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Archive for the ‘Related Medical News & Information’ Category

New recommendations out of a recent conference in Austria as reported by the Heart.org.  This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org,  in”Case made for metabolic bariatric-surgery eligibility criteria,”  new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs.  Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes.  That’s because the majority of type II diabetic patients are  overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes.  Many of the surgeons previously interviewed for numerous projects here at Cartagena Surgery were involved in several early studies on the effects of surgery in moderate overweight patients with diabetes.

More interestingly, researchers at the conference are also suggesting possible gastric bypass procedures for patients with ‘pre-diabetes’ or patients with an hemoglobin A1c greater than 5.7 % but less than 6.5% (6.5% is the cut off for diagnosis of diabetes.)

This is wonderful news – it means committees and such are finally getting around to following all of the research that has been published and presented over the last ten years..  But then it just one more important step…

Call it by its name

So I have my own suggestion to doctors and researchers – and it’s one that I’ve made been – a nomenclature change.  We need to stop calling it “pre-diabetes”, because the name is a falsehood – and leads everyone (patients, nurses and doctors astray.)

– Greater than 95% of patients with ‘pre-diabetes’ will develop diabetes – so without a drastic intervention (far beyond diet and exercise)  it’s pretty much a certainty.

– Many of the devastating complications of diabetes develop during this so-called pre-diabetic period.

– Doctors are now recommending surgical treatment to cure this “pre” disease state.

So….  

if almost everyone who has ‘pre-diabetes’ gets diabetes, and it’s already causing damage PLUS we now recommend a pretty radical lifestyle change (surgical removal of most of the stomach) —> that sounds like a disease to me.  Call it early diabetes, call it diabetes with minimal elevation of lab values, but call it what it is….Diabetes..

This is critical because without this firm diagnosis:

insurance won’t pay for glucometers, medications, diabetic education, dietary counseling (or surgery for that matter).  That’s a lot of out-of-pocket expenses for our patients to bear, for something that is treated like a ‘maybe’.

– patients (and healthcare providers) alike won’t take it seriously..  Patients won’t understand how crucial it is to take firm control of glucose management, patients won’t be started on preventative regimens to prevent the related complications like renal failure, heart disease and limb ischemia.

– Patients may not receive important screening to prevent these complications – and we already know that at the time for formal diagnosis (usually SEVEN years after initial glucose derangements are seen) – these patients will already have proteinuria (a sign of kidney disease), retinopathies, vasculopathies and neuropathies..

I work with providers every day, and the sad fact is that too many of them (us) shrug their shoulders and say – yeah – he /she should eat better, get more exercise, shrug.. But they don’t treat the disease – they don’t start checking the glucose more often, they don’t start statin drugs, the don’t screen for heart disease and they don’t consult the specialists – the diabetic educators, the nutritionists, the endocrinologists – and yes, the bariatric surgeons…

Chances are if your doctors and your nurses don’t take it seriously; and don’t make a big deal out of it – and don’t talk to you, at length about what “pre-diabetes” IS and what it really means for your life and your health –

then neither will you.

For related content:  see the Diabetes & Bariatric tab

the Weight of a Nation: the obesity epidemic

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Gastric bypass to ‘cure’ diabetes goes mainstream

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In the wake of wide-spread cardiac device recalls as well as the recent FDA decision to approve and extend TAVI eligibility criteria to ‘moderate’ risk, surgically eligible patients; we need to ask:

How valuable is FDA approval?”

“How rigorous is this process?”

“Does this mean the devices are safe for patient use?”

Well, we know that FDA approval is extremely valuable for companies wanting to market their devices in the United States; it brings in billions and billions of dollars.  But how valuable is this process in protecting patients?

It’s something that Dr. Connie Chen is currently questioning.  As reported in “Most high-risk CV devices approved without tests vs standard care.” in the Heart.org few of these devices are ever even tested against the therapies they are designed to replace.

In the attached article, “We wondered what that [evidence base] looked like for devices,” Dhruva explained. “Our feeling is that these high-risk devices are often permanently implanted, and device removal can be treacherous. So the issue is, if you decide you are going to place a device, you want to make sure the indication is appropriate.”

Now that the FDA has issued a statement (October) about fast-tracking new devices and drugs to American consumers, it is something that we need to continue to consider.

