Implementation of a gastrostomy care bundle reduces dislodgements and length of stay

PurposePediatric gastrostomy tubes (G-tubes) are associated with considerable utilization of healthcare resources. G-tube dislodgement can result in tract disruption and abdominal sepsis. We aimed to reduce early G-tube dislodgement by 25%.MethodsAn interdisciplinary team convened to identify key drivers of G-tube dislodgement and implement initiatives to reduce this complication. A G-tube care bundle was implemented in 2018. Rates of early G-tube dislodgement (within 90 days of insertion) were tracked. 15 months of cases after bundle implementation were compared to 20 months of cases before implementation. Length of stay (LOS, balancing measure) and bundle compliance (process measure) were tracked.ResultsG-tube dislodgements decreased 47% after bundle implementation. Overall, dislodgements after G-tube insertion decreased from 43% to 19% dislodgements per tube inserted, p = 0.004. Reductions were observed for dislodgements occurring in both the inpatient (14% vs. 1.5%) and outpatient (29% vs. 18%) settings. Median LOS was reduced from 15.3 to 7.1 days following implementation, p = 0.004. Process measures demonstrated 75% or greater compliance one year after implementation.ConclusionAn interdisciplinary team using quality improvement science methodology can significantly reduce G-tube dislodgement and improve value after pediatric gastrostomy tube insertion.Type of studyLongitudinal cohort study.Level of evidenceIII.     

Just Say No: The Case Against Opioid-Based Postoperative Pain Management Regimens Following Breast Surgery

Annals of Surgical Oncology -     

Basismaßnahmen zur Wiederbelebung Erwachsener (Basic Life Support)

Notfall + Rettungsmedizin - Der Europäische Rat für Wiederbelebung hat diese Leitlinie – Basismaßnahmen zur Wiederbelebung – auf Grundlage des...     

A Novel Telemedicine System for Care of Statewide Hand Trauma

Background: Telemedicine is an evolving tool to increase patients’ access to subspecialty care. Since 2014, Arkansas has been utilizing telemedicine in the evaluation of patients with hand injuries. The purpose of this study is to assess the effect of this novel telemedicine system for the management of hand trauma on patient transfer. Methods: We reviewed data from the first year of the telemedicine program (2014) and compared it to data from the year prior (2013). Data collection from both years included number of hand consults and need for transfer. From the 2014 data, we also recorded the use of telemedicine, type of transfer, distance of transfer, and time to disposition. Results: During 2013 (pre-telemedicine), there were 263 hand traumas identified. In all, 191 (73%) injuries required transfer to a higher level of care, while 72 (23%) were managed locally. In the first year of the telemedicine program (2014), a total of 331 hand injuries were identified. A total of 298 (90%) resulted in telemedicine consultation with 65% (195) utilizing video encounters. After telemedicine consultation, local management was recommended for 164 injuries (55%) while transfer was recommended for 134 (45%). Using telemedicine, there was a significant decrease in the percentage of transfer for hand injuries (P < .001). Conclusions: The telemedicine program was well utilized and provided patients throughout the state with continuous access to fellowship trained hand surgeons including regions where hand subspecialty care is not available. The program resulted in a significant decrease in the number of hospital transfers for the management of acute hand trauma.     

Boundaries during normal and abnormal brain development: in vivo and in vitro studies of glia and glycoconjugates.

This paper focuses on transient boundaries of glia and glycoconjugates during development of the mouse central nervous system (CNS). Lectin-bound glycoconjugates, glial fibrillary acidic protein, and the J1/tenascin glycoprotein are distributed coextensively within boundaries around developing substructural arrangements (e.g., developing nuclei, and at a finer level, somatosensory cortical "barrels" related to individual facial vibrissae) throughout the CNS during pattern formation events. Electron microscopy has shown that the J1/tenascin glycoprotein, for example, is present in immature astrocytes, on glial and neuronal plasma membranes, and within the pericellular space that could be extracellular matrix (ECM). The findings presented on the expression of this well-characterized ECM molecule suggest that previously described glial and glycoconjugate boundaries reported by our group are in part composed of specific recognition molecules. The J1/tenascin glycoprotein, a chondroitin sulfate-containing antigen termed the 473 proteoglycan, and the adhesion molecule on glia are expressed within discrete boundary regions and associated axonal pathways. There, they may sculpture fine aspects of functional cytoarchitectonic arrangements and help guide axons to specific targets. The expression and developmental regulation of glycoproteins such as J1/tenascin may thus be integral events during pattern formation and synaptogenesis in the CNS. The presence of abnormal glial arrangements and glycoconjugate boundaries in the cortices of the genetic mutant mouse reeler, and findings on plasticity of boundaries following various perturbations, suggest that boundary expression is controlled by both genetic and epigenetic factors. Some future directions for studying developmental boundaries, including use of cultured explants for in vitro "bioassays," are also discussed.     

