Simulation Based Educational Intervention for Enhancing Irrigation Skills of Nurses Caring for Patients With Cutaneous Continent Urinary Diversions and Orthotopic Neobladders.

PURPOSE: The purpose of this study was to investigate the effect of a nurse practitioner-led simulation-based education program on nursing knowledge and confidence in the care of patients with a cutaneous continent urinary diversion (Indiana pouch) or orthotopic neobladder. DESIGN: Single-group, before-after study. SUBJECTS AND SETTING: The sample comprised 11 RNs practicing at New York Presbyterian Hospital in New York City. Subjects were predominantly female, ethnically diverse, and held a bachelor's degree. About half of the subjects had less than 3 years of experience, and more than half reported prior experience caring for patients with a urinary diversion. METHODS: Participants completed a demographic survey, and a continent urinary diversion confidence survey and pretest measuring knowledge of nursing care of patients with a urinary diversion. Following baseline data collection, an educational session focused on the irrigation of a continent urinary diversion was made available for participants to review. An onsite simulation experience was scheduled several weeks later. Investigators provided education on proper irrigation of a continent urinary diversion and observed participants' skills when irrigating a continent urinary diversion on a high-fidelity simulated patient mannequin. The simulation intervention was followed by video replay and debrief providing feedback on each participant's performance. At the conclusion of the onsite simulation intervention, participants completed a postintervention confidence survey and a knowledge posttest related to the care of a continent urinary diversion. The Wilcoxon signed rank test was used to analyze baseline and postintervention changes in nursing knowledge and confidence. RESULTS: Participants achieved significant improvements in knowledge (P = .005) and confidence (P = .009) following the simulation-based educational intervention. CONCLUSIONS: A nurse practitioner-led simulation-based educational program for RNs caring for patients with continent urinary diversions demonstrates enhanced nursing knowledge and confidence caring for patients with continent urinary diversions. We anticipate this experience will enhance care we provided to patients undergoing cystectomy and continent cutaneous urinary diversion or orthotopic neobladder construction.

Stop the Bleed: Effective Training in Need of Improvement.

BACKGROUND: The "Stop the Bleed" (StB) campaign aims to educate laypersons on performing bleeding control techniques in any setting that requires hemorrhage control, such as motor vehicle crashes or mass casualty incidents. Participants undergo a didactic and practical session, the latter incorporating a mannequin. We hypothesized that participants would increase content knowledge after StB participation and that the training could be improved by a more life-like bleeding modification of the mannequin. MATERIALS AND METHODS: From July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training. Participants provided demographic data regarding prior emergency training and were asked pre- and post-test questions (five-point Likert scale) regarding their response to hemorrhage. Individuals also evaluated the mannequin on bleeding simulation. Scores were reported as means with standard deviation or medians with interquartile ranges (IQRs) with subset analysis stratified by experience. RESULTS: Of 402 participants, 310 provided complete data. On the composite, pre-test self-assessment, participants had a median score of 24 of 30 points (IQR 16-30). Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 25-30, P < 0.05). Subset analysis by prior emergency training (n = 102) demonstrated that both those with prior emergency training and those with no prior emergency training had significant improvement. On evaluation of the mannequin, participants reported that a more realistic model would increase their confidence in technique. Both subgroups reported that training would be enhanced if the mannequins were more realistic. CONCLUSIONS: StB is an effective education program. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement. Regardless of background, participants reported overwhelmingly that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating pulsatile blood flow and cessation of hemorrhage could enable learners to actually "Stop the Bleed".

Advancing the Education of Stop the Bleed: Development of a Perfused Synthetic Cadaver Model.

BACKGROUND: As active shootings and mass casualty incidents have become more prevalent, courses designed to teach basic hemorrhage control to laypersons have proliferated. Participants currently undergo Stop the Bleed (StB) training currently use a synthetic limb mannequin. In a prior survey of 88 participants, there was overwhelming sentiment that the mannequin was limited by its inability to demonstrate cessation of bleeding when hemorrhage control techniques were applied. We hypothesized that simulated bleeding that can be controlled by StB techniques would improve the mannequin and increase confidence of trainees in achieving bleeding control. METHODS: The mannequin was redesigned to be a self-contained model mimicking bleeding, with fluid flowing from a reservoir into a latex tubing with a laceration mimicking an arterial wound. Fluid was pumped by a rubber bulb attached to the tubing and held in the instructor's hand. Twenty StB trainers conducted beta testing of the perfused mannequin. Forty participants underwent training with both old and new models and completed posttraining surveys. RESULTS: Beta-testers reported positive feedback regarding both realism of the perfused mannequin and participants' ability to obtain bleeding control using StB techniques. Participants who trialed the mannequin reported increased awareness of the rate of blood flow out of a wound, which in turn increased their sense of urgency to achieve hemostasis. CONCLUSIONS: In an effort to address shortcomings noted by participants in the current StB mannequin, we developed a novel perfused bleeding mannequin, which responds appropriately to various hemorrhage cessation techniques and is both high fidelity and low cost.

