News Director: Maureen Shawn Kennedy, MA, RN E-mail: [email protected]

No Place Like Home—For Fatal A steep rise in deaths points to a need for intervention.

eaths caused by mixing elderly in clinical settings. coauthor. She notes that antide- prescription These results suggest that “more pressants or painkillers like Dwith alcohol or street research should be devoted to codeine can cause major prob- drugs—especially in patients’ middle-aged patients and domes- lems when taken with alcohol. homes—have increased dramati- tic settings,” write the authors. These results show that nurses cally over the past 22 years, Over the 22 years of the must more closely evaluate pa- according to findings from the study, services have shifted from tients’ ability to manage medica- first large-scale U.S. study of inpatient to outpatient care, tions, screen them more often out-of-hospital medication use. many drugs once administered in for alcohol and drug , and Researchers at the University hospitals are taken at home, and educate them more thoroughly. of California, San Diego, exam- more drugs once given only by Nurses “are in a good position ined nearly 50 million death cer- prescription are available over to give patients clear directions tificates filed between 1983 and the counter. All of these factors about drug use,” Barker says, 2004, focusing on those citing can make it easier for people to “and point out the dangers of medication as the cause of mix medications with alcohol or combining drugs or drinking death. Fatal medication errors street drugs—which many peo- alcohol with drugs.”—Carol overall rose 361% from 1983 to ple don’t know “can be a serious Potera 2004 and were classified into mistake,” says epidemiologist Phillips DP, et al. Arch Intern Med 2008; four categories: Gwendolyn E. C. Barker, a study 168(14):1561-6. • type 1: at home, involving alcohol or street drugs or both (rose a staggering 3,196%) • type 2: at home, not involving alcohol or street drugs (rose 564%) 8 Arab countries formed a nurses’ union at a July nursing conference in Amman, • type 3: not at home, involving Jordan, reported the Kuwait News Agency. Ten Arab countries were represented at alcohol or street drugs or both the conference. Mohammed Hatamlah, the dean of the Jordanian nurses’ union, (rose 555%) noted that Arab nurses of both sexes think nursing has enjoyed less progress in Arab • type 4: not at home, not countries than other disciplines have. The new Arab Union of Nurses will confront involving alcohol or street the profession’s problems in order to advance and regulate nursing in their countries. drugs (rose only 5%) By way of comparison, in the 8 New HIV and AIDS recommendations are available from the World Health same period deaths from alcohol Organization, which launched a guide, Priority Interventions: HIV/AIDS Prevention, or street drug use alone—not Treatment, and Care in the Health Sector, at the 15th International AIDS Conference combined with medication in Mexico City in August. Continual updates to the guide will reflect the latest recom- error—rose 41%, deaths from mendations. The authors intend the guide to help countries provide universal access to medication adverse effects rose HIV prevention and services by 2010. To print out a copy of the guide, go to 33%, and deaths from surgical www.who.int/hiv/pub/guidelines/2008priorityinterventions/en/index.html. error rose 43%. Increases in fatal medication errors were found in 8 Nurses’ bill of rights endorsed at AIDS conference. Recognizing that many nurses, all age groups except children especially those in developing countries, are at high risk for HIV, the Association of ages nine and younger. Adults 40 Nurses in AIDS Care and for Human Rights issued a joint call to action to 59 years old showed the great- at the 15th International AIDS Conference in August. Calling upon world leaders to est increase, whereas those older provide for the health needs of nurses and other workers and to enact than 60 showed the smallest. policies and programs to ensure the health and safety of nurses in the workplace, the Before this study, most research statement is available at http://actnow-phr.org/campaign/nurses_health_rights. on medication errors focused on [email protected] AJN M November 2008 M Vol. 108, No. 11 19 For HIV-Positive Mothers: To Breastfeed or Not to Breastfeed? New research supports it where other risks are higher.

