The bill is sponsored by Senator Susan Collins [R-ME] and is co-sponsored by Daniel Akaka [D-HI], Kent Conrad [D-ND], Daniel Inouye [D-HI], Tim Johnson [D-SD], Jeff Merkley [D-OR], John Reed [D-RI], and Ron Wyden [D-OR]. According to the US federal government, this bill revises limitations for “home health care services. Allows payment for home health services to Medicare beneficiaries by: (1) a nurse practitioner, (2) a clinical nurse specialist working in collaboration with a physician in accordance with state law, (3) a certified nurse-midwife, or (4) a physician assistant under a physician's supervision.” The bill has been referred to the Senate Finance Committee.

Cost cutting techniques involve reducing the number of nurses in hospitals and medical clinics. The release of this data now links cost cutting techniques with increased death rates. Nearly a decade ago, another study linked the proper staffing of nurses to better patient outcomes. This follow-up study now highlights the dangers of nursing shortages.

The Results
In one finding, understaffing of nurses leads to inappropriate and dangerous levels of patient transfers and discharges. The study also concludes that nursing shortages are directly linked to higher nursing shift turnover rates. The study concluded the risk of death increased 2% for patients exposed to shifts below target RN staffing levels. The average patient was exposed to 3 nursing shifts below target levels thereby creating a 6% higher risk of death. High turnovers of nursing shifts resulted in a 4% higher death rate.

American Nurses Association
The ANA (American Nurses Association) has commented on this finding by saying that policymakers need to focus on reimbursement systems that reward hospitals for proper nurse staffing levels. The ANA’s recommendations follow an emerging philosophy of creating monetary rewards for better patient outcomes rather than that from cost-per-patient profits.

Reference:
Nurse Staffing and Inpatient Hospital Mortality. Jack Needleman, Ph.D., Peter Buerhaus, Ph.D., R.N., V. Shane Pankratz, Ph.D., Cynthia L. Leibson, Ph.D., Susanna R. Stevens, M.S., and Marcelline Harris, Ph.D., R.N. N Engl J Med 2011; 364:1037-1045.

Risk Profile
The vaccines in question generate billions of dollars of revenue every year for the manufacturers. While the vaccines provide protection, a concern remains as to the risk-benefit analysis of the vaccines. Once concern is that several of the children who died received a combination of other vaccines simultaneously including those for diptheria, pertussis, and tetanus. Multiple vaccines pose a potential drug interaction issue. This concern may lead to changes in vaccine schedules to minimize potential adverse effects. By definition, vaccines introduce toxins into the body in an effort to prevent future illness. At question is whether or not the introduction of the vaccine can be safely handled by the immune system of children who are very young, have received multiple vaccines, or who are immunocompromised. The Japanese investigation determined that there were no manufacturer defects in the vaccines at issue.

US Supreme Court
This is a hot issue in light of a current pending vaccine case in the US Supreme Court, Bruesewitz v. Wyeth. In this case, the US Justice Department is siding with Pfizer pharmaceuticals to limit the liability of pharmaceutical manufacturers in cases of illnesses caused by vaccination. At issue is whether or not a pharmaceutical company is liable if they are aware of a better designed vaccine (one with fewer side effects) yet continue to use the less safe vaccination.

The federal Vaccine Court system provides compensation for vaccine injured persons from the money generated by a tax on vaccine manufacturers. In Bruesewitz v. Wyeth, the parents of Hannah Bruesewtiz were denied compensation in the Vaccine Court system and now seek the right to receive compensation through State court. Six month old Hannah received a DPT (diphtheria, pertussis, tetanus) vaccination and immediately suffered a series of 125 seizures over a period of 16 days. Now 18 years of age, Hannah cannot speak or care for herself as a result of her injuries. The vaccine used on Hannah has since been discontinued in favor of safer alternatives. Before the Supreme Court, attorneys for the Bruesewitz family argue that safer alternatives were available at the time Hannah received her vaccine and that the manufacturer had the responsibility of providing the safer alternative and at the very least had the responsibility of providing labeling noting that a safer alternative was available.

Justice Ginsburg showed deep concern in this case, “there were an unusual number of adverse reactions to the particular lot that this child's third vaccine came from, and that those adverse reactions were not disclosed to the doctors. And the doctors -- the child's doctor said if I had known about the unusual number of adverse reactions, I never would have used this vaccine.” Justice Breyer noted that the1986 National Childhood Vaccine Injury Act legally protects drug companies from lawsuits due to unavoidable harm (such as side effects from vaccinations) but that the drug company lawyers in this case are now suggesting that they are also protected from avoidable harm lawsuits. Avoidable harm includes withholding information from the government and the public concerning safer vaccines and also not informing doctors and nurses of high incidences of reactions to particular batches of vaccines. The attorney for the drug company replied that if manufacturers were to be sued for avoidable harm they would be “driven from the market” and she reiterated her position that pharmaceutical manufacturers should only be held liable for manufacturing defects and warning claim issues. The drug company lawyer argued that pharmaceutical companies are not responsible for informing nurses, doctors, the pubilc, and the government if safer vaccines are available.

