectomy and excess iodine ingestion on the incidence of LT in Buf rats has been examined. Buf rats were thymectomized at 1 day of age and randomized at 4 weeks of age to receive either standard rat chow with tap water (controls), or standard rat chow with 0.05% iodine in the drinking water (iodine group) for 12 weeks. The serum was assayed for TSH, antithyroglobulin antibodies, and iodine. The thyroids were fixed in Bouin's solution and stained with hematoxylin and eosin, and the presence of thyroiditis was determined. Iodine increased the incidence of LT from 31% in the control group to 73% in the iodine-treated group (P less than 0.05). Serum TSH concentrations and levels of thyroglobulin antibodies were significantly higher in the iodine-treated rats, primarily due to the increased incidence of LT and subsequent iodine-induced hypothyroidism. These data suggest that iodine enhances the effect of neonatal thymectomy on LT in Buf rats and support the concept that iodine may play an important role in the expression of LT in predisposed animals.

We describe the case of a 56-year-old woman with terminal metastatic breast cancer who had delirium in the form of frightening hallucinations, paranoid delusions, and nightmares resulting in violent agitation. During this period, her bone pains from metastases were well controlled with narcotic analgesics, but her delirium proved refractory to standard doses of drugs such as lorazepam, diazepam, and haloperidol. We report the use of a subcutaneous infusion of midazolam at home and its effectiveness in control of her delirium after other drugs had failed.

The duration of therapy for pulmonary tuberculosis (TB) is now shortened to 6 or 9 months with the use of bactericidal drugs. There are few reports on the results of short course chemotherapy (SCC) in extrapulmonary tuberculosis (EP). It is unlikely that many controlled studies shall be forthcoming in the future because of involvement of many sites with the disease, each of which has special problems. However, available controlled studies and clinical experiences in EP indicate early success. The site of the disease appears to be less important since the bacterial population is much smaller in EP than in TB and is easily amenable to the bactericidal drugs. Present bactericidal drugs (isoniazid [INH], rifampin [RIF], pyrazinamide [PZA]) penetrate well into tissues and attain bactericidal levels to kill the organisms. Our experience with 9-month SCC consisting of INH 300 mg and RIF 600 mg daily for one month, followed by INH 900 mg and RIF 600 mg twice weekly for another 8 months in 478 cases of EP showed overall success in over 95% of those patients who completed therapy over a median follow-up of 42 months. The drugs may be given daily throughout with the same success. Thus, 9-month therapy with INH and RIF is highly effective in EP due to drug sensitive organisms. In TB, the duration may be shortened to 6-months with initial intensive four-drug therapy consisting of INH, RIF, PZA and streptomycin (SM) or ethambutol (EMB) daily for 2 months, followed by INH and RIF daily or twice weekly for another 4 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Validity measures derived from the Test of Memory Malingering Trial 1 (TOMM1) and errors across the first 10 items of TOMM1 (TOMMe10) may be further enhanced by combining these scores with "embedded" behavioral responses while patients complete these measures. In a sample of nondemented veterans (n = 151), five possible behavioral responses observed during completion of the first 10 items of the TOMM were combined with TOMM1 and TOMMe10 to assess any increased sensitivity in predicting Medical Symptom Validity Test (MSVT) performance. Both TOMM1 and TOMMe10 alone were highly accurate overall in predicting MSVT performance (TOMM1 [area under the curve (AUC)] = .95, TOMMe10 [AUC] = .92). The combination of TOMM measures and behavioral responses did not increase overall accuracy rates; however, when specificity was held at approximately 90%, there was a slight increase in sensitivity (+7%) for both TOMM measures when combined with the number of "point and name" responses. Examples are provided demonstrating that at a given TOMM score (TOMM1 or TOMMe10), with an increase in "point and name" responses, there is an incremental increase in the probability of failing the MSVT. Exploring the utility of combining freestanding or embedded validity measures with behavioral features during test administration should be encouraged.

