DiversityNursing Blog

By Steven Reinberg

Residents of the southern United States may be at risk for a parasitic infection that can lead to severe heart disease and death, three new studies suggest.

Chagas disease, which is transmitted by "kissing bugs" that feed on the faces of humans at night, was once thought limited to Mexico, Central America and South America.

That's no longer the case, the new research shows.

"We are finding new evidence that locally acquired human transmission is occurring in Texas," said Melissa Nolan Garcia, a research associate at Baylor College of Medicine in Houston and the lead author of two of the three studies.

Garcia is concerned that the number of infected people in the United States is growing and far exceeds the U.S. Centers for Disease Control and Prevention's estimate of 300,000.

In one pilot study, her team looked at 17 blood donors in Texas who tested positive for the parasite that causes Chagas disease.

"We were surprised to find that 36 percent had evidence of being a locally acquired case," she said. "Additionally, 41 percent of this presumably healthy blood donor population had heart abnormalities consistent with Chagas cardiac disease."

The CDC, however, still believes most people with the disease in the United States were infected in Mexico, Central and South America, said Dr. Susan Montgomery, of the agency's parasitic diseases branch.

"There have been a few reports of people becoming infected with these bugs here in the United States," she said. "We don't know how often that is happening because there may be cases that are undiagnosed, since many doctors would not think to test their patients for this disease. However, we believe the risk of infection is very low."

Maybe so, but kissing bugs -- blood-sucking insects called triatomine bugs -- are found across the lower half of the United States, according to the CDC. The insects feed on animals and people at night.

The feces of infected bugs contains the parasite Trypanosoma cruzi, which can enter the body through breaks in the skin. Chagas disease can also be transmitted through blood.

It's a silent killer, Garcia said. People don't feel sick, so they don't seek care, but it causes heart disease in about 30 percent of those who get infected, she said.

In another study, Garcia's team collected 40 insects in 11 Texas counties. They found that 73 percent carried the parasite and half of those had bitten humans as well as other animals, such as dogs, rabbits and raccoons.

A third study found that most people infected with Chagas aren't treated.

For that project, Dr. Jennifer Manne-Goehler, a clinical fellow at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, collected data on nearly 2,000 people whose blood tested positive for Chagas.

Her team found that only 422 doses of medication for the infection were given by the CDC from 2007 to 2013. "This highlights an enormous treatment gap," Manne-Goehler said in a news release.

The findings of all three studies, published recently in the American Journal of Tropical Medicine and Hygiene, were to be presented Tuesday in New Orleans at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Symptoms of Chagas can range from none to severe with fever, fatigue, body aches and serious cardiac and intestinal complications.

"Physicians should consider Chagas when patients have swelling and enlargement of the heart not caused by high blood pressure, diabetes or other causes, even if they do not have a history of travel," Garcia said.

However, the two treatments for this disease are "only available [in the United States] via an investigative drug protocol regulated by the CDC," Garcia said. They are not yet approved by the Food and Drug Administration.

Efforts are under way to develop other treatments for Chagas disease, Montgomery said.

"Several groups have made some exciting progress in drug development," she said, "but none have reached the point where they can be used to treat patients in regular clinical practice."

Source: health.usnews.com

By JESSICA FIRGER

When Donna Tookes learned she had breast cancer last winter, the 59-year-old thought she had no choice but to accept one of the most dreaded side-effects of chemotherapy: losing her mane of silver hair, a feature that strangers young and old frequently stopped to admire.

"I had resigned myself," Tookes told CBS News. "I had purchased an array of scarves, about 10. And I actually practiced tying them."

Tookes was diagnosed with breast cancer in January after her annual mammogram, when her doctors detected some mild calcifications in her right breast. These clusters of white flecks visible on her scan indicated there might be something seriously wrong. After a few subsequent tests, Tookes learned she had HER2 breast cancer, an especially aggressive form that can be difficult to treat. Though her doctors caught the cancer early, they wanted to be certain it would never return, which meant a unilateral mastectomy followed by 12 rounds of punishing chemotherapy.

"You have a consultation before you start chemotherapy," said Tookes, who lives with her husband and children in Stamford, Connecticut, and has worked for more than three decades as a flight attendant. "I was told I would lose my hair. And then the nurse assured me, she told me 'you're beautiful,' and that I was one of the only ones who could carry the bald look because I have that bone structure."

But her family could see that losing her hair would take a serious toll on her psyche. Tookes had heard about some treatment in Europe that helps prevent chemo-related hair loss, though she didn't know many details. Secretly, her husband began to conduct research. He wrote to friends in Sweden, who were able to obtain information about a new and innovative therapy called a scalp cooling cap. He soon found out that Mount Sinai Beth Israel in New York City was involved in a clinical trial on the device, known as the DigniCap System, which is worn by a patient during chemotherapy transfusions.

