The importance of keeping your skin healthy can’t be overemphasized. It’s the body’s first defense against disease and infection, and it protects your internal organs from injuries. It is, in fact, the largest organ in the body. The skin helps regulate body temperature and prevents excess fluid loss, and it also helps your body remove excess water and salt.

Skin conditions can affect anyone-young and old, men and women. Acne, psoriasis and eczema are just a few examples of common skin disorders. The good news is that there are a number of simple ways to keep skin healthy, and there also are now many options available to treat skin conditions, if treatment is necessary.

If you think you may have a skin problem, or need to learn how to better care for your skin, consultation with a dermatologist-a physician who specializes in treating the skin and keeping it healthy-may be in order. Skin problems can be difficult to diagnose because many skin conditions share similar symptoms. An evaluation is key to effective treatment.

The Structure of Skin

To understand how to keep your skin healthy, it may help to learn about your skin’s structure.

Skin is composed of two layers: the epidermis (the outermost layer of skin-about the thickness of a piece of paper) and the dermis (the middle layer). The thickness of the dermis is variable depending on the location. For example, eyelid dermis is quite thin, but back dermis is about 1/2 inch thick. The epidermis has four layers: the stratum corneum, the granular layer, the squamous cell layer and the basal cell layer.

The stratum corneum or outer layer of the epidermis is the layer of skin that can be seen and felt. Proteins known as keratin, a fatty, waterproof envelope, and flat corneocyte cells make up the stratum corneum. This layer is the barrier between your body and the outside world.

The granular layer produces protein and lipids (fat) for the stratum corneum.

The squamous cell layer produces keratin for the stratum corneum and also transports water. Friction blisters occur in the squamous cell layer.

The basal cell layer is the lowest layer of the epidermis. This is where the skin cells are reproduced and give rise to the more superficial layers of the epidermis. The most common form of skin cancer, basal cell carcinoma, arises from this cell layer. Melanocytes, which produce melanin, or skin pigment, sit along this layer among these cells. Melanoma, one of the two main groups of skin cancer, originates from these pigment-producing cells.

It takes about one month for skin cells to move from the basal cell layer to the top of the stratum corneum and slough off. One to two layers of these skin cells are sloughed off every day.

The dermis is the deeper layer of skin. It is a diverse combination of blood vessels, nerves, hair follicles and sebaceous (or oil) glands. The proteins collagen and elastin are found in the dermis. They provide support and elasticity to the skin. The sun’s rays can break down these proteins and, eventually, the skin begins to wrinkle and sag.

The subcutaneous layer, or subcutis, is a layer of fatty tissue that provides nourishment to the dermis and upper layers of skin. It also conserves body heat and cushions internal organs against trauma. Blood vessels, nerves, sweat glands and deeper hair follicles extend from the dermis into the fat (hypodermis).

Look Your Best-Limit Sun Exposure

Facial skin typically looks its best during a woman’s 20s. As you age, your skin becomes thinner and often drier. Thinning skin is a result of a breakdown of collagen and elastin fibers. As it ages, skin loses elasticity — especially if it has been exposed to excessive sunlight — and becomes more fragile and dry. However, there are a number of dietary and lifestyle changes that you can make to help keep your skin healthy and young-looking.

Because exposure to the sun causes about 80 percent of the skin changes associated with aging, protecting the skin from the sun is the single most important skin care practice you can adopt. Significant exposure to the sun will wrinkle and dry the skin. Uneven pigmentation-from freckles to small or large brown spots-is another side effect of frequent sunning. Melasma, commonly associated with pregnancy, is brought out by the sun and produces large brown patches on the forehead and cheeks.

The most serious consequence of sun exposure is skin cancer. Skin cancer is the most common type of cancer, making up nearly half of all diagnosed cases of cancer, according to the American Cancer Society (ACS). Most sun damage occurs prior to the age of 18, but skin cancer can take up to 20 or more years to develop; children who experience as few as two to three sunburns are believed to have an increased risk of developing skin cancer later in life.

ABSTRACT. Background: Metabolic bone disease (MBD) is a significant complication in patients receiving long-term home parenteral nutrition (HPN). Pamidronate has been poorly studied in this population. We examine the prevalence and risk factors for MBD and examine changes in bone mineral density (BMD) after pamidronate administration. Methods: First, a chart review of patients receiving HPN for >1 year was performed, and Pearson correlations were used to assess associations between MBD (defined as t score
The incidence of metabolic bone disease (MBD) in patients receiving long-term home parenteral nutrition (HPN) is unknown. Reports from 20 years ago suggested a high prevalence of both osteoporosis and osteomalacia directly related to the administration of HPN.1-3 One recent study suggested a prevalence of MBD of 84% in patients receiving HPN.4 Other recent studies, however, suggest that perhaps MBD in patients receiving long-term HPN may primarily be a consequence of the underlying medical illness as opposed to toxicity of HPN.5

