Improving transparent team communication with the 'Glass Door' decal communication tool: a mixed methods analysis of family and staff perspectives.

OBJECTIVE: To determine the value and perspectives of intensive care unit (ICU) healthcare professionals (HCPs) and families about the Glass Door (GD) decal team communication tool. DESIGN: Quality improvement methodology was used to design, test and implement the GD. Uptake was measured through audit. Impact was assessed through mixed methodology (survey of ICU HCPs (n=96) and semi-structured interviews of HCPs (n=10) and families (n=7)). SETTING: Eighteen bed, closed, mixed medical-surgical-cardiac ICU in a tertiary care, university-affiliated, paediatric hospital. POPULATION: Interdisciplinary ICU HCPs and families of children admitted to the ICU. INTERVENTION: A transparent template (the GD) applied to the outside of ICU patients' doors with sections for HCPs names, physiological goals and planned tests and treatments for the day. Medical staff completed the GD in rounds (AM and PM) and any HCP caring for the patient updated it throughout the day. MEASUREMENTS AND MAIN RESULTS: After 3 months, 96% of 613 doors were employed of which 99% respected confidentiality. ICU HCPs reported improved understanding of the patient's plan (84% today vs 59% pre-GD, p<0.001) and sense that families were up-to-date (79% today vs 46% pre-GD, p<0.001). Based on semi-structured interviews, the GD promoted a shared understanding of the plan contributing to care continuity. The GD reassured families the team is working together and fostered family engagement in the care. Routine family experience surveys showed no change in families' sense of privacy during admission; families denied the GD's anticipated compromise of confidentiality. CONCLUSIONS: The GD decal communication tool, visible on the patient's door, improved ICU HCPs' perceived knowledge of their patient's plan. The GD improved the shared mental model, facilitated teaching and information transfer and fostered family engagement. Challenges included knowing the rules for use and consistent application. Concerns initially raised by HCPs about confidentiality were denied by families.

In vivo durability and safety of rolled acellular dermis in a submucosal pocket in pigs.

Objective : This study explored posterior nasopharyngeal augmentation with an acellular dermal matrix sheeting. Design : Evaluation of the persistence and safety of a submucosal implant of rolled acellular dermis over a 3-month period in a piglet model. Setting : Institute Hills Facility, part of the Mayo Clinic Rochester health care facility. Participants : Fifteen 5-week-old domestic piglets of unspecified gender. Interventions : Twelve piglets were implanted at age 5 weeks with a rolled sheet of acellular dermal matrix (Strattice). Implants were inserted in a submucosal pocket in the soft palate. Three piglets underwent sham operations, with creation of submucosal pockets without implantation. After a 3-month observation period, the palates were harvested for evaluation. Results : Grossly, persistence of bulk at the surgical site in 5 of the 12 implanted piglets was noted at 3 months. Histologically, no persistence of the dermal matrix could be observed. Incorporation and/or resorption of the dermal matrix occurred with minimal to no host inflammatory response. Conclusion : This experiment demonstrated the safety of a rolled acellular dermal implant in a submucosal location in a pig model, without surgical complication, host inflammatory reaction, or rejection. Minimal, if any, bulk of the implant persisted in the implanted location after 3 months. Although acellular dermal matrix sheeting appears to be safe and well-tolerated, it does not offer a long-term treatment option for posterior pharyngeal augmentation.

Endoscopic forehead approach for minimally invasive benign tumor excisions.

IMPORTANCE: Direct transcutaneous resection has been a widely accepted standard for the removal of benign forehead lesions. In recent years, the endoscopic approach has become more prevalent because of its noninvasiveness. To date, only a few studies with limited case numbers have reported on this technique. We report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach. OBJECTIVES: To evaluate results of the endoscopic forehead approach for benign tumor excisions, to give a more nuanced insight into this procedure, and to discuss technical pearls and potential pitfalls from our experience. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, retrospective case study at 2 university centers and 1 private practice among 36 patients aged 18 to 72 years (mean age, 44 years) who underwent the endoscopic forehead approach for benign tumor resections. MAIN OUTCOMES AND MEASURES: Symptoms at presentation, surgical procedure and duration, type of lesions, intraoperative and postoperative complications, recurrences, and patient satisfaction. RESULTS: In total, 34 patients had an asymptomatic forehead mass, while 2 patients reported discomfort and headache. Among all patients, complete tumor excision was achieved endoscopically. The mean operative time was 36 minutes. Histopathological examination revealed 18 lipomas, 13 osteomas, 2 dermoid cysts, and 1 bone fragment after previous rhinoplasty. In 2 patients, no specimen was submitted. No hematomas, infections, scalp numbness, contour irregularities, temporal branch paralysis, or tumor recurrences occurred. One patient had a prolonged area of alopecia, which resolved on its own. All patients attested to a high satisfaction rate. CONCLUSIONS AND RELEVANCE: The endoscopic approach offers excellent aesthetic results and allows for safe tumor removal. It has proven to be an effective and minimally invasive alternative to the conventional open approach. LEVEL OF EVIDENCE: 4.