California State law limits the power of the California Insurance Commissioner to control rate hikes by health insurance companies. Blue Shield plans to raise insurance rates approximately 35 percent in addition to two other recent rate hikes. In total, some Californians will see an increase of up to 60 percent in their health care premiums from 2010 to 2011.

Blue Shield has released a statement that the rate hikes are unrelated to the Affordable Care Act. Blue Shield notes that the rate hikes in California are due to increased medical costs.

“At low intake levels, fluoride has been shown to have therapeutic value in the prevention of dental caries; however, slightly higher levels, particularly in children during the period of enamel development can lead to dental fluorosis, a condition in which the enamel covering of the teeth fails to crystallize properly. Possible resulting problems include enamel defects ranging from barely discernable markings to brown stains and surface pitting. Prolonged high intake of fluoride, at any age, can result in skeletal fluorosis, a condition which may increase bone brittleness, and in a potential increase in risk of bone fracture. In high-dose cases, severe bone abnormalities can develop, crippling the affected individual.”²

The HHS noted that access to fluoride has increased and that health and safety concerns prompted the change in policy. The HHS published, “Water is now one of several sources of fluoride. Other common sources include dental products such as toothpaste and mouth rinses, prescription fluoride supplements, and fluoride applied by dental professionals… This updated recommendation is based on recent EPA and HHS scientific assessments to balance the benefits of preventing tooth decay while limiting any unwanted health effects.”³

Comprehensive evaluations of many patient case studies appear in EPA reports. One patient, for example, was cited as contracting severe dental and skeletal fluorosis due to the fact that he drank a lot of water because he lived in the dry climate of Arizona. The study reads, “He presented with neurological deficits and severe weakness in both legs. Fluorosis was confirmed in an extracted tooth in which fluoride content ranged from 614 to 5299 ppm, depending on the part of the tooth….The characteristic vertebral changes of skeletal fluorosis and severe osteophytosis were probably the basis for the patient’s neurological deficits…. the neurological symptoms are adequately explained by the marked narrowing of the sagittal diameter of the cervical and lumbar spinal cord and the vertebral osteophytosis secondary to fluorosis. Neurological deficits occurred as a manifestation of spinal cord and nerve root bony compression.”⁴

Gov. Brown’s Plan
Gov. Brown’s plan is divided into several tiers of renewable energy projects, which include solar, wind, small hydro, geothermal, and biomass. The first tier is to build 12,000 MWs of localized electricity generation. This focuses on onsite energy systems or systems near the area where the electricity is consumed. This cuts down on costs associated with energy transmission lines and environmental impact. Solar systems on roofs of warehouses, parking lot structures, schools, and commercial buildings can typically handle 2 MW solar systems. Larger public and private lands and solar panels alongside highways can typically handle 20 MW systems. Gov. Brown also notes that legislation to limit rates and protect consumers must accompany this part of the plan.

Large Scale Production
The second tier of Gov. Brown’s system is to build 8,000 MW of large-scale renewable energy production and associated transmission lines. He has several legislative solutions to focus on cutting red tape. Notably, he calls for a general plan with one, large environmental review. Gov. Brown has a fast track plan to cut California’s infamous ‘red tape’ beuracratic burden for new clean energy projects, which currently makes the average large scale project a 6 to 8 year ordeal. His plan will reduce that time to less than three years. Also, he plans to push for legislative standards to require a minimum of 33 percent renewable energy for the State of California.

Jobs
Next, Gov. Brown plans to create 8,500 jobs by incentivizing the development of energy storage systems to offset peak energy demands. Also, he has a plan to increase the energy efficiency of buildings and appliances. Gov. Brown’s energy plan will also incentivize cogeneration. Cogeneration is combined heat and power projects, which makes use of excess heat or electricity generated by industrial and power plants.

The healthcare impact may be substantial if Gov. Brown can achieve his goal of 20,000 new megawatts (MW) of renewable electricity by 2020. Reducing air pollution will reduce asthma rates and other diseases and the subsequent impact on the hospital system, nurses, nursing professionals, doctors, acupuncturists, and many other healthcare professionals.

