Evaluating De-Escalation Training for Direct and Indirect Employees Caring for Residents With Huntington's Disease.

INTRODUCTION: Little is known about reducing the challenges for caregivers and patients with Huntington's disease (HD). HD creates behavioral disturbances, cognitive decline, and motor disorder progression over the lifetime requiring some individuals to need long-term facility care. AIMS: There are concerns about safety and confidence of employees caring for residents with HD. METHODS: Nursing staff, administrators, and auxiliary employees were recruited from a long-term care (LTC) facility in rural Iowa, from July 2020 to August 2020. A de-escalation training intervention was delivered. The 1-day intervention included resident behaviors, planning and safety, teamwork, communication, and included role play and simulation. A pre- and post-survey measured confidence and competence in caring for people with HD before and after a training intervention. A resident medical record audit explored challenging behaviors before and after the training intervention. RESULTS: Of 25 participants, six were registered nurses/licensed practical nurses (RNs/LPNs; 24%), four administrators (16%), eight nursing assistants (32%), and seven auxiliary employees (28%). There was improvement in employees perceived safety (33.3%), co-workers enjoyment working with HD residents (54%), understanding symptoms of HD (44.4%), confidence in job abilities (21.0%), and confidence in ability to care for patients with HD (26.3%). A medical record audit showed decreased documentation of resident aggression and care refusal post-intervention. CONCLUSIONS: These findings suggest de-escalation training in LTC facilities increased perception of job safety, co-workers' enjoyment, understanding HD symptoms, confidence in ability to care for patients with HD, and decreased resident agitation and care refusal.

Percutaneous Harvest of Calcaneal Bone Autograft: Quantification of Volume and Definition of Anatomical Safe Zone.

Bone grafting is commonly used in reconstructive foot and ankle surgery. The calcaneus provides an excellent site for graft harvest due to its rich vascularity and access to corticocancellous or strictly cancellous bone. The relatively thin soft tissue envelope makes dissection easy compared to more proximal autograft sites. In this investigation we quantified cancellous autograft volume from the calcaneus while simultaneously defining anatomical safe zones and identifying anatomical structures at risk. Nine matched-pair (18 total) fresh-frozen cadaveric below-knee limbs were utilized. All limbs were thawed at room temperature prior to the procedure. Calcaneal autograft was harvested following the senior author's (D.J.E.) technique. Bone graft was packed and quantified by podiatric medical students (B.R. and J.T.). An independent investigator (K.S.) meticulously dissected the lateral calcaneal soft tissue envelope to determine rates of neurovascular compromise. Anatomical safe zones were defined by measurements of the harvest site compared to vital anatomical structures. Cancellous autograft averaging 0.85 cc was obtained through an average cortical opening of 0.77 cm. The stab incision is approximately 2.2 cm anterior to the posterior aspect of the calcaneus and 1.6 cm superior to the inferior aspect of the calcaneus. This incision is an average 1.8 cm from the main branch of the sural nerve. No neurovascular damage was found. This study details percutaneous harvest of calcaneal autograft for use in forefoot or midfoot surgeries with an emphasis on feasibility of this additional procedure. The technique proposed is valuable based on simplicity, wide anatomic safe zone, and potential improvement of surgical outcomes.

Seckel syndrome presenting with complete heart block.

Seckel syndrome is a rare autosomal recessive disorder characterized by facial dysmorphic features known as bird-headed dwarfism. Only about 100 cases have been reported. Cardiac anomalies have been described as a potential association with Seckel syndrome. We report a 21-year-old woman with Seckel syndrome and epilepsy who presented with status epilepticus. She was hypotensive and bradycardic. Her electrocardiogram showed complete heart block. She was placed on transcutaneous pacer with no response. A transvenous pacemaker was placed before inserting a suitable permanent pacemaker for her size. This is the third case of complete heart block associated with Seckel syndrome and raises concern about the potential association.

Giant Left Ventricular Thrombus Formation in the Setting of Severe Aortic Stenosis and Heavy Cigarette Smoking.

The harmful effects of cigarette smoking on the human body have been well documented. However, whether tobacco use is an independent risk factor of valvular heart disease remains debatable. Cigarette smoking has been associated with an inflammatory state and increased levels of tumor necrosis factor alpha, which in turn activates protein kinases involved in ventricular remodeling. Subsequent ventricular dysfunction predisposes to the formation of mural thrombi which may lead to further worsening of hemodynamics. We present a case of severe aortic stenosis and giant left ventricular thrombus formation associated with chronic cigarette smoking.

Stability and Transport of Graphene Oxide Nanoparticles in Groundwater and Surface Water.

The effects of groundwater and surface water constituents (i.e., natural organic matter [NOM] and the presence of a complex assortment of ions) on graphene oxide nanoparticles (GONPs) were investigated to provide additional insight into the factors contributing to fate and the mechanisms involved in their transport in soil, groundwater, and surface water environments. The stability and transport of GONPs was investigated using dynamic light scattering, electrokinetic characterization, and packed bed column experiments. Stability results showed that the hydrodynamic diameter of the GONPs at a similar ionic strength (2.1±1.1 mM) was 10 times greater in groundwater environments compared with surface water and NaCl and MgCl2 suspensions. Transport results confirmed that in groundwater, GONPs are less stable and are more likely to be removed during transport in porous media. In surface water and MgCl2 and NaCl suspensions, the relative recovery was 94%±3% indicating that GONPs will be very mobile in surface waters. Additional experiments were carried out in monovalent (KCl) and divalent (CaCl2) salts across an environmentally relevant concentration range (0.1-10 mg/L) of NOM using Suwannee River humic acid. Overall, the transport and stability of GONPs was increased in the presence of NOM. This study confirms that planar "carbonaceous-oxide" materials follow traditional theory for stability and transport, both due to their response to ionic strength, valence, and NOM presence and is the first to look at GONP transport across a wide range of representative conditions found in surface and groundwater environments.

Efficacy of articaine versus lidocaine as a supplemental buccal infiltration in mandibular molars with irreversible pulpitis: a prospective, randomized, double-blind study.

INTRODUCTION: Profound pulpal anesthesia in mandibular molars with irreversible pulpitis (IP) is often difficult to obtain and often requires supplemental injections after an ineffective inferior alveolar nerve block (IANB). The purpose of this prospective, randomized, double-blind study was to compare the efficacy of 4% articaine with 2% lidocaine for supplemental buccal infiltrations (BIs) after an ineffective IANB in mandibular molars with IP. In addition, the use of articaine for IANB and intraosseous injections was investigated. METHODS: One hundred emergency patients diagnosed with IP of a mandibular molar were selected and received an IANB with 4% articaine. All injections were 1.7 mL with 1:100,000 epinephrine. All patients reported profound lip numbness after IANB. Patients with ineffective IANB (positive pulpal response to cold or pain on access) randomly received 4% articaine or 2% lidocaine as a supplemental BI. Endodontic access was initiated 5 minutes after deposition of the infiltration solution. Success was defined as no pain or no more than mild pain during endodontic access and instrumentation as measured on a visual analogue scale. RESULTS: Seventy-four patients failed to achieve pulpal anesthesia after IANB with 4% articaine, resulting in IANB success rate of 26%. Success rates for supplemental BIs were 62% for articaine and 37% for lidocaine (P < .05). This effect was most pronounced in second molars (P < .05). CONCLUSIONS: Supplemental BI with articaine was significantly more effective than lidocaine. The IANB success rate of 4% articaine confirmed published data.