Craniofacial pain secondary to occult head and neck tumors.

OBJECTIVES: To review the natural history of occult head and neck malignancy presenting with facial pain and evaluate the risk factors, diagnostic workup, and management of facial pain in the setting of occult malignancy. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care center. SUBJECTS AND METHODS: All patients presenting from 1980 to 2010 with facial pain and a delayed diagnosis of a head and neck cancer were reviewed. RESULTS: Thirty-eight patients were included. Onset of pain was rapid or sudden in 94.7%, intermittent in 84.2%, and sharp in 86.8%. Facial nerve weakness was present in 15.8%. Five patients had a history of locoregional skin cancer, and 14% had a history of malignancy. Average delay to diagnosis was 18.4 months. On average, the suspicious lesion was identified on the second scan (mean, 2.1; range, 1-4 scans). Diagnosis was suggested by magnetic resonance imaging in 54.8% and computed tomography in 38.7% of patients. The most common pathology was squamous cell carcinoma (39.5%), and the predominant location was the parotid gland (28.9%). Surgical resection (66%) was the most common intervention. In patients who received treatment and had clinical follow-up available for review, 97.0% (32/33) reported symptomatic improvement. CONCLUSIONS: In our series, sudden-onset, intermittent, sharp facial pain without resolution or improvement was associated with occult malignancy and should be considered in the differential diagnosis for facial pain. Based on the high incidence of early negative imaging, consideration should be given to repeat imaging when there is concern for malignancy. Therapeutic interventions often result in improvement of facial pain.

Localized tongue amyloidosis: a single institutional case series.

OBJECTIVE: Review Mayo Clinic experience of localized tongue amyloidosis. STUDY DESIGN: Case series with retrospective chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Cases of localized tongue amyloidosis were identified from the dysproteinemia database at the Mayo Clinic in Rochester, Minnesota. Electronic records were reviewed with focus on presenting symptoms, laboratory results (ie, serum or urine immunoelectrophoresis, bone marrow biopsy, and fat aspirate analysis), treatment modality, and status of disease at follow-up. RESULTS: Six cases of localized tongue amyloidosis presented to the Mayo Clinic between 1969 and 2011. Mean patient age was 69 years (range, 43-90). Patients presented with asymptomatic tongue mass(es). Biopsy of the tongue mass in all patients showed amyloid on Congo red stains. Work-up for systemic amyloidosis, including bone marrow biopsy, fat aspiration, and serum and urine protein immunoelectrophoresis, was negative for all 6 patients, nor was there other organ involvement. Two patients underwent resection of the lesions, and the remaining patients elected for observation. Recurrence requiring repeat excision occurred in 1 of the patients that underwent resection. Repeat evaluation for systemic involvement was performed in 3 patients 1 to 3 years after the initial diagnosis. None of these patients went on to develop systemic involvement. CONCLUSIONS: Localized tongue amyloidosis remains a rare diagnosis and requires exclusion of systemic involvement. Localized lesions may be observed or resected; however, recurrence may occur with resection. Patients with localized tongue amyloidosis do not appear to be at increased risk of developing systemic involvement.

Closure of scalp and forehead defects using external tissue expander.

OBJECTIVE: To describe the novel use of an external tissue expander in the reconstruction of scalp and forehead defects. METHODS: A prospective review was performed on 7 patients who underwent extirpation of head and neck malignant neoplasms resulting in scalp and forehead defects. Reconstruction was performed using an external tissue expander device. Patient clinical factors, defect size, and photographs were collected. RESULTS: Seven patients had large scalp and forehead defects ranging in greatest dimension from 5.0 ×4.0 to 8.0 ×7.0 cm. The external tissue expander was in place for 6 to 14 days, reducing the defect sizes by 50% to 99%. At the time of device removal, primary closure was achieved in 5 patients. One patient required bilateral advancement rotation flaps, and 1 patient healed by second intention. One patient with a history of scalp irradiation and diabetes had partial skin loss after device removal and required reconstruction with a latissimus dorsi myocutaneous free flap. There were no other postoperative complications, wound breakdown, or device failures. CONCLUSION: External tissue expansion is a safe and effective technique for closing large scalp and forehead defects that would otherwise require skin grafting or free flap reconstruction.