The snug cap is secured onto a patient's head each time she undergoes chemotherapy. It chills the scalp down to 5 degrees Celsius so that the blood vessels surrounding the hair roots contract, meaning that less of the toxins from chemo enter the hair follicle. This minimizes -- and in some cases completely stops -- a patient's hair from falling out.

At first, Tookes was slightly skeptical, but her family finally convinced her to move her cancer treatment from her hospital in Connecticut to Mount Sinai Beth Israel in New York City.

Dr. Paula Klein, assistant professor of medicine, hematology and medical oncology at the Icahn School of Medicine at Mount Sinai and principal investigator for the clinical trial, told CBS News the device has been effective at limiting hair loss in nearly all of her patients enrolled.

"Unfortunately, in breast cancer the two most active agents are associated with significant hair loss," said Klein. "For many women with early stage breast cancer, they are getting chemotherapy for prevention of recurrence."

Klein said overall, women who use the cap lose just 25 percent of their hair. There are some patients who lose more and a lucky handful who lost no hair at all.

The clinical trial is now in its final phase. The company behind the cap, Dignitana, will be submitting results to the U.S. Food and Drug Administration by the end of November, and hope to win FDA approval for the cap in 2015.

For women struggling through a difficult medical ordeal, the benefit is significant. Research published in 2008 in the journal Psycho-Oncology looked at 38 existing studies on breast cancer treatment and quality of life issues, and found hair loss consistently ranked the most troubling side effect of treatment for women. "Significant alopecia [hair loss] is problematic," said Klein. "Every time you look in the mirror, you remember you're getting cancer treatment."

Many breast cancer survivors report that even when their hair finally grows back after chemotherapy it is often different in color or texture than the hair they had before, due to the period of time it takes the hair follicles to recover from the damage caused by the drugs.

Moreover, the feelings associated with hair loss impact nearly every aspect of a breast cancer patient's life -- from her self-image and sexuality to whether or not she is comfortable at work or even walking into the supermarket to buy a quart of milk.

When she first prepared for treatment, Tookes worried how people would react to her appearance if she lost all of her hair. But it didn't happen. Seven weeks into chemo, she finally felt confident enough to return the unused wardrobe of scarves. She still had a full head of hair. Because the cooling therapy was used only on her scalp, Tookes did still lose her eyebrows and "everything south of there."

Tookes is now cancer-free and says the therapy helped her stay optimistic about her prognosis. "My mother used to say, you just comb your hair and get yourself together and you'll get through hard times," she said.

Source: www.cbsnews.com

By Alice Gomstyn

How do you pass the time when cancer treatment means you're largely confined to your hospital room for weeks on end?

Tom Gillin, a 19-year-old college student, chose a less-than-obvious choice: He filmed a funny rap video channeling Jay-Z via the cancer ward.

"Some of the other videos I've seen about cancer patients are somewhat depressing," said Gillin, who was diagnosed with the pediatric cancer acute myeloid leukemia in April. "We wanted to flip the switch and do something that was the opposite of that."

Gillin teamed with several staffers at The Children's Hospital of Philadelphia to create "Bald So Hard." The video's title refers to Gillin's chemotherapy-related hair loss but is also a play on the phrase "ball so hard" featured prominently in a hit song by Jay-Z and Kanye West. The song is parodied in Gillin's video, as is Jay-Z's "Empire State of Mind."

The rollicking video — promoted on Twitter with the hashtag #BaldSoHard — is full of swagger. Gillin is seen mouthing lyrics such as "bald so hard my head got shiny" while dancing with his oncologist, playing basketball and even steering a "boat," a cardboard cutout made by hospital art therapist Abbien Crowley. (The actual rap was performed, mostly off camera, by University of Pennsylvania medical student David Blitzer.)

But Gillin didn't shy away from the fatigue and boredom confronting hospital cancer patients. It took him and his hospital pals some two months to complete the three-minute video since chemotherapy treatments often left him too weak to shoot.

The song's lyrics, written by Gillin and CHOP music therapist Mike Mahoney, manage to make light of it: "They gave me sleeping meds all day and I was dozing/When I got up I was so bored that I watched 'Frozen.'"

Gillin said his main motivation for making the video was to raise awareness of pediatric cancer, though he'd also appreciate it if Jay-Z — one of the teen's favorite rappers — took note of the unusual homage and paid the hospital a visit.

But don't expect Gillin to use the video to launch his own hip hop career. "I'm not that musically inclined," he insists.

Instead, he's looking forward to completing his final round of chemotherapy in a couple of weeks and ultimately returning to student life at the University of California, Los Angeles, where he's studying civil engineering.

For now, he's enjoying the happy reactions to his video, which has generated more than 20,000 views on YouTube since it debuted late last month. The Jigga Man himself hasn't yet weighed in but plenty of others say they love Gillin's jam, with one YouTube user dubbing it "best medicine in the world."

