Improving water quality in a dialysis unit using root cause analysis.

Background: Water quality levels from hemodialysis (HD) and reverse osmosis (RO) machines in dialysis units must meet standards set by the American Association of Medical Instrumentation. Researchers used a root cause analysis (RCA) approach to identify and address factors affecting water quality in the HD and portable RO machines at our institution.

Methods: A multidisciplinary team reviewed processes, interviewed staff members, and identified opportunities to improve the current sampling and machine disinfection processes.

Subtotal Nasal Reconstruction: Military-civilian Collaboration in Care of an Afghan-American Woman's Plight.

Military plastic surgeons perform reconstructive surgeries for various congenital, oncologic, and traumatic craniofacial injuries or deformities. Recently, our Walter Reed National Military Medical Center Plastic Surgery team was tasked to care for a woman who bravely sought a new and better life in the United States after she suffered amputation of her nose and bilateral ears while in her home country of Afghanistan. A military-civilian team collaborated throughout her reconstructive planning, treatment, and postoperative course to create both an aesthetically acceptable and functional subtotal nasal reconstruction.

On the scene: St Mary's Hospital, Madison, Wisconsin.

In this article, we discuss Shared Governance as the foundation of our nursing professional practice model. Through the use of case examples and reflections from our management team, we demonstrate how this accountability-based practice model promotes excellence through developing, connecting, and engaging people, clarifying and communicating goals, using data to make decisions, and even shaping our organizational response to a critical incident. We close with a look to our future as our hospital embraces whole-system shared decision making.

Analysis of candidate genes on chromosome 2 in oral cleft case-parent trios from three populations.

Isolated oral clefts, including cleft lip with/without cleft palate (CL/P) and cleft palate (CP), have a complex and heterogeneous etiology. Case-parent trios from three populations were used to study genes spanning chromosome 2, where single nucleotide polymorphic (SNP) markers were analyzed individually and as haplotypes. Case-parent trios from three populations (74 from Maryland, 64 from Singapore and 95 from Taiwan) were genotyped for 962 SNPs in 104 genes on chromosome 2, including two well-recognized candidate genes: TGFA and SATB2.

Relief of upper airway obstruction with mandibular distraction surgery: Long-term quantitative results in young children.

Objective: To evaluate the long-term benefits of mandibular distraction on sleep-related upper airway obstruction in young children with mandibular hypoplasia.

Design: Cross-sectional study. Subjects were examined for sleep-disordered breathing using medical history, physical examination results, and a written questionnaire.

Human sexuality, sex hormones, and epilepsy.

The function of the hypothalamic-pituitary axis (HPA), including the production of luteinizing hormone, follicle-stimulating hormone, gonadotropin-releasing hormone, and prolactin, and the concentrations and metabolism of its end products, such as estrogen, testosterone, and dehydroepiandrosterone, appear to be modified in many people with epilepsy. Effects of the disorder itself and effects of antiepileptic drugs (AEDs) both appear to contribute to these hormonal alterations, which may be associated with sexual dysfunction. Focal epileptic discharges from the temporal lobe may affect HPA function, as is suggested by the normalization of androgen levels seen in men with temporal lobe epilepsy who become seizure-free after surgery.

Guided bone regeneration at the donor site of iliac bone grafts for future use as autogenous grafts.

Background: Autogenous bone grafting is considered the standard in management of bony defects but has some disadvantages, including limited source of graft material, especially in children. This study represents an attempt to regenerate bone at the donor site of iliac bone grafts using the guided bone regeneration principle for future use in multistage bone reconstruction by grafting.

Methods: Critical size defects were created in 24 iliac bones of 12 skeletally mature New Zealand White rabbits.

Role of guided bone regeneration principle in preventing fibrous healing in distraction osteogenesis at high speed: experimental study in rabbit mandibles.

