Essay Describing An Individual From A Biopsychosocial Perspective

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This essay will focus on an individual the writer has been involved in caring for during a community practice placement. It will give a brief and relevant history about the patient. It will describe the term ‘biopsychosocial’ and how it is related to holistic care with specific reference to Dementia. For the purpose of discussion, the essay will focus on an individual with early onset dementia and will discuss biopsychosocial factors affecting this client group and the prognosis of the condition. In line with Nursing and Midwifery council (NMC, 2008) confidentiality will be observed throughout this work. However for the facilitation of discussion, the client will assume the name Gonzo.

It has been highlighted by Campbell and Rohrbaugh (2006) that the term biopsychosocial refers to the relationship amongst biological, psychological and social aspects of an individual. It is imperative to look at the patient as a whole when caring for patients as it entails embracing the spiritual, social, emotional, physical and intellectual needs during assessments and treatment as they are necessary to all human beings as indicated by Clarke and Walsh (2009).

Gonzo is a 64 year old male patient who was diagnosed in year 2000 with Alzheimer’s type Dementia (Young Onset) according to World Health Organisation (WHO, 2007). However his wife also reported that he had been presenting some of the symptoms about four years prior to his diagnosis and it is also around the time he had a cardiovascular accident on his right side which slightly affected movement of his right eye and speech. He had reported to his wife that his parents gave him away at a very young age thus leaving him growing up in an orphanage until the age of thirteen. He did very well at school and prior to him being diagnosed with this condition he had been running his own business. He had stated to his wife that he does not wish to end up in an institution. His wife finds it difficult to cope and feels he now needs a respite so she can have a break.

Through reading his notes I found that due to the progression of his condition his wife started managing the finances of the business but he felt like she was taking over. Already he had started avoiding his friends and relatives. Furthermore he had held his wife tightly in an angry manner leaving her bruised which is something he had never done previously. At the moment he attends a day centre where he used to play table tennis when he first attended but now he cannot even raise the bat.

However dementia is a condition due to disease of the brain cells usually of a long lasting or progressive nature. The brain changes by decreasing and shrinking showing that some of the nerves connection established early in life and die later in life (Norman I and Ryrie I, 2009). There are many types of dementia and manifestation of dementia can only be taken into account by the relationship between neurological impairment, physical health and social resources (Woods and Clare, 2008). Stroke is known to step up the risk of dementia and to advance the onset of degenerative disease such as Alzheimer’s disease (Bridges J, 2005). Neurotransmitters’ activity in turn affects how the individual processes information in turn may affect behaviour as indicated by his physical aggression towards his wife.

Health psychology deals with the physical health in association with the psychological health. When cognition has been affected it means the physical wellbeing will also suffer in the sense that people would end up not attending to their activities of daily living and eventually basic activities (Gross and Kinnison, 2007).

It has been indicated that the declining of cognition maybe a precursor to people with dementia as they will come to experience changes in their cognition, language, behaviour and personality limiting their daily functioning (Warren M, 2008).

Hence all the changes Gonzo has been exposed to make feelings of anxiety and frustrations worse.

Woods (2007) indicated that people with early onset dementia are encouraged to face familiar immediate environment and building up of memory and maintaining cognitive functioning. Moving to a nursing home for respite would make it difficult for Gonzo to have social interaction with friends as some of them might have difficulties to visit mainly because of distance. Furthermore (Bercedis, 2008) stated that relocation and life events can lead to deterioration for people with dementia as this is associated with depressive or disturbed behavioral. However Mittelman et al, 2006, indicated that living at home has some positive advantages for the person with dementia yet a nursing home placement has been reported to create a more confused state. Although this would have a big impact on this client group their caregivers are also exposed to some stressful situations as they would be experiencing a loss.

According to Perren et al (2006) states that where there is a loss or threat of resources stress occurs and may improve when there is a resource profit. Providing day care services for example a day centre would not only be including the patient but also taking some of the burden from the caregiver. Furthermore the psychiatric needs of patients with dementia not only do they affect the individual with the condition. They also affect the health and well being of their caregivers as well as all those in the household for they would be vulnerable to suffering from psychological burden because they would be providing constant care (Boustani et al, 2007).

It is felt that there are several factors that affect people with different types of dementia. Woods and Clare (2007) highlighted that the sense of self is known to be threatened by the disintegration as a result from symptoms and loss of functioning, loss of social networks and reduced personal interactions. These early stages have been described to be very painful by Gonzo as he is aware of the painful changes (Balfour, 2006). For instance Gonzo has already started avoiding his friends and feels his wife is already taking control of his life. Woods and Clare (2007) went on to state that care and support can be drained from a psychosocial knowledge of the dementia process which entails. Whereas this would be including the holistic care that would meet all the needs of an individual. For example Gonzo had already expressed that he would not want to end his life in an institution but he had been lacking some of those social interactions other spending more time with his wife.

Furthermore his wife would need a respite of which this would have been contradictory to his beliefs. According to Woods and Clare (2007) the progression of dementia has major impact on relationships and a sense of loss regarding the future as people would no longer be able to do things together like they used to in the past. However Jacoby stated that the risk of dementia progression increases as people get older with increasing social isolation and minimum contact with friends and relatives. The writer feels this would have an impact on Gonzo as he still has slight insight of his illness because of the connotations linked to the most developed stage of this condition. The stigma attached to the term dementia leaves patients with this diagnosis being seen as no longer having any psychological needs leading on to patients using behaviour to communicate unmet needs.

Sociology is the understanding of the world we live and aspects of human behaviour (Haralambos et al, 2000). According to Dilts (2001), in life there is ample evidence which suggests that the loss of confidentiality, public’s view and knowledge, perception, isolation and discrimination from social interaction has harmful effects to humans. According to Clark & Bond (2000) caregivers are exposed to restricted lifestyles, loss of privacy, lack of social interaction, reduced commencement of social activities and limited time for hobbies when the people they care for have been diagnosed with dementia. In situations like this it is best to provide patients with home care or day care packages or respite so as to give their carers a break.

In view of the above I have learnt that biopsychosocial and holistic care all play an important role in healthcare and should use them when carrying out patients’ assessments as they focus on the needs and presentations of an individual without leaving any aspect of need as it may affect the actual reason why people respond the way they do. When looking at the holistic approach in nursing care, this extends to the dimensions that are looked at when looking at an individual. Biopsychosocial factors all play an integral part to all individuals with dementia and they should be treated as individuals with their rights. It is difficult to point at one perspective as the causative to Dementia. I have also learnt that biopsychosocial factors affect family and significant others who live day in day out with the patient and that they should be included when addressing the needs of the patient. If its believed to be from a biopsychosocial perspective then interventions should take the same approach to address the problem.

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History and Development of the Nurse Practitioner Role

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Exploring the profession of Nurse Practitioner

“People will forget what you said, they will forget what you did, but they will never forget how you made them feel,” said Maya Angelou, a famous American poet, singer, memoirist, and civil right activist. Although this phrase was used in the context of using appropriate words while communicating with others, it holds so true in the health care industry. Health care field, America’s largest service industry is facing a healthcare crisis past many decades. While the policymakers struggle year to year to bring in the balance between the rising demand for health care needs and the number of professionals catering it, the dearth of health care professionals continues. Increase in the number of births and aging seems to be the hindering factor in maintaining this balance. To address this issue, America came up with the solution of evolving midlevel providers such as Nurse Practitioners (NP), Advance Practice Registered Nurses (APRN), and Physician Assistants (PA). The profession of NPs has leaps and bounds past few decades. NPs are trying to fulfill the most crucial demand of this time by attaining rigorous training and performing excellently.