Source: http://www.today.com

By JANE E. BRODY

The teenage years can be tough enough under the best of circumstances. But when cancer invades an adolescent’s life, the challenges grow exponentially.

When the prospects for treatment are uncertain, there’s the fear of dying at so young an age. Even with an excellent chance of being cured, teenagers with cancer face myriad emotional, educational and social concerns, especially missing out on activities and losing friends who can’t cope with cancer in a contemporary.

Added to that are the challenges of trying to keep up with schoolwork even as cancer treatment steals time and energy, and may cause long-lasting physical, cognitive or psychological side effects.

Sophie, who asked that her last name be withheld, was told at 15 that she had osteosarcoma, bone cancer. After a bout of how-can-this-be-happening-to-me, she forged ahead, determined to stay at her prestigious New York high school and graduate with her class.

Although most of her sophomore year was spent in the hospital having surgery and exhausting chemotherapy, she went to school on crutches whenever possible. She managed to stay on track, get good grades — and SAT scores high enough to get into Cornell University.

Now 20, Sophie is about to start her junior year and is majoring in biology and genetics with a minor in computer science. She plans to go to medical school, so this summer she has been studying for the MCATs and volunteering at a hospital.

Her main concern now is that people meet and get to know her as a whole, normal person, not someone who has had cancer, which is why she asked that I not identify her further.

“I’m pretty healthy, and I don’t want people to think I’m weak and need special care,” she said in an interview.

“Having cancer puts other issues into perspective,” she added. “I feel like I have to do as much as I can. I’ve gotten involved in so much. I try to enjoy myself more. And I don’t regret for a minute how I’ve been spending my time.”

Sophie’s determination to do the most she can and her desire for normalcy are hardly unusual, said Aura Kuperberg, who directs an extraordinary program for teenagers with cancer and their families at Children’s Hospital Los Angeles. Dr. Kuperberg, who has a doctorate in social work, started the program, called Teen Impact, in 1988. It operates with the support of donations and grants and deserves to be replicated at hospitals elsewhere.

“The greatest challenge teens with cancer face is social isolation,” she said in an interview. “Many of their peers are uncomfortable with illness, and many teens with cancer may withdraw from their friends because they feel they are so different and don’t fit in.”

In the popular young adult novel “The Fault in Our Stars,” a teenager with advanced cancer says, “That was the worst part of having cancer, sometimes: The physical evidence of disease separates you from other people.”

Within the family, too, teenagers can feel isolated, Dr. Kuperberg said. “Patients and parents want to protect one another. They keep up a facade that everything will be O.K., and feelings of depression and anxiety go unexpressed.”

Teen Impact holds group therapy sessions for young patients, parents and siblings so they “don’t feel alone and realize that their feelings are normal,” Dr. Kuperberg said. The goal of the program, which also sponsors social activities, is to help young cancer patients — some still in treatment, others finished — live as normally as possible.

“For many, cancer is a chronic illness, with echoes that last long after treatment ends,” Dr. Kuperberg said. “There are emotional side effects — a sense of vulnerability, a fear of relapse and death, and an uncertainty about the future that can get in the way of pursuing their hopes and dreams. And there can be physical and cognitive side effects when treatment leaves behind physical limitations and learning difficulties.”

But, she added, there is often “post-traumatic growth that motivates teens in a very positive way.”

“There’s a lot of altruism,” she said, “a desire to give back, and empathy, a sensitivity to what others are going through and a desire to help them.”

Sophie, for example, took notes for a classmate with hearing loss caused by chemotherapy. She recalled her gratitude for the friend “who was there for me the whole time I was in treatment, who would come over after school and sit on the couch and do puzzles while I slept.”

One frequent side effect of cancer treatment now receiving more attention is the threat to a young patient’s future reproductive potential.

In an opinion issued this month, The American College of Obstetricians and Gynecologists urged doctors to address the effects of cancer treatment on puberty, ovarian function, menstrual bleeding, sexuality, contraceptive choice, breast and cervical cancer screening, and fertility.

“With survival rates pretty high now for childhood cancers, we should do what we can to preserve future fertility,” said Dr. Julie Strickland, the chairwoman of the college’s committee on adolescent health care. “We’re seeing more and more cooperation between oncologists and gynecologists to preplan for fertility preservation before starting cancer treatment.”

The committee suggested that, when appropriate, young cancer patients be referred to a reproductive endocrinologist, who can explore the “full range of reproductive options,” including the freezing of eggs and embryos.

For boys who have been through puberty, it has long been possible to freeze sperm before cancer treatment.

Although some female patients may be unwilling to delay treatment, even for a month, to facilitate fertility preservation, at the very least they should be offered the option, Dr. Strickland said in an interview.

