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The American Academy of Pediatrics recommends an emergency information form (EIF) for children with medical complexity (CMC) to facilitate emergency care. We sought to increase the EIF completion rate at our children's hospital's CMC clinic and to evaluate the effect on caregiver and emergency department (ED) provider opinion of preparation, comfort, and communication.We used a pre/post-quality improvement design. The main outcomes were (1) the proportion of completed EIFs and (2) caregiver and ED provider opinion of preparation, comfort, and communication, using a Likert scale survey (1, low; 5, high).Emergency information form completion increased from 3.1% (4/133) before the intervention to 47.0% (78/166) after (P0.001). Twenty-three providers completed presurveys, and 8 completed postsurveys. Seventy-two caregivers completed presurveys, and 38 completed postsurveys (25 with ED visit and 13 without). There were no changes in preparation, comfort, or communication for caregivers who had an ED visit after the intervention. For those without a postintervention ED visit, caregiver median scores rose for preparation (4 [interquartile range {IQR}, 3-5] vs 5 [IQR, 4-5], P = 0.02) and comfort (4 [IQR, 2.25-5] vs 5 [IQR, 4-5], P = 0.05). After the intervention, ED providers had increased median communication scores (3 [IQR, 2.75-4.25] vs 5 [IQR, 4-5], P = 0.02), whereas scores of preparation and comfort were unchanged.A quality improvement project at a CMC clinic increased EIF completion, caregiver preparation and comfort, and ED provider communication in emergencies.

Significance This case illustrates a novel screening protocol for linezolid-induced toxic optic neuropathy. Purpose To present a case report and analysis of linezolid-induced optic neuropathies in adult patients to develop screening recommendations. Case report A case report of optic neuropathy from extended use of linezolid illustrates its potential effects on vision. We conduct a retrospective analysis of 39 reported cases to derive a recommended screening protocol for linezolid-induced toxic optic neuropathy in adult patients. Of 39 reported adult cases, 32 presented with optic neuropathy within 90 to 365 days of treatment. Within this subset, the duration of linezolid dosage to first symptoms is 235 ± 71 days. Seven outliers either experienced optic neuropathy within the first 28 days or between 600 and 1125 days. Of the 33 cases that quantified visual recovery, 30 reported final binocular visual acuity equivalent to 20/40 or better when the medication was discontinued from 0 to 268 days after symptom onset. Recovery potential was reported over a period of 2 weeks to approximately 6 months after cessation. To evaluate the effect of cumulative dose, the data were separated into patients taking 600 mg twice daily and those at 600 mg once daily. At the higher dosage, a mean of 180 ± 96 days with a mean cumulative dosage of 216 ± 115 g was noted at first symptom, whereas at lower dosage, a mean of 201 ± 102 days was noted with a mean cumulative dose of 138 ± 69 g. Conclusions We recommend screening adult patients within 1 month after initiating linezolid, followed by a subsequent evaluation every 30 to 60 days beginning 3 months from initiation. Substantial visual recovery is reported when linezolid is discontinued. Toxicity appears to be correlated to duration of treatment, rather than cumulative dose.

