Deanna E. Grimes

A meta-analysis of nurse practitioners and nurse midwives in primary care.

This meta-analysis was an evaluation of patient outcomes of nurse practitioners (NPs) and nurse midwives (NMs), compared with those of physicians, in primary care. The sample included 38 NP and 15 NM studies. Thirty-three outcomes were analyzed. In studies that employed randomization to provider, greater patient compliance with treatment recommendations was shown with NPs than with physicians. In studies that controlled for patient risk in ways other than randomization, patient satisfaction and resolution of pathological conditions were greater for NP patients. NPs were equivalent to MDs on most other variables in controlled studies. In studies that controlled for patient risk, NMs used less technology and analgesia than did physicians in intrapartum care of obstetric patients. NMs achieved neonatal outcomes equivalent to those of physicians. Limitations in data from primary studies precluded answering questions of why and under what conditions these outcomes apply and whether these services are cost-effective.

The Effects of Self-Management Education for School-Age Children on Asthma Morbidity: A Systematic Review

The effects of asthma self-management education for school-age children on number of school days missed, emergency department visits and hospital admissions were evaluated through a systematic review of the published research. A total of 9 studies on asthma education programs that were conducted in schools by school nurses and health educators and targeted children 5–18 years of age were reviewed. The studies were all published between 1998 and 2009. The school-based asthma education programs delivered interventions in multiple sessions over short consecutive time periods of about a month to a month and a half. Follow-up data were collected in varying intervals from 1 month to 1 year postinterventions. Results indicated that a decrease in school days missed can be expected from such programs. The data regarding emergency department visits and hospital admissions was less definitive.

Antibiotic resistance in Staphylococcus aureus-containing cutaneous abscesses of patients with HIV

PURPOSE The aim of this study was to document the resistance patterns found in exudates from cutaneous abscesses of HIV-infected persons. BASIC PROCEDURES Patient records were reviewed on 93 culture and sensitivity tests performed on exudates taken from incised and drained abscesses of HIV-infected persons. MAIN FINDINGS Of the specimens, 84.6% were Staphylococcus aureus. Of these, 93.5% were penicillin resistant, 87% oxacillin resistant, 84.4% cephazolin resistant, 84.4% erythromycin resistant, 52.2% ciprofloxacin resistant, and 15.6% tetracycline resistant. Fifty-eight specimens were tested for clindamycin with 29.3% found resistant; 85.7% were methicillin-resistant S aureus (MRSA) (defined as resistant to both penicillin G and oxacillin). All specimens were resistant to multiple antibiotics including antimicrobials that might be considered for use in MRSA. No specimens were resistant to trimethoprim-sulfamethoxazole, rifampin, or vancomycin. CONCLUSIONS Empiric antimicrobial therapy of HIV-infected persons with cutaneous abscesses must be tailored to the high frequency of antimicrobial drug resistance including MRSA in this population.

Assessment of readiness to initiate antiretroviral therapy

Abstract PURPOSE: An important factor in adherence to antiretroviral therapy (ART) is the patients commitment to follow the regimen, which suggests that therapy should be initiated only when the patient is ready to make such a commitment. Because there has been no research on patient readiness for ART, this study was undertaken to investigate factors that influence the decision of an HIV-positive person to seek medical care and to initiate ART. METHOD: The investigators surveyed 83 HIV-infected patients on ART. Participants completed a questionnaire that obtained information on the length of time from when they learned of their HIV-positive status to when they sought medical care, the length of time from when they learned of their HIV-positive status to when they were ready to initiate therapy, and psychological and social factors thought to be associated with readiness. RESULTS: Respondents had a mean age of 37 years, 71% were male, and 65% were African American. Only 42% said they sought medical care immediately upon learning their HIV diagnosis. Fifty percent were ready to initiate therapy immediately upon learning their diagnosis, and 25% were ready within 1 year. Sixty-four percent of respondents experienced barriers that interfered with therapy initiation. Although 98% of respondents experienced at least one emotional response to HIV diagnosis, less than 25% of respondents thought that their responses interfered with readiness. However, five emotional responses demonstrated an association with readiness through chi-square analysis. CONCLUSION: Further research is needed to explain the relationships among emotional responses to HIV diagnosis, readiness to initiate ART, and adherence.

Self-help and life quality in persons with HIV disease

This study examined factors contributing to life quality in persons with HIV disease. Selected concepts and statements in a model designed to explain self-help and life quality in persons with chronic conditions were tested. Eighty-three persons with a diagnosis of HIV disease (58% with AIDS) completed a demographic profile and four instruments to measure dependence for help with daily living, enabling skills, self-help and life quality. The instruments had been used by researchers testing the Self-Help Model on persons with other chronic diseases. Direction and magnitude of the relationships, revealed through causal modelling procedures, were consistent with previous tests of the model. Diagnosis of AIDS explained 29% of the variance in dependency, but had no explanatory value for enabling skill. Enabling skill (beta = 0.32) and dependency (beta = -0.49) explained 33% of the variance in self-help. Self-help (beta = 0.59) explained 34% of the variance in life quality. Results suggest that self-help is influenced negatively by dependency and positively by enabling skill. Enabling skill appears to mediate the negative effect of dependency on self-help and can be a target of interventions to improve quality of life in persons with HIV disease.