hould HIV-positive mothers of infants born to 3,016 breast- reducing vertical transmission of living in underdeveloped feeding HIV-positive women in HIV, say the two studies under- Scountries choose optimal Malawi who were treated pro- score the belief that the odds nutrition for their infants by phylactically with antiretroviral favor breastfeeding for HIV- breastfeeding? Or should they risk drugs: the control group received positive mothers who otherwise malnutrition to minimize HIV a single dose of nevirapine plus would have no choice but to put transmission? Two recent studies zidovudine for the standard one- their infants at risk for malnutri- offer renewed support for breast- week treatment period, and the tion or from contami- feeding in “low-resource” areas. other two groups received the nated water or bottles. In one study, Kumwenda and control regimen for the standard “Here, in the first six months colleagues examined three groups week and further antiretroviral of life, the 4% to 5% transmis- for 14 weeks, one sion rate associated with HIV group with nevirapine and the isn’t that high compared with other with nevirapine and zidovu- the 8% to 9% of children dying dine. After nine months, the two of diarrhea and pneumonia, irre- groups on the extended regimen spective of HIV,” says Bland. had significantly lower rates of But in countries where infant postnatal HIV-1 infection (5.2% mortality rates are low, the bal- and 6.4% in the single- and dual- ance would favor avoidance of prophylaxis groups, respectively) breastfeeding. than the control group (10.6%). Denese Gomes, an NP at In the second study, Kuhn the Infectious Clinic and colleagues recruited 958 at Virginia Commonwealth HIV-positive mothers in Zambia University Medical Center in to determine whether the recom- Richmond, puts these findings mended practice of early wean- into context when discussing ing helps reduce postnatal HIV mothers in developed countries. transmission. One group (n = In the , she says, 481) was encouraged to wean “even if an HIV-positive woman their infants abruptly at four has an undetectable viral load at months; 69% stopped within the time of delivery, we don’t five months, most within two advocate breastfeeding. We have days of beginning weaning. The every resource in this country to other group (n = 477) was provide adequate and safe nutri- encouraged to breastfeed as long tion, so the risks of getting HIV l l e as they wanted; the median far outweigh the danger” of r r a

F duration was 16 months. No malnutrition or other infection. s i n e significant differences in HIV- Ultimately, says Bland, “there D

/ free survival at 24 months were is no blanket policy for every- s s e r

P found between the two groups one.” Clinicians tailoring recom- d e t (68% and 64%, respectively), mendations must take into a i c o suggesting no benefit in early account the potential for drug s s A weaning. resistance in both mother and Zelda Dlamini feeds her two-month-old baby Banele a bottle These results support efforts infant, their access to medical of formula at their home in Soweto, South Africa, on March 8. to develop guidelines for this care, and social norms.—Sibyl New U.S. funded studies indicate that the risk of a baby con- tracting HIV through breast milk is lower than the health risks of region. Marie-Louise Newell and Shalo, BSN, RN being denied its nutritional and protective benefits, particularly Ruth Bland at the Africa Centre in poor countries where mothers don’t have sure access to for Health and Population Kumwenda NI, et al. N Engl J Med 2008; clean water with which to prepare formula. 359(2):119-29; Kuhn L, et al., for the Zambia Studies in Somkhele, South Exclusive Breastfeeding Study. N Engl J Med Africa, whose work focuses on 2008;359(2):130-41.

20 AJN M November 2008 M Vol. 108, No. 11 http://www.nursingcenter.com Eye Contact and Study links reduced eye contact with social disability in autistic children.

uring the first few months of life, infants focus on Dthe faces of their care- givers, learning the cues of social interaction through eye contact. But children with autism tend to focus less on the eyes, suggesting that they learn a different means of socialization early on. t s

In a study conducted by the o P m

Yale Child Study Center in New i T ,

Haven, Connecticut, researchers o i d a

attempted to determine whether R c i l

the amount of eye contact made b u by children with autism was dif- P a t o s

ferent from that of other children e n n and whether that measurement i M could be used to predict levels of / s s e social disability. Among 66 two- r P d e year-olds studied, 15 had autism t a i c

