The "Frankentower:" A clinician-driven approach to enhancing endoscopic data technology.

OBJECTIVE: To develop a more efficient endoscopy tower and evaluate its capability to improve retrieval and storage of videos across 6 clinical sites. METHODS: Descriptive study that took place at tertiary care Pediatric Otolaryngology Department over a 2 year period. In collaboration with our Information Services Department and Otolaryngology endoscopy vendors, we assembled our "Frankentower" endoscopy cart using components from 3 medical device manufacturers. RESULTS: It is feasible to create a functional composite endoscopic tower. Implementation of "Frankentower" improved overall management and retrieval of endoscopy video and images in our department which lead to better patient care and facilitated education for medical students, residents and faculty. CONCLUSIONS: The "Frankentower" is a feasible, cost-effective solution to streamline the capture, access and storage of patient endoscopy exams across our operating rooms, inpatient consult service, Emergency Department and outpatient clinics.

Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families.

OBJECTIVE: We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner. METHODS: Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days. RESULTS: Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children's study results. DISCUSSION: Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner. IMPLICATIONS FOR PRACTICE: With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.

Interventions to Improve Response Time to Nurse Triage Phone Calls in a Tertiary Care Pediatric Otolaryngology Practice.

Importance: Delay in response for telephone triage calls that need clinician input for resolution can result in delay of care and unintended frustration for patients and families. It can be a challenge to manage calls in a high-volume pediatric otolaryngology practice. Objective: To improve the percentage of nurse triage clinically relevant phone calls returned within 2 hours to parents or caregivers. Design, Setting, and Participants: This was a quality-improvement study of a tertiary care pediatric otolaryngology practice with more than 32 000 clinic visits and more than 9000 surgical patients per year. Interventions: In 2014, a collaborative team was created at our center to determine the optimal time for triage callback to families and to define an optimal process that would allow more rapid response time for calls that the triage nurses needed to escalate to the patient's managing surgeon. Several plan-do-study-act cycles were performed to optimize the process. The utilization of advanced practice nurses as an intermediary step was crucial in allowing a more efficient flow of communication. Main Outcomes and Measures: Percentage of triage phone calls returned within 2-hour time frame. Results: Over 40 months, 4839 clinically relevant phone calls occurred, averaging 128 calls per month. The baseline mean was 101 calls per month, and the postintervention mean was 130 calls per month. Prior to this project, only 42% of calls were being addressed within 2 hours. After our interventions, the average time for caregiver callback within 2 hours decreased from 15.3 hours preintervention to 3.9 hours postintervention. In addition, caregivers received clinician callback within 2.0 hours 76.7% of the time postintervention compared with 42.0% with a baseline shift (difference probability between preintervention and postintervention, 0.21; 95% CI, 0.15-0.27). Outcomes were sustained for 3 years and continue to be monitored. Conclusions and Relevance: The most effective intervention was using advanced practice nurses to efficiently resolve patient triage concerns that were outside the scope of practice of the registered nurse. By establishing clear pathways of communication and standardized education among our team, we successfully improved our processes, which resulted in more optimal care for our patients.

Initial experience from a multidisciplinary pediatric salivary gland disorder clinic.

OBJECTIVE: This study is the first in the literature to characterize and detail the clinical and surgical experience of one of the few multidisciplinary salivary gland disorder clinics in North America. METHODS: This is a retrospective chart review of a descriptive nature, including patient information from February 2013 to August 2014. The Salivary Gland Disorder Clinic (SGDC) is located at Nationwide Children's Hospital, a public academic hospital. All patients seen at the SGDC were included in this study, 54 in total. Patients were seen for any salivary gland disorder presentation, ranging from sialorrhea to glandular masses. RESULTS: A total of 70.4% of patients presented to the SGDC with a chief complaint of sialorrhea. Nearly 28% had previously experienced documented aspiration, and drooling severity and frequency was 4.06 and 3.3 on the Thomas-Stonell and Greenberg Drooling Rating Scales. 50% of patients presented with neurologic comorbidities and 25.9% with aerodigestive tract anatomic defects. Over 35% of patients had previously attempted medical treatment and 31.5% had no prior treatment attempts. 87% of all patients were offered further treatment options, including interventional, surgical, medical, and conservative measures. CONCLUSIONS: Pediatric salivary gland disorders, especially sialorrhea, can profoundly impact overall health and quality of life. Appropriate management of this symptom requires expert training and knowledge of the upper aerodigestive tract anatomy and appropriate treatment modalities. Our study demonstrates that there is community need for a centralized salivary gland disorder clinic given the complex comorbidities and social challenges that face this population. Many patients present with great risk for aspiration-related complications and the vast majority are offered new treatment options.

