Answers:

Contestant #1: Valerie Knasinski, RN

$100 Question

A. Staph epidermis is the most common bacteria we have on our skin.

$200 Question

B. Home.

The most common cause of catheter related blood stream infection (CR-BSI) is a patient’s normal flora. Other potential causes include health care worker’s hands, contaminated infusate, dissemination from distant sites, hub contamination and contaminated disinfectants.

$300 Question

C. Wash your hands again and again.

Keeping your house clean and spraying Lysol may help to prevent infection, but washing your hands meticulously is the best way to prevent sepsis.

$500 Question

B. $5,000 to $32,000 is the average cost per patient episode of infection.

$1,000 Question

D. All of the above.

Povidone iodine (PVP), otherwise known as Betadine, took 60 seconds of exposure to kill 96% of the organisms; where 0.5% Chlorhexidine in ethanol 80% took less than 15 seconds to kill all organisms. Additionally there have been multiple documented outbreaks of infection due to contamination of PVP.

$2,000 Question

C. 30 years of experience to support its safety as an agent for washing health care worker’s hands.

An allergic reaction to CHG is sometimes found in the Asian population because they have a higher exposure to CHG through Asian-made skin care products.

$4,000 Question

A. Tolerating formulas.

$8,000 Question

A. PORT-A-CATH̉

PORT-A-CATH̉ have the lowest infection rate at 0.2 infections per 1000 days, but are not designed for daily access. Comparable rates for other catheters are as follows: PICC .4 infections/1,000 days; HICKMAN̉ catheter 1.1 infections/1000 days (with a cuff) and 2.8 infections/1000 days (without a cuff).

$16,000 Question

C. Chlorhexidine.

$32,000 Question

A. Substance abuse and malnutrition.

Some of the risk factors for blood stream infections include: malnutrition (<3.0 albumin), congestive heart failure, hyper/hypotension, trauma, obesity, burns, substance abuse, transplant, HIV, cancer and low white blood cell count.

$64,000 Question

B. Balancing energy, finances, schoolwork and relationships are the four most commonly cited challenges facing young HPN consumers as they transition to independence.

$125,000 Question

B. Michael Nesmith’s mother

Sorry Valerie!

Contestant #2: Darlene Kelly, MD, PhD

$100 Question

A. Travel and vacation as tolerated.

Traveling to a destination where there is no running water, however, is probably too risky for HPEN consumers.

$200 Question

C. Carry at least several days worth of infusion materials/equipment onto the plane

(See "Tips for Flying with Heightened Airport Security")

$300 Question

A. Check with the cruise company before booking to make sure they can accommodate your HPEN needs.

$500 Question

B. Travel with a letter from your physician regarding your need for HPEN.

It is not likely that U.S. customs cares about what you are leaving the country with; however it is likely that the destination country cares what you are bringing in.

$1,000 Question

C. Carry TPN in a portable electric cooler or on ice in an ice chest.

Freezing TPN and some formulas can cause the ingredients to separate out, so it is NOT a good idea to freeze either one.

$2,000 Question

D. Take plenty of bags of hydration fluids/oral rehydration solution.

You many need extra hydration when you are exposed to the sun a lot or are exerting yourself while touring. Also, remember to limit other fluids, such as Minute Maid, soda and even plain water, which can increase your GI losses through rapid output.

$4,000 Question

C. On the table after cleaning it.

The table has less germs than the bathroom or floor, and is easier to clean than the bed.

$8,000 Question

C. Take proper supplies and stick to your normal regimen.

Site care is necessary wherever you are and not worth the risk of putting off.

$16,000 Question

A. Maintain hydration by infusing hydration fluids either intravenously, via feeding tube, or orally, until you receive your supplies from your home care company.

You will probably be okay for several days, simply infusing hydration. This may involve going to a local hospital. Contacting a local home care company is likely to be difficult.

$32,000 Question

B. Contact a physician for assessment.

You should never ignore a fever, and don’t pull a catheter/feeding tube without a clinician showing it’s absolutely necessary first. It is possible to clear at least 50-65% of catheter infections without removing the catheter.

$64,000 Question

C. Notify your home health care provider at least 6 weeks ahead for international travel and 2 weeks ahead for travel within the U.S.

This is especially important when traveling abroad, as your home care company may need lead time to call customs and make other arrangements for your supplies.

$125,000 Question

A. You.

The airlines do not take responsibility for your possessions, and your physician and home care company are not going to be able to help you much when you’re away from them.

$250,000 Question

C. A variety of countries and U.S. territories.

Some U.S. territories and other countries are difficult to get medications into, including Puerto Rico and Singapore, but other countries are no trouble at all.

$500,000 Question

C. Weeks before travel, possibly with the help of the country’s embassy.

Your local airport and the airline company probably can’t help you much. You really need to contact officials in the country you are traveling to, and should do so before you arrive.

$1,000,000 Question

C. Skiing

Sorry Dr. Kelly!

Contestant #3: Michael Shapiro, MD

$100 Question

C. Digestive system.

Motility disorders can be caused by a problem with smooth muscle control or nerve control of hollow organs.

$200 Question

A. It causes esophageal blockage.

Achalasia is a disease that involves dysfunction or depletion of various nerve cells in the esophagus, and causes it to not empty well.

$300 Question

A. Food and drink empty poorly from the stomach.

Gastroparesis involves a dysfunction of the muscle or nerves of the stomach. It interrupts the role of the stomach as a reservoir and it’s function of pumping nutrients to the small bowel. It presents with nausea, a feeling of fullness, and vomiting several hours after a meal. It may cause some reflux.