Traditional risk factors for MBD include female gender, advancing age, low body weight, glucocorticoids, excessive alcohol consumption, smoking, and physical inactivity.6 Multiple parenteral nutrition (PN) factors contribute toward MBD. These include calcium, vitamin D, and phosphate deficiencies; aluminum toxicity; acidosis; vitamin D toxicity; and amino acid infusions. Amino acid infusion increases urinary calcium excretion. Particularly, infusions exceeding 2 g/kg enhance urinary calcium loss to degrees greater than that originally infused.7 Phosphate enhances calcium reabsorption by the renal tubules.8 Adequate amounts of phosphorus must be present in PN in order to achieve a positive calcium balance. Chronic metabolic acidosis is known to impair vitamin D metabolism, leading to MBD similar to osteomalacia.9 Additionally, acidosis can lead to bone loss directly. In the early days of HPN, aluminum toxicity had a role in contributing toward MBD. Aluminum contamination resulted from contamination of amino acid solutions prepared from protein hydrolysates.10 Aluminum toxicity reduces parathyroid hormone (PTH) secretion and decreases serum levels of 1,25 dihydroxyvitamin D. In the past few years, there has been minimal contamination of amino acid with aluminum; hence, MBD resulting from aluminum toxicity should be far lower. However, there is still aluminum present in various trace elements, but in such low quantities that it is not felt to contribute to MBD to any significant degree. Vitamin D toxicity is possibly associated with MBD in patients receiving long-term HPN.2

Multiple studies have demonstrated that the risk of fractures increases with declining bone mineral density (BMD).11,12 The European Prospective Osteoporosis Study showed the risk of vertebral fracture increased by a factor of 1.5 per 0.1 g/cm^sup 2^ decrease in the BMD of the spine.13 There are no prospective trials assessing the relationship between dual energy x-ray absorptiometry (DEXA) and fracture risk in patients receiving HPN.

Nishikawa et al14 showed that IV pamidronate improved BMD in the lumbar spine after pamidronate infusion in patients receiving HPN for short bowel syndrome.

No recent Canadian study has evaluated the prevalence of MBD in patients receiving long-term HPN, nor have there been many studies evaluating the efficacy of IV pamidronate in this population. Due to the controversial issue of PN as a risk factor of MBD, we sought to examine the prevalence and risk factors for MBD in patients who are currently receiving long-term HPN in the Toronto General Hospital HPN program, and we also evaluated the change in bone density after administration of pamidronate in this patient population.

METHODS

First, a retrospective chart review of 25 patients enrolled in the HPN program for a minimum of 1 year was performed. The 25 patients studied represented all of the patients receiving HPN in our program for at least 1 year. Ethics approval was obtained from the University Health Network Research Ethics Board. All patients signed informed consent forms. Twenty patients receiving long-term HPN had BMD of the lumbar spine, femoral neck, and hip evaluated using DEXA scan. Not all patients had their DEXA performed with the same machine. Although all patients are part of the Toronto General Hospital program, some are scattered throughout the province. Hence, most of these patients’ investigations were performed closer to their home and not at Toronto General Hospital. The DEXA machines used for this study were not calibrated between centers.

Protein hydrolysate solutions were changed to free amino acid solutions with a much lower aluminum contamination in 1985. Two patients began receiving HPN before this date. One patient had been receiving HPN for 13 years, whereas the other patient started receiving HPN 6 months before 1985.

Osteopenia was defined according to the most recent WHO criteria oft score -2.5

Second, changes in BMD after administration of pamidronate were analyzed prospectively from 1998 to 2005. A subgroup of 11 patients with established osteoporosis received IV pamidronate. BMD was performed before receiving pamidronate and after 22.15 ± 5.44 months of therapy. Pamidronate was infused at home over 2 hours at a dose of 30 mg every 3 months.

ABSTRACT. Background: Mild liver dysfunction is common after prolonged use of parenteral nutrition (PN), but end-stage liver failure occurs only rarely. Few treatment options other than combined liver-intestine transplantation exist for patients with liver failure associated with PN use, however. Herein, we report the results of a cohort of patients undergoing isolated orthotopic liver transplantation (OLT) for PN-associated liver injury. Methods: A retrospective cohort study of 80 patients (73 pediatric patients and 7 adults) who have undergone isolated OLT for PN-associated liver injury as the primary indication for transplantation was performed. Results: At the time of OLT, the mean total serum bilirubin was 19.5 mg/dL and the mean serum albumin level was 2.9 mg/dL. Severe hepatic encephalopathy was seen in 5%, spontaneous bacterial peritonitis was seen in 6.3%, and respiratory failure requiring mechanical ventilation was seen in 14% of patients at the time of OLT. Overall 1- and 5-year survival rates were 72% and 52%, respectively, with infection being the most common cause of death after OLT. Retransplantation was required in 25% of patients, and the 5-year posttransplant patient survival rate only reached 35% in these cases. Conclusions: Patients with end-stage liver disease associated with PN administration often have very severe liver disease, multiple comorbidities, and poor prognosis by the time they are listed for OLT. Nonetheless, isolated OLT is associated with good long-term survival and should be considered for selected patients with combined intestine-liver failure. (Journal of Parenteral and Enteral Nutrition 30:526-529, 2006)

Parenteral nutrition (PN) has become an essential means of supporting patients who are be unable to sustain themselves on enterai feedings or intravenous (FV) carbohydrate solutions alone. Although lifesaving, PN is often associated with significant complications, including liver injury that can range from self-limited cholestasis to end-stage cirrhosis.1″5 Few good treatment options exist once cirrhosis has developed from long-term PN use. Perhaps the best option for those with PN-associated cirrhosis and continuing need for PN is a combined liver-intestine transplant, an option associated with 49%-55% long-term survival.6,7 Isolated orthotopic liver transplantation (OLT) exists as an option for selected patients, but in contrast to the combined liver-intestine procedure, the outcomes of OLT for PN-associated liver injury have only been described for single cases and single-institution series of no more than 10 patients.8,11 The current study was undertaken to estimate the long-term patient survival in pediatric and adult patients undergoing OLT for this rare indication.