Verifying Quantitative Stigma and Medication Adherence Scales Using Qualitative Methods among Thai Youth Living with HIV/AIDS

HIV/AIDS-related stigma has been linked to poor adherence resulting in drug resistance and the failure to control HIV. This study used both quantitative and qualitative methods to examine stigma and its relationship to adherence in 30 HIV-infected Thai youth aged 14 to 21 years. Stigma was measured using the HIV stigma scale and its 4 subscales, and adherence was measured using a visual analog scale. Stigma and adherence were also examined by in-depth interviews. The interviews were to determine whether verbal responses would match the scale’s results. The mean score of stigma perception from the overall scale and its 4 subscales ranged from 2.14 to 2.45 on a scale of 1 to 4, indicating moderate levels of stigma. The mean adherence score was .74. The stigma scale and its subscales did not correlate with the adherence. Totally, 17 of the respondents were interviewed. Contrary to the quantitative results, the interviewees reported that the stigma led to poor adherence because the fear of disclosure often caused them to miss medication doses. The differences between the quantitative and the qualitative results highlight the importance of validating psychometric scales when they are translated and used in other cultures.

Bioterrorism: Class A Agents and Their Potential Presentations in Immunocompromised Patients

A bioterrorism attack would be particularly challenging for medical professionals caring for patients with cancer who often have weakened immune systems. Knowledge of the class A agents and the potential variable presentations in immunocompromised patients is key to early recognition of an outbreak and prompt reporting. The purpose of this article is to present the class A agents: Bacillus anthracis (anthrax), botulinum toxin (botulism), variola virus (smallpox), Yersinia pestis (pneumonic plague), and Francisella tularensis (tularemia). The variable signs and symptoms that may be present in immunocompromised patients with cancer will be discussed with a focus on assessment and early recognition of an outbreak. The availability of vaccines and the implications for patients with cancer receiving these vaccines also will be discussed.

Management of Steroid-Induced Hyperglycemia in Hospitalized Patients With Cancer: A Review

PROBLEM IDENTIFICATION Glucocorticoids are prescribed for hospitalized patients with cancer for a variety of reasons, including cerebral edema, treatment and prevention of nausea, and as part of cancer treatment regimens. Glucocorticoids are known to cause hyperglycemia. The purpose of this study was to integrate the published research on the management and the effects of steroid-induced hyperglycemia in hospitalized adult patients with cancer with or without preexisting diabetes. LITERATURE SEARCH MEDLINE®, PubMed, EMBASE, CINAHL®, and Scopus electronic databases were used to identify relevant articles. Bibliographies of included studies were reviewed for any pertinent studies that were not obtained through database search.Data Evaluation: 1,392 studies were identified. A total of 18 studies that met criteria were fully reviewed, 6 of which met all of the inclusion criteria. DATA ANALYSIS Data were abstracted from the included studies using a systematic code sheet to document characteristics of the studies and findings on management of hyperglycemia. Characteristics of the studies and findings on management of hyperglycemia were organized into three tables: the patients did not have preexisting diabetes, the patients had preexisting diabetes, and patients with or without preexisting diabetes were both included in the study. Management and effects of management of hyperglycemia were then compared and synthesized.Presentation of Findings: Hyperglycemia occurs in hospitalized patients with cancer irrespective of whether patients have a prior history of diabetes. Hyperglycemia resulting from steroids is treated in a variety of ways, but the resulting glycemic control has not been consistently documented. However, this review suggests that scheduled insulin (basal-bolus) is effective in attainment of glucose targets. IMPLICATIONS FOR PRACTICE Nurses should be aware of the effect that steroids have on glycemic control in patients and should be empowered to request or perform blood glucose monitoring when appropriate. Nurses can identify those patients receiving steroids and assess for signs and symptoms of hyperglycemia. They also can review routine laboratory results and assess for hyperglycemia in patients receiving steroids.

Psychological states in HIV disease and the nursing response

The authors review the four major psychological states of HIV infection as described by Nichols (1985) and adapt these manifestations for use by the nurse in the clinical setting. The states and their likely impacts are described. The diagnostic tools for recognizing the states, assessment questions that help establish the patients psychological state, and nursing interventions are included.

Patient Readiness to Adhere to HAART

Objectives: to determine 1) whether patients’ statements of readiness to take HAART predicted adherence and 2) whether previous experience with HAART enabled patients to better predict adherence. Method: Thirty-nine patients (24 naïve to HAART and 15 reinitiating HAART after a hiatus of >6 months) indicated readiness to take HAART on a Likert scale and a visual analog scale (VAS). Adherence was measured by prescription renewals. Results: Participants were 72% male; 62% African/American; 23% Anglo-White, and 13% Hispanic. Patients considered themselves quite ready to initiate therapy on both scales. Adherence for 5 months ranged from 24% to 100%; mean = 68%; median = 78%. Adherence was not associated with readiness as measured by the Likert scale (F = .15, p = .86) or the VAS (r = -.078, p = .64). VAS readiness scores did not correlate with adherence for naïve (r = -.16; p = .47) or experienced (r = .09; p = .76) patients. Conclusions: Patients’ statements of readiness to take HAART do not predict their adherence.