A Steering committee has been established to coordinate health evaluations, treatment programs, and monitoring. It is comprised of representatives from the Centers for Excellence (servicing WTC responders), firefighters, police, NYC employees, and recovery and cleanup workers (including healthcare professionals such as nurses and nursing practitioners) who responded to the September 11, 2001 terrorist attacks. The steering committee also has 3 representatives from New York City. One will be selected by the NYC police commissioner, another by the NYC health commissioner, and another by the mayor of New York City.

Contamination Oversight
One provision of the Food Safety Modernization Act is a new requirement for manufacturers and farmers to develop anti-contamination protocols. The act also gives the FDA authority to review food industry and farm internal records. Further, the act requires imported food to be certified as meeting US safety standards. The act also increases the frequency of safety inspections at industrial food processing plants. Under current provisions, the FDA inspects plants approximately once every ten years. Under the new proposed law, this will occur at least once every five years at high-risk facilities.

Politics of Food
Sen. Harry Reid notes that 5,000 people die every year in the US due to food poisoning. He notes that the new act empowers the FDA to prevent outbreaks from contaminants such as E. Coli bacteria in the food supply. In an interesting twist, a provision to self-fund the act with user fees collected from food companies was removed from the House version before passage. Republican Rep. Jack Kingston, who has oversight authority of the FDA because he sits on the House appropriations subcommittee, objects to the new law citing that it is too expensive at a cost of $1.4 billion over a period of five years. Had the user fees been included in the proposed law, this issue would not exist. All three GOP lawmakers on the House appropriations subcommittee voted against the Food Safety Modernization Act.

Overview of Provisions
The Food Safety Modernization Act provides for inspection of food production records, registration of food facilities, hazard analysis and risk-based preventive controls, performance standards, standards for produce safety, protection against intentional adulteration of foods, a national agriculture and food defense strategy, food and agriculture coordinating councils, building domestic capacity, sanitary transportation of food, food allergy and anaphylaxis management, and requirements for guidance relating to post harvest processing of raw oysters. Improvements in the capacity to detect and respond to food safety problems include targeting of inspection resources for domestic facilities, foreign facilities, and ports of entry; laboratory accreditation for analyses of foods, an integrated consortium of laboratory networks, enhancing tracking and tracing of food and recordkeeping, mandatory recall authority, administrative detention of food, decontamination and disposal standards and plans, improving the training and continuing education of State, local, territorial, and tribal food safety officials, enhancing food safety, and improving the reportable food registry. Improvements to imported food safety include a foreign supplier verification program, a voluntary qualified importer program, authority to require import certifications for food, prior notice of imported food shipments, building capacity of foreign governments with respect to food safety, inspection of foreign food facilities, accreditation of third-party auditors, foreign offices of the Food and Drug Administration, and controls to identify smuggled food. Other provisions include whistleblower protections and methods to determine budgetary effects.

The Votes
The FDA Food Safety Modernization Act, HR 2751, passed in the House on June 9^th and passed in the Senate with changes by voice vote on Dec. 19^th. The act was cleared for the White House on Dec. 21^st, 2010 when the House of Representatives agreed with the Senate’s changes by a vote of 215 Ayes, 144 Nays, and 74 Present/Not Voting. The Dec. 21^st vote was 205 Democrats and 10 Republicans voting in favor of the measure. Opposing the food safety act were 8 Democrats and 136 Republicans.

Improvements in air quality and the impact on public health were not included in the estimates. Improved air quality as a result of stringent vehicle emissions standards reduces the health impact on Americans. Doctors, nurses, acupuncturists, and all health care professionals treat many disorders such as COPD, asthma, and cancer that are more prevalent with increased airborne carcinogens and pollutants. Reduced vehicle emissions and the associated improvements in air quality will ease the health impact of hydrocarbon related health hazards on hospitals and insurance costs. Moreover, better mileage for trucks and buses will ease financial burdens on businesses burdened by fuel costs.

Chief Justice Roberts Agrees with Justice Sotomayor

The Supreme Court Justices seemed concerned that design defects were disallowed as a reason to sue in the court system as a result of prior rulings in this case. Justice Sotomayor asked pointedly of Ms. Sullivan, attorney for the pharmaceutical company Pfizer, Inc. (now owner of Wyeth), “Point me to the FDA regulations or law where the FDA, in giving a license to or permitting a new vaccine, actually looks at whether that vaccine is the most efficacious way with the least serious harm to the population. Is there a regulation that requires that judgment by them before they issue permission to market?” Ms. Sullivan replied, “There is not, Justice Sotomayor.” Justice Sotomayor responds, “All right. What is the motivation? If there is no -- there's no approval mechanism for the FDA to look at that issue, what is the motivation for manufacturers to voluntarily remove a drug that is causing harm to the public before the FDA acts? If they are completely immune under your reading of this preemption statute, what motivates them to act more quickly?” The drug company lawyer did not respond with an answer. Justice Sotomayor continued, “Could you please just answer that question? What is the motivation for the manufacturer to either continue the testing of their product and voluntarily stopping it if a better design has been found by someone else or even an inducement for them to find a better design if a competitor comes around? Because I don't see why they should stop until they have caused as many injuries as they need to before the FDA says stop.” Once again, Ms. Sullivan did not answer the question only to be probed by Chief Justice Roberts, “Before you get to that, I think your answer to Justice Sotomayor's question is: Nothing; the manufacturers have no reason to take the vaccine off the market until the FDA tells them to.”

