Meeting report on the NIDDK/AUA Workshop on Congenital Anomalies of External Genitalia: challenges and opportunities for translational research.

Congenital anomalies of the external genitalia (CAEG) are a prevalent and serious public health concern with lifelong impacts on the urinary function, sexual health, fertility, tumor development, and psychosocial wellbeing of affected individuals. Complications of treatment are frequent, and data reflecting long-term outcomes in adulthood are limited. To identify a path forward to improve treatments and realize the possibility of preventing CAEG, the National Institute of Diabetes and Digestive and Kidney Diseases and the American Urological Association convened researchers from a range of disciplines to coordinate research efforts to fully understand the different etiologies of these common conditions, subsequent variation in clinical phenotypes, and best practices for long term surgical success. Meeting participants concluded that a central data hub for clinical evaluations, including collection of DNA samples from patients and their parents, and short interviews to determine familial penetrance (small pedigrees), would accelerate research in this field. Such a centralized datahub will advance efforts to develop detailed multi-dimensional phenotyping and will enable access to genome sequence analyses and associated metadata to define the genetic bases for these conditions. Inclusion of tissue samples and integration of clinical studies with basic research using human cells and animal models will advance efforts to identify the developmental mechanisms that are disrupted during development and will add cellular and molecular granularity to phenotyping CAEG. While the discussion focuses heavily on hypospadias, this can be seen as a potential template for other conditions in the realm of CAEG, including cryptorchidism or the exstrophy-epispadias complex. Taken together with long-term clinical follow-up, these data could inform surgical choices and improve likelihood for long-term success.

No. 292-Abnormal Uterine Bleeding in Pre-Menopausal Women.

BACKGROUND: Abnormal uterine bleeding is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for this problem during their reproductive years. This guideline replaces previous clinical guidelines on the topic and is aimed to enable health care providers with the tools to provide the latest evidence-based care in the diagnosis and the medical and surgical management of this common problem. OBJECTIVE: To provide current evidence-based guidelines for the diagnosis and management of abnormal uterine bleeding (AUB) among women of reproductive age. OUTCOMES: Outcomes evaluated include the impact of AUB on quality of life and the results of interventions including medical and surgical management of AUB. METHODS: Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of location in Canada, type of practice, subspecialty expertise, and general gynaecology background. The committee reviewed relevant evidence in the English medical literature including published guidelines. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. RESULTS: This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of AUB. The resulting recommendations may be adapted by individual health care workers when serving women with this condition. CONCLUSIONS: Abnormal uterine bleeding is a common and sometimes debilitating condition in women of reproductive age. Standardization of related terminology, a systematic approach to diagnosis and investigation, and a step-wise approach to intervention is necessary. Treatment commencing with medical therapeutic modalities followed by the least invasive surgical modalities achieving results satisfactory to the patient is the ultimate goal of all therapeutic interventions. EVIDENCE: Published literature was retrieved through searches of MEDLINE and the Cochrane Library in March 2011 using appropriate controlled vocabulary (e. g., uterine hemorrhage, menorrhagia) and key words (e. g., menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English and published from January 1999 to March 2011. Searches were updated on a regular basis and incorporated in the guideline to February 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology- related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Implementation of the guideline recommendations will improve the health and well-being of women with abnormal uterine bleeding, their families, and society. The economic cost of implementing these guidelines in the Canadian health care system was not considered. SUMMARY STATEMENTS: RECOMMENDATIONS.

How to set up and administer an enteral feed via a nasogastric tube.

Rationale and key points Nasogastric tube feeding is a method of enteral feeding commonly administered by nurses. Feed can be administered either using a volumetric enteral feeding pump (pump feeding) or via an enteral syringe (bolus feeding). This article explains how nurses can safely undertake these two methods of nasogastric tube feed administration at the patient's bedside. ¼ Nasogastric tube feeding can be used to provide some or all of the patient's nutrition, fluid or medication. ¼ Nurses should be equipped with the relevant knowledge to flush a nasogastric tube before the administration of feed or medication; set up and administer an enteral feed via a volumetric enteral feeding pump; and set up and administer a feed using a bolus method. ¼ The position of the distal tip of the nasogastric tube must be confirmed as sitting in the patient's stomach before the tube is used to administer enteral feed, fluid or medication. Reflective activity 'How to' articles can help you update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice when setting up and administering an enteral feed via a nasogastric tube. 2. How you could use this resource to educate your colleagues about nasogastric tube feeding via an enteral feeding pump or bolus feeding.