The profession of NP has seen detailed history overtime. The first NP program was founded in 1965 by Loretta Ford, EdD, PNP, FAAN, and Henry Silver, MD, at the University of Colorado (Cronenwett et al. 9) in response to the scarcity of primary care providers, particularly for children, in urban and rural areas of the United States. The NP is a registered nurse with advanced training, graduation from an accredited NP program, and successful completion of the state licensing exam. The NP profession grew so rapidly from its infancy of 15,000 NP in the year 1979 to 205,000 in the year 2015 (Pulcini and Wagner, 51). Per the statistics of American Association of Nurse Practitioners, there are more than 270,000 NPs licensed in the U.S. (“2017 National Nurse Practitioner Sample Survey Results”).

The education for NP is very rigorous and time-consuming. It begins with enrollment into a BSN program of two to four years depending upon the college. The associate degree in the same stream can be obtained in as quick as nine months through accelerated programs. Not to forget that the enrollment is competitive and requires the completion of general education courses like English composition 1 & 2, anatomy and physiology, college algebra, chemistry, general biology, and Test of Essential Academic Skills (TEAS). Once the BSN is completed, one can certify their degree as a Registered Nurse (RN) by completing the National Council Licensure Examination (NCLEX) exam in either NCLEX-RN or NCLEX-PN. The latter is used for practical and vocational nursing graduates.

As a certified RN, one can practice in their choice of field to gain experience. To earn a graduate degree, preferably post two years of clinical practice, there are two choices of either pursuing a master’s degree (MSN) or a doctoral program (DNP). Although, the American Association of College of Nursing (AACN) recommends the new standard for entry becomes the DNP starting 2015 so the NPs could gain more autonomy, work without any supervision, and provide advanced care in par with other intraprofessional education. There are very few colleges who have accepted this policy while others are still proceeding with the master’s program, with the hope that eventually it will all following the same policy. Post completion of MSN or DNP, state licensing is mandatory for an NP to practice. Licenses are issued by the State while the certification is awarded by the national agencies. Five different agencies issue this certificate depending upon the specialty. The license must be renewed every 3-5 years depending upon the specialty. What is lucrative for the current generation is NP degree can be obtained even online, while one continues to work so there is no economic burden for pursuing this profession.

NPs not only play a demanding but challenging role. Independently and in collaboration with other health care providers, NPs provide a broad range of primary, acute, specialty health care services. At first, NPs primarily worked in pediatrics but soon they ventured into other health care specialties such as family medicine, adult health, gerontology health, neonatal health, oncology, psychiatric/mental health, women’s health, etc. Besides, there is no subspecialty in medicine where NPs are restricted to work. The data published by Bureau of Labor Statistics in 2017 showed the effectiveness of NPs in reducing the hospitalization rates and attaining better client satisfaction (Occupational Employment and Wages, May 2018) proving that this model is not only successful but is also fulfilling the healthcare crisis to a larger extent.

The importance of NPs has been explored in several surveys and research studies. With such intensive training and several years of education, NP is ranked second in the U.S. News list of best healthcare jobs in 2017 (2017 National Nurse Practitioner Sample Survey Results). This ranking is based on things like great demand in the healthcare sector, best-paid salary, future growth, greater work satisfaction, and work-life balance. The AANP National Nurse Practitioner Sample Survey of 2018 reported that the mean, full-time base salary for NPs was $107,480 per year in 2017, of course, this varies from specialty and the location of practice (Occupational Employment and Wages, May 2018). The majority of NPs (57.4%) see at least 3 patients per hour assuring job satisfaction (2018 AANP National Nurse Practitioner Sample Survey). The average age of NP is 49 years proving that they have tremendous experience even before they attain their degree and it is never too late to become an NP (2018 AANP National Nurse Practitioner Sample Survey). As of today, there are 21 states and D.C allow NPs to practice on their own and this number is expected to rise with time.

Becoming an NP unites the nurse’s compassion and skills with the autonomy to practice, diagnose, and treat patients holistically. NPs have proven to be extremely valuable to the medical community and patients. With intensive training, increasing demand, challenging and rewarding career, NPs seems to be the best possible answer to the healthcare crisis of America.

Works Cited

  • Cronenwett, Linda, et al. “The doctor of nursing practice: A national workforce perspective.” Nursing Outlook 59.1 (2011): 9-17
  • Pulcini, Joyce, and Mary Wagner. “Nurse practitioner education in the United States.” Clin Excell Nurse Pract 6.2 (2002)
  • “Nurse Practitioner Role Grows to more than 270,000.”

    AANP

    , 28 Jan. 2019, www.aanp.org/news-feed/nurse-practitioner-role-continues-to-grow-to-meet-primary-care-provider-shortages-and-patient-demands>
  • “Occupational Employment and Wages, May 2018 29-1171 Nurse Practitioners.”

    United States Department of Labour

    , www.bls.gov/oes/2017/may/oes291171.htm. Accessed 16 September 2019.
  • Snider, Susannah. “Unveiling the best jobs of 2017.”

    US & World Report News

    , 11 Jan 2017, www.money.usnews.com/money/careers/articles/2017-01-11/unveiling-the-best-jobs-of-2017.
  • “2017 National Nurse Practitioner Sample Survey Results.”

    AANP

    , 08 Aug. 2018. www.aanp.org/news-feed/2017-national-nurse-practitioner-sample-survey-results.

Discuss Madeleine Leininger’s Cultural care model with particular reference to the three (3) Professional modes of action or decisions.

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Discuss Madeleine Leininger’s Cultural care model with particular reference to the three (3) Professional modes of action or decisions.

Topic: Lebanese Arabic Cultural Competence Report in relation to Nursing
Order Description
1) Research a culture. Lebanese Arabic. That has relevance to nursing practice and present a report that has the following
a) Cultural patterns.
b) Communication.
c) Health beliefs and practices.
And

2) Discuss Madeleine Leininger’s Cultural care model with particular reference to the three (3) Professional modes of action or decisions, in cultural approaches to
nursing care for people from your above chosen culture.

Its a report not a essay. It is not religious based but cultural based.

you may need more references. I can send some journal articles. Discard what you don’t need.

– A comprehensive level of insight and knowledge of the cultural communication patterns and health beliefs and practices of the selected culture.

– Leininger’s cultural care model is discussed at an exemplary level.
Deep and thorough insight in the application of all the modes of action in the delivery of culturally sensitive practice.

 

Research risk management programs for health care facilities or organizations.

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Research risk management programs for health care facilities or organizations.

For this assignment, you will research risk management programs for health care facilities or organizations. Review the criteria below in order to select an exemplar that applies to your current or anticipated professional arena. (Note: Select an example plan with sufficient data to be able to complete the assignment successfully.)