MATERIALS AND METHODS

Patients enrolled in this study were identified through the United Network for Organ Sharing (UNOS) Organ Procurement and Transplant Network liver transplant database. This database contains patient and graft outcome data for >62,000 patients who underwent OLT in the United States between January 1988 and December 31, 2003. Patients with a primary diagnosis of PN-associated liver injury were selected for study. Patients who had received previous small intestine transplants or simultaneous multiorgan transplant were excluded.

Descriptive statistics for each cohort were calculated using all available pretransplant and peritransplant variables. Patient and allograft survival was assessed using Kaplan-Meier survival analysis, and survival rates of subgroups were compared with the log rank test. All statistical analyses were performed with SPSS version 11.0 (SPSS Corporation, Chicago, IL). A p value of

RESULTS

Patient Characteristics

Since 1988, a total of 80 patients have undergone isolated OLT, with PN-associated liver injury listed as the primary indication for transplantation. These patients were predominantly pediatric at the time of initial OLT. Specifically, 40 (50%) were

At the time of OLT, the mean total serum bilirubin was 19.5 mg/dL (range, 0.6-54.0 mg/dL), the mean serum creatinine was 0.58 mg/dL (range, 0.10-9.0 mg/dL), and the mean serum albumin was 2.9 mg/dL (range, 1.9-4.5 mg/dL). Eleven patients (14%) required mechanical ventilation at the time of OLT, and at least 1 had required dialysis in the week before OLT. Four patients (5.0%) had a history of spontaneous bacterial peritonitis, and 5 patients (6.3%) had a history of grade III or IV hepatic encephalopathy.

Twenty-three of the 73 pédiatrie recipients (32%) have been transplanted since the Pédiatrie End-Stage Liver Disease (PELD) model has been used to rank candidates awaiting OLT. Of these, 12 (52%) were listed as status 1 (high urgency, expected survival without transplantation of

Transplant and Allograft Characteristics

The median time from a candidate’s addition to the waiting list to the time of OLT was 35 days (range, 0-684 days). Of the 80 initial OLTs performed for PN-associated liver failure, whole-liver allografts obtained from cadaveric donors were used in 52 (65%), partial or reduced allografts from cadaveric donors were used in 9 (11%), and split-liver allografts from cadaveric donors were used in 7 (8.8%). Segmentai allografts from living donors were used in 10 (13%); 7 of these were obtained from the patient’s parents. The source of the remaining 2 allografts (3%) was unknown. The median length of posttransplant hospitalization was 38 days (range, 2-308 days).

ABSTRACT. Background: We devised a consistent approach to instituting and advancing enteral nutrition among neonatal intensive care unit (NICU) patients

Developing consistent approaches to various practices and procedures in neonatology has been suggested as a means of improving outcomes.1-3 As an example, the Vermont Oxford Network “Got Milk” focus group developed guidelines for enterai nutrition that were tested by Kuzma-O’Reilly et al3 and found to improve nutrient intake and growth, with a reduced length of stay and reduced costs. As part of an overall effort to improve outcomes, we used a multidisciplinary consensus development process to devise a consistent approach to enteral nutrition of low-birthweight infants. The multidisciplinary group produced a set of feeding guidelines for neonates

Details of the feeding guidelines are posted on the Intermountain Healthcare website. Briefly, the guidelines give specific instructions to the bedside nurses, according to the birth weight of the patient, categorized as

We analyzed data from all patients

The day of birth was termed “day of life 0,” and the day beginning 1 minute after their first midnight was termed “day of life 1.” The time to reach 80 mL/k/d was selected as a significant outcome because of an IHC systemwide program to reduce line-associated infections in the NICU, calling for consideration of removing central catheters when 80 mL/k/d of enterai intake is reached.4 PN was defined as an amino-acid-containing, multivitamin-containing, IV solution ordered on the IHC “PN program” and prepared by the hospital pharmacy PN team.

Descriptive statistics were calculated using Stata 8.3 (College Station, TX). Between-group means were tested using independent-sample t- tests when parametric assumptions were met, with Wilcoxon ranksum tests used for nonparametric comparisons. Proportions were compared between groups using ?^sup 2^ tests with Yate’s continuity correction or, when expected counts were small, Fisher’s exact test. Between-group variances were tested using independent-samples standard deviation F tests. For demographic features, two-tailed tests were used. Otherwise, one-tailed tests were conducted. For all tests, ? was set at .05.