Analysis of Origins of Admission for Solid Tumor Oncology Inpatients: Disease Severity and Outcomes.

PURPOSE: Hospital transfers may affect clinical outcomes. Evaluation of admission by source of transfer, time of admission, and provider type may identify opportunities to improve inpatient outcomes. METHODS: We reviewed charts of patients admitted to the solid tumor oncology service between July and December 2014 from the Cleveland Clinic Foundation (CCF) Main Campus emergency department (ED), CCF Regional EDs, outside hospital (OSH) ED, OSH inpatient services, and CCF outpatient clinics. Data collected included time of admission, mortality and severity risk scores, and provider type. Risk factors were assessed for clinical outcomes, including activations of the Adult Medical Emergency Team, intensive care unit transfers, in-hospital mortality, and length of stay (LOS). RESULTS: Five hundred admissions were included. OSH inpatient transfers had significantly higher disease severity compared with all other origins of admission. OSH inpatient transfers demonstrated significantly longer LOS compared with all other origins of admission, and higher mortality rates compared with the outpatient direct admits and CCF Main Campus ED admits. After adjusting for disease severity and risk of mortality, OSH ED patients remained at higher risk for Adult Medical Emergency Team activation, OSH inpatient transfers had the longest LOS, and CCF Main Campus ED patients had the lowest risk of mortality. Time of admission and provider type were not associated with any of the outcomes. CONCLUSION: Oncology inpatients transferred from an outside health care facility are at higher risk for adverse outcomes. The magnitude of difference is lessened, but still significant, after adjustment for disease severity and risk of mortality.

A Comparison of Health-Related Quality of Life of Women Awaiting Pelvic Organ Prolapse Surgery versus Hip or Knee Replacement.

OBJECTIVE: Pelvic organ prolapse (POP) can significantly decrease the health-related quality of life (HRQOL) of women. In 2005, provincial and territorial wait time benchmarks were set in areas such as hip and knee replacement, but such efforts were lagging for urogynaecological surgeries. This study aimed to compare wait times and HRQOL scores of females awaiting surgery for POP with those of women awaiting hip or knee replacement. METHODS: This was a prospectively planned study comparing women undergoing surgical repair of POP to women having a hip or knee replacement. All women completed a validated HRQOL questionnaire, the Short Form 36 Health Survey. The date of the decision to operate was recorded and patients were followed up prospectively to determine surgical wait time. RESULTS: Three of four physical health concepts were significantly worse for orthopedic patients compared with urogynaecology patients, including the physical component summary (29.2 vs. 41.5, respectively, P < 0.001). Urogynaecology and orthopedic patients had similar emotional and mental well-being, as demonstrated by similar mental component summaries (41.5 vs. 44.6, respectively, P = 0.09). The mean wait time at our institution for hip or knee replacement was 98 days, which was significantly shorter than the mean wait time of 210 days for POP surgery (P < 0.001). CONCLUSION: Despite less physical and pain impact, urogynaecology patients showed similar emotional distress and mental impact compared with orthopedic patients based on a validated HRQOL questionnaire. Because urogynaecology patients waited more than twice as long for their surgery, resources should be directed to prioritize and improve the surgical wait time for urogynaecology patients.

Improving the Management of Patients With Low-Risk Neutropenic Fever at the Cleveland Clinic Taussig Cancer Institute.

PURPOSE: Neutropenic fever (NF) is an oncologic emergency and has resulted historically in inpatient management. The Multinational Association for Supportive Care in Cancer (MASCC) score can be used to identify patients with NF at a low risk of complications who can be managed safely as outpatients. Despite established guidelines supporting outpatient management of low-risk neutropenic fever (LRNF), provider awareness is low, and inpatient admission for intravenous antibiotics continues to be standard of care. METHODS: Inpatient provider algorithm implementation and education began in the second quarter of 2014. Providers calculated MASCC scores for patients with nonleukemia hematologic malignancies and solid tumors at admission. Data were collected in a prospectively maintained registry. Patients identified as low risk by MASCC score were placed under observation and started on oral antibiotics. If exclusion criteria and social barriers were not identified, discharge within 48 hours was planned. RESULTS: Eighty-three patients with NF were admitted to the Taussig Cancer Institute inpatient oncology unit between November 2014 and June 2015. Fifty-three patients (64%) had LRNF by MASCC score. Patients with LRNF had an average length of stay of 3.3 days, compared with 6.2 days in our historical cohort. Sixteen patients (30%) were discharged within 24 hours. Only two patients with LRNF had a culture-proven infection, both Enterococcus urinary tract infections. Three patients required nonelective readmission. There were no deaths caused by NF. CONCLUSION: This pilot study demonstrates that a formal algorithm for LRNF management combined with provider education can improve current inpatient standard of care and length of stay without an increase in morbidity.