But as quoted in the heartwire article, the FDA is well aware of shortcomings..

“Contacted by heartwire, the FDA issued a response attributed to Dr Owen Faris, deputy director of the Division of Cardiovascular Devices. According to Faris, the FDA is “aware” that a minority of cardiovascular devices over the past decade have been approved without being tested against an active comparator.”

What about consumers?

“‘Given the focus on these issues, he and his colleagues think physicians and patients should be aware of just how few high-risk cardiovascular devices meet comparative-effectiveness standards.”

“The FDA doesn’t have sufficient resources, it’s underfunded,” Dhruva points out. “Perhaps if they had more resources for more staff and were less dependent on the companies who are applying for approval, they may have the opportunity to review these trials in more depth.”

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From Reuters business pages comes news of the latest ‘non-inferiority’ trial from medical equipment mega-giants, Medtronic.  They are using the occasion to push the TAVI valve for ‘intermediate risk’ patients with aortic stenosis.

Who is intermediate risk?  Well, when it comes to people with aortic stenosis – the case can be made – just about everyone.

So what’s my bias – you ask?  The same as always – the slick talking and flexible result reporting behind ‘non-inferiority’ trials and their trial designs.  We talked about this data manipulation before – during another discussion of cardiology studies – the stent versus CABG studies (Syntax trial).

Want to know more about non-inferiority trials and study designs?

Snappin has an excellent article describing this research design here.

More on non-inferiority trials by Schumi & Wittes

“By contrast, non-inferiority trials tend to reward the careless. The less rigorously conducted the trial, the easier it can be to show non-inferiority. As treatments improve, showing benefit of a new therapy becomes more and more difficult, but showing non-inferiority becomes ever easier, stemming from ‘lack of constancy’ (deliciously termed ‘biocreep’ in drugs and ‘technocreep’ in devices).”

Here’s another explanation that’s a little less technical..

“Non-inferiority really means “not too inferior”, and how inferior is too inferior must be determined. You should plan on plenty of pre-protocol discussion over this topic.” – Nancy Stark

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A frightening decision by the FDA just as a savvy reader forwarded an episode of last season’s Grey’s Anatomy – which highlights the issues involved in the use of TAVI.   In this article, “FDA extends Sapien use to high-risk surgical patients“, Shelly Wood at the heart.org explains the FDA’s recent decision to expand eligibility criteria for TAVI use to patients eligible for surgery, (but deemed high risk).  No mention is made of the recent controversy over TAVI due to higher than expected complications.

At the same time, a reader encouraged me to watch last season’s Grey’s Anatomy episode where a low-risk patient demands (and RECEIVES) TAVI instead of traditional surgery because he doesn’t want a scar to mar his physique.  Of course, there is no mention on the show of post-procedural complications (because it’s a fictional program on television) but the very manner in which the episode was handled is frightening.

There was no discussion of unnecessary risk for the patient using experimental technology, or of the Major vascular complications that occur in more than one in seven TAVR patients: according the PARTNER trial.  There is also no mention of the drastic increase in mortality if these complications occur.  In the episode, the resident researches the procedure – and decides (appropriately) that the procedure is not suitable for the patient.  He is then scooped by the cardiac surgeon, who decides, “hey – what the heck – seize the day!”

Link to clip of Grey’s Anatomy

But as I said – it’s only television, right?  Except that it isn’t.  It’s a powerful medium used to disseminate information to the millions of people who watch that program.  (9.5 million people, according to recent ratings information.)  They also make a pretty huge leap on the program – changing TAVI from a procedure supposedly for patients with no other option (surgery ineligible) to a low-risk patient who wants to avoid a scar..

and now – the FDA expands criteria – despite a turbulent summer which included  previous criticism (by the FDA) based on irregularities in the PARTNER trial itself – and a violent controversy over the safety of this procedure.  The British Medical Journal also published an article over the summer decrying the overuse of the procedure.

