A Quality Improvement Project to Increase Infection Control Compliance Among Endoscopy Staff at a Large Urban Medical Center.

Although nurses and other healthcare professionals play a key role in preventing hospital-associated infections, studies show that infection control compliance rates have remained low. The purpose of this quality improvement project was to increase infection control compliance of hand hygiene and procedure room disinfection among endoscopy staff at a large urban medical center in Cincinnati, Ohio. This quality improvement project provided an education session on current evidence-based infection control guidelines to 20 participants, including registered nurses and technicians within the endoscopy department. Direct observational audits were conducted 4 weeks before and 4 weeks after the education session, measuring compliance with hand sanitizer, soap and water, and procedure room disinfection, over a period of 150 days. The project goals were met, as hand sanitizer compliance improved by 12%-83%; overall soap and water compliance improved by 20%-75%; and endoscopy procedure room disinfection compliance improved by 14%-92%.

The complete genome sequence of Francisella tularensis, the causative agent of tularemia.

Francisella tularensis is one of the most infectious human pathogens known. In the past, both the former Soviet Union and the US had programs to develop weapons containing the bacterium. We report the complete genome sequence of a highly virulent isolate of F. tularensis (1,892,819 bp). The sequence uncovers previously uncharacterized genes encoding type IV pili, a surface polysaccharide and iron-acquisition systems. Several virulence-associated genes were located in a putative pathogenicity island, which was duplicated in the genome. More than 10% of the putative coding sequences contained insertion-deletion or substitution mutations and seemed to be deteriorating. The genome is rich in IS elements, including IS630 Tc-1 mariner family transposons, which are not expected in a prokaryote. We used a computational method for predicting metabolic pathways and found an unexpectedly high proportion of disrupted pathways, explaining the fastidious nutritional requirements of the bacterium. The loss of biosynthetic pathways indicates that F. tularensis is an obligate host-dependent bacterium in its natural life cycle. Our results have implications for our understanding of how highly virulent human pathogens evolve and will expedite strategies to combat them.

Implementation of a best-practice guideline: Early enteral nutrition in a neuroscience intensive care unit.

Current evidence suggests that early enteral nutrition is a best practice and leads to improved clinical outcomes. An evidence-based practice project was implemented in a busy neurointensive care unit in a midwestern tertiary care facility that was designed to improve care by implementing the early nutrition portion of Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and the American Society for Enteral and Parenteral Nutrition. The Registered Nurses' Association of Ontario's (RNAO) Toolkit: Implementation of Best Practice Guidelines (BPGs) was selected and followed to guide implementation and achieve optimal results. During a 90-day implementation period, this project resulted in a 100% improvement in early nutrition. Interventions included the use of a series of cards that reminded the team to order enteral nutrition and prepacked bundles of nasogastric tube supplies. The RNAO toolkit served as a structured and effective step-by-step methodology for the implementation of a BPG.

Surgical planning for composite tissue allotransplantation of the face using 320-detector row computed tomography.

We report initial surgical planning computed tomographic protocols for composite tissue allotransplantation of the face. This complex procedure replaces missing facial structures with anatomically identical tissues, restoring form and function. Achieved results are superior to those accomplished with conventional techniques. As a growing number of patients/recipients have undergone multiple reconstructions, vascular imaging plays an increasingly critical role in surgical planning and successful execution of the operation.

Implementation of a clinical practice guideline in a primary care setting for the prevention and management of obesity in adults.

Over two-thirds of American adults have obesity or overweight, increasing the risk of comorbidities, mortality, and healthcare costs. Despite this growing issue, screening and counseling for an unhealthy weight are not common in primary care and clinical practice guidelines (CPGs) for prevention and management of obesity are underutilized. Following the stepwise approach outlined in the Registered Nurses' Association of Ontario Toolkit: Implementation of Best Practice Guidelines, the Institute for Clinical Systems Improvement: Prevention and Management of Obesity for Adults were implemented in a primary care office in Lexington, KY. Education was implemented with providers and staff. An assessment of readiness for change was completed at check-in and customizable phrases were built into the electronic health record. After a 12-week implementation, providers were consistently assessing for comorbidities, setting goals, and managing weight in those with obesity using evidence-based strategies. Readiness for change was being documented in less than 40% of those patients. For those with overweight providers were assessing readiness for change in only 30% of patients and were setting goals in just over 40% of patients. After the implementation, care more closely followed the CPG but additional steps are necessary to improve the prevention and management of obesity in this population.

