Michael Douglas: Raising awareness about HPV and Oropharyngeal Cancer

Michael Douglas recently raised our awareness about the risk of Human Papillomavirus (HPV) infection leading to oropharyngeal cancer.  HPV is a common Sexually Transmitted Disease (STD) – here is a link to some information about HPV: http://www.cdc.gov/hpv/whatishpv.html.  HPV can lead to both minor and major health problems, including warts on the hands or feet, genital warts, and cancers.  There are more than 160 types of HPV – over 40 of which are transferred by mucosal or genital transmission, of these 40, two are responsible for most of the cancer risk, HPV 16 and HPV 18, including cervical, anogenital and oropharyngeal cancers (Saraiya,2013).  Information on HPV-associated cancers can be found here: http://www.cancer.org/ and on oropharyngeal cancer here: http://wwwnc.cdc.gov/eid/article/16/11/10-0452_article.htm.  

It is laudable that Douglas would disclose this, particularly given the stigma related to STD’s.  He raises awareness of the risk of this STD to individuals (like middle aged and older adults) who may not consider themselves at risk from exposure to HPV decades earlier.  Unfortunately little can be done to detect this form of cancer early.  Here is a useful guide from the American Cancer Society related to oropharyngeal cancer: http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/index

Michael Douglas at the Vanity Fair party for the 2012 Tribeca Film Festival; by David Shankbone, 4/17/2012. (Use of this photograph does not imply endorsement of the author or the ideas shared)   Image from: http://en.wikipedia.org/wiki/File:Michael_Douglas_VF_2012_Shankbone.JPG

Douglas’ acknowledgement of the possibility of his cancer being linked to sexual activity and HPV transmission has naturally raised the question of what should be done about this risk? Men are at much higher risk of developing oropharyngeal cancer from HPV than women.  Should we screen all men for HPV like women are screened with pap smears to reduce cervical cancer risk?  Unfortunately there are difficulties to screening for this type of cancer.  Here is a video by the New York Times discussing some of these concerns: http://www.nytimes.com/video/2013/06/10/health/100000002273386/a-collective-gulp.html?smid=pl-share

While screening programs are common and they are usually viewed as only good – there are actually down-sides to screening – for example what happens when it is very difficult to detect the presence of the HPV virus (HPV-16 or HPV-18) that leads to throat cancer?  What if attempting to detect the presence of a virus to prevent its eventual turn to cancer actually has dangers to the individual?  Particularly in a situation where the rate of cancer development from this virus is low?  For example, although nearly everyone who is sexually active will acquire HPV, most virus types are not cancerous – and cancers are rare even in those infected with high risk HPV types (HPV 16 and 18), requiring persistent infection (Saraiya, 2013).  There were an average of approximately 32,000 new HPV-associated cancers identified between 2005 and 2009 in the US, of which 20,000 were identified in women (89% genital cancers), while 12,000 were identified in men (78% were oropharyngeal ) (Saraiya, 2013).

Similar to other screening programs, we should be judicious in use of societal resources to identify disease – it is difficult to weigh the risks and benefits of screening because not all diseases are simple to detect, and often our methods of detection are less than perfect – leading to many individuals who test positive for a disease by a not-so-good screening method to initially believe they have cancer only to find out later it was a false-positive result.  This of course is true in mammography where women often have lumps that require follow up ultrasound or biopsy – which then pushes the woman into a limbo of fear of actually having breast cancer – only to find out later it was an innocuous lump.  Depending on the type of lump found, some women undergo lengthy periods of heightened screening– leading to anxiety and greater exposure to ionizing radiation – however this screening is of great benefit when the risk of disease is high. 

While early identification and treatment of disease are important goals for our health care system, the actual ability of providers and detection methods to deliver this result is often limited by the lack of research and technology to accurately detect the disease.   In the case of HPV there are immunizations that prevent infection, however evidence is not yet available that these vaccines are effective in those who are already infected – this is one reason why the immunization focus is on youth who are not yet sexually active- it is hoped that most infections with HPV 16 will be prevented in the future, thus eliminating risk of cancer from this infection.  With continued research we will accumulate efficacy data from immunization.  Hopefully someday we will also better understand how to prevent cancer in those with acquired HPV infection  and also have better methods for early identification of the infection before the cancer occurs.

References & Links used to prepare this summary:

Saraiya, M. (2013). Public health importance of human papillomavirus infection and disease. CDC: Division of Cancer Prevention and Control. Accessed on 6/11/2013: http://www.cdc.gov/about/grand-rounds/archives/2013/pdfs/GR_HPV_Feb19.pdf

http://www.cdc.gov/hpv/whatishpv.html

http://www.cancer.org/

http://wwwnc.cdc.gov/eid/article/16/11/10-0452_article.htm

http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/index

http://www.nytimes.com/video/2013/06/10/health/100000002273386/a-collective-gulp.html?smid=pl-share

Nursing the Mentally Ill in Soweto, South Africa

I am pleased to introduce readers to Carmen Rivera, a nurse with interest in forensic nursing and violence prevention.  Carmen has a BS in Nursing and has discovered a love for writing... and is currently a freelance writer who is passionate about issues concerning mental health and how they affect communities worldwide.  Please email if you ever want to discuss the article:

Nursing the Mentally Ill in Soweto, South Africa  by Carmen Rivera

Nearly 20 years after the end of apartheid, the Soweto neighborhood of Johannesburg, South Africa, remains a striking relic of the country’s unequal, separatist past. Originally established as an urban district for mining workers and blacks evicted from the city, many Soweto residents still live in poverty, suffering from the remnants of institutional racism imposed by apartheid government.

Recently, two sexual assaults occurred in Soweto, which shed light on an alarming kind of discrimination and something not typical discussed outside of the confines of forensic nursing programs: discrimination against the mentally disabled. In April of 2012, seven Soweto teenagers were accused of gang raping a mentally disabled girl. Video of the attack was recorded on a cell phone then posted on the Internet. Shortly after that, two Soweto females were arrested and accused of raping a mentally disabled 17-year-old boy.

This disturbing trend illuminates a larger problem of sexual abuse rates and the historical oppression of the mentally disabled in South Africa. These attacks also highlight systemic problems that plague forensic investigations, education programs and ensuring victims’ allegations are adequately heeded by authorities. While forensic school programs are advancing with every class of students, there are still areas in which they can improve, something prevalent in these cases.