Additional References – more in archives

1.  Amabile N, Azmoun A, Ghostine S, Ramadan R, Haddouche Y, Raoux F, To NT, Troussier X, Nottin R, Caussin C. (2012).  Incidence, predictors and prognostic value of serious hemorrhagic complications following transcatheter aortic valve implantation. Int J Cardiol. (2012 Oct 15). pii: S0167-5273(12)01131-X. doi: 10.1016/j.ijcard.2012.09.025. [Epub ahead of print]

Since the article is not available – I have included the abstract.

Abstract

BACKGROUND:

TAVI is an alternative solution for patients with aortic valve stenosis (AS) who are refused for conventional surgery. We sought to evaluate the incidence, characteristics, predictors and prognosis impact of serious hemorrhagic complications following transcatheter aortic valve implantation (TAVI).

METHODS:

One hundred and seventy-one consecutive patients with symptomatic severe AS (83.5±6.1y; 53% women; mean EuroSCORE=22.1±12.3) underwent transapical (TA) or transfemoral (TF) TAVI in our institution using Edwards SAPIEN© and Medtronic CoreValve© devices. The primary evaluated criterion was the incidence of any bleeding complication, according to the Valve Academic Research Consortium (VARC) criteria.

RESULTS:

VARC serious hemorrhagic complications occurred in 34.5% of patients (n=23 life-threatening/disabling (LT/D) and n=36 major bleedings). Most of these complications were related to access site complications (69%). Multivariable analysis revealed that TA access, low weight and underlying coronary artery diseases were independent predictors for development of serious bleeding. The mortality was significantly higher in patients with serious events compared to patients without bleeding (p=0.008, log-rank analysis). Although the survival didn’t significantly differ in patients with major hemorrhagic events, subjects with LT/D bleeding events had a higher mortality than the subjects with no hemorrhagic complications (p<0.001, log-rank analysis). Occurrence of VARC LT/D event independently predicted all-cause mortality (HR=5.35 [2.51-11.43], p<0.001) during the first year following TAVI in multivariate Cox regression analysis.

CONCLUSION:

Severe bleeding is frequent following TAVI procedure and is mainly related to local hemorrhage. VARC LT/D events are associated with decreased survival after AS correction.

2.  Gul M, Erkanli K, Erol MK, Bakir I. (2012).  Ventricular Embolization of Edwards SAPIEN Prosthesis Following Transcatheter Aortic Valve Implantation.  J Invasive Cardiol. 2012 Oct;24(10):537-8.  While this is a single case, this illustrates much of the data presented in a previous post.

3.  Latsios G, Toutouzas K, Tousoulis D, Stathogiannis K, Tentolouris C, Synetos A, Filis K, Stefanadis C.  (2012).   Prosthetic aortic valve removal from the abdominal aorta after successful “valve-through” TAVI.  Int J Cardiol. 2012 Oct 12. pii: S0167-5273(12)01285-5. doi: 10.1016/j.ijcard.2012.09.164. [Epub ahead of print]
Given that the patient almost lost his leg (and was taken to the operating room for emergency limb salvage surgery with a vascular surgeon), I think ‘success’ is a bit presumptuous for the title.  Reminds me of an old medical joke around the hospital when I was in training (which I have made some adjustments to.)
Dr. [exhultant as he leaves the cath lab] “I successfully implanted the new TAVI valve.”
Nurse:  But doctor, the patient died twenty minutes ago, [as she covers wheels corpse out of cath lab.]
Want more information on TAVI and aortic stenosis?  Just look in our archives.

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XXIX Congreso Latinoamericano de cirugia vascular y angiologia

Santa Cruz de la Sierra, Bolivia

Dr. Berrio, Vascular Surgeon, Tulua, Colombia

Dr. Jhon Jairo Berrio is  the Chief of Vascular Surgery at the Clinica San Francisco, Tulua, Colombia, which is a small community outside of Cali.  He attended medical school in Colombia, completing his general surgery residency at Hospital clinics for Carlos.  He completed additional training at New York University and he completed his vascular surgery residency in Bogota at the Hospital de Kennedy  and trained under the instruction of Dr. Albert Munoz, the current president of the Association of Latin American Vascular Surgery and Angiography (ALCVA) .  He does a range of vascular procedures such as aortic aneurysm repair, fistula creation as well as endovascular surgery but his favorite procedures are limb salvage procedures such as aorto-femoral bypass, femoral-popliteal bypass and other treatments designed to prevent amputation.

