Comfort First: Development and pilot testing of a web-based video training to disseminate Comfort Matters dementia care.

BACKGROUND: Alzheimer's disease-related dementias (ADRD) are a leading cause of disability and death. In late-stage ADRD most people prioritize comfort, but care to achieve comfort is rare. Comfort Matters combines palliative and geriatric care practices for nursing home dementia care, but in-person training reaches few sites. To facilitate dissemination, we developed Comfort First, a web-based training toolkit with video demonstration of Comfort Matters practices. METHODS: We developed and pilot-tested Comfort First (NIA Intervention Stage 1). Stakeholder advisors representing nursing home residents, caregiver, and clinical perspectives guided development. Professional videographers filmed Comfort Matters staff to illustrate comfort-focused dementia care skills. Video training modules, supported by an implementation manual, address Understanding the Person with Dementia, Promoting Quality of Life and Comfort, Working as a Team, Responding When People with Dementia are Distressed, Addressing Pain, and Making Comfort First a Reality. We then delivered Comfort First to 3 nursing homes. Implementation and outcome evaluation assessed the number and clinically diverse roles of trained staff and post-test knowledge. RESULTS: Nursing home staff roles (n = 146) were diverse: certified nursing assistants (40%), nurses (19%), administrators (11%), activities staff (6%), therapy staff (5%) and other roles. Individual participants' knowledge scores ranged from 50-100%; however average post-test knowledge scores were high, ranging from 90% (Addressing Pain) to 99% (Promoting Quality of Life and Comfort, Making Comfort First a Reality). CONCLUSIONS: The Comfort First web-based training toolkit combines best practices in palliative care and geriatric care for ADRD, using video demonstrations to support broader dissemination of these skills. Initial evaluation demonstrates acceptability and knowledge uptake for staff in diverse clinical roles; future research should include evaluation of practice change. Consistent with the intent of its public funding, Comfort First will be widely disseminated at a minimal cost.

Federal seafood safety response to the Deepwater Horizon oil spill.

Following the 2010 Deepwater Horizon oil spill, petroleum-related compounds and chemical dispersants were detected in the waters of the Gulf of Mexico. As a result, there was concern about the risk to human health through consumption of contaminated seafood in the region. Federal and Gulf Coast State agencies worked together on a sampling plan and analytical protocols to determine whether seafood was safe to eat and acceptable for sale in the marketplace. Sensory and chemical methods were used to measure polycyclic aromatic hydrocarbons (PAHs) and dispersant in >8,000 seafood specimens collected in federal waters of the Gulf. Overall, individual PAHs and the dispersant component dioctyl sodium sulfosuccinate were found in low concentrations or below the limits of quantitation. When detected, the concentrations were at least two orders of magnitude lower than the level of concern for human health risk. Once an area closed to fishing was free of visibly floating oil and all sensory and chemical results for the seafood species within an area met the criteria for reopening, that area was eligible to be reopened. On April 19, 2011 the area around the wellhead was the last area in federal waters to be reopened nearly 1 y after the spill began. However, as of November 9, 2011, some state waters off the Louisiana coast (Barataria Bay and the Delta region) remain closed to fishing.

Risk factors associated with requiring a stoma for the management of anal cancer.

PURPOSE: Combination chemotherapy and radiation therapy has become the standard of care for epidermoid carcinoma of the anus. This treatment modality has allowed for preservation of the anus in most patients, sparing them the morbidity of a stoma. Some patients will ultimately require a stoma as a result of salvage surgery or to manage complications of chemoradiotherapy. We hypothesized that tumor characteristics and radiation dose had an impact on the requirement for stoma formation. METHODS: Data on all patients with epidermoid carcinoma of the anal canal who were treated with chemoradiation with curative intent at Ochsner Clinic Foundation were entered into a prospective registry. We excluded four patients who were lost to follow-up and one patient who died during chemoradiation therapy. RESULTS: Fifty-one patients were followed for an average of 5.6 years. Primary tumor size average was 3.9 cm. Six patients had Stage I disease, 33 patients had Stage II disease, and 12 patients had Stage III disease (N+ disease). The average radiation dose was 57 +/- 17 Gy. Univariate analysis revealed pretreatment tumor size to be the only significant factor associated with the need for a stoma ( P = 0.01). Radiation dose was not an important factor ( P = 0.38). An additional finding was that the pretreatment tumor size and N+ disease were significant predictors of mortality; however, logistic-regression analysis revealed that N+ disease was the only independent predictor of mortality ( P = 0.02). CONCLUSIONS: Patients who have large tumors on presentation should be made aware of the possibility of requiring salvage surgery to treat persistent or recurrent disease. Toxicities from chemoradiotherapy do arise, but patients are not at increased risk for requiring a stoma.

Inferior mesenteric artery reimplantation does not guarantee colon viability in aortic surgery.

Reimplantation of the inferior mesenteric artery (IMA) at the time of aortic surgery has been advocated to prevent colon ischemia in patients deemed to have inadequate perfusion of the left colon. The purpose of this study was to determine whether IMA reimplantation is globally protective against colon necrosis. We reviewed the medical records of all patients who were diagnosed with colon ischemia after aortic surgery during a 10-year period. Cases were indexed from the institution's operative database and from the vascular morbidity and mortality registry. Ten patients (eight men, two women; mean age 71 +/- 9 years) were identified during the study period. Five patients (50%) underwent successful IMA reimplantation for inadequate Doppler signals on the antimesenteric border of the sigmoid colon. Five other patients (50%) did not undergo IMA reimplantation because they were deemed to have adequate colon perfusion. Transmural colon necrosis occurred in 6 of the 10 study patients, 4 of whom had IMA reimplantation. Five of the six patients had intraoperative hypotension. Three of the four patients with colon ischemia presenting less than 24 hours after aortic revascularization survived (mortality 25%), but both patients with late colon ischemia died of multisystem organ failure (mortality 100%). Four patients developed mucosal ischemia and did not undergo colectomy. Only one of these had IMA reimplantation. Colon ischemia was detected more than 1 week postoperatively in three patients. All four patients were treated with supportive therapy and antibiotics, and all four survived to discharge after a mean length of stay of 14 +/- 10 days. These data show that IMA reimplantation does not ensure colon viability in aortic surgery. Transmural colon necrosis tends to present sooner than mucosal ischemia and may be attributable to nonanatomic variables such as intraoperative hypotension. Although transmural necrosis is a highly morbid complication after aortic surgery, timely colectomy may lead to survival in some patients.

Hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic, debilitating disease of apocrine gland-bearing skin. Its management must be individualized according to the site and extent of the disease. Initial conservative measures with antibiotics, local wound care, and limited incision and drainage can alleviate the acute symptoms, but more radical surgery will likely eventually be necessary in order to control and prevent recurrent disease. Options include unroofing and marsupialization, local excision, or more extensive operative excision with primary or secondary closure, skin grafting, or flap coverage of defects. Wide excision will offer the most definitive therapy, with the trade-off being a higher morbidity. Split-thickness skin grafts in the anal canal may contract and result in anal stenosis and should be avoided. Perianal disease is often best managed with local excision alone, with primary closure for small defects, and either unroofing or healing by secondary intention for larger wounds.