or autism spectrum disorder, 36 o s s were normally functioning, and A 15 had developmental delays Caitlyn Wheeler, right, takes part in an exercise intended to help kids with Asperger’s that did not include autism. feel more comfortable with eye contact in this photo (date unknown). Kids with Asperger’s don’t The toddlers were shown 10 have problems with language like those with more serious forms of autism. For them the chal- lenges are more social in nature. They have a hard time understanding body language and short videos of actresses looking facial expressions. They tend to avoid physical contact. And they prefer not to make eye contact. into a camera and engaging them in games like pat-a-cake and peek- a-boo. Eye-tracking equipment, including a camera programmed than did the other children. “Babies learn a great deal by ex- to pan and tilt in response to a Autistic children also focused ploring the world with their eyes,” child’s movements, gauged where more on the women’s bodies and says Warren Jones, a study coau- the children were focusing: on the on other objects. There was a sig- thor. “If they are actively seeking eyes, mouth, body, or objects. The nificant correlation between fixa- out nonsocial interaction, they are researchers found that autistic chil- tion on the eyes and social ability: going to develop along a different dren spent 24% less time focused children who focused less on the pathway.”—Tammy Worth on the women’s eyes and 14% eyes than their counterparts were Jones W, et al. Arch Gen Psychiatry 2008; more time focused on their mouths more socially impaired. 65(8):946-54.

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ÄNo Medicare reimbursement for three more preventable hospi- ÄA new voice for nursing quality and safety? tal conditions. The Centers for Medicare and Medicaid Services The Department of Nursing Education at the George named three new categories of preventable hospital complica- Washington University School of and Health tions—conditions resulting from medical error or improper care— Sciences is embarking on a 12-month project to gauge for which it will no longer reimburse hospitals; eight such compli- the interest in an organization specifically dedicated to cations were named last year. This year’s new categories are improving the quality and safety of patient care; it would • of surgical sites after elective procedures, such as be called the Nursing Quality and Safety Alliance bariatric and some orthopedic procedures. (NQSA). With support from the Robert Wood Johnson • pulmonary embolism or deep-vein thrombosis after hip Foundation, the school will convene representatives from replacement or total knee replacement. major nursing organizations and others to explore the • some symptoms of poorly controlled blood glucose levels. feasibility of such an alliance. For information, contact The policy went into effect on October 1. Ellen Kurtzman: [email protected].

[email protected] AJN M November 2008 M Vol. 108, No. 11 21 Maternal Diabetes and Birth Defects Poor glucose control may increase risk.

he link between diabetes dren with birth defects as the to the study authors, the associa- and birth defects is not general population. But as a tions of defects to gestational dia- T completely understood, woman’s glucose levels climb, so betes “were weaker and generally but good control of glucose lev- does her risk of having a child limited to offspring of women els appears to play a large role in with birth defects. with a prepregnancy” body mass prevention. Pregestational diabetes. Wo- index of 25 kg/m2 or higher. The Researchers from the Centers men who gave birth to children authors think it likely that many for Disease Control and Preven- with any birth defect were three of these women had undiagnosed tion examined nearly 18,000 times more likely to have pregesta- pregestational diabetes. records from the National Birth tional diabetes, and those who had According to coauthor Adolfo Defects Prevention Study (4,895 babies with multiple defects were Correa, the study results are “a control subjects, and 13,030 cases more than nine times more likely call to action . . . to improve of children with birth defects) in to have pregestational diabetes. access to preconception care for an attempt to understand the Gestational diabetes. Although women with pregestational dia- impact of maternal diabetes on a women who had children with betes, especially those who are wide range of birth defects. Their birth defects were about 1.5 times obese or overweight.”—Tammy study found that diabetic women more likely to have gestational Worth with good glucose control have diabetes, weight may play a large Correa A, et al. Am J Obstet Gynecol the same chance of having chil- role in that outcome. According 2008;199(3): 237.e1-237.e9.