I have reported the case of a 21-year-old woman who was thrown from her car, sustaining multiple severe closed pelvic fractures with avulsion of the uterus at the corpocervical junction. Laparotomy showed massive hemoperitoneum due to avulsion of the uterus. After subtotal hysterectomy, she was placed in skeletal traction, and later had open reduction and internal fixation with a cancellous iliac bone graft. At two-month follow-up, she was ambulatory on crutches, and x-ray films showed a stable pelvis with healing of the fractures.

This study tests for the effects of Black residents' community satisfaction/dissatisfaction, which we see as a surrogate measure of chronic community stress, on their psychological depression in rural and urban areas of Tennessee. The data utilized include responses from 398 rural West Tennessee Black participants interviewed in 1979 and 326 Black residents of Nashville, Tennessee, interviewed in 1980–82. Multiple regression analyses show, as predicted, that dissatisfaction with the community has a relatively greater influence on mental distress in the sample of rural Black residents than does our measure of transient stress (life events). In fact, unlike findings of many past studies, life events are unrelated to depression for this rural group. However, in contrast to these rural findings, life events for the urban Black residents are both significant and more important predictors of depressive symptoms than is our measure of community contentment. The effects of friendship and extended family relations on depression in both rural and urban Black samples are also assessed.

OBJECTIVE: Evaluate the impact a post graduate year 2 (PGY-2) pharmacy resident run clinic incorporated into the patient centered medical home (PCMH) model may have on achieving reduction in glycosylated hemoglobin (A1c), low density lipoprotein (LDL), and systolic and diastolic blood pressures (SBP and DBP) over six months in type 2 diabetics within the Veterans Health Administration (VHA). METHODS: This was a prospective, quasi-experimental study enrolling type 2 diabetics referred to the pharmacist-run clinic not meeting American Diabetes Association (ADA) treatment goals for A1c less than 7%, and/or LDL less than 100 mg/dL, and/or blood pressure (BP) less than 130/80 mmHg. Once signed informed consent was obtained, veterans were followed according to usual standards of care for six months with visits and lab follow-up at baseline, three, and six months (±45 days). The primary endpoint was the change in HbA1c, LDL, and BP from baseline to six months. Secondary endpoints included the change from baseline to three months in A1c, LDL, and BP and the percentage of patients who achieved ADA treatment goals for A1c, LDL, and BP at six months. RESULTS: Among the 24 patients included in the data analysis (100% male, 92% Caucasian), A1c decreased significantly from 7.56% to 7.19% (p = 0.0122) as well as LDL from 92.9 to 68.5 mg/dL (p = 0.0023), SBP from 131 to 124 mmHg (p = 0.0302), and DBP from 71.5 to 64.8 mmHg (p = 0.0012). The proportion of patients at recommended goal A1c <7% rose from 17% to 38%, as did the percentage of patients meeting ADA goals for LDL (75% to 96%), SBP (46% to 71%), and DBP (79% to 92%). CONCLUSION: Patients followed in a resident run pharmacotherapy clinic in the PCMH model with interventions over six months showed significant improvements in clinical endpoints including A1c, LDL, SBP, and DBP.

