Pediatric patients who receive antibiotics for fever and neutropenia in less than 60 min have decreased intensive care needs

Background

Antibiotic delivery to patients with fever and neutropenia (F&N) in <60 min is an increasingly important quality measure for oncology centers, but several published reports indicate that a time to antibiotic delivery (TTA) of <60 min is quite difficult to achieve. Here we report a quality improvement (QI) effort that sought to decrease TTA and assess associated clinical outcomes in pediatric patients with cancer and F&N.

Procedure

We used Lean‐Methodology and a Plan‐Do‐Study‐Act approach to direct QI efforts and prospectively tracked TTA measures and associated clinical outcomes (length of stay, duration of fever, use of imaging studies to search for occult infection, bacteremia, intensive care unit (ICU) consultation or admission, and mortality). We then performed statistical analysis to determine the impact of our QI interventions on total TTA, sub‐process times, and clinical outcomes.

Results

Our QI interventions significantly improved TTA such that we are now able to deliver antibiotics in <60 min nearly 100% of the time. All TTA sub‐process times also improved. Moreover, achieving TTA <60 min significantly reduced the need for ICU consultation or admission (P = 0.003) in this population.

Conclusion

Here we describe our QI effort along with a detailed assessment of several associated clinical outcomes. These data indicate that decreasing TTA to <60 min is achievable and associated with improved outcomes in pediatric patients with cancer and F&N. Pediatr Blood Cancer 2015;62:807–815. © 2015 The Authors. Pediatric Blood & Cancer, published by Wiley Periodicals, Inc.     

Rapid reversal of endothelial dysfunction in hypercholesterolemic apolipoprotein E-null mice by recombinant apolipoprotein A-I(Milano)-phospholipid complex

OBJECTIVES: In this study, we examined whether a reconstituted high-density lipoprotein (HDL) utilizing recombinant apolipoprotein A-I(Milano) (apo A-I(M))/phospholipid complex (PC) could restore normal endothelial function in hypercholesterolemic apolipoprotein (apo) E-null mice. BACKGROUND: We have previously shown antiatherosclerotic and vasculoprotective effects of recombinant apo A-I(M). METHODS: A perfused vessel preparation was used to examine vascular responses in control wild-type, untreated, and treated apo E-null mice. Aortic tissue cholesterol content and platelet aggregation were also measured. RESULTS: Endothelium-dependent vasodilator responses to acetycholine were significantly inhibited in untreated apo E-null mice compared with control wild-type mice (p < 0.001). Treatment of the mice for five weeks with once every-other-day intravenous bolus injections of apo A-I(M)/PC restored endothelium-dependent dilation in a dose-dependent manner (p < 0.01 at 80 mg/kg dose). The improvement in endothelial function was associated with a reduction in aortic cholesterol content and reduced platelet aggregability and occurred despite severe and persistent hypercholesterolemia. Neither treatment with free protein nor phospholipid carrier alone produced any significant effects. We performed additional experiments in vitro in isolated rabbit carotid arteries to compare the effects on lysophosphatidylcholine (LPC)-induced endothelial dysfunction. Treatment with apo A-I(M)/PC prevented impairment of endothelium-dependent vasodilator responses to acetylcholine to a greater degree than either wild-type apo A-I or plasma-derived HDL. CONCLUSIONS: Our results indicate a rapid improvement in endothelial dysfunction with recombinant apo A-I(M)/PC that is associated with mobilization of tissue cholesterol. Taken together with previously established antiatherosclerotic and antithrombotic effects, these findings suggest significant vasculoprotective effects with apo A-I(M)/PC therapy.     

Retromesenteric course of the middle colic artery—challenges and pitfalls in D3 right colectomy for cancer

Background

The middle colic artery (MCA) is of crucial importance in abdominal surgery, for laparoscopic or open right and transverse colectomies. Against this background, a high number of reports concerning anatomical variations of the MCA have been published intended to contribute to the improvement of operative techniques for the treatment of colon cancer. Despite this extensive literature, briefly reviewed in the present paper, a course of the MCA posterior to the superior mesenteric vein, called a retromesenteric trajectory, has been related to only once, to the best of our knowledge.

Methods

A total series of 507 patients included in two prospective trials concerning laparoscopic or open right colectomy for cancer between 2011 and 2017 are reported. The investigation included preoperative or postoperative multidetector-computed tomography angiography.