In a 1,000-1,250 word paper, provide an analysis that includes the following:

  1. Brief summary description of the type of risk management plan you selected (new employee, specific audience, community-focused, etc.) and your rationale for selecting that example.
  2. Description of the recommended administrative steps and processes in a typical health care organization risk management program contrasted with the administrative steps and processes you can identify in your selected example plan. (Note: Select an example plan with sufficient data to be able to complete the assignment successfully.)
  3. Analyze the key agencies and organizations that regulate the administration of safe health care and the roles each play in the risk management oversight process.
  4. Evaluation of the selected exemplar risk management plan regarding compliance with the American Society of Healthcare Risk Management (ASHRM) standards relevant to privacy, health care worker safety, and patient safety.
  5. Proposed recommendations or changes you would make to your selected risk management program example to enhance, improve, or to secure compliance standards.

You are required to support your analysis with a minimum of three peer-reviewed references.

Prepare this assignment according to the guidelines found in the APA Style Guide,

Improving Metabolic Outcomes of Type 2 Diabetics

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ABSTRACT


Purpose

Diabetes is a complex chronic condition that imposes a substantial burden on society, both locally and worldwide.  Many patients with type 2 diabetes receive suboptimal treatment in the primary care setting; therefore we sought to improve metabolic outcomes by implementing a protocol based on the American Diabetes Association standards of medical care.


Methods

Inthisquality improvement initiative we implemented a comprehensive protocol in the form of a checklist and based on the American Diabetes Association standards of medical care on all diabetic patients, as well as implement individualized diabetes self-management education at a local underserved primary care practice.  Data was collected in a retrospective chart review pre project implementation and post project implementation.  Data will be analyzed using the IBM SPSS platform


Results

A collaborative approach in care of the adult type 2 diabetic patient that includes a comprehensive medical evaluation, glycemic control through self-monitoring and A1C levels, pharmacological interventions as appropriate and diabetes self-management education and support optimize diabetes management.  Detailed final results will be provided at project implementation completion.


Conclusions

This study provides preliminary evidence that diabetes self-management education and the implementation of clinical practice guidelines can improve metabolic outcomes for type 2 diabetics by increasing patient self-efficacy and increasing provider knowledge in evidence-based practices.


Keywords

Type 2 Diabetes, Diabetes Self-Management Education, Clinical practice guidelines, primary care


Abbreviations

ADA-American Diabetes Association

A1C-Glycosolated hemoglobin

BMI-Body Mass Index

BP-Blood pressure

DSME-Diabetes Self-Management Training

INTRODUCTION

Type 2 diabetes is a fast-growing global epidemic.  The disease affects 25 million Americans, with the annual economic cost exceeding $327 billion.1,2   Of this population, 90% receive treatment in the primary care setting, all the while enduring poor glycemic control.3  The rise in obesity, sedentary lifestyle, high caloric diets, and an ageing population, has contributed to the number of patients with type 2 diabetes, catapulting the projected prevalence rate to 1 in 3 people having the disease by 2050.4,5  Increased disease burden is experienced as a result of suboptimal glycemic control.  Complications associated with poor glycemic control include microvascular issues such as retinopathy, neuropathy and nephropathy, as well as higher risk macrovascular complications, such as coronary artery disease, peripheral artery disease, and stroke.6

Diabetes significantly impacts the racial and ethnic minorities, as well as the socioeconomically disadvantaged populations.7    Research has discovered a geographically recognizable area known as the ‘Diabetes Belt,’ which is located in the southern United States and characterized by a diabetes prevalence of 11% or greater among the adult population.8 Georgia holds the unfortunate distinction of being one of the states included in this region.  In Georgia, 11.6% of adults have been diagnosed with diabetes, a prevalence 20% higher than the national average, causing a death rate 8% higher than the national average and costing the state approximately $5.1 billion in 2013 alone.9  Despite these staggering statistics, studies have demonstrated many complications can be prevented or delayed through effective disease management.

Methodical management and support in the treatment of diabetes is crucial considering suboptimal disease management can result in increased morbidity and mortality.  Evidence shows that the integration of comprehensive best practices including pharmacologic and nonpharmalogical modifications such as lifestyle changes, medical nutrition therapy, and telemonitoring improve hemoglobin A1C.  With every percentage point decrease in A1C level there is a 25% reduction in diabetes-associated deaths, 35% reduction in the risk of microvascular complications, and 18% reduction in combined fatal and non-fatal myocardial infarctions.4,10,11   Despite the recommendation for comprehensive best practices in the management of diabetes, there are limited studies on the utilization of a multi-faceted approach that includes the pairing of the implementation of a protocol/checklist based on the American Diabetes Association (ADA) standards of medical care, as well as diabetes self-management education.  We therefore implemented a quality improvement project at a local underserved primary care office to determine the efficacy of this multi-faceted approach.

METHODS

Study Design and Setting

The project was a 12-week comprehensive quality improvement effort, based on the ADA standards of medical care and granted a statement of Institutional Review Board exemption.  The predominant purpose of the project was to improve metabolic outcomes, patient self-efficacy, and quality of life for type 2 diabetic patients.  The quality improvement project was conducted at a local primary care practice located in an underserved area in Riverdale, GA.  The population of the local county in 2015 was 273, 955; diverse, less educated, lower income earning, and with a poverty rate of 24%, higher than the state of Georgia.12

Sample

Inclusion criteria for participation was a diagnosis of type 2 diabetes, A1C > 7.5%, ages 18 to 64 years, English speaking and no cognitive deficits.  Excluded from the study were patients with a diagnosis of pre-diabetes or type 1 diabetes, pregnancy, non-English speaking, and positive cognitive and mental dysfunction.  Patients were recruited through a convenience sample over a period of approximately 5 weeks, via poster announcement, flyer distribution, one on one meetings, phone calls and office staff recommendation.

Intervention Description

A comprehensive protocol in the form of a checklist and based on the ADA standards of medical care was initiated on all diabetic patients at the practice.  Clinical practice guidelines standardize work processes, promote safety, and improve communication thereby increasing quality of care and improve health outcomes.13 Front-line staff attended several educational trainings on the importance of consistent utilization of the diabetes checklist; the trainings were conducted during project development and prior to project implementation.  Once patient eligibility was determined and informed consent was gained, a follow-up appointment was set up to begin individualized diabetes self-management education (DSME).  Literature supports the use of DSME for increasing patient self-efficacy and improving overall health.14   During the initial visit, a retrospective chart audit was conducted to collect baseline data of the core measures: most recent A1C, body mass index (BMI), and blood pressure (BP).  During the initial visit and prior to initiating DSME training, the Diabetes Knowledge Test was administered to gauge participant’s knowledge of diabetes.  The Diabetes Knowledge Test score also collected as a core measure for the quality improvement project.  The Diabetes Knowledge Test is a 23 question test originally validated in 1998 to assess a patient’s diabetes and diabetes self-care knowledge; the test was later revised with reliability, validity and generalizability re-evaluated and supported.15  Once the pretest was completed, an intense self-care management training was conducted and included goal setting, healthy eating, active lifestyle, self-blood glucose monitoring, medication compliance, risk reduction effects, and healthy coping mechanisms.  To re-iterate the importance of the information discussed during the individualized education training session, patients were given pedometers, blood glucose logs, an ADA plan your portions plate portion guide placemat, and additional diabetes management information.  Weekly follow-up support was provided via telephone or in person meeting for the remainder of project implementation. The follow up appointments provided further opportunity to coach and support patients, as well as answer questions to ensure successful outcomes.  At the end of the 12-week project, the Diabetes Knowledge Test was re-administered to determine a change in self-management behaviors, and A1C, BMI and BP was reassessed and compared to pretest results.