The Court is Stunned

In the following argument, Justice Kennedy is concerned that the pharmaceutical company attorney asserts that the drug company need never inform the government of safer vaccines and that the consumer may not sue on the basis of the drug company intentionally withholding drug safety information. Justice Kennedy asked, “But if the manufacturer is slow or remiss or negligent or willful in not giving the information to the Government, there is nothing the injured person can do. There is still complete preemption, under your view?” The drug company attorney replied, “Of design defect claims, Justice Kennedy, but not of warning claims.” Justice Kennedy replied, “The warning doesn't have to say, 'Warning: We could make something better if we wanted to'." The court then erupted in laughter.

Avoidable Harm vs. Unavoidable Harm Protection

Justice Breyer then noted that the1986 National Childhood Vaccine Injury Act legally protects drug companies from lawsuits due to unavoidable harm (such as side effects from vaccinations) but that the drug company lawyers are now suggesting that they are also protected from avoidable harm lawsuits. Avoidable harm includes withholding information from the government and the public concerning safer vaccines and also not informing doctors and nurses of high incidences of reactions to particular batches of vaccines. The attorney for the drug company replied that if manufacturers were to be sued for avoidable harm they would be “driven from the market” and she reiterated her position that pharmaceutical manufacturers should only be held liable for manufacturing defects and warning claim issues.

Health professionals and scientists have been trying to get BPAs banned from food packaging to prevent BPAs from leaching into infant formulas, canned foods, and beverages. This new discovery shows that major retailers are using BPA contaminated paper in their receipts including: McDonald’s, CVS, KFC, Whole Foods, Walmart, Safeway, and the US Postal Service. However, many receipts contain little or no BPAs such as those at Target, Starbucks, and Bank of America ATMs. BPAs can be directly absorbed through the skin into the bloodstream.

The Centers for Disease Control and Prevention (CDC) shows that over 90% of US citizens over the age of 6 have BPAs in th bloodstream. People working in retail have 30% more BPAs than the average US adult. This is approximately 7 million people. BPA-free receipts are available but are not required. In Japan, the Japan Paper Association eliminated the use of BPAs in paper by 2003. In Wisconsin, the largest thermal paper manufacturer, Appleton Papers, discontinued the use of BPAs in their papers.

The EPA has issued a warning for residents of coastal Connecticut, the entire state of Rhode Island, and south coastal Massachusetts due to excessively “unhealthy air quality” predicted for July 24. For Massachusetts, this includes Cape Cod and the islands. EPA’s New England administrator, Curt Spalding, states that “EPA and the medical community suggest that people limit their strenuous outdoor activity.” Ground-level ozone is expected to exceed healthy limits which prompted the official warning by the EPA. Children and those with respiratory conditions are at the highest risk of damage due to elevated ozone levels.

Medical Conditions

Public Action Urged

Areas Hit Hardest

Nearly all of the high ozone level days have occurred in July for New England. However, areas of Connecticut such as Cornwall, Danbury, and Middletown had elevated levels of ozone as early as May. Other areas getting hit by high ozone levels in May include Acadia NP (Cadillac Mountain) in Maine, the Ware area in Massachusetts, and Miller State Park in New Hampshire. Vermont has not had a single day of high ozone levels, Massachusetts has had 9 days exceeding healthy limits, and Connecticut tops the list with 17 days reaching hazardous levels to human health. The highest readings of ozone were recorded in Martha’s Vineyard in Massachusetts on July 4. For Massachusetts, Martha’s Vineyard exceeded healthy limits 5 times between June and July followed by Fairhaven at four times and East Milton, Truro, and Ware at two times. Areas of Connecticut exceeding healthy limits several times were Greenwich, Stratford, Westport, Danbury, Madison, and Middletown.

Median wages for RNs were approximately $62,500 in 2008. The highest 10% of nurses earned an average of approximately $92,500. Nursing remains attractive because many employers offer flexible work schedules, child care, educational benefits, and bonus programs. 21% of nurses are union members. Looking to the future, an increase in educational opportunities for students to train in the nursing profession is essential to meet upcoming demand. Lack of available space for qualified applicants at nursing schools persists and is fueling an increasing shortage of filled nursing positions.

