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Infections caused by oropharyngeal flora include epiglottitis, mastoiditis, inflammation of salivary tissue, and suppurative parotitis [ 77 , 83 ]. Because the epiglottis may swell dramatically during epiglottitis, there is a chance of sudden occlusion of the trachea if the epiglottis is disturbed, such as by an attempt to collect a swab specimen. Blood cultures are the preferred sample for the diagnosis of epiglottitis; if swabbing is attempted, it should be in a setting with available appropriate emergency response. Oropharyngeal flora also can extend into tissues of the middle ear, mastoid, and nasal sinuses, causing acute infection [ 77 , 84 ]. Aspirated material, saline lavage of a closed space, and tissue or tissue scrapings are preferred specimens and must be transported in a sterile container. Tissues should be transported under sterile conditions and kept moist by adding a few drops of sterile, nonbacteriostatic saline. Although rarely implicated, if anaerobic bacterial pathogens are suspected, anaerobic transport is required. Note that filamentous fungi are common causes of chronic sinusitis, and they may not be recovered on swabs, even those obtained endoscopically. Endoscopic aspirates or tissue scrapings are the specimens of choice. For microbiology analysis, it is always best to submit the actual specimen, not a swab of the specimen.

Infections caused by exogenous pathogens (not part of the oral flora) include malignant otitis externa, mastoiditis, animal bites and trauma, irradiation burns, and complications of surgical procedures [ 84 , 85 ]. Mucosal flora may play an etiologic role in these infections, most frequently gram-negative bacilli and staphylococci.

Key points for the laboratory diagnosis of head and neck soft tissue infections:

A swab is not the specimen of choice for these specimens. Submit tissue, fluid, or aspirate when possible.

Resist swabbing in cases of epiglottitis.

Use anaerobic transport containers if anaerobes are suspected.

Keep tissue specimens moist during transport.

The following tables include the most common soft tissue and tissue space infections of the head and neck that originate from odontogenic, oropharyngeal, and exogenous sources. The optimum approach to establishing an etiologic diagnosis of each condition is provided.

Table 14.

Laboratory Diagnosis of Infections of the Oral Cavity and Adjacent Spaces and Tissues Caused by Odontogenic and Oropharyngeal Flora

Abbreviations: AFB, acid-fast bacilli; EDTA, ethylenediaminetetraacetic acid; HE, hematoxylin and eosin; KOH, potassium hydroxide; NAAT, nucleic acid amplification test; RT, room temperature.

Alert! Consider risk. During specimen collection, airway compromise may occur, necessitating the availability of intubation and resuscitation equipment and personnel.

Blood cultures should be performed at the discretion of the healthcare provider.

Note that nucleic acid tests are not usually available locally and must be sent to a reference laboratory with a resulting longer turnaround time.

The laboratory should be alerted if cultures will be requested so that appropriate media are available at the time the specimen arrives in the laboratory; even then, the yield of culture is very low. When available, nucleic acid testing is more sensitive. A portion of the specimen should be sent to the histopathology laboratory for HE and Warthin-Starry stains.

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Table 14.

Laboratory Diagnosis of Infections of the Oral Cavity and Adjacent Spaces and Tissues Caused by Odontogenic and Oropharyngeal Flora

Abbreviations: AFB, acid-fast bacilli; EDTA, ethylenediaminetetraacetic acid; HE, hematoxylin and eosin; KOH, potassium hydroxide; NAAT, nucleic acid amplification test; RT, room temperature.

Alert! Consider risk. During specimen collection, airway compromise may occur, necessitating the availability of intubation and resuscitation equipment and personnel.

Blood cultures should be performed at the discretion of the healthcare provider.

Note that nucleic acid tests are not usually available locally and must be sent to a reference laboratory with a resulting longer turnaround time.

The laboratory should be alerted if cultures will be requested so that appropriate media are available at the time the specimen arrives in the laboratory; even then, the yield of culture is very low. When available, nucleic acid testing is more sensitive. A portion of the specimen should be sent to the histopathology laboratory for HE and Warthin-Starry stains.

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Table 15.

Laboratory Diagnosis of Mastoiditis and Malignant Otitis Externa Caused by Oropharyngeal and Exogenous Pathogens

Abbreviations: AFB, acid-fast bacilli; RT, room temperature.

View Large
Table 15.

Laboratory Diagnosis of Mastoiditis and Malignant Otitis Externa Caused by Oropharyngeal and Exogenous Pathogens

Abbreviations: AFB, acid-fast bacilli; RT, room temperature.

View Large

Infections in the upper respiratory tract usually involve the ears, the mucus membranes lining the nose and throat above the epiglottis, and the sinuses. Most infections involving the nose and throat are caused by viruses (see Section XIV for testing information). Inappropriate utilization of antibiotics for viral infections is a major driver of increasing antibiotic resistance. Proper diagnosis of infectious syndromes in this environment must involve laboratory tests to determine the etiology and thus inform the proper therapy.

