Forty-six patients who underwent colectomy with end ileostomy for ulcerative colitis (n = 33) or Crohn's disease (n = 13) have been reviewed for paraileostomy hernia (PIH) formation 1-16 years after surgery. PIH developed in 13 of these patients (28 per cent) and was not related to the original disease or excessive weight gain. Twenty-eight patients underwent limited computed tomography (CT) scanning of the stomal region. Eight of these had a clinically detectable PIH, which was demonstrated on CT. A further two patients had PIH demonstrated on CT which was not detected by clinical examination. The rate of PIH was similar where the stoma emerged lateral to the rectus abdominis muscle (six out of 16 patients, 37 per cent) to where the stoma emerged through the rectus (four out of 12 patients, 33 per cent). Recurrence following operative repair of PIH was common. PIH occurs more frequently than previously supposed. CT can detect PIH and may be useful in evaluating a patient with stoma-related symptoms for occult PIH formation.
BACKGROUND AND OBJECTIVES: Excessive cardiac monitor alarms lead to desensitization and alarm fatigue. We created and implemented a standardized cardiac monitor care process (CMCP) on a 24-bed pediatric bone marrow transplant unit. The aim of this project was to decrease monitor alarms through the use of team-based standardized care and processes.METHODS: Using small tests of change, we developed and implemented a standardized CMCP that included: (1) a process for initial ordering of monitor parameters based on age-appropriate standards; (2) pain-free daily replacement of electrodes; (3) daily individualized assessment of cardiac monitor parameters; and (4) a reliable method for appropriate discontinuation of monitor. The Model for Improvement was used to design, test, and implement changes. The changes that were implemented after testing and adaptation were: family/patient engagement in the CMCP; creation of a monitor care log to address parameters, lead changes, and discontinuation; development of a painfree process for electrode removal; and customized monitor delay and customized threshold parameters. RESULTS:From January to November 2013, percent compliance with each of the 4 components of the CMCP increased. Overall compliance with the CMCP increased from a median of 38% to 95%. During this time, the median number of alarms per patient-day decreased from 180 to 40.CONCLUSIONS: Implementation of the standardized CMCP resulted in a significant decrease in cardiac monitor alarms per patient day. We recommend a team-based approach to monitor care, including individualized assessment of monitor parameters, daily lead change, and proper discontinuation of the monitors. Pediatrics 2014;134:e1686-e1694 2 Providers feel overwhelmed as they differentiate between the large amount of alarms, and they may become desensitized. 3 Desensitization to alarms, or "alarm fatigue," leads to a lack of response to the alarms due to sensory overload.In January 2010, excessive alarms reached national headlines when a patient' s death was directly related to alarm fatigue. 4,5 However, the dangers from excessive alarms are more than an isolated case. From 2005 to 2010, the Emergency Care Research Institute reported 216 physiologic monitor-related deaths. 6 The institute publishes an annual top 10 technology list, and "Alarm Hazards" has been at the top of the list for the last several years. [6][7][8] In April 2013, the Joint Commission announced a Sentinel Event Alert to all hospitals based on alarm fatigue and cardiac monitor device care. 9 They reported 80 alarm-related deaths between January 2009 and June 2012, all traced back to alarm-related issues. The major factors reported in these deaths were from alarm fatigue, alarm parameters not customized to the patient, and inadequate staff training on the functioning of the monitors.The present improvement project was performed in the bone marrow transplant (BMT) unit at Cincinnati Children' s Hospital Medical Center (CCHMC). Hospital guidelines recommend cardiopulmonary ...
Point-of-care ultrasound (PoCUS) has become an essential skill in the practice of emergency medicine (EM). Various EM residency programs now require competency in basic PoCUS applications. The education literature suggests that deliberate practice is necessary for skill acquisition and mastery. We used an educational theory, Ericsson's model of deliberate practice, to create a PoCUS curriculum for our Royal College of Physicians and Surgeons of Canada EM residency.Although international recommendations around curriculum requirements exist, this will be one of the first papers to describe the implementation of a specific PoCUS training program. This paper details the features of the program and lessons learned during its initial 3 years. Sharing this experience may serve as a nidus for scholarly discussion around how to best approach medical education in this area. RÉSUMÉL'échographie au point de service (EPS) est devenue une habileté essentielle dans la pratique de la médecine d'urgence (MU). Divers programmes de résidence en MU exigent maintenant l'acquisition de compétences dans des applications de base de l'EPS. D'après la documentation en éducation, la pratique intentionnelle serait nécessaire à l'acquisition et à la maîtrise de compétences. Les auteurs ont donc appliqué une théorie de l'éducation, le modèle de pratique intentionnelle d'Ericsson, pour élaborer un programme d'EPS dans le cadre de la résidence en MU du Collège royal.Bien qu'il existe des recommandations internationales sur les exigences du programme, le présent article est le premier d'une série portant sur la mise en oeuvre d'un programme particulier de formation en EPS. Il y sera question surtout des éléments du programme et des leçons tirées au cours des trois premières années de mise en oeuvre. Ainsi, l'exposé de l'expérience vécue peut servir de matière à des discussions théoriques sur la meilleure façon d'aborder la formation médicale dans le domaine.
Congenital absence of the major salivary glands is uncommon with only a few reported cases in the world literature. Agenesis may be partial or total; the more severely affected patients suffer from a dry mouth, an increased rate of dental decay and difficulty in wearing dentures. Following exclusion of the more common causes of a dry mouth by the clinician, the diagnosis of salivary gland agenesis can be confirmed by computed tomography (CT) and a 99Tcm-pertechnetate scintiscan.
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