Quality Improvement as the Foundation for Health Care Advancement.

The rising cost of health care continues to be a key driver of the growing national debt. Improving the nation's health requires a dedicated and holistic advancement of access to quality and affordable patient-centered health care, as well as a strong focus on the core elements of prevention, including nutrition. Programs must be put in place, such as the Malnutrition Quality Improvement Initiative (MQii), to identify and address the root causes of malnutrition. Registered dietitian nutritionists have an important role to lead malnutrition quality improvement efforts in their organizations to promote better patient health outcomes, keep health care costs affordable, and protect Medicare. It is a unique time where there is an opportunity to achieve meaningful change in malnutrition care, and working together to implement quality improvement programs can ensure the health and vitality of current and future generations of Americans. FUNDING/SUPPORT: Publication of this supplement was supported by Abbott. The Academy of Nutrition and Dietetics does not receive funding for the MQii. Avalere Health's work to support the MQii was funded by Abbott.

The lack of specificity of tracheal aspirates in the diagnosis of pulmonary infection in intubated children.

OBJECTIVES: Ventilator-associated pneumonia is the first or second most commonly diagnosed nosocomial infection in the PICU. Centers for Disease Control diagnostic criteria include clinical signs or symptoms in conjunction with a "positive" tracheal aspirate, defined as more than 10 colony-forming units/mL of bacteria on quantitative culture and/or more than 25 polymorphonuclear neutrophils per low-power field on Gram stain. We hypothesized that tracheal aspirate cultures and Gram stains would not correlate with clinical signs and symptoms and would therefore not distinguish between colonization and infection. DESIGN: Prospective observational study. SETTING: PICU in an academic tertiary care center. PATIENTS: Children intubated more than 48 hours. INTERVENTIONS: Sequential tracheal aspirate quantitative cultures and Gram stains in conjunction with daily collection of concordant clinical signs and symptoms. MEASUREMENTS AND MAIN RESULTS: Time since intubation correlated strongly (p < 0.001) with the proportion of positive (> 10 colony-forming units/mL) tracheal aspirate quantitative cultures, but Centers for Disease Control-defined clinical signs or symptoms of ventilator-associated pneumonia, either singly or in combination, did not. Use of in-line suction catheters versus new, sterile catheters to obtain tracheal aspirates was associated with significantly greater proportion of positive tracheal aspirate bacterial cultures (p < 0.001). Most subjects had more than 25 polymorphonuclear neutrophils per low-power field on Gram stain; polymorphonuclear neutrophils on Gram stain correlated with positive bacterial culture (p = 0.04). Seventy-seven percent of the bacterial isolates detected in positive quantitative cultures were "pathogens." Antibiotic use at the time tracheal aspirates were obtained was associated with a lower frequency of positive quantitative cultures only with antibiotic regimens that included cefepime. CONCLUSIONS: Positive bacterial cultures of tracheal aspirates increase rapidly after intubation and usually include bacteria considered to be pathogens. Tracheal aspirate cultures and Gram stains do not appear to distinguish between infection and colonization. Antibiotic regimens that include cefepime decrease the frequency of positive cultures, but the significance of this is unclear.

Impact of supplemental vitamin K1 administration on postoperative blood component requirements after craniosynostosis repair: a prospective, placebo-controlled, randomized, blinded study.

Total cranial vault craniosynostosis repairs often require additional blood transfusions in the intensive care unit. Vitamin K1 participates in hepatic production of procoagulant proteins, and body stores of vitamin K1 are limited and dietary dependent. Surgical stress and diet interference may place infants at risk for vitamin K deficiency. Through design of a surgically stratified, randomized, placebo-controlled, blinded pilot study, we evaluated impact of vitamin K1 supplementation on coagulation parameters in infants after craniosynostosis repair. Patients received intramuscular vitamin K1 or placebo coincident with surgical incision. Serum vitamin K1 levels, protein induced in vitamin K absence-prothrombin, and factor VII were obtained at predetermined intervals after surgery. Patients received blood products in the intensive care unit in accordance with transfusion thresholds. Fifteen patients (vitamin K1 = 6, placebo = 9) completed the study procedures. Despite group assignment, patients received an average of 3 postoperative transfusions. Variations were observed with respect to intraoperative resuscitation of patients between comparably trained pediatric anesthesiologists. Thirty-three percent of patients were vitamin K1 deficient on 1 or more laboratory specimens. All breast-fed patients became deficient. Compared with placebo, elevated serum vitamin K1 levels at 6, 12, and 24 hours in the active drug group (P < 0.0001) were not associated with increased factor VII levels or reduced need for postoperative blood products. However, lack of a standardized intraoperative resuscitation plan may contribute to postoperative coagulopathy and is a major study limitation.