The formation of fibrous tissues at the distraction gap may result from the accumulation of rapidly migrating fibroblasts at the site of an osteotomy, especially when distraction is rapid. Addition of osteopromotive membranes could theoretically prevent fibroblasts from entering the distraction gap, allowing the osteotomy site to be filled with only osteogenic cells. This study is an attempt to achieve a rapid successful distraction without fibrosis through the use of collagen membranes.

Evidence for linkage of nonsyndromic cleft lip with or without cleft palate to a region on chromosome 2.

Results from a genome-wide screen of 10 multiplex families ascertained through probands with nonsyndromic cleft lip with or without cleft palate (CL/P) in Mexico, Argentina, and the United States yielded suggestive evidence of linkage to chromosomes 2, 6, 17 and 18. Fine mapping excluded all regions except chromosome 2. Subsequent analysis was performed on the original 10 families plus an additional 16 families using 31 markers on chromosome 2.

Genetic and environmental risk factors for sagittal craniosynostosis.

The authors investigated whether genetic and environmental factors influence risk for sagittal craniosynostosis. Cases were ascertained from craniofacial clinics in the Baltimore-Washington metropolitan region. Controls were recruited from the Johns Hopkins newborn nursery and a large pediatric practice in Baltimore County.

Testing candidate genes for non-syndromic oral clefts using a case-parent trio design.

Markers in five candidate genes were examined on 269 case-parent trios ascertained through a child with an isolated, non-syndromic oral cleft (cleft lip, CL; cleft palate, CP; or cleft lip and palate, CLP). Cases and their parents were ascertained through treatment centers in Maryland. Markers at two of the five candidate genes, transforming growth factor beta3 (TGFbeta3) and MSX1, showed consistent evidence of linkage and disequilibrium due to linkage using several statistical tests (e.

A case-control study of nonsyndromic oral clefts in Maryland.

Purpose: Isolated, nonsyndromic oral clefts cases (n = 171) and unaffected controls (n = 182) were used to identify both genetic and environmental risk factors.

Methods: Infants born in Maryland between 1992 to 1998 with an isolated, nonsyndromic oral cleft [cleft lip (CL), cleft lip and palate (CLP), or cleft palate (CP)] were recruited and exposure plus family history data were collected. Controls were unaffected infants.

An assistive device for the treatment of positional plagiocephaly.

An assistive device (AD) was used to treat 122 infants with moderate-to-severe positional plagiocephaly. Clinical evaluations indicate that the AD provided the most benefit when applied to 2- to 8-month-old children. Our results suggest that the AD may join molding helmets and physical therapy as a treatment for moderate-to-severe positional plagiocephaly in infants under the age of 1 year.

Three-dimensional morphological analysis of isolated metopic synostosis.

Morphological differences were quantified in three-dimensions among individuals with untreated isolated metopic synostosis and between those individuals and similar aged-matched normal dry skulls to test two hypotheses: first, that the dysmorphology is a self-correcting condition; and second, that a lack of vertical growth of the skull produces this dysmorphology. Three-dimensional (3D) coordinates were recorded for 22 craniofacial landmarks from CT scans of 15 metopic patients, ranging from 5- to 32-months-old, and of four normal dry skulls, ranging in age from 6- to 36-months-old. The patient population was diagnosed with isolated metopic synostosis at The Johns Hopkins Medical Institutions in Baltimore, Maryland or Children's Hospital in St.

Improved free musculocutaneous flap survival with induction of heat shock protein.

The cellular response to a wide variety of stresses results in the synthesis of a family of stress response proteins termed heat shock proteins. Recent studies have demonstrated that heat shock proteins produced in response to an initial stress seem to protect against subsequent unrelated stresses. Importantly, hyperthermia-induced heat shock proteins provided protection from ischemia/reperfusion injury in several organ transplantation models.

Application of transmission disequilibrium tests to nonsyndromic oral clefts: including candidate genes and environmental exposures in the models.