Evidence-based practice (EBP) is the process of collecting, processing, and implementing research findings to improve clinical practice, the work environment, or patient outcomes. According to the American Nurses Association (ANA), nursing interventions should be practical, methodical decisions based on EBP research studies. Utilizing the EBP approach to nursing practice helps us provide the highest quality and most cost-efficient patient care possible. Here we'll discuss the key characteristics of EBP relating to nursing research. It's a trend! Involving all disciplines, EBP is an approach to clinical practice that's been gaining ground since its formal introduction in 1992. Starting in medicine, it then spread to other fields, such as nursing, psychology, and education. Currently, 55% of all nursing practices are based on research findings. The ANA predicts that by 2020, 90% of all nursing practice will be based on EBP research findings. When you incorporate up-to-date information from new EBP research, you'll be able to question current practices. You may ask questions such as, “Are my current nursing interventions the most effective or safest for my patients?” or “Could we utilize these new EBP interventions in my work area?” Nurses committed to EBP will compare current professional and clinical practices with new research facts and outcomes as they emerge. To meet the 2020 goal, nurses must become proficient in evaluating various types of EBP research because they provide effective, proven rationales for nursing actions (see Learn the lingo!). As you incorporate this new knowledge into your clinical practice and work areas, you become a role model and a positive change agent. Share these discoveries with your healthcare team to improve the essential components of your role and work environment. Knowing where to look Nurses can find EBP research published in scholarly single-blind or double-blind peer-reviewed journals. Many state and national nursing organizations, such as the ANA, conduct nursing research. The National Institute of Nursing Research is well-known for comprehensive research studies that build the scientific foundation of our nursing practices; enhance hospice and palliative care; and help guide the prevention, treatment, and innovative management of diseases. Many universities, colleges, and formal nursing programs also conduct and publish research findings in their newsletters or scholarly journals, or on their websites. Remember to look for the latest research findings relevant to your job role. Consider obtaining appropriate institutional approval and conducting a formal research project of your own if you identify areas for improvement within your job role or work environment (see Caution: permission required). EBP research can be conducted in any area of nursing, including hospice care, geriatric or long-term care settings, in-patient hospital units, home care, substance abuse programs, and risk management. Besides improving patient outcomes and the work environment, research can help you evaluate social interactions, improve patient safety, resolve environmental issues affecting health, enhance quality of life, develop theories, explore healthcare economic issues, and address benchmarking needs or barriers. Four key elements When evaluating EBP nursing research studies, focus on these four criteria: validity—the legitimacy, accuracy, and soundness of all aspects of the study reliability—the extent to which a measurement's result is consistent relevance—the logical connection between two ideas, tasks, or events outcome—the conclusions reached through the process of research. If a study's outcome doesn't demonstrate validity, reliability, or relevance, using it to make a change in current practices that have a proven history of effectiveness, efficiency, and positive outcomes may not be justified. But if the study's outcome is valid, reliable, and relevant to your work environment or patient population, you should consider incorporating the new information into current clinical practice. Failure to utilize EBP to guide nursing care increases the risk of poor outcomes. The dynamic duo Quantitative and qualitative research are the two types of EBP research that nurses perform, evaluate, and utilize to guide nursing interventions and improve patient care (see Quantitative versus qualitative research). Research can be specifically quantitative or qualitative, or a combination of both. When a research project utilized both quantitative and qualitative data, it's commonly called a mixed–methods research study. Three types of quantitative research Quantitative research consists of information expressed in numbers, variables, and percentages. It seeks to confirm that all problems, dilemmas, or hypotheses have clear, concrete, and objective solutions that can be expressed in a numerical format. This type of research focuses on specific, narrow questions in a double-blind study, usually with a large random group and variables. The data collected can be analyzed with the help of statistics in an unbiased manner with the objective to explain, describe, or predict. Quantitative research contains the following elements: a hypothesis a random or specific study group with a common similarity variables (any element or behavior that can affect or change the outcomes of a study, such as a medication, treatment, or nursing intervention) outcomes. Quantitative research is usually conducted in a controlled environment, such as a lab or healthcare unit. It can be categorized as follows. Correlational research is the methodical investigation of relationships or interactions between two or more variables without determining the cause-and-effect