Neonatal enteroviral sepsis/meningoencephalitis and hemophagocytic lymphohistiocytosis: diagnostic challenges

We present the clinical course of three neonates with proven enteroviral infection and an initial clinical picture suggestive of hemophagocytic lymphohistiocytosis (HLH). After a complete workup, only one was treated for HLH. Of particular interest, the first newborn presented with hemophagocytic cells in the cerebrospinal fluid (CSF) and proved to have enteroviral meningoencephalitis but was ultimately not diagnosed with HLH. A fourth infant, who fulfilled the diagnostic criteria for HLH but did not have enteroviral infection, is included for comparison. We suggest that severe neonatal enteroviral infection and HLH are difficult to distinguish. Careful assessment is recommended, as prognosis and treatment differ between these two entities. Literature regarding neonatal enteroviral infection and HLH is reviewed, to demonstrate the continuum between the inflammation triggered by enteroviral infection and the occurrence of HLH, as well as their comparable CSF findings.     

Management of borderline change in endocervical cells: a more dependable approach

Background:

There are limited data and guidance from the UK on borderline nuclear change in endocervical cells (BNCs). The objective of this study is to determine the clinical outcome of women with BNCs, to determine the accuracy of colposcopy and propose a more robust management algorithm.

Methods:

This is a retrospective review of all BNC referrals between January 2006 and December 2011 at the Northumbria Healthcare Trust. Histological diagnosis was based on high-grade histology (CIN 2 or worse). Any high-grade histology in the first year of follow-up was included in the final diagnosis.

Results:

Of the 9001 new referrals, 167 women had BNCs. Thirty-seven (22%) were diagnosed with high-grade histology on initial assessment. Sixty women had satisfactory and negative colposcopy, out of which 7 (12%) were detected with high-grade histology/cytology in the first year of follow-up. Overall, 50 high-grade histology (30%), including two invasive carcinomas were detected.

Conclusions:

Current follow-up of BNCs relies heavily on colposcopic assessment. A significant proportion of women with negative colposcopy was found to have high-grade histology in the first year of follow-up. We propose a more robust management algorithm to lower the probability of missed high-grade histology in this subgroup of women.     

PS1-62: Assessing Readiness for Team Care in Community-based Clinics: Barriers and Facilitators to Implementing an Evidence-based Intervention to Improve BP Control

Background/Aims Understanding the barriers and facilitators to implementing evidence-based models of care in typical community settings is critical to the successful translation of research-tested interventions into practice. The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP), implemented in a large, integrated group practice, demonstrated that team-care and incorporating a pharmacist to manage hypertension via secure e-mail communications in an existing patient-shared electronic health record (EHR) resulted in almost twice the rate of BP control compared to usual care. We sought to assess whether e-BP could be implemented in community-based primary care clinics with very different contextual features (e.g. inexperience with pharmacist team members, limited IT infrastructure, and vulnerable patient populations). Methods We conducted interviews with purposive samples of health care providers, pharmacists and patients associated with four community-based, primary care clinics. Using template analysis incorporating a priori codes drawn from the Chronic Care Model and the Consolidated Framework for Implementation Research, we identified themes illuminating contextual barriers and facilitators, as well as strategies for adapting core components of e-BP for implementation to control hypertension in community practice settings. Results Community-based patients, pharmacists, providers and staff expressed eagerness to participate in an intervention like e-BP. They characterized its approach to healthcare as "the right thing to do" and expressed hope that participation would yield enough evidence about the benefits of this care model to support significant reimbursement reform. The intervention's sustainability was of paramount importance to stakeholders and needs to be considered in planning for implementation. Stakeholders were more concerned about being able to overcome barriers related to regulations and reimbursement than to clinic-level factors. Discussion Community-based clinic stakeholders would like to improve hypertension control and the care of other chronic conditions using team care and communications outside of office visits. However, ensuring a business case for implementation and sustainability of these models was a persistent theme. Using this case study, we will discuss methods and models for adaptation and implementation of evidence-based interventions into community practice.     

