Larry Wayne Lawhorne

Rapid Bacteriophage Sedimentation in the Presence of Polyethylene Glycol and its Application to Large-Scale Virus Purification

Abstract Bacteriophages may be readily concentrated from crude lysates of infected bacteria after addition of polyethylene glycol (PEG). A general procedure is presented which can be used for lysate volumes of 17 liters or more with nearly quantitative recovery of infectivity over a wide range of phage titers (105 to 1013 PFU/ml). All the bacteriophages tested (λ, T4, T7, P22, fd, φX174, R17) are efficiently removed from solution by simple settling at concentrations of PEG 6000 between 2% and 10%. Bacteriophage pellets are redissolved in a small amount of buffer, allowing 100-fold concentration of the original lysate. While lower molecular weight polyethylene glycols are much less effective for concentrating bacteriophages than the PEG 6000 used, the efficiency is relatively insensitive to changes in pH and ionic strength. Asymmetric particles (tobacco mosaic virus and bacteriophage fd) are especially susceptible to PEG, and they can be purified from more symmetrical particles at low PEG 6000 concentrations (2% or less). Although the exact mechanism by which bacteriophages can be concentrated with PEG is unknown, a phase partition rather than a normal precipitation reaction seems to be involved, since the fraction of infective phages removed from solution by a fixed concentration of PEG is nearly invariant to changes in bacteriophage concentration over as much as a 108-fold range. Extension of this method to concentration and purification of other viruses and nucleic acids, as well as some preliminary mechanistic studies, are discussed.

Understanding Clinical Dehydration and Its Treatment

Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patients history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.

An Evaluation of Antiepileptic Drug Therapy In Nursing Facilities

OBJECTIVES: To describe the prescribing and use of anti‐epileptic drug (AED) therapy in nursing facility residents.

Nursing Staff Beliefs and Expectations About Continence Care in Nursing Homes

OBJECTIVE The purpose of this qualitative study was to consider the current beliefs of nursing assistants and directors of nursing about management of urinary incontinence (UI) among the residents in nursing homes. DESIGN This was a qualitative study using purposive sampling and a focus group methodology. SETTING AND SUBJECTS Three focus groups including 38 participants were held in 2 different regions. Two of the focus groups comprised nursing assistants and 1 comprised directors of nursing. METHOD The focus groups were facilitated by 2 different advanced practice nurses (BR and LJK), and 2 similar interview guides were used: 1 for the nursing assistants and 1 for the nurses. The interviews were tape recorded and transcribed verbatim; data were analyzed via content analysis. RESULTS Ten themes were identified from the data; 3 focused on resident factors that influence UI, 4 related to staff and family contributors to UI, and 3 focused on recommendations to improve UI management in the nursing home setting. CONCLUSIONS The findings from this study can be used to guide interventions to decrease or eliminate barriers to continence care and thereby facilitate the implementation of clinical practice guidelines and evidence-based interventions to improve urinary continence among nursing home residents.

Urinary Incontinence: A Neglected Geriatric Syndrome in Nursing Facilities

PURPOSE Urinary incontinence (UI) is common but inadequately assessed and treated in nursing facility (NF) residents. The purpose of this study is two-fold: (1) to determine perceptions about the importance of UI and its management in the NF setting compared with other geriatric syndromes and (2) to compare barriers to UI care as perceived by physicians, geriatric nurse practitioners (GNPs), directors of nursing and other nurses in administrative positions (DONs), and nursing assistants (NAs). METHODS Computer-based surveys of physicians and DONs and a hard copy survey of NAs at their national meetings; an online survey of GNPs. RESULTS Responses included 395 physicians (31% response rate), 152 DONs (34%), 118 GNPs (23%), and 277 NAs (60%). Physicians, GNPs, and DONs evaluated and managed UI significantly less often than 5 other geriatric syndromes (behavioral symptoms of dementia, falls, unintended weight loss, pain, and delirium). In contrast, NAs were more likely to be involved in UI care than in care provided for residents with any of the other 5 syndromes. All 4 groups agreed that UI has less effect on clinical outcomes than the other 5 syndromes. However, DONs rated UI first with respect to cost of care; NAs third behind falls and pain; and physicians and GNPs rated UI fourth behind falls, behavioral symptoms, and delirium. With respect to quality of life effects, physicians and GNPs rated UI fifth and fourth respectively and DONs fourth. In contrast, NAs rated UI second only to pain with respect to its effect on quality of life. Perceived barriers differ among the 4 groups with physicians relatively more concerned that drug treatment alone is ineffective (P = .002); GNPs relatively more concerned with lack of effective nondrug interventions (P = .001); and DONs relatively more concerned about sufficient time to assess and manage UI (P = .001). NA respondents rated concern about anticholinergic drug effects lower than did respondents in the other 3 groups (P = .001). CONCLUSION Physicians, GNPs, and DONs are more likely to be involved in evaluating and managing behavioral symptoms of dementia, pain, falls, delirium, and unintended weight loss than UI in the NF setting. This leaves NAs as first-line managers for a condition that they perceive to have an important impact on quality of life. Perceived barriers to improving UI care differ among the 4 groups suggesting that approaches to overcoming the barriers should be multi-faceted.