A new approach to reconstruction models of dendritic branching patterns.

Quantitative models for characterising the detailed branching patterns of dendritic trees aim to explain these patterns either in terms of growth models based on principles of dendritic development or reconstruction models that describe an existing structure by means of a canonical set of elementary properties of dendritic morphology, which when incorporated into an algorithmic procedure will generate samples of dendrites that are statistically indistinguishable in both canonical and emergent features from those of the original sample of real neurons. This article introduces a conceptually new approach to reconstruction modelling based on the single assumption that dendritic segments are built from sequences of units of constant diameter, and that the distribution of the lengths of units of similar diameter is independent of location within a dendritic tree. This assumption in combination with non-parametric methods for estimating univariate and multivariate probability densities leads to an algorithm that significantly reduces the number of basic parameters required to simulate dendritic morphology. It is not necessary to distinguish between stem and terminal segments or to specify daughter branch ratios or dendritic taper. The procedure of sampling probability densities conditioned on local morphological features eliminates the need, for example, to specify daughter branch ratios and dendritic taper since these emerge naturally as a consequence of the conditioning process. Thus several basic parameters of previous reconstruction algorithms become emergent parameters of the new reconstruction process. The new procedure was applied successfully to a sample of 51 interneurons from lamina II/III of the spinal dorsal horn.

The pharmacokinetics of rituximab following an intravitreal injection.

Rituximab is a monoclonal antibody directed against the CD20 B-cell antigen and is approved for the treatment of B-cell lymphoma. We investigated the pharmacokinetics of rituximab following intravitreal administration to assess the feasibility of treating primary intraocular lymphoma. Intravitreal injections of rituximab 0.1 ml (1 mg) were performed in rabbits. Drug concentrations in the aqueous and vitreous humor were measured at intervals from 2 to 17 days after administration. The half-life of the total amount of rituximab in the two compartments was calculated to be 4.7 days. The aqueous and vitreous humor drug levels decayed in parallel maintaining an average ratio of approximately seven. Fitting the data to a two-compartment model yielded a clearance from the aqueous humor of 1.2 microl/min. The clearance was less than the reported rate of aqueous humor outflow indicating that elimination by this route could have been sufficient to account for the disappearance of the drug from the eye. The duration of time over which sustained levels of rituximab were achieved suggest that intravitreal administration warrants further investigation as an approach to treating vitreous and anterior chamber infiltrates in patients with primary intraocular lymphoma.

Management of epilepsy in adults. Diagnosis guidelines.

In this first of two articles on new epilepsy guidelines for primary care physicians, the authors present detailed algorithms for the diagnosis and classification of seizure disorders in adults. They discuss the differentiation between generalized and partial seizures and stress that accurate identification is especially important because the type of seizure determines the appropriate treatment. The second article (page 29) looks at the treatment portion of the new guidelines.

Management of epilepsy in adults. Treatment guidelines.

In this second of two articles on new epilepsy guidelines for primary care physicians, the authors discuss which treatments are the most effective in adults with this disease. They describe the antiepileptic drugs that are currently approved and elucidate the differences between established and newer options. Detailed algorithms cover pharmacotherapy, follow-up, and ongoing maintenance.

Structural insights into the coordination and extraction of Pb(II) by disulfonamide ligands derived from o-phenylenediamine.

The o-phenylenediamine-derived disulfonamide ligands 1 and 2 complex and efficiently extract Pb(II) from water into 1,2-dichloroethane via ion-exchange, in combination with 2,2'-bipyridine (97.5% and 95.0%, respectively, for 1:1 ligand-to-Pb ratios). The corresponding Pb(II)-sulfonamido binary complexes of ligands 1 and 2 (3 and 4, respectively), and ternary complexes with 2,2'-bipyridine (5 and 6, respectively), were isolated and characterized. (1)H NMR spectra of the organic phases after extraction show the formation of ternary Pb-sulfonamido-bipy complexes. X-ray characterization of 3, 4, and the ternary complex 5 consistently demonstrates four primary coordination sites and a stereochemically active lone pair on Pb. The X-ray structure of 3 shows a pseudo trigonal bipyramidal configuration on Pb, with the lone pair occupying one of the equatorial sites, and the formation of an unusual "hemidirected" coordination polymer via axial S=O-Pb coordination. The same axial S=O-Pb coordination pattern with two DMSO molecules is observed in the structure of 4.[2(CH(3))(2)SO)], thus rationalizing the high solubility of the binary complexes in strongly coordinating solvents. In contrast, the X-ray structure of the ternary complex 5 reveals a distorted four-coordinate configuration with only weak S=O-Pb coordination leading to dimer formation, thus explaining its higher solubility in weakly coordinating solvents. FT-IR spectroscopy confirms the X-ray data, since the ligand nu(S)(=)(O) stretching frequencies shift to lower values in the binary Pb(II)-sulfonamido complexes and are again altered upon formation of the ternary Pb(II)-sulfonamido-bipy complexes, as would be expected for 2,2'-bipy complexation and hindered S=O-Pb coordination.

