Riddle Hospital

Patient medication safety in the acute care setting is a foundational action provided by nurses and healthcare providers for safe patient care. Hospitalization of patients with Parkinson's disease (PD) can be dangerous due to the unique and variable medication regimen required. Patients with PD often have their medication administered inappropriately in the acute care setting (e.g., holding a PD medication in preparation for surgery, not administering the medication on the patient's home schedule, and delaying administration). The research question posed in this study was the following: does a PD medication educational intervention in the clinical setting enhance knowledge, comfort, and competence of practicing nurses in the care of patients with PD regarding their medication safety? A mixed methods study design was used for this 5-month, two-part study with a sample of practicing RNs at three different hospitals. Part one of the study assessed nurses' initial knowledge of PD and PD medication safety and included an educational intervention. Part two of the study occurred 3 months later and evaluated if knowledge from the educational intervention was retained. The study was conducted in two parts and included a pre-test, educational intervention, post-test, and follow-up test 3 months later. The educational intervention consisted of a 15-minute video of two PD advanced practice nurses being interviewed regarding the general care of a patient with PD. The pre-test, post-test, and follow-up test were identical and consisted of six questions regarding knowledge, comfort, and self-perceived competency. Participants were additionally asked three open-ended questions at follow-up to gain insight on the effectiveness of the educational intervention. A total sample of 252 RNs participated in this study. Statistically significant improvements in knowledge, comfort, and self-perceived competency were observed in the post-test scores compared to pre-test scores. These statistically significant improvements were retained after 3 months, despite a 42.9% decrease in the number of responders (n = 252 vs. n = 144). Additionally, compared to the post-test, there were no statistically significant declines in knowledge, comfort, or competency in the follow-up test. Qualitative findings indicated that the training regarding PD medications was retained and found to be valuable, even if it was seldom applied in practice. A review of the literature and this study both support the need for increased education for practicing nurses as it relates to PD and PD medication safety. Healthcare systems, organizations, and associations that support continuing education for nurses create a stronger workforce. Education has been found to keep nurses up to date on the latest advances in care and treatment while also providing exposure to other areas of nursing beyond their clinical settings. Promoting better patient outcomes through safe medication administration is a hallmark of nursing care excellence. This study found that supporting the use of an educational intervention of PD medication safety for nurses improved RN levels of knowledge, comfort, and competency up to 3 months later. As the population of those with PD increases, healthcare systems, and nurses must now, more than ever, be poised to care for these individuals. This is a critical point in PD patient care since persons with PD are hospitalized 1.5 times more than their peers without PD.

De berechting binnen een redelijke termijn. Een empirisch onderzoek naar doorlooptijden in handelszaken Dit artikel betreft een empirisch onderzoek naar de doorlooptijden in civiele zaken. Het gaat in op de categorie van zaken die te kampen hebben met de langste doorlooptijden: handelszaken met een belang van boven de € 1 miljoen. Van honderd van dergelijke zaken zijn de procedure in eerste aanleg en in hoger beroep nader bestudeerd en is het procesverloop in kaart gebracht. Het onderzoek maakt inzichtelijk welke tijd is gemoeid met de afzonderlijke stappen in de procedure.

INTRODUCTION: We present a case of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE), an exceedingly rare disorder, specifically targeting the small bowel. CASE DESCRIPTION/METHODS: A 47 year-old female was referred for recurrent small bowel obstructions (SBO) and opioid-induced constipation. She denied bloody stool, mouth ulcers, rashes, joint pain, and use of NSAIDs. She reported a 20-pound weight loss over a few years. She had no significant tuberculosis risk factors and no family history of IBD or celiac disease. She had a surgical history of appendectomy, cholecystectomy, and abdominoplasty. Physical exam was only notable for surgical scars. Labs were pertinent for iron deficiency anemia and elevated inflammatory markers. She was negative for HIV, HCV, and celiac disease. Patient had 3 episodes of SBO conservatively managed. CT of the abdomen/pelvis showed wall thickening of mid-small bowel loops, SBO, and multiple enlarged mesenteric lymph nodes (3.1 × 3.7cm). Upper endoscopy and colonoscopy showed no inflammation or ulcerations. Video capsule endoscopy could not be performed, due to patency capsule retention. MR enterography (MRE) showed angulation of mid-small bowel loops with areas of wall thickening, narrowing, and distention, no abnormalities of distal and terminal ileum, and enlarged mesenteric lymph nodes. Interventional radiology could not access the lymph nodes to rule out lymphoma. She ultimately underwent a diagnostic laparoscopy, partial small bowel resection, and mesenteric lymph node biopsy. Pathology showed areas of superficial and circumferential ulceration with submucosal fibrosis and thickened muscularis mucosa, favoring CMUSE. DISCUSSION: The differential diagnosis for this presentation included Crohn’s disease and NSAID induced enteropathy. However, based on the clinical features, MRE, and histology, CMUSE is the most likely diagnosis. CMUSE typically has a prolonged presentation, over decades, notably with exclusive small intestine involvement without colonic or gastric pathology or extraintestinal manifestations. As seen in this case, ulcers are predominantly in the ileum, while sparing the terminal ileum. Histology is remarkable for absence of severe inflammation, even in the ulcerated areas, without typical Crohn’s features. Genetic basis and pathogenesis remains unknown, with mutations being investigated. Both surgical management as well as immunomodulators are used, though data remains limited.Figure 1.: Specimen site: small bowel. Several pauci-inflammatory, well delineated areas of ulceration with expansion and fibrosis of the underlying submucosa and thickening of the muscularis mucosae. The muscularis propria and subserosa are normal. The bowel immediately adjacent to the ulcerated areas is not affected. Typical features of Crohn's disease are absent.