The numbers are staggering. In 2008 there were 2,618,700 nurses in the US. It is projected that there will be a need for 3,200,200 by 2018. That's a creation of 581,500 new nursing positions, a 22% increase. However, the rate of employment growth is not projected to be even across all nursing healthcare settings. Growth of nursing jobs in hospitals is expected to grow only 17% while growth in physician’s offices will grow at a 48% rate. This is attributed to the slow growth of inpatients (patients remaining in the hospital over 24 hours), earlier discharges, and an increase in outpatient procedures. Home healthcare services will grow at a rate of 33%, nursing care facilities at a 25% rate, and RN jobs in employment services at a 24% rate. An aging population combined with financial pressures on hospitals to release patients earlier will drive the growth rate of residential care facilities and home healthcare. A spike in job growth is anticipated for nurses providing care for the long-term rehabilitation of stroke and head injury patients and also patients suffering from Alzheimer’s disease.

Nursing education is continuing to run into difficulties. A continuing increase in nursing education applicants has caused many nursing schools to reject qualified applicants due to a shortage of nursing faculty. An increase in availability in nursing schools and nursing continuing education programs could help meet the growing demand. Hospitals will also face difficulties in attracting nurses to their facilities. Although the growth in new nursing jobs at hospitals is expected to be only 17%, the high turnover rate of existing jobs will drive shortages. The largest shortages are expected in rural areas and inner city regions. An especially high demand is expected for advanced practice specialties in nursing: clinical nurse specialists, nurse practitioners, nurse-midwives, and nurse anesthetists. In many areas, nurses will represent a substantial percentage of primary care providers to the public.

The memorandum establishes a task force which focuses on parent nutritional education, physical exercise, and affordable food options in schools and communities.  The task force includes cabinet members such as the Secretaries of the Interior, Agriculture, Health and Human Services, and Education. The Assistant to the President and the Chief of Staff to the First Lady are also included in the task force. The task force will focus on federal responses to the obesity crisis as well as nongovernmental actions that can be implemented. Special attention will be given to healthy, affordable food; increased physical activity in schools and communities, healthier food in schools, and informing parents and caregivers concerning healthy choices. Let’s Move takes up these initiatives and actively works to achieve these health related goals.

Building on this momentum, the new health reform law requires that chain restaurants and vending machines with more than 20 locations to label food calorie information. The new health reform law, the Patient Protection and Affordable Care Act, signed recently by President Obama provides funding for a childhood obesity reduction project. The health reform law identifies obesity reduction as an important method to prevent illness. As such, obesity related services take an important role in the Patient Protection and Affordable Care Act and obesity related healthcare is cited multiple times in the 2,393 page law. Educational and counseling services as well as community funding for projects to end obesity are included in the new law.

President Bill Clinton’s foundation, in conjunction with the American Heart Association, created the Alliance for a Healthier Generation which shares the same goals as the Obama initiative. Partnership for a Healthier America is a foundation newly formed to combine multiple nonpartisan efforts to fight obesity. This new foundation combines efforts with the Alliance for a Healthier Generation, The California Endowment, Kaiser Permanente, Nemours, the Robert Wood Johnson Foundation, and the W.K. Kellogg Foundation. First Lady Michelle Obama serves as Honorary Chair and both a prominent Republican and a prominent Democrat will be named as Honorary Vice Chairs to underscore the organization’s nonpartisan position.

The bipartisan and nonpartisan fitness initiatives and organizations of today starkly contrast the USDA’s (US Department of Agriculture) reclassification of ketchup as a vegetable during President Reagan’s term in office. This allowed school lunch programs to meet minimum standards required for federal reimbursements even if they replaced vegetables with a small amount of ketchup. Overnight, vegetables disappeared from school lunch programs and paper containers with a small helping of ketchup appeared on school cafeteria trays. Democratic politicians seized the opportunity to dramatize this USDA snafu, termed ketchupgate, by staging photo ops of democrats dining on nutritionally void meals that met the new lax standards. Newsweek magazine reported the story and the ketchup as a vegetable policy was subsequently abandoned.

Learn more about healthcare and insurance issues affecting nurses, doctors, and patients at HealthCMI Online, http://www.healthcmi.com .

Learn more about nursing and medical continuing education news at HealthCMI by clicking Nursing Continuing Education Online.

2-17-10: The iPad is a generational shift from the laptop computer to the handheld computer and will directly impact online continuing education courses. Mostly, the use of a laptop requires the user to be in an upright seated position whereas the iPad sports enhanced mobility similar to that of smart phones. The iPad allows users to shift from semi-mobile laptop computing to highly mobile handheld device computing thus opening up new possibilities to easily study continuing education courses on subways, at bus stops, at a park, in vehicle passenger seats, while waiting in a line, etc….