She described experimental but promising possibilities, like freezing part or all of an ovary and then implanting it after cancer treatment ends. It is already possible to move ovaries out of harm’s way for girls who need pelvic radiation.

Source: http://well.blogs.nytimes.com

By Associated Press

New York state can end its three-decade HIV crisis by the year 2020, Gov. Andrew Cuomo said Sunday as he announced an ambitious plan to deliver a knockout blow to the epidemic by boosting testing, reducing new infections and expanding treatment.

The governor said the state is aiming to reduce new HIV diagnoses to 750 by the end of the decade - about the same number of tuberculosis cases seen in New York City each year - down from 3,000 expected this year and 14,000 new cases of the disease in 1993. If the state is successful, it would be the first time the number of people living with HIV has gone down since the crisis began with the first widely reported cases in 1981.

"Thirty years ago, New York was the epicenter of the AIDS crisis," Cuomo said. "Today I am proud to announce that we are in a position to be the first state in the nation committed to ending this epidemic."

To expand treatment, the state's Department of Health has negotiated bulk rebates with three companies producing HIV drugs. The state is also taking steps to make it easier to get tested, changing how HIV cases are tracked to ensure patients continue to receive treatment, and boosting access to "pre-exposure" drugs that can help high-risk people avoid infection.

Cuomo did not offer an estimate of the cost of the plan, but said it would end up saving the state more than $300 million per year by 2020 by reducing the amount the state pays for medical care for those with HIV.

Groups that have long advocated for HIV patients praised the governor's announcement, saying it shows that efforts to fight the disease are paying off, and that a scourge that once seemed unbeatable can be successfully fought.

"We have the tools and know-how to end the AIDS epidemic in New York, the only question is whether we have the political will," said Jason Walker, an organizer at VOCAL-NY, which advocates for low-income HIV patients. "Even without a vaccine or cure, Cuomo understands that we can dramatically reduce new infections below epidemic levels and ensure all people living with HIV achieve optimal health."

While the state's plan may sound overly optimistic, the number of new HIV cases in New York has dropped nearly 40 percent in the last 10 years because of better, faster tests; access to condoms; public outreach campaigns and other initiatives. Meanwhile, those with the disease are living longer thanks to significantly more effective treatments.

The goal of bringing the disease to below epidemic levels "is ambitious," said Mark Harrington, executive director of the anti-HIV organization Treatment Action Group, but "grounded in reality."

Source: foxnews.com

By Michael McFall

At first, they want to die.

And then forensic nurses such as Monique Turner get to them. She talks to them, asks them about the sexual assault in a safe environment and tends to them — all while collecting the evidence police and attorneys will need to put the perpetrator away. By the time Turner is done, the victims feel like they can face the next day.

"People are ultimately grateful, it’s the greatest thing that we can give them," Turner said.

Forensic nurses have the added expertise to document wounds, collect DNA and look for evidence of neglect or abuse, as well as the ability to comfort a sexual assault victim and ultimately testify in court. And nowhere else are they needed more: Utah ranks 19th in the nation for reported forcible rapes, according to the Utah Department of Health. One in three women in the state will experience some kind of sexual assault in her lifetime, and one in eight will be raped, according to the department.

But as vital as their role is to the criminal justice system, it is one the public is relatively unaware of. November featured National Forensic Nurses Week; you may not have known. You may not have even heard of a forensic nurse before. But their early interactions with victims help define how they deal with their trauma for years to come, and their forensic skills help decide whether the attacker sees the inside of a prison cell.

—

"The worst day of their life, forever" » As an emergency room nurse at University Hospital, Turner had never heard of a forensic nurse until a few years ago when she met one. There are several regional teams of forensic nurses around the state, including one that serves the Salt Lake Valley — Salt Lake Sexual Assault Nurse Examiners (SANE). Turner was looking for a little extra money, and with her affinity for "CSI" and familiarity with pelvic exams, she figured it could be a good fit.

Then she got started. Her first case was a woman who had been kidnapped, taken across state lines and been abused the whole way.

"It is really, really hard to see the evil that people do to each other; to listen to how horrible this person was to them," Turner said.

Nationwide, there is a lot of burnout: almost one out of every two forensic nurses will quit within a year. While a whole team of experts, including law enforcement, victims advocates and a Rape Recovery Center representative step in to help, forensic nurses tend to be the first or second people to interact with victims.

But in the three to four hours the exam takes, the nurses see the transformation.

"Our major job is excellent health care and compassionate initial response. It’s that first response a patient gets that has the potential to decide whether they can heal from this traumatic event and whether they stay engaged in the criminal justice system," said Susan Chasson, a forensic nurse on the Salt Lake City team who trains prospective members. "… There’s so much self-blame [after an assault], if we say ‘Oh yeah, it’s your fault,’ we compound that. When someone has a negative response, that keeps them from telling somebody else for a long time."