Data Analysis

Pre and post project quantitative data analysis was performed using the IBM SPSS platform to examine the effects of DSME on A1C, BMI, BP and Diabetes Knowledge.  A1C measures hyperglycemia and determines a patient’s risk for developing chronic complications.  Research supports a relationship between obesity, insulin resistance and hypertension due to the shared chemical reactions of increased oxidative state, deficient glucose, lipid metabolism, elevated inflammatory mediators, hypercoagulability and endothelial cell damage.16,17  Baseline and outcome data was compared to evaluate overall project success with integrating the comprehensive ADA protocol to the treatment plan of diabetics

RESULTS

A quality improvement project was implemented at a local, underserved primary care office in Riverdale, GA.  The project focused on the implementation of a comprehensive quality improvement protocol based on the ADA standards of medical care utilizing a collaborative approach with proactive providers and receptive patients; thereby improving glycemic control, decreasing morbidity and mortality, and optimizing self-care management by achieving target metabolic outcomes and improved self-care knowledge.  There were 15 participants recruited for the study, 3 men and 12 women.  Participant age ranges from 26-64.  Project aims include (a) 5% decrease in baseline A1C, (b) 5 to 7 mmHg decrease in systolic and diastolic BP, (c) 7% decrease in baseline BMI, and (d) 15% increase in Diabetes Knowledge test scores. Project aims will be evaluated by collecting and comparing pre and post-project A1C, BMI, BP and Diabetes Knowledge Test score ranges with means through a retrospective chart analysis.

DISCUSSION

The effects of type 2 diabetes on society cannot be ignored. Continued efforts to empower and educate patients are critical in disease management.  Lifestyle modification and the implementation of clinical practice guidelines can help prevent or delay diabetes complications.13,14  A detailed summary of the key findings will be discussed at project implementation completion.  The project has been successful thus far as evidenced by patient enthusiasm.  Two major project strengths include multi-component intervention implementation that allows maximum improvement and individualized education and support through face-to –face or telephone means to create a relaxed and convenient atmosphere.  Limitations to the project include small sample size, increased incompletion rates, and patients’ unwillingness to change behavior. Small sample size limited the project generalizability.  Increased incompletion rates were noticed due to the extended project length. Patient’s unwillingness to change behavior is often related to lack of motivation.  The implications of this study will hopefully confirm that an enhanced relationship between healthcare providers and patients improve processes of care and health outcomes; thereby directly influencing disease burden, rate of disease progression and co-morbidities which are essential  factors in improving outcomes and lowering overall health costs.  Future research can help develop additional innovative, technologically savvy ways to support patients during lifestyle change as we fight to implement evidence-based strategies in an effort to optimize diabetes care by improving metabolic outcomes. .


References

1. Beck J, Greenwood D, Blanton. 2017 national standard for diabetes self-management education and support. Diabetes Edu. 2017;43(5):449-464.

2. Peterson M. Economic costs of diabetes in the U.S. in 2017. Diabetes Care. 2018;41(5): 917-928.

3. Waddell J. An update on type 2 diabetes management in primary care. Nurse Pract. 2017;42(8):29-30.

4.  Yacoub TG. Combining clinical judgment with guidelines for the management of Type 2 diabetes: Overall standards of comprehensive care. Postgrad Med J. 2014;126(3):85-94.

5. Chatterjee S, Khunti K, Davies MJ. Type 2 diabetes. Lancet Diabetes Endocrinol. 2017; 389(10085):239-2251.

6.  Dodds S. The how-to for Type 2. Nurs Clin North Am. 2017;52(4):513-522.

7. Williams IC, Utz SW, Hinton I, Yan G, Jones R, Reid K. Enhancing Diabetes Self-care Among Rural African Americans With Diabetes. Diabetes Educ. 2014;40(2):231-239.

8. Myers CA, Slack T, Broyles ST, Heymsfield SB, Church TS, Martin CK. Diabetes prevalence is associated with different community factors in the diabetes belt versus the rest of the United States. Obesity. 2017;25(2):452-459.

9.  Georgia Department of Public Health. Georgia Diabetes report and action plan 2015. https://dph.georgia.gov/sites/dph.georgia.gov/files/Diabetes%20Action%20Plan%20FINAL%20DEC%202015-no%20watermark.pdf. Accessed October 8, 2018.

10. Lashkari T, Borhani F, Sabzevar S. Effect  of telenursing on glycemic control and body mass index of type 2 diabetes patients. Iran J Nurs Midwifery Res. 2013;18(6):451-456.

11. Asante E. Interventions to promote treatment adherence in type 2 diabetes mellitus. Br J Community Nurs. 2013;18(6):273- 276.

12.  Southern Regional Medical Center. Community health needs assessment 2016. http://www.southernregional.org/documents/CHNA-Plan-.pdf. Accessed October 8, 2018.

13. Wong M, Wang H, Kwan M, Fan C, Liang M, Li S. The adoption of the reference framework for diabetes care among primary care physicians in primary care settings: A cross-sectional study. Medicine.2016; 96(31): 1-7.

14. Cunningham A, Crittendon D, White N, Mills G, Diaz V, Lanoue M. The effect

of diabetes self-management education on HbA1c and quality of life in African-

Americans: A systematic review and meta-analysis. BMC Health Serv Res. 2018; 18(367): 1-13.

15. Fitzgerald J, Funnell M, Anderson R, Nwankwo R, Stansfield R and Piatt G. Validation of the Revised Brief Diabetes Knowledge Test (DKT2). Diabetes Edu. 2016; 42(2):178-187.

16. Britton KA, Pradhan AD, JM Gaziano, Mason JE, Rider PM, Buring JE. Hemoglobin A1C, body mass index and the risk of hypertension in women. Am J Hypertens. 2011; 24(3):328-334.

17. Zhou MS, Wang, A, Yu, H.  Link between insulin resistance and hypertension: What is the evidence from evolutionary biology? Diabetol Metab Syndr.  2014;6(12):1-8.

Evidence-based Practice for Venous Thromboembolism

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VENOUS THROMBOEMBOLISM

What is evidence-based practice (EBP) and why is it important in the healthcare field?  EBP is research that is conducted on specific practices that pertain to patient care with the anticipation of integrating the new and updated findings in to the healthcare setting.  EBP studies are important to allow for evolvement to keep up with the changing times.  Although, it may take years for the implementations of EBP research to be put into effect, the results have proven to be beneficial not only for patients but for the healthcare facility as well, saving the establishment from incurring costs on unfortunate, preventable outcomes.  Prophylaxis for venous thromboembolism (VTE) is a prime example of one of the practices that was brought about by EBP research.