A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital

The aim of an Intensive Care Nurse Consultant (ICNC) service is to optimise care of complex ward patients and reduce adverse events. Despite their widespread implementation, specific assessment of ward nurses' attitudes towards such is lacking. Accordingly, we surveyed ward nurses' attitudes towards our ICNC service in five domains: (a) accessibility and approachability; (b) perceived ICNC skill and knowledge; (c) perceived influence on patient management; (d) usefulness as a resource of clinical information; (e) impact upon adverse outcomes. To achieve this, an anonymous Liker-type questionnaire was distributed to 208 ward nurses in our hospital. We also included space for free text. Completed questionnaires were entered manually into a SURVEYMONKEY? pro-forma to permit automatic report generation and results summary. The major findings were that ICNC staff were perceived as being approachable and good communicators, were skilled at early detection of deteriorating patients, and that they reduce serious adverse events. In addition, nurses believe the ICNC service provides continuity of care post discharge from the intensive care unit (ICU), as well as assisting staff to prioritise clinical issues following medical emergency team (MET) review or ICU discharge. The ward nurses did not believe that the ICNC service reduced their skills in managing ward patients. In contrast, respondents stated that the ICNC service needed to improve the processes of referral to allied health and education of ward staff regarding deteriorating patients. Finally, ward nurses suggest they would call the MET service rather than the ICNC service for patients who had already deteriorated. This survey suggests that the ICNC service is valued, and is perceived to prevent the development of adverse events, rather than playing a major role in the management of the deteriorating patient. There is a need to improve referrals to allied health and further educate ward nurses.     

Developing a Practice‐Based Research Network by Integrating Quality Improvement: Challenges and Ingredients for Success

Improving patient outcomes in community‐based settings is the goal of both the Clinical Translational Science Award program and practice‐based quality improvement (QI) programs. Given this common goal, integrating QI and outcomes research is a promising strategy for developing, implementing, and evaluating clinical interventions. This article describes the challenges and strengths illuminated by the conduct of a combined research/QI study in a nascent practice‐based research network. Challenges include research''s exclusion of clinic patients who might benefit from the intervention; QI programs’ less uniform approach to intervention implementation; and the need for both academic and clinically relevant products and publications. A major strength is the increased likelihood of both engaging clinical practices in research and developing successful clinical interventions. Required elements for success include identification of enthusiastic clinical research “champions,” involvement of researchers with clinical experience, and adequate funding to support both research and clinical resources and dissemination. Combined Ql/research projects in the practice‐based research environment have the potential to improve and shorten the cycle from good idea to improved clinical outcomes in real‐world settings. Clin Trans Sci 2012; Volume 5: 351–355     

Performance monitoring following conflict: Internal adjustments in cognitive control?

The purpose of this study was to investigate the effects of strategic conflict-related adjustments in cognitive control processes on indices of performance monitoring. Previous research has examined the ability of parametric task-related manipulations to bias attention to errors; however, the present study sought to elucidate the effects of internal adjustments in control mediated by the anterior cingulate cortex on error-related conflict processing. High-density event-related potentials (ERPs) were obtained from 124 healthy individuals (68 female, 66 male) during a modified Eriksen flanker task. Behavioral measures (i.e., error rates, response times [RTs]) and N2 amplitudes showed significant conflict adaptation (i.e., previous-trial congruencies influenced current-trial measures). For error trials, the error-related negativity (ERN) was more negative for errors on high-conflict (i.e., incongruent) trials following high-conflict trials relative to errors on high-conflict trials following low-conflict (i.e., congruent) trials. These findings indicate that error-related conflict-monitoring processes adjust according to the post-conflict recruitment of strategic cognitive control and suggest an ongoing interplay between conflict and internal adjustments in control resources. Interpretations from the perspective of the conflict monitoring theory of cognitive control, the reinforcement learning theory, and the response-outcome theory of the ERN are discussed.