Terri Simpson

Relationships among sleep dimensions and factors that impair sleep after cardiac surgery

Factors associated with the attempted length, disturbance, effectiveness, and nap supplementation of sleep were analyzed in 97 patients recovering from cardiac surgery a few days before hospital discharge. Patients rated sleep for the prior night and factors that impaired their sleep after transfer from the critical care unit. The group averaged little sleep, with moderate disturbance and effectiveness and low nap supplementation. The disturbance, effectiveness, and attempted length of sleep were associated with an inability to perform their usual routine before sleep, inability to get comfortable, pain, noises, procedural care, and an unfamiliar bed. Patients encounter difficulties with sleep, even near discharge from the hospital. Interventions should be tested to mitigate specific factors that affect selected dimensions of sleep.

Appraisal of recommended respiratory infection control practices in primary care and emergency department settings

Background The severe acute respiratory syndrome (SARS) epidemic and concern about pandemic influenza prompted the Centers for Disease Control and Prevention (CDC) to develop guidelines to prevent the transmission of all respiratory infections in health care settings during first contact with a potentially infected person. The extent to which health care workers and institutions use these CDC recommended practices is uncertain. Methods The study examined health care worker adherence to CDC recommended respiratory infection control practices in primary care clinics and emergency departments of 5 medical centers in King County, Washington, using a self-administered questionnaire. All clinical, allied, and administrative health care workers in study settings were invited to participate: 653 (53%) responded, and 630 were included. Results The survey revealed important shortcomings in overall personal and institutional use of CDC recommended practices, including deficiencies in posted alerts, patient masking and separation, hand hygiene, personal protective equipment, staff training, and written procedures. Use of recommended measures was generally higher among nursing staff than medical practitioners. Conclusion This study found significant gaps in adherence to CDC recommendations for the control of respiratory infections in ambulatory care clinical settings. Practical strategies are needed to identify and reduce barriers to implementation of recommended practices for control of respiratory infections.

Soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1) as a Diagnostic Marker of Ventilator-Associated Pneumonia

OBJECTIVE: To determine the utility of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) levels in bronchoalveolar lavage fluid (BALF) and exhaled breath condensate (EBC) samples from patients who underwent bronchoscopy for a clinical suspicion of ventilator-associated pneumonia (VAP), to categorize patients as VAP positive and VAP negative, when compared to quantitative culture results of BALF. METHODS: Observational study conducted on admitted patients in the trauma-surgical, medical-cardiac, burn, and neurosurgical ICUs of Harborview Medical Center between March 2009 and May 2010. BALF and EBC samples were obtained from 45 patients with clinically suspected VAP. Bronchoscopy was performed on the day of clinically suspected VAP. sTREM-1 levels in EBC and BAL fluid were measured using quantikine human TREM-1 immunoassay. VAP was diagnosed by quantitative cultures of BALF. RESULTS: The concentrations of sTREM-1 in BALF and EBC did not correlate with VAP status. sTREM-1 levels did not discriminate VAP positive from VAP negative patients, when compared to quantitative cultures of BALF as the gold standard. Using a cutoff value of 204 pg/mL for BALF sTREM-1 levels resulted in a sensitivity of 79% and a specificity of 23%. A cutoff value of 10 pg/mL for EBC sTREM-1 levels resulted in a sensitivity of 42% and a specificity of 50%. CONCLUSIONS: EBC and BALF sTREM-1 levels did not effectively categorize patients as VAP positive or VAP negative when using direct bronchoscopic quantitative culture samples as the comparison standard.

Triggering receptor expressed on myeloid cells type 1 as a potential therapeutic target in sepsis.

Excessive and unregulated inflammation contributes to multiorgan failure and death in sepsis. Triggering receptor expressed on myeloid cells type 1(TREM-1) is expressed on neutrophils and monocytes and is upregulated in the presence of bacterial pathogens. Engagement of TREM-1 results in increased expression of proinflammatory chemokines and cytokines and amplifies the inflammatory response. In this article, we will review the structure and signaling pathway of TREM-1 and review the role of TREM-1 and soluble TREM-1 in the inflammatory response during sepsis. Based on these studies, modulation of the TREM-1 signaling pathway has been suggested as a potential therapeutic strategy for the treatment of sepsis, to dampen the inflammatory response without interrupting the ability of the host to clear pathogens. This basic science research may someday lead to other treatments for sepsis and other diseases.

Tuberculosis education for nurse practitioner students: where we are and where we need to go.

