Development and validation of a tool to assess the readiness of a clinical teaching site for interprofessional education (InSITE).

Interprofessional education within clinical teaching sites is a key part of training for pre-professional students. However, the necessary characteristics of these interprofessional clinical teaching sites is unclear. We developed a tool, the Interprofessional Education Site Readiness, or InSITE, tool, for individuals at a site to use as a self-assessment of the site's current readiness for providing interprofessional education. The tool progressed through six stages of development, collecting evidence for validity and reliability, resulting in a final tool with 23 questions distributed across five domains. Data from 94 respondents from a variety of national sites were used for the item analysis showing acceptable item-to-total correlations. Internal reliability testing gave a Cronbach's coefficient alpha of more than 0.70 for each group level comparison. Known groups validity testing provides strong evidence for its responsiveness in detecting differences in sites where IPE is implemented. The results of the testing lead us to conclude that the InSITE tool has acceptable psychometric properties. Additionally, we discovered that the process in which the InSITE tool was used demonstrated that it can facilitate learning in practice for the health professionals and can help make implicit, informal workplace learning and the hidden curriculum explicit.

A Holistic Clustering Methodology for Liver Transplantation Survival.

BACKGROUND: Liver transplants account for a high number of procedures with major investments from all stakeholders involved; however, limited studies address liver transplant population heterogeneity pretransplant predictive of posttransplant survival. OBJECTIVE: The aim of the study was to identify novel and meaningful patient clusters predictive of mortality that explains the heterogeneity of liver transplant population, taking a holistic approach. METHODS: A retrospective cohort study of 344 adult patients who underwent liver transplantation between 2008 through 2014. Predictors were summarized severity scores for comorbidities and other suboptimal health states grouped into 11 body systems, the primary reason for transplantation, demographics/environmental factors, and Model for End Liver Disease score. Logistic regression was used to compute the severity scores, hierarchical clustering with weighted Euclidean distance for clustering, Lasso-penalized regression for characterizing the clusters, and Kaplan-Meier analysis to compare survival across the clusters. RESULTS: Cluster 1 included patients with more severe circulatory problems. Cluster 2 represented older patients with more severe primary disease, whereas Cluster 3 contained healthiest patients. Clusters 4 and 5 represented patients with musculoskeletal (e.g., pain) and endocrine problems (e.g., malnutrition), respectively. There was a statistically significant difference for mortality between clusters (p < .001). CONCLUSIONS: This study developed a novel methodology to address heterogeneous and high-dimensional liver transplant population characteristics in a single study predictive of survival. A holistic approach for data modeling and additional psychosocial risk factors has the potential to address holistically nursing challenges on liver transplant care and research.

Predictors of Liver Transplant Patient Survival.

OBJECTIVE: Liver transplantation is a costly and risky procedure, representing 25 050 procedures worldwide in 2013, with 6729 procedures performed in the United States in 2014. Considering the scarcity of organs and uncertainty regarding prognosis, limited studies address the variety of risk factors before transplantation that might contribute to predicting patient's survival and therefore developing better models that address a holistic view of transplant patients. This critical review aimed to identify predictors of liver transplant patient survival included in large-scale studies and assess the gap in risk factors from a holistic approach using the Wellbeing Model and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. DATA SOURCE: Search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed from the 1980s to July 2014. STUDY SELECTION: Original longitudinal large-scale studies, of 500 or more subjects, published in English, Spanish, or Portuguese, which described predictors of patient survival after deceased donor liver transplantation. DATA EXTRACTION: Predictors were extracted from 26 studies that met the inclusion criteria. DATA SYNTHESIS: Each article was reviewed and predictors were categorized using a holistic framework, the Wellbeing Model (health, community, environment, relationship, purpose, and security dimensions). CONCLUSIONS: The majority (69.7%) of the predictors represented the Wellbeing Model Health dimension. There were no predictors representing the Wellbeing Dimensions for purpose and relationship nor emotional, mental, and spiritual health. This review showed that there is rigorously conducted research of predictors of liver transplant survival; however, the reported significant results were inconsistent across studies, and further research is needed to examine liver transplantation from a whole-person perspective.

The Interprofessional Collaborative Competency Attainment Survey (ICCAS): A replication validation study.

