OSF St. Joseph Medical Center

Many patients dislike the taste of the oral gastrointestinal lavage solutions utilized prior to colonoscopy. Specifically, patients dislike the salty taste and the quantity of the polyethylene glycol-electrolyte solution that they are required to ingest. In an attempt to reduce the salty taste and potentially improve patient compliance and tolerance of the preparation, flavoring was added to the lavage solution. Fifty-six patients received standard or flavored polyethylene glycol-electrolyte lavage solution in random order prior to colonoscopy. In group I, lemon-flavored Colyte was compared with standard Colyte: 93% (25/27) of subjects preferred the flavored solution. In group II, standard Colyte was compared with lemon/lime-flavored Colyte, and 80% (8/10) of subjects preferred standard Colyte. In group III, lemon-flavored Colyte, standard Colyte, and NuLYTELY were compared. Ninety percent (17/19) of the subjects preferred lemon-flavored Colyte, 10% of the subjects preferred standard Colyte, and none of the subjects preferred NuLYTELY. Overall, patients preferred lemon-flavored solution over other solutions.

OBJECTIVE: The purpose of this project was to increase nurse compliance with bedside report and increase patient satisfaction scores. BACKGROUND: Bedside report is an evidence-based practice used to increase patient involvement in their care and improve patient satisfaction. A change management strategy and standardized approach to bedside report can help increase nurse compliance with the process. METHODS: This study used a quasi-experimental, between-group, preimplementation and postimplementation comparison of patient satisfaction scores from returned surveys on 2 units in a 149-bed community hospital. We also compared nurse compliance with bedside report preimplementation and postimplementation. RESULTS: Five months after using a change management strategy to "hardwire" (ingrain systems and tools) bedside report, nurse compliance with bedside report and patient satisfaction scores improved in both intervention units. CONCLUSIONS: A change management strategy and standardized approach to bedside report helped increase nurse compliance with the process, leading to improved patient satisfaction.

More than 90 members of the American Association of Colleges of Nursing and 190 practice sites have partnered to develop the clinical nurse leader role. The partnership has created synergy between education and practice and nurtured innovation and diffusion of learning on a national basis. In this ongoing department, the editor, Jolene Tornabeni, MA, RN, FAAN, FACHE, showcases a variety of nurse leaders who discuss their new patient care delivery models in preparation for the clinical nurse leader role and clinical nurse leaders who highlight partnerships with their clinical colleagues to improve patient care. This article focuses on one organization's efforts to redesign the patient care delivery model in preparation for the clinical nurse leader.

Several healthcare organizations across Minnesota have developed formal pharmacogenomic (PGx) clinical programs to increase drug safety and effectiveness. Healthcare professional and student education is strong and there are multiple opportunities in the state for learners to gain workforce skills and develop advanced competency in PGx. Implementation planning is occurring at several organizations and others have incorporated structured utilization of PGx into routine workflows. Laboratory-based and translational PGx research in Minnesota has driven important discoveries in several therapeutic areas. This article reviews the state of PGx activities in Minnesota including educational programs, research, national consortia involvement, technology, clinical implementation and utilization and reimbursement, and outlines the challenges and opportunities in equitable implementation of these advances.

Primary sarcomas of the sellar region are uncommon, although a wide variety have been reported. To date, no cases of primary synovial sarcoma have been described as occurring at this site. We report an immunohistochemically and molecular genetically confirmed primary synovial sarcoma involving the sellar/parasellar region and cavernous sinus in an adult male. Subtotal resection and radiosurgery proved to be efficacious. The spectrum of primary sellar region sarcomas is summarized.

This project compared nurses' knowledge retention after completion of either a competency-based, written self-learning module or a competency-based, didactic lecture module. Using a pretest/posttest quasiexperimental design, a convenient sample was selected from a group of registered nurses who attended a mandatory yearly review of standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Occupational Safety and Health Association (OSHA). The 67 subjects were given pretests, the same content material using the two types of presentations, and posttests. An analysis of covariance was used to determine posttest differences between the groups, controlling for pretest scores. Results indicated no significant differences among posttest scores of the treatment group and the control group; alpha level was 0.05. Knowledge retention essentially was the same, regardless of the antecedent teaching methodology. The advantages of one teaching method versus another may be in the flexibility afforded the staff educator. After desired outcomes are identified, a teaching method can be determined based on the staff educators' requirements, the resources available, and the learners' needs.