The iPad will increase mobile online continuing education usage far greater than other eReaders such as the Amazon Kindle and the Sony Reader Touch.  The Kindle text readout is a form of eInk that is visible in daylight without backlighting and has extremely long battery life. The iPad features only up to 10 hours of battery time and does not have the eInk advantages in daylight. However, sharper text resolution and improved ergonomics are major reasons for the inevitable success of the iPad in the eReader market.

Online continuing education programs are provided in several ways including the eBook  format which is often purchased online then downloaded in the form of Adobe PDF files. The iPad supports high definition, full color text with images. This enhances courses delivered in the PDF format over the black and white readout of the Kindle. The iPad’s combination of color text, photos, and video allows for a greater diversity of course content and layout thereby making a more user friendly experience for learners.

Online continuing education courses are also delivered through streaming media and downloadable video files, often in Apple’s Quicktime format. The Kindle and several other eReaders will falter in comparison to the iPad’s 3G and Wifi ability to deliver streaming video content. More than this, the iPad has an intuitive touch screen display allowing users to flip through eBook content in much the same way as turning the pages in a book. The iPad brings the tactile experience of opening and flipping through a book to the end user. A major factor in the adoption of the iPad into the continuing education marketplace is familiarity. The touch screen hand gestures used by the Macintosh computer mousepad, iPhone, and iPod touch devices are employed in iPad navigation. Millions of end users are already familiar with the ergonomics of Apple touch-screen hand gestures thereby making the cross-grade from the laptop to the iPad an intuitive process.

More speculative is the likability factor of the iPad’s handheld usability. Apple’s intention is to have the iPad become as comfortable as holding a pad of paper, leafing through a newspaper, or reading a book. It is likely that the comfort level for end users will reach this goal based on the reasonable size, weight, and thinness of the iPad. More than this, the iPad is compatible with many existing online content delivery systems such that specialized programming and development is unnecessary. This makes the iPad an out-of-the-box educational solution for both end users and content providers. Moreover, it is probable that the popularity of the iPad will encourage publishers to provide more textbook titles in eBook format.

The iPad requires no additional programming for educational providers using most learning management systems (LMSs). An LMS is the server side software used to host online schools and universities. LMSs allow students to register for courses, download course materials, take quizzes, receive certificates of completion, view grades, interact with other students and faculty, and view streaming video and media content. The LMSs of providers such as the Healthcare Medicine Institute (HealthCMI) and Lynda.com are compatible with the Apple Safari internet browser. Currently, the Safari browser functions on the iPad, iPhone, iPod Touch, Windows computers, and Mac computers. Learners at HealthCMI and Lynda.com will be right at home with the iPad and the downloadable materials and streaming media content will behave exactly the same way on the iPad as on desktop and laptop computers.

The iPad can act as a virtual stack of books or as a streaming media portal for learners. Online educational environments will move beyond the laptop generation and find its way into the handheld environment. In other words, mobile usage can move from sitting to standing and moving. This puts the iPad in the same range of flexibility offered by books and newspapers and also makes access to continuing education online as ubiquitous as a Wifi or 3G connection to the internet.

Learn more about continuing education online at HealthCMI by clicking Nursing Continuing Education.

About the Author: Adam White, L.Ac., Dipl.Ac. is an Acupuncture Continuing Education provider with the Healthcare Medicine Institute (HealthCMI). To learn more about medical news and medical continuing education visit http://www.healthcmi.com .

The patient’s right to choose their own medical practitioner is not federally guaranteed by law. Additionally, there is no guarantee an insurance company will pay for medical services and patients often have no way to determine what will be paid until after a claim is submitted and a response is generated the insurance company’s claims department. The federal government seeks to mandate health insurance coverage for all US citizens yet has not stipulated that insurance companies must reimburse patients for medical expenses nor is there language to address oversight of the determination of medical necessity.

The determination of reimbursements is often based on what is termed as ‘usual and customary.’ Insurance companies have sole discretion over this aspect of reimbursement for general health insurance policies and may choose to exclude many procedures, office visits, and medical tests whether or not teams of doctors agree that such medical services are vital to the patient’s survival, recovery, or comfort.

The US House of Representatives and the US Senate have not addressed these details which represent core issues affecting healthcare outcomes for patients. Until these unresolved issues are rectified, it is unclear whether or not US citizens with health insurance coverage will have adequate access to medical care.


About the Author: Adam White, L.Ac., Dipl.Ac. is an Acupuncture & Nursing Continuing Education provider with the Healthcare Medicine Institute (HealthCMI).  To learn more about medical news and medical continuing education visit http://www.healthcmi.com .