Introduction: The death of young athletes is devastating to families and communities. Despite routine pre-participation screening, 80–100/yr die or suffer cardiac arrest, with 65% occurring in high school athletes. AHA/ACC recommendations for pre-participation screening do not include routine electrocardiogram (ECG), in contrast to some international guidelines. Methods: We designed a pilot study to test feasibility of a larger trial, scaled to 1% of the estimated 800,000 participants required to power for detection of sudden death/arrest. Athletes and band members enrolled in eight high schools in two Texas school districts were randomized in block fashion to standard screening alone versus the addition of ECG. ECGs were interpreted using CardeaScreen software, over-read by an independent expert. Students with abnormal ECGs received cardiology evaluation at no cost. Text messages assessing for cardiac events or hospitalizations were sent to both groups biannually. Results: Of the ~8,000 eligible students, the intervention group enrolled 847 students who received ECG (21%); the non-intervention group enrolled 655 students (16%). CardeaScreen identified 20 of 847 ECGs as abnormal (2.4%) and the expert identified 19 as abnormal (2.2%) Six of 20 ECGs (30%) identified as abnormal by CardeaScreen were over-read as normal, and 5 of 827 ECGs (0.6%) identified as normal by CardeaScreen were over-read as abnormal (PPV 70%, NPV 99.4%). Twenty-five follow up visits were attempted, 22 were completed (88%), and specialist referrals were sent for 6 (29%). New diagnoses included Wolf-Parkinson-White syndrome, coronary anomaly, and depressed LV function. Follow up with SMS surveys yielded 737 responses at 6 months and 441 responses at 16 months. No sudden cardiac death or arrest was reported. Conclusion: Randomized ECG testing and follow-up of high school students is feasible, though with low enrollment and relatively low yield. Automated ECG interpretation is viable but leads to significant false + results. Low participation in enrollment and follow up present challenges to a large-scale ECG screening study powered for clinical events. Possible solutions include an “opt-out” enrollment strategy and use of alternate follow up methods such as social media.

PURPOSE Pseudo-abducens palsy is a neurologic limitation in abduction with an intact abducens nerve. This rare condition can be observed when voluntary eye movements show impairment in lateral gaze, yet the vestibulo-ocular reflex (VOR) demonstrates full abduction. The intact VOR indicates the integrity of the infranuclear abducens nerve, thus suggesting that a pseudo-abducens palsy is likely caused by supranuclear pathology. CASE REPORT A 63-year-old African American man presented with sudden-onset, binocular, horizontal diplopia. Extraocular motilities revealed a complete restriction of abduction OS on pursuits with intermittent spasm of the right medial rectus that was most evident in primary and left gazes. No cyclodeviation or vertical deviation was found. Doll's head maneuver was used to stimulate the VOR, which facilitated complete abduction OS, despite its gross limitation on pursuits. The intact VOR and impaired abduction on pursuits, coupled with contralateral esotropia, yielded a diagnosis of pseudo-abducens palsy. CONCLUSIONS Although considered to be a rare condition, it is important for the clinician to differentiate pseudo-abducens palsy from a classic abducens infranuclear palsy. Presented is a case displaying the typical features of a pseudo-abducens palsy, in conjunction with contralateral esotropia, which further supports the theory of a dysfunctional supranuclear vergence pathway.

PURPOSE Purtscher's retinopathy is a rare condition that is associated with complement-activating systemic diseases such as acute pancreatitis. After pancreatic injury or inflammation, proteases such as trypsin activate the complement system and can potentially cause coagulation and leukoembolization of retinal precapillary arterioles. Specifically, intermediate-sized emboli are sufficiently small enough to pass through larger arteries yet large enough to remain lodged in precapillary arterioles and cause the clinical appearance of Purtscher's retinopathy. This pathology may present with optic nerve edema, impaired visual acuity, visual field loss, as well as retinal findings such as cotton-wool spots, retinal hemorrhage, artery attenuation, venous dilation, and Purtscher flecken. CASE REPORT A 57-year-old white man presented with an acute onset of visual field scotomas and decreased visual acuity 1 week after being hospitalized for acute pancreatitis. The retinal examination revealed multiple regions of discrete retinal whitening surrounding the disk, extending through the macula bilaterally, as well as bilateral optic nerve hemorrhages. The patient identified paracentral bilateral visual field defects on Amsler Grid testing, which was confirmed with subsequent Humphrey visual field analysis. Although the patient presented with an atypical underlying etiology, he exhibited classic retinal findings for Purtscher's retinopathy. After 2 months, best corrected visual acuity improved and the retinal whitening was nearly resolved; however, bilateral paracentral visual field defects remained. CONCLUSIONS Purtscher's retinopathy has a distinctive clinical presentation and is typically associated with thoracic trauma but may be a sequela of nontraumatic systemic disease such as acute pancreatitis. Patients diagnosed with acute pancreatitis should have an eye examination to rule out Purtscher's retinopathy. Although visual improvement is possible, patients should be educated that there may be permanent ocular sequelae.