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ÄExtensively drug-resistant tuberculosis was cured in ÄA ketogenic diet reduced or eliminated seizures among 60% of 48 Peruvian outpatients, according to a report in children with epilepsy as a result of focal malformation of the August 7 issue of the New England Journal of cortical development, reported the journal Pediatrics in Medicine. None of the 48 patients had HIV, and all August. A total of 47 children (average age, 47 months) received personalized regimens—typically, high doses of who were candidates for epilepsy surgery were first five drugs that researchers judged to be most appropri- treated with the classic ketogenic diet: high in fat, with ate. Most regimens lasted more than two years. adequate protein, and low in carbohydrates. Those Adherence was high because of daily supervision by who showed progress at a three-month evaluation health care workers, who also managed any adverse remained on the diet for two years. At the three-month effects. In addition, more than two-thirds of the 603 evaluation, the seizure frequency in 29 (62%) of the patients with less serious multidrug-resistant tuberculosis children had decreased by more than half—including were cured. 21 (45%) who were seizure free. Of those, 16 remained seizure free after two years on the diet, and nine com- ÄTopical lidocaine relieves the pain of mammography, pleted the diet and stayed seizure free over nearly four a study published in the September issue of Radiology years of follow-up. found. Comparing the use of 4% lidocaine gel (Topicaine) with oral acetaminophen or ibuprofen about ÄInhaling mannitol improves lung function in patients 60 minutes before a mammogram, researchers found with cystic fibrosis, the journal Chest reported in June. that women who applied the gel reported significantly The 39 subjects received two weeks’ treatment with less discomfort; the oral medications brought no pain twice-daily fine-particle active mannitol or placebo; after relief. And the gel did not impair the quality of the a two-week washout, the study arms were reversed. image. Because lidocaine gel is water-based, women Forced expiratory volume in one second increased by an can apply about one ounce at home an hour before their average of 7% in those receiving mannitol, a sugar alco- appointment, then remove it just before the procedure hol that draws water into the airways to help clear the with a wet washcloth or paper towels. thick mucus produced in cystic fibrosis. M

22 AJN M November 2008 M Vol. 108, No. 11 http://www.nursingcenter.com FROM THE NATIONAL INSTITUTE OF NURSING RESEARCH What’s Behind Heavy Bleeding in Early Menopause? Hormonal changes do not appear to be the cause.

hanges and irregularities in the men- urinary hormone measurements to self-reported strual cycle and the amount of bleeding and other clinically measured characteristics of are perceived to be the norm as women 804 women, including demographics, menstrual transition to menopause, but they can calendars (tracking cycle duration and intervals also be indicative of health problems, between cycles) and estimates of bleeding, medical Cincluding endometriosis, fibroid tumors, and conditions, and body mass index (BMI). malignancy. While it’s generally accepted that Results of the analyses indicate that although both changes in hormone levels are associated with short and long cycle durations were significantly anovulation and changes in the duration of the associated with hormonal indicators of anovulation menstrual cycle, an association between changes in (as was intervals between cycles), heavy bleeding was hormone levels and the amount of bleeding during not. However, there was a significant relationship menses hasn’t been confirmed. between heavy bleeding and both a BMI greater than In the Daily Hormone Study, researchers or equal to 30 and leiomyomata (smooth muscle hypothesized that changes in the timing and neoplasms such as uterine fibroids). Researchers also amount of bleeding in early menopause would noted a positive association between diabetes and have a detectable hormonal basis. In order to long cycle intervals. These findings suggest that study the fluctuation and variation in daily hor- health care providers who encounter perimenopausal mone levels in midlife women, researchers evalu- patients with heavy menstrual bleeding shouldn’t ated a subset of women (ages 43 to 54 years) assume it to be the result of changing hormone lev- drawn from the Study of Women’s Health Across els; instead, they should consider uterine lesions and the Nation, a multiethnic, longitudinal study of obesity as possible causes. 3,302 midlife women. Researchers compared daily Van Voorhis BJ, Obstet Gynecol 2008;112(1):101-8.

NEW FROM THE CDC The Hazards of Hospital Employment A new brochure helps nurses handle problems related to stress.

oo heavy a workload, understaffing, and time in nurses, including exposure to infectious , T pressures are three of the many factors linked to needlestick , exposure to work-related violence or among nurses who work in hospitals. threats, , and dealing with difficult or Depression and anxiety from job stress are common seriously ill patients—to name but a few. among health care workers, and rates of substance abuse A new brochure from the Centers for Disease Control and and suicide may be higher in health care than in other Prevention aims to mitigate some of that stress. Exposure to fields. The stress of working in health care can also be Stress: Occupational Hazards in Hospitals specifies sources seen in high rates of burnout, staff turnover, absenteeism, of on-the-job stress, lists many of the adverse health effects rates of errors, and dissatisfied patients and families. of occupational stress, and recommends work practices that There are many factors in addition to work overload, can reduce occupational stress. For more information, go to understaffing, and time pressures that are linked to stress www.cdc.gov/niosh/docs/2008-136. M

[email protected] AJN M November 2008 M Vol. 108, No. 11 25