An improved quantitative method to assess adhesive properties of Trichomonas vaginalis to host vaginal ectocervical cells using flow cytometry.

Microbial adhesion is a critical step for infection and colonization of the host. Trichomonas vaginalis, a human urogenital extracellular parasite, relies on host cell adhesion for infection and pathogenesis. Although host cell adhesion of T. vaginalis is strain-dependent and it may be influenced by many environmental factors, a technical limitation to quantify T. vaginalis adhesion falls upon a laborious and time-consuming protocol of fluorescent microscopy. This technical limitation reduces the ability of screening multiple parameters or detecting multiple cell types simultaneously. Here we tested the capability of using flow cytometry as a qualitative and quantitative method to measure adhesion of this human infectious microorganism to vaginal ectocervical cells. Various strains of T. vaginalis with different adhesion properties were stained with CellTracker Orange (CMTMR) prior to incubation with host cells. Analyses by flow cytometry revealed that adhered CMTMR-stained parasites were clearly distinguishable from the host cells and also enabled absolute cell counts to be determined. This method was validated with the comparison of parasite strains that display variable degrees of host cell adhesion. This assay can now be applied to test many variables and environmental factors simultaneously that may affect T. vaginalis adhesion.

Megavoltage planar and cone-beam imaging with low-Z targets: dependence of image quality improvement on beam energy and patient separation.

PURPOSE: The purpose of this study is to investigate the improvement of megavoltage planar and cone-beam CT (CBCT) image quality with the use of low atomic number (Z) external targets in the linear accelerator. METHODS: In this investigation, two experimental megavoltage imaging beams were generated by using either 3.5 or 7.0 MeV electrons incident on aluminum targets installed above the level of the carousel in a linear accelerator (2100EX, Varian Medical, Inc., Palo Alto, CA). Images were acquired using an amorphous silicon detector panel. Contrast-to-noise ratio (CNR) in planar and CBCT images was measured as a function of dose and a comparison was made between the imaging beams and the standard 6 MV therapy beam. Phantoms of variable diameter were used to examine the loss of contrast due to beam hardening. Porcine imaging was conducted to examine qualitatively the advantages of the low-Z target approach in CBCT. RESULTS: In CBCT imaging CNR increases by factors as high as 2.4 and 4.3 for the 7.0 and 3.5 MeV/Al beams, respectively, compared to images acquired with 6 MV. Similar factors of improvement are observed in planar imaging. For the imaging beams, beam hardening causes a significant loss of the contrast advantage with increasing phantom diameter; however, for the 3.5 MeV/Al beam and a phantom diameter of 25 cm, a contrast advantage remains, with increases of contrast by factors of 1.5 and 3.4 over 6 MV for bone and lung inhale regions, respectively. The spatial resolution is improved slightly in CBCT images for the imaging beams. CBCT images of a porcine cranium demonstrate qualitatively the advantages of the low-Z target approach, showing greater contrast between tissues and improved visibility of fine detail. CONCLUSIONS: The use of low-Z external targets in the linear accelerator improves megavoltage planar and CBCT image quality significantly. CNR may be increased by a factor of 4 or greater. Improvement of the spatial resolution is also apparent.

Spatial and dosimetric variability of organs at risk in head-and-neck intensity-modulated radiotherapy.