Tuberculosis (TB) has reemerged as a public health concern. This study tested the reliability and validity of an instrument examining self-efficacy in providing TB care, beliefs about educational preparation, and knowledge about TB among nurse practitioner students from diverse programs. A one-time self-report instrument was distributed during a final clinical course. Rasch analysis was used to assess the instruments reliability and validity. Most of the 92 respondents were from family nurse practitioner programs and had received TB education via lecture. Students were moderately knowledgeable on TB content and had a moderate level of perceived self-efficacy. They valued TB education as it related to both their current program and their clinical practice. The instrument had excellent reliability (alpha = 0.96 to 0.98), and it appears to be an effective measure to help faculty understand student knowledge and confidence in the care of individuals with TB.

Quantitative and qualitative QuantiFERON(®)-TB gold in-tube results among groups with varying risks of exposure to tuberculosis.

OBJECTIVE We sought to describe qualitative and borderline quantitative QuantiFERON(®)-TB Gold In-Tube (QFT-IT; Cellestis, Valencia, CA) results among persons screened in the context of routine reasons, employment, contact investigation, high-risk foreign-born arrivals in the United States ≤ 5 years, and high-risk United States residents >5 years. METHODS We performed a retrospective review of 3288 QFT-IT results from a clinical laboratory in the Pacific Northwest from January 2, 2008 to June 5, 2009. Interferon-γ (IFN-γ) responses were quantified as low, borderline, or high for tuberculosis (TB) antigens (IFN-γ [TB]) and a positive mitogen control (IFN-γ [mitogen]), after subtracting a background control (IFN-γ [nil]). Qualitative results were categorized as negative, positive, or indeterminate. RESULTS Quantitative values categorized as borderline, well above, or well below the cut-point were associated with qualitative results for IFN-γ (TB-nil) (χ(2) = 2913.178, degrees of freedom [df] = 4, P < .001) and IFN-γ (mitogen-nil) values (χ(2) = 2559.758, df = 4, P < .001). CONCLUSION Quantitative data enhance the interpretation of qualitative QFT-IT results for persons with varying risks of exposure.

Screening for Mycobacterium tuberculosis using an interferon-gamma release assay.

CONTEXT The Centers for Disease Control and Prevention recommend analyzing characteristics of populations screened for Mycobacterium tuberculosis infection using interferon-gamma release assays (IGRAs). OBJECTIVE We characterized requests for IGRA analyses submitted to the first laboratory in Washington State that began to offer IGRAs as a tuberculosis screening test. In addition, we chronicled the process by which this program was launched. DESIGN Through a retrospective record review we recorded the IGRA results, source of the request, and reason(s) for each request along with demographic information, risk factors, and prior exposure for each subject. Through dissemination and quality control measures, IGRA analyses began within the health district but quickly spread throughout the state and the West. SETTING AND PARTICIPANTS A regional health district clinical laboratory in the Pacific Northwest received 4422 IGRA requests for 4218 unique subjects from January 2, 2008, through June 5, 2009. RESULTS Most (96%) requests originated from public health clinics or centers, hospitals, private laboratories or practitioners, and Indian Health Centers. Community and migrant health centers had the highest rates of positive IGRA results (28%, Φc = 0.159, P = .000). About one-half of all requests were for employment or high-risk surveillance. Persons with a positive IGRA had a larger TST induration (M = 16.66 mm, 95% CI: 15.18-18.14) than those with a negative IGRA (M = 13.53 mm, 95% CI: 12.92-14.15) but did not differ for those with an indeterminate IGRA (M = 13.29 mm, 95% CI: 5.95-20.62). CONCLUSIONS Public and private agencies use IGRAs for surveillance of persons employed, routinely screened, at high risk, or foreign-born. The TST induration varies widely for persons with an indeterminate IGRA. The process for implementing IGRA analyses serves as a model for other programs seeking to conduct similar reviews of test use and results.

Educational competencies to strengthen tuberculosis curricula in undergraduate nursing programs.

Worldwide, at least two million people die annually from tuberculosis (TB), with projections of 36 million more global deaths between the years 2003 and 2020. To help nursing faculty strengthen TB curricula and standardize TB content in national and international undergraduate nursing programs, the Nurse Discipline Group of the National Tuberculosis Curriculum Consortium (NTCC) has developed comprehensive TB core competencies and specific student objectives for the classroom setting. These core competencies address the knowledge, ability, and/or skills required for an undergraduate nursing student to provide qualified holistic care for patients, families, and communities impacted by TB. The NTCC is comprised of a team of multidisciplinary health care educators in the United States, with the primary mission to instill knowledge, skills, and appropriate attitudes in the management of active and latent TB among undergraduate health care students.