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Conjunctival Intraepithelial Neoplasia: A Case Report
Get PDFBackground: Gelatinous, vascularized lesions of the conjunctiva are a subset of ocular surface tumors that are derived from various cell types. The more worrisome origins include diagnoses of conjunctival intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC). Topical treatments such as mitomycin-C, 5-fluorouracil, and interferon alfa-2b are now used as single therapy or in conjunction with surgical excision.
Case Report: This case features a 78-year-old Caucasian male with CIN treated with surgical removal and topical interferon alfa-2b. In addition to discussing the details of this case, this report highlights important caveats of the treatment and management of the condition as well as a review of ocular surface squamous neoplasia.
Conclusion: Clinical observation of a conjunctival lesion can assist with determining severity and includes documentation of the size, shape, and consistency of the lesion, presence of a feeder vessel (indicating a more advanced ocular surface lesion), and anatomical location. The clinician can determine if the lesion is wholly within the conjunctiva or fixed to the globe by simple physical manipulation of it.Gonioscopy can provide the clinician with information regarding intraocular angle and posterior cornea involvement. Additional testing such as B-scan, anterior segment OCT, and MRI can provide additional information about the invasiveness of such lesions. Depending on the surgeon’s preference, excision and cryotherapy, topical monotherapy, or a combination treatment may be used in these cases. Prognosis is favorable in most cases if treated early and there is limited recurrence
Implementing Evidence-Based Treatment of Patients with Opioid Use Disorder in an Inpatient Addiction Treatment Center
Get PDFPatients with opioid use disorder are at increased risk for overdose and death should they relapse due to reduced opioid tolerance after a period of abstinence. A retrospective chart review was performed at an inpatient drug and alcohol treatment center to identify areas in need of improvement. The global aim of this project was to promote patient adherence to treatment, as well as increase the prevention of patient overdose and death after inpatient treatment. Project objectives include improving provider management of opioid use disorder through standardizing patient education, increasing prescription of relapse prevention medication, initiating prescription of naloxone at discharge for overdose reversal, and consolidating documentation following the 2020 American Society of Addiction Medicine (ASAM) guidelines and standards of care. Provider education sessions were held. The sessions reviewed improvement opportunities identified in the chart review, changes in the ASAM guidelines, evidence-based practices, and methods to increase interprofessional collaboration. Provider interventions included patient education addressing harm reduction strategies, prescription of relapse prevention medication with patient consent, and standardized documentation of medication-assisted therapies offered. The rate of naloxone distribution increased from 0 to 88%. The rate of patients who trialed oral naltrexone increased by 7%, but the rate of naltrexone prescriptions at discharge and Vivitrol administration was unchanged. Only 20-30% of individuals who receive treatment for opioid abuse maintain long-term abstinence. Implementation of evidence-based care is critical to improve this vulnerable population’s treatment success and reduce the probability of overdose after treatment
Novel genetic mutations in genes AGBL5 and TULP1 for presumed unilateral retinitis pigmentosa managed with low vision rehabilitation: A case report and review
Get PDFBackground: Retinitis pigmentosa is a group of hereditary retinal diseases characterized by the degeneration of rod and cone photoreceptors. It commonly results in night blindness followed by tunnel vision and central vision reduction. The classic triad of clinical signs includes pigmented bone spicules, waxy disc pallor, and arterial attenuation. Unilateral retinitis pigmentosa is rare and can be supported with ancillary testing including genetic and laboratory studies to rule out differential diagnoses.
Case Report: A 68-year-old Hispanic female was referred to the low vision rehabilitation clinic due to progressive vision loss in the left eye (OS) that began 15 years ago. The vision was normal in the right eye (OD). Additionally, she suffered from hearing loss in the right ear since age 3. Examination revealed abnormal visual acuity, visual field, fundus appearance, optical coherence tomography, and electrodiagnostic test results in the OS only. Laboratory studies ruled out various infectious, autoimmune, traumatic, and toxic drug etiologies. Genetic testing revealed novel mutations in genes associated with retinitis pigmentosa.