He is here in Bolivia giving a presentation on the use of Prostaglandin E1 for critical ischemia / and last chance limb salvage.

Today we are talking to Dr. Berrio about the use of prostaglandin E1 (Iloprost/ iprostadil) for peripheral vascular disease (PAD).  In the past, we have used a myriad of treatments including statins, pentoxifylline, clopidogrel and even quinine for the prevention and relief of claudication symptoms.  However, all of these previous agents are designed for early PAD and are only minimally effective at treating later stages of disease.  Treatment of severe disease (rest pain or ulceration/ ischemia wounds) has been limited to stenting (angioplasty) and surgical revascularization – but this strategy often fails for patients with microvascular disease (or disease that affects vessels that can not be operated on.)

Last effort at Limb Salvage in critical ischemia

No – Prostaglandin E is not some magic ‘panacea’ for peripheral vascular disease.  There is no such thing – but it is a medication in the treatment arsenal for vascular surgeons – and it has shown some promising results particularly in treating limb-threatening ischemia.  In fact, the data goes back over 20 years – even though most people in the United States have never heard of it.  That’s because prostaglandin E1 is more commonly used for other reasons in the USA.  It is a potent vasodilator, and in the US, this medication is often used in a different (aerosolized form) for primary pulmonary hypertension.  It is also used for erectile dysfunction.  Despite a wealth of literature supporting its use for critical ischemia it is not currently marketed for such use in the United States – and thus – must be individually compounded in a hospital pharmacy for IV use.  Supplies of this medication in this form are often limited and costly.

Intravenous Prostaglandin E1

This medication offers a desparately needed strategy for patients with critical ischemia who (for multiple reasons) may not be surgical candidates for revascularization and is a last-ditch attempt to treat ‘dry’ gangrene and prevent amputation and limb loss.  Since more than 25% of all diabetes will undergo amputation due to this condition – this is a critical development that potentially affects millions of people.  (Amputations also lead to high mortality for a variety of reasons not discussed here.)

What is Prostaglandin E1?

As mentioned above, prostaglandin E1 is a potent vasodilator – meaning it opens up blood vessels by forced the vessels to dilate.  This brings much-needed blood to ischemia tissue (areas of tissue dying due to lack of blood.)

Treatment details:

A full course of treatment is 28 days.  Patients receive 60 micrograms per day by IV.

Patients must be admitted to the hospital for observation for the first intravenous administration of prostaglandin E1.  While side effects such as allergic reactions, rash or tachycardia are rare – since this medication is given as an IV infusion, doctors will want to observe you for the first few treatments. The most common side effect is IV irritation.  If this occurs the doctors will stop the infusion and dilute it further to prevent discomfort.  Once your treatment has been established, doctors may arrange for you to have either out-patient therapy at an infusion center, or home health – where a nurse comes to your house to give you the medication.

The surgeons will evaluate your legs before, during and after treatment.  If the ischemia or rest pain are not improving, or worsen during treatment – doctors may discontinue therapy.

Prostaglandin E1 therapy is compatible with other medications for PAD such as clopidogrel, aspirin, pentoxifylline and statins, so you can continue your other medications for PAD while receiving this treatment.  However, if you are taking nitrates such as nitroglycerin, (Nitro-dur, Nitropaste) or medications for pulmonary hypertension or erectile dysfunction – please tell your surgeon.

In Colombia, the average cost of the entire course of treatment (4 weeks of daily therapy) is 12 million Colombian pesos.  At today’s exchange rate – that is  a little under $ 7000.00  (seven thousand dollars, USD).

While this is a hefty price tag – it beats amputation.  In some cases, arrangements can be made with insurance companies to cover some of the costs.  (Insurance companies know that amputation-related costs are higher over the long run, since amputation often leads to a lot of other problems due to decreased mobility).

Additional Information about Dr. Berrio:

Dr. Jhon Jairo Berrio, MD

Vascular surgeon

Calle 414 – 30

Buga, Colombia

Tele: 236 9449

Email: vascular@colombia.com

Speaks fluent English, Espanol.

