Personalized Pre-clinic Nursing Telemedicine Visit: An Efficient and Efficacious Approach for Bowel and Bladder Dysfunction in Children

OBJECTIVES

To evaluate the effectiveness and efficacy of a Registered Nurse (RN) led educational pre-clinic telephone call on compliance and outcomes in children with bowel and bladder dysfunction (BBD).

METHODS

A retrospective chart review of a prospectively applied protocol in a single academic institution was performed for children aged 4-17 presenting with BBD. All children underwent a pre-clinic RN telemedicine visit where they were educated on pathophysiology of BBD, provided personalized urotherapy and bowel recommendations and instructed to complete pre-clinic questionnaires and voiding diaries. Patients were evaluated by a provider 4weeks following RN call. Data collected included compliance with forms, bowel management and need for imaging/testing, medications, and biofeedback. Patients were considered to improve with urotherapy alone if they were discharged from urology without the need for medications and/or biofeedback.

RESULTS

In total, 277 patients completed an RN call and 224 patients attended a provider visit between December 2020 and June 2022. Mean age was 9.4years (3:1 Female to Male ratio). During the RN call, 154 (56%) patients had bowel management initiated. Of the 224 patients seen by a provider, 69% (n = 154) had symptom improvement or resolution with urotherapy alone. Thirty-eight patients (17%) enrolled in biofeedback with 7 (3%) completing all 8 sessions. Thirty-two patients (14%) required medication for daytime bladder symptoms.

CONCLUSION

Our novel RN-led pre-clinic telemedicine visit demonstrates excellent compliance and patient outcomes for children with BBD and can reduce the use of unnecessary imaging, medications, and time-consuming treatments such as biofeedback.

Establishment of Systems to Enable Isolation of Porcine Monoclonal Antibodies Broadly Neutralizing the Porcine Reproductive and Respiratory Syndrome Virus

The rapid evolution of porcine reproductive and respiratory syndrome viruses (PRRSV) poses a major challenge to effective disease control since available vaccines show variable efficacy against divergent strains. Knowledge of the antigenic targets of virus-neutralizing antibodies that confer protection against heterologous PRRSV strains would be a catalyst for the development of next-generation vaccines. Key to discovering these epitopes is the isolation of neutralizing monoclonal antibodies (mAbs) from immune pigs. To address this need, we sought to establish systems to enable the isolation of PRRSV neutralizing porcine mAbs. We experimentally produced a cohort of immune pigs by sequential challenge infection with four heterologous PRRSV strains spanning PRRSV-1 subtypes and PRRSV species. Whilst priming with PRRSV-1 subtype 1 did not confer full protection against a subsequent infection with a PRRSV-1 subtype 3 strain, animals were protected against a subsequent PRRSV-2 infection. The infection protocol resulted in high serum neutralizing antibody titers against PRRSV-1 Olot/91 and significant neutralization of heterologous PRRSV-1/-2 strains. Enriched memory B cells isolated at the termination of the study were genetically programmed by transduction with a retroviral vector expressing the Bcl-6 transcription factor and the anti-apoptotic Bcl-xL protein, a technology we demonstrated efficiently converts porcine memory B cells into proliferating antibody-secreting cells. Pools of transduced memory B cells were cultured and supernatants containing PRRSV-specific antibodies identified by flow cytometric staining of infected MARC-145 cells and in vitro neutralization of PRRSV-1. Collectively, these data suggest that this experimental system may be further exploited to produce a panel of PRRSV-specific mAbs, which will contribute both to our understanding of the antibody response to PRRSV and allow epitopes to be resolved that may ultimately guide the design of immunogens to induce cross-protective immunity.

Program and Policy Issues Affecting Home and Community-Based Long-Term Care Use: Findings from a Qualitative Study

This paper describes a qualitative study of factors affecting decisions about use of Medicaid-funded long-term care (LTC) services in Arkansas for the elderly (aged 65+), non-elderly adults with physical disabilities (aged 21-64), and adults with developmental disabilities (aged 18+). From focus groups with LTC service providers and key informant interviews with consumers and other decision-makers, three themes for improving LTC services emerged: (1) Leveling the playing field for home and community-based services (HCBS) and institutional services; (2) information dissemination and counseling; and (3) expanding services to meet unmet needs. Policy recommendations are made to improve access to HCBS.

