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Purpose Nonventilator hospital‐acquired pneumonia (NV‐HAP) is an underreported and unstudied disease, with potential for measurable outcomes, fiscal savings, and improvement in quality of life. The purpose of our study was to (a) identify the incidence of NV‐HAP in a convenience sample of U.S. hospitals and (b) determine the effectiveness of reliably delivered basic oral nursing care in reducing NV‐HAP. Design A descriptive, quasi‐experimental study using retrospective comparative outcomes to determine (a) the incidence of NV‐HAP and (b) the effectiveness of enhanced basic oral nursing care versus usual care to prevent NV‐HAP after introduction of a basic oral nursing care initiative. Methods We used the International Statistical Classification of Diseases and Related Problems (ICD‐9) codes for pneumonia not present on admission and verified NV‐HAP diagnosis using the U.S. Centers for Disease Control and Prevention diagnostic criteria. We completed an evidence‐based gap analysis and designed a site‐specific oral care initiative designed to reduce NV‐HAP. The intervention process was guided by the Influencer Model™ (see Figure ) and participatory action research. Findings We found a substantial amount of unreported NV‐HAP. After we initiated our oral care protocols, the rate of NV‐HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%). The overall number of cases of NV‐HAP was reduced by 37% during the 12‐month intervention period. The avoidance of NV‐HAP cases resulted in an estimated 8 lives saved,$1.72 million cost avoided, and 500 extra hospital days averted. The extra cost for therapeutic oral care equipment was $ 117,600 during the 12‐month intervention period. Cost savings resulting from avoided NV‐HAP was$1.72 million. Return on investment for the organization was $ 1.6 million in avoided costs. Conclusions NV‐HAP should be elevated to the same level of concern, attention, and effort as prevention of ventilator‐associated pneumonia in hospitals. Clinical Relevance Nursing needs to lead the way in the design and implementation of policies that allow for adequate time, proper oral care supplies, ease of access to supplies, clear procedures, and outcome monitoring ensuring that patients are protected from NV‐HAP.

Objectives Sepsis is defined as the host's inflammatory response to a life‐threatening infection. The endothelium is implicated in immunoregulation during sepsis. Macrolides have been proposed to display immunomodulatory properties. The goal of this study was to analyze whether macrolides can exert immunomodulation of endothelial cells (ECs) in an experimental model of sepsis. Methods Human ECs were stimulated by proinflammatory cytokines and lipopolysaccharide before exposure to macrolides. ECs phenotypes were analyzed by flow cytometry. Cocultures of ECs and peripheral blood mononuclear cells (PBMCs) were performed to study the ECs ability to alter T‐cell viability and differentiation in the presence of macrolides. Soluble factor production was assessed. Results ECs act as non‐professional antigen presenting cells and expressed human leukocyte antigen (HLA) antigens, the adhesion molecules CD54, CD106, and the coinhibitory molecule CD274 after septic stimulation. Incubation with macrolides induced a significant decrease of HLA class I and HLA class II HLA‐DR on septic‐stimulated ECs, but did not alter either CD54, CD106, nor CD274 expression. Interleukin‐6 (IL‐6) and IL‐8 production by stimulated ECs were unaltered by incubation with macrolides, whereas Clarithromycin exposure significantly decreased IL‐6 gene expression. In cocultures of septic ECs with PBMCs, neither the proportion of CD4 + , CD8 + T nor their viability was altered by macrolides. T‐helper lymphocyte subsets Th1, Th17, and Treg polarization by stimulated ECs were unaltered by macrolides. Conclusion This study reports phenotypic and gene expression changes in septic‐stimulated ECs exposed to macrolides, without resulting in altered immunogenicity of ECs in co‐cultures with PBMCs. In vivo studies may help to further understand the impact of macrolide therapy on ECs immune homeostasis during sepsis. This study reports phenotypic and gene expression changes in septic‐stimulated microvascular endothelial cells after exposure to macrolides. Although a significant decrease in cell‐surface human leukocyte antigen (HLA) class I and HLA‐DR expression and in interleukin‐6 (IL‐6) gene expression was observed, these modifications did not result in altered functional response following endothelial cells' interaction with peripheral blood mononuclear cells (PBMCs) regarding T‐lymphocyte viability, cytokine production, or CD4 + ‐T differentiation.

