Remote Didactic Education Effectively Increases Cardiac Critical Care Nursing Staff Knowledge in Low-Resource Settings.

Background: While progress has been made to decrease mortality in children under age five, there continues to be a need for improvement in the treatment of children with congenital heart disease. Many of these patients require surgical correction and live in areas without the expertise of surgical teams. Research has shown that appropriate training is critical to ensure the best clinical outcomes. The Ethiopian government has identified the need for increased training of health care professionals as a method to improve hospital outcomes. Methods: Twenty-five cardiac critical nurses participated in a remote didactic education curriculum over the course of multiple months. We used a pre- and post-test model to evaluate knowledge acquisition and retention after the curriculum. Nurses completed post-tests at 1-, 3-, 6-, and 12-month intervals to monitor knowledge retention over time. Results: We found a significant increase in nursing knowledge that was retained over the course of 12 months. Nursing knowledge on pre- and post-tests was impacted by experience level. However, after completion of the curriculum experience was not a significant factor. Conclusion: Virtual curriculum delivered via remote didactic education is an inexpensive and effective way to increase nursing knowledge in cardiac critical care. It encourages bidirectional learning and allows the sharing of expertise from individuals who may otherwise be limited by travel or finances. Our approach is generalizable and further research needs to be done to evaluate the effectiveness of this type of curriculum in other environments.

Case report: Acute necrotizing encephalopathy: a report of a favorable outcome and systematic meta-analysis of outcomes with different immunosuppressive therapies.

Acute Necrotizing Encephalopathy (ANE) is a condition characterized by symmetric, bilateral lesions affecting the thalamus and potentially other areas of the brain following an acute febrile illness. It manifests clinically as abrupt development of encephalopathy, or alteration in mental status that often includes development of seizures and progression to coma. Treatment strategies combine immunosuppressive therapies and supportive care with varying levels of recovery, however there are no universally accepted, data-driven, treatment algorithms for ANE. We first report a case of a previously healthy 10-year-old female with acute onset diplopia, visual hallucinations, lethargy, and seizures in the setting of subacute non-specific viral symptoms and found to have bilateral thalamic and brainstem lesions on MRI consistent with ANE. She was treated with a combination of immunomodulatory therapies and ultimately had a good outcome. Next, we present a meta-analysis of 10 articles with a total of 158 patients meeting clinical and radiographic criteria for ANE. Each article reported immunosuppressive treatments received, and associated morbidity or mortality outcome for each individual patient. Through our analysis, we confirm the effectiveness of high-dose, intravenous, methylprednisolone (HD-IV-MP) therapy implemented early in the disease course (initiation within 24 h of neurologic symptom onset). There was no significant difference between patients treated with and without intravenous immunoglobulin (IVIG). There was no benefit of combining IVIG with early HD-IV-MP. There is weak evidence suggesting a benefit of IL-6 inhibitor tocilizumab, especially when used in combination with early HD-IV-MP, though this analysis was limited by sample size. Finally, plasma exchange (PLEX) improved survival. We hope this meta-analysis will be useful for clinicians making treatment decisions for patients with this potentially devastating condition.

Social needs screening during the COVID-19 pandemic.

BACKGROUND: Millions of Americans lost their jobs as a result of the COVID-19 pandemic, placing immeasurable stress on families and making it difficult for parents to support their children's basic needs. Research shows that screening for social determinants of health is an important part of a child's well visit, noting that awareness of these factors leads to more holistic and improved quality of care. Due to increased precautions during the COVID-19 pandemic and a significant decrease in well-child visits and in-person appointments, there was a marked decrease in the number of face-to-face opportunities for these screenings. In a time of increased need, methods such as telephone screenings represent an opportunity to assess needs and connect patients and families with helpful resources. METHODS: This study occurred in Baltimore, Maryland at the University of Maryland Pediatrics at Midtown outpatient practice (PAM). Five paediatric resident physicians and 17 medical students developed a telephone welfare screening tool and called families receiving primary care at the clinic over a 9-week period. The team documented identified needs and used a community resources database to provide resources to families over the phone. Data regarding the identified needs was collected and analysed throughout the screening process. RESULTS: Volunteers contacted 671 families using our finalized screening tool. Of those, 349 answered the telephone call (52%), and 328 (49%) agreed to participate in the screening. Results showed that families commonly identified food insecurity (20%) and symptoms of depression (18%). This was consistent across families' home locations as analysed by postal ZIP code. CONCLUSIONS: This study suggests that telephone screening is a feasible and informative method for identifying and addressing the social needs of paediatric primary care patients and their families. Furthermore, our study supports the notion that there are significant and widespread social needs resulting from the COVID-19 pandemic.

Implementation and Impact of a Hospital-Wide Instrument Set Review: Early Experiences at a Multisite Tertiary Care Academic Institution.