A 2009 study conducted by South Africa's Research Council concluded that one in four South African men admit to having sex with a woman without her consent, while 46% admit that they have done it more than once.

Until 2002, many of South Africa’s mentally disabled were involuntarily committed in psychiatric facilities as per apartheid-era legislation. Their treatment dates to the Mental Health Act of 1973, which was enacted after a mentally ill gunman assassinated Prime Minister Hendrik Frensch Verwoerd. The mobilization of this Act relied heavily on the precepts of fear to strip the South African mentally disabled of the rights given to other South Africans.

Legislation enacted in 2002 aims to right the care of the mentally disabled by drastically reducing the amount of involuntarily committed patients, essentially downsizing state-run mental hospitals. To accommodate discharged patients, the legislation seeks to provide mental health screening and treatments as part of primary care, as well as implement community-based mental health programs, both of which emphasize the role that nurses play in caring for the mentally disabled. An additional provision of the bill seeks parity in providing black and low-income South Africans, many of them based in Soweto, with better access to mental health care.

As of a 2007 study conducted by the World Health Organization, the outcome of the deinstitutionalization of mental health treatment has achieved few of its initial goals. Poverty, lack of transportation and the social stigma associated with mental disorders has all provided a serious challenge for nursing the mentally disabled.  The two rape cases previously discussed provide further insight into the intolerance of the mentally disabled culled from 30 years of indignity.
Sexuality in Africa magazine links the high instances of sexual assault in South Africa to nationwide gender discrimination and a history of violence. The Soweto rapes further illustrate the use of sexual violence as a means of asserting dominance against a marginalized group, the mentally disabled.

In addition to health care reform, the South African government has taken steps to address the high rates of sexual assault within the country. The Domestic Violence Act 116 and the Bill on Sexual Offences both seek to more strictly define and prosecute perpetrators of sexual assault. Additionally, several South African-based non-governmental organizations—many of them staffed by volunteer nurses—have been established to assist victims of sexual assault while promoting prevention. Still, the reporting rate of sexual abuse remains low, and many victims do not receive the care that they need.

Nursing Soweto’s mentally disabled provides a necessary step to the prevention of sexual assault and other violent acts against South Africa’s mentally disabled. As access to community-based health care and stricter prosecution of perpetrators of sexual abuse progress in South Africa, Soweto’s mentally disabled will be better protected from these disturbing acts of aggression and violence.

UN work on Human Rights

I was lucky enough to visit the United Nations yesterday with a group of colleagues and students from Sigma Theta Tau.  We toured the building (which I haven't been in since I was in 7th grade!) and also attended two briefings. I am thankful to my colleague Dr. Jerri Marrocco (here is a link to her faculty web page) http://nursing.yale.edu/marrocco who arranged the visit for our group.  I am so pleased to have met Dr. Holly Shaw who leads Sigma Theta Tau's program that is working on global human rights issues. This link provides an overview of our Honor Society's work in this area, which has developed under Holly's leadership. http://www.nursingsociety.org/GlobalAction/UnitedNations/Pages/STTIandtheUN.aspx  This project is one excellent example of why I really like STTI as an organization.  Their perspective is broader and less myopic than many organizations which often seem to have a myopic focus on nurses only.  This is very important work and I am hoping to offer service related to these issues in the future. Here is a summary of ways we all can make a difference in these efforts:  http://www.nursingsociety.org/GlobalAction/UnitedNations/Pages/MakeaDifference.aspx

Dr. Shaw arranged a briefing on the status of women globally and one on work to eradicate child labor.  We had wonderful and knowledgeable speakers who shared their global perspective and experiences on working in these areas.  It was inspiring.

In addition it was disturbing.  Despite the fact that we are among the leaders of developed nations, I realized that even we will not meet the UN's millenium goals... the first of which is to eradicate poverty and hunger.  here is a link to the goals so you can learn more about them.  http://www.un.org/millenniumgoals/poverty.shtml
I hope they inspire you to work for change in these important worldwide problems.

Respect for the Rights of Individuals with Mental Health Problems

Just left a very interesting class discussing psychiatric advanced directives...
We discussed an article by Swanson (2008) evaluating whether individuals with Psychiatric Advanced Directives (PAD's) had reduced risk of coercive crisis interventions.  (here is the reference to the article: Swanson, J., Swartz, M., Elbogen, E., Van Dorn, R., Wagner, H.R., Moser, L., Wilder, C., & Gilbert, A. (2008) Psychiatric advance directives and reduction of coercive crisis interventions.  Journal of Mental Health, 17, 255-267.)  The short answer was yes... completing the psychiatric advanced directive may reduce coercive interventions... you may want to read the article.

This article also finds at baseline high rates of lifetime prevalence of being placed in handcuffs (41.8%) or transported by police to treatment (67.8%).  Rates of involuntary commitment were 61% and use of physical restraints was 37.7% in their population...  Nothing to be very happy about there.  (reminds me of my last post...!)

More importantly, what is your experience with PAD's?  Do your patients come to you with them?  Do you ask if they have one?  Many states require them and some have very specific requirements.  I would love to hear more about the 'reality' of them.

In my view they set a frame for partnership of individuals with their care providers.  What an important discussion to have.  It seems setting the stage for this kind of work together is very important and provides a sense of respect and dignity to individuals we work with.

Tell me what you think!

Traumatic Experiences in Psychiatric Settings

A colleague shared an article with me this week which reports that a large proportion of patients experience trauma or traumatic events from psychiatric care in the public setting. The study looked at a sample of 142 randomly selected patients in a day hospital program.  It asked them what kinds of experiences they had during their treatment in the public mental health system. The study used the Psychiatric Experiences Questionnaire (PEQ) which was designed to query about experiences specific to psychiatric settings such as aggression, seclusion, restraint, sexual assault, and forced medication.  Some interesting results:
-65% had been handcuffed and transported in police cars (an average of 3.4 times!)
-54% reported having been around other patients who were very violent or frightening  (an average of 7.2 times!)
-39% witnessed one patient being physically assaulted by another patient
-34% had been put in some kind of restraint (an average of 2.9 times)
-24% had been strip searched (an average of 2.7 times)

This is very disturbing.  However I can't say it is surprising.  We tend to follow tradition of a variety of practices over time in the psychiatric setting.  These practices (seclusion, restraint for example) may or may not be therapeutic.  I believe they are carried out to maintain safety (or I want to believe that).  But unfortunately we see that in fact they are traumatizing the people we are actually intending to treat!