Nursing Continuing Education Online

Palatal myoclonus is a spasmodic action of the palatal muscles which are located on the roof of the mouth. This often results in a clicking noise that can be heard both by the patient and people nearby.  Lesions of the central tegmental tract are often involved.  Once important and effective treatment is acupuncture to alleviate this disorder.

Focus: Ulcertative Colitis and Crohn's Disease

Chronic inflammatory disease of the large bowel is divided into two major entities-nonspecific ulcerative colitis & Crohn's disease  of the large bowel (regional enteritis, granulomatous colitis).  Both involve abdominal pain, diarrhea, and rectal bleeding.  Crohn’s disease is  one-fifth as common as ulcerative colitis in the US.

Crohn's disease is a nonspecific chronic transmural inflammatory dz that most commonly affects the distal ileum and colon but may also occur in any part of the GI tract from the mouth to the anus and perianal area.  Chemicals and low-fiber diets of industrialized nations facilitate this onset of this disease.  It occurs more commonly in Jewish people of Eastern European descdent and has familial tendencies.  Most cases begin before age 40 and have peak incidence in the 20's.

The earliest macroscopic lesions of Crohn’s disease appear to be tiny focal "aphthoid" ulcerations of the mucosa, usually with underlying nodules of lymphoid tissue.  The inflammation may regress or progress to involve all layers of the intestinal wall.

The transmural inflammation, deep ulcerations, edema, and fibrosis are responsible for obstruction, deep sinus tracts and fistulas and mesenteric abscesses.  Chronic diarrhea associated with abdominal pain, fever, anorexia, weight loss, and a right lower quadrant mass or fullness are the most common presenting features.  However, many patients are first seen with an "acute abdomen" simulating acute appendicitis or intestinal obstruction.

Ulcerative colitis, however, is usually a series of attacks of bloody diarrhea varying in intensity and duration interspersed with asymptomatic intervals.  Onset of an attack may be acute and fulminant with  sudden violent diarrhea, high fever, signs of peritonitis and profound toxemia.

Psychological aspects of ulcerative colitis play a secondary role in attack onset.  The initial pathologic lesion is confined to the mucosal layer and consists of abscess formation in the crypts, as opposed to Crohn’s disease, which involves the entire thickness of the bowel wall.  Ulcerative colitis reveals a friable and intensely inflamed mucosa with exudate. Usually, the rectosigmoid area of the colon is involved.  The disease may extend from this area but always in a continuous fashion, in contrast with Crohn’s disease, which tends to skip.  Ulcerative colitis patients  may have narrowing of the bowel lumen as a result of fibrosis, which is generally mild compared to Crohn’s disase.  Age onset differs.  Ulcerative colitis peaks at 15-30 years and also 50-70 years of age.

Foucs: Peptic Ulcers

HealthCMI brings special FYI information on common questions in nursing continuing education and medicine.

Peptic ulcers are circumscribed breaks in the continuity of mucosa, extending below the epithelium. Strictly speaking, breaks in the mucosa not extending below are called erosions, although they are often referred to as ulcers. Chronic ulcers have scar tissue at the base. Peptic ulcers can be located in any part of the gastrointestinal tract exposed to the acid-pepsin gastric juice, including the esophagus, stomach, duodenum and after gastroenterostomy, the jejunum. Although the peptic digestive activity of the gastric juice is an important etiologic factor, there is evidence that this is only one of many factors in its pathogenesis. Both cortisone and aspirin produce qualitative changes in the gastric mucus which may facilitate its degradation by pepsin.

Aspirin, alcohol, bile salts, and other substances injurious to the gastric mucosa alter the permeability of the epithelial barrier, which allows back diffusion of hydrochloric acid with resultant injury to underlying tissues, especially blood vessels. Histamine is liberated, which stimulates further acid and pepsin secretion and increased capillary permeability to proteins. The mucosa becomes edematous, and large amounts of plasma proteins may be lost. The mucosal capillaries may be damaged, resulting in interstitial hemorrhage and bleeding. Severe stress, especially chronic, is another major cause of gastric ulcers. Overall, acidity is the major pathogenic factor, so that a malfunction of Brunner's glands, which produce a mucoid secretion that neutralizes the acid chyme, would lead to ulceration. If normal tissue resistance defense systems like this are overwhelmed- ulcer. Also important to tissue resistance is vascular supply, proper epithelial regeneration - normally replaced every 3 days. HealthCMI will feature food cures for nursing continuing education online courses on this topic- coming soon!

Other causes: Indomethacin, phenylbutazone, and corticosteroids, also- caffeine. Associated diseases: Liver cirrhosis, chronic pancreatitis, chronic lung dz, hyperparathyroidism, and Zollinger-Ellison syndrome. In addition, bile reflux from abnormal pyloric sphincter function disrupts the mucosal barrier.