A VTE is a blood clot that originates in a vein, usually in the lower extremities.  Risk factors for developing a VTE are: surgery, cancer, immobilization, hospitalization, and women who are pregnant or on oral contraceptives or hormone therapy.  A patient has the potential of developing one of two types of VTE: deep vein thrombosis (DVT) or pulmonary embolism (PE).  The difference between a DVT and a PE is a DVT is a clot in a deep vein and a PE is a clot that has broken free from a vein wall and travels to the lungs and partially or completely blocks of the blood supply.  According to the American Heart Association (2017), VTEs are the third leading vascular diagnosis after a heart attack and stroke, affecting between 3000,000 to 600,000 Americans each year.  Because VTEs are serious and life-threatening, but most significantly preventable, EBP guidelines were developed.  Some mechanical and pharmacological implementations that a patient may encounter are: placement of sequential compression devices (SCDs) on the lower extremities that mimic the movement of walking, wearing compression stockings (available in various lengths), and the administration of an anticoagulant (Heparin, Lovenox, Coumadin).

In order for the patient to receive the benefits of VTE prophylaxis treatment there first has to be an order placed; however, not all health care providers are initiating the EBPs of the VTE protocol.  In 2007, believing that the prevention of VTE was an underused protocol, Lloyd et. al (2012) conducted a 3 month survey amongst Canadian health care workers in an attempt to understand why prophylaxis of VTE was underutilized.  The results showed that health care workers found the following as potential barriers to implementation: concerns of bleeding, lack of indications, contraindications of DVT prophylaxis, patient discomfort from injections, and lack of time to consider DVT prophylaxis in every patient.  From this study, two “novel barriers were identified: misperception of DVT prophylaxis underutilization, and confusion about roles and responsibilities in the area” (Lloyd et. al, 2012).

Safety in health care requires a commitment to continuing education.  Every member of the interdisciplinary team must be aware of new guidelines for diagnostic or preventative measures that have been established by the health care facility.  Zieler et. al (2008) recognized a need in the community for appropriate VTE education, which in turn spawned the creation of the “VTE Safety Toolkit”. The intention of the toolkit was to enlighten not only providers but patients and the public as well.  Although, the toolkit originated in 2008 it can still provide useful information that can be utilized in today’s age such as patient education materials and strategies for providers to use for continuity of care.  There are 10 components to the toolkit that are evidence-based guidelines for preventing, diagnosing, treating, and educating patients and providers about VTE. “The components are as follows:

  • VTE prophylaxis guidelines.
  • VTE risk assessment tool.
  • DVT diagnostic algorithm.
  • PE diagnostic algorithm.
  • HIT (heparin-induced thrombocytopenia) assessment.
  • VTE treatment pathway.
  • DVT outpatient treatment order set.
  • Vascular laboratory requisition.
  • Neural-axial anesthesia guidelines.
  • Patient education (prevention and treatment) pamphlets.”

(Zieler et. al, 2008)

It is important to understand that VTE is a medication issue that requires a coordination of care among an array of individuals during diagnosis, prophylaxis, or treatment so the implementation of another tool to help bridge the gap on education is welcomed addition.

With the advent of electronic medical record (EMR) systems, providers are now able to determine if a patient is a high risk for VTE development based on the electronic entry of their assessment, therefore the patient can now be screened simultaneously to see if they are a candidate for needing a VTE protocol order with no additional work needed.  With a VTE prevention protocol in place, “it provides specific, sequential steps for patient care delivered by nurses and other health care professionals” (Tietze & Gurley, 2014).  There is a clear structure that should be followed.  In the health care field, many times the main focus is to address the patient’s acute medical issue, neglecting to see the importance of prophylactic VTE prevention.  By adhering to the VTE protocol, nurses are providing total care that is in the best interest of the patient.

Health care providers should strive to deliver quality care with an emphasis on patient safety.  After all that is why many health care providers made a conscious decision to join the medical field.  With the nursing staff acting as a patient advocate, the patient is then given an opportunity to focus on their recovery rather than have to worry about developing any complications such as a VTE, morbidity, or mortality.



References

  • American Heart Associations. (2017). What is Venous Thromboembolism (VTE)?. Retrieved from https://www.heart.org/en/health-topics/venous-thromboembolism/what-is-venous-thromboembolism-vte.
  • Lloyd, N.S., Douketis, J.D, Cheng, J., Schünemann, H.J., Cook, D.J., Thabane, L., Pai, M., Spencer, F.A., & Haynes R.B.  Thromboprophylaxis: Survey on Barriers. J. Hosp. Med 2012;1;28-34. doi:10.1002/jhm.929
  • Tietze, M., & Gurley, J. (2014). VTE Prevention: Development of an Institutional Protocol and the Nurse’s Role. MEDSURG Nursing, 23(5), 331-333.
  • Zierler BK, Wittkowsky A, Peterson G, et al. Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK43659/


Provide a summary/conclusion about this experience/assignment and what you learned about nursing care models.

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Provide a summary/conclusion about this experience/assignment and what you learned about nursing care models.

Read your text, Finkelman (2016), pp- 111-116.
Observe staff in delivery of nursing care provided. Practice settings may vary depending on availability.
Identify the model of nursing care that you observed. Be specific about what you observed, who was doing what, when, how and what led you to identify the particular model.
Write a 5-7 page paper that includes the following:
Review and summarize two scholarly resources (not including your text) related to the nursing care model you observed in the practice setting.
Review and summarize two scholarly resources (not including your text) related to a nursing care model that is different from the one you observed in the practice setting.
Discuss your observations about how the current nursing care model is being implemented. Be specific.
Recommend a different nursing care model that could be implemented to improve quality of nursing care, safety and staff satisfaction. Be specific.
Provide a summary/conclusion about this experience/assignment and what you learned about nursing care models.
Write your paper using APA format using Microsoft Office 2010 or later.

Homeostasis Within the Nervous System

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What is Homeostasis?

Homeostasis is the condition of equilibrium in the body’s internal environment due to the consistent interaction of the body’s main regulatory processes (Tortora and Derrickson, 2009). This process developed by Claude Bernard in 1865 and then named by Walter Cannon in 1926, is used by the endocrine and nervous system in order to maintain a psychological internal environment disregarding external influences. As the environment is always changing the body is constantly trying to regulate factors within it such as water concentration, PH levels, Oxygen levels, nutrients, urea and levels of salt, sugar and electrolytes.

During homeostatic regulation the body uses negative feedback to move the body back to within its normal range of values. To do this a receptor detects and responds to a stimuli from the internal or external environment , once detected the receptor sends information of the stimuli down the afferent pathway to a controller. Once received the controller then determines an appropriate response to the stimuli and sends a signal down the efferent pathway to the effector. Once received the effector then makes a change in order to balance out the effects of the stimuli and once again create a dynamic equilibrium within the body. Body temperature is regulated by the autonomic nervous system. Once body temperature rises above the norm it stimulates temperature receptors in the skin dermis, information regarding this change is then sent to the controller which in this instance is the hypothalamus within the brain. The hypothalamus then processes the information and sends a signal to the effector to start the process of negative feedback. The effector responds by starting the process of vasodilation which in this case would cause the sweat gland to activate in order to lower the body’s core temperature.