Victims are not forced to have the exam in the first place, and at any point, they can decline a specific part of the exam. The nurses do that to give back to them that sense of control that a sexual assault robbed from them.

The victims are clearly traumatized, but spending time with them, supporting them and returning "some of that power to them, they walk out … with their head up," said Diane Fuller, who founded the Salt Lake City team. The care does not get rid of their trauma, but it gives them a stronger sense of self, she added.

"I’m sure we can all think back to the many patients who cried and said thank you, and gave us a big hug and said ‘I can’t imagine what I would do if you guys weren’t here,’ " said Beth Weekley, who joined the team about six and a half years ago. That is what keeps Turner and Weekley on the team.

"We help them realize that they can go on, they don’t have to die," Turner said. Few other nursing jobs have such a huge impact on someone, said Turner, who joined the team shortly before Weekley. "… This is usually the worst day of their life, forever. … It’s really, really hard, but the emotional payoff is worth all of the evil nastiness."

And they make sure officers and attorneys have the evidence they need to put that nastiness behind bars.

Salt Lake City police Detective Cody Lougy credits forensic nurses for helping end a high-profile serial date rape investigation he worked several years ago. Azlen Marchet was convicted of sexually assaulting four women in Salt Lake County from 2002 to 2007. He is currently serving 45 years to life in prison.

Forensic nurses also help new officers working their first rape cases — Lougy remembers how nervous he was during his — with their years of expertise, guiding the officer in what to look for based on the evidence they collect.

—

Brave new era » As vital as they have become, the nurses are a relatively new addition to the crime scene. The speciality only came about 21 years ago, created by nurses at the University of Minnesota School of Nursing. The Salt Lake City-based forensic nurse team formed about 12 years ago.

"The community needs simply weren’t being met," Fuller said. When she founded the team in 2001, she started off with eight people pulled from all over the place. Now she has 18, and her team is unique to most of the country: they respond to hospitals across the valley instead of being housed in hospitals, which would require the victims to drive to them.

When the nurses start out, they face a lot of intimidation in knowing how to care for a patient in emotional trauma, when before their jobs were focused on the physical.

"It’s a very different ball game," said Weekley, who joined the team shortly after Turner. "Thank goodness we work closely with [the Rape Recovery Center]. They’re with us on every single case we do. I cannot even imagine doing this without them."

Advocates from the Rape Recovery Center work with the nurse during the exam, talking to the victims as well, helping them with paperwork and understanding what comes next and the resources available to them, said Holly Mullen, executive director of the center. She admires the nurses’ ability, with the help of evolving technology, to collect evidence even days after the event, and even if the perpetrator left behind no bodily fluids. Most victims strongly want to see resolution in their case, built in part by that evidence.

But when it comes to testimony, the advocate is a "confidential communicator" — they cannot testify in a case. Not so with the nurses. They play a big part in not only objectively relating what they observed in the exam, but also in educating the jury about what that means, Fuller explained.

Like the first time approaching a traumatized victim, entering the courtroom can be intimidating for a nurse — at first. But since in their day jobs they spend much of their time educating patients, whether about wound care or healthy living, almost every nurse that Fuller has watched on the stand transitions naturally into that mode within the first couple minutes. They are still educating, but this time it’s the jury, not a patient.

Forensic nurses can potentially play a "very significant role" in trial when their findings corroborate one side or the other, said Blake Nakamura, Salt Lake deputy district attorney. "They can be pretty valuable and influential in making the case."

The quality of the evidence they bring is phenomenal, added Salt Lake District Attorney Sim Gill. "What they do is essential for law enforcement, prosecution, and what the victim is going through."

—

Healing the healers » As much comfort as they bring to the victims, even the forensic nurses need someone to do the same for them. The team has a counselor on hand when a case hits a nurse particularly hard. For Turner, it was when she was examining a girl about her daughter’s age. "She had so much in common that it really hit home. The counselor helped me box that up."

Weekley knows just what that is like. Many of the stories they hear are haunting. "It might sound callous," she said, "but you need to have some boundaries to not let it completely affect you and your life."

The team is also in touch with people involved in the case if they need to vent or talk it out — since when Turner goes home to her husband, patient-privacy laws prevent her from discussing what she went through that day.

A lot of nurses burn out before long, either from the emotional burden or the hours; for most, being a forensic nurse is a second job. They sign up for six-hour shifts, which cover every hour of every day, during which they could be called out to anywhere in the valley. Turner goes on three to four calls a month, while others might go on five or six.

The nurses who stick around take hiatuses for a few months at a time — Turner is on one now — to recharge or focus on other areas of their lives.

"We want to make the world a better place and provide care in a field that not everybody can do," Weekley said. "We take pride in that. … It takes a special person to be able to do this job."