How do we change this?  For example, is it really necessary to strip search patients? Might we either use some other method, or distinguish when or if searching is needed?  Aren't wands available to detect weapons?  If you aren't a suicide risk must we search for pills, razors and other contraband?  Or if we do search people, how can we do it in the most sensitive, private and non-intrusive manner?  I do realize that people do attempt to 'smuggle in' a variety of things.  But it seems in the majority of cases this is not a problem.  I think over 3 years working inpatient, I found only 1 or 2 situations that this happened out of hundreds. 

How many of these experiences would be prevented if we turned the system upside down and instead of treating everyone as if they cannot be trusted we actually treated people with a sense of trust? It seems we are attempting to control for the very rare events that occur by controlling everyone and everything (i.e. a patient swallows a staple from the bulletin board, so no staples allowed; or a patient tries to break a light bulb to electrocute themselves so we encase all lights - and end up with a dim environment).  You only have to look at research on what is considered 'contraband' on units to see how variable and really ineffective many of these practices are.  All patients suffer/are treated as if they are not able to be safe and responsible because a few are unsafe. 

As for handcuffing patients, I can't imagine when or why this is really needed.  Must we treat people as if they are criminals and cannot be trusted?  I have seen patients transported by law enforcement in this way.  It is often justified by a concern that the person will jump out of the vehicle and try to escape or kill themselves.  Again, how many cases really involve this risk?  Don't the vehicles have locks you cannot open?  Can't we come up with a better way?

Unfortunately the violence in the setting - patients assaulting one another, staff and patient physical altercations -which judging from this study patients perceive as staff assaulting them - is a major problem.  This will not be easily tackled.  Maybe culture change is in order.

Recently we have seen the growth of the 'comfort room'.  This is a fine idea and way to replace the seclusion room... but why aren't entire units 'comfort units'?  Must it only be one room where you can find quiet, privacy, relaxation.  Why wouldn't we design the entire unit around this concept? Isn't that truly what our patients need?

I was in Europe recently and in the UK patients now have private rooms.  This allows them some space and privacy when needed.  What a brilliant idea!  If a patient is grossly psychotic and responding to internal stimuli must they be in the middle of the busy day room?  Wouldn't we expect this to make them worse and more overstimulated?  Is it surprising that others would find them frightening and fear their presence at times? 

Of course some will say if we did any of these things all kinds of unsafe mayhem would prevail.  I can't say that there would not be risk.  We would need to do our job of assessing and therapeutically working with patients very well.  Would any of us complain about that?  

However I suspect that in many settings unsafe events occur regardless of the rules promulgated on how searches are done, where patients can and can't be, etc.  Isn't that how we come up with new rules... and so the cycle goes on.

Maybe we need a better separation of settings in terms of who is safe to be where with what and then a system of procedures that follows this...

It just seems to me that if we had a truly comforting and therapeutic environment we would be starting from a basis of treating people more humanely.  From there we might find we are more able to appeal to the healthy aspects of the individual who does have some wish to get better.  Maybe those most unsafe and immediately at risk are managed in a 'safer' area - with greater degree of environmental controls (but still comfortable and comforting- not a cell)- this would create a dynamic of wanting to be out in the more comforting less controlled areas... which if managed carefully and therapeutically would encourage patients to be more responsible for keeping themselves safe... And just imagine instead of assigning people to run around and get patients belongings that we keep locked up or simply denying use of (and making them angry and frustrated... which then starts that cycle...), we could spend those extra minutes talking with our patients so we are aware of and in touch with the individual needs of each one.  Spending more time on 'controlling things' does result in less time to be therapeutic.  I do think we have a lot of work to do in mental health settings.  I know a lot of
clinical workers who agree with this and would love to be engaged in redesigning how inpatient mental health care is provided.  Why aren't we doing that?  If you are, tell me and tell us how you got there and what you are doing?!

If we start by wanting to treat our patients as equal human beings, and respecting their needs, I think we would be moving in the right direction. I sincerely believe that most workers totally agree with this and in the majority of cases follow through on this in their day to day work... The problem is that our unit and organizational cultures do not support this.  That is a difficult problem to solve... but one that we desperately need to address. 

That study shows how inhumane treatment can really be.  Unfortunately it strikes home that it is not uncommon.  I encourage you all to review the article (it is not new - although I have never seen or heard of this study previously).  You would think this study would have called for a tidal wave of change in how things work in the inpatient psychiatric setting... (as well as all psychiatric settings...)  I can't help but think that stereotype and stigma again victimize our most vulnerable patients and that is why there wasn't a tidal wave of action on learning these results.

Here is the reference if you are interested in reviewing the article for yourself...
Frueh, B.C., Knapp, R.G., Cusack, K.J., Grubaugh, A.L., Sauvageot, J.A., Cousins, V.C., Yim, E., Robins, C.S., Monnier, J., Hiers, T.G. (2005). Patients' reports of traumatic or harmful experiences within the psychiatric setting. Psychiatric Services, 56, 1123-1133.
Here is a link - I hope it works!  http://www.annafoundation.org/Patients%20rpts%20of%20trauma%20or%20harm%20in%20psychiatric%20setting.pdfh
 or try this one...
http://ps.psychiatryonline.org/article.aspx?volume=56&page=1123

Defective equipment and worker safety

I received a letter today from Janssen pharmaceuticals regarding problems that have been identified with the syringes used with risperdal consta.  The problem is that the needles can detach during use.   I was pleased to be notified of the problem, and naturally thought the rest of the letter would identify how they had re-engineered the syringe to eradicate the problem. 

I was initially pleased that the company had even gone so far as to be transparent in informing healthcare professionals about the problem.  The problems include:

• the needle could fall off before, during, or after administration, 
• the needle may remain in the arm after withdrawal of the syringe. 
• detachment resulted in several workers being stuck with a contaminated syringe.  

Luckily none of these needle stick injuries have resulted in transmission of HIV or hepatitis... At least not yet.

Imagine my dismay when I read the rest of the letter, which explained the procedure to follow to avoid or reduce the chance of needle disengagement during preparation or administration of the injection! 

There is something wrong with this picture!