Without homeostasis a

homeostatic imbalance

could occur, organisms need to be able to maintain nearly constant internal environments in order to survive grow and function properly (Guyton and Hall, 2006). Enzymes within the body operate to their full potential within a specific range of conditions. By maintaining PH levels and body temperature enzyme linked reactions can occur efficiently. By maintaining changes in water potential homeostasis protects essential cells needed for processes within the body. Changes in water potential could possibly affect the amount of water within tissue fluid and cells, this could potentially cause the cells to desiccate or burst. Therefore, failure to maintain this could possibly lead to a positive feedback mechanism taking over and the possibility of further complications or death.

What is the endocrine system?

The endocrine system consists of glands that are present throughout the body and secrete hormones in order to control actions that maintain homeostasis, preparing the body for the process of fight or flight, controlling growth and controlling sexual development and reproduction. The glands which make up the endocrine system are the hypothalamus, pituitary, thyroid, parathyroid, adrenals, the islet of Langerhans in the pancreas, pineal, the ovaries and testes. Hormones are chemical messengers that are released into the bloodstream; they are carried within blood plasma and affect target cells. Target cells have receptors that attach to specific hormones which have their own receptor. The hormones that are secreted are slower acting however are long-lasting and are good for assisting in areas within the internal environment that require constant adjustments. Therefore assisting with homeostasis.

Glucose enters the blood from the small intestine, the body’s blood glucose levels are monitored by a gland called the Islet of Langerhans which is located within the pancreas. A bodies normal range of blood glucose levels are between 4-8mmol/l, these levels frequently change due to eating and exercise. A stable blood glucose level is important within the internal environment as it provides the brain with a strong energy source to enable it to operate and also enables mitochondria to produce Adenosine Triphosphate which is used by cells to perform some of the body’s most important functions such as respiration. Homeostatic regulation of glucose happens when the pancreas detects that the glucose levels become too high or too low as blood passes through it. In the event of Hypoglycemia, where the glucose levels becoming too low the receptor, that is found on the surface of alpha cells within the pancreas stop the production of insulin and start to produce a controller, the hormone glucagon. Glucagon then stimulates the stores of glycogen in the liver and muscles to convert back to glucose, this process is called glycogenesis. If this is not enough to bring the sugar levels back to normal, glucagon begins to convert fatty acids in to glucose using a process called Gluconeogenesis within the effectors. The effectors in this situation are the liver cells, muscles cells and fatty cells. Once converted the glucose is then released into the blood stream causing the bodies glucose levels to rise. In addition to this process, during periods of intense exercise where glucose levels drop the hormone adrenaline will convert glycogen into glucose. In the event of Hyperglycemia, where glucose levels become too high, the receptor which is located on the surface of the beta cells within the pancreas produce a controller to counter act the effects. The controller in this instance is a hormone called insulin. Once insulin is secreted into the bloodstream, glucose levels within the body decrease because the excess glucose is converted into glycogen through a process called Glycogenesis within the effectors, namely the liver cells and muscles cells.

The nervous system

Within the process of homeostasis the nervous system detects and responds to adaptions within the body’s internal and external environments by sending fast electrical impulses through nerves to the brain which instructs an effector and enables them to react quickly and return the body to a state of equilibrium. The nervous system consists of the central nervous system which is subdivided into the spinal cord and the brain and the peripheral nervous system which is subdivided into the somatic nervous system which controls our voluntary muscles and the autonomic nervous system which controls our involuntary muscles which helps to create homeostatic regulation of functions within the body such as heart rate. Nerves within these subdivisions transport impulses between the central nervous system and the body. Blood pressure is the force applied on the inner walls of the blood vessels within the body by blood. Blood pressureis measured in millimeters of mercury (mmHg), A blood pressure reading below 130/80mmHg is considered to be normal (NHS Choices) The first numerical factor within a blood pressure reading is the systolic pressure of the blood which is the amount of beats you heart makes per minutes to pump blood away from the heart. The second numerical factor refers to the diastolic pressure which is the pressure of the blood when tour heart is at rest, in-between beats. During homeostatic regulation of blood pressure if a baroreceptor located in the aortic arch and internal carotid arteries detects a decrease in blood pressure it will send fewer impulses to the controllers, the cardiac centre and the vasomotor centre located in the medulla oblongata of the brain simultaneously. By sending fewer impulses to the cardiac centre it excites the sympathetic impulses and inhibits the parasympathetic impulses. This process excites the effector, Sino-atrial node in order to increase the heart rate, by doing this it causes the hearts cardiac output to increase. Alongside this process the fewer impulses being sent to the controller, the vasomotor centre also excites the sympathetic impulses which cause the effector, the smooth muscle within the arterioles to constrict this results in vasoconstriction and increased peripheral resistance. The combinations of these processes cause the blood pressure to increase back to within a normal range. During the detection of high blood pressure by the baroreceptors it sends more impulses to the controllers, the cardiac centre and the vasomotor centre simultaneously. By sending decreasing impulses to the cardiac centre it decreases sympathetic input and an increase in parasympathetic input which decreases the heart rate and cardiac output. Alongside this process the increase in impulses to the vasomotor centre causes an effector, the smooth muscle in the arterioles to dilate. This results in vasodilation and peripheral resistance decreases causing blood pressure to decrease. In addition to the baroreceptors, the kidneys are also involved in the monitoring of blood pressure. If blood pressure decreases the kidneys release a hormone called renin that caused the adrenal cortex to release aldosterone. The release of aldosterone causes the kidneys to retain sodium and allows water to flow without resistance causing blood volume and pressure to rise.

Nephrotic syndrome

Nephrotic syndrome tends to affect primary school age children. Between two and four children in every 100,000 develop nephrotic syndrome (NHS GOSH)

Nephrotic syndrome is a condition where the glomeruli leak a substantial amount of protein therefore not enough protein remains in the blood to enable it to soak up water. This causes the water to move into body tissues causing oedema which presents itself as severe swelling. Proteins provide the body with antibodies this can cause a child with nephrotic syndrome to have a low immune system which results in an increased risk of infection. Other complications of this condition is difficulties in growth and development and prone to blood clots. If protein continues to leak this can lead to a loss of kidney function and ultimately kidney failure. A treatment option for this condition is a medication called furosemide, a loop diuretic that obstructs the reabsorption of sodium and water in the ascending loop of hele, achieved through competitive inhibition. This causes the osmotic gradient through the nephron to be destroyed due to the lumen becoming more hypertonic. This enables the kidney to secrete sodium onto the collecting ducts, attracting water volume which is then excreted by the bladder by producing more urine. This will result in less water retention in tissue that would be putting pressure on organs such as the lungs.

The Electronic Medicines Compendium States that the pharmacodynamics properties of Furosemide are, it promotes sodium and chloride reabsorption. Furosemide inhibits mechanisms in the epithelial cells in order for sodium and chloride to enter and is transported through the secretory pathway in the proximal tubule. It decreases renal excretion of uric acid and increases loss of potassium in the urine and excretion of ammonia by the kidney.

The dosages available for children with oedema as stated by the BNF for Children are orally.

Neonate 0.5–2mg/kg every 12–24 hours (every 24 hours if corrected gestational age under 31 weeks),Child 1 month–12 years 0.5–2mg/kg 2–3 times daily (every 24 hours if corrected gestational age under 31 weeks); higher doses may be required in resistant oedema; max. 12mg/kg daily, not to exceed 80mg daily, Child 12–18 years 20–40mg daily, increased in resistant oedema to 80–120mg daily.