BACKGROUND AND IMPORTANCE: A novel technique in which microcatheter neck bridging of a ruptured wide-neck posterior communicating artery aneurysm was performed by intra-aneurysmal catheter navigation into a fetal configuration posterior cerebral artery (PCA) branch vessel arising from the sac. CLINICAL PRESENTATION: An 88-year-old woman with a Hunt and Hess grade 1 and Fisher grade 4 subarachnoid hemorrhage was identified as having a wide-neck posterior communicating artery aneurysm and an isolated fetal configuration PCA with origins from the aneurysm sac. Delivery of a bare platinum Guglielmi detachable coil within the aneurysm lumen resulted in persistent coil prolapse into the parent vessel with occlusion of the incorporated vital PCA origin. A microcatheter was then navigated through the aneurysm lumen and into the fetal configuration PCA. This was retained within the PCA with resultant aneurysm neck narrowing and branch vessel protection. A second microcatheter was placed in the aneurysm lumen for coil delivery. Complete aneurysm occlusion with patency of the PCA without coil loop prolapse into the parent vessel was achieved. CONCLUSION: The presence of normal branch vessels arising from the dome is a limitation for endovascular techniques. To the best of our knowledge, no prior description of a dual-microcatheter technique with selective catheter placement within an important intra-aneurysmal branch vessel has been published. The vital branch vessel was protected and the wide-neck aneurysm completely occluded. Novel placement of microcatheters further expands the range of complex configuration aneurysms amenable to endovascular coiling.

STUDY DESIGN: Resident's case problem. BACKGROUND: Abdominal pain is a common symptom, but not a common diagnosis, of patients referred to physical therapists for examination and intervention. For patients with primary symptoms of abdominal pain, a thorough evaluation must be performed to determine if symptoms are musculoskeletal in nature or of a nonmusculoskeletal origin that would warrant a referral to a different healthcare provider. This report describes the management of 3 adults with primary complaints of abdominal pain who were referred for physical therapy evaluation and treatment. DIAGNOSIS: Two of the patients had secondary symptoms of hip and/or low back pain and had previously undergone extensive medical testing for their chronic abdominal pain, without a definitive diagnosis having been determined. A physical therapy evaluation was conducted, and treatment, including manual physical therapy and exercise, was administered to address all relative impairments, once the physical therapist had determined that the patients' symptoms were of musculoskeletal origin. The third patient included in this series was referred to a physical therapist with a diagnosis of greater trochanteric versus iliopsoas bursitis. However, the patient had abdominal pain that was more acute in nature and a history and physical examination findings that were concerning for abdominal pain of nonmusculoskeletal origin. Both patients with abdominal pain of musculoskeletal origin showed marked improvement in pain and disability after 7 treatment sessions. The third patient was referred to her primary care physician, and ultrasound examination of the abdomen revealed several intrauterine masses that were consistent with uterine fibroids. Following uterine fibroid embolization, the patient was symptom free. DISCUSSION: Although not routinely managed by physical therapists, abdominal pain is a relatively common patient symptom that can have several causes, both musculoskeletal and nonmusculoskeletal. This paper emphasizes the importance of physical therapists having the necessary differential diagnostic skills to determine if patients with primary symptoms of abdominal pain require physician referral or physical therapist intervention.

BACKGROUND AND PURPOSE: To compare safety and efficacy of cerebral aneurysm embolization with and without Neuroform stent placement at a low procedural volume center. METHODS: Retrospective cohort study of unruptured aneurysm coil embolization with and without Neuroform stent assistance over a period of 53 months at a center performing 14.4 interventions per year. Neuroform stent-assisted embolization was performed for 26 aneurysms in 25 patients (mean age: 61.3 years). Twelve patients (mean age: 64.3 years) with 12 unruptured aneurysms were treated without stent support. Comparative analysis of complications, angiographic findings, and clinical outcomes was performed. RESULTS: Procedural complications for the Neuroform stent group was 7.69% (2/26) versus 8.34% (1/12) for aneurysms without (P=0.7; OR: 1.1; CI: 0.09-13.35).The Modified Rankin Scale (MRS) and Glasgow Outcome Scale (GOS) scores for all patients in the stent and non-stent groups were 0 and 5, respectively. Three out of 20 aneurysms (15%) were retreated for major recurrence in the stent group and two of 10 (20%) in the non-stent group (P=0.55; OR: 1.42; 95% CI: 0.20-10.23). At a mean follow-up of 16.9 months, persistent complete occlusion was observed in 36.8% (7/19) of aneurysms with stent support. At a mean of 15.9-month follow-up in 10 non-stented aneurysms, persistent complete occlusion was observed in 50% of aneurysms (P=0.69; OR=2.3; 95% CI: 0.38-14.2). CONCLUSION: Neuroform stent-assisted coil embolization at a low volume center is efficacious and does not increase procedural risk with optimal operator experience.