Albornoz, M. Anthony MD; Baldassari, Michael Philip BA; Albornoz, Christian Anthony BA; Boghosian, Garen MD Author Information

Background: Our aim was to determine whether a structured stroke follow-up clinic (SFC) could reduce 30-day and 90-day readmission rates for patients discharged home with ischemic/hemorrhagic stroke or TIA. Methods: Prior to discharge, NPs identified patients at high risk for readmission, an RN performed follow-up phone calls, and the clinic visit included a standardized and comprehensive stroke nurse practitioner (NPs) assessment. Phase 1 of the SFC (10/2012) consisted of phone calls within 7 days of discharge, and 2 NPs seeing patients within 2 weeks of discharge, which focused on education, prevention, recovery and evaluation for complications. Phase 2 (9/2014) expanded to an RN calling 90% of patients discharged home within 2 days, and any issues identified were managed by NPs before the SFC visit. Demographics, medical history, and processes of care were entered into a REDcap database. Differences in these factors and readmission across the 2 phases of the SFC were assessed. Multivariate logistic regression models for 30-day and 90-day readmissions were performed with adjustment for NIHSS and hospitalizations prior to the index stroke. Results: We analyzed 280 consecutive patients through 4/2015. Mean age 66.1 y ± 14.5, 51% women, median NIHSS 3 (IQR 1-5), 34% prior stroke/TIA, and 20% with prior hospitalizations. From phase I to phase 2, days from discharge to SFC decreased, and 90-day readmissions decreased (table). Patients readmitted within 30 days had lower SFC show rates (60% vs 82.9% not readmitted; p=0.006), as well as 90-days (69% vs 83% not readmitted; p=0.034). Multivariable modeling after adjustment for prior hospitalizations, prior stroke, and NIHSS showed that SFC show rate was associated with a 74% reduction in 30-day readmission (OR 0.26; 95% CI 0.11-0.66) and a 63% reduction in 90-day readmission (OR 0.37; 0.15-0.89). Conclusions: Stroke patients’ show rate for this SFC was independently associated with reduced 30-day and 90-day readmission.

Objective: Determine if differential long-term neurodevelopmental effects exist across commonly used antiepileptic drugs (AEDs). Background The primary outcome (age 6 year IQ) of the NEAD study and other cognitive findings at this age are reported here. Preliminary findings at age 3 were previously reported (Meador et al. NEJM 2009). Design/Methods: Pregnant women with epilepsy on AED monotherapy (carbamazepine, lamotrigine, phenytoin, or valproate) were enrolled in a prospective observational multicenter study in the USA and UK from 1999-2004. Multivariate analyses were conducted on intent-to-treat (n=310) and completer samples (n=224) with appropriate follow up analyses and secondary analyses of other cognitive measures. Results: Children exposed to valproate (adjusted mean IQ = 99) had significantly lower IQ scores than children in each of the other AED groups (carbamazepine = 105, lamotrigine = 108, phenytoin = 106). Children in the valproate group also performed more poorly vs. each of the other three AEDs on measures of verbal abilities and memory, and more poorly vs. lamotrigine on measures of non-verbal and executive functions. Valproate dose was negatively associated with IQ, verbal, non-verbal, memory, and executive functions, but the other AEDs did not demonstrate a dose relationship. Age 6 IQ correlated positively with IQ at earlier ages, and IQ scores improved with age across all AEDs. Verbal abilities were impaired compared to non-verbal abilities for all AEDs combined and for each individual AED except phenytoin. Children exposed to peirconception folate exhibited higher IQ (108 vs. 102 for those not receiving folate). Conclusions: Fetal valproate exposure is associated with lower IQ and reduced cognitive abilities across a range of cognitive domains at age 6 years. Verbal abilities may be impaired by several commonly used AEDs. Periconceptional folate may have positive effects on cognitive outcomes. Many unanswered questions remain, and additional research is needed. Supported by: NIH [NS038455 and NS050659] and UK Epilepsy Research Foundation [RB219738]. Disclosure: Dr. Meador has received research support from Cyberonics, Neuropace, Pfizer, and UCB Pharma. Dr. Baker has received personal compensation for activities with UCB as a speaker. Dr. Baker has received research support from UCB and Sanofi Aventis. Dr. Browning has nothing to disclose. Dr. Cohen has received personal compensation for activities with the Children9s Memory Scale. Dr. Brombley has received personal compensation for activities with Sanofi-Aventis Pharmaceuticals, Inc. Dr. Brombley has received research support from Sanofi-Aventis Pharmaceuticals, Inc. Dr. Clayton-Smith has received personal compensation in an editorial capacity for Clinical Dysmophology. Dr. Kalayjian has received personal compensation for activites with GlaxoSmithKline as a speaker. Dr. Kanner has received research support from Pfizer Inc. Dr. Liporace has received personal compensation for activities with UCB Pharmaceuticals as a speaker. Dr. Pennell has nothing to disclose. Dr. Privitera has received personal compensation for activities with UCB Pharmaceuticals and GSK as a consultant and speaker.Dr. Privitera has received research support from UCB Pharmaceuticals and Eisai. Dr. Loring received personal compensation from NeuroPace as a consultant.