relationship the variables may have on each other. An example is studying two chemotherapy medications for compatibility without studying how the medications can have adverse interactions with food or other common medications. Quasi-experimental research explores a cause-and-effect relationship among variables. It also evaluates the underlying cause of a problem and studies the effects of variables (such as a nursing intervention) to evaluate their effect on the problem. Descriptive research offers an accurate representation of the characteristics of a particular individual, situation, or group. Descriptive research is a way of discovering new meaning, describing numerically something that currently exists, determining the frequency with which something occurs, and categorizing information. Five types of qualitative research The goal of qualitative research is to generate new insight or knowledge, or to validate existing knowledge. Qualitative research data are usually driven by the participants' thoughts, reactions, perceptions, and experiences. This type of research focuses on systems, steps, rituals, processes, best practices, observations, or personal experiences, and may or may not have an outcome. Qualitative research can be used to gain a better understanding of a topic, inform the reader about how to perform a task, or gain a new perspective on a topic. It's helpful to explain sensitive, unique, and difficult-to-understand information that can't be conveyed quantitatively.FigureTable: Quantitative versus qualitative researchQualitative research may consist of the following elements: a hypothesis or theory an observation through experience or interactive study practice-based interventions implementation strategies casual or formal approaches approaches to adaptation or variation how-to guidance unanticipated adverse reactions if applicable relevant background or circumstantial factors. The five types of qualitative nursing research are as follows. Ethnography involves the analysis or observation of a culture or social group's customs, rituals, and behaviors, and their understanding of disease and illness within that culture. It requires methodical collection, detailed descriptions, and analysis of the information to help refine or develop cultural theories. Ethnographic studies allow the reader to understand a subject group's way of life and the cultural forces that shape the group's rituals, behaviors, thoughts, or feelings. The research may have a specific or global focus; for example, the group's interaction among themselves or with others, or social norms or taboos. Grounded theory is often referred to as “theory building” because concepts, problems, and theories are continuously reevaluated. It's designed to discover what problems exist in a specific social environment and how these problems are resolved. It involves devising a theory, testing the theory, and refining the theory until the core problem or solution is identified. This type of research often includes personal or professional first-hand experiences. A common core question within grounded theory is, “What's the basic problem and how are we going to resolve or improve it?” An example is a patient describing how he or she copes with existing or new health conditions. Another example: A nurse describes the methodical steps that have improved a patient's experience or health, or resolves the knowledge deficits of other healthcare personnel. Symbolic interactionism focuses on patterns of communication, interpretation of that communication, and understanding how this communication forces adjustments between individuals who react to their interpretation of their world or social group. This type of research reflects the theory that people behave or react in response to what they believe is true or correct, and not just based on what's objectively true. Teenagers who are overwhelmed with information on the health risks of smoking are one example: Despite this information, they may still smoke because they believe it will help them fit in with their peer group. Historical research involves understanding and gathering information on the history of a topic, group, or culture. This type of research allows the reader to systematically evaluate historical information via a detailed analysis of past occurrences and guides the reader to what's been proven to be beneficial or ineffective in certain situations in the past. Armed with this knowledge, nurses can develop a plan to improve results or outcomes for their patients, work environment, or clinical practice. An example of this type of research is Florence Nightingale's discovery that unsanitary wound care and infrequent hand washing led to poor patient outcomes and that sanitary wound care with good hand washing improved patient outcomes. Phenomenology utilizes personal experiences to gain insight, empathy, or knowledge about a specific topic, situation, or “phenomenon.” With this type of research, the investigator attempts to describe or understand a person's or group's perception, perspective, and understanding of a phenomenon and tries to answer the question, “What's it like to experience a given situation?” By understanding how patients view or experience events, nurses can formulate new treatment plans to enhance the healthcare experience or resolve knowledge deficits. By looking at multiple perspectives on the same situation, a researcher can make generalizations about what something is like from an insider's point of view. This research is typically focused on specific topics, such as a patient's response to illness, physical disability, healthcare procedures, or healthcare work environments. Become an EBP cheerleader Encourage your