A quantitative approach to evaluating caring in nursing simulation.

AIM: This study was designed to test a quantitative method of measuring caring in the simulated environment. BACKGROUND: Since competency in caring is central to nursing practice, ways of including caring concepts in designing scenarios and in evaluation of performance need to be developed. Coates' Caring Efficacy scales were adapted for simulation and named the Caring Efficacy Scale-Simulation Student Version (CES-SSV) and Caring Efficacy Scale-Simulation Faculty Version (CES-SFV). METHOD: A correlational study was designed to compare student self-ratings with faculty ratings on caring efficacy during an adult acute simulation experience with traditional and accelerated baccalaureate students in a nursing program grounded in caring theory. RESULTS: Student self-ratings were significantly correlated with objective ratings (r = 0.345, 0.356). CONCLUSIONS: Both the CES-SSV and the CES-SFV were found to have excellent internal consistency and significantly correlated interrater reliability. They were useful in measuring caring in the simulated learning environment.

Acute cardiac arrhythmias following surgery for congenital heart disease: mechanisms, diagnostic tools, and management.

This article focuses on the management of those cardiac arrhythmias most commonly seen in the immediate postoperative period. They include ventricular tachycardia, ventricular fibrillation, atrial flutter, junctional ectopic tachycardia, bradycardia, and atrioventricular block. The mechanisms of cardiac arrhythmias are reviewed followed by a brief overview of the predominant acute arrhythmias, tools used for the diagnostic evaluation of these arrhythmias, management strategies, and, finally, nursing considerations.

Design, synthesis and SAR of a series of 1,3,5-trisubstituted benzenes as thrombin inhibitors.

A novel 1,3,5-trisubstituted benzamide thrombin inhibitor template was designed via hybridization of a known aminopyridinoneacetamide and a known 1,3,5-trisubstituted phenyl ether. Optimization of this lead afforded a novel potent series of biaryl 1,3,5-trisubstituted benzenes with excellent functional anticoagulant potency.

Fluorescence in situ hybridization for detecting urothelial carcinoma: a clinicopathologic study.

BACKGROUND: Because urothelial carcinoma (UC) is associated with a significantly high risk of disease recurrence and progression, patients with UC require long-term surveillance. Fluorescence in situ hybridization (FISH) has been shown to be more sensitive than cytology in the detection of UC. The current study evaluated the use of FISH for detecting UC. METHODS: A pathology database was used to identify patients who had urine cytology and FISH performed at the study institution between 2004 and 2006. Urinary specimens were analyzed using UroVysion FISH probes for abnormalities in centromeric chromosomes 3, 7, and 17 and locus-specific 9p21. FISH results were correlated with cytologic findings and a minimal clinical follow-up of 24 months. RESULTS: A total of 1006 consecutive urinary specimens from 600 patients (448 men and 152 women) who were monitored for recurrent UC (915 specimens) or evaluated for urinary symptoms (91 specimens) were identified. On FISH analysis, 669 specimens were found to be negative for UC and 272 specimens were positive for UC. Sixty-five (6%) specimens were insufficient for FISH analysis. The sensitivity and specificity of FISH for UC were 58% and 66%, respectively, and 59% and 63%, respectively, when FISH and cytology results were combined. Factors contributing to decreased FISH sensitivity included the paucity or absence of tumor cells, low-grade tumors, degenerated cells, method of specimen collection, type of specimen, and obscuring inflammatory cells or lubricant. CONCLUSIONS: UroVysion FISH appeared to have good sensitivity and specificity for detecting UC in urinary specimens. It is important to correlate the FISH results with the cytologic findings.