This study replicates a validation of the Interprofessional Collaboration Competency Attainment Survey (ICCAS), a 20-item self-report instrument designed to assess behaviours associated with patient-centred, team-based, collaborative care. We appraised the content validity of the ICCAS for a foundation course in interprofessional collaboration, investigated its internal (factor) structure and concurrent validity, and compared results with those obtained previously by ICCAS authors. Self-assessed competency ratings were obtained from a broad spectrum of pre-licensure, health professions students (n = 785) using a retrospective, pre-/post-design. Moderate to large effect sizes emerged for 16 of 20 items. Largest effects (1.01, 0.94) were for competencies emphasized in the course; the smallest effect (0.35) was for an area not directly taught. Positive correlations were seen between all individual item change scores and a separate item assessing overall change, and item-total correlations were moderate to strong. Exploratory factor analysis was used to understand the interrelationship of ICCAS items. Principal component analysis identified a single factor (Cronbach's alpha = 0.96) accounting for 85% of the total variance-slightly higher than the 73% reported previously. Findings suggest strong overlaps in the proposed constructs being assessed; use of a total average score is justifiable for assessment and evaluation.

Total Pancreatectomy With Islet Autotransplantation Improves Quality of Life in Patients With Refractory Recurrent Acute Pancreatitis.

BACKGROUND & AIMS: Therapeutic options are limited for patients with recurrent acute pancreatitis who have intractable symptoms despite maximal endoscopic and medical treatment, but equivocal or no morphologic or functional evidence of chronic pancreatitis. We performed a prospective observational cohort study to determine the efficacy of total pancreatectomy with islet autotransplantation (TPIAT) for these patients. METHODS: We collected data from all patients undergoing TPIAT at the University of Minnesota from 2007 through 2013; 49 patients (42 female; mean age, 32.8 ± 7.8 years) had a diagnosis of recurrent acute pancreatitis not provoked by intervention, with negative or equivocal findings from nondiagnostic imaging or pancreatic function tests for chronic pancreatitis, and intractable pain between episodes. Data on insulin use, narcotic requirements, pain scores, and health-related quality of life were collected before TPIAT; 3 months, 6 months, and 1 year afterward; and then yearly. RESULTS: All 49 patients studied required narcotics before TPIAT (45 daily users and 4 intermittent users); 2 had insulin-treated diabetes. At 1 year after TPIAT, 22 out of 48 patients (46%) reported no use of narcotic pain medications (P < .001 vs baseline). Health-related quality of life score, measured by the physical and mental component summary score, increased by approximately 1 standard deviation from the population mean (P < .001 for the physical component summary; P = .019 for the mental component summary). At 1 year after TPIAT, 21 out of 48 patients (45%) were insulin independent; their mean percent glycosylated hemoglobin A1c at 1 year after TPIAT was 6.0% ± 0.9% (5.2% ± 0.6% pre-TPIAT). CONCLUSIONS: Patients with recurrent acute pancreatitis but lacking clear chronic pancreatitis benefit from TPIAT, with outcomes similar to those previously described for patients with chronic pancreatitis (improved quality of life and reduced narcotic use). For these patients who have otherwise limited surgical treatment options, TPIAT can be considered when medical and endoscopic therapies have failed.

Longterm health-related quality of life after living liver donation.

There are little data on longterm outcomes, health-related quality of life (HRQoL), and issues related to living donor right hepatectomy specifically. We studied longterm HRQoL in 127 living liver donors. A donor-specific survey (DSS) was used to evaluate the living liver donor morbidity, and the 36-item short-form health survey (short-form 36 health survey, version 1 [SF-36]) was used to assess generic outcomes. The DSS was completed by 107 (84.3%) donors and the SF-36 by 62 (49%) donors. Median follow-up was 6.9 years. Of the 107 donors, 12 (11.2%) donors reported their health as better, whereas 84 (78.5%) reported their health the same as before donation. Ninety-seven (90.7%) are currently employed. The most common postdonation symptom was incisional discomfort (34%). Twenty-four donors (22.4%) self-reported depression symptoms after donation. Ninety-eight (91.6%) rated their satisfaction with the donation process ≥ 8 (scale of 1-10). Three factors-increased vitality (correlation, 0.44), decreased pain (correlation, 0.34), and a recipient who was living (correlation, 0.44)-were independently related to satisfaction with the donor experience. Vitality showed the strongest association with satisfaction with the donor experience. Mental and physical component summary scale scores for donors were statistically higher compared to the US population norm (P < 0.001). Donors reported a high satisfaction rate with the donation process, and almost all donors (n = 104, 97.2%) would donate again independent of experiencing complications. Our study suggests that over a longterm period, liver donors continue to have above average HRQoL compared to the general population.

Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases.

OBJECTIVE: Our objective was to analyze factors predicting outcomes after a total pancreatectomy and islet autotransplantation (TP-IAT). BACKGROUND: Chronic pancreatitis (CP) is increasingly treated by a TP-IAT. Postoperative outcomes are generally favorable, but a minority of patients fare poorly. METHODS: In our single-centered study, we analyzed the records of 581 patients with CP who underwent a TP-IAT. Endpoints included persistent postoperative "pancreatic pain" similar to preoperative levels, narcotic use for any reason, and islet graft failure at 1 year. RESULTS: In our patients, the duration (mean ±â€ŠSD) of CP before their TP-IAT was 7.1 ±â€Š0.3 years and narcotic usage of 3.3 ±â€Š0.2 years. Pediatric patients had better postoperative outcomes. Among adult patients, the odds of narcotic use at 1 year were increased by previous endoscopic retrograde cholangiopancreatography (ERCP) and stent placement, and a high number of previous stents (>3). Independent risk factors for pancreatic pain at 1 year were pancreas divisum, previous body mass index >30, and a high number of previous stents (>3). The strongest independent risk factor for islet graft failure was a low islet yield-in islet equivalents (IEQ)-per kilogram of body weight. We noted a strong dose-response relationship between the lowest-yield category (<2000 IEQ) and the highest (≥5000 IEQ or more). Islet graft failure was 25-fold more likely in the lowest-yield category. CONCLUSIONS: This article represents the largest study of factors predicting outcomes after a TP-IAT. Preoperatively, the patient subgroups we identified warrant further attention.

Translation of obesity practice guidelines: measurement and evaluation.

OBJECTIVE(S): A public health nurse (PHN) in the Midwestern United States (U.S.) led a collaborative system-level intervention to translate the Institute of Clinical Systems Improvement (ICSI) Adult Obesity Guideline into interprofessional practice. This study (1) evaluated the extent of guideline translation across organizations and (2) assessed the Omaha System as a method for translating system-level interventions and measuring outcomes. DESIGN AND SAMPLE: This retrospective, mixed methods study was conducted with a purposeful sample of one administrator (n = 10) and two to three clinicians (n = 29) from each organization (n = 10). MEASURES: Omaha System Problem Rating Scale for Outcomes Knowledge, Behavior, and Status (KBS). KBS ratings gathered from semi-structured interviews and Omaha System documentation were analyzed using standard descriptive and inferential statistics and triangulated findings with participant quotes. RESULTS: KBS ratings and participant quotes revealed intervention effectiveness in creating sustained system-level changes. Self-reported and observed KBS ratings demonstrated improvement across organizations. There was moderate to substantial agreement regarding benchmark attainment within organizations. On average, self-reported improvement exceeded observer improvement. CONCLUSIONS: System-level PHN practice facilitator interventions successfully translated clinical obesity guidelines into interprofessional use in health care organizations. The Omaha System Problem Rating Scale for Outcomes reliably measured system-level outcomes.

Total pancreatectomy and islet autotransplantation in children for chronic pancreatitis: indication, surgical techniques, postoperative management, and long-term outcomes.

