BACKGROUND/RATIONALE : The number of individuals with chronic illness is growing at an astonishing rate because of the rapid aging of the population and the increased longevity of persons with chronic conditions. Nurses in clinical nurse specialist (CNS) roles are well positioned and ideally suited to meet the needs of a growing population with chronic diseases; yet, to date, there has been no critical review of the CNS in chronic diseases. PURPOSE/OBJECTIVES : This article provides a critical review of the literature in order to better define and understand the CNS related to patients living with chronic illnesses (cardiovascular and oncology). DESCRIPTION OF THE PROJECT/INNOVATION:: Using the guidelines of DiCenso et al (2005) for evaluating health services interventions, the literature was appraised in order to identify the characteristics of CNS roles, and the strengths and limitations of research about the effectiveness of CNS in chronic disease management. IMPLICATIONS : Clinical nurse specialists with master's-level preparation provided high-quality and cost-effective care to patients with chronic diseases. The CNSs had a positive impact on patient, family, and healthcare team outcomes. Further evaluation of the CNS role in the research domain of practice is recommended.

BACKGROUND: Rituximab, an anti-CD20 chimeric monoclonal antibody, has been used successfully to treat patients with relapsed or refractory thrombotic thrombocytopenic purpura (TTP); however, the optimal dose and frequency and the role of rituximab maintenance remain uncertain. STUDY DESIGN AND METHODS: We describe a 45-year-old woman with chronic relapsing immune thrombocytopenia who responded to rituximab retreatment administered in four doses over the course of 12 months. Previously, she had received four doses of rituximab and sustained a remission for 19 months. During her latest TTP relapse, multiple treatments were administered including rituximab retreatment. After the first dose (375 mg/m(2)), she developed serum sickness requiring further doses to be deferred. Three subsequent doses were administered at 4-month intervals over the course of 12 months. ADAMTS13 activity was measured by von Willebrand factor (VWF) digestion. ADAMTS13 inhibition was measured by a modification of the VWF digestion assay and anti-ADAMTS13 antibodies were measured by enzyme-linked immunoassay (enzyme-linked immunosorbent assay, American Diagnostica). RESULTS: Clinical and laboratory remission were achieved after one dose of rituximab, with normalization of ADAMTS13 activity and disappearance of ADAMTS13 inhibitor. Three subsequent doses of rituximab were given without incident and the patient remained in remission after 3.5 years of follow-up (2.5 years since her last dose of rituximab). CONCLUSION: Maintenance dosing of rituximab should be considered in some patients with relapsing TTP.

ABSTRACT: BACKGROUND: Identifying every pregnancy, regardless of home or health facility delivery, is crucial to accurately estimating maternal and neonatal mortality. Furthermore, obtaining birth weights and other anthropometric measurements in rural settings in resource limited countries is a difficult challenge. Unfortunately for the majority of infants born outside of a health care facility, pregnancies are often not recorded and birth weights are not accurately known. Data from the initial 6 months of the Maternal and Neonatal Health (MNH) Registry Study of the Global Network for Women and Children's Health study area in Kenya revealed that up to 70% of newborns did not have exact weights measured and recorded by the end of the first week of life; nearly all of these infants were born outside health facilities. METHODS: To more completely obtain accurate birth weights for all infants, regardless of delivery site, village elders were engaged to assist in case finding for pregnancies and births. All elders were provided with weighing scales and mobile phones as tools to assist in subject enrollment and data recording. Subjects were instructed to bring the newborn infant to the home of the elder as soon as possible after birth for weight measurement. The proportion of pregnancies identified before delivery and the proportion of births with weights measured were compared before and after provision of weighing scales and mobile phones to village elders. Primary outcomes were the percent of infants with a measured birth weight (recorded within 7 days of birth) and the percent of women enrolled before delivery. RESULTS: The recorded birth weight increased from 43 +/- 5.7% to 97 +/- 1.1. The birth weight distributions between infants born and weighed in a health facility and those born at home and weighed by village elders were similar. In addition, a significant increase in the percent of subjects enrolled before delivery was found. CONCLUSIONS: Pregnancy case finding and acquisition of birth weight information can be successfully shifted to the community level.

Objectives. To evaluate the impact of birth attendant training using the World Health Organization Essential Newborn Care (ENC) course among traditional birth attendants, with a particular emphasis on the effect of acquisition of skills on perinatal outcomes. Design. Population-based, prospective, interventional pre-post design study. Setting. 11 rural clusters in Chimaltenango, Guatemala. Population. Health care providers. Methods. This study analyzed the effect of training and implementation of the ENC health care provider training course between September 2005 and December 2006. Outcome measures. The primary outcome measure was the rate of death from all causes in the first seven days after birth in fetuses/infants ≥1500g. Secondary outcome measures were overall rate of stillbirth, rate of perinatal death, which included stillbirths plus neonatal deaths in the first seven days in fetuses/infants ≥1500g. Results. Perinatal mortality decreased from 39.5/1000 pre-ENC to 26.4 post-ENC (RR 0.72; 95%CI 0.54-0.97). This reduction was attributable almost entirely to a decrease in the stillbirth rate of 21.4/1000 pre-Essential Newborn Care to 7.9/1000 post-ENC (RR 0.40; 95%CI 0.25-0.64). Seven-day neonatal mortality did not decrease (18.3/1000 to 18.6/1000; RR 1.05; 95%CI 0.70-1.57). Conclusion. Essential Newborn Care training reduced stillbirths in a population-based controlled study with deliveries conducted almost exclusively by traditional birth attendants. Scale-up of this intervention in other settings might help assess reproducibility and sustainability.