Through a slow intravenous injection, Neonate 0.5–1mg/kg every 12–24 hours (every 24 hours if corrected gestational age under 31 weeks), Child 1 month–12 years 0.5–1mg/kg repeated every 8 hours as necessary; max. 2mg/kg (max. 40mg) every 8 hours and a Child 12–18 years 20–40mg repeated every 8 hours as necessary; higher doses may be required in resistant cases

Through a continuous intravenous infusion ,Child 1 month–18 years 0.1–2mg/kg/hour (following cardiac surgery, initially 100micrograms/kg/hour, doubled every 2 hours until urine output exceeds 1mL/kg/hour)

The Pharmacokinetic properties as stated by the Electronic Medicine Compendium of Furosemide are that it is a weak carboxylic acid which exists in the gastro-intestinal tract. Furosemide is rapidly absorbed but 60-70% id absorbed on oral administration within the upper duodenum at PH level 5.0. Furosemide binds to albumin proteins and the volume of distribution ranges between 170 – 270 ml/Kg.

69-97% is excreted in the first four hours after the drug is given and 80-90% of Furosemide is excreted through the kidneys.


Reference list

Tortora, G.T. and Derrickson, B.H. (2009)

Principles of Anatomy and Physiology: Organisation, Support, Movement, and Control Systems of the Human Body

. 12th ed. Asia: John Wiley and Sons.

Guyton, A.C. and Hall, J.E. (2010)

Textbook of Medical Physiology

. 12th ed. Philadelphia: Saunders Elsevier Inc.

NHS Choices (2014) High Blood Pressure Available from:

http://www.nhs.uk/conditions/Blood-pressure-(high)/Pages/Introduction.aspx

[Accessed 19.11.2014].

NHS GOSH (2012) Childhood nephrotic syndrome information Available from:

http://www.nhs.uk/Conditions/nephrotic-syndrome/Pages/Introduction.aspx

[Accessed 22.11.2014]

BNF for Children (2014-2015) FUROSEMIDE Available from:

https://www.medicinescomplete.com/mc/bnfc/current/PHP11437-lasix.htm?q=furosemide&t=search&ss=text&p=3#PHP11437-lasix

[Accessed 23.11.2014]

Electronic Medicine Compendium (2014) Furosemide 10mg/ml Solution for Injection or Infusion, 20mg in 2ml and 250mg in 25ml Available from:

https://www.medicines.org.uk/emc/medicine/20958

[Accessed 23.11.2014]

History of Chemotherapy and Cancer Treatment Research

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An Early Victory

A few doors from Freireich’s office at the NCI, Min Chiu Li and Roy Hertz had been studying choriocarcinoma, a cancer of the placenta, which often metastasizes rapidly into the lung and the brain. Choriocarcinoma cells secrete a hormone called choriogonadotropin. The level of that hormone, also called the hcg level, was used by Li to track the course of the cancer as it responded to the therapy.

In 1956, a young woman called Ethel Longoria suffered from choriocarcinoma that had metastasized to her lungs. Her tumors had begun to bleed into the linings of her lungs. Li and Hertz stabilized her and then treated her with methotrexate. After the first dose, when the doctors left for the night, they didn’t expect that they’d find her in rounds the next morning. But she was alive. After four rounds of therapies, her tumor disappeared; the chest X-ray improved; and the hcg level rapidly plummeted toward zero. The tumors had actually vanished with chemotherapy.

The trouble was the hcg level had not gone all the way to zero. Although the tumor seemed to have vanished, Li continued to treat her with chemotherapy based on her elevated hCG levels. The NCI administration disapproved, feeling that Li was experimenting on his patients, and fired him in July 1957.

However, Li was ultimately proven to be right. Those patients whose chemotherapy were stopped once the visible tumors disappeared inevitably relapsed, while those who continued the treatment until their hcg levels had gone to zero were cured. Li had stumbled on a fundamental principle of oncology: “Cancer needed to be systemically treated long after every visible sign of it had vanished.”


Mice and Men

Adding vincristine to the arsenal of chemotherapy drugs had put the researchers at the NCI in a bind. It would take forever for the consortium to finish its trials because of the large number of permutations and combinations of drugs needed to be tested.

Howard Skipper, a scientist from Alabama, provided Frei and Freireich a way out of the impasse. Skipper, who called himself a “mouse doctor,” was an outsider to the NCI. He had tested chemotherapy drugs in mice with leukemia, lymphomas and solid tumors as models for human cancers and came up with two pivotal findings:

  1. Chemotherapy kills a fixed percentage of cancer cells per treatment. The patients would need to be treated multiple times to get the compounded iterative effect; and
  2. Chemotherapy drugs are more effective when given in combination to optimize cancer killing capacity while minimizing drug resistance and side effects.

Freireich and Frei were now ready to tackle a four-drug regimen known as VAMP, with each letter standing for one drug.


VAMP

When Frei and Freireich presented their preliminary plan for VAMP to the Acute Leukemia Group B (ALGB) at a national meeting on blood cancers, the audience hesitated. The group refused to sponsor VAMP until the many other trials had been completed. But Frei Came up with a compromise: VAMP would be studied at the NCI, outside the purview of the ALGB.

The VAMP trial was launched in 1961. At the end of three intensively painful weeks, the leukemia cells went into remission. The remissions persisted for weeks, exceeding everyone’s expectation at the NCI. A few weeks later, the NCI sent another small cohort of patients to try VAMP. Once again, after the initial catastrophic dip, the leukemia vanished. The remissions were reliable and durable.

In the fall of 1963, some children in remission came back to the clinic with minor neurological complaints such as headaches, numbness, and seizures. To investigate the possibility of cancer cells invading the brain, Frei and Freireich examined the children’s spinal fluid, and confirmed that leukemia cells were colonizing the brain. The neurological complaints were early signs of a more serious devastation. Eventually all the children came back with neurological complaints went into coma.

It was a consequence of the body’s own defense system. The blood-brain barrier had kept VAMP out of the central nervous system, allowing the leukemia cells to colonize the one place that is unreachable by chemotherapy.

But not all children had relapsed and died. About 5 percent of the treated children never relapsed with leukemia in the central nervous system. They remained in remission not just for weeks or months, but for years.


An Anatomist’s Tumor

In 1832, an English anatomist named Thomas Hodgkin (1798-1866) found a strange systemic disease among a series of cadavers. The disease was characterized by “a peculiar enlargement of lymph glands.” He wrote up the case of seven such cadavers and presented it to the Medical and Chirurgical Society. It was received with little enthusiasm. Soon after publishing his paper, Hodgkin drift away from medicine, and his anatomical studies slowly came to a halt.

Hodgkin’s disease is a cancer of the lymph glands. The tumor moves from one contiguous node to another. It is a local disease on the verge of transforming into a systemic one. In 1898, an Austrian pathologist named Carl Sternberg discovered the cancerous lymph cells when looking through a microscope at a patient’s glands.