References/ Additional information about peripheral arterial disease (PAD) and prostaglandin e1

Pharmacotherapy for critical limb ischemia  Journal of Vascular Surgery, Volume 31, Issue 1, Supplement 1, January 2000, Pages S197-S203

de Donato G, Gussoni G, de Donato G, Andreozzi GM, Bonizzoni E, Mazzone A, Odero A, Paroni G, Setacci C, Settembrini P, Veglia F, Martini R, Setacci F, Palombo D. (2006).  The ILAILL study: iloprost as adjuvant to surgery for acute ischemia of lower limbs: a randomized, placebo-controlled, double-blind study by the italian society for vascular and endovascular surgery.  Ann Surg. 2006 Aug;244(2):185-93.  An excellent read – even for novices.

S Duthois, N Cailleux, B Benosman, H Lévesque (2003).   Tolerance of Iloprost and results of treatment of chronic severe lower limb ischaemia in diabetic patients. A retrospective study of 64 consecutive cases .  Diabetes & MetabolismVolume 29, Issue 1February 2003Pages 36-43

Katziioannou A, Dalakidis A, Katsenis K, Koutoulidis V, Mourikis D. (2012).  Intra-arterial prostaglandin e(1) infusion in patients with rest pain: short-term results.  Scientific World Journal. 2012;2012:803678. Epub 2012 Mar 12.e Note extremely small study size (ten patients).

Strecker EP, Ostheim-Dzerowycz W, Boos IB. (1998).  Intraarterial infusion therapy via a subcutaneous port for limb-threatening ischemia: a pilot study.  Cardiovasc Intervent Radiol. 1998 Mar-Apr;21(2):109-15.

Ruffolo AJ, Romano M, Ciapponi A. (2010).  Prostanoids for critical limb ischaemia.  Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006544.

Volteas N, Leon M, Labropoulos N, Christopoulos D, Boxer D, Nicolaides A. (1993).  The effect of iloprost in patients with rest pain.  Eur J Vasc Surg. 1993 Nov;7(6):654-8.

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Heading out-of-town for a conference for a few days – but in the meantime, I’ll be working one several case reports from recent surgeries.

We will also be talking about the latest stories from the Heart.org about the recent rise in off-label use of dabigatran (Pradaxa) use.

Rise in Pradaxa (dabigatran) linked to off-label use

Off-label uses

While this new anti-coagulant has been touted as the ‘easy’ alternative to warfarin since serum monitoring is not required – it is currently approved for the use of non-valvular atrial fibrillation only in the United States.

While it is approved for deep vein thrombosis prevention (DVT prophylaxis) in Europe – it is not, and should not be used for anti-coagulation in patients with mechanical valves.  

Off-label use in Canada leads to life-threatening complications

However, that is apparently exactly how doctors in Canada have been using it – with life-threatening consequences.  In a separate article at the Heart.org, doctors report that two female patients with mechanical valves who were recently switched from warfarin to dabigitran suffered from valvular thrombosis.

The “easy button” strikes again

More concerning, these patients had previously been successfully managed on warfarin without problems prior to the switch.  (So they were taken off a drug that was working well – and switched to a drug that is not approved for this condition because it was perceived to be easier to use.)

Within one month of the switch both patients began experiencing symptoms and were then diagnosed with valvular thrombosis.  Fortunately, neither of these patients died – but they certainly could have.

My former boss had a saying, “the enemy of good is better” meaning that if we try too hard to improve on something that is already working  – we unnecessary risk the lives and health of our patients.

Anticoagulants are not all the same

This just brings home the message that drugs that may seem similar, aren’t.  The way that dabigatran works is very different that warfarin, aspirin, clopidogrel (Plavix), abciximab (Reopro) or the other myriad of anti-coagulation type drugs.  Some of these drugs work on platelets – some of these drugs work on different parts of a complex mechanisms of coagulation (the coagulation cascade).   ‘Anti-coagulants’ is just a blanket term for these medications – and certainly doesn’t fully cover the intricacies of the pharmacology involved.  ‘Easy’ it isn’t – but medicine rarely is.

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Long time readers (and former patients) will be familiar with my aspirin mantra but now Medscape has published a CME course by Dr. Desiree Lie for health care providers in primary practice, general surgery (and other areas that may not be familiar with post-cardiac patient recommendations.)  As I may have mentioned before, in cardiac surgery – we routinely start aspirin in our patients prior to bypass surgery.