A multidisciplinary team of nurses, sterile processing technicians, and surgeons reviewed 609 otolaryngology-head and neck surgery (OHNS) surgical instrument sets at the study institution's 3 hospitals. Implementation of the 4-phase instrument review resulted in decreased OHNS surgical instrument set types from 261 to 234 sets, and a decreased number of instruments in these sets from 18 952 to 17 084. The instrument set review resulted in an estimated savings of $35 665 in sterile processing costs for the OHNS department. Instrument review applied to all 10 surgical specialties at the institution would result in an estimated annual savings of $425 378. Through effective leadership, multidisciplinary participation of all key stakeholders, and a systematic approach, this study demonstrates that a hospital-wide quality improvement intervention for instrument set optimization can be successfully performed in a large, multisite tertiary care academic hospital.

Trends in Utilization and Cost of Cervical Spine Surgery Using the National Inpatient Sample Database, 2001 to 2013.

STUDY DESIGN: A retrospective review. OBJECTIVE: The aim of this study was to determine national rates of cervical spine surgery and to examine factors that underlie cost variation. SUMMARY OF BACKGROUND DATA: There has been an increase in the rate and cost of spinal surgery over the past decades, but there is little understanding of the drivers of cost variation at the national level. METHODS: We analyzed 419,830 patients who underwent cervical spine surgery (anterior cervical fusion, posterior cervical fusion, posterior cervical decompression, combined anterior/posterior cervical fusion) for degenerative conditions in the 2001 to 2013 NIS database. We determined the rates of surgery by time and geographic region, and then created univariate and multivariate models to evaluate the effect of these factors on total hospital costs: patient age, gender, race, insurance, income, county of residence, elective versus nonelective case, length of stay, risk of mortality, severity of illness, hospital bed size, wage index, hospital type, and geographic region. RESULTS: The most common type of cervical spine surgery was anterior fusion (80.6% of all surgeries). The national rates of all cervical spine surgery decreased slightly from 2001 to 2013 (75.34 to 72.20 per 100,000 adults), while the mean inflation-adjusted cost increased 64%, from $11,799 to $19,379, during this time period. Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs. The wage index was positively correlated with cost, and hospitals in the western U.S. were 27% more expensive than those in the Northeast. CONCLUSION: The rate of cervical spine surgery decreased slightly, while the mean case cost increased at a rate double that of inflation from 2001 to 2013. Even after controlling for patient and hospital factors including wage index, there was significant geographic variation in the cost for cervical spine surgery. LEVEL OF EVIDENCE: 3.

Epigenetic mechanisms drive the progression of neurofibromas to malignant peripheral nerve sheath tumors.

THINKING OUTSIDE THE BOX: The polycomb repressive complex 2 (PRC2) is a histone methyltransferase complex known to repress gene expression. There is a large body of experimental evidence that supports its role in promoting tumorigenicity by suppressing tumor suppressor genes. Here, we discuss the surprising findings that, in neurofibromas, it may have a completely different role as a tumor suppressor; mutations of PRC2 lead to conversion of benign neurofibromas into malignant peripheral nerve sheath tumors (MPNSTs) by de-repressing and thereby activating genes driving cell growth and development. These findings have potentially powerful clinical applications in both diagnosing and treating MPNSTs. HYPOTHESIS: PRC2 loss drives malignant transformation of neurofibromas.

The impact of a patient education bundle on neurosurgery patient satisfaction.

BACKGROUND: As reimbursements and hospital/physician performance become ever more reliant on Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) and other quality metrics, physicians are increasingly incentivized to improve patient satisfaction. METHODS: A faculty and resident team at the University of California, San Francisco (UCSF) Department of Neurological Surgery developed and implemented a Patient Education Bundle. This consisted of two parts: The first was preoperative expectation letters (designed to inform patients of what to expect before, during, and after their hospitalization for a neurosurgical procedure); the second was a trifold brochure with names, photographs, and specialty/training information about the attending surgeons, resident physicians, and nurse practitioners on the neurosurgical service. We assessed patient satisfaction, as measured by HCAHPS scores and a brief survey tailored to our specific intervention, both before and after our Patient Education Bundle intervention. RESULTS: Prior to our intervention, 74.6% of patients responded that the MD always explained information in a way that was easy to understand. After our intervention, 78.7% of patients responded that the MD always explained information in a way that was easy to understand. "Neurosurgery Patient Satisfaction survey" results showed that 83% remembered receiving the preoperative letter; of those received the letter, 93% found the letter helpful; and 100% thought that the letter should be continued. CONCLUSION: Although effects were modest, we believe that patient education strategies, as modeled in our bundle, can improve patients' hospital experiences and have a positive impact on physician performance scores and hospital ratings.