TOPIC.  Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient‐centered care to prevent the development and progression of this largely preventable disease. OBJECTIVE.  The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision‐making, reduction of relapse to unhealthy behaviors, and increased long‐term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence. METHOD.  Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine. RESULTS.  Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self‐efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets. CONCLUSION.  Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision‐making between patient and healthcare provider.

Monocytes contribute to immune responses as a source for subsets of dendritic cells and macrophages. Human blood monocytes are classified as classical, non-classical and intermediate cells. However, the particular functions of these subsets have been hard to define, with conflicting results and significant overlaps. One likely reason for these ambiguities is in the heterogeneity of these monocyte subsets regrouping cells with divergent functions. To better define monocyte populations, we have analysed expression of 17 markers by multicolour flow cytometry in samples obtained from 28 control donors. Data acquisition was tailored to detect populations present at low frequencies. Our results reveal the existence of novel monocyte subsets detected as larger CD14 + cells that were CD16 + or CD16 neg . These large monocytes differed from regular, smaller monocytes with respect to expression of various cell surface molecules, such as FcR, chemokine receptors, and adhesion molecules. Unsupervised multidimensional analysis confirmed the existence of large monocytes and revealed interindividual variations that were grouped according to unique patterns of expression of adhesion molecules CD62L, CD49d, and CD43. Distinct inflammatory responses to TLR agonists were found in small and large monocytes. Overall, refining the definition of monocyte subsets should lead to the identification of populations with specific functions.

Jaundice is a common problem affecting over half of all full-term and most preterm infants. Jaundice describes the yellow orange hue of the skin caused by excessive circulating levels of bilirubin that accumulate in the skin. In most healthy full-term newborns, jaundice is noticed during the first week of life. Shortened hospital stays and inconsistent follow up, especially for first-time breastfeeding mothers, prompted the American Academy of Pediatrics (AAP) to update management guidelines. Health care providers need to be familiar with the diagnosis and management of jaundice to prevent brain, vision, and hearing damage. Treatment of choice for jaundice remains close observation and frequent feeding followed by phototherapy, and finally exchange transfusion for severe or refractory cases.

Shared medical appointments (SMAs) are an innovative way for multidisciplinary teams to work together to meet veteran needs and encourage adherence to healthy lifestyle recommendations. The purpose of this study was to explore the experiences of veterans who participated in SMAs. Focus groups were utilized to obtain information about SMA experiences. This method encouraged veterans to expand on and clarify the meaning of their experiences. Audio recordings were transcribed and analyzed by the researchers using N'Vivo software and an exploratory process to obtain consensus about themes. The following themes emerged as a result of the focus group analysis: \"empowerment, peer support, awareness, positive provider characteristics, teamwork, benefits, and convenience.\" Veterans reported improvement in their overall health and well-being, improved self-management skills, and satisfaction with the SMA format. Veterans reported feeling empowered to improve their health and described a deep connection with their peers and group leaders. The connection they experienced with other veterans in the SMAs was similar to the close-knit relationships held with other members of their military unit.

Objectives: Sepsis is defined as the host's inflammatory response to a life-threatening infection. The endothelium is implicated in immunoregulation during sepsis. Macrolides have been proposed to display immunomodulatory properties. The goal of this study was to analyze whether macrolides can exert immunomodulation of endothelial cells (ECs) in an experimental model of sepsis.Methods: Human ECs were stimulated by proinflammatory cytokines and lipopolysaccharide before exposure to macrolides. ECs phenotypes were analyzed by flow cytometry. Cocultures of ECs and peripheral blood mononuclear cells (PBMCs) were performed to study the ECs ability to alter T-cell viability and differentiation in the presence of macrolides. Soluble factor production was assessed.Results: ECs act as non-professional antigen presenting cells and expressed human leukocyte antigen (HLA) antigens, the adhesion molecules CD54, CD106, and the coinhibitory molecule CD274 after septic stimulation. Incubation with macrolides induced a significant decrease of HLA class I and HLA class II HLA-DR on septic-stimulated ECs, but did not alter either CD54, CD106, nor CD274 expression. Interleukin-6 (IL-6) and IL-8 production by stimulated ECs were unaltered by incubation with macrolides, whereas Clarithromycin exposure significantly decreased IL-6 gene expression. In cocultures of septic ECs with PBMCs, neither the proportion of CD4 + , CD8 + T nor their viability was altered by macrolides. T-helper lymphocyte subsets Th1, Th17, and Treg polarization by stimulated ECs were unaltered by macrolides.Conclusion: This study reports phenotypic and gene expression changes in septic-stimulated ECs exposed to macrolides, without resulting in altered immunogenicity of ECs in co-cultures with PBMCs. In vivo studies may help to further understand the impact of macrolide therapy on ECs immune homeostasis during sepsis.