Why not package the shot with a safer more reliable syringe-needle attachment?!  The best way to deal with an occupational safety problem is to universally protect workers... in this case by re-engineering of the needle-syringe (remember that hierarchy of controls?).  

I am deeply disturbed that hundreds or maybe thousands of nurses everyday place themselves at risk of a needle stick injury while doing their job.  Isn't there something wrong with this? I think these types of syringes are used in many settings.  What are they thinking?  (by the way - I recognize that it may not be Janssen that manufactures the syringe/needle used -but they are requiring us to use the system to be able to reconstitute and prepare the injection)

I have actually read and re-read their directions several times in the past.  I have always been left to wonder whether this new safety covered needle is really worth the effort?  If you look at the drug information leaflet (http://www.janssencns.com/shared/pi/risperdal/risperdalconsta.pdf) you can see the 'simple' 17 steps involved in preparing the injection!!!  

Doesn't the addition of this new risk move the equation to the side of not worth the effort? 

Am I alone in thinking this was a misguided attempt to use the current technology despite evidence of a problem?  Is the device really that much better than others available?

Am I supposed to inform my patient that there is a risk of the needle remaining in his arm after I withdraw the syringe? This is a risk of the procedure, should it be part of consenting?  Unfortunately that may not happen often given that the reason we use injectable depot antipsychotics is to improve adherence in that group of patients who are not as interested in staying on the medication or don't actually want to take it every day.

Again, what are they thinking?  Can anyone provide a reality check for me on this subject?

If HIV had been transmitted would that change things and promote the withdrawal of a poorly designed and manufactured syringe-needle product? 

Could they perhaps try a little harder to fix the needle disengagement issue?

Actually, I remember using similar needles in the past, with detailed directions on how to 'correctly use' the  syringe.  I think I recall a flu shot clinic many years ago as well as other pre-filled type syringes where this can happen.

I have had the experience of the needle remaining behind in the patients arm... Not a very happy moment in my practice experience. I am pretty sure that was the last flu shot that person ever came in for.  Luckily I did not get stuck while removing the needle from the patient's arm - and miraculously the patient allowed us to perform the procedure again (with a different syringe and needle). 

So if this is both a patient and worker safety problem, why isn't it being fixed?  I would think the risk of HIV or hepatitis transmission would be a great enough risk that someone would push for recall of the device?

I would love to hear what all of you think about this!

Higher Mortality Rates in Homeless, but not in Psychiatrically Ill Adults

In a recently released study, Nielsen et al (2011), identify mortality rates of those who are homeless in Denmark. As one might expect, the rate of mortality in those who are homeless is 5.6 to 6.7 times higher (SMR = 5.6 for men and 6.7 for women) than that of the general population. Death risk was even higher when the individual had a substance abuse problem. However this points out another inequality in society, directly illuminating the health disparities for those most vulnerable. The homeless population is of course more likely to have a psychiatric disorder. In this study 58% of homeless men and 62% of homeless women had a prior psychiatric disorder diagnosis. Most surprising was that those with psychiatric disorders were not at higher mortality risk than those without a psychiatric disorder.


This is quite interesting, as offhand I would think that the psychiatrically ill would be at greater mortality risk when combined with homelessness. This study suggests that the factor of import may be the socioeconomic disparity and vulnerabilities associated with being homeless NOT the mental illness or its treatment (i.e. drug side effects like metabolic syndrome). Of course I will need to more closely review the study and its design… and in Denmark there are wonderful data sources available to be able to determine rates like this in the homeless population. In the US we have a very difficult time trying to determine rates due to the homeless population being disenfranchised from any system of care.

Here is link to a report of the study and the reference for the study too!

http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/27048?utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&userid=230719
 
Nielsen SF, et al "Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study" Lancet 2011; DOI: 10.1016/S0140-6736(11)60747-2.
 
JGeddes JR, Fazel S "Extreme health inequalities: Mortality in homeless people" Lancet 2011; DOI: 10.1016/S0140-6736(11)60885-4.

50 worker's lives at risk: The Fukushima 50

I saw the wife and small child of one of the nuclear power plant workers on the morning news today.  I can only imagine the fears and anxiety associated with having a loved one in this situation.  I am sure many share the same feelings I do in terms of the courage and bravery of these workers, who are daily putting their lives at risk to prevent even greater disaster than has already been experienced. Here is a link to the news story:
http://today.msnbc.msn.com/id/26184891/vp/42207681#42207681 

I imagine these workers have already been exposed to high levels of radioactivity while at work securing these plants.  They are literally risking their lives for those in the area of the plant, as well as society at large.

I always find it disturbing when workers are put in harm's way to earn a paycheck.  Regardless of the fact that they get paid and in some dangerous jobs they may earn extra pay due to the great risk involved, it seems hard to imagine that trade off. I often worry that decisions like this are made without full understanding of the risk.... Or perhaps without other options?

More disturbing is that this man-made industry is of course capable of catastrophic disaster.  Despite systems of safety procedures developed and strict standards and requirements to protect the public.  We only need to consider the 'disaster of the moment' to realize that despite the perception that we can control things with rules and requirements, things do go wrong...earthquakes and tsunami's are possible.  Terrorist attacks (and yes, unfortunately on US soil) are possible.  Terrible mistakes, accidents and weather events are possible.

We would like to think we are civilized and mostly in control of what happens.  Yet we are every so often reminded of our own helplessness and vulnerability.  As with risks of other rare events- we do not think about these risks in a regular way and often are struck by the possibility only when confronted by a one in a million event.

I think each of us identifies with those workers.  We have all had the experience of loyalty or devotion to a job or role.  Or a sense of duty or responsibility for getting a job done.

Do they continue today at work for the paycheck or the extra bonus due to the risk?  I doubt that.  I suspect they sacrifice their own safety for the others they protect outside of the plant walls... The wife and child I watched today, anxiously awaiting their safe return.  I suspect the paycheck is low on their priorities now.  I suspect their employer is also not high on their list either.

To those workers and to all workers who risk their own safety for the greater good... We are all indebted to you.

Most of us have the luxury of allowing work to be 'only a job'.  We are never faced with such decisions.  Hopefully those of us who don't risk our lives aren't part of the reason these workers may pay with their lives.