Results

We found four (0.79%) cases of retromesenteric MCA. They all underwent meticulous image analysis with mesenteric vessels’ road mapping, detailed morphometry, and surgical validation which revealed that, apart from their course, those cases did not differ significantly from the rest of the series.

Conclusion

This paper therefore documents the worth-knowing behavior causing considerable confusion for the operating surgeon unaware of the abnormality and shows its concrete impact on patient-tailored surgical practice, in particular for laparoscopic D3 colectomy (including the “uncinated process first” approach).

     

Significance of serum fucose, sialic acid, haptoglobine and phospholipids levels in the evolution and treatment of breast cancer.

Serum fucose, sialic acid, haptoglobine and phospholipids were determined in 167 women with breast cancer stages I--III, 30 with benign lesions of the breast, 42 women in various physiological states of the mammary gland (pregnancy, early childbed and lactation) and compared with 30 healthy women as control. Serial determinations of these parameters during the radio-surgical treatment were done in 28 patients with breast cancer stage III. Fucose and phospholipids levels were significantly increased respectively decreased in the group of patients with breast cancers but unmodified in the others. Sialic acid and haptoglobine -- increased in patients with cancer -- were also elevated in patients with early childbed and benign affections of the breast. The surveillance of these four parameters during the radio-surgical treatment of breast cancer evidenced a good correlation between their modified levels and clinical state of the patients. The increase in fucose, sialic acid and haptoglobine respectively the decrease in phospholipids levels was associated with the clinical evidence of recurrences and metastases.     

Wireless remote monitoring of reconstructed 12-lead ECGs after ablation for atrial fibrillation using a hand-held device

ObjectiveAtrial fibrillation (AF) surveillance using a wireless handheld monitor capable of 12-lead electrocardiogram reconstruction was performed, and arrhythmia detection rate was compared with serial Holter monitoring.MethodsTwenty-five patients were monitored after an AF ablation procedure using the hand-held monitor for 2 months immediately after and then for 1 month approximately 6 months postablation. All patients underwent 12-lead 24-hour Holter monitoring at 1, 2, and 6 months postablation.ResultsDuring months 1-2, 425 of 2942 hand-held monitor transmissions from 21 of 25 patients showed AF/atrial flutter (Afl). The frequency of detected arrhythmias decreased by month 6 to 85/1128 (P < .01) in 15 of 23 patients. Holter monitoring diagnosed AF/Afl in 8 of 25 and 7 of 23 patients at months 1-2 and month 6, respectively (P < .01 compared with wireless hand-held monitor). Af/Afl diagnosis by wireless monitoring preceded Holter detection by an average of 24 days.ConclusionsWireless monitoring with 12-lead electrocardiogram reconstruction demonstrated reliable AF/Afl detection that was more sensitive than serial 12-lead 24-hour Holter monitoring.     

Evaluation of Primary Stability of Self‐Tapping and Non‐Self‐Tapping Dental Implants. A 12‐Week Clinical Study

Purpose: The aim of this study was to investigate the relationship between surgical techniques and implant macro‐design (self‐tapping/non‐self‐tapping) for the optimization of implant stability in the low‐density bone present in the posterior maxilla using resonance frequency analysis (RFA). Materials and Methods: A total of 102 implants were studied. Fifty‐six self‐tapping BlueSkyBredent® (Bredent GmbH&Co.Kg®, Senden, Germany) and 56 non‐self‐tapping Standard Plus Straumann® (Institut Straumann AG®, Waldenburg, Switzerland) were placed in the posterior segment of the maxilla. Implants of both types were placed in sites prepared with either lateral bone‐condensing or with bone‐drilling techniques. Implant stability measurements were performed using RFA immediately after implant placement and weekly during a 12‐week follow‐up period. Results: Both types of implants placed after bone condensing achieved significantly higher stability immediately after surgery, as well as during the entire 12‐week observation period compared with those placed following bone drilling. After bone condensation, there were no significant differences in primary stability or in implant stability after the first week between both implant types. From 2 to 12 postoperative weeks, significantly higher stability was shown by self‐tapping implants. After bone drilling, self‐tapping implants achieved significantly higher stability than non‐self‐tapping implants during the entire follow‐up period. Conclusions: The outcomes of the present study indicate that bone drilling is not an effective technique for improving implant stability and, following this technique, the use of self‐tapping implants is highly recommended. Implant stability optimization in the soft bone can be achieved by lateral bone‐condensing technique, regardless of implant macro‐design.