OBJECTIVE: Describe the surgical technique, complications, and long-term outcomes of total pancreatectomy and islet autotransplantation (TP-IAT) in a large series of pediatric patients. BACKGROUND: Surgical management of childhood pancreatitis is not clear; partial resection or drainage procedures often provide transient pain relief, but long-term recurrence is common due to the diffuse involvement of the pancreas. Total pancreatectomy (TP) removes the source of the pain, whereas islet autotransplantation (IAT) potentially can prevent or minimize TP-related diabetes. METHODS: Retrospective review of 75 children undergoing TP-IAT for chronic pancreatitis who had failed medical, endoscopic, or surgical treatment between 1989 and 2012. RESULTS: Pancreatitis pain and the severity of pain statistically improved in 90% of patients after TP-IAT (P < 0.001). The relief from narcotics was sustained. Of the 75 patients undergoing TP-IAT, 31 (41.3%) achieved insulin independence. Younger age (P = 0.032), lack of prior Puestow procedure (P = 0.018), lower body surface area (P = 0.048), higher islet equivalents (IEQ) per kilogram body weight (P = 0.001), and total IEQ (100,000) (P = 0.004) were associated with insulin independence. By multivariate analysis, 3 factors were associated with insulin independence after TP-IAT: (1) male sex, (2) lower body surface area, and (3) higher total IEQ per kilogram body weight. Total IEQ (100,000) was the single factor most strongly associated with insulin independence (odds ratio = 2.62; P < 0.001). CONCLUSIONS: Total pancreatectomy and islet autotransplantation provides sustained pain relief and improved quality of life. The ß-cell function is dependent on islet yield. Total pancreatectomy and islet autotransplantation is an effective therapy for children with painful pancreatitis that failed medical and/or endoscopic management.

Health-related quality of life: two decades after liver transplantation.

In this study, we describe a cohort of patients who received liver transplants before January 1, 1989 at the University of Minnesota Medical Center (UMMC), and we evaluate the health-related quality of life (HRQOL) of the survivors of this group. One hundred sixty-one patients--66 adults and 95 children--received whole deceased donor liver transplants. Thirteen transplants occurred before 1980, and all these patients died within 6 months; they were excluded from the survival analysis because they came from the pre-cyclosporine era. The survival rates at 1, 5, 10, and 20 years were 72%, 57%, 49%, and 37%, respectively (34% when pre-1980 patients were included). The median survival time was approximately 10 years for adult and pediatric recipients. The causes of death were ascertained by chart reviews. Technical failures were common between the years 1980 and 1984, and they decreased to 0% by 1988. As for HRQOL, 53 patients (36%) survived and were contacted to complete a 12-item health survey [Short Form 12 (SF-12)]. Retransplants were excluded. Sixty-eight percent returned the SF-12 survey. The median age for all respondents was 31.4 years: the median was 67.4 years for adult survivors and 28.8 years for pediatric survivors. The Mental Component Summary (MCS) score was 54.6 for adult survivors and 48.6 for pediatric survivors. The Physical Component Summary (PCS) score was 39.3 for adult survivors and 49.2 for pediatric survivors. Both the MCS and the PCS were norm-based to the US population with a mean of 50 and a standard deviation of 10. In conclusion, 35.8% of liver transplant recipients from UMMC were alive 20 years after liver transplantation. Technical failure-related deaths decreased dramatically from 1980 to 1988. The mental health of pediatric and adult survivors was similar to that of the general population. The physical health of the pediatric survivors was equivalent to that of the general population, but it was slightly less than what was expected with adjustments for age. The physical health of the adult survivors was approximately 1 standard deviation below that of the general population.

Urgent ERCP with pancreatic stent placement or replacement for salvage of post-ERCP pancreatitis.

BACKGROUND AND STUDY AIMS: Urgent placement or replacement of pancreatic stents shortly after endoscopic retrograde cholangiopancreatography (ERCP) might attenuate the course of evolving post-ERCP pancreatitis (PEP). PATIENTS AND METHODS: Salvage ERCP with de novo pancreatic stent placement or replacement of outwardly migrated stents was performed within 2 - 48 hours in patients with evolving PEP accompanied by severe pain, systemic inflammatory response syndrome (SIRS), and major elevations in serum amylase and lipase. Serial pain scores, amylase and lipase levels, and hospital course were studied. RESULTS: PEP according to Cotton consensus criteria developed after 64 (2 %) of 3216 ERCPs over 3 years. Of the 64 patients with PEP, 14 underwent salvage ERCP (5 without and 9 with prior pancreatic stents, 7 of which had migrated outwards prematurely). All patients had SIRS and a high score (≥ 3) for the bedside index for severity in acute pancreatitis. Median clinical onset of PEP was at 5 hours (range 0 - 68 hours) in patients with prophylactic pancreatic stents vs. 2 hours (range 0.5 - 2.5 hours) in patients without prophylactic pancreatic stents (P < 0.05). Salvage ERCP was performed at a median of 10 hours (interquartile range [IQR] 2.4 - 22.7 hours). Improvement in pain, amylase, lipase, and resolution of SIRS were statistically significant at 24 hours after salvage ERCP (P = 0.003). Median length of hospital stay was 2 days (IQR 1 - 4.75). No necrotizing pancreatitis or late complications occurred. CONCLUSION: Urgent salvage ERCP with de novo pancreatic stent placement or replacement of a migrated stent is a novel approach in the setting of early PEP, and was associated with rapid resolution of clinical pancreatitis and reduction in levels of amylase and lipase.