RESULTS

In period 1, 301 patients were admitted to the NICU, of which 58 (19.3%) weighed

Of the 58 patients admitted to the NICU in period 1, 2 died; a 700-g male infant (23 weeks’ gestation) who died on day O, and a 720-g female infant (26 weeks) who died after 6 weeks. The first of these was not considered in the feeding and growth calculations (Table III), because no feedings were given, but the second was included because that patient survived for 37 days and received enterai feedings. Of the 68 patients in period 2, 2 died; a 657-g male patient (23 wks) and a 990-g female patient (24 weeks). Both died on day of life 1. Neither received any enterai feedings, and neither was included in the feeding-outcome data (Table III).

In periods 1 and 2, the median days to first milk feedings was 1. However, the variability (range, 0-24 days in period 1 vs 0-6 days in period 2) was far less in period 2 (p

DISCUSSION

During the 6-month period after implementing feeding guidelines, we observed fewer NPO days and fewer days where PN was used. Although these improvements were statistically significant, they were relatively minor improvements compared with those observed by Kuzma-O’Reilly et al3 after they implemented feeding guidelines. They found that adopting feeding guidelines greatly reduced the initial NPO days, improved nutrient intake and growth, and reduced the length of hospital stay. Perhaps one reason we failed to see such marked improvements was that our baseline rates were quite different than theirs. For instance, implementing their guidelines was associated with a reduction in days to start enterai feedings from day of life 8.9 before guidelines to day 4.7 after. In contrast, before instituting guidelines our enterai feeding was begun on (median) day of life 1. Similarly, before guidelines were instituted their neonates required 19 days to achieve an enterai intake of 80 kcal/k/d, and this fell to 6.5 days after. In contrast, before guidelines our neonates required only 7 days to reach an enterai intake of 100 kcal/k/d. Thus, our patients already had very early initiation of feedings and quite rapid escalation of feedings, even before the guidelines were adopted.

Although the magnitude of our improvements, after adopting written feeding guidelines, was not as great as those of Kuzma-O’Reilly et al,3 our trends were similar. Perhaps if we had a much larger sample size, the reduction in NPO days and days to achieve various feeding milestones would have been more impressive. However, the fact that we observed less variability in all feeding-related outcomes measured suggests that adopting guidelines can produce benefits even among NICUs that have already instituted early enterai nutrition and relatively rapid feeding escalation practices.

ABSTRACT. Background: Parenteral nutrition (PN) is known to induce villus atrophy, epithelial cell (EC) apoptosis, and increase mucosal permeability. The study hypothesized that increasing amounts of energy delivery to mice would result in the best outcome, with the least effects on the mucosa. Methods: Mice were randomized to enteral controls (saline infusion with ad libitum enteral food) or to 1 of 3 PN groups (with no enteral nutrition): full (100% of daily average energy intake for the mouse), reduced (75% of energy intake) or very low (50% of energy intake). Mice received PN for 7 days. Mucosal morphology, EC apoptosis, and bacterial translocation were assessed. Results: Villus height decreased significantly with decreasing levels of caloric intake and was significantly lower in all PN groups compared with controls. Body weight loss was significantly greater in PN groups vs controls and was greatest in mice with the lowest caloric delivery. A consistent trend toward a higher EC apoptotic index with decreasing caloric intake was observed, and apoptosis in all PN groups exceeded controls (2-fold). All PN groups demonstrated greater bacterial translocation than controls. Conclusions: PN induces intestinal EC apoptosis and villus and crypt atrophy, even at 100% of predicted energy needs, and such changes increased with greater reduction of energy intake. This study supports a concept that lack of enteral nutrition, rather than absolute caloric levels, is responsible for many of the adverse effects of PN. The study also allows the investigators to better optimize a mouse model of PN delivery. (Journal of Parenteral and Enteral Nutrition 30:474-479, 2006)

Patenterai nutrition (PN) is known to induce significant changes in mucosal structure and function. These changes include villus atrophy, epithelial cell (EC) apoptosis, and altered mucosal permeability. PN administration is associated not only with morphologic changes in the intestine but also with bacterial translocation and a loss of mucosal barrier function.1″3 The mechanisms of PN-associated loss of epithelial integrity and morphologic changes have been studied extensively using a mouse model.1″6 The use of a mouse model can offer great insights into these PN-associated effects on the gastrointestinal tract. Recent work by our group has helped to identify mechanisms that contribute to the occurrence of bacterial translocation and villus atrophy.1-3,6 Unlike other animal models, the use of mice is relatively inexpensive, allows for an extensive study of the alterations in their immune system, and can be managed in a small laboratory setting. Delivery of PN to mice, however, is a challenge and has been associated with a moderate mortality.7 To address this problem, this study was designed to determine the amount of energy delivery via PN using a mouse model, whereby the closest approximation to energy needs is met and with the fewest number of complications. We also sought to determine whether different levels of energy delivery, administered as PN, correlated with PN-associated intestinal changes. We further attempted to determine the most optimal amount of energy delivery while optimizing mouse survival and morbidity. We hypothesized that higher energy delivery via PN would result in fewer aberrations in intestinal morphology and improved survival.

MATERIALS AND METHODS

Animals

C57BL/6J male specific-pathogen-free mice (8 weeks old) were obtained from Jackson Laboratory (Bar Harbor, ME) and were maintained under temperature-, humidity-, and light-controlled conditions. Mice were initially fed ad libitum with standard mouse chow and water and allowed to acclimate. During the administration of IV solutions, mice were housed in metabolic cages to prevent coprophagia. The studies reported here conformed to the guidelines for the care and use of laboratory animals established by the University Committee on Use and Care of Animals at the University of Michigan, and protocols were approved by that committee (No. 7703).