I consider the individuals reassuring us of safety when there are unanswered questions or they really are not sure.  No one really can be sure of safety in all circumstances.  Do business priorities sometimes encourage risks to be taken or safety standards or concerns to be overlooked?  When faced with a tragedy like this I wonder why didn't we imagine the possibility of a situation like this?  Why didn't we imagine the oil spilling into the gulf last year...  Competing interests sometimes do not result in good decisions for society.  A reason we have standards and oversight and why money or profit as a driver is not always a good thing.

I hope we all very carefully consider the responsibilities we carry out that do affect the health and safety of others. If only we could act as bravely and courageously in protecting society as those 50 workers are.  I would like to believe they would not risk other's safety for profit.

Here is another view on the story...
http://www.telegraph.co.uk/news/worldnews/asia/japan/8393018/Japan-nuclear-crisis-Fukushima-Fifty-cut-off-from-family.html

Should we ban football and other sports with a high likelihood of injury?

Medpagetoday has a survey about football and whether or not it should be banned. Should it be banned? Here is the link: http://www.medpagetoday.com/Surveys/ Maybe you should register your vote.

I know there was an article in the paper in the past few weeks about a prominent medical examiner who suggested football be banned for those under 18 years. (Here is a link to the abc news report: http://abcnews.go.com/Health/chicago-bears-football-player-dave-duersons-suicide-renews/story?id=13003593 )

I’ve blogged before about the use of protection (mouthguards) and their role in prevention of injury (here is the link –it was a while ago…. http://mentalnotesbyjoanne.blogspot.com/2009/09/sports-and-risks-of-concussion.html --you will see some comments from one of my very knowledgeable and bright students as well). I am not clear however on the remaining risks despite use of much protective equipment.

Here is an interesting article –written in 1977 – by a chiropractor who suggested way back then that there should be a switch from football to soccer. He made the suggestion based on his experience treating up to 1/3 of those playing in his local football league… http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2378736/pdf/canfamphys00306-0030.pdf His rationale is based on not only the often serious spinal, ligament and muscular injuries he treated, but his belief that soccer is a better cardiovascular conditioning sport.

Some of the comments on the medpagesurvey also suggest that youth are encouraged to ‘bulk up’ for the team, potentially adding cardiovascular risk to the list of other health hazards.

I must admit, other than being an occasional football spectator, I know little about the sport and its culture. As an outsider it does seem to be one of the sports where brute strength and physical contact are the norm, and the crowds seem to love to see the physical contact and a great brawl… (although other sports also have these qualities).

There is also a culture in athletics today where children are involved in both school and recreational athletic programs. If a child has talent, they can belong to an ‘elite’ team. It is quite an industry today that I don’t think existed in the past. I think it is common also for parents to partially live out their own athletic dreams in the performance of their child. At what point is society going too far? At a recent athletic competition I was very aware of the wrist, ankle and other splints being worn by the athletes. I’ve watched children ‘shake off’ an injury and continue in competition… is this a good practice?

I think we have much better data today about the problem of injury and long term health consequences in sports. Here is a blog written by a neurologist, who speaks to the long term effects of hitting your head that does not result in a concussion. The result is Chronic Traumatic Encephalopathy (CTE) – previously known as dementia pugilistica. http://www.psychologytoday.com/blog/neuro-atheism/201102/ban-football As Dr. Weisman so aptly notes, we are not measuring the regular head blows that occur in this or any contact sport. So we underestimate exposure all the time! A positive currently is that we are much more focused on the identification and treatment of concussion– a step in the right direction, but one that does not necessarily resolve the problem.

As a scientist and a parent, I am concerned about sports injury. I am deeply disturbed that many children enter adulthood with chronic injuries that they will live with forever. In the case of head injury, my concerns are of course deepened. Football is not alone… many sports share very high risk of injury and athletes, parents, and coaches must consider and reconsider this dilemma.

Happiest Places to Live List! (or best and worst places to live?)

Gallup just reported on their "Gallup- Healthways Well-Being Index" from 2010. This was a telephone survey (yes think of the ramifications of that...) which measures 'well being'. Areas of well-being included self evaluation, emotional health, work environment, physical health, healthy behavior and basic access to care, exercise and community life. Here is a link to the story:
http://www.livescience.com/13100-happiest-states-gallup-survey.html

Hawaii came in first place! That sounds wonderful to me... I just heard they had a need for Psych APRN's there! Grab that job - the beaches, sunshine and everything else I imagine about Hawaii do sound wonderful! Other states that made the top 10: Wyoming - having visited there the past couple of summers, I do agree that it would be a very cool place to live. Alaska was number 4... Colorado 5.

As for the 'worst' (or as Jeanna Bryner, author tactfully identifies, The bottom 10 states) West Virginia and Kentucky were the first two.

It surprised me that Connecticut would be number 9 in the 10 best list... mainly because we really don't get very much sunshine here in CT... and I really do notice that... However maybe CT made it due to the kinds of access we have here, the number of folks with advanced education... and perhaps good jobs? I don't know... of course I would love to see that data!

Using an Inhaled Antipsychotic for Agitation

Here is a link to an interesting trial of inhaled loxapine to treat agitation. It looks like it was effective vs. placebo. The comments suggest the chosen analysis was perhaps easier to find a significant effect with.

The idea of this is intriguing.... I would love to hear from any of you that have used/administered this inhaled agent... I certainly have seen loxapine used - just not inhaled... actually it probably would never have been my first choice agent to treat agitation also.

So can anyone out there describe how exactly this agent is used? At what point it kicks in? Is it an inhaler like those used for asthma (i.e. I am sure we can't 'spray' the drug at people... or we'd all be dosed! that might be amusing!)

Is the administration of an inhaled version easier in agitated folks than the shot (I know personally I would prefer most anything to a shot... particularly if onset of action for the drug is equal to or faster than onset IM....)

Here is a link to the summary page I found... I'll have to track down the actual study later...!

http://plus.mcmaster.ca/EvidenceUpdates/NewArticles.aspx?Page=1&ArticleID=38260#Data

Psych APRN Licensure, Certification and Education: Psych CNS & Psych NP

Here is a message I wrote on the APNA Member's Bridge today regarding the dilemmas faced by Psych Mental Health APRN's. I hope you visit the APNA website and become a part of the conversation...