Short-term Uresta efficacy (SURE) study: a randomized controlled trial of the Uresta continence device.

INTRODUCTION AND HYPOTHESIS: An intravaginal device (Uresta) is currently available for the treatment of stress urinary incontinence (SUI). Case-series data on its effectiveness exist; however, controlled data are lacking. The objective of this study is to determine the short-term efficacy of the Uresta device using a randomized placebo controlled trial. The hypothesis is that the Uresta device might significantly reduce urinary loss. METHODS: A single blind randomized controlled trial was conducted among women with urodynamic SUI recruited from a single urogynecology unit. Participants were randomized to receive the Uresta device or a placebo vaginal silastic ring placed high in the vagina for the duration of a pad test. Pad tests were performed before and after device placement. The primary outcome was the achievement of a 50 % or greater reduction in pad weight after device placement, in a comparison of the two groups. Sample size calculation showed a need for 18 subjects per group. Fisher's exact test was used to analyze the primary outcome. Research Ethics Board approval was obtained. RESULTS: Eighteen subjects per group completed the study protocol. The percentage of patients who achieved the primary outcome was 66.7 % in the Uresta group and 22.2 % in the placebo group (p = 0.01). The baseline demographic data were similar in the two groups. There were no adverse events during the test period. CONCLUSIONS: The Uresta intravaginal continence device significantly reduces the short-term objective measures of urine loss due to SUI. Further study to assess subjective outcomes and long-term patient satisfaction is required.

How to insert a nasogastric tube and check gastric position at the bedside.

Rationale and key points A nasogastric tube (NG tube) can be used to aspirate stomach contents or to administer feed, medication or fluid into the stomach. ▶ A blind technique is used to insert the NG tube through the nostril, along the nasopharynx, through the oesophagus and into the stomach. ▶ It is important for nurses to be able to recognise problems that may arise when inserting a NG tube blindly, and to know what actions to take if it is suspected that the distal tip of the NG tube is not sitting in the stomach, or they are unable to identify its location. ▶ Misplacement and subsequent use of a NG tube to administer feed, medication or fluid is a 'never event' ( NHS England Patient Safety Domain 2015 ). Reflective activity Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice. 2. How you could use this resource to educate your colleagues. Subscribers can update their reflective accounts at rcni.com/portfolio.

Reducing Unplanned Medical Oncology Readmissions by Improving Outpatient Care Transitions: A Process Improvement Project at the Cleveland Clinic.

PURPOSE: Reducing 30-day unplanned hospital readmissions is a national policy priority. We examined the impact of a quality improvement project focused on reducing oncology readmissions among patients with cancer who were admitted to palliative and general medical oncology services at the Cleveland Clinic. METHODS: Baseline rates of readmissions were gathered during the period from January 2013 to April 2014. A quality improvement project designed to improve outpatient care transitions was initiated during the period leading to April 1, 2014, including: (1) provider education, (2) postdischarge nursing phone calls within 48 hours, and (3) postdischarge provider follow-up appointments within 5 business days. Nursing callback components included symptom management, education, medication review/compliance, and follow-up appointment reminder. RESULTS: During the baseline period, there were 2,638 admissions and 722 unplanned 30-day readmissions for an overall readmission rate of 27.4%. Callbacks and 5-day follow-up appointment monitoring revealed a mean monthly compliance of 72% and 78%, respectively, improving over time during the study period. Readmission rates declined by 4.5% to 22.9% (P < .01; relative risk reduction, 18%) during the study period. The mean direct cost of one readmission was $10,884, suggesting an annualized cost savings of $1.04 million with the observed reduction in unplanned readmissions. CONCLUSION: Modest readmission reductions can be achieved through better systematic transitions to outpatient care (including follow-up calls and early provider visits), thereby leading to a reduction in use of inpatient resources. These data suggest that efforts focused on improving outpatient care transition were effective in reducing unplanned oncology readmissions.

The nurse's role in patient nutrition and hydration.

Abstract Evans L, Best C (2015) Meeting patients' nutrition and hydration needs. The Nursing and Midwifery Council's new code was introduced in March 2015. For the first time, nutrition and hydration are mentioned specifically within the code. This article explores why this has become necessary and how nursing responsibility for the nutritional care of the patient has changed over the past 150 years. It also looks in more depth at how the nutritional care can meet the standards of the code.