—

Spreading the word » The team is always looking for new members. They hold biannual, three-day training sessions for prospective nurses, though only two or three people in any given 20-person turnout actually want to join the Salt Lake City team, Turner said. Most are either from other areas in the state, are just there to learn or back out once they realize what the job is like.

Ultimately, Turner would like the team to hire enough nurses to have two on call during each six-hour shift, as opposed to the one per shift they have now.

The next training is scheduled for March, then again next fall in Blanding. There is a big need in that corner of the state, since the nurses there often cannot take the time off to travel to Salt Lake City, Chasson said. Bringing the training to them also gives nurses in tribal communities and in neighboring southwestern Colorado, who are likewise isolated, the same opportunity.

Anyone interested in becoming a team member can find more information at slsane.org or by emailingslsane@comcast.net. The website also connects victims with hospitals and law enforcement in the Salt Lake Valley, with a comprehensive list of phone numbers they can call.

Regardless of whether a victim’s region has a trained forensic nurse at the hospital or on call, Mullen encourages victims to call the police or go to the nearest emergency room and report the rape.

Mullen and Fuller worry about the culture surrounding rape that blames the victim instead of the perpetrator that can keep victims silent. More than 88 percent of rapes are not reported to law enforcement, according to a 2007 health department survey.

Regardless of whether a victim’s region has a trained forensic nurse at the hospital or on call, Mullen encourages victims to call the police or go to the nearest emergency room and report the rape.

Mullen and Fuller worry about the culture surrounding rape that blames the victim instead of the perpetrator that can keep victims silent. More than 88 percent of rapes are not reported to law enforcement, according to a 2007 health department survey.

Still, they are thankful to see a slow and steady shift to placing blame where the blame is deserved — with the rapist. For Fuller, her nurses are seeing that proof firsthand.

Years ago, a typical victim would come in two to three days after the assault, Fuller said. Now they are seeing victims within the first 24 hours. "That’s public opinion changing. There is great care available, people really are believing you."

Source: The Salt Lake Tribune

By Jackie Farwell, BDN Staff

After a routine mammogram in the fall of 2011, Laurie Thornberg learned she had breast cancer. Over the next nine months, as the Oakland woman endured surgery and rounds of chemotherapy, she watched as friends and loved ones attempted to explain her condition to their children.

Some struggled. One person described Thornberg’s cancer to her children “like I had the plague,” she said. Others were more comfortable, including a close friend and neighbor Thornberg ran into while out for a walk.

“[She] told her children in a kind and gentle way,” Thornberg, a registered nurse, wrote in an email.

Thornberg chronicled the encounter with her neighbor in her new children’s book, “Julie’s Dream,” which she hopes families will use as a tool to talk with their children about cancer and its treatment, as well provide hope to cancer victims and their loved ones.

“Children, even young ones, can be very aware of their surroundings and have questions when they notice family members being upset, someone who is sick a lot, or even as simple as a person suddenly has no hair,” Thornberg said.

In the book, Thornberg’s neighbor explains to her children, “See our friend? She wears that bonnet to cover her head because she got sick and had to take a special medicine that made her hair fall out.”

One of the children turns to Thornberg, asking, “Why don’t you take off that bonnet? I’m sure you’re beautiful under there.”

The book goes on to detail the main character’s dream about magically being healed. Thornberg’s friend and the book’s illustrator, Juliana Muzeroll, had that very dream about her, Thornberg said.

“I liked this approach a lot because it gives the reader freedom to interpret the outcome to fit their own personal situation,” she said. “Meaning, that whether the loved one survives or passes away, there is always healing at the end of a cancer journey.”

Thornberg remains in remission 18 months after her last round of chemotherapy. She now realizes that the disease freed her from stressing over the demands of a life as a full-time hospital nurse, mother, and daughter caring for her disabled mother, said Thornberg, who now works in home health care and said she’s able to focus on what’s really important in life.

“Getting cancer took me away from my excessive stress,” she said. “I often say ‘cancer healed my life.’”

“Julie’s Dream” is available in softcover or as an e-book on amazon.com, barnesandnoble.com, and authorhouse.com, by searching the title and author together.

Source: Bangor Daily News

The American Nurses Foundation, the philanthropic arm of the American Nurses Association, in June announced a $75,000 grant to the University of Pennsylvania School of Nursing in Philadelphia to develop a post-traumatic stress disorder tool kit to help RNs better assess and treat PTSD in the nation’s veterans and military service members. Penn Nursing’s Nancy Hanrahan, RN, PhD, CS, FAAN, will lead the project at the university.