I wanted to share my views about a conversation that has come up sporadically over time...
First I would like to start with a Thank you to the APNA group that examined the issue of advanced practice preparation, and made recommendations regarding our future. I think you tackled one important part of the many questions that have arisen since LACE came out. I agree that an important starting place for Advanced Practice Psychiatric Nursing in the future is to have one base of preparation and certification that is unified, and that prepares nurse clinicians for basic (i.e. beginning) competence and practice in the roles of psychotherapist, pharmacotherapy, and consultation-liaison work. I agree that the education should be across the lifespan if we seek to have a basic level of unified certification. Calling this clinician a Psychiatric Mental Health Nurse Practitioner (PMHNP) is fine with me. I thank the group for finding consensus around this issue.

There are 2 extremely important issues that relate to LACE that require further planning in my view. They are: 1. What happens to already certified, practicing Advanced Practice PMH nurses, particularly those with CNS certification. (but also in the future depending on whether separate 'family' vs. 'adult' PMHNP certifications remain - i.e. whichever certification goes by the wayside, that group could be potentially disenfranchised as well).

2. Who will be deemed eligible to educate, precept, 'train' new Advanced Practice PMH nurses.

In my view APNA needs a very clear plan that is very careful not to disenfranchise all of the highly experienced, practicing Advanced Practice PMH nurses. We need careful planning beyond a statement like,
'in 2015 or 2020 we will have 'enough' PMH NP certified APRN's to educate the new PMHNP's'
'in 2015 or 2020 all of the practicing, certified and licensed CNS's will have retired'
The problem here is that I have not seen a workforce analysis that truly indicates we will ever 'have enough' nursing faculty. I know I currently do not have enough practicing APRN's certified as CNS's and NP's to cover the number of students we would like to admit to our program.
I agree we will have more PMHNP's by 2020, but that does not mean CNS's should retire at that time.
We need some way to use our experienced APRN's in psych that is inclusive of both types of certification.
(and I do not expect that all CNS's should be required to return to school for the 3- P's and 500 clinical hours like I just finished to a cost of between $8000 - $10,000).

We need to issue continued clear statements that in PMH nursing the roles of the CNS and NP are nearly identical (i.e. was it 95% or 98% the same (per the logical job analysis paper by Rice & MOller I believe)).

To not be inclusive of both types of certification will risk that our current expert nurse faculty are out of their jobs... or preceptors will no longer be 'eligible to precept' (who by the way with CNS certification developed the role of PMHNP and educated our current group of PMHNP's... so I suspect they know something about the role and how to teach students to be PMHNP's.)

I do not want to get into a conversation about who is better or which certification is 'better'.
I completely agree that perhaps the better title today is Psych NP.
I do see individuals sharing opinions about who is better or differences in role that are typically state-bound. Meaning that in some states the board of nursing does not allow one kind of certified psych nurse to do the same thing as the other. We need to recognize that this does vary from state to state. Just because CNS's in one state can't prescribe and NP's can prescribe does not mean that in other states both CNS's and NP's can prescribe.

In my view the education and training for CNS's and NP's are (like the role/job) nearly identical. If anything the CNS has more role components in their education. In today's school of nursing, the preparation should be nearly identical. This however does mean that some clinicians can also choose not to prescribe and that is fine with me. Just as some clinicians may not choose to do family therapy. If that role or responsibility is not wanted by a clinician, I don't think we should force them to.

As for who can precept a student being prepared to be a PMHNP. I would hope we keep our heads about this matter too. I believe that the student should be precepted by certified and licensed APRN's in their clinical work. (this means certified as a psych CNS or psych NP) I believe that whoever precepts should be competent to perform and/or supervise the objectives that are part of the course that the student is taking. I believe that that APRN can also call upon other clinicians they work with - whether MD's, psychologists, MSW's, or RN's - to offer experiences that are coordinated and reviewed in the APRN's supervision with the student.
In a state where there is role delineation that does not allow prescribing by a CNS, then I think the faculty should work to be sure that a student is guided to learn the prescribing role either from an NP or MD.

I think we need to be careful to not divide up the PMH Advanced Practice role in a way that is blind to the full areas of practice available at the Advanced Practice level.

My final thought: Let us be very careful to understand that being educated in a lifespan way is very different from being an expert in child or being an expert in adult. That requires specific focus and training. Some programs do offer this (I believe ours is a good example). In my view we also need to be careful in what we are really saying when we identify what we mean by beginning competence, a lifespan approach, and expertise with particular age groups.

Thanks for letting me have my say,

Joanne

Here is a link to the APNA member bridge where this was posted... and where the conversation is continuing... http://community.apna.org/APNA/APNA/eGroups/DigestViewer/Default.aspx?GroupId=7&UserKey=82d60e30-46b4-40dd-b96b-77c0b0f2bd19

Here is the link to APNA's statement on Advanced Practice PMH roles: http://www.apna.org/i4a/pages/index.cfm?pageid=4354

Here is the link to the LACE document that has created controversy regarding roles:
http://www.apna.org/i4a/pages/index.cfm?pageid=3498

I hope you all make your voices heard!!!

Deafness linked to Dementia?

A recent article suggests that those with moderate to severe hearing loss may be at greater risk of dementia. The association was found in the Baltimore Longitudinal Study of Aging, in a prospective study, a group of 795 participants had both hearing and cognitive testing over a five year period from 1990 to 1994, and were free of confirmed or suspected dementia at baseline. The authors suggest a relationship between loss of ability to hear verbal communication and dementia.

The idea that the social isolation due to hearing loss might be harmful is not a new one. However to find such a direct link of hearing loss to something as serious as dementia is interesting. What kinds of things would be important to know about the study? Well, things like: When was the baseline evaluation identifying individuals as free of confirmed or suspected dementia? Was it in 1958 or was it in the 90’s when this evaluation occurred? AND Why was the hearing test done? Was it part of the longitudinal study protocol or was it individuals who also had a test that was then obtained by the study?
So what could this mean? Does it mean that social isolation is harmful? (do other socially isolated people get dementia at higher rates?) Does it mean that some similar mechanism is involved with both hearing loss and dementia? Is it a physiologic process? If so, what might be involved?

Do others with moderate to severe hearing loss have the same association with dementia? (what about those with hearing loss from birth or early in life? What about hearing loss due to accidental injury?) Do those with dementia have a higher rate of moderate to severe hearing loss?

An interesting finding – but one that certainly raises many more questions. I would think several of these questions could be answered in existing cohorts of those with dementia or those with hearing loss.