Don’t stop Aspirin before surgery

I’ve converted the CME course, Don’t stop Aspirin before surgery into a pdf – but if you want credit – you will have to go to Medscape and log in.  (For everyone else – it’s a nice read – and explains the importance of continuing aspirin in patients who are taking it for “secondary prevention” or are at high risk of cardiovascular events.

That’s because the complications of discontinuing aspirin therapy in these patients are WORSE than the minor risk of bleeding.  (Bleeding issues for most patients taking aspirin are fairly minor.. Now, clopidogrel (Plavix) and prasugrel (Effient) are another story!)

Wait a second… What’s secondary prevention?

They way to think about secondary prevention is “closing the barn after the cows are loose,” as one of my colleagues explains it.  This means that Aspirin has been prescribed to these patients after something has already happened – like a stroke, a heart attack, stents or cardiac surgery.  So in these patients – secondary prevention can be thought of as preventing a second event or further complications from a disease process we already know about.

Now, patients that are at high risk for cardiovascular events like diabetics or people with other kinds of blockages (peripheral vascular disease, renal artery stenosis) haven’t had a heart attack yet – but we think that they are at a high risk of this happening – so they take aspirin to prevent this (primary prevention).

In people who are at low or moderate risk – low cholesterol, nonobese, normal glucose, nonsmokers:  these people may take aspirin, but (probably not prescribed) and it is safe for them to discontinue aspirin before surgery.

But in the first two classes of patients (secondary prevention group/ high risk group) – stopping aspirin may actually INCREASE the risk of having a heart attack, stroke or other thrombotic event during surgery.  But if you are having surgery – be sure to check with your cardiologist or cardiac surgeon before.  Don’t rely on your PCP or general surgeon (it’s not their area of expertise) and they may not be up-to-date on the latest recommendations [hence the continuing education course].

A new chapter at Cartagena Surgery: the DNP program

Nashville, Tennessee

Back in Mexicali, MX after spending a week in Nashville, Tennessee for the start of my doctoral program in nursing.  It felt weird to be back in Nashville after so long (I lived there while attending Vanderbilt for my masters degree).  It was surprising how much had changed – the medical center and the university campus just continue to grow and grow!

But then again – with 70 people in the Fall 2012 DNP class, I guess it’s no surprise that the campus is growing.  About 15 of us are full-time students.  I’ll be heading off to Bogotá in a week to start some specialized study there – so between the DNP program and Bogotá – I might be posting a bit less often.

Fall 2012 class for DNP (doctorate of nursing practice) at Vanderbilt University

The DNP is a new degree that takes the place of the DNSc (doctorate of nursing science) or the ND (nursing doctorate) – depending on who you ask.  I know that sounds like alphabet soup to many people, so I’ll post some more information about the degree soon.  But the main thing to think about when thinking about doctoral degrees – is the focus behind the degree.

PhD – or a doctorate in Philosophy are Research degrees. (research with a capital ‘R’)  Think about labs, nursing theories and hard-core research..so think ‘nurse-scientists’.. I tell people to picture a nurse with a beaker and a bunsen burner.. Not entirely accurate but a good mental picture.

DNP – is a clinical doctorate – used to translate much of this research into improved clinical practice.  Clinical, clinical, clinical.. This is the degree for people who are still planning on working in the clinical (hospital-based or clinic-based) setting, seeing patients.  The courses in this program are designed to promote evidence-based practice – or using all of that research that our nurse-scientists (and other researchers) are publishing.

So the hope is that the DNP will be able to improve the care of patients by creating protocols and such.  As it is still a fairly new degree – there is currently a lot of cross-over among PhD trained nurses, and I suspect there always will be – it’s more a matter of preference in what a nurse wants to focus on during her doctorate education. (So don’t be surprised if your nurse practitioner has a PhD.)

There are still plenty of doctorates in education and other fields as well like administration because it takes all types of nurses to serve as faculty, deans of educational programs, and hospital administrators.

There are even a few doctorate of nursing science programs left – in Louisiana and Puerto Rico..

Now I apologize because this is a simplistic explanation that leaves out a lot of nuance but I’ll provide more information soon.  But now, I better get back to the books!

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