Operative Procedures and Study Groups

Mice were anesthetized with sodium pentobarbital (50 mg/kg/body weight, intraperitoneal). All surgical procedures were performed under magnification in a sterile fashion. The left jugular vein was exposed and cannulated with a silicone rubber catheter (0.012-inch ID, 0.025-inch OD; Dow Corning, Midland, MI). The distal end of the catheter was tunneled subcutaneously and exited between the scapulae. The catheter was attached to a swivel spring, which allowed the mice freedom of movement in their individual cages (Metamount System, Instech Corp, Plymouth Meeting, MA). Catheterized mice were immediately connected to an infusion pump (AIM pain provider pump, generously donated by Abbott Laboratories, Abbott Park, IL) and saline (dextrose 5% in 0.45 NS with 20 mEq KCVL) was infused at an initial rate of 4.8 mL/d. After 24 hours, the animals were randomized to control or PN groups. Of note, the AIM pain provider pump is one of the most accurate available to date. Nevertheless, the delivery is cyclical and not continuous. Thus, as infusion rates increased, we found that some mice developed extravasation of IV PN. These mice were not included in the study results.

ABSTRACT. Background: There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. Methods: Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enterai feedings with 72 hours. Results: Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37 ± 12 years and a mean injury severity score of 24 ± 10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. Conclusions: Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population. (Journal of Parenteral and Enteral Nutrition 30:503-506, 2006)

Nutrition support in the traumatic brain-injured patient continues to be a very important factor in the care of these unique high-risk patients. Because of various factors, including multiple surgeries and aggressive treatment modalities, that may hinder gastric emptying, nutrition support is often compromised. This increases the risk of poor outcome and, thus, may negatively affect outcome. The traumatic braininjured patient who has intractable intracranial hypertension represents a unique patient population that is at the far end of the spectrum in terms of risk and adverse outcome.

The traumatic brain-injured patient rapidly becomes the paradigm of unchecked metabolism and catabolism.1 A hypermetabolic and hypercatabolic state ensues, and daily caloric and protein needs may be in excess of twice the normal predicted basal caloric and protein needs. Impaired immune function may result as a consequence of this hypermetabolic response and inadequate nutrition, leading to increased susceptibility to infection and adverse outcome.2 Early nutrition in these patients has been demonstrated to ameliorate the profound negative nitrogen balance caused by this excessive protein catabolism.1′3

The ability to provide adequate nutrition support is often hindered when patients require neuromuscular blockers and other sedative agents as major components of their clinical management.4′5 Both traumatic brain injury and these classes of medications impair gastric emptying and thus lead to intolerance of gastric feeding.6 Pentobarbital-induced coma is a treatment strategy reserved for the traumatic brain-injured patient with refractory intracranial hypertension. This treatment modality decreases the tone and amplitude of contractions of the gastrointestinal tract and is mediated centrally and peripherally. Therefore, patients are more likely to not tolerate enterai nutrition.

There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enterai nutrition in a select group of trauma patients.

METHODS

Prospective data were collected over a 4-year period (1999-2003) on 57 consecutive severely traumatic brain-injured patients admitted to the R. Adams Cowley Shock Trauma Center who were induced into a barbiturate coma due to refractory intracranial hypertension. Barbiturate coma was denned as per American Association of Neurological Surgeons (AANS) guidelines (Table I). Feeding tolerance was not evaluated until there was a physical examination consistent with barbiturate coma (no cough or gag reflex) or burst suppression by electroencephalogram (EEG) measurements. All patients were initially fed with an immuneenhanced formula via the enterai route using a nasogastric feeding tube. Patients who did not tolerate enterai feedings within 48 hours of barbiturate coma initiation began receiving a standard prokinetic regimen (Reglan, AH Robins Co., Division of American Home Products, Madison, NJ; 10 mg IV every 6 hours) and switched over to a semielemental or elemental formula as per the staff clinical nutritionist. Placement of nasal-jejunal tubes, either blindly or endoscopically assisted, in patients that failed to tolerate enterai feedings despite prokinetic therapy was at the discretion of the intensive care unit (ICU) attending physician. Feeding tolerance was defined as the ability to tolerate enterai feedings with 72-hour period from initiation of barbiturate coma. Patients who did not tolerate gastric feedings within 72 hours started receiving parenteral nutrition (PN) via the central venous route. Caloric requirements and rates of nutrition infusion were determined in a multidisciplinary fashion by the critical care physician, critical care nutritionist, and trauma physician.

