Utilization of Workflow Process Maps to Analyze Gaps in Critical Event Notification at a Large, Urban Hospital.

Stroke care is a time-sensitive workflow involving multiple specialties acting in unison, often relying on one-way paging systems to alert care providers. The goal of this study was to map and quantitatively evaluate such a system and address communication gaps with system improvements. A workflow process map of the stroke notification system at a large, urban hospital was created via observation and interviews with hospital staff. We recorded pager communication regarding 45 patients in the emergency department (ED), neuroradiology reading room (NRR), and a clinician residence (CR), categorizing transmissions as successful or unsuccessful (dropped or unintelligible). Data analysis and consultation with information technology staff and the vendor informed a quality intervention-replacing one paging antenna and adding another. Data from a 1-month post-intervention period was collected. Error rates before and after were compared using a chi-squared test. Seventy-five pages regarding 45 patients were recorded pre-intervention; 88 pages regarding 86 patients were recorded post-intervention. Initial transmission error rates in the ED, NRR, and CR were 40.0, 22.7, and 12.0 %. Post-intervention, error rates were 5.1, 18.8, and 1.1 %, a statistically significant improvement in the ED (p < 0.0001) and CR (p = 0.004) but not NRR (p = 0.208). This intervention resulted in measureable improvement in pager communication to the ED and CR. While results in the NRR were not significant, this intervention bolsters the utility of workflow process maps. The workflow process map effectively defined communication failure parameters, allowing for systematic testing and intervention to improve communication in essential clinical locations.

Simultaneous typical and extraordinary imaging findings of AIDS-associated cytomegalovirus encephalitis.

Encephalitis caused by cytomegalovirus (CMV) is a devastating disease that occurs mostly in profoundly immunocompromised individuals, particularly in the setting of advanced HIV infection or organ transplantation. Imaging findings in AIDS-associated cytomegalovirus encephalitis that have been described range from ventriculitis (more common) to solitary mass lesions (less common). We describe a fatal case of AIDS-associated cytomegalovirus encephalitis that included typical imaging findings but also atypical features with widespread, multifocal lesions demonstrating restricted diffusion on magnetic resonance imaging (MRI). It is likely that these diffusion abnormalities are appreciated due to changes in imaging technology from the pre-highly active antiretroviral therapy era in which the typical imaging findings of CMV encephalitis were first described. The differential diagnosis of widespread, multifocal lesions with restricted diffusion in the setting of AIDS should now include CMV encephalitis.

AIDS and optic neuritis in a rhesus monkey infected with the R5 clade C SHIV-1157ipd3N4.

A Chinese rhesus macaque infected with the pathogenic CCR5-tropic clade C simian-human immunodeficiency virus, SHIV-1157ipd3N4, had persistent viremia, depletion of CD4(+) T cells to <200 cells/µl, opportunistic infections, coagulopathy, and gradual development of bilateral blindness. MRI revealed marked thickening of both optic nerves. Histopathological evaluation showed diffuse cellular infiltration at necropsy and a focus of SHIV-infected cells. This is the first report of CNS pathology following chronic infection with an obligate R5 SHIV.

Human immunodeficiency virus-associated cytomegalovirus infection with multiple small vessel cerebral infarcts in the setting of early immune reconstitution.

Cytomegalovirus (CMV) infection is an important cause of neurologic disease in the context of advanced human immunodeficiency virus (HIV) infection and is recognized as a cause of immune reconstitution inflammatory syndrome (IRIS) after initiation of highly active antiretroviral therapy (HAART). Central nervous system vasculitis secondary to CMV has only rarely been described in the context of HIV, despite the established ability of CMV to infect microvascular endothelial cells in the brain. However, we report a case that demonstrates the association between CMV and multiple small vessel cerebral infarct lesions after initiation of HAART.

The accuracy of computed tomography in assessing cervical pedicle screw placement.

STUDY DESIGN: A blinded, prospective comparison of computed tomography scan accuracy for determining the location of cervical pedicle screw position in human cadavers. OBJECTIVES: To establish recommended computed tomography technique guidelines for assessing location of cervical pedicle screws. SUMMARY OF BACKGROUND DATA: A small number of studies have described the accuracy of roentgenography regarding the assessment of pedicle screw position. However, a few studies have investigated the accuracy of computed tomography in this respect. Ebraheim et al evaluated the relation of lateral mass screws to the nerve roots within the intervertebral foramen on oblique radiographs. No study has been undertaken, to our knowledge, to specifically define the reliability and validity of computed tomography scans in the case of cervical pedicle screw placement. METHODS: As a pilot study, 10 cadaveric cervical spines from another study with bilateral 3.5 mm titanium pedicle screws were scanned with 1.0 mm axial slices. After the scans were interpreted by three blinded readers, each panel member was "trained" with regard to individual accuracy. Ten more cadaveric cervical spines were instrumented with 3.5 mm titanium screws in each pedicle (C2-C7). The specimens were then scanned with a variety of computed tomography techniques, including spiral acquisitions at 1.0 mm, 1.0 mm + reconstruction, 2.5 mm, 5.0 mm slices, and the three-dimensional Stealth Station recipes. The specimens were dissected, and malpositioned screws were recorded and photographed by independent raters. The same three readers from the pilot study then read each new scan in random order. RESULTS: Reader accuracies in the pretraining pilot study were 74%, 68%, and 52%, with kappa coefficients of 0.49, 0.37, and 0.07, respectively, and significant intrarater variances (P = 0.014). After training, the accuracy rate improved significantly to 89%, 88%, and 85% in posttraining study, and the kappa coefficients were 0.81, 0.78, and 0.73, respectively. Kappa statistical analysis showed negligible interreader variance on the entire pivotal study except by the three-dimensional Stealth Station format. The overall mean kappa coefficients were 0.77, 0.75, and 0.73. Assessment of pedicle screw position was statistically inferior with 5.0 mm axial slices, in contrast to slices <3.0 mm. CONCLUSIONS: We demonstrated that reliance on computed tomography scan data in determining the misplacement of a pedicle screw is usually accurate given proper scan acquisition, presentation windows, and adequate reader training, but a clinically significant error rate remains. A conventional computed tomography scan should not be treated as a gold standard, particularly without regard to the readers' training.