healthcare team members to utilize and participate in EBP research studies when opportunities arise. This broadens our knowledge base and allows us to validate our clinical and operational practices. There are numerous ways that you can become an EBP cheerleader in your work area and encourage your healthcare team to be EBP leaders. For example: consider starting a nursing journal club. Each member can bring a new, relevant EBP study to share with the group at each weekly or monthly meeting. consult with your healthcare and administrative team about forming an EBP committee within your unit or facility. The group can explore new EBP data that may be beneficial in more than one area or unit of your healthcare facility. interactively participate in grand rounds with your physicians and other healthcare team members on a regular basis. Engage your colleagues and educate them on new EBP practices, studies, or interventions that may benefit their work environment or patients. The management team should set the example by supporting and acknowledging nurses who participate in, publish, or otherwise share new EBP research data that may benefit nurses and patients in their facilities and the community. As the field of nursing continues to evolve, we must become proficient in evaluating, participating in, and sharing EBP research with our healthcare team to improve our clinical practice and our patients' outcomes. To read more about EBP research, visit http://nursingplanet.com/Nursing_Research/. Caution: permission requiredFigureDon't approach patients, families, or coworkers about participating in a research study until you've provided your healthcare facility with a clear research plan, including a hypothesis, objectives, and known variables. After presenting the research plan, obtain permission according to your healthcare facility's policy. To proceed with research, you must typically obtain permission from your healthcare facility, governing bodies, management teams, ethical standards boards, patients, families, and coworkers, if applicable. Patients recruited for the research should be given full disclosure of all the known variables so they can make informed decisions that are consistent with their ethical values and beliefs. It's important for all members of the research team to be socially and ethically considerate of all participants in a research study. Never pressure, coerce, or exert direct or indirect pressure on any potential participant in a research study. Learn the lingo! Research studies often contain language that may be unfamiliar to nurses. Don't be intimidated! You can easily learn the basic lingo that's commonly found in research studies, such as: abstract: a brief summary or overview of the research study. case study: a collection of detailed information about a person or specific group. causality: the relationship between the cause and effect of a situation or event. consent: an agreement given by a competent person to participate in a research study. control group: randomly selected participants from the research group who won't receive the experimental treatment or variable. Those in the control group will be compared with those receiving the treatment or variable under investigation to establish the effectiveness or ineffectiveness of the variable/treatment. double-blind study: a research study conducted in which neither the investigators nor the participants know specific details of the study, such as whether a placebo or trial medication is being administered. experimental research group: randomly selected participants from the research group who will receive the experimental treatment, medication, or variable. hypothesis: an educated guess about the expected outcome of a study. mean: the average score between two variables or outcomes. single-blind study: a research study conducted in which the investigators know specific details of the study but the participants don't. variable: an intervention, action, or medication that's being studied to observe its effect on the research group. For example, a group of oncology patients may receive a new cancer medication to study its effectiveness on reducing tumor cell growth. In this scenario, the new medication is the intervention or variable. memory joggerFigureWhen conducting research, think DIDACTIC. Develop a hypothesis Identify common variables Design (pick a specific research design) Acquire pertinent data such as past medical records Communicate your research goals with the healthcare team Talk with the research study participants (goals, risks, and benefits) Implement your plan after you obtain the participants' written consent Collect the data and write your conclusion

Physicians will recognize Lyme disease faster if they maintain a high index of suspicion in a young patient with arthritis accompanied by negative rheumatoid factor and antinuclear antibody in combination with cardiac conduction problems or lymphocytic meningitis. The Lyme spirochete (Borrelia burgdorferi) has notable sensitivity to tetracycline, penicillin, and erythromycin; therefore, proper and complete treatment of the disease, once it is identified, can be easily achieved. Finkel observed that Lyme disease manifests itself as a "great imitator," as do many disorders caused by a spirochete. The total impact of Lyme disease on public health will be known only when the disease is fully recognized, consistently reported, and adequately managed.

