The Physiologic Approach to the Management of Itching

Various physiologic factors of itch are reviewed, including relationship to pain, types of itch, the itch-scratch cycle and the function of dry skin and miliaria in itch. Basic pharmacologic experiments in control of pruritus are also reviewed. These facts are then applied in the therapy of pruritus.     

Fecal Incontinence: A Stepwise Approach to Primary Care Management

Fecal incontinence can adversely affect quality of life, leading to embarrassment and social isolation. It occurs more often in older adults and is a common reason for nursing home referrals. Numerous treatments are available, but most patents self-treat and often do not report their symptoms. Advanced practice nurses providing primary care develop a rapport with the patient, allowing him or her to elicit important information about this sensitive subject. Interventions are designed to relieve symptoms and decrease incontinence episodes, ultimately improving quality of life. Management follows a stepwise approach beginning with conservative methods and newer technologies when indicated.     

Female Genital Cutting: An Evidence-Based Approach to Clinical Management for the Primary Care Physician

The United States has more than 1.5 million immigrants from countries in Africa and the Middle East where female genital cutting (FGC) is known to occur. Often, FGC occurs in infancy and childhood in the countries where it is practiced, but patients of any age can present with complications. Lack of understanding of this common problem can potentially alienate and lower quality of care for this patient population. We provide an introduction to the practice of FGC and practice guidelines for the primary care physician. We reviewed original research, population-based studies, and legal research from PubMed, Scopus, CINAHL plus, PsycINFO, and Legal Trac. The terms searched included female genital cutting, female genital circumcision, and female genital mutilation alone and with the term complications or health consequences; no limit on date published. Legal databases were searched using the above terms, as well as international law and immigration law. Editorials and review articles were excluded. This review discusses the different types of FGC, important cultural considerations for physicians caring for patients with FGC, the common early and late medical complications and their management, and psychosocial issues associated with FGC. Current laws pertaining to FGC are briefly reviewed, as well as implications for patients seeking asylum status in the United States because of FGC. Finally, the article presents evidence-based, culturally sensitive approaches to discussions of FGC with girls and women for whom this is an issue.     

Surgical Scheduling: A Lean Approach to Process Improvement

A large teaching hospital in the northeast United States had an inefficient, paper-based process for scheduling orthopedic surgery that caused delays and contributed to site/side discrepancies. The hospital’s leaders formed a team with the goals of developing a safe, effective, patient-centered, timely, efficient, and accurate orthopedic scheduling process; smoothing the schedule so that block time was allocated more evenly; and ensuring correct site/side. Under the resulting process, real-time patient information is entered into a database during the patient’s preoperative visit in the surgeon’s office. The team found the new process reduced the occurrence of site/side discrepancies to zero, reduced instances of changing the sequence of orthopedic procedures by 70%, and increased patient satisfaction.     

Late Whiplash Syndrome: A Clinical Science Approach to Evidence-Based Diagnosis and Management

▪ Abstract:   The purpose of this article is to narrow the gap that exists in the clinical application of scientific research and empiric evidence for the evaluation and management of late whiplash. Considering that 14% to 42% of patients are left with chronic symptoms following whiplash injury, it is unlikely that only minor self-limiting injuries result from the typical rear-end impact. As psychosocial issues play a role in the development of persistent whiplash symptoms, discerning the organic conditions from the biopsychosocial factors remains a challenge to clinicians. The term "whiplash" represents the multiple factors associated with the event, injury, and clinical syndrome that are the end-result of a sudden acceleration-deceleration trauma to the head and neck. However, contentions surround the nature of soft-tissue injuries that occur with most motor vehicle accidents and whether these injuries are significant enough to result in chronic pain and limitations. The stark contrast in litigation for whiplash that exists among industrialized nations and less developed countries suggests another factor that could influence one's interpretation of symptoms' chronicity associated with Late Whiplash Syndrome. There are no gold standard tests or imaging techniques that can objectify whiplash-associated disorders. A lack of supporting evidence and disparity in medico-legal issues have created distinct camps in the scientific interpretations and clinical management of late whiplash. It is likely that efforts in research and/or clinical practice will begin to explain the disparity between acute and chronic whiplash syndrome. Recent evidence suggests that Late Whiplash Syndrome should be considered from a different context. The purpose of this article is to expound on several of the significant findings in the literature and offer clinical applications for evaluation and management of Late Whiplash Syndrome. ▪     

No Surgical Items Left Behind: A Multidisciplinary Approach to the Surgical Count Process

The counting process is designed to prevent retained foreign bodies while providing optimal perioperative patient safety. Intraoperative distractions are prevalent and potentially contribute to patient safety risks. Counting is an important preventative measure that is a human process prone to error, especially in this busy environment where multiple things are happening simultaneously. We sought to evaluate the impact of distractions during the count process on patient safety. Trained, nationally certified registered nurses used a validated tool to observe the number of interruptions that occurred during the count process in cardiac surgery. Observation included the key personnel that lead the count process including the scrub person, circulating nurse, attending surgeons, fellows, and residents of all disciplines. Observation included scheduled cases in the cardiac specialty for the adult population including all shifts (24 hours). The predictor in this study was distraction. The primary measure of distraction was the total number of distraction for each case. There are different distraction levels for each distraction. Thus, weighted distraction score for each case was created as the summation of distraction level and it is the secondary measure of distraction. To detect a medium effect size with 80% power at 0.05 level, we needed a minimum sample size of 54. We correlated the relationship between the number of interruptions observed and sequelae. Working together as a cohesive team to minimize interruptions can enhance patient safety and decrease additional workload across departments.