Atypical Pattern of Leukocytoclastic Vasculitis in Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA), formerly Wegener's granulomatosis, is a small- and medium-vessel vasculitis with characteristic cutaneous morphologic presentation and systemic involvement. Most patients have palpable purpura at some point in their disease course, but this is not always the presenting manifestation. This autoimmune disorder can affect a range of organs, with the upper and lower respiratory tract, kidneys, and nervous system being commonly implicated, while gastrointestinal and cardiac involvement is less frequent. This is a 44-year-old female presenting to the emergency department (ED) with polyarthralgia and palpable purpura. Palpable purpura was distributed on the oral palate, elbow, and lower back, and a punch biopsy revealed leukocytoclastic vasculitis (LCV). While this was an atypical distribution for leukocytoclastic vasculitis, the skin biopsy provided the necessary evidence to diagnose GPA. This case characterizes non-specific and atypical signs and symptoms of GPA that all providers should be aware of in order to diagnose the condition early in its disease course.

Utilization of Palliative Care in Osteosarcoma: A National Cancer Database Review.

Background: Osteosarcoma is the most common form of bone cancer, but the utilization of palliative care (PC) in patients with this cancer has not previously been investigated in the National Cancer Database (NCDB). Methods: Patients diagnosed with osteosarcoma (2004-2017) were identified within the NCDB. Cross tabulations with Chi-square analysis were performed to evaluate frequencies of palliative care use by patient, facility, and tumor characteristics. Multivariate logistic binary regression was performed to evaluate relationships between patient, treatment facility, and tumor characteristics and the use of palliative care. Results: A total of 7498 patients were analyzed with 2.8% of patients diagnosed having any form of palliative care utilization. Of this group, 53.37% received PC within the first 12 months after diagnosis. Of the 2.8% of patients receiving PC the most common forms of PC utilized were non-curative symptom-directed surgery, radiation, or chemotherapy, or a combination of these modalities (56.7%). Palliative care usage was increased in patients with greater tumor diameter, tumors in the bones of the midline, or stage IV tumors. Palliative care usage was decreased in patients living within 25-49 miles of their treatment facility, those living in pacific states, those with chondroblastic osteosarcoma, or those with private insurance. Conclusion: Palliative care use in patients with osteosarcoma increases with tumor stage, tumor size, or more proximal tumors, but overall utilization remains markedly low. Future studies should further define these patterns of care and help expand the utilization of PC.

New Insights into Spin Coating of Polymer Thin Films in Both Wetting and Nonwetting Regimes.

Spin coating is a common method for fabricating polymer thin films on flat substrates. The well-established Meyerhofer relationship between film thickness (h) and spin rate (ω), h ∝ ω-1/2, enables the preparation of thin films with desired thickness by adjusting the spin rate and other experimental parameters. The 1/2 exponent has been verified by previous studies involving organic thin films prepared on silicon wafers. In this study, 88% and >99% hydrolyzed poly(vinyl alcohol) (PVOH) polymers were adsorbed and spin-coated from an aqueous solution onto four different substrates. The substrates were prepared by covalently attaching poly(dimethylsiloxane) (PDMS) of different molecular weights onto silicon wafers (SiO2). Atomic force microscopy images indicate that the PVOH films transitioned from stable on SiO2, to metastable, and then to unstable as PDMS molecular weight was increased. Notably, none of the polymer-substrate systems studied here exhibited the thickness-spin rate profile predicted by the Meyerhofer model. Based on the experimental results, a more general adsorption-deposition model is proposed that decouples the total spin-coated thickness into two components─the adsorbed thickness (h1) and the spin-deposited thickness (h2). The former accounts for polymer-substrate interactions, and the latter depends on polymer concentration and spin rate. In unstable systems, the exponents were found to be ∼0 because slip takes place at the solution-substrate interface during spin and the spin-deposited thickness is 0. In metastable and stable systems, a universal relationship between spin-deposited thickness and spin rate emerged, independent of the substrate type and polymer concentration for each polymer examined. Our findings indicate the importance of film stability and polymer-substrate interactions in the application of spin coating.

The Role of Haptic Feedback in Robotic-Assisted Retinal Microsurgery Systems: A Systematic Review.