Sudden cardiac death in the young.

Sudden cardiac death (SCD) in children and adolescents is an uncommon event, yet it is devastating to families who lose a child so suddenly and unexpectedly. Sudden cardiac death in adults is primarily caused by coronary artery disease; however, SCD in the young is due to different etiologies. This article presents the following etiologies associated with SCD in the young: structural and functional abnormalities, primary electrical diseases also known as channelopathies, and a lesser-known cause, that is, commotio cordis. Prevention and treatment strategies to be discussed include noninvasive testing for risk stratification, screening for competitive athletes, genetic testing, implantable cardioverter defibrillators, automated external defibrillators, and patient advocacy. Nursing implications will include guidance for patient and family education, recommendations for sports participation, and forging partnerships with communities.

Chromosomal abnormalities detected by multicolor fluorescence in situ hybridization in fine-needle aspirates from patients with small lymphocytic lymphoma are useful for predicting survival.

BACKGROUND: Fine-needle aspiration (FNA) of lymph nodes is commonly used to assess disease progression in patients with small lymphocytic lymphoma (SLL). Although cytologic features are helpful for diagnosing typical SLL and transformed large-cell lymphoma (tLCL), SLL in accelerated phase (SLLacc) is more difficult to diagnose. Additional tests are needed to identify those patients who are transforming to a higher-grade lymphoma. This study evaluated the use of a multicolor fluorescence in situ hybridization (FISH) probe panel specifically designed for chronic lymphocytic leukemia (CLL)/SLL and assessed the association between FISH findings and cytologic diagnosis, proliferation index, and risk of death. METHODS: FNA specimens from 50 patients (32 men and 18 women; mean age, 57 years [range, 36-77 years]) with histologically confirmed CLL and/or SLL were evaluated in this study for chromosomal abnormalities of 11q22 (ATM), 12, 13q14.3, 13q34.3 (LAMP1), and 17p13.1 (p53) by using a multiprobe FISH kit. One of the 50 cases was excluded because of an insufficient number of cells for FISH analysis. The FISH findings were compared with the cytologic diagnoses (26 SLLs, 12 SLLaccs, and 11 tLCLs), Ki-67 immunostaining, and risk of death. RESULTS: Abnormal signal patterns for 17p13.1 and 13q34.3 were associated with tLCL. Aberrations of 17p13.1 were found to be significantly associated with Ki-67 staining. Of the 49 patients with interpretable FISH results, 22 (45%) had died at the time of the study, with a mean overall survival time of 17 months after FNA. Patients with aberrations of 17p13.1 and 11q22 had 3.7 and 2.7 times the risk of death, respectively, compared with patients with normal patterns. CONCLUSIONS: FISH can be performed on FNA specimens from patients with a history of SLL/CLL. Chromosomal aberrations of 17p13.1 and 11q22 are associated with an increased risk of death. Knowledge of genetic abnormalities from FNAs may be useful in deciding when and how to treat indolent or progressive SLL.

Combination of cytologic evaluation and quantitative digital cytometry is reliable in detecting recurrent disease in patients with urinary diversions.