Benefit coverage of novel antipsychotics in Medicaid programs and the Veterans Health Administration

When risperidone, olanzapine, and quetiapine were introduced, concerns were raised regarding the extent to which drug benefit policies might constrain their use. A national survey of eligible Medicaid programs (N = 47; 100%) and Veterans Health Administration facilities (N = 141; 94%) in 1998 found that within Medicaid, open formularies were common, preauthorization requirements were rare, and few barriers existed, whereas VHA facilities reported relatively more constraints in terms of formulary restrictions and preauthorization requirements. Although drug benefit policies have the potential to exert a major influence over prescribing practices, it is unlikely that these policies significantly restricted access to these antipsychotics.

Reduction of slab boundary artifact with multiple overlapping thin slab acquisition in MR angiography of the cervical carotid artery

Multiple overlapping thin slab acquisition (MOTSA) is a magnetic resonance (MR) angiography technique combining advantages of two- and three-dimensional time-of-flight techniques. The authors studied three image acquisition parameters (flip angle, TR, and the slab excitation fraction [SEF]) and a postprocessing algorithm, to evaluate their effect on MOTSA image quality, including contrast-to-noise ratio (C/N) and the severity of the slab boundary artifact. By increasing SEF from 0.75 to 1.10, the slab boundary artifact was reduced by 29%-56% (P < .0001). The boundary artifact can be reduced an additional 46% by postprocessing of the overlapping section data. In the healthy volunteers studied, C/N of the cervical carotid artery could be increased sixfold (P < .0001) by increasing the flip angle from 10 degrees to 50 degrees, without significant worsening of the boundary artifact due to top-of-slab saturation. The effect of TR on image quality was not statistically significant for the range studied (52-70 msec). We conclude that the slab boundary artifact seen with the MOTSA MR angiography technique can be reduced significantly by optimizing imaging acquisition parameters and using a postprocessing algorithm to combine overlapping section information.

Cervical carotid MR angiography with multiple overlapping thin-slab acquisition: comparison with conventional angiography

OBJECTIVE

Multiple overlapping thin-slab acquisition (MOTSA) is a hybrid time-of-flight MR angiography technique that combines the advantages of two- and three-dimensional methods. A venetian blind-like artifact, resulting from variations in signal intensity at slab boundaries, is a potentially significant disadvantage. The objective of this study was to determine the accuracy of MOTSA MR angiography for the measurement of stenosis and to evaluate the effectiveness of modifications to reduce the venetian blind artifact.

SUBJECTS AND METHODS

Fifty-one consecutive patients undergoing conventional and MR angiography of the carotid arteries for suspected atherosclerotic disease were studied. Methods established in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) were used to measure stenosis. Measurements from the conventional angiograms were compared with those from the MR angiograms. Modifications of the MR angiographic technique that were instituted after the initial 26 patients to reduce the venetian blind artifact included new acquisition parameters and the use of a postprocessing algorithm.

RESULTS

After modification, highly significant improvements in Spearman ranked correlation coefficients were observed for MR angiography interobserver comparison (.573 to .974, p < .001) and comparison of conventional and MR angiography (.774 to .949, p < .001). A corresponding reduction was observed in the standard deviation of the difference measurement for percent stenosis for both interobserver (34.5% to 11.7%, p < .001) and intertechnique (22.6% to 12.6%, p < .001) comparisons. In the postmodification group, the interobserver correlation coefficients for conventional and MR angiography were not significantly different (.969 vs .974). The areas under the receiver-operating-characteristic curves used to predict surgically significant disease for the premodification and postmodification groups were 0.79 and 0.98, respectively, for observer A and 0.85 and 0.95, respectively, for observer B.

CONCLUSION

Improved acquisition parameters and postprocessing significantly reduce the severity of the venetian blind artifact and increase the accuracy of MOTSA MR angiography in the measurement of percent stenosis. With these improvements, MOTSA MR angiography shows promise for noninvasive evaluation of stenosis of the carotid arteries.