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Article Text

Original research
How do explicitly stated hospital trust values relate to their CQC ratings?

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(NHS) Trusts in the process of setting internal organisational values, it would be useful to see if there was a correlation between certain organisational values and Care Quality Commission (CQC) ratings to enable quality improvement.

Methods To examine this, we identified the CQC ratings of the NHS England provider trusts and identified and listed the trust’s values. These values were then categorised and a comparison made of well-performing and underperforming trusts.

Results A total of 43 different values were identified, with a total of 800 values being used across all 188 trusts. In the reviewed hospitals, a broad range of values were found with some not meeting common definitions of what a value is. All trusts included some aspect of behaviour in their values.

Conclusion Well-performing hospitals are more likely to be open and honest with aspirational values, whereas those which are not are more likely to be focused on day to day service delivery with operational or proscriptive values. There was considerable variation from the published NHS constitution values with outstanding and good trusts having more variance from the values in the NHS constitution than trusts rated requiring improvement or inadequate.

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Footnotes

Contributors NW planned and submitted the study. NH, NP and KN conducted the study. TH advised on the study.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

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Most people with disabilities don’t work, especially in Maine. Nationally, 34.9 percent of people with disabilities ages 18 to 64 worked in 2015, compared to 76 percent for people without disabilities, according to census data. But in Maine, just 29.6 percent of people with disabilities worked in 2015.

There are lessons Maine could learn from North Dakota, South Dakota and Wyoming, the states with the highest employment rates for people with disabilities, where around half of all people ages 18 to 64 with disabilities are employed.

The success of these states seems to rest on strong collaboration between the government, employers, and individuals with disabilities, as well as robust outreach programs to educate businesses on the benefits of hiring people with disabilities.

Here’s a closer look at what these three states are doing to get more people with disabilities to work:

North Dakota — 50.6 percent of people with disabilities employed (2011 to 2015 average)

North Dakotans with disabilities don’t view their disabilities as preventing them from working, said Russ Cusack, the director of the state’s vocational rehabilitation program, which helps people with disabilities find and maintain employment.

“It’s an expectation that people work,” Cusack said. “They might view themselves as needing some kind of an accommodation to do their work but the word ‘disabled’ doesn’t really come into their vocabulary … individuals with disabilities are viewed as individuals with abilities.”

North Dakota’s vocational rehabilitation program works with local businesses to identify what kinds of skillsets businesses need and connect them with individuals with disabilities who want to work, Cusack said. To do that, they have assigned certain vocational rehabilitation counselors to focus on interacting with the business community, figuring out if a local business needs more workers, for example, or someone with a particular set of qualifications.

If you suspect an intent vs impact conversation is in order, try broaching the subject with an opener like, “I’m not sure what your intent was when you made that comment, but the impact on me was ________,” or “I’m concerned that when I said X, it may have had an unintended impact of ________.” Then invite the other party to share their perspective, and do your best to listen with an open mind.

Tension can be overcome by having a conversation that focuses on the impacts of behavior rather than bickering over intent.

Nothing stokes conflict better than a misunderstanding of goals. One party might as well be trying to solve a problem the other person doesn’t even see –if you’ve assumed the wrong end point (or assumed that the other people involved are on board with yours, without expressly articulating it), productive conversation will be hard to come by.

A friend of mine recently hit up against this issue when mentoring a junior designer who kept coming to him with ideas: “What if we make it this color? What if we used this technology?” The junior colleague’s approach wasn’t conducive to collaboration because he failed to articulate the problems he was trying to solve – or put another way, the goals he was trying to achieve – through his suggestions. Now that he’s learned to reframe his comments to identify a problem first, he’s better able to convince his colleagues to see the benefits of his proposed solutions.

If you can agree on your goals, you’re at least halfway to finding common ground for agreement on how to reach them.

Even if everyone agrees on the big-picture goals, individual team members are liable to have different priorities based on their area of responsibility, personal work style, and workload (just how many “important” issues can you reasonably expect to tackle in a day?).

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It could well be that your teammate’s insistence on sourcing the least expensive materials is in tension with your commitment to quality. Laying that out in black and white will make a productive conversation far more likely than arguing which is better: cheap or good.

If you’re on the same page with goals and priorities, but still at a loggerhead, consider that you may have conflicting definitions of success. Ask your opponent(s) to describe to you what their vision of a successful outcome would be. Get as many details as you can –both measurable and qualitative outcomes are valuable to hear. You may discover some core areas of disagreement that can be teased out once a clear picture of the ideal future has been painted. Maybe they’re imagining a utopia that doesn’t look quite so sunny to you. In that case, it’s no wonder you disagree on how to get there. But if you can understand how an ideal outcome looks to them, you’re better equipped to negotiate a win-win approach.

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