Henry Kaplan, a professor of radiology at Stanford wanted to use radiation to treat human cancers. He knew radiation could treat solid tumors could be treated with radiation, but the outer shell of the cancer needed to be penetrated deep enough to kill cancer cells. A linear accelerator (linac) with its sharp, dense beam would be ideal for that purpose. In 1953, he persuaded Standford to tailor-make a linac for the hospital. With the linac in operation, Kaplan contemplated on his cancer target. Since Linac could only focus on local sites, his natural target was Hodgkin’s disease, a predictable local tumor. Kaplan wanted to prove that he could improve relapse-free survival by using a technique called extended field radiation (EFR). Under EFR, the X-rays are delivered to an entire area of lymph notes rather than to a single swollen node.

In 1962, Kaplan conducted a trial. The result showed that EFR had significantly reduced the relapse rate of Hodgkin’s disease. In 1964, he did another trial with a larger field of radiation on a limited cohort of patients with tumors in just a few contiguous lymph nodes. The result showed even greater relapse-free intervals, stretching out into years.

Wasn’t the logic of extended field radiation similar to radical surgery -carving out larger and larger areas for treatment? Why did Kaplan succeed where others had failed?

Kaplan was successful because he restricted radiotherapy to patients with early stage local cancers. Those are the natural disease for radiotherapy. Advanced-stage cancers are inherently different and would require other forms of treatment.


An Army on the March

In 1963 at the NCI Clinical Center in Bethesda, a group of researchers, including Zubrod, George Canellos, Frei, Freireich, and Vincent DeVita were making a list of cytotoxic drugs on one side of a blackboard. On the other side was a list of new cancers they want to target – breast, ovarian, lymphomas, lung cancers. Connecting between the two lists were lines matching combinations of drugs to cancers. One question that came to their mind was whether chemotherapy could ever cure patients with any advanced cancers. The only way to answer that generic question was to direct the growing army of drugs against other cancers. They knew leukemia responded to combination chemotherapy. If another kind of cancer also responded to that strategy, then combination chemotherapy might cure all cancers.

To test the principle, they focused on Hodgkin’s disease-a cancer that was both solid and liquid, a stepping-stone between leukemia and, say, breast cancer or lung cancer. Kaplan had proved that radiation therapy can cure local forms of Hodgkin’s disease. If they could prove that combination chemotherapy can cure metastatic Hodgkin’s disease, then the equation would be fully solved.

In 1964, DeVita led the test of combination chemotherapy for metastatic Hodgkin’s disease. He combined four drugs-nitrogen mustard, oncovin, prednisone, and procarbasine into a highly toxic cocktail called MOPP. The nausea that accompanied the therapy was devastating. The toxic cocktail had weakened the immune system allowing pneumocystis carinii (PCP), a rare form of pneumonia, to sprout up. The therapy had caused permanent sterility in men and some women.

The result of the study was remarkable. At the end of six months, 35 of the 43 patients had a complete remission.

The most disturbing side effect would emerge a decade later. Several patients, cured of Hodgkin’s disease, would relapse with a second cancer, typically a drug-resistant leukemia caused by the prior MOPP therapy.

***

In May 1968, Frei and Freireich’s VAMP combination chemo had cured most of the children with leukemia in their bone marrow, but not the leukemia that had spread to their brain. A 36-year-old oncologist name Donald Pinkel thought that VAMP had not been intensive enough. Pinkel, a protégé of Farber’s, had been recruited from Boston to start the leukemia program at St. Judes’s Hospital in Memphis. He determined to push the logic of combination chemotherapy to its limit with four crucial innovations:

  1. To use combinations of combinations of drugs mixed and matched together for maximum effect;
  2. To instill chemotherapy directly into the nervous system via the spinal cord;
  3. To kill residual cells in the brain by high-dose radiation; and
  4. To continue chemotherapy for month after month, even after the cancer seemed to have disappeared.

The treatment protocol started with the standard chemotherapy drugs given in rapid-fire succession. The spinal canal was injected with methotrexate at defined intervals. The brain was irradiated with high doses of X-rays. The treatment lasted up to 30 months. It was an “all-out combat.”

In July 1968, the St. Jude’s team published its results: Twenty-seven out of the thirty-one treated had a complete remission. Ten had never relapsed. The median time to relapse had increased to five years.

By 1979, 278 patients had completed their chemotherapy. About 20 percent had relapsed, 80 percent was still in complete remission, disease free, after chemotherapy.


The Cart and the House

By the fall of 1968, the successes of the trials in Bethesda and in Memphis shifted the landscape of cancer therapy. The success of chemotherapy for both leukemia and Hodgkin’s disease made it seem like a unifying solution for cancer. In Boston, Farber celebrated the news by throwing a public party. He recast the occasion as the symbolic twenty-first birthday of Jimmy. Conspicuously missing from the guest list was the original Jimmy himself-Einar Gustafson. The real Jimmy had returned to a private life in Maine, where he now lived with his wife and three kids.

As clinical oncologists were offering their unifying solution for cancer, cancer scientists were offering its unifying cause: viruses. The grandfather of this theory was Peyton Rous, a chicken virologist at the Rockefeller Institute in New York.

In 1911, Rous discovered that a malignant tumor growing on a chicken could be transferred to another chicken by exposing the healthy bird to a filtrate derived from the tumor cells. He concluded that the cancer was transmitted by a virus. This virus is now known as the Rous sarcoma virus, or RSV.

This discovery had set off a frantic search for more cancer viruses. In 1958, an Irish surgeon named Denis Burkitt discovered an aggressive form of lymphoma among children in Africa. Analyzing the cancer cells from these children, two British virologists discovered a human virus inside them. The new virus was named Epstein-Barr virus or EBV.

Because viral diseases were potentially preventable, the NCI inaugurated a Special Virus Cancer Program in the early 1960s to systematically hunt for human cancer viruses.

The cancer virus theory needed a deeper explanation: how might viruses cause a cell to become malignant? The success of cytotoxic chemotherapy raised a fundamental question: how would the therapy, the cure, connect with the cause of the cancer? As Kenneth Endicott, the NCI director, acknowledged in 1963: “The program directed by the National Cancer Institute has been derided as one that puts the cart before the horse by searching for a cure before knowing the cause.”

But for Mary Lasker, this cart would have to drag the horse.

How does a managed care model of mental health care reduce health care spending?

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How does a managed care model of mental health care reduce health care spending?

You have recently been employed by a small rural hospital as a Registered Nurse in the emergency room. The hospital does not provide any mental health services. You are assigned the task of gathering information for your supervisor that would help develop a plan to place the mentally ill in appropriate care. In your report to your supervisor, include your responses to the following: What is the definition of mental illness? Can mental illness be as clearly defined as a physical illness such as diabetes? Can mental illness be cured? Has the concept of deinstitutionalization been effective in providing needed services to the mentally ill? Why or why not? What populations or groups were most adversely affected by deinstitutionalization? What are the benefits of deinstitutionalization? Are health care professionals who provide mental health care integrated with other systems of care? What are the consequences of separating mental health from physical health care? What other services (social and health) might be needed by the mentally ill? What are three governmental sources that pay for mental health care? What populations are covered by these sources? What are some of the challenges to using a managed care approach in mental health care? How does a managed care model of mental health care reduce health care spending? How would you ensure the mentally ill are placed into the appropriate care facility? Discuss the ethical and legal implications