"Given that June is PTSD Awareness Month, this was the perfect time to highlight the serious consequences of PTSD, if left untreated, and what nurses can do to ensure that veterans receive the highest level of care," ANF Chairwoman Joyce J. Fitzpatrick, RN, PhD, MBA, FAAN, said in a news release. "At ANF, we are striving to transform the nation’s health through the power of nursing. We are excited about this new project because these tools will help nurses learn detection and treatment options that can help our nation’s veterans and service members transition successfully back into civilian life." 

ANF will work with Penn Nursing to develop an interactive, PTSD-focused website, an e-learning module based on advanced gaming techniques and a downloadable smartphone app that will provide immediate access to materials for RNs to assess, treat, and refer military members and veterans for help with their symptoms. These e-learning tools will certify that an RN is grounded in assessment, treatment, referral and non-stigmatizing educational approaches to self-care and mutual help, according to the release. 

"In the United States, there are more than 3 million registered nurses that work in the community and in hospitals," Hanrahan said in the release. "By virtue of the large numbers of RNs and their presence in common community settings, military members and their families can receive timely access to self-care and help from RNs."

The grant to Penn Nursing was made possible by funding from the Jessie Ball duPont Fund. The tool kit will be piloted in Pennsylvania during the fall with a national launch planned for 2014. Additionally, Penn Nursing’s forthcoming health technology lab program will support RN inventors who desire to use technology and game theory to address healthcare challenges. 

Source: Nurse.com

New guidelines from the United States Public Health Service update the recommendations for the management of healthcare personnel with occupational exposure to HIV and the use of postexposure prophylaxis. 

The guidelines, published in the September issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America, emphasize the immediate use of a postexposure prophylaxis regimen containing three or more antiretroviral drugs after any occupational exposure to HIV. 

The PEP regimens recommended in the guidelines encourage the consistent use of a combination of three or more antiretroviral agents, which are said to be better tolerated than those recommended in the previously published guidelines from 2005, for all occupational exposures to HIV. Eligible antiretrovirals are from the following six classes of drugs: nucleoside and nucleotide reverse-transcriptase inhibitors, nonnucleoside reverse-transcriptase inhibitors, protease inhibitors, a fusion inhibitor, an integrase strand transfer inhibitor and a chemokine (C-C motif) receptor 5 antagonist. 

The guidance eliminates the previous recommendation to assess the level of risk associated with individual exposures to help determine the appropriate number of drugs recommended for PEP. 

“Preventing exposures should be the leading strategy to prevent occupational HIV infections,” David Kuhar, MD, an author of the guidelines and a medical epidemiologist with the CDC’s Division of Healthcare Quality Promotion, said in a news release. “However, when exposure occurs, it should be considered an urgent medical concern and a PEP regimen should be started right away, ideally within hours of the potential exposure.”

Expert consultation should be sought, but not at the expense of delaying treatment, according to the guidelines. Exposed healthcare personnel taking HIV PEP should complete a full four-week regimen and undergo follow-up HIV testing, monitoring for drug toxicity and counseling, beginning with follow-up appointments within 72 hours of the exposure. 

If a newer fourth-generation HIV antigen/antibody combination test is used for follow-up testing, an option to conclude HIV testing at four months, rather than the recommended six months after exposure, is provided. Many of the revised recommendations are intended to make the PEP regimen better tolerated, increasing the possibility that healthcare personnel complete the full regimen. 

The guidelines were developed by an interagency Public Health Service working group comprised of representatives from the CDC, National Institutes of Health, FDA and the Health Resources and Services Administration, in consultation with an external expert panel. The updated revisions were based upon expert opinion. 

Many HCP exposures to HIV occur outside of health clinic hours of operation, and initial exposure management often is overseen by emergency physicians or other providers who are not experts in the treatment of HIV infection or the use of antiretroviral medications, according to the news release. As such, the updated guidelines should be distributed and made readily available to emergency physicians and other providers as needed.

Read the guidelines: www.jstor.org/stable/10.1086/672271

Source: Nurse.com

By Karen Long

While all nurses evaluate the four vital signs of temperature, pulse, blood pressure and respiratory rate, Ellen Cunningham, RN, MSN, is among many RNs who assess a fifth: pain.

"Every patient has the right not to suffer in pain," said Cunningham, nurse manager at the Interventional Pain Center at North Shore-LIJ Health System’s Syosset (N.Y.) Hospital.

But assessing the pain of patients in the critical care setting can be difficult, especially if they have cognitive impairments or can’t speak. 

"Inability to provide a reliable report about pain leaves the patient vulnerable to under-recognition and under- or over-treatment," the American Society for Pain Management Nursing stated in a July 2011 position paper about pain assessments in patients unable to self-report. "Nurses are integral to ensuring assessment and treatment of these vulnerable populations."

