Improving on National Quality Indicators of Breast Cancer Care in a Large Public Hospital as a Means to Decrease Disparities for African American Women

Background

In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for stage I, II, and III breast cancer. The purpose of this study was to document compliance with the 3 NQF breast quality indicators during 2 time intervals in a metropolitan public hospital.

Materials and Methods

Tumor registry and medical records were used to identify patient demographics and treatments before (2005–2006) and after (2008) implementations in 2007 as a result of the NQF audit. Program changes included: hiring a dedicated medical oncology nurse practitioner, requiring the radiation oncology case manager to attend weekly multidisciplinary conferences, educating Patient Navigators of the importance of multimodal care, and providing support groups for patients addressing importance of completion of all treatment options.

Results

A total of 213 female patients were diagnosed with and treated for stage I, II, or III breast cancer in 2005–2006 and 2008. Of these, 189 (89%) were African American (AA) women. Also, 70 patients of 86 (81.3%) received radiation therapy, 60 of 77 (77.9%) received or were considered for adjuvant chemotherapy, and 124 of 144 (86.1%) for hormonal therapy according to NQF indicators. After 2007, patients receiving radiation therapy increased from 75.8 to 95.8%. Patients receiving or considered for adjuvant chemotherapy or hormonal therapy increased from 73.7 to 93.7% and from 84.1 to 90.0%, respectively.

Conclusions

NQF breast cancer indicators provided a mechanism to improve compliance of multimodal treatment in our center. Raising awareness of these indicators in the multidisciplinary conference, hiring dedicated personnel, and educating patients has led to major improvements in breast cancer care.     

Matched unrelated umbilical cord blood transplantation for a patient with chemotherapy resistant Wilms tumor

We report a patient with chemotherapy refractory Wilms tumor who underwent an unrelated donor cord blood transplant for chemotherapy refractory disease. The preparative regimen consisted of busulfan, melphalan, and anti‐thymocyte globulin, and was well tolerated. This patient did not experience significant toxicity related to the chemotherapy regimen and did not develop any graft versus host disease from his HLA (A, B, DR) 6/6 matched cord blood transplant. Follow‐up CT scans 2 years post‐transplant have shown no evidence of disease progression, with only a few pulmonary nodules remaining, which are unchanged in size from his pre‐transplant CT scan. It is possible that high‐dose chemotherapy and stem cell transplantation can be curative in patients with tumors that are non‐responsive to conventional chemotherapy. Pediatr Blood Cancer. 2010;55:763–765. © 2010 Wiley‐Liss, Inc.     

Arterial complications associated with cardiac catheterization in pediatric patients with a previous history of kawasaki disease

Objectives : To determine whether patients with Kawasaki Disease (KD) undergoing percutaneous catheter angiography were at increased risk of arterial complications at the point of arterial access compared to patients with structural heart abnormalities, but normal vessels. Background : Systemic arterial damage can occur as a result of KD. Methods : Medical histories of all patients with KD undergoing percutaneous catheter angiography at The Hospital for Sick Children between January 1990 and August 2008 were reviewed. Results : A total of 44 patients with KD underwent 82 catheter procedures. Of these, 3 were associated with important arterial complications (2 males; age: 4 months, 3 and 17 years). All patients who experienced complications had multiple large and/or giant coronary artery aneurysms and two were within 3 months of the acute phase of KD. All patients developed pseudoaneurysms of the femoral artery which had been utilized for catheter access. All pseudoaneurysms were treated with ultrasound‐guided thrombin injection and compression, and resolved with no long‐term complications. One patient also developed a substantial arteriovenous fistula of the femoral circulation which had to be surgically repaired with no permanent sequela. Odds for arterial complications in patients with KD were 10.4 times greater (95%CI: 3.2–33.8) than that noted for the general pediatric cardiac catheterization population (3.6% vs. 0.4%, P < 0.0001) which indicates higher risk associated with arterial access in patients with KD. Conclusions : Greater care in obtaining arterial access for angiography is warranted, especially in the first month directly following the acute phase, possibly related to systemic arterial damage associated with KD. © 2009 Wiley‐Liss, Inc.     