The headache of SAH responds to sumatriptan.

We report the first case of the headache of subarachnoid hemorrhage (SAH) possibly responding to a triptan. Recent evidence suggests that triptans block transmission from the trigeminal nerve to second-order neurons in the trigeminal nucleus caudalis; thus, any meningeal nociceptive process would be aborted. The triptans and ergots are not specific for migraine, but for any process that activates trigeminal fibers, including migraine, cluster headache, SAH, and meningitis. The failure to respond in the reported cases of meningitis may be due to sensitization.

Fluorescent sensing and selective Pb(II) extraction by a dansylamide ion-exchanger.

The (bis)dansylated sulfonamide 1,2-C6H4(NHSO2C10H6-5-N(CH3)2)2 (1) extracted Pb(II) selectively from water into 1,2-dichloroethane via an ion-exchange mechanism and showed fluorescence quenching upon Pb(II) extraction. The distribution ratios for metal extraction (determined by ICP-MS) for Pb(II) were 133-1410 times higher than those for other metal cations [Co(II), Ni(II), Cu(II), Zn(II), and Cd(II)] under identical conditions. Fluorescence quenching was observed upon Pb(II) extraction, which was dependent on Pb(II) concentration. The monodansylated control, C6H5NHSO2C10H6-5-N(CH3)2 (2), showed neither extraction nor quenching, indicating that the fluorescence effects are a direct result of Pb coordination to 1. The observed selectivity for Pb(II) is ascribed to the formation of a low-coordinate binary Pb(II)-Sulfonamido complex in the organic phase.

Pb(II) coordination and synergistic ion-exchange extraction by combinations of sulfonamide chelates and 2,2'-bipyridine.

The disulfonamide ligands 1,2-C(6)H(4)(NH(2)SO(2)C(6)H(5))(2) (1) and 1,2-C(6)H(4)(NH(2)SO(2)C(6)H(4)-p-Bu(t))(2) (2), which are readily available in good yields from o-phenylenediamine and the corresponding sulfonyl chlorides, efficiently extract Pb(II) from water into 1,2-dichloroethane when used in synergistic combinations with 2,2'-bipyridine via an ion-exchange mechanism. The extraction was shown to proceed via the formation of a ternary Pb-sulfamido-2,2'-bipyridine complex. The X-ray crystal structure of the binary Pb-sulfamido complex 3 shows a coordination polymer with a stereochemically active lone pair on Pb formed by S=O-Pb axial coordination.

Fatigue in multiple sclerosis: a rational approach to evaluation and treatment.

With the publication of the Multiple Sclerosis Council Guideline on the management of multiple sclerosis (MS) fatigue, there has been increased appreciation for the role fatigue can play in MS. Secondary fatigue is fatigue caused by other etiologies than those directly related to MS. Once these causes are ruled out, fatigue is related to MS. Secondary MS-related fatigue comes as result of the symptoms of MS that drain energy. Once secondary MS causes are ruled out, then the patient is deemed as having primary MS fatigue. Fatigue management is both nonpharmacologic and pharmacologic. Occupational therapists are the major allied health providers that address the role fatigue plays in MS patients. Over the past two decades, numerous clinical trials have been conducted on drugs for treating MS-related fatigue. Of these agents, amantadine has been studied for the longest period, and has shown efficacy in about one third of patients with MS-related fatigue on several commonly used scales. Two randomized -trials of the central nervous system stimulant pemoline have yielded unimpressive results; efficacy was seen at higher doses but coupled with an unacceptable risk of adverse events. The wake-promoting agent modafinil is the only agent to show efficacy compared with placebo on the Fatigue Severity Scale, a measure that is highly resistant to "impulse answering" and is thus viewed as one of the most difficult scales on which to show -benefit. This article reviews fatigue in MS and proposes a rational strategy for evaluation and management of this most common MS symptom.

Rituximab therapy for CNS lymphomas: targeting the leptomeningeal compartment.

Most lymphomas that involve the central nervous system are B-cell neoplasms that express the cell surface molecule CD20. After intravenous administration, rituximab can be reproducibly measured in the cerebrospinal fluid (CSF) in patients with primary central nervous system lymphoma; however, the CSF levels of rituximab are approximately 0.1% of serum levels associated with therapeutic activity in patients with systemic non-Hodgkin lymphoma. Because lymphomatous meningitis is a frequent complication of non-Hodgkin lymphoma, we have conducted an analysis of the safety and pharmacokinetics of direct intrathecal administration of rituximab using cynomolgus monkeys. No significant acute or delayed toxicity, neurologic or otherwise, was detected. Pharmacokinetic analysis suggests that drug clearance from the CSF is biphasic, with a terminal half-life of 4.96 hours. A phase 1 study to investigate the safety and pharmacokinetics of intrathecal rituximab in patients with recurrent lymphomatous meningitis will be implemented based on these findings.