The purpose of this article is to describe the social and political events that have had a major influence on the shaping of physical therapy education since the beginning of the profession. This theme was developed by looking at the early history of the development of the field in the United States followed by an examination of the effects of World War I and the Great Depression on development of the education of the physical therapist. Following this, there is an exploration of the effects of World War II and the postwar period on the further development of the education of the physical therapist related to the social and political changes occurring in the nation. During the 1960s, there was a great deal of change in the nation’s political, cultural, and social values, and these changes were explored in relationship to the physical therapy profession’s educational changes. From the 1970s to the 1990s, rapid changes were taking place in terms of accreditation and education of the physical therapist, and these changes are discussed. During this time, increased legislative activity leading to direct access occurred, and the initiative to develop a postbaccalaureate degree as the primary method for education for the physical therapist began. The postbaccalaureate degree discussion finally led to the development of the Doctor of Physical Therapy (DPT) degree being adopted as a goal for the profession. In the late 1990s and at the beginning of the 21st century, changes took place in physical therapist practice requiring the profession to deal for the first time with a potential surplus of physical therapists. Also discussed is the concept of strategic adaptation and the successes and failures of the adaptations that the profession has made. Finally, there is a discussion of the transition to the DPT degree and the continuing changes that are occurring in the field of physical therapy.

Social and political events have had a major influence on higher education institutions and activities during the time period that physical therapy emerged and developed as a health care profession. Many have made the observation that survival of institutions and professions is related to how well change is managed. In general, higher education has continuously changed over the past 100 years as universities and colleges in this country have adapted to the needs of a society requiring more access to higher education as well as accommodating the needs of emerging professions and occupations. Progress in these areas often seems to be made both grudgingly and slowly, but viewed over the long run, the changes are remarkable and impressive.

Lawrence1 has suggested that in medicine and other health care professions, the most important roles have traditionally been practice, research, and teaching. The teaching role referred to here is the role of preparation of those who want to enter the professions represented by health care. The Flexner report on medical education of 1914 caused a revolution in medical education that has influenced thinking in all health care professions.2 The Flexner report set the general framework for health care professions education and stressed the importance of the education of the health care professional and the importance of a relationship between professional education and universities.

It is a daunting task to explain the political and social issues that have shaped physical therapy education. I am not a political scientist nor a historian, and certainly not a sociologist. I am a physical therapist with significant experience in both the clinical practice and higher education aspects of physical therapy; therefore, the perspective presented will basically be one that is, in many ways, personal and anecdotal.

EARLY HISTORY OF THE FIELD

We begin with the historical perspective. The role of the physical therapist as a practitioner began to grow in this country out of the posture and scoliosis clinics established by physicians at the turn of the 19th to the 20th century.3,4 These physicians sought assistance from women with backgrounds in physical education to assist them. During this time, poliomyelitis epidemics occurred, and orthopedic surgeons, primarily in the New England area, expressed a need for help in caring for patients with poliomyelitis after the acute stage of their illness. This need was met primarily by employing women who were physical educators who provided prograins of exercise and what we would now call rehabilitation. During this period, hospital departments in Boston and Philadelphia were established for the management of orthopedic problems in addition to poliomyelitis.4

WORLD WAR I TO THE GREAT DEPRESSION

Although physical therapy was being recognized as an important service, a great deal of growth did not occur until World War I. The war was a key factor in the development of the profession.1-6 During WWI, the Army took on the role of educating women as reconstruction aides. Physicians were the primary force in recognizing that soldiers and other military personnel with front-line and battlefield injuries would need a great deal of assistance in reaching their full potential as their wounds and injuries healed. Reconstruction aides trained by the Army at Walter Reed Hospital and also at Reed College in Oregon among others formed the backbone of what was to become the profession of physical therapy. Reed College was among the first institutions to offer education to women who desired this training and who were not prepared directly by the Army.

This article describes the developmental processes underlying the implementation of the Doctor of Physical Therapy (DPT) program at Creighton University. Creighton University established the first professional (entry-level) UPT program in physical therapy. An explanatory case study was used to frame the analysis of specific decisions and key events. A case study database was created using documentation, archival records, interviews with key decision makers, and authors’ experiences as participant observers. Critical factors in the development of this program included institutional and school leadership, institutional commitment and capacity, contributions of key educational leaders in physical therapy, a strong institutional mission consistent with work of health care professions, and a strong faculty belief system focused on the key role of clinical doctoral education for preparation of a professional physical therapist.

In 1985, Geneva Johnson, PT, PhD, FAPTA, in the 20th Mary McMillan Lecture, advocated for the development of the clinical or professional doctorate for the first professional degree for physical therapists: “Changes in education are key to full professional status…. I expect us to develop the professional doctorate in physical therapy as a standard for entry-level education within the next five years.”1(pp1693-1694) During this time, physical therapy education was in the midst of transition from the baccalaureate degree level to the master’s degree level. The Education Division of the American Physical Therapy Association (APTA) did not initiate widespread discussion on doctoral education until the late 1980s. The 1989 Report on Doctoral Education clarified distinctions between PhD programs, designed to prepare scholars, and professional or clinical doctoral (DPT) programs, designed to prepare students for entry into the profession. The report also included recommendations for continued discussion within the physical therapy community on doctoral education.2 In 1993, Creighton University initiated the first professional (entry-level) physical therapist program that would lead to the Doctor of Physical Therapy (DPT) degree upon completion.

This article is an explanatory case study focused on analysis of the critical factors and influences that led to the planning and implementation of the DPT program at Creighton University.

CASE STUDY METHOD

Case study methodology can be used to illuminate a decision or set of decisions surrounding a specific process or program.3 In this instance, the case is focused on the development and implementation of the DPT program at Creighton University. The explanatory case will focus on why decisions were made and how decisions were implemented leading to the realization of the initial DPT program.