Adult outcomes of childhood and adolescent depression. I. Psychiatric status

The present study was based on the clinical data summaries ("item sheets") of children who attended the Maudsley Hospital, London, England, during the late 1960s and early 1970s. These summaries were used to identify a group of 80 child and adolescent psychiatric patients with an operationally defined depressive syndrome. The depressed children were individually matched with 80 nondepressed psychiatric controls on demographic variables and nondepressive childhood symptoms by a computer algorithm. At follow-up, on average 18 years after the initial contact, information was obtained on the adult psychiatric status of 82% of the total sample. Adult assessments were made "blind" to case/control status. The depressed group was at an increased risk for affective disorder in adult life and had elevated risks of psychiatric hospitalization and psychiatric treatment. They were no more likely than the control group to have nondepressive adult psychiatric disorders. These findings suggested that there is substantial specificity in the continuity of affective disturbances between childhood and adult life.     

Cell-specific coupling of the cloned human 5-HT1F receptor to multiple signal transduction pathways

We recently described the cloning of a fifth member of the 5-hydroxytryptamine (5-HT)₁ (serotonin₁) receptor class that inhibits adenylyl cyclase, namely the human 5-HT_1F receptor (Adham et al. 1993 a). In the present study we have examined in greater detail the functional coupling of the 5-HT_1F receptor in two different cell lines, NIH-3T3 and LM(tk^–) fibroblasts (receptor densities of 1.7 and 4.4 pmol/mg protein, respectively). The maximal inhibitory response elicited by 5-HT was significantly greater in NIH-3T3 as compared to LM(tk^–) cells, whereas the EC₅₀ values were comparable.To investigate the relationship between receptor occupancy and inhibition of cAMP accumulation mediated by 5-HT_1F receptors in NIH-3T3 cells (and hence the degree of receptor reserve), we used the irreversible receptor antagonist N-ethoxycarbonyl-2-ethoxy-1,2-dihydroquinoline (EEDQ). The half-maximal response required only about 10% receptor occupancy, consistent with a receptor reserve of 90% (88±2.1%, n = 4) for 5-HT-induced inhibition of FSCA. Despite the presence of such a high degree of receptor reserve, a range of intrinsic activities was displayed by structurally diverse classes of compounds. For example, sumatriptan and lysergol were as efficacious as 5-HT itself and thus acted as full agonists, whereas metergoline and 1-NP behaved as partial agonists and as shown previously (Adham et al. 1993a), methiothepin was a silent antagonist (K_b = 438 nM).We have also investigated activation of additional signal transduction pathways by the 5-HT_1F receptor and found that the responses differ in the two cell lines with respect to stimulation of phospholipase C. For example, in NIH-3T3 cells no elevation of inositol phosphates (IP) of [Ca²⁺]_i was observed even at very high agonist concentrations (100 M). In contrast, in LM(tk^–) cells concentrations of 5-HT as low as 10 nM induced stimulation of IP and a rapid increase of [Ca²⁺]i. The 5-HT_1F receptor failed to alter arachidonic acid release in either cell line.The maximal increase in IP accumulation in LM(tk^–) cells was modest, averaging about 100% above basal. The increases of IP and [Ca²⁺]_i required 5-HT concentrations less than one order of magnitude greater than those inhibiting FSCA (EC₅₀ = 17, 55 and 8 nM, respectively), and both responses were blocked by 100 M methiothepin. All three responses (cAMP, IP, and [Ca²⁺]_i) were sensitive to pertussis toxin pre-treatment, suggesting the involvement of G_i/G_o protein(s) in these signal transduction pathways. [Ca²⁺]_i was also elevated by sumatriptan, which may provide a mechanism by which this drug causes constriction of the vasculature. In conclusion, these data indicate that the human 5-HT_1F receptor can couple to multiple effectors, and that this coupling is cell-type dependent.Abbreviations FSCA forskolin-stimulated cAMP accumulation - [Ca²⁺] intracellular free calcium concentration - AA arachidonic acid - EEDQ N-ethoxycarbonyl-2-ethoxy-1,2-dihydroquinoline - CHO chinese hamster ovary cell - LM(tk^–) mouse fibroblast cell - B_max maximal binding site density - K_i apparent dissociation constant obtained from competition binding studies - G protein guanine nucleotide-binding protein - HBS HEPES-buffered saline - IP inositol phosphates - IP₃ inositol 1,4,5 trisphosphate - PLC phospholipase C - K_b antagonist dissociation constant - K_d equilibrium dissociation constant - N-1F-6 stable NIH-3T3 cells expressing the cloned 5-HT_1F receptor - L-1F-3 stable LM(tk^–) cells expressing the cloned 5-HT_1F receptor - PTX pertussis toxin - BSA bovine serum albumin - METH methiothepin - SUMA sumatriptan - 5-MeO-DMT 5-methoxy-N,N-dimethyltryptamine - 1-NP 1-(1-napthyl)piperazine - 5-CT 5-carboxyamidotryptamine Correspondence to: N. Adham at the above address