Here is a link to a report of this study which was originally published in the Archives of Neurology (Lin, 2011, Hearing Loss and incident dementia., Archives of Neurology, 68(2), 214-220).
http://www.medpagetoday.com/Neurology/Dementia/24867?utm_content=GroupCL&utm_medium=email&impressionId=1297757253079&utm_campaign=DailyHeadlines&utm_source=mSpoke&userid=230719

Diet Soda and Cardiovascular Disease

The media is reporting an interesting study by a researcher at the University of Miami, Hannah Gardener (I believe based on an abstract presented at a conference - I cannot find a link to the actual study info). It finds that those who drink diet soda daily have a 61% greater risk of having a heart attack or stroke. (and who knows why in remembering this I'm thinking of diet cola? or a particular brand of diet cola?)

Is this surprising? Well as it is currently being reported by the media - that diet soda 'causes' stroke or heart attack - that is stunning! However we really need to have some more information about that study to appropriately digest it and decide whether it has anything to do with causality or disease outcomes.

As I note, I have not seen the actual study - just a couple of media reports (see links below) - so it is impossible to know... but here is what I would consider:

• At what point in life were people studied? Is it young people drinking diet soda and ending up with strokes or older folks?
• When were measures made of diet soda ‘exposure’ vs. when outcomes were identified?
• How does risk in diet soda drinkers compare to risk in drinkers of ‘regular’ soda?
• Who drinks diet soda? What cardiovascular disease (CVD) risk factors do they have already?
• What other things do diet soda drinkers do that could increase their risk? Is there a tendency for those who are overweight or obese to drink it? Is there a tendency for those who drink diet soda to exercise less? What is the overall health of diet soda drinkers as a group? Do we know that obesity and lack of exercise increase risk for heart attack and stroke? (I think we all know the answer to that)
• What other factors associated with greater risk of heart attack and stroke may be common to diet soda drinkers?
• How were these common risk factors managed in the study - were those with early signs of CVD excluded from the study?
• If all other risk factors were controlled for in the study is it still possible to get an erroneous result (yes, because there is probably great similarity between these factors which tends to result in difficulty modeling things statistically)
• Perhaps most important of all: What would be the proposed mechanism of how diet soda 'causes' heart disease or stroke? Is it additives of some sort? Is it caffeine? Is it artificial sweeteners?

From some of the reports I saw, the researcher was careful to say that all this result meant was that further examination of the role of diet soda was needed... I agree with that… but the media has gone way beyond that in some cases…

It's also interesting to think about how you could design a study to prove/disprove this... would we take a healthy group of people and randomize them to drink diet soda daily vs. some other non-diet 'placebo type drink' (i.e. not regular soda I am certain) and see if there is greater risk at the end of the study? How long would we need to wait to see outcomes?
It is tough to actually know and adequately study this question...

Here are the links... http://www.denverpost.com/nationworld/ci_17345702 or

http://health.usnews.com/health-news/family-health/heart/articles/2011/02/09/can-diet-soda-boost-your-stroke-risk or

http://www.dbtechno.com/health/2011/02/09/diet-soda-increases-your-chance-of-having-a-heart-attack/

Modeling Internet Addiction

Most of us use the internet regularly. It has replaced earlier forms of communication like writing letters, reading news or magazines, phoning, or visiting. Many would agree that it is easier and more convenient than more traditional forms of communication. I also think that the stimulation of using the internet is far more rewarding than other formats offer. I can’t back that up with evidence, but I do know I look forward to checking my email, text messages, etc in much the same way that once a day checking of my mailbox offered (at least until adulthood when bills were often the most frequent arrivals!). Remember the wonderful surprise of finding a letter from a friend addressed to you! We currently have all kinds of places to ‘check’ for stimulation and reward on our computers or other electronic devices.

I am sometimes amazed at myself and others when I see the interest involved in electronic devices… including laptops, ipads, ipods, iphones, androids, and handheld electronic games (like the Nintendo DS). Our internet service was out for a few days this week and we were frustrated and annoyed that we were limited and could not interact with or easily check our devices as usual. It is interesting to reflect on how much we do rely on various forms of electronic communication.

An interesting study was done by Kwon & Chung (2011) studying the use of internet games by adolescents. They applied Baumeister’s escape from self theory (1991) to the phenomenon of pathologic use of internet games. Baumeister’s model has been used to understand other self-destructive behaviors including suicide and addictions to both substances and gambling. This model brings together many of the factors that prior research identifies as associated with internet game addiction, for example depressive symptoms, differences between real and idealized perceptions of self, escape from self, and interpersonal problems involving family and friends.

This model does not directly investigate the role of impulsivity and sensation seeking in internet game addiction. Kwon & Chung (2011) find that differences between real and idealized self perception are associated with depressive mood, which is associated with escape from self and also associated with internet game addiction. The study uses structural equation modeling to identify the strength and type of associations. However this form of modeling does not really offer a cause and effect analysis of events, it is based on cross sectional data which means all factors were present at the same time in participants. But it does establish that these relationships are important in the addiction behavior.

The authors identify that in Korean adolescents, use of internet games begins quite early. I suspect this is also true in other locations. I wonder about the changes that might be taking place in our brains and our children’s brains as we feed ourselves the stimulation readily available from electronic devices today. It is quite different from growing up with TV and radio – which was less satisfying given that you could not find material at any time of day that was personally satisfying and stimulating like we can today. The major factor missing in the study by Kwon is that there is no accounting for potential physiologic effects of electronic stimulation. The immediacy of gratification and plethora of forms of stimuli are so different than for prior experience and generations.

I think I will spend some free time exploring the internet for information about physiologic effects :) (who’s addicted?!) and perhaps I will see if I can buy an electronic version of Baumeister’s book on escape theory! If you know of work that has been done on the physiology let me know- send me a link or do tell about it in the comments!

References:
Kwon, J.H., & Chung, C.S. (2011). The effects of escape from self and interpersonal relationship on the pathological use of internet games. Community Mental Health Journal, 47, 113-121. http://www.ncbi.nlm.nih.gov/pubmed/19701792

Here are references to Baumeister’s model if you are interested:
Baumeister, R.F. (1990). Suicide as escape from self. Psychological Review, 9, 90-113.
Baumeister, R.F. (1991). Escaping the self: Alcoholism, spirituality, masochism, and other flights from the burden of selfhood. New York, NY: Harper Collins.