Data Sources

Data sources for the case study database included: (1) documentation that included letters, memoranda, agendas, meeting minutes, written reports, and administrative documents such as progress reports and proposals; (2) archival records that included organizational and institutional records; (3) selected interviews with key decision makers in the process; and (4) participant observation of authors who were all involved at various times in program development and implementation.

Case Study Creation

Three core principles were followed in the creation of the case study. First was the use of multiple sources of evidence, second was the creation of a case study database, and third was the maintenance of a chain of evidence. A chain of evidence means that one goes beyond single sources of data and looks for connections and patterns of evidence across the data sources.3 Review of the case for verification of assertions and interpretations was done by selected key stakeholders and decision makers.

Case Descriptive Framework

One analytic strategy for case study creation is development of a descriptive framework for organizing the case. While the stated purpose of this article is descriptive and explanatory, it also provides a historical view of the development of the first professional DPT program. Therefore, the framework will be centered on a chronology of decisions and actions across time (Tables 1 and 2).3

INITIAL BEGINNINGS: FROM IDEA TO FEASIBILITY

In the fall of 1986, Father Michael G Morrison, SJ, president of Creighton University, in conjunction with Richard L O’Brien, MD, vice president for Health Sciences, requested that the School of Pharmacy and Allied Health Professions consider the establishment of a physical therapist education program. Creighton University initiated an occupational therapist program in 1985. The university was interested in investigating the possibility of initiating other health care professions programs. A related factor in the president’s interest in physical therapy came from a personal contact-his sister was a physical therapy faculty member at Marquette University. She suggested that if he was interested in starting health care professions programs, he should consider physical therapy.

Background and Purpose. Professional (entry-level) education in physical therapy, as an enterprise distinct from, yet central to, the profession of physical therapy as a whole, has reached a level of maturity at which there is value in reviewing its development. The authors identify major elements of importance in professional education, including the nature and institutional setting of professional education programs, curriculum content and design, and characteristics of students and faculty. Major events and developments are highlighted for each major element. Methods and Materials. Information has been drawn from published materials dating from the 1910s through the end of the 20th century and from archival records maintained by individual professional education programs and professional organizations in or related to physical therapy. This information has been augmented by the authors’ personal experience of professional education during the years from the 1940s through the end of the century. Summary of the Literature. Comprehensive reviews of professional education in physical therapy have been conducted at various points in time. Detailed analyses of different aspects of physical therapy education have been published throughout the 20th century. Comprehensive, but nonscholarly, histories of the profession of physical therapy, including discussions of events pertaining to professional education, also have been published, most recently in the mid 1990s. Conclusion. The article provides an overview of the history of professional education in physical therapy.

A thorough discussion of professional (entry-level) education in any field needs to address a variety of related topics, including curriculum content and format, institutional setting and program resources, faculty and student characteristics, and program standardization and accreditation. Fortunately, a number of these specific concerns are addressed in other articles in this special issue. This article, while not attempting to do complete justice to the remaining topics, will highlight the major issues and developments that occurred during the 20th century in regard to curriculum content and design, faculty and student characteristics, and institutional setting of professional education in physical therapy.

Put yourself in the position of responding to the hypothetical requests for information that are interspersed throughout this article. What might you emphasize in response to each one? How might your response have varied in each circumstance?

Lucy C_

Boston, Mass

Dear Cousin Lucy, February 21, 1918

I was so excited to hear that you have decided to apply to be one of these new Reconstmction Aides. It sounds so thrilling! I have been thinking that maybe I could do that, too, if I could get into a training program this summer, rather than going to normal school as I had planned. Could you tell me more about it? Where would I have to go to get training, and what would it be like?

I’m sorry you were not able to be home for Christmas . . .

Your loving cousin, Beth

The Cedars, Park City, Iowa

If Beth was considering attending normal school in the fall, she almost certainly would have been much too young to become a Reconstruction Aide, the lower age limit for applicants being 25 years.2 Her cousin Lucy, if she was entering training in the Boston area, had open to her a choice of three programs that had been identified by the Office of the Surgeon General of the Army, the American School of Physical Education, the Boston School of Physical Education, and the Posse Normal School of Gymnastics.3 Another East Coast school also was identified by this time, the New Haven Normal School of Gymnastics. Later, in 1918, a new training program was instituted at Walter Reed General Hospital under the auspices of the Medical Department of the Army. If Beth had been of an age to consider entering a Reconstruction Aide program, she would have found one nearer to hand at the Normal School of Physical Education in Battle Creek, Mich. Or she could, as did many individuals from all over the country, have attended the program at Reed College in Portland, Ore.4 If Lucy had already received training considered appropriate for a Reconstruction Aide, she might eventually have refined her knowledge and skills under the direction of Janet Boyd Merrill at the advanced training program established jointly by Harvard University and the Boston Children’s Hospital in 1918.