Improving nutrition in older people in acute care.

Older people have an increased risk of becoming malnourished when they are ill. Admission to hospital may affect their nutritional intake and nutritional status. Nutrition screening and implementation of nutrition care plans can help minimise the risk of malnutrition in acute care settings, if used effectively. The nutritional care provided to older inpatients should be timely, co-ordinated, reviewed regularly and communicated effectively between healthcare professionals and across shifts. This article explores what malnutrition means, why older people in hospital might be at risk of malnutrition and the effect hospital admission might have on nutrition and fluid intake. It makes suggestions for addressing these issues, encourages nurses to look at the nutritional care provided in their clinical area, to reflect on what they do well and consider what can be done to improve patients' experiences.

Managing malnutrition in patients with dementia.

As dementia progresses, an individual may experience increasing difficulties in eating and drinking safely. Evidence suggests that admission to hospital may exacerbate these problems. This article aims to familiarise readers with some of the issues associated with providing good nutritional care for a patient with dementia in hospital. Strategies to address the maintenance of oral intake are suggested. The article also explores the use of artificial nutrition in dementia, with examples to clarify when its use may be helpful.

Hospital nurses' comfort in and frequency of delivering heart failure self-care education.

BACKGROUND: Nurses are expected to deliver pre-discharge heart failure education in 8 content areas: what heart failure means, medications, diet, activity, weight monitoring, fluid restriction, signs/symptoms of worsening condition and signs/symptoms of fluid overload. AIMS: To examine nurses' comfort in and frequency of delivering heart failure education to hospitalized patients. METHODS: A multicenter, descriptive, correlational design and questionnaire methods were used. General linear models were performed to assess associations of comfort in and frequency of delivering patient education after controlling for significant nurse characteristics. RESULTS: Of 118 nurses, mean age was 39 ± 11.6 years, 61.9% worked on cardiac units and 58.3% spent <15 min providing pre-discharge heart failure education. Comfort in delivering education was highest for weight monitoring and lowest for activity, and was associated with nurse age (p=0.019), years in profession (p=0.004) and minutes providing pre-discharge education (p=0.003). Frequency delivering education was highest for signs/symptoms of worsening condition (mean frequency, 71.5% ± 29%) and lowest for activity (42.7% ± 29.4%) and was associated with comfort in educating patients (all p<0.001); and pre-discharge education minutes, p<0.001. Using general linear modeling, minutes spent delivering pre-discharge education remained associated with overall comfort in (p=0.04) and frequency of (p<0.001) heart failure education delivery. CONCLUSIONS: Nurses' comfort in and frequency of delivering education varied by heart failure self-care content area. Self-care education areas most important to survival and hospitalization had the lowest rates of nurse comfort and frequency. Systems and processes are needed to facilitate education delivery prior to hospital discharge.

Accurate assessment patient weigh.

Measuring patient weight is considered a routine assessment that is frequently delegated to unregistered staff. Yet patient weight is a fundamental part of nutrition assessment and may be used to calculate drug dosages and assess fluid balance. It is vital that staff carrying out this measurement are trained and have access to appropriate equipment that is regularly calibrated.

Patient and family views of nutritional status.

Providing adequate food in hospitals remains a concern for those involved in healthcare as well as patients and relatives. We conducted a small-scale survey to explore relatives' and patients' perceptions about the risk of developing malnutrition in hospital and to gauge whether further more in-depth audit was required.

Guidelines for routine gastrostomy tube replacement in children.

Endoscopic placement of a gastrostomy is the safest method of inserting a gastrostomy in children who are going to require full or supplemental enteral feeding for more than six weeks. Once a stoma tract has formed successfully following initial placement of a gastrostomy tube, the device can be changed to a balloon, button or non-balloon type. Community nursing teams often support a number of children with gastrostomies and their families, replacing the devices as necessary. Guidance for the safe insertion and replacement of balloon and button gastrostomies has been produced by the National Nurses Nutrition Group, the Patient Safety Agency and manufacturers, but standardised national guidelines are required.

Nasogastric feeding in the community: safe and effective practice.

A small percentage of patients receiving enteral tube feeding in the community receive feed via a nasogastric tube. There are risks associated with this method if the correct procedures for monitoring tube displacement are not in place. Guidance for checking tube position has been provided by the National Patient Safety Agency (NPSA). Nurses caring for patients with nasogastric tube feeds need to be aware of how NPSA alerts impact on practice and the advice and support they may need to offer patients.