Identifying Alzheimer’s Disease prior to disease onset

I am happy to see that progress is being made in identifying better ways to diagnose Alzheimer’s disease. On the other hand, I am also disturbed given the nature of getting a diagnosis like Alzheimer’s disease. The epidemiologist and researcher in me is always glad for a discovery like this. In designing studies we have a valuable way to identify people with an abnormality indicative of the disease. This improves the features of the study and its measure of identification of this disease. There is immense value in that. In studies where we can only approximate the outcome (i.e. in AD definitive diagnosis is usually only available by autopsy) our research is negatively impacted in looking for treatments or a cure for the disease. If a group of patients we ‘think’ have AD really do not, and we seek treatments based on their responses or physiology, then the potential for error in these studies is large. So for research in AD this is a huge finding… and very important to progress in the field.

Here is the link to the NYT article that reviews the study to be published today in Archives of Neurology… I’ll have to review the study later to evaluate it. http://www.nytimes.com/2010/08/10/health/research/10spinal.html?_r=1&th&emc=th

The question I’m left with really is… what do we do with the information once we have it? The article is a bit vague… implying maybe the doctor doesn’t tell the patient of the diagnosis. That is scary and a little like getting cancer more than 30 years ago… You could be dying in a hospital bed and no one would tell you the diagnosis.

With AD, we really don’t have ways to change the outcome. Do we want to be diagnosing people with Alzheimer’s earlier? If there was a real way to change the progression then there is no question… of course! But today, if I had the test, would I want to know the results? It is hard to say. Part of me says I could plan for the changes to come… I could mourn my loss of my ‘senior’ years… I could prepare my family for the worst… But these would be extremely difficult to do, even for the healthiest of us.

Would you want the test?

Dissolving Tobacco: ‘Candy’ to feed nicotine addiction

Who ever thought that tobacco companies would come up with a way to market a tobacco product that does not light up or need to be spit out? Camel Orbs and other forms (sticks or strips) are being marketed now. It is interesting, a dissolving product that delivers from 0.6 to 3.1mg of nicotine (depending on form vs. 1mg per usual smoked cigarette). It is made from ground tobacco, and flavored. You would think given the dose of nicotine delivered that it is considered at least an over the counter agent?

I learned of this from a recent newsletter for clinicians (Here is the link where the article is posted:http://www.smartbrief.com/servlet/wireless?issueid=41F0A8DB-0D52-4644-A460-C671DA25785E&sid=4424389f-4968-420d-b19a-428ead999285). I think they missed the boat on the focus to report: that babies or children might accidentally put the small tic-tac size ‘candies’ in their mouth and ingest toxic doses of nicotine. This report follows a study from Connelly et al.( 2010) in Pediatrics (http://pediatrics.aappublications.org/papbyrecent.dtl). This is a concern to be sure. Adults might shake out a few from their childproof container and leave them where a child could find them. In addition, the ‘candies’ are flavored, so they taste good and encourage eating more than one? An important point and users should beware.

A bigger concern, is that tweens and teens might be interested in trying this substance for the effects of nicotine without smoking! It even tastes good. Let’s see if we can hook a whole new generation on tobacco and call it candy this time. Not a good idea. There are enough other substances in the world to get hooked on. Do we really need a new one? I can see the rationalizing already, it isn’t smoked so won’t cause lung cancer, secondary smoke, etc…

When a product delivers a pharmacologically active agent like nicotine, shouldn’t it require strong regulation? More than that of a tic tac? Particularly when we have reams of data about how addictive the substance is? I don’t think this is much different than other nicotine products, which pharma created and I’m sure went through many hoops to get approved. Shouldn’t this product be treated the same way?

The New York Times coverage of this story yesterday, (here is the link: http://www.nytimes.com/2010/04/19/business/19smoke.html) identifies that in fact the FDA does regulate tobacco now… R.J. Reynolds did submit documents showing research and other material about this new ‘candy’, but the FDA still has 2 years to determine the safety of the product. I guess they can begin marketing it before we know its safety?

From what I can find, they are also available as ‘sticks’ (like a toothpick that dissolves) and ‘strips’ (like a breath mint strip). Here is a picture of the product, in case you are interested:

Psych RN Salary Low...

Well, just got some bad news... Advance for Nurses just arrived and the lead article is a New England Salary Survey for nurses. The good news? Nurse earnings range from an average of $22.50 per hour in Vermont to $39.88 per hour in Massachusetts. Connecticut nurses are doing pretty well at $34.18/hr. The problem is this: the hourly rate by specialty area for New England nurses ranges from $30.05/hr to $43.00/hr and guess which specialty is at the rock bottom? Psychiatric Nurses.

Why would this be? Is it mostly new nurses bringing down that average? New nurses (< 5 yrs at work) earn considerably less, $27.92/hr, while rates increase to $32.20 at 6-15yrs, and $40.30/hr with 16-25yrs experience. (Interesting that those with 26+ years experience have lower hourly rates on average ($39.42/hr)- that does not sit well with me either.) Mary Jane Krebs, APRN-BC VP of clinical and nursing services at Spring Harbor Hospital in Maine identifies the average age of psychiatric nurses is 47years. I don't think that supports the lack of experience argument.

Perhaps it is location of employment. I don't know the numbers, but I am sure many psych nurses work for state or federal (VA) facilities which have the lowest annual salaries ($66,823 vs. nonprofits of $71,061). That might be part of the reason. I don't think it is a good reason, but perhaps benefits packages are better? I suspect the work is very difficult in government facilities...

My worst fear would be that the stigma of working in psychiatry is alive and well. I can't tell you how many times I have heard that people who work in psych are crazy... I'm tired of that. As a group we need to actively thwart those who perpetuate this myth.

As a group we should be paid on par with all other specialties. We have extremely difficult jobs, and deserve to be paid well for our services.

Happy to Help Another Nurse Blogger!

Here's something different for my blog today... I was asked to post a link to the following blog. So here it is: “101 Blog Posts Every New Nurse Should Read” at http://nursepractitionerschools.org/101-blog-posts-every-new-nurse-should-read/ by Jennifer Johnson. I don't know Jennifer, but I briefly perused her blog, and it has some interesting blogs to link to about nursing and the experiences of both nurses and students. Happy reading to all of you on one of my favorite topics... Nurses and Nursing!