Retinal microsurgery is one of the most technically difficult surgeries since it is performed at the threshold of human capability. If certain retinal conditions are left untreated, they can lead to severe damage, including irreversible blindness. Thus, techniques for reliable retinal microsurgery operations are critical. Recent research shows promise for improving surgical safety by implementing various types of sensory input and output. Sensory information is used to inform the surgeon about the environment inside the eye in real time. This review examines literature that discusses human factors and ergonomics (HFE) of sensory inputs and outputs of retinal microsurgery instrumentation with a focus on force and haptic feedback. Thirty-four studies were reviewed on the following topics: (1) variation between different input sensory devices and their performance, (2) variation between alternative output sensory devices and their performance, and (3) variation between alternative output sensory devices and their user satisfaction. This review finds that the implementation of HFE is important for the consideration of retinal microsurgery devices, but it is largely missing from current research. The addition of direct comparisons between devices, measures of user acceptance, usability evaluations, and greater realism in testing would help advance the use of haptic sensory feedback for retinal microsurgery instruments.

Findings of a Naloxone Database and its Utilization to Improve Safety and Education in a Tertiary Care Medical Center.

INTRODUCTION: Analyzing hospital naloxone use may assist in identification of areas for quality and safety improvement. Our primary objective is to quantitate the incidence of hospital naloxone use and to assess certain patient populations at risk. METHODS: During the years 2008 to 2011, each clinical scenario where naloxone was administered on an in-patient care ward was reviewed. The events were assessed to separate situations where naloxone rescue was effective in reversing opioid-induced intoxication vs. others. Further analysis was conducted to stratify patient populations at greatest risk. RESULTS: Naloxone was administered for well-defined opioid-induced respiratory depression and oversedation 61% of the time, the remainder used for patient deterioration of other etiology. Surgical populations are at risk with an incidence of 3.8/1,000 hospitalized patients, and this is the greatest within 24 hours of surgery. General surgical patients represent the highest surgical patient risk at 5.5/1,000. Medical patients represent lower risk at 2.0/1,000. Patients with patient-controlled analgesia and epidural opioid infusion are high risk at 12.1 and 13.1/1,000 patients, respectively. Many quality and safety interventions were gradually implemented in response to this data and are summarized. These include nursing and provider education, electronic medical record modification, and more stringent patient monitoring practices. CONCLUSION: Examination of naloxone use can assist in the identification and stratification of patients at risk for opioid-induced respiratory depression and oversedation and can serve as a driver for improvements in hospital patient safety. This information can also guide other institutions interested in similar improvements.

Immune globulin IV therapy: optimizing care of patients in the oncology setting.

PURPOSE/OBJECTIVES: To review major clinical applications of immune globulin IV (IGIV) therapy, properties of currently available IGIV preparations, procedures for dosing and administration, management of infusion-related adverse effects, and strategies for effective patient education. DATA SOURCES: Published articles, abstracts, and textbook chapters. DATA SYNTHESIS: IGIV therapy supports immune function by providing immunoglobulin G antibodies for protection against pathogens and modulation of autoimmune and other potentially damaging host responses. Licensed uses include treatment of primary immune deficiencies and autoimmune conditions and prophylaxis against viral infection. CONCLUSIONS: The safety and effectiveness of IGIV therapy depend on selection of an appropriate product, dosage, and infusion rate; patient comorbidities and other risk factors; and patient education and treatment adherence. IMPLICATIONS FOR NURSING: Nurses have an essential role in the safe and effective use of IGIV, from educating patients about the rationale for and effects of therapy to administering the product and monitoring for adverse effects.

Palisaded neutrophilic granulomatous dermatitis in rheumatoid arthritis.

Palisaded neutrophilic granulomatous dermatitis (PNGD) is an entity that has not been clearly defined either clinically or histopathologically. It is seen in patients with rheumatoid arthritis and other connective tissue diseases. In the past, many cases of PNGD have been described under several different names including palisaded neutrophilic and granulomatous dermatitis, linear subcutaneous bands, interstitial granulomatous dermatitis with cutaneous cords and arthritis, rheumatoid papules, and Churg-Strauss granuloma. We report 7 additional cases of PNGD. Clinically, 6 patients presented with erythematous to violaceous plaques, papules, and nodules on multiple body sites; one presented with subcutaneous linear bands on the shoulder. Five had rheumatoid arthritis; one had adult-onset Still's disease; and one showed clinical signs of rheumatoid arthritis, although serologically the rheumatoid factor was negative. On histologic examination, a spectrum of changes was observed ranging from urticaria-like infiltrates to leukocytoclastic vasculitis and granuloma annulare with neutrophils. We report these cases to expand the histologic spectrum of this entity and to further delineate the different forms of clinical presentation.