Both the Reconstruction Aide training programs authorized in January 1918 by the Office of the Surgeon General of the ArmyS and acceptable physical education programs were expected to have provided the potential Reconstruction Aide with knowledge and skills in the areas of massage and corrective exercise, with emphasis on the application of these interventions to pathological conditions. The programs identified as of January 1918, were-with the probable exception of the one at Battle Creek-situated within institutions with established, relatively standard physical education certificate or degree-awarding programs. Even though the Reconstruction Aide training programs in these institutions were much shorter in length-rarely lasting longer than 3 months-than the full preparation for physical education, they did incorporate such basic course work as anatomy (structural and functional), pedagogy, and various sports as well as the medically oriented courses in pathology,6 massage, and corrective exercise.7 Clinical application was closely integrated with didactic work, with students typically spending part of the day in supervised clinical practice and the remainder in class.

The authors review the recognition of physical therapy education programs from 1928 to the present and describe the chronological activities that led to the accreditation process as we know it today. The history, current practice, and the broader national accreditation environment in which the Commission on Accreditation in Physical Therapy Education (CAPTE) must operate are explained. The evolution of the standards used in making accreditation decisions in physical therapist professional education is described along with the changes in the arenas of education and practice that have influenced the accreditation process. Possible and probable changes for the future are proposed.

In 2003, the year after the Commission on Accreditation in Physical Therapy Education (CAPTE) celebrated its 25th year of national recognition as an accrediting agency, a 1977 quote from Rosemary Scully, PT, EdD, which predated CAPTE’s initial recognition, is still quite applicable to the profession:

Physical Therapy has an ancient history, a proud past, an exciting present, and a challenging future. Education for physical therapy practice has been built on a strong foundation and with resourcefulness and wisdom it should be able to meet the demands of the present and the challenges of the future.1(p159)

This article will explore the history of accreditation in physical therapy and the evolution of the standards used in making accreditation decisions in physical therapist professional education. It will describe the changes in the arenas of education and practice that have influenced the accreditation process and the national environmental influences with which each nationally recognized accreditation agency must deal. The work of CAPTE also includes the activities of accreditation related to physical therapist assistant education programs. However, this article will not compare the evolution of the criteria related to those programs nor the changes within the practices of physical therapists that have clearly led to changes in the work done by physical therapist assistants.

HISTORY-THE EARLY YEARS

Education programs for the preparation of physical therapists have been recognized in some manner since 1928. The American Physical Therapy Association (APTA) first published a list of approved programs in the June 1928 issue of The Physiotherapy Review and continued to publish such a list through 1933. Little is known about the process used to approve programs, but the standards by which they were measured are well documented in the Minimum Standard for Schools of Physical Therapy.2

In 1933, because APTA lucked the financial and human resources needed to manage the accreditation effort, APTA requested and received agreement from the American Medical Association’s Council on Medical Education and Hospitals (AMA/CME) to become involved in accreditation and recognition of programs in physical therapy.3 During 1934 and 1935, no additional programs were granted approval, nor was approval withdrawn by either organization.

The AMA/CME inspected and approved13 programs in physical therapy using as its standards for approval the Essentials of an Acceptable School for Physical Therapy Technicians.4 An annual list of approved programs was published in the Journal of the American Medical Association beginning August 29, 1936. From 1936 to 1956, the AMA was solely responsible for accreditation activities, though AMA staff did submit a report on each program to the APTA Executive Committee prior the AMA/CME action.5 The Essentials of an Acceptable School of Physical Therapy6 was developed and adopted in December 1949 in collaboration and cooperation with the Council on Physical Medicine and Rehabilitation, APTA, and the AMA Council on Medical Education and Hospitals.

COLLABORATION AND CHANGE Although documented evidence is difficult to find, it is rumored that in the mid 1950s the AMA approached APTA and requested that its members become involved in a collaborative accreditation effort. The APIA’S former director of education, Patti Evans, recalls Sarah Rogers’ vivid recollections of the complaints, conditions, and conversations that led to the request that physical therapists join in that collaboration (Patricia Evans; personal communication; September 16, 2003). One might surmise that by this time APTA’s members were well prepared to assume roles of responsibility in the survey visits and decision-making processes and were more plentiful in numbers than during the 20 years prior when a similar request was made by APTA to the AMA.

From 1957 to 1963, AMA and APTA shared an informal arrangement, and from 1964 to 1976, a formal collaborative arrangement existed for accreditation of only physical therapist education programs using the December 1955 revision of the Essentials of an Acceptable School of Physical Theraphy.7

In 1967, while the collaborative effort with the AMA was operating for the accreditation of physical therapist education programs, the APTA House of Delegates (House) authorized the education of physical therapist assistants at APTA’s Annual Conference by adopting a policy statement regarding the training and utilization of physical therapist assistants.5 At th time, the AMA/CME was not interested in accrediting these programs, so APTA developed standards for education programs for the physical therapist assistant and established approval procedures. The first Standards for Physical Theraphist Assistant Education were adopted by the APTA Board of Directors (Board) in June 1972 and were published in the September 1972 issue of Physical Theraphy.8 After discussion with representatives from the National Commission on Accreditation, the US Office of Education (USOE), and the American Association of Community and Junior Colleges, the APTA Board adopted the Statement of Interpretations and implemented the Interim Approval Program for Education Programs for the Physical Therapist Assistant.5 The first interim approval decisions were granted by APTA in 1971 with effective dates that retroactively included graduates of the first class from each approved program. The first published list of APTA interim approved programs for the physical mcrapist assistant appeared in Physical Theraphy in 1972.9