Letters1 September 1996The Cardiomyopathy of Obstructive Sleep ApneaRobert Joseph Thomas, MDRobert Joseph Thomas, MDAlvin C. York Veterans Affairs Medical Center, Murfreesboro, TN 13129Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-125-5-199609010-00029 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:A 44-year-old man was hospitalized for the management of recently diagnosed and refractory congestive cardiac failure, deep venous thrombosis of the left lower extremity, atrial fibrillation, mild hypothyroidism, and morbid obesity (weight, 450 pounds). When questioned, the patient admitted to severe excessive daytime somnolence.Blood gas analysis showed the following results: pH, 7.31; Pao2, 51.3 mm Hg; Pco2, 71.3 mm Hg; and HCO3, 41.4 mEq/L. The ejection fraction was estimated to be 30% by echocardiography and radionuclide ventriculography. Polysomnography established severe obstructive sleep apnea with an apnea–hypopnea index of 95. The response to nasal continuous positive airways ...References1. Malone S, Liu PP, Holloway R, Rutherford R, Xie A, Bradley TD. Obstructive sleep apnea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure. Lancet. 1991; 338:1480-4. Google Scholar2. Zohar Y, Talmi YP, Frenkel H, Finkelstein Y, Rudnicki C, Fried M, et al. Cardiac function in obstructive sleep apnea patients following uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg. 1992; 107:390-4. Google Scholar3. Guilleminault C, Motta J, Mihm F, Melvin K. Obstructive sleep apnea and cardiac index. Chest. 1986; 89:331-4. Google Scholar4. Shiomi T, Guilleminault C, Stoohs R, Schnittger I. Leftward shift of the interventricular septum and pulsus paradoxus in obstructive sleep apnea syndrome. Chest. 1991; 100:894-902. Google Scholar5. Garpestad E, Parker JA, Katayama H, Lilly J, Yasuda T, Ringler J, et al. Decrease in ventricular stroke volume at apnea termination is independent of oxygen desaturation. J Appl Physiol. 1994; 77:1602-8. Google Scholar Author, Article, and Disclosure InformationAuthors: Robert Joseph Thomas, MDAffiliations: Alvin C. York Veterans Affairs Medical Center, Murfreesboro, TN 13129 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byChange in quality of life with nasal CPAP in patients with OSASleep-Disordered Breathing in Patients With Idiopathic Cardiomyopathy.Sleep-related breathing disorders and cardiovascular diseaseThe prevalence of carotid atheromas seen on panoramic radiographs of patients with obstructive sleep apnea and their relation to risk factors for atherosclerosisQuality of Life in Patients with Obstructive Sleep Apnea 1 September 1996Volume 125, Issue 5Page: 425KeywordsApneaBloodEjection fractionGas analysisHeart failureSevere blood lossSleep apneaStrokeSystoleWeight loss ePublished: 15 August 2000 Issue Published: 1 September 1996 Copyright & PermissionsCopyright © 1996 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

BACKGROUND: Sitagliptin is recommended for initial and maintenance dosing at 100 mg daily. Downward dose adjustment is recommended in patients with moderate or severe renal insufficiency. OBJECTIVE: To determine the prevalence of the potentially inappropriate initial dosing of sitagliptin based on estimated glomerular filtration rate (GFR) at baseline for pharmacist versus nonpharmacist prescribers in an internal medicine department of a private physician-owned multispecialty clinic that included a pharmacist-managed diabetes program. METHODS: This was a retrospective cross-sectional cohort analysis using data from an electronic medical record database of a private physicianowned multispecialty clinic that included a pharmacist-managed diabetes program. For patients prescribed sitagliptin between October 17, 2006, and June 5, 2008, the variables of interest were (a) the initial sitagliptin dose; (b) the GFR, calculated for each patient using the 4-point Modification of Dosing in Renal Disease (MDRD) formula at the time of initiation of sitagliptin; and (c) whether the clinician initiating the dose was a pharmacist or nonpharmacist (i.e., internal medicine physician, nurse practitioner, or physician assistant). RESULTS: Of the 290 patients prescribed sitagliptin for the first time between October 17, 2006, and June 5, 2008, 35 (12.1%) received a potentially inappropriate initial dose according to product labeling regarding renal function; 21 were over-dosed and 14 were under-dosed. Potentially inappropriate dosing occurred in 1 of 158 patients (0.6%) who had initial dosing prescribed by a pharmacist compared with 34 of 132 patients (25.8%) for nonpharmacists (P < 0.001, Fisher's exact test). CONCLUSION: Potentially inappropriate initial dosing of sitagliptin based on assessment of renal function was more likely to occur with nonpharmacist prescribers than with a pharmacist prescriber.

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) commonly co-occur. Emerging research suggests that both distress tolerance and impulsivity may underlie this comorbidity. However, to our knowledge no studies have examined whether these 2 constructs predict outcome in PTSD-SUD treatment. The current study investigated whether pretreatment distress tolerance and impulsivity predicted posttreatment PTSD and cravings severity in a sample of 70 Veterans receiving concurrent treatment for PTSD and SUD in a residential day treatment program. Veterans completed measures of symptom severity before and after treatment. Results demonstrated that pretreatment distress tolerance predicted posttreatment PTSD severity while controlling for pretreatment PTSD. By contrast, pretreatment impulsivity was not predictive of posttreatment PTSD while controlling for pretreatment values. Neither distress tolerance nor impulsivity predicted posttreatment cravings severity. The findings support the notion that distress tolerance may help to explain the co-occurrence of PTSD and SUD and suggest that targeting this construct in PTSD-SUD treatment may be important for successful outcomes.