The deidentified electronic medical records of 1,452 veterans with a history of smoking and assigned to an outpatient Department of Veteran Affairs Medical Center were examined. Descriptive statistics and two repeated measures ANCOVA were performed to determine the demographic characteristics of the sample and the relationships between the independent variable of tobacco use group on the dependent variables of LDL cholesterol and HbA1c levels, during the years 2003 through 2007. There was no statistically significant relationship between tobacco use and LDL levels when controlling for weight. There was a statistically significant difference in the tobacco use groups and HbA1c levels. Current smokers had higher HbA1c levels than did former smokers throughout the observational period, but the difference was statistically significant only for the years 2003 and 2007. Thus health care providers are challenged to monitor for cardiovascular risk factors, assist patients with smoking cessation, and prevent tobacco use.

Preseptal versus Orbital Cellulitis Preseptal cellulitis is an infection of the eyelid and surrounding soft tissue with an acute onset of erythema and edema of the eyelid.8 Preseptal cellulitis is less severe than orbital cellulitis but has been known to progress to a more serious infection, especially in children.2 Orbital cellulitis is a potentially life-threatening infection involving the soft tissues behind the orbital septum, which progresses rapidly.2,11 Etiology Preseptal cellulitis is commonly associated with trauma, sinusitis, and upper respiratory tract infections.8,10 The majority of cases of orbital cellulitis are associated with sinusitis, of which 98% involve the ethmoid sinuses.2-3,9,10 Other causes include extension of infection from the lacrimal sac, dental infection, eyebrow piercing, eyelid surgery, strabismus correction surgery, retinal and intraocular surgery, retained foreign objects, or blunt trauma to the orbit.2,3 The most common organisms include Staphylococcus aureus, staphylococcus epidermidis, streptococcus, and anaerobes, which are commonly seen on the skin or cause respiratory tract infections and sinusitis.8 Pathophysiology Orbital cellulitis occurs when infection extends from the paranasal sinuses and face, direct inoculation from trauma or surgery, or spread of bacteria through the blood stream.3 The thin medial wall of the orbit allows bacteria to spread from the ethmoid and maxillary sinuses.3 In addition, the orbital veins do not have valves, which allows infection to spread in both directions.3 Microorganisms found in the sinuses and upper respiratory tract multiply and invade the swollen tissue of the orbit, and this effect is enhanced by blockage of flow through the sinus cavities.3 When orbital cellulitis is caused by infection in the sphenoid sinuses, there is risk of optic nerve compression, vision loss, and infection in the brain.6 Retinal and optic nerve ischemia leads to blindness within 2-3 hours.12 In addition to orbital cellulitis, sinusitis may lead to epidural, subdural, and intracerebral abscesses and meningitis.13 Nearly half of patients with intracranial complications of sinusitis present with orbital cellulitis or abscess.14 Clinical Presentation and Physical Examination With both preseptal and orbital cellulitis, patients may present with unilateral periorbital erythema and edema, leukocytosis, and fever; these findings alone cannot be used to distinguish one disorder from the other.8 Patients with preseptal cellulitis may report a recent history of local skin abrasions or insect bites to the eyelid, but the eye is relatively uninvolved.2 Patients with either disorder may complain of rhinorrhea, epiphora (excessive tearing), and difficulty opening the eye.8,11 Sinus pain, headache, fever, painful eye movement, blurred or double vision, and generalized malaise are seen in patients with orbital cellulitis.2 The patient's eyelids should be inspected for trauma, and the patient should be examined for cervical, submandibular, and preauricular lymphadenopathy.8 The presence and quality of eye drainage should be noted, as well as testing for gross visual acuity, pupillary response to light, and extraocular movements.

Vocal cord dysfunction is often incorrectly identified as asthma. Unlike asthma, this condition does not respond to inhalers and affects the upper airway. These patients may present with a sudden onset of inspiratory stridor or wheeze, choking sensation, tightness, or heaviness over the larynx that ends just as abruptly with deep-breathing exercises or distraction. Treatment includes gradual taper and discontinuation of unnecessary asthma medications, diaphragmatic breathing exercises, adequate hydration, nasal saline lavage to reduce postnasal drainage, prevention and treatment of gastroesophageal reflux, and treatment of allergies and chronic sinusitis.