Computer algorithm compared with routine clinical practice in screening for deep venous thrombosis in the leg in an emergency department.

OBJECTIVE: To audit routine clinical practice in screening patients admitted to an accident and emergency department for deep venous thrombosis in the leg (DVT) and compare it with a computer algorithm. DESIGN: Retrospective study of case notes with data subsequently entered into a computer algorithm followed by a comparison of the diagnosis and recommended management from each modality. SETTING: Emergency department at a London teaching hospital. POPULATION OR SAMPLE: A convenience sample of 43 patients attending the emergency department. METHODS: Evaluation of clinical notes for completeness of assessment and correct diagnosis; entry of the same data into the computer algorithm. MAIN OUTCOME MEASURES: Completeness of data collection, diagnosis of presence or absence of DVT, and recommended therapy. RESULTS: The Wells score was missing in the clinical evaluation in 60% of cases. Clinicians relied primarily on the results of ultrasound scans and in six cases the absence of required D-Dimer measurements meant that the algorithm stalled. Clinical and algorithm analysis and recommendations were not compliant in 10 cases (23%). CONCLUSIONS: Clinical assessment of potential DVT in the accident and emergency department is poorly performed when compared with a computerised algorithm. Clinicians rely heavily on scan reports rather than clinical assessment which may have cost implications.

The overlooked heroines: three Silver Star nurses of World War I.

As members of forward-deployed combat hospitals, World War I Army nurses Miss Jane Rignel, Miss Linnie Leckrone, and Miss Irene Robar received the Citation Star for gallantry in attending to the wounded while under artillery fire in the month of July 1918. In 1932, they were authorized to exchange their Citation Stars for the new Silver Star Medal. Nursing in the war was difficult and required caring for patients exposed to chemical weapons and trauma while in harsh field conditions. These women were among the many Army nurses decorated for their performance in World War I.

The Role of Army Nurse Practitioners Supporting Wars in Iraq and Afghanistan.

Family nurse practitioners are an essential member of the military medical team. They were incorporated into the Army medical system almost as soon as there was an academic program to develop the role in primary care settings. The role for nurse practitioners during deployment has not been as clear. Even though they have been around for 50 years, the specific role nurse practitioners provide is still evolving. This article explores the incorporation of nurse practitioners into Army medicine with a focus on deployed medicine. Nurse practitioners have been shown to be very versatile providers with the requisite skill sets to meet the demands of the combat environment and are able to substitute for other medical assets that are critically short due to sustained conflict. Clarifying the value a nurse practitioner brings to medical care in the combat environment is essential to insure all assets are being employed to provide the best medical care to the US fighting force.

Characterization of the O antigen gene cluster and structural analysis of the O antigen of Francisella tularensis subsp. tularensis.

A gene cluster encoding enzymes involved in LPS O antigen biosynthesis was identified from the partial genome sequence of Francisella tularensis subsp. tularensis Schu S4. All of the genes within the cluster were assigned putative functions based on sequence similarity with genes from O antigen biosynthetic clusters from other bacteria. Ten pairs of overlapping primers were designed to amplify the O antigen biosynthetic cluster by PCR from nine strains of F. tularensis. Although the gene cluster was present in all strains, there was a size difference in one of the PCR products between subsp. tularensis strains and subsp. holarctica strains. LPS was purified from F. tularensis subsp. tularensis Schu S4 and the O antigen was shown by mass spectrometry to have a structure similar to that of F. tularensis subsp. holarctica strain 15. When LPS from F. tularensis subsp. tularensis Schu S4 was used to immunize mice that were then challenged with F. tularensis subsp. tularensis Schu S4, an extended time to death was observed.

Characterisation of an acapsular mutant of Burkholderia pseudomallei identified by signature tagged mutagenesis.