CLINIC: upper abdominal pain usually 2 hours after a meal and is relieved by foods and antacids; sometimes pain in the middle of the night (duodenal ulcer), and weight loss (gastric ulcer).

COMPLICATIONS: intractability, hemorrhage, perforation, and pyloric obstruction. Some ulcers are malignant, others may lead to iron-deficiency anemia, shock in the case of bleeding. Perforation may lead to chemical peritonitis and therefore intense pain, a fear of moving and breathing, and a rigid abdomen. If the pancreas is involved, pain may radiate to the back. Obstruction may lead to anorexia, nausea, and bloating after eating and weight loss; also, sever pain and vomiting.

STRESS ULCER: Brain injury, shock, sepsis, burns and drugs

Highlight on Food

Food delivers the staple nutrition required to maintain health and a proper diet also speeds recovery from illness.  It follows that hospitals need to focus on quality foods for patients, staff, and for the public.  Under a holistic model of health, the hospital setting is an opportunity to provide quality food for its health benefits and to set an example to the community for healthy eating.  One strong example of a quality food delivery system in the hospital setting is Sutter Maternity and Surgery Center in Santa Cruz, California.  This 30 bed not-for-profit hospital serves fresh locally grown and certified organic foods.  Patients can order meals in a similar fashion to food service in quality hotels.  In addition, the fresh organic foods are available in the food cafeteria for the general public and staff.  The process is accomplished with Sutter’s model of purchasing food directly from a farm.  By contrast, the food courts in many hospitals provide fast-foods that provide profits but miss the mark in terms of healthy eating.

For a link to the US FDA Click Here .

Nurse to Patient Ratio Issues

Job Burnout and Quality Patient Care

HealthCMI will feature important nursing continuing education courses on quality of life factors for nurses. Nursing continuing education will focus on important roles that nurses can empower themselves with in the working environment. Look forward to nursing continuing education online at HealthCMI!

In one of the most interesting studies concerning the nursing profession (JAMA. 2002 Oct 23-30;288(16):1987-93), important results were tabulated concerning nurse to patient ratios. Research articles are often dry. Not this one. The opening description of the abstract notes, “The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice.” The research was conducted by the Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania. The results showed, “each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% increase in the odds of burnout and a 15% increase in the odds of job dissatisfaction.” The study was conclusive that the mortality rate for surgical patients is higher with fewer nurses per patient and job burnout for nurses increases as well.

Registered nurses represent the largest number of healthcare providers in the United States.  There are 2.5 million nurses and over 50 percent of them work in the hospital setting.  The educational preparation for a career in nursing may include a bachelor’s degree, an associate degree, or a diploma from a dedicated nursing program.  There is an increasing demand for nurses in the US and over a 500,000 new nursing positions are expected to be created by the year 2015. 

Registered nurses (RN’s) work with both patients and the general public in an effort to educate people about treatment paths for medical conditions.  Nurses treat patients, perform and analyze diagnostic tests, and administer medications.  Nurses also perform record keeping responsibilities and work with patient rehabilitation.  Very importantly, nurses provide emotional support to patients and their families. 

Nurses are essentially on the “front lines” of medicine.  They may be responsible for reviewing and explaining issues concerning post-operative recovery, dietetics, and for helping patients to understand their responsibilities regarding recovery from illness and also how to maintain wellness.  Many nurses operate in a public health capacity in an effort to education the public concerning the signs and symptoms regarding disease processes.  Other efforts include working at immunization clinics, physical therapy centers, blood drives, and the operation of important medical equipment for diagnostic, analytic, and treatment purposes. 

Nurses provide an important role in monitoring and administering medications including the checking of dosages.  Other nurses may be charged with administering intravenous (IV) fluids including pharmacological agents and blood.  Nurses may also oversee and manage nursing aids.  Nurses with advanced certifications may have the power to prescribe medications.

Specialization in nursing takes several directions.  Many nurses perform perioperative procedures for work in operating rooms and act as assistants to surgeons.  Other nurses manage long term cases of illness involving the careful monitoring of lifestyle, medications, and follow-up visits.  Nursing specialties can be quite specific to a particular demographic, organ, or disease type.  There are several major categories of nursing specialties.  They include perioperative nurses, rehabilitation nurses, long-term care nurses, ambulatory care nurses, emergency nurses, hospice care nurses, infusion nurses, home health care nurses, transport nurses, critical care nurses, palliative care nurses, radiology nurses, perianesthesia nurses, mental healthcare nurses, transplant nurses, and more.  The income for nurses ranges from approximately $40,000 to over $80,000.