Family home visiting outcomes for Latina mothers with and without mental health problems.

OBJECTIVE: To evaluate outcomes of a public health nursing family home visiting (FHV) intervention for Latina mothers with and without mental health problems. DESIGN AND SAMPLE: Retrospective cohort analysis of de-identified FHV data. Latina clients served by public health nurses (PHNS) in an urban Midwest public health agency (2007-2010). Of the 680 clients there were 158 with mental health problems (n = 30, 14-17 year olds; n = 128, 18-52 year olds) and 522 without mental health problems (n = 100, 14-17 year olds; n = 422, 18-52 year olds). MEASURES: Client age, number of problems, number of visits, length of service, presence of mental health problem, and Omaha System knowledge, behavior, and status scores for all client problems. Analysis included general linear mixed models adjusted for co-variables (i.e., age, comorbidities). RESULTS: All groups improved knowledge, behavior, and status. Knowledge improvement was not significantly different across groups. Behavior improved more among adults with mental health problems (p = .013). Status improved more among adolescents with mental health problems (p = .012). CONCLUSIONS: Latina mothers, particularly those with mental health problems, improve after PHN FHV services. Further study should examine intervention patterns associated with these outcomes, and seek explanations for differences in outcomes.

Benchmark attainment by maternal and child health clients across public health nursing agencies.

OBJECTIVES: Benchmark client outcomes across public health nursing (PHN) agencies using Omaha System knowledge, behavior, and status ratings as benchmarking metrics. DESIGN AND SAMPLE: A descriptive, comparative study of benchmark attainment for a retrospective cohort of PHN clients (low-income, high-risk parents, primarily mothers) from 6 counties. MEASURES: Omaha System Problem Rating Scale for Outcomes data for selected problems. Benchmark measures were defined as a rating of 4 on a scale from 1 (lowest) to 5 (highest). INTERVENTION: Family home visiting services to low-income, high-risk parents. RESULTS: The highest percentage of benchmark attainment was for the Postpartum problem (knowledge, 76.2%; behavior, 94.0%; status, 96.6%), and the lowest was for the Interpersonal relationship problem (knowledge, 21.7%; behavior, 69.0%; status, 40.7%). All counties showed significant increases in client knowledge benchmark attainment, and 4 of 6 counties showed significant increases from baseline in behavior and status benchmark attainment. Significant differences were found between counties in client characteristics and benchmark attainment for knowledge, behavior, and status outcomes. CONCLUSIONS: There were consistent patterns in benchmark attainment and outcome improvement across counties and family home visiting studies. Benchmarking appears to be useful for comparison of population health status and home visiting program outcomes.

Pushing the envelope: living donor pancreas transplantation.

PURPOSE OF REVIEW: More than 160 living donor segmental pancreas/islet transplants have been done since the first in 1977, more than three-quarters at one institution. We review this three-decade experience to project future application. Initially, living donor pancreas transplants were done because the results with deceased donors were poor. As the results with deceased donors improved, the incentive to do living donor transplants declined but never disappeared. A living donor simultaneous pancreas-kidney transplant in a uremic diabetic can correct diabetes and pre-empt dialysis with one operation, obviating the high mortality rate of waiting for a deceased donor. Solitary pancreas transplant candidates with preformed human leukocyte antigen antibodies but a negative cross match to a living donor volunteer also benefit. RECENT FINDINGS: The technical failure rate of living donor pancreas transplants was high in the initial cases (>1/3), nearly double that for deceased donors, but has since declined to nearly zero. Living donor segmental pancreatectomy has little surgical morbidity (currently done laparoscopically) with only a small risk for diabetes by strict selection criteria. living donor and deceased donor graft survival rates are equivalent. Islet allografts have been done from three living donors, the last one successfully, showing the potential for further application. SUMMARY: The incentives for living donor transplants are to eliminate long-wait times for a deceased donor organ and to improve outcomes. With both the incentive is high, but either by itself is sufficient. As the number of pancreas transplant candidates increase, so will wait times for a deceased donor organ. For this reason, living donor pancreas/islet transplant volume will likely increase in the years to come.