Letters19 May 2009Reversal of Haloperidol-Induced Cardiac Arrest by Using Lipid EmulsionGuy Weinberg, MD, Guido Di Gregorio, MD, David Hiller, MD, Agnes Hewett, MD, and Archie Sirianni, MDGuy Weinberg, MDFrom University of Illinois at Chicago College of Medicine, Chicago, IL 60612, and Riddle Memorial Hospital, Media, PA 19063., Guido Di Gregorio, MDFrom University of Illinois at Chicago College of Medicine, Chicago, IL 60612, and Riddle Memorial Hospital, Media, PA 19063., David Hiller, MDFrom University of Illinois at Chicago College of Medicine, Chicago, IL 60612, and Riddle Memorial Hospital, Media, PA 19063., Agnes Hewett, MDFrom University of Illinois at Chicago College of Medicine, Chicago, IL 60612, and Riddle Memorial Hospital, Media, PA 19063., and Archie Sirianni, MDFrom University of Illinois at Chicago College of Medicine, Chicago, IL 60612, and Riddle Memorial Hospital, Media, PA 19063.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-150-10-200905190-00023 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Infusion of lipid emulsion has been reported to be an effective way to treat local anesthetic–induced cardiac toxicity, and recent reports suggest that it might also be effective in other forms of drug-related cardiac arrest (1).Objective: To report a case of successful resuscitation of a patient with haloperidol-induced cardiac arrest after lipid emulsion infusion.Case Report: A 45-year-old woman came to the hospital reporting palpitations and chest pain. Her medical history included untreated hypertension, anxiety, depression, opioid abuse, and cigarette smoking. She was extremely agitated. Her heart rate was 64 beats/min, respiratory rate was 30 breaths/min, and blood ...

Fetal exposure of animals to antiepileptic drugs at doses lower than those required to produce congenital malformations can produce cognitive and behavioral abnormalities, but cognitive effects of fetal exposure of humans to antiepileptic drugs are uncertain. Between 1999 and 2004, we enrolled pregnant women with epilepsy who were taking a single antiepileptic agent (carbamazepine, lamotrigine, phenytoin, or valproate) in a prospective, observational, multicenter study in the United States and the United Kingdom. The primary analysis is a comparison of neurodevelopmental outcomes at the age of 6 years after exposure to different antiepileptic drugs in utero. This report focuses on a planned interim analysis of cognitive outcomes in 309 children at 3 years of age. At 3 years of age, children who had been exposed to valproate in utero had significantly lower IQ scores than those who had been exposed to other antiepileptic drugs. After adjustment for maternal IQ, maternal age, antiepileptic-drug dose, gestational age at birth, and maternal preconception use of folate, the mean IQ was 101 for children exposed to lamotrigine, 99 for those exposed to phenytoin, 98 for those exposed to carbamazepine, and 92 for those exposed to valproate. On average, children exposed to valproate had an IQ score 9 points lower than the score of those exposed to lamotrigine (95% confidence interval [CI], 3.1 to 14.6; P=0.009), 7 points lower than the score of those exposed to phenytoin (95% CI, 0.2 to 14.0; P=0.04), and 6 points lower than the score of those exposed to carbamazepine (95% CI, 0.6 to 12.0; P=0.04). The association between valproate use and IQ was dose dependent. Children's IQs were significantly related to maternal IQs among children exposed to carbamazepine, lamotrigine, or phenytoin but not among those exposed to valproate. In utero exposure to valproate, as compared with other commonly used antiepileptic drugs, is associated with an increased risk of impaired cognitive function at 3 years of age. This finding supports a recommendation that valproate not be used as a first-choice drug in women of childbearing potential.