Conclusion: The genetic testing results along with the clinical examination and electrodiagnostic evaluation supports the diagnosis of unilateral retinitis pigmentosa
Depression Screening Upon Admission at an Addiction Facility: A Quality Improvement Project
Get PDFMore than one in six Americans will have a diagnosis of a substance use disorder at some time in their life. According to the National Institute on Drug Abuse (2020), those with a substance use disorder will have an increased rate of having a comorbidity of depression or depression symptoms during treatment, leading to poorer outcomes. The purpose of this quality improvement project was to increase provider and staff adherence to the treatment standards outlined in the Veteran’s Affair/Department of Defense Clinical Practice Guideline for the Management of Major Depressive Disorder (Veteran’s Affairs/Department of Defense, 2016). During this 10-week process, providers and staff were educated on the guidelines and were able to put what they learned into practice. Patients who were 18-years and older were screened upon admission to the addiction center for depression using the patient health questionnaire screening tools two and nine for depression. Patients were given treatment by providers and staff based on the Clinical Practice Guidelines. Treatment involved group cognitive behavioral therapy with or without a serotonin reuptake inhibitor, and education on depression. Applicable patients another depression screening was performed prior to discharge. Throughout this project, 100% of staff were educated on the guidelines, and 42 patients were screened for depression. Of the 42 screened, 69% had indications for treatment of depression or depression symptoms. Treating these patients’ depression increased the likelihood of improving outcomes after recovery. It is important to use current practice guidelines in addiction healthcare facilities to help improve patient outcomes for substance
Formalizing a High-Risk Obstetrical Initiative: Focus—Hypertensive Disorders
Get PDFBackground: Hypertensive disorders during pregnancy have a detrimental effect on maternal and fetal outcomes, causing low birth weights, preterm births, and stillbirths. During pregnancy, hypertensive disorders affect up to 13% of all pregnancies and make up 10% of all maternal mortality in the United States (Centers for Disease Control and Prevention [CDC], 2019). Purpose: The purpose of this DNP project was to implement and standardize a high-risk obstetrical initiative for hypertensive mothers. Summary of Evidence: Data suggest that increased education and increased surveillance for high-risk obstetric patients decreases the need for obstetric services and decreases the evolution of hypertensive disorders during pregnancy. Objectives: This project aimed to decrease mother and infant morbidity and mortality by standardizing an FQHC’s high-risk OB initiative, which attempted to provide face-to-face education with weekly telehealth follow-ups by a Registered Nurse in addition to regular obstetrical appointments. Interventions: Interventions included implementing a standardized enrollment and referral process, creating an electronic dashboard, and providing standardized in-person education and follow-up monitoring by a Registered Nurse. Increasing education and weekly follow-up monitoring will assist in early recognition of hypertensive disease progression and timely patient-specific interventions. Outcomes: The program increased patient program enrollment by 940% and educated fifty-seven pregnant women on the signs and symptoms of preeclampsia and eclampsia. Implications for Practice: This program provides a framework to reduce perinatal and maternal mortality related to hypertensive disorders during pregnancy. This program also strives to empower women during their pregnancy to be active participants in their pre- and post- birth health
Implementation of Comprehensive Footcare Program Within Primary Care
Get PDFThe incidence of diabetes and its complications is escalating, with over 34.2 million adults in the US having diabetes (CDC, 2020). Despite a decade-long decline in lower-extremity amputations, the incidence is growing (Nichols, 2019), with little emphasis on preventive foot evaluations within primary care. The purpose of this project was the implementation of a multi-faceted program aimed at early identification of lower extremity complications with focused patient education, improved assessment, and documentation, and referral for specialty care. The intervention process included staff training, patient education, foot examination, monofilament testing, pinprick tests, ankle reflex, and tuning fork test. Foot abnormality, loss of protective sensation, differentiation of sharp and dull sensation, vibratory sensation or perceptions, and ankle reflexes were evaluated and measured with the Michigan Neuropathy Screening Instrument (MNSI) to provide objective scoring and determine referrals. Between January and May 2021, 100% of diabetic patients (n=197) received comprehensive foot assessments and specialty referrals compared to near-zero % foot assessments in the previous year. We identified 14.1% patients who had high self-foot assessment scores indicating an increased risk of foot ulcers and amputation. All patients received education; 37% had bilateral foot abnormalities, of which 21% required referrals. Approximately 43% of the patients assessed had decreased sensation, without ulcerations. Documentation was completed 100%. Approximately 50% of diabetic foot complications can be prevented with foot care programs that include patient education, regular examination, testing, footwear, nail care, and specialty referrals; all components that can be implemented and sustained by nurse practitioners within primary care
Learning About Two Immigrant Families\u27 Educational Experiences and Educational Needs for Cultural Transmission From Trigenerational Family Storytelling
Get PDFResearch Focus. It is estimated that approximately one-third of children in the United States will be raised in immigrant families (Feliciano & Lanuza, 2017). Due to generational gaps and language mismatches from acculturation, immigrant family members tend to have difficulty communicating and interacting with one another (Buckingham & Brodsky, 2015; Ng, He, & Loong, 2004; Simes & Pietka-Nykaza, 2015). The researcher experienced similar challenges growing up, which led to her interest in studying how cultural differences among family members impact their dynamics. This research is important because it pertains to a large and growing group in our community as well as the researcher’s own understanding of her family relationships. This research can help immigrant families or professionals who work with this population by providing insight about two families’ experiences and what they deem important.