BACKGROUND: Detecting recurrent bladder carcinoma early is important because it is a multifocal disease that may affect the bladder mucosa, ureters, urethra, and renal pelvis and is associated with high morbidity and mortality rates. However, specimens from patients who have undergone cystectomy with urinary diversion can be difficult to interpret by cytologic evaluation because they often contain degenerated epithelial cells, histiocytes, acute inflammatory cells, bacteria, and cellular debris. In this retrospective study, the reliability of quantitative digital cytometry (QDC) in conjunction with cytologic evaluation in detecting recurrent disease was determined in these patients. METHODS: In all, 116 specimens were identified from the cytology files from 83 patients who had undergone radical cystectomy with urinary diversion for bladder carcinoma at the study institution between 2002 and 2005; all specimens underwent cytologic evaluation and 105 underwent QDC. Two cytospin slides were prepared for cytologic evaluation and 1 for QDC. At least 100 of the most atypical cells were interactively digitized and evaluated for ploidy, the percentage of proliferating cells, and the percentage of cells with a DNA content greater than 5c. Based on these parameters, the DNA histograms were grouped by pattern: diploid, abnormal diploid, tetraploid, and aneuploid. The cytologic evaluation and QDC results were compared with the clinical follow-up data. RESULTS: In all, 103 specimens were negative for recurrent disease or had atypical cells on cytologic examination and were found to have diploid or abnormal diploid patterns on QDC. None of these cases had clinical evidence of upper urinary tract disease at the time the first specimen was obtained. However, recurrent urothelial carcinoma was found in subsequent conduit specimens from 2 patients. Thirteen specimens from 9 patients were suspicious or positive for malignancy by cytology. Five of these patients had an upper urinary tract recurrence and their specimens were found to be abnormal on cytologic evaluation and QDC, with 15% of cells with a DNA content greater than 5c. CONCLUSIONS: Combined cytologic evaluation and QDC is a reliable method of detecting recurrent disease in patients with urinary diversions and can be used to regularly monitor these high-risk patients.

Grading follicular lymphoma on fine needle aspiration specimens. Comparison with proliferative index by DNA image analysis and Ki-67 labeling index.

OBJECTIVE: To determine whether follicular lymphoma (FL) can be graded on fine needle aspiration (FNA) biopsies by determining the percentage of centroblasts in the neoplastic follicles on the smears. STUDY DESIGN: Eighty-nine cases of histologically confirmed cases of FL, including 31 grade 1, 46 grade 2 and 12 grade 3, were evaluated. Proliferative index (PI) by DNA image analysis (DIA) and Ki-67 labeling index (LI) were obtained on all cases. A minimum of 200 cells were counted per case (range, 200-800 cells) at 40x magnification, and the number of large cells (centroblasts) was expressed as a percentage of the total number of cells counted within the follicles. RESULTS: The percentage of centroblasts in the follicular aggregates was 9.7 +/- 2.9% in grade 1 FLs, 24.7 +/- 5.6% in grade 2 and 48.4 +/- 7.5% in grade 3. These differences were significant (P < .05). DNA image analysis of PI and Ki-67 LI differed significantly between grade 1 FLs and grade 2 and 3 FLs (P < .05), but there were no significant differences between grade 2 and 3 FLs. CONCLUSION: Determining the percentage of centroblasts in the follicular aggregates on FNA specimens is a good method of grading FLs. Using the percentage of centroblasts per follicular structure, FL grades 1, 2 and 3 were adequately distinguished. PI by DIA and Ki-67 LI clearly distinguished FL grade 1 from FL grades 2 and 3; however, it did not clearly distinguish between grades 2 and 3.

Design and synthesis of 8-hydroxy-[1,6]naphthyridines as novel inhibitors of HIV-1 integrase in vitro and in infected cells.

Naphthyridine 7 inhibits the strand transfer of the integration process catalyzed by integrase with an IC50 of 10 nM and inhibits 95% of the spread of HIV-1 infection in cell culture at 0.39 microM. It does not exhibit cytotoxicity in cell culture at < or =12.5 microM and shows a good pharmacokinetic profile when dosed orally to rats. The antiviral activity of 7 and its effect on integration were confirmed using viruses with specific integrase mutations.

Readers Panel - Qualified to care.

As a discarded EN I find the idea of an all-graduate workforce perplexing. Having several levels of nurses at the bedside has many advantages. In my day the auxiliaries often teamed up with the EN while the SRN took charge of the medications. The versatile EN stepped in while the SRN was away.