Quality of life improves for pediatric patients after total pancreatectomy and islet autotransplant for chronic pancreatitis.

BACKGROUND & AIMS: Total pancreatectomy (TP) and islet autotransplant (IAT) have been used to treat patients with painful chronic pancreatitis. Initial studies indicated that most patients experienced significant pain relief, but there were few validated measures of quality of life. We investigated whether health-related quality of life improved among pediatric patients undergoing TP/IAT. METHODS: Nineteen consecutive children (aged 5-18 years) undergoing TP/IAT from December 2006 to December 2009 at the University of Minnesota completed the Medical Outcomes Study 36-item Short Form (SF-36) health questionnaire before and after surgery. Insulin requirements were recorded. RESULTS: Before TP/IAT, patients had below average health-related quality of life, based on data from the Medical Outcomes Study SF-36; they had a mean physical component summary (PCS) score of 30 and mental component summary (MCS) score of 34 (2 and 1.5 standard deviations, respectively, below the mean for the US population). By 1 year after surgery, PCS and MCS scores improved to 50 and 46, respectively (global effect, PCS P < .001, MCS P = .06). Mean scores improved for all 8 component subscales. More than 60% of IAT recipients were insulin independent or required minimal insulin. Patients with prior surgical drainage procedures (Puestow) had lower yields of islets (P = .01) and greater incidence of insulin dependence (P = .04). CONCLUSIONS: Quality of life (physical and emotional components) significantly improve after TP/IAT in subsets of pediatric patients with severe chronic pancreatitis. Minimal or no insulin was required for most patients, although islet yield was reduced in patients with previous surgical drainage operations.

A randomized, placebo-controlled trial of aprotinin to reduce primary graft dysfunction following lung transplantation.

PURPOSE: Severe primary graft dysfunction (PGD) is the major early problem following lung transplantation. Aprotinin, a serine protease inhibitor, has many anti-inflammatory properties that might reduce or prevent lung injury. Our hypothesis was that the incidence of PGD could be reduced by a combination of donor lung perfusion and systemic administration of aprotinin to recipients. METHODS AND MATERIALS: The study was randomized and placebo controlled. Donor lungs were perfused during procurement with 4 L Perfadex containing aprotinin (280 mg load + 70 mg/hL) or placebo. Aprotinin or placebo was also administered peri-operatively to the recipients. The study was powered to detect a 10% improvement in the primary endpoint of developing ISHLT grade III PGD anytime within 48 hr following the transplant procedure. RESULTS: There were 48 patients randomized. Diagnosis and the use of bypass were different between groups. The study was stopped prematurely at the planned interim analysis point because of published concerns about renal toxicity of aprotinin. There was no difference in the occurrence of the primary endpoint between groups of patients. The median change from the baseline creatinine level at 24, 48, 72 hr; 7 and 30 d following the transplant was not associated with the administration of aprotinin. CONCLUSIONS: There was no statistically significant difference in the incidence of the primary endpoint between groups in the study. Excess renal failure related to aprotinin administration in a patient population at high risk for the event was not observed.

Public health nurses tailor interventions for families at risk.

OBJECTIVES: To use structured clinical data from public health nurse (PHN) documentation to describe client risk, to describe family home visiting interventions, including tailoring, and to assess the associations between client risk and intervention tailoring. DESIGN AND SAMPLE: Retrospective cohort design. A cohort of 486 family home visiting clients who received at least 3 visits from PHNs in a local Midwest public health agency (2000-2005). MEASURES: Omaha System variables documenting assessments, interventions, and outcomes. A risk index was created to identify low- and high-risk clients. Descriptive and inferential methods were used to describe interventions, and to assess intervention tailoring between groups. INTERVENTION: Routine PHN family home visiting practice. RESULTS: The risk index meaningfully discriminated between groups. PHNs provided more visits and interventions to clients in the high-risk group, with variations in problem, category, and target by group, demonstrating that PHNs tailored interventions to address specific client needs. CONCLUSIONS: Standardized terminologies and structured clinical data are useful tools to support PHN practice, and may be useful to advance health care quality research, program evaluation, policy development, and population health outcomes.

Referral patterns for undescended testis: A 7 year comparative analysis of primary care providers.