Clostridium perfringens type C is one of the most important agents of enteric disease in newborn foals. Clostridium difficile is now recognized as an important cause of enterocolitis in horses of all ages. While infections by C. perfringens type C or C. difficile are frequently seen, we are not aware of any report describing combined infection by these two microorganisms in foals. We present here five cases of foal enterocolitis associated with C. difficile and C. perfringens type C infection. Five foals between one and seven days of age were submitted for necropsy examination to the California Animal Health and Food Safety Laboratory. The five animals had a clinical history of acute hemorrhagic diarrhea followed by death and none had received antimicrobials or been hospitalized. Postmortem examination revealed hemorrhagic and necrotizing entero-typhlo-colitis. Histologically, the mucosa of the small intestine and colon presented diffuse necrosis and hemorrhage and it was often covered by a pseudomembrane. Thrombosis was observed in submucosal and/or mucosal vessels. Immunohistochemistry of intestinal sections of all foals showed that many large bacilli in the sections were C. perfringens. C. perfringens beta toxin was detected by ELISA in intestinal content of all animals and C. difficile toxin A/B was detected in intestinal content of three animals. C. perfringens (identified as type C by PCR) was isolated from the intestinal content of three foals. C. difficile (typed as A(+)/B(+) by PCR) was isolated from the intestinal content in 3 out of the 5 cases. This report suggests a possible synergism of C. perfringens type C and C. difficile in foal enterocolitis. Because none of the foals had received antibiotic therapy, the predisposing factor, if any, for the C. difficile infection remains undetermined; it is possible that the C. perfringens infection acted as a predisposing factor for C. difficile and/or vice versa. This report also stresses the need to perform a complete diagnostic workup in all cases of foal digestive disease.

Near-infrared spectroscopy (NIRS) is a noninvasive technique that monitors regional tissue oxygenation reflecting perfusion status. Near-infrared spectroscopy has the ability to continuously and simultaneously monitor tissue perfusion in different organ systems at the bedside without interrupting routine care. Research has demonstrated its benefit in monitoring cerebral, intestinal, and renal perfusion to detect potential ischemic episodes. Near-infrared spectroscopy can augment current physiologic monitoring to increase awareness of abnormal perfusion status in the preterm population and potentially reduce risks associated with many diseases that may lead to ischemic injury. This article provides an overview describing NIRS technology and function, its current use in neonatology, and pertinent research findings illustrating its benefit in the neonatal population. Near-infrared spectroscopy may evolve into an important diagnostic and prognostic tool for neonatal treatment and outcome.

Reducing greenhouse gas emissions 80% below 1990 levels by 2050 is the subject of vigorous policy debate, but there has been little physically realistic modeling of the energy and economic transformations required. We analyzed the infrastructure and technology path required to meet this goal in a specific economy (California), using detailed modeling of infrastructure stocks, resource constraints, and electricity system operability. We find that technically feasible levels of energy efficiency and decarbonized energy supply alone are not sufficient. Rather, widespread electrification of transportation and other sectors is required. Decarbonized electricity becomes the dominant form of energy supply, posing challenges and opportunities for economic growth and climate policy. The transformation demands technologies that are not yet commercialized and coordination of investment, technology development, and infrastructure deployment.

BACKGROUND: International guidance recommends the scale up of routinely recommended, offered, and delivered health care provider-initiated HIV testing and counseling (PITC) to increase the proportion of persons who know their HIV status. We compared HIV test uptake under PITC to provider-referral to voluntary counseling and testing (VCT referral) in two primary health centers in South Africa. METHODS: Prior to introducing PITC, clinical providers were instructed to refer systematically selected study participants to VCT. After PITC and HIV rapid test training, providers were asked to recommend, offer and provide HIV testing to study participants during the clinical consultation. Participants were interviewed before and after their consultation to assess their HIV testing experiences. RESULTS: HIV test uptake increased under PITC (OR 2.85, 95% CI 1.71, 4.76), and more patients felt providers answered their questions on HIV (104/141 [74%] versus 73/118 [62%] for VCT referral; p 0.04). After three months, only 4/106 (3.8%) HIV-positive patients had registered for onsite HIV treatment. Providers found PITC useful, but tested very few patients (range 0-15). CONCLUSION: PITC increased the uptake of HIV testing compared with referral to onsite VCT, and patients reported a positive response to PITC. However, providing universal PITC will require strong leadership to train and motivate providers, and interventions to link HIV-positive persons to HIV treatment centers.