A Burkholderia pseudomallei mutant which was attenuated in a mouse model of melioidosis was identified by a signature tagged mutagenesis approach. The transposon was shown to be inserted into a gene within the capsular biosynthetic operon. Compared with the wild-type bacteria this mutant demonstrated a 10(5)-fold increase in the median lethal dose in a mouse model and it did not react with a monoclonal antibody against high mol. wt polysaccharide of B. pseudomallei. To determine the kinetics of infection, mice were dosed intraperitoneally (i.p.) and intravenously (i.v.) with mutant and wild-type bacteria. After i.p challenge, the number of mutant bacteria in the peritoneal cavity declined, whereas wild-type bacteria proliferated. When administered by the i.v. route, the mutant was able to cause disease but the time to death was increased compared with the wild type. Mice were dosed with the mutant and subsequently challenged with wild-type B. pseudomallei, but the mutant failed to induce a protective immune response.

Computed tomography angiography for transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an established alternative to surgery for patients with severe, symptomatic aortic stenosis who are not suitable candidates for surgical replacement of the aortic valve. The computed tomography (CT) technologist has a critical role in the care of patients undergoing TAVR. Because image acquisition and postprocessing for TAVR planning are highly complex, it is important for CT technologists involved in the planning to understand clinical detail, protocols, potential pitfalls, and factors that may influence workflow. PURPOSE: To describe, from the CT technologist's point of view, the details of CT angiography acquisition and postprocessing at 1 institution for patients being screened for TAVR. DISCUSSION: For TAVR patients, CT image acquisition and postprocessing is essential for a successful intervention. It is clinically essential to maintain and execute a detailed, standardized imaging approach. CONCLUSION: TAVR planning is among the most complex procedures in radiology. For these patients, meticulous image acquisition and image postprocessing protocols are paramount, and successful patient outcomes depend on attention to clinical detail, protocols, potential pitfalls, and factors that may influence workflow.

Iodinated contrast injection data from a new technology.

PURPOSE: To introduce a new power injection technology that generates data as a digital imaging and communications in medicine (DICOM) image linked to individual patient imaging studies. In addition, to determine the fraction of patients in a subject cohort whose contrast injection data was captured as a DICOM image and to analyze contrast injection properties for those patients. METHODS: Over a 1-month period, authors performed a retrospective evaluation of 242 patients' consecutive contrast-enhanced computed tomography (CT) studies from a single 320-detector CT scanner in an academic radiology department. Authors gathered unique patient and examination identifiers, prescribed and injected contrast and saline volumes, prescribed and injected flow rate, and mean and maximum injection pressures. The literature was reviewed for the initial description of power injectors in radiology. RESULTS: Of the 242 CT studies evaluated, 98% had contrast injection data amended to the radiology images. For all patients, the mean volume of residual contrast was 5 mL. The differences between the prescribed and actual flow rate were small. Three patients reached the maximum pressure of 300 psi. There were no contrast extravasations. Discussion The most clinically relevant finding was that the injector and software system generated a detailed report of contrast administration. In 98% of the cases, this report was incorporated into the patient's permanent medical record and was available to the radiologist via a single DICOM image. CONCLUSION: Contrast injection data can be captured in DICOM format and reliably attached to a clinical contrast-enhanced CT image set for radiologist use.

Preoperative vascular mapping for facial allotransplantation: four-dimensional computed tomographic angiography versus magnetic resonance angiography.

BACKGROUND: Facial allotransplantation requires a detailed arterial and venous assessment for surgical planning. Target vessels are often depleted by multiple reconstructive attempts or the severe facial injury itself. The purpose of this study was to retrospectively compare the diagnostic performance of computed tomography and magnetic resonance angiography in the preoperative assessment. METHODS: Four-dimensional (three spatial planes plus time) computed tomographic and magnetic resonance images including 126 potential vessels (76 arteries and 50 veins) from five candidates were analyzed independently by two radiologists using a four-point image quality scale. Computed tomographic versus magnetic resonance image quality was compared directly, using a computed tomographic angiography consensus read as reference standard. Vessels with metal artifact on magnetic resonance imaging, computed tomography, or both underwent separate analyses to determine the impact of metal implants on image quality. RESULTS: Considering all 126 vessels, the mean computed tomographic image quality was superior to that of magnetic resonance angiography. When considering individual vessels, all except for major neck vessels were better visualized by computed tomography. Images of 26 vessels were degraded by metal artifact; magnetic resonance image quality was inferior for those vessels. Considering images of major vessels with no metal artifact, there was no significant mean image quality difference between computed tomography and magnetic resonance imaging. CONCLUSIONS: Computed tomographic angiography should be used as the first-choice modality for preoperative imaging of facial transplant patients because, when compared with magnetic resonance imaging, the visualization of small vessels is far superior and images have fewer artifacts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Noninvasive vascular images for face transplant surgical planning.