To present a novel case of pupillary involvement in ocular neuromyotonia (ONM), a rare ocular syndrome that causes intermittent diplopia because of an abnormal delay in extraocular muscle relaxation and to conduct a literature review.A case report is presented to demonstrate clinical characteristics and treatment of ONM. In addition, a literature review is conducted by searching Medline and Embase databases. Data are collected from all known published cases listed in these databases to collate patient demographic data, presumed etiology or associated pathologies, and treatment strategies.The presented case demonstrates successful carbamazepine treatment of thyroid-related orbitopathy-associated ONM involving cranial nerve III. A review of the literature elicits 66 published cases of ONM, three of which were deemed to be associated with thyroid-related orbitopathy. The most common cause of reported ONM is suprasellar pathology, comprising approximately 60% of documented cases. Most published ONM cases (n = 41) were treated with carbamazepine, demonstrating a success rate of 87.8%. Of the published cases, cranial nerve III was involved 56% of the time, cranial nerve VI was affected in 39% of cases, and only 9% of ONM cases involved cranial nerve IV.Ocular neuromyotonia is a rare cause of intermittent diplopia. Unlike most neurologic etiologies of diplopia, this syndrome can often be treated effectively with carbamazepine by stabilizing the neural cell membrane. To the authors' knowledge, this is the first presentation of ONM associated with thyroid-related orbitopathy, demonstrating bilateral but asymmetric miosis during episodes of muscle spasm.

This article proposes a definition of nursing information. Nurses use information to plan, implement, and evaluate patient care. They seek information from colleagues, books, electronic sources, and equipment, and give information to multiple audiences. Even with the pervasiveness of information in nursing practice, there has been little research aimed at developing a definition of nursing information. This study was undertaken to start filling that gap. The Hybrid Model of Concept Development served as the study design. This model consists of three phases: theoretical, fieldwork, and final analytical. In the theoretical phase, a working definition of nursing information was developed. The fieldwork phase involved observations and interviews of 13 expert nurses working in a critical care unit. The qualitative data obtained from the fieldwork phase were analyzed to refine and extend the working definition. Previously identified categories in the definition--context, form, communication, and value--were validated in the analysis. New categories--multidimensionality, intervening/doing, and power--emerged during the final analytical phase, and the definition was revised to include this new knowledge. The utility of the definition of nursing information and its impact on nursing practice, information technology, and theory development is discussed.

Small and medium congenital melanocytic nevi are relatively common but present a small but significant risk of malignant transformation. Because prophylactic excision of all nevi is impractical, dermoscopic evaluation has a role in the clinical decision-making process. Dermoscopy of benign congenital nevi reveals a globular or homogenous pattern, black or brown dots and globules, small milia-like cysts within the globules, and terminal hairs. Dermoscopic criteria of melanoma are outlined here, with discussion of common scoring methods, the seven-point checklist, the ABCD rule, pattern analysis, and the Menzies criteria. Serial examination of congenital nevi with dermoscopy and excision of those lesions with malignant criteria are useful in the management of congenital melanocytic nevi.

Bloody otorrhagia in the perioperative period is an uncommon event. We present a case of bilateral bloody otorrhagia after uncomplicated robotic-assisted laparoscopic prostatectomy in a 66-year-old man. Anesthetic management was unremarkable. No symptoms were noted by the patient. Postoperative otolaryngology evaluation revealed bilateral ear canal hematomas with intact tympanic membranes. The patient was discharged with Ciprodex ear drops on postoperative day 1. One-month otolaryngology follow-up revealed no long-term sequelae. Although the etiology is unclear, there seems to be a trend in the literature toward occurrence with laparoscopy in the Trendelenburg position.