INTRODUCTION: Cryptorchidism, or undescended testis (UDT), is identified in 1% of boys by one year of age and carries long term risks of infertility and testicular neoplasia. In 2014, the American Urological Association (AUA) released a guideline statement stating that patients with UDT should be referred to a urologist by 6 months of age in order to facilitate timely surgical correction. This study is the follow-up to a 2010 study assessing referral patterns to our university center from primary care providers. OBJECTIVE: In this new study, we aim to identify changes in referral patterns in response to the establishment of the 2014 AUA guidelines and to understand how our referring physicians stay abreast of current knowledge regarding UDT. STUDY DESIGN: A 9 question anonymous survey regarding UDT referral patterns was sent to providers who had previously referred a patient to our pediatric urology practice. The results were categorized by specialty and were compared to the similar survey from 2010. RESULTS: Surveys were sent to 500 physicians with 138 (27.6%) responses received. Less than half of respondents reported that they would refer a boy with unilateral or bilateral palpable UDT by 6 months of age (37.0% and 38.4% respectively). This was not significantly different than the 2010 survey (p = 0.68 and 0.27 respectively). Two-thirds of physicians would refer a patient with unilateral nonpalpable UDT within the recommended time frame (68.8%); this was also unchanged from 2010 (p = 0.87). There was an improvement in respondents who would refer immediately for bilateral nonpalpable testes from 49.8% in 2010 to 53.6% in 2017 (p = 0.01). Residency training was most commonly cited as the primary source of knowledge regarding UDT although 89.3% of respondents citing this were >5 years removed from residency training. DISCUSSION: Delayed referral patterns were reported by the majority of providers for palpable UDT and by greater than one-third of providers for nonpalpable UDT. There was minimal change in referral patterns between 2010 and 2017 despite the release of the AUA cryptorchidism guidelines in 2014. In both 2010 and 2017, residency training was identified as the primary source of knowledge regarding management of UDT. CONCLUSION: These findings suggest an unmet need for education regarding contemporary management of UDT for the primary care physicians in our community.

The incontinence-associated dermatitis and its severity instrument: development and validation.

PURPOSE: To develop and test the validity and interrater reliability of the Incontinence-Associated Dermatitis and its Severity Instrument, a novel tool describing incontinence-associated dermatitis and its severity. METHODS: Investigators consulted 2 certified WOC nurse experts to determine face validity of the instrument. Seven additional certified WOC nurses evaluated the tool for content validity. The instrument was tested for interrater reliability by attendees at the 2007 WOCN Society National Conference and employees at a health care system in Minnesota. Criterion validity was determined by comparing IAD severity scores of testers with those of the 2 WOC experts and PI. RESULTS: Consultants determined that the instrument had face and content validity. Two hundred forty-seven attendees at the WOCN Society's National Conference (mean nursing experience 25±9 years [mean±SD]), 100 nursing staff in Minnesota: 84 staff nurses (mean nursing experience 17±12 years), and 16 nursing assistants (mean nursing experience 7±7 years) determined that the instrument has content validity. There were no significant differences in scores of IAD severity for the 4 cases among the 3 types of testers (P>.05). Overall agreement between the 347 raters and the experts using intraclass correlation was 0.98 (P=.006). CONCLUSION: The Incontinence-Associated Dermatitis and its Severity Instrument demonstrated good validity and interrater reliability and its development fulfills an unmet need in both research and clinical practice settings.

Early Trends in PaO(2)/fraction of inspired oxygen ratio predict outcome in lung transplant recipients with severe primary graft dysfunction.

BACKGROUND: The development of severe primary graft dysfunction (PGD) is a risk factor for perioperative death following lung transplantation. Our goal is to improve the predictive value of the earliest Pao(2)/fraction of inspired oxygen (P/F) measurements that gauge PGD severity. METHODS: We identified 96 patients with severe PGD (P/F < 200) at ICU arrival through a retrospective review of 431 lung transplants performed at our institution from 1992 to 2005. The P/F trend, represented as quartiles of the 12-h percentage change in P/F, was analyzed using multivariate logistic regression. Study outcomes were 90-day death and long-term survival. RESULTS: The median percentage change in P/F over 12 h was + 52% (interquartile range, +20 to 90%). We observed the highest early mortality among those in the lowest quartile of the P/F trend (an increase in P/F