How to assess a critically ill patient

Determining a nonverbal patient’s pain is "definitely like unpeeling an onion," Cunningham said. Many nurses follow a hierarchy for pain assessment to evaluate the pain of a patient who cannot self-report, said Barbara St. Marie, ANP, PhD, GNP, ACHPN, pain specialist and former member of the American Society for Pain Management Nursing’s board of directors. The ASPMN outlines the steps in its position paper as follows: 

Try to have the patient self-report pain. It often is difficult with critically ill patients, Cunningham said. Obtaining that information "may be hampered by delirium, cognitive and communication limitations, altered level of consciousness, presence of endotrachael tube, sedatives and neuromuscular-blocking agents," according to the position paper. Those patients might not be able to rate pain on a scale of one to 10, but could use a gesture such as grasping the nurse’s hand or blinking their eyes to indicate pain, St. Marie said.

Identify potential causes of pain. That could include surgery, trauma, catheter removals, wound care or constipation, Cunningham said.

Observe patient behavior. Several tools also exist to help nurses assess pain in patients who are unable to speak, said Donna Gorglione, RN, BSN, clinical nurse manager of the ICU and progressive care unit at Hudson Valley Hospital Center in Cortlandt Manor, N.Y. For patients who are aware but not able to voice their pain, nurses can use the Wong-Baker FACES Pain Rating Scale, said Maggie Adler, RN, MSN, WCC, associate director of standards and quality at HVHC. 

The Pain Assessment in Advanced Dementia Scale measures behaviors such as restlessness, agitation, moaning and grimacing that can indicate pain. Nurses observe the patient and score a zero, one or two in five areas — breathing independent of vocalization, negative vocalization, facial expression, body language and consolability — then add up the score. Zero equates to no pain while 10 means severe pain. Nurses then treat the patients based on the pain score, Adler said. For example, a two might indicate the patient’s pain could be eased with Tylenol, while a seven would dictate a more serious intervention, such as narcotics.

The critical care pain observation tool and Face, Legs, Activity, Cry, Consolability tool also are useful, St. Marie said. Changes in blood pressure, heart rate or respiration could be indicators of pain. "I always say that if someone has a physiologic indicator, that’s the point where you start investigating more," she said.

Obtain a proxy report. Parents of young children or caregivers and family members of the elderly can provide vital information about what is causing patients’ pain, Cunningham said. "Credible information can be obtained from family members who know the patient well and may be a very consistent caregiver throughout their illnesses," St. Marie said.

Try an analgesic trial. If the other methods to determine pain yield inconclusive results, a trial could help, St. Marie said. Nurses administer low doses of any number of opioids and look for the patient to settle down, change facial expression or otherwise indicate a decrease in pain. According to Cunningham, any of those would indicate the patient had pain and not distress.

Pain management treatments

After assessing the patients’ pain, level of consciousness and respiratory status, nurses look at other indicators such as comorbidities, kidney and liver function, estimated blood loss from surgery and amount of opioids received in the OR and PACU. Nurses can use a variety of treatments to block pain through multiple receptors and pathways, St. Marie said.

Medications — such as nonsteroidal anti-inflammatory drugs, opioids, acetaminophen, local anesthetic agents and antiepileptics — through various pathways are common ways to treat pain. "Pain mechanisms involve our entire body, so it’s not just one pathway" that pain is transmitted through, St. Marie said. Nurses can now help block pain at many of those pathways.

Not all pain can be eliminated, Gorglione said. In some cases, a patient’s goal is to reduce pain to a tolerable level. "That’s an important piece of pain management," she said. "Sometimes we can’t get your pain to zero. If you can tolerate a level of three or four, we can get your pain there, and you can perform your activities of daily living."

Besides medications, patients can benefit from holistic therapies including music, massage or even hand-holding or warm blankets, Gorglione said.

"The tendency with medicine is to run right to the medicine cabinet," Adler said, noting other therapies can be effective. For some patients at HVHC, music has made a difference. "We’ve had patients and patients’ families thank us for the special attention and how relieved they were and how much it helped," Gorglione said. An integral part of pain management is reassessment after treatment. Nurses should use the same tool they used for assessments to determine whether the patient has a lower level of pain, St. Marie said.

Challenges in treating pain

Along with determining the right treatment, nurses face a variety of challenges in pain management. For example, some patients think pain is a normal part of their illnesses and refuse pain medication, Adler said. Elderly patients often have anxiety about becoming dependent on medications, Gorglione said. In those cases, educating the patient about pain management can help.

In other situations, the challenges come from providers. Patients who arrive in the ICU and have addiction issues often are stigmatized or marginalized because providers blame the victim, St. Marie said. But a patient going through withdrawal needs "serious pain control," she said.

Nurses have to overcome the challenges to be able to assess, treat and reassess patients’ pain, Cunningham said.

"No matter how old someone is, no matter how cognitively impaired they might be, it never takes away that they might be in pain," she said.

Source: Nurse.com