$500 Question

B. Low residue.

Dietary management can profoundly affect how individuals with motility disorders feel. A lactose free diet is important, but it is only one component of a low residue diet. Certain foods empty less efficiently, many of these foods are high in fiber. And because fat slows emptying of the stomach, it is not good for people with a motility disorder. People on a low residue diet should avoid uncooked vegetables, salads, milk and red meats.

$1,000 Question

D. Lactose digests poorly because of a possible lactase deficiency.

Lactose intolerance is a significant problem with patients who have pseudo obstruction, because their motility disturbance is most often in the small bowel and can upset their bacterial balance there, which in turn can result in a lactase deficiency.

$2,000 Question

C. Bacteria accumulate because of stasis.

Bacterial overgrowth is common in patients with pseudo obstruction because the bowel is not moving intestinal contents, including bacteria, through the system as it should.

$4,000 Question

B. Poor digestion of fat.

Poor digestion of fat and nutrients, resulting from bacterial overgrowth, can cause diarrhea.

$8,000 Question

B. It empties better from the stomach.

Bezoars (bird nest like mesh of materials that haven’t emptied from the stomach) are promoted by high residue in the diet.

$16,000 Question

C. Bile acids are broken down by bacterial overgrowth.

$32,000 Question

D. Tube to decompress distended bowel.

Venting ostomies bring relief to many individuals with motility disorders who are uncomfortable because of their "obstructive" symptoms.

$64,000 Question

A. Diabetes can cause gastroparesis.

Diabetes is the main cause of nerve dysfunction that leads to motility disturbances. Many individuals with diabetes have problems with stomach emptying.

$125,000 Question

A. Gastric pacing.

Patients feel better and experience a modest decrease in stomach emptying dysfunction when they have had their stomach paced over a 6-12 month period. However, this therapy is helpful for only a small group of patients with refractory gastroparesis. Although Cisapride is an effective drug for helping many individuals with stomach and small bowel motility disorders, it was taken off the market because of life-threatening side effects for certain patients. Also, Nexium’s proton pump inhibitor is effective at managing GER but is similar to other inhibitors and therefore not novel.

$250,000 Question

B. Bacterial overgrowth.

Bacterial overgrowth can cause fat malabsorption, some protein and carbohydrate malabsorption (because of injury to the mucosa), and competes for B12 from the host.

$500,000 Question

D. Diet candy and bean sprouts.

Sorry Dr. Shapiro!

Contestant #4: Ezra Steiger, MD

$100 Question

C. Nutrition intake

$200 Question

B. Chromium

Vanadium has not been identified as causing a deficiency state in HPN patients, and Molybdenum has been identified only once or twice as being deficient in PN patients, so neither is routinely added to PN solutions.

$300 Question

B. Magnesium

Body Content for 70 kg Human by % Body Weight*

% Body Weight

A. Iron -----------------------------0.0057%

B. Magnesium ---------------------0.0357%

C. Selenium ----------------------<0.001%

D. Zinc -----------------------------0.0029%

Definition Trace Elements <0.01% body weight
*Rombeau/Caldwell, Clinical Nutrition: Parenteral Nutrition, 2nd edition, 1993

$500 Question

D. Manganese

$1,000 Question

C. Manganese

Physicians routinely monitor trace elements in PN patients at least once every six months, and more often if there are major abnormalities. Selenium often needs to be supplemented; Iron is usually not elevated; and Zinc levels in patients may be low — especially in patients who have a large GI output.

$2,000 Question

D. Selenium

(See chart in $4,000 Question)

$4,000 Question

D. Iodine

Multiple Trace Element Injections

MTE-4 MTE-5 MTE-6 MTE-7

Chromium .......................X ............X ........X ............X

Copper ............................X ............X ........X ...........X

Manganese ......................X............ X ........X........... X

Zinc .................................X ............X ........X ...........X

Selenium .........................................X ........X ...........X

Iodine ..........................................................X ..........X

Molybdenum .............................................................X

$8,000 Question

C. Iron

Iron deficiency can cause anemia, low hemoglobin and low hermaticrit; the signs and symptoms of this are weakness and anemia.

$16,000 Question

A. Chromium

Chromium deficiency causes glucose intolerance in long term PN patients. When a patient is tolerating the glucose level very readily, then blood sugars start to go up and urinary dextrose spills become prominent, chromium levels are often low. The patient may have weight loss too.

$32,000 Question

B. Zinc

$64,000 Question

D. Manganese

An over abundance of manganese is associated with some liver and neurological problems.

$125,000 Question

B. Selenium

Selenium deficiencies in long term PN patients may present with cardiac myopathies and cardiac arrhythmias. With ventricular arrythmias, the ventricles can start beating in funny ways and can lead to sudden death. Selenium deficiencies are also associated with congestive heart failure.

$250,000 Question

D. Zinc

Zinc deficiencies can cause angry bullous eczematoid lesions, usually around the mouth and face, but they can occur elsewhere on the body. The good news is that adding extra zinc will usually start to improve the condition in one or two weeks. Other deficiencies in PN patients that can lead to skin lesions include essential fatty acid deficiency (which is more likely to cause a scaly, dandruff like condition of the skin), and biotin deficiency.

$500,000 Question

D. Copper

Copper can cause an anemia that looks very much like an iron deficiency anemia. It causes a difficulty in iron being properly utilized to manufacture red blood cells.

$1,000,000 Question

C. 5.0%

Congratulations Dr. Steiger!

Note: PORT-A-CATH̉ is a registered trademark of Smiths Medical MD, inc.

HICKMAN̉ catheter is a registered trademark of C.R. Bard, Inc. and its related company, BCR, Inc.