The purpose of this dissertation was to explore education and cultural transmission, or the preservation of heritage cultures and passing it on to future generations, from the perspectives of two immigrant families and their trigenerational family stories (Mchitarjan & Reisenzein, 2014. This dissertation answered the following research questions: What happens when two immigrant families participate in trigenerational family storytelling? How does education and cultural transmission emerge in trigenerational family storytelling for two immigrant families? How does the researcher reflect on these immigrant families’ stories of education and cultural transmission?
Research Methods. An autoethnographic comparative case study was implemented for this study. The two cases were “Family A”, a Vietnamese-Khmer-American family, and “Family B”, a Mexican-American family, during trigenerational family storytelling. The researcher conducted group observations and follow-up individual interviews to collect data. Then, thematic analysis was used to find themes within the two cases.
Research Results/Findings. The researcher used a combination of the participants’ stories, the participants’ interview responses, her stories of comparable experiences, and the theory of cultural transmission in minorities to gather conclusions (Mchitarjan & Reisenzein, 2014). Education was the most discussed subject for both families, implying its importance to these two immigrant families. For example, Family A immigrated from Vietnam to give the future generations in their family the opportunity to receive education. On the other hand, the opportunity for an education was taken away when Family B immigrated from Mexico.
Family A used the activity to catch up with the youngest participating family member about school, to remember loved ones, and to jokingly discuss their language barriers. Family B used the activity to gain understanding with one another as well as discuss the generational changes in their family and motherhood. Ultimately, Family A and Family B used the activity of trigenerational family storytelling as a method of cultural transmission by sharing information about their educational experiences, cultural-transmission motives, and threats to cultural transmission (Mchitarjan & Reisenzein, 2014).
Conclusions from Research. The researcher reflected on this study in her roles as a researcher, educator, and an immigrant family member to make meaning of the findings in different perspectives as well as to make research appealing to multiple audiences, which included creating a children’s book (Adams & Manning, 2015). The researcher learned to consider cultural norms of participants during the research process, utilizing family stories in the classroom to learn about students and their families, and the importance of spending trigenerational family time. The researcher encourages others to take the time to listen to family stories because the intergenerational learning outcomes may outweigh cultural differences. These considerations will be useful when working with immigrant families or creating resources to support this population
A System Intervention of Tetanus, Diphtheria, and Pertussis Vaccination for Pregnant Women in Primary Care
Get PDFThe health care system in the United States has been described as having a deficit in care for women during pregnancy (IOM, 2019), and as a result there has been a resurgence over the last decade in diseases like pertussis, which is a severe respiratory infection that is particularly dangerous for infants less than 3 months of age (Tan & Gerbie, 2013). The primary objective of this project was to implement a Tdap vaccination program and increase the rates of Tdap vaccinations of obstetrical patients at a San Antonio clinic. The intervention included: 1) establishing standing orders for the Tdap vaccination, 2) encouraging physician recommendation of the vaccination to every pregnant patient (with each pregnancy), and 3) providing educational materials on the safety and benefits of the Tdap vaccination. Between February 3 – May 3, 2020, the clinic provided care to 338 obstetrical patients. All received a physician recommendation for the Tdap vaccination and were given further educational information at their initial prenatal appointment. Two-hundred and seven patients (59.2%) were eligible for vaccination (27-36 weeks’ gestation) and received Tdap recommendations prior to vaccination (mean gestational age was 29 weeks). Ten women (5%) declined the Tdap vaccine after recommendation. Establishing an evidence-based process for Tdap vaccination ensured 100% of eligible patients were given recommendations and were offered the vaccination between 27-36 weeks of pregnancy. Ultimately, the combination of implementing standing orders within the host health center, securing a physician recommendation, and increasing patient and staff education influenced an increase in the Tdap vaccination in obstetrical patients
Optimizing Peripheral Neuropathy Management Through Vitamin B12 Screening in Adults With Type Two Diabetes Mellitus Taking Metformin
Get PDFPeripheral neuropathy is a significant co-morbidity for patients with diabetes and as early as 1969, metformin was linked to reductions in vitamin B12, leading to deficiency. Vitamin B12 deficiency causes increased levels of homocysteine and methylmalonyl-CoA which are toxic to the nervous system and therefore can contribute to demyelination. This quality improvement study aimed to optimize the management of peripheral neuropathy symptoms by implementing a process to identify patients with clinical or subclinical vitamin B12 deficiency and initiating replacement therapy. Adult patients presenting for a scheduled office visit with a diagnosis of type two diabetes and are taking metformin or medications containing metformin were included in the study. The Michigan Neuropathy Screening Instrument (MNSI) and the NC-stat DPNcheck was used to evaluate symptoms of neuropathy, and serum vitamin B12 levels were used to evaluate vitamin B12 status. The implementation of this process increased the identification of patients with low vitamin B12, thereby reducing the risk of patients in the sample population from developing peripheral neuropathy, reducing symptoms of peripheral neuropathy, or limiting the progression of peripheral neuropathy symptoms. This therefore, has the potential to improve the quality of life for patients living with type two diabetes that are taking metformin