Extensive epidemiological and genetic studies of the cause of oral clefts have demonstrated strong familial aggregation but have failed to yield definitive evidence of any single genetic mechanism. We used the transmission/disequilibrium test (TDT) to investigate the relationship between oral clefts and markers associated with five candidate genes by utilizing 160 parent-offspring trios. Conditional logistic regression models extended the TDT to include covariates as effect modifiers, thus permitting tests for gene-environment interactions.

Testing for interaction between maternal smoking and TGFA genotype among oral cleft cases born in Maryland 1992-1996.

Objective: Infants born in Maryland between June 1992 and June 1996 were used in a case-control study of nonsyndromic oral clefts to test for effects of maternal smoking and a polymorphic genetic marker at the transforming growth factor alpha (TGFA) locus, both of which have been reported to be risk factors for these common birth defects.

Design And Setting: Cases were infants with an oral cleft ascertained through three comprehensive treatment centers, with additional ascertainment through a registry of birth defects maintained by the Maryland Health Department. Controls were healthy infants.

Lambdoid synostosis and occipital plagiocephaly: clinical decision rules for surgical intervention.

Lambdoid craniosynostosis has been regarded as one of the least common categories of premature fusion of the cranial sutures, yet reports have suggested the incidence may be increasing. To guide treatment decisions, the authors describe a set of rules based on radiographic indicators and clinical assessment in the child. Experience suggests that children can have abnormal-appearing cranial sutures with normal neurological status and normal-appearing sutures with neurological deficits or marked cerebral compression.

Rigid fixation of internal orbital fractures.

When large portions of the internal orbit are destroyed (two to four walls), standard bone-grafting techniques for immediate and late orbital reconstruction may not yield predictable eye position. Critical bone support is most often deficient inferomedially. CT analysis of orbital volume in cases where eye position was unsatisfactory reveals that displacement of bone grafts is one mechanism of the unsatisfactory result.

The redistribution of collagen in expanded pig skin.

Silicone tissue expanders were inserted subcutaneously in the buttocks of nine young pigs and gradually inflated to maximum capacity over 5 weeks. On the control side the expanders were left uninflated. Island buttock flaps were then raised, the expanders removed and the flaps spread into the same sites for 10 days.

Rigid stabilization of sagittal fractures of the maxilla and palate.

Rigid stabilization of sagittal fractures of the palate is described that utilizes plate and screw fixation in the palatal vault. Accurate reduction of facial width is obtained, and stability is significantly enhanced. An existing laceration or a longitudinal incision in the palatal mucoperiosteum provides exposure for maxillary adaption plate application.

Techniques for improved visibility and lid protection in orbital explorations.

Visualization during exploration of the orbit is hampered by herniation of orbital fat around the malleable retractor in posterior orbital dissection. A thin stiff disc of plastic sheeting, placed between the dissected orbital soft tissue contents and the malleable retractor, reduces prolapse of fat around the edges of the orbital retractor. The technique is utilized in acute fracture treatment and in late orbital reconstruction.

Comparative viability of expanded and unexpanded axial pattern skin flaps in pigs.

A comparison of viable areas of axial pattern flaps post inset was made between expanded and non-expanded pig buttock island flaps. The deep circumflex iliac artery and vein supply approximately the proximal 14 x 10 cm area of this flap. Larger flaps were raised on expanded and control sides of eight pigs to determine if expansion increased the area of survival.

Changes in area and thickness of expanded and unexpanded axial pattern skin flaps in pigs.

The pig buttock flap model was used firstly, to compare changes in expanded axial skin flap area with control flaps prior to flap elevation and 3 or 4 months post-flap inset and, secondly, to compare the thickness of expanded and control flaps at elevation and for 3 to 6 months post-flap inset. Following 5 weeks' expansion and prior to elevation, the expanded tissue had gained a significant 63.3% mean increase in area compared with the control tissue (p less than 0.

The reverse latissimus dorsi muscle flap for closure of meningomyelocele.

Closure of the meningomyelocele wound requires stable coverage of the dural repair. In the case presented, multiple conventional attempts at reconstruction failed. A modification of the "reverse" latissimus dorsi flap is presented that successfully managed this low lumbar defect.