Development and Implementation of a Proactive Geriatrics Consultation Model in Collaboration with Hospitalists

Acutely ill hospitalized older adults often experience a decline in function that may be preventable using a proactive, interdisciplinary, patient-centered approach. Hospitalists are treating an increasing number of these patients. A collaborative geriatrics consultation model to prevent functional decline and improve care for older patients with geriatrics syndromes was developed and implemented in partnership with a large hospitalist group in a community teaching hospital. A team of a geriatrician and a geriatrics nurse practitioner led the new consultation service. The team assisted with identifying cases, provided consultation early in the hospital stay, focused its evaluation on functional and psychosocial issues, and assisted in clinical management to optimize implementation of recommendations. In the first 4 years, the consultation service conducted 1,538 consultations in patients with a mean age of 81 (range 56–103). The most frequent geriatrics diagnoses were gait instability, delirium, and depression; recommendations usually included consulting physical therapy, increasing activity, and changing medications. The number of referrals and referring physicians grew steadily each year. Twenty-eight of 34 (82%) of the referring hospitalists completed a Web-based satisfaction questionnaire. All responding hospitalists agreed that proactive geriatrics consultation helped them provide better care; 96% rated the service as excellent. Analysis of hospital administrative data revealed a lower length of stay index and lower hospital costs in patients receiving a geriatrics consultation. The Proactive Geriatrics Consultation Service represents a promising model of collaboration between hospitalists and geriatricians for improving care of hospitalized older adults.     

Rapid detection of IgH/BCL2 rearrangement in follicular lymphoma by interphase fluorescence in situ hybridization with bacterial artificial chromosome probes

Follicular lymphomas (FLs) can be difficult to diagnose on aspirated specimens since the architectural pattern is not present. FLs characteristically have rearrangements in the IgH and BCL2 genes resulting from the reciprocal t(14;18) (q32; q21) translocation. Because of the dispersed distribution of breakpoints, fluorescence in situ hybridization (FISH) using genomic probes that span or flank the breakpoints is ideal for detecting this rearrangement in fine-needle aspiration (FNA) biopsies. To develop a set of probes, a bacterial artificial chromosome library was screened and the clones were mapped by fiber FISH. The probes were produced by the direct incorporation of fluorochrome-labeled nucleotides. The colocalization base FISH assay was applied to Cytospin preparations from FNA biopsies of lymph nodes from 26 patients with FL and 10 patients without FL. In those with FL, the percentage of cells with at least one IgH/BCL2 fusion signal ranged from 22% to 100% (mean, 63%), which was statistically significantly higher than that in FL-negative samples (mean, 2.7%). The probes demonstrated a significantly lower cutoff value (7%) in normal controls and effectively reduced the false-positive rate in FL-negative cases. These results were confirmed with fiber FISH assays on the same specimens. This interphase FISH assay is rapid and reliable for detecting rearrangements in the IGH/BCL2 gene, thereby aiding in the diagnosis of FL on FNA biopsy specimens.     

Polyanalgesic Consensus Conference—2012: Recommendations on Trialing for Intrathecal (Intraspinal) Drug Delivery: Report of an Interdisciplinary Expert Panel

Introduction: Trialing for intrathecal pump placement is an essential part of the decision‐making process in placing a permanent device. In both the United States and the international community, the proper method for trialing is ill defined. Methods: The Polyanalgesic Consensus Conference (PACC) is a group of well‐published experienced practitioners who meet to update the state of care for intrathecal therapies on the basis of current knowledge in the literature and clinical experience. Anexhaustive search is performed to create a base of information that the panel considers when making recommendations for best clinical practices. This literature, coupled with clinical experience, is the basis for recommendations and for identification of gaps in the base of knowledge regarding trialing for intrathecal pump placement. Results: The panel has made recommendations for the proper methods of trialing for long‐term intrathecal drug delivery. Conclusion: The use of intrathecal drug delivery is an important part of the treatment algorithm for moderate to severe chronic pain. It has become common practice to perform a temporary neuroaxial infusion before permanent device implantation. On the basis of current knowledge, the PACC has developed recommendations to improve care. The need to update these recommendations will be very important as new literature is published.