PURPOSE: The accuracy of intensity-modulated radiotherapy (IMRT) delivery may be compromised by random spatial error and systematic anatomic changes during the treatment course. We present quantitative measurements of the spatial variability of head-and-neck organs-at-risk and demonstrate the resultant dosimetric effects. METHODS AND MATERIALS: Fifteen consecutive patients were imaged weekly using computed tomography during the treatment course. Three-dimensional displacements were calculated for the superior and inferior brainstem; C1, C6, and T2 spinal cord; as well as the lateral and medial aspects of the parotid glands. The data were analyzed to show distributions of spatial error and to track temporal changes. The treatment plan was recalculated on all computed tomography sets, and the dosimetric error was quantified in terms of the maximal dose difference (brainstem and spinal cord) or the mean dose difference and the volume receiving 26 Gy (parotid glands). RESULTS: The mean three-dimensional displacement was 2.9 mm for the superior brainstem, 3.4 mm for the inferior brainstem, 3.5 mm for the C1 spine, 5.6 mm for the C6 spine and 6.0 mm for the T2 spine. The lateral aspects of both parotid glands showed a medial translation of 0.85 mm/wk, and glands shrank by 4.9%/wk. The variability of the maximal dose difference was described by standard deviations ranging from 5.6% (upper cord) to 8.0% (lower cord.) The translation of the left parotid resulted in an increase of the mean dose and the volume receiving 26 Gy. CONCLUSION: Random spatial and dosimetric variability is predominant for the brainstem and spinal cord and increases at more inferior locations. In contrast, the parotid glands demonstrated a systematic medial translation during the treatment course and thus sparing may be compromised.

Buffering airway acid decreases exhaled nitric oxide in asthma.

BACKGROUND: The human airway is believed to be acidified in asthma. In an acidic environment nitrite is converted to nitric oxide (NO). OBJECTIVE: We hypothesized that buffering airway lining fluid acid would decrease the fraction of exhaled NO (F(ENO)). METHODS: We treated 28 adult nonsmoking subjects (9 healthy control subjects, 11 subjects with mild intermittent asthma, and 8 subjects with persistent asthma) with 3 mL of 10 mmol/L phosphate buffered saline (PBS) through a nebulizer and then serially measured F(ENO) levels. Six subjects also received PBS mouthwash alone. RESULTS: F(ENO) levels decreased after buffer inhalation. The maximal decrease occurred between 15 and 30 minutes after treatment; F(ENO) levels returned to pretreatment levels by 60 minutes. The decrease was greatest in subjects with persistent asthma (-7.1 +/- 1.0 ppb); this was more than in those with either mild asthma (-2.9 +/- 0.3 ppb) or healthy control subjects (-1.7 +/- 0.3 ppb, P < .001). Levels did not decrease in subjects who used PBS mouthwash. CONCLUSION: Neutralizing airway acid decreases F(ENO) levels. The magnitude of this change is greatest in persistent asthma. These data suggest that airway pH is a determinant of F(ENO) levels downstream from NO synthase activation. CLINICAL IMPLICATIONS: Airway biochemistry modulates F(ENO) levels. For example, nitrite is converted to NO in the airway, particularly the inflamed airway, by means of acid-based chemistry. Thus airway pH should be considered in interpreting clinical F(ENO) values. In fact, PBS challenge testing integrates airway pH and F(ENO) analysis, potentially improving the utility of F(ENO) as a noninvasive test for the type and severity of asthmatic airway inflammation.

Effects of immobilization mask material on surface dose.

This work investigates the increase in surface dose caused by thermoplastic masks used for patient positioning and immobilization. A thermoplastic mask is custom fit by stretching a heated mask over the patient at the time of treatment simulation. This mask is then used at treatment to increase the reproducibility of the patient position. The skin sparing effect of mega-voltage X-ray beams can be reduced when the patient's skin surface is under the mask material. The sheet of thermoplastic mask has holes to reduce this effect and is available from one manufacturer with two different sizes of holes, one larger than the other. This work investigates the increase in surface dose caused by the mask material and quantifies the difference between the two samples of masks available. The change in the dose buildup was measured using an Attix parallel plate chamber by measuring tissue maximum ratios (TMRs) using solid water. Measurements were made with and without the mask material on the surface of the solid water for 6-MV and 15-MV X-ray beams. The effective thickness of equivalent water was estimated from the TMR curves, and the increase in surface dose was estimated. The buildup effect was measured to be equivalent to 2.2 mm to 0.6 mm for masks that have been stretched by different amounts. The surface dose was estimated to change from 16% and 12% for 6 MV and 15 MV, respectively, to 27% to 61% for 6 MV and 18% to 40% for 15 MV with the mask samples.