Who cares for Missouri's Medicaid nursing home residents? Characteristics of attending physicians.

Objective: To describe the characteristics of physicians attending Medicaid recipients in Missouris certified nursing homes (NH).

Clinical practice guidelines, process improvement teams, and performance on a quality indicator for urinary incontinence: a pilot study.

BACKGROUND Previous work by the AMDA Foundation Long-Term Care (AMDA-F LTC) Research Network suggests that urinary incontinence (UI), while prevalent, is not a high priority in the nursing facility (NF) and that barriers to better continence care are discipline-specific. Other studies report that interventions for UI in the NF often are not individualized or are poorly implemented. Implementation of processes of care may be more dependent on facility characteristics than on the attitudes, knowledge, and skill of individual health care workers. We tested the hypothesis that better facility performance on a quality indicator (QI) for continence care (toileting) is associated with a more systematic approach to continence care. METHODS This is a descriptive study of a cohort of 34 for-profit NFs in the AMDA-F LTC Research Network. Facilities were categorized as either good performers or poor performers based on percentile ranking during a 1-year period on the quality indicator for toileting. Good performers and poor performers were compared based on a number of characteristics. RESULTS There were no significant differences between good performers (17 facilities) and poor performers (17 facilities) with respect to occupancy, turnover, performance on other QIs, and cost of continence products. The prevalence of pharmacotherapy for UI was between 7% and 8%, which is consistent with other reports and did not differ between good performers and poor performers. However, good performers were more likely to report the presence of a process improvement team (PIT) for UI (53% versus 18%, P = .03) and more likely to report using a clinical practice guideline (CPG) for UI along with a UI PIT (47% versus 6%, P = .007). CONCLUSIONS Facilities that are good performers on the quality indicator for toileting are more likely to report the presence of a process-improvement team for urinary incontinence. Better performance is even more strongly associated with both the presence of a process improvement team and reported use of a clinical practice guideline for urinary incontinence.

Reflections on the Under-Researched Topic of Grief in Persons With Dementia: A Report From a Symposium on Grief and Dementia

This article describes a symposium about the clinical challenges of providing care to persons with dementia and their families. The plenary session addressed the bereavement process in the general older adult population, neurocognitive processes that alter the grief process in persons with dementia, and therapeutic approaches to support grieving persons in different stages of dementia. Participants from diverse health care disciplines met in small groups to identify (1) current responses to persons with dementia and their families who experience a loss; (2) barriers to providing effective responses; and (3) possible interventions to improve care. Two general types of interventions emerged: practical/agency support and spiritual/affective engagement.

Evaluation of Academic Detailing for Primary Care Physician Dementia Education

The objective of this evaluation study was to assess the effect of academic detailing (AcD) as a strategy to increase early detection of dementia in primary care practice and to improve support and management of Alzheimer’s disease and other dementia disorders by increasing communication and referrals to local community agencies. As designed for dementia education, AcD consisted of 15-minute educational sessions delivered in primary care practice offices. Twenty-nine visits were conducted by trained teams comprised of a physician and representatives of the Alzheimer’s Association (AA) and Area Agency on Aging (AAA). A key outcome of the visits was increased knowledge of the specific programs and services available. In all, 77.4% rated the visit very effective, and follow-up evaluation suggests visits led to an increase in referral to these agencies (55%) and potentially enhanced early detection of dementia by physicians as measured by 35% making changes in the way they identify at-risk patients.

Individualized Behavior Management Program for Alzheimer’s/Dementia Residents Using Behavior-Based Ergonomic Therapies

Person-centered, nonpharmacological interventions for managing Alzheimer’s/dementia-related behavioral disturbances have received significant attention. However, such interventions are quite often of a single type limiting their benefits. We develop a comprehensive nonpharmacological intervention, the Behavior-Based Ergonomic Therapy (BBET), which consists of multiple therapies. This low-cost, 24/7 program uses learning, personality, and behavioral profiles and cognitive function of each resident to develop a set of individualized therapies. These therapies are made available through an accessible resource library of music and video items, games and puzzles, and memory props to provide comfort or stimulation depending on an individual resident’s assessment. The quantitative and qualitative benefits of the BBET were evaluated at the dementia care unit in a not-for-profit continuing care retirement community in west central Ohio. The 6-month pilot study reduced falls by 32.5% and markedly reduced agitation through increased resident engagement.