ABSTRACT Background: The effect of intravenous tissue plasminogen activator (IV tPA) administration before endovascular intervention as compared to without at thrombectomy-capable low-volume centers on procedural aspects and patient outcomes has not been investigated. Methods: Retrospective chart review was performed in all consecutive large vessel cerebrovascular accident patients treated with endovascular therapy at two select rural primary stroke centers between 2011 and 2015. Patients’ data regarding age, sex, and medical history, as well as thrombus location by catheter-based cerebral angiography, postprocedural reperfusion status, and clinical outcomes were reviewed. The primary outcome measure of the study was a comparison of modified Rankin scale (MRS) at 90 days in patients’ postendovascular thrombectomy with prior IV tPA administration versus those who underwent thrombectomy and did not qualify for preprocedural IV tPA. Results: After application of the set inclusion and exclusion criteria, data of 46 out of 65 patients were analyzed. Twenty-three patients (50%) received IV tPA before thrombectomy and 23 patients did not qualify for IV tPA (50%). Successful recanalization (thrombolysis in cerebral infarction 2b/3) was achieved in 86% (20/23 patients) of thrombectomy patients without preprocedural IV tPA and 82% (19/23) of patients who received it (odds ratio [OR]: 0.03, confidence interval [CI]: 95% 0.062–0.16, P < 0.0001). MRS of 2 or less at 90 days was 43.4% (10/23) in patients with no preprocedural IV tPA and 39.1% (9/23) in the combined therapy group (OR: 0.84, CI: 0.26–2.70, P = 0.8). Conclusion: Patients undergoing endovascular thrombectomy for large vessel occlusion at select low-volume rural centers showed benefit from this treatment regardless of IV tPA administration. Clinical outcomes and complications at select low-volume thrombectomy-proficient centers are comparable to large volume comprehensive stroke centers as well as the landmark studies proving the efficacy of endovascular treatment.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common form of hereditary cerebral angiopathy. We present a case in which a pattern of diffusion signal change compatible with bihemispheric acute watershed infarcts occurred in a symptomatic patient demonstrating global hypoperfusion. To our knowledge, watershed infarcts in the clinical presentation of CADASIL have not been previously described.

We present a case of an incidentally discovered holohemispheric developmental venous anomaly (DVA) in a 12 year old, conclusively characterized by 3D T2* multi-echo sequence susceptibility weighted angiographic imaging (SWAN). For the evaluation of head trauma, abnormal right intraparenchymal and periventricular vascularity was identified by a non contrast head CT scan. Conventional MRI sequences revealed prominent veins with findings suspicious of a DVA. A definitive diagnosis was made by identifying angiographic features typical for DVA by augmented susceptibility weighted angiographic imaging. Using this sequence the entire hemispheric extent of the anomaly without complicating features was definitively characterized, negating the need for a catheter based angiographic study. A holohemispheric DVA in a child to our knowledge has not been previously described.

BACKGROUND AND IMPORTANCE: High-flow spontaneous vertebral arteriovenous shunts in patients with fibromuscular disease (FMD) are rare. Onyx embolization of the recipient veins with shunt disconnection and preservation of the affected vertebral artery in a patient with FMD has not been reported. CLINICAL PRESENTATION: A 59-year-old female presented with progressive dizziness, pre-syncopal episodes, and tinnitus. Catheter-based angiography identified features of fibromuscular dysplasia and a high-flow right cervical vertebral artery arteriovenous shunt. Onyx embolization of the principle draining veins was performed with initial detachable coil placement. Complete disconnection of the shunt was achieved without sacrifice of the parent vertebral artery. CONCLUSION: Spontaneous high-flow vertebral arteriovenous shunts can be successfully occluded with Onyx/detachable coil embolization of the principle recipient veins.

Hemangiomas are rare tumors in the calvarium and represent 2% of osseous calvarial lesions. Dynamic Tc-99m RBC blood pool scintigraphy has a high positive predictive value for cavernous hemangiomas of the liver. This scintigraphic technique can be used for identifying cavernous hemangiomas at other anatomic sites. We present a case in which a tagged RBC blood pool scan was used for further characterizing a symptomatic calvarial lesion as a cavernous hemangioma. This avoided an unnecessary workup for metastatic disease and was valuable in surgical planning for anticipated increased intra-operative blood loss. Histological confirmation of a cavernous hemangioma was made after surgical resection.

BACKGROUND AND PURPOSE A complex middle cerebral artery (MCA) aneurysm failed surgical clipping. The aneurysm morphology was characterized by a broad neck with incorporated diminutive branch vasculature and mural calcification. To preserve flow within incorporated branch vessels, coil embolization with intraaneurysmal Neuroform stent implantation was achieved with a novel technique. METHODS AND RESULTS A 52-year-old female presented with an unruptured complex configuration right MCA bifurcation aneurysm. Endovascular coil embolization with intraaneurysmal stent deployment and compartmental dual microcatheter placement was performed a month after failed surgical clipping. Successful occlusion of the aneurysm with coil packing within and external to the stent was achieved with preservation of flow to the branch vessels. CONCLUSIONS Neuroform stent implantation within the aneurysm lumen and subsequent dual catheter coil embolization of the compartments external and internal to the stent is useful for successful occlusion of complex configuration cerebral aneurysms with incorporated branch vasculature.