OBJECTIVE: Face transplantation replaces substantial defects with anatomically identical donor tissues; preoperative vascular assessment relies on noninvasive imaging to separate and characterize the external carotid vessels and branches. The objective is to describe and illustrate vascular considerations for face transplantation candidates. METHODS: Novel noninvasive imaging using computed tomography and magnetic resonance imaging over 3 spatial dimensions plus time was developed and tested in 4 face transplant candidates. Precontrast images assessed bones and underlying metal. Contrast media was used to delineate and separate arteries from veins. For computed tomography, acquisition over multiple time points enabled the computation of tissue perfusion metrics. Time-resolved magnetic resonance angiography was performed to separate arterial and venous phases. RESULTS: The range of circulation times for the external carotid system was 6 to 14 seconds from arterial blush to loss of venous enhancement. Precontrast imaging provided a roadmap of bones and metal. Among the 4 patients, 3 had surgical clips, metal implants, or both within 1 cm of major vessels considered for surgery. Contrast-enhanced wide area detector computed tomographic data acquired in the axial mode separated these structures and provided arterial and venous images for planning the surgical anastomoses. Magnetic resonance imaging was able to distinguish between the large vessels from the external carotid systems. CONCLUSIONS: Vascular imaging maps are challenging in face transplantation because of the rapid circulation times and artifact from the initial injury, prior reconstructive attempts, or both. Nevertheless, face transplant candidates require high spatial and temporal resolution vascular imaging to determine those vessels appropriate for surgical anastomoses.

Imaging features of intramural hematoma of the aorta.

Intramural hematoma (IMH) is defined as localized hemorrhage within the aortic wall and is included in the acute aortic syndrome spectrum with aortic dissection and penetrating aortic ulcer. The mortality from IMH is similar to classic aortic dissection (21%). 16% of patients with IMH will evolve to classic aortic dissection over time. Despite this confusion exists regarding the precise definitions and radiologic features of IMH versus penetrating ulcers with mural thrombus and overt aortic dissection.

Genome-wide DNA microarray analysis of Francisella tularensis strains demonstrates extensive genetic conservation within the species but identifies regions that are unique to the highly virulent F. tularensis subsp. tularensis.

Francisella tularensis is a potent pathogen and a possible bioterrorism agent. Little is known, however, to explain the molecular basis for its virulence and the distinct differences in virulence found between the four recognized subspecies, F. tularensis subsp. tularensis, F. tularensis subsp. mediasiatica, F. tularensis subsp. holarctica, and F. tularensis subsp. novicida. We developed a DNA microarray based on 1,832 clones from a shotgun library used for sequencing of the highly virulent strain F. tularensis subsp. tularensis Schu S4. This allowed a genome-wide analysis of 27 strains representing all four subspecies. Overall, the microarray analysis confirmed a limited genetic variation within the species F. tularensis, and when the strains were compared, at most 3.7% of the probes showed differential hybridization. Cluster analysis of the hybridization data revealed that the causative agents of type A and type B tularemia, i.e., F. tularensis subsp. tularensis and F. tularensis subsp. holarctica, respectively, formed distinct clusters. Despite marked differences in their virulence and geographical origin, a high degree of genomic similarity between strains of F. tularensis subsp. tularensis and F. tularensis subsp. mediasiatica was apparent. Strains from Japan clustered separately, as did strains of F. tularensis subsp. novicida. Eight regions of difference (RD) 0.6 to 11.5 kb in size, altogether comprising 21 open reading frames, were identified that distinguished strains of the moderately virulent subspecies F. tularensis subsp. holarctica and the highly virulent subspecies F. tularensis subsp. tularensis. One of these regions, RD1, allowed for the first time the development of an F. tularensis-specific PCR assay that discriminates each of the four subspecies.