Fistulous cerebrovascular injuries can occur spontaneously, iatrogenically following surgical procedures, or can result as a consequence of penetrating trauma. To our knowledge, this is only the second reported case of blunt-trauma induced cervical vertebral artery arteriovenous fistula (AVF) formation in a 55-year-old male. This was successfully occluded with N-butyl cyanoacrylate (NBCA) embolization of the recipient vein and endovascular coil ligation of the vertebral artery.

Vertebrobasilar insufficiency leading to posterior circulation infarcts caused by congenital hypoplasia of the bilateral transverse foramina at the C2 level, affecting the caliber and flow of the bilateral distal cervical vertebral arteries in an adult, has not been previously reported. A 41-year-old male presented with episodic dizziness for a period of 1 year prior to consultation. Computed tomography angiography of the head and neck demonstrated congenital hypoplasia of the bilateral C2 transverse foramina, with absence of the vertebral arteries in each of the foramina and collateral reconstitution of diminutive intracranial vertebral artery segments. Brain MRI showed postinfarction encephalomalacia in the bilateral cerebellar hemispheres. The patient was considered not a surgical or endovascular candidate and was managed conservatively with antiplatelet therapy. Congenital anomalies of the bilateral cervical transverse foramina may present with vertebrobasilar insufficiency and infarction in adulthood.

INTRODUCTION: Endovascular trans-femoral access catheter aspiration of thrombus within the proximal subclavian, brachial, radial and ulnar arteries for symptomatic upper extremity ischemic pain has not been previously reported. We describe a case in which a successful clinical outcome was achieved using long length neuro-endovascular aspiration catheters. PRESENTATION OF CASE: A 45 year old female presented with diffuse left upper limb pain. Sonography revealed compromised upper extremity blood flow. Thrombus was identified in the proximal left subclavian artery by CT angiography. Surgical retrograde brachial artery access thrombectomy was performed. Occlusion of the left vertebral artery with embolic infarcts of the cerebellar hemispheres was noted post-procedurally. Trans-femoral mechanical aspiration thrombectomy and angioplasty of the subclavian, brachial, ulnar and radial arteries was subsequently performed with successful recanalization. CONCLUSION: Recanalization of vasculature to the upper arm through safer femoral access can be achieved with thrombo-aspiration catheters of sufficient length.

OBJECTIVE: The study aims to describe factors associated and injuries sustained with inpatients who fell while hospitalized and identify the impact of a revised fall-prevention bundle. BACKGROUND: Approximately 1 million falls occur in hospitals annually, accounting for approximately 70% of inpatient accidents. Inpatient falls can result in physical injury, increased patient mortality and morbidity, decreased quality of life, and increased length of stay and cost. METHODS: We used a retrospective review of patient fall data for adult inpatients who fell while hospitalized. RESULTS: After reeducation and implementation of all elements of a revised fall-prevention bundle, there were fewer falls per patient day. We identified additional characteristics indicating when patients were more likely to be injured in a fall. CONCLUSIONS: A fall-prevention bundle is effective in decreasing inpatient falls and falls with injury. Raising awareness of additional factors may decrease risk of injuries during an inpatient fall.

Background and study aims: Gastroesophageal reflux (GER) and its long-term sequelae remain a concern following peroral endoscopic myotomy (POEM). POEM with fundoplication (POEM-F) is simultaneous fundoplication via pure natural orifice transluminal endoscopic surgery (NOTES). In this study, we evaluated the efficacy and safety of POEM-F in mitigating post-POEM GER. Methods: and Q statistics. Results: We included seven studies comprising 127 patients. Pooled technical success for POEM was 96.90%; 95% confidence interval [CI] 91.40-98.90. Pooled technical success of fundoplication was 92.30%; 95% CI 85.20-96.10. Clinical success in treating achalasia was 96.40%; 95% CI 90.70-98.60. Rate of wrap integrity on follow-up was 84.00%; 95% CI 66.00-93.40. Composite clinical success of POEM-F in mitigating post-POEM GER was 86.20%; 95% CI 73.80-93.20. Mean total procedure duration and fundoplication time was 115.74 minutes; 95% CI 103.53-126.96 and 55.28 minutes; 95% CI 47.35-63.20, respectively. The overall pooled major adverse events (AE) rate was 3.60%; 95% CI 1.40-9.40. Conclusions: POEM-F is an effective procedure with an acceptable AE rate in expert hands. It appears to offer clinical benefit in mitigating post-POEM GER. However, further standardization for evaluating clinically significant post-POEM GER and long-term benefit of POEM-F is warranted.