Short- and Long-Term Outcomes of Hematologic Malignancy Patients After Cardiopulmonary Resuscitation: Experience of a Large Oncology Center.

PURPOSE: The objective of this study is to describe characteristics and short- and long-term outcomes of patients with hematologic malignancies who received cardiopulmonary resuscitation (CPR). METHODS: A retrospective review was conducted of all Code Blues at a large comprehensive cancer center. Demographic, clinical, and outcome variables were analyzed for patients with a hematologic malignancy who underwent CPR. RESULTS: Of 258 patients, 60.1% had leukemia. Outcomes included return of spontaneous circulation (70.2%), hospital survival (12%), and 90-day, 6-month, and 1-year survival rates of 9.8%, 8.2%, and 5.9%, respectively. Factors associated with hospital mortality included establishing a do not resuscitate order after CPR (p < .0001), location of CPR (p = .0004), cause of arrest (p = .0019), requiring vasopressors (p = .0130), mechanical ventilation (p = .0423), and acute renal failure post CPR (p = .0006). Although no difference in hospital survival between leukemia and non-leukemia patients was found, more non-leukemia patients were alive at 90 days (p = .0099), 6 months (p = .0023), and 1 year (p = .0119). CONCLUSIONS: Factors including organ dysfunction, location of CPR, and cause of arrest are associated with hospital mortality post CPR. However, immediate survival post CPR does not seem to be affected by a diagnosis of leukemia. These data should assist health care providers with discussions regarding advance care planning and goals of care after cardiac arrest.

Preliminary evaluation of an educational model for promoting positive team attitudes and functioning among pain medicine fellows.

OBJECTIVE: In response to the Accreditation Council for Graduate Medical Education's (ACGME) new pain medicine fellowship requirement, which emphasizes multidisciplinary training strategies aimed at providing improved clinical care for pain patients, we developed a multidisciplinary team training education model for trainees in our institution's Fellowship Program in Pain Medicine. Although the biopsychosocial model guides the delivery of care by multidisciplinary pain teams, there is a gap on how to improve team attitudes and functioning within an already extensive pain medicine curriculum. The current study aimed to fill that gap by developing and incorporating an educational model that focuses on interpersonal relationships among team members and strategies for improving team performance over time. DESIGN, SETTING, PARTICIPANTS, INTERVENTION, AND OUTCOME MEASURES: Here, we provide a brief overview of our institution's pain medicine fellowship training program highlighting how we have included a team training component into lectures, interdisciplinary case conferences, and journal club articles that focus on topics in the ACGME pain medicine curriculum. We present data from a team attitude and functioning assessment battery administered to 11 pain medicine fellows at the outset and end of their fellowship. RESULTS AND CONCLUSIONS: Mean assessment scores increased from the beginning of the fellowship to the end of the fellowship on interdisciplinary pain team knowledge, current team skills, and attitude toward health care teams. The current study demonstrated effective ways for assessing team attitudes and functioning and including this educational component into a 1-year pain medicine curriculum. Based on our results, we will continue to teach and model effective teamwork in an effort to enhance our trainees' attitudes toward working on an interdisciplinary pain team.

Factors influencing implementation of team-based learning in health sciences education.

BACKGROUND: Limited studies have looked at factors that lead to successful implementation of team-based learning (TBL). The purpose of this study was to identify contextual factors associated with implementation of TBL with a larger pool of individuals. METHOD: The authors administered a questionnaire who had implemented TBL via the Web to participants who attended TBL workshops; 297 of 594 responded. We used the constant comparative method to analyze responses. RESULTS: Analysis revealed five factors important to successful implementation of TBL: buy-in, expertise, resources, time, and course characteristics, with 60%, 38%, 37%, 36%, and 16% of respondents identifying each factor, respectively. CONCLUSIONS: When health science faculty and administrators implement TBL or other educational innovations, they must have buy-in, ensure adequate time and resources, develop needed expertise, and determine best fit within a course. Although these results are specific to TBL, they are consistent with models of dissemination and have implications for other educational innovations.

Fatal hemorrhagic pneumonia: Don't forget Stenotrophomonas maltophilia.

We present a case of fatal hemorrhagic pneumonia secondary to Stenotrophomonas maltophilia in a patient with acute myeloid leukemia. S. maltophilia is commonly a non-virulent pathogen. However, in the immunocompromised, it is generally associated with bacteremia after central venous catheter placement or pneumonia. Hemorrhagic pneumonia is a rare presentation of this bacteria, with only 31 cases reported in the literature, and has 100% mortality within 72 hours. Rapid recognition and early suspicion should be key in the treatment of these patients.

Team learning in medical education: initial experiences at ten institutions.

PURPOSE: In the midst of curricular reforms that frequently call for reducing lectures and increasing small-group teaching, there is a crisis in faculty time for teaching. This paper describes the initial experiences of ten institutions with team learning (TL), a teaching method which fosters small-group learning in a large-class setting. METHOD: After initial pilot studies at one institution, nine additional institutions implemented TL in one or more courses. RESULTS: Within 18 months, TL has been used in 40 courses (from.5% to 100% of the time) and all ten institutions will increase its use next year. CONCLUSIONS: We surmise that this relatively rapid spread of TL into the medical curriculum is due to the sound pedagogy and efficiency of TL as well as the modest financial resources and support we have provided to partner institutions.

Enhanced external counterpulsation in patients with heart failure: a multicenter feasibility study.

To assess the feasibility of using enhanced external counterpulsation to treat patients with heart failure, 26 patients with stable heart failure (New York Heart Association classes II-III), with a left ventricular ejection fraction at or below 35%, and without fluid overload, were treated with enhanced external counterpulsation (1 hour daily, 5 days a week, to a total of 35 hours). Patients were followed for 6 months after completing the course of enhanced external counterpulsation. The primary parameter was safety as reflected by adverse events or by changes in laboratory parameters. Secondary end points included changes in exercise capacity and quality of life. There were no clinically significant problems associated with the administration of enhanced external counterpulsation. Significant improvements were seen in exercise capacity (peak oxygen uptake and exercise duration), and in quality of life assessments, at 1 week and 6 months after the course of enhanced external counterpulsation. This study suggests that enhanced external counterpulsation is safe and well tolerated in patients with stable heart failure, and that a randomized, controlled study of enhanced external counterpulsation in these patients is warranted.

Validation of an observation instrument for measuring student engagement in health professions settings.

Documenting student engagement has received increased emphasis in medical schools, as teaching strategies are changing to include more student-to-student interactions. The purpose of this study was to develop and evaluate a measure of student engagement completed by independent observers that would not interfere with student learning time. Data from 3,182 observations completed by nine observers in 32 educational classroom settings with 23 different instructors were used to evaluate the interobserver reliability and gather validity evidence for our observational instrument, named the STROBE. Results indicated that interobserver agreement was good to excellent when observations were conducted simultaneously on randomly selected students in the same classroom (84% average agreement and 0.79 average kappa coefficient) and when observations were conducted on different randomly selected students (79% average agreement). Results also provided strong evidence for validity. Overall, findings indicate that the STROBE demonstrates promise for educational research and evaluation by documenting student engagement in medical education settings.

Team-based learning at ten medical schools: two years later.

PURPOSE: In 2003, we described initial use of team-based learning (TBL) at 10 medical schools. The purpose of the present study was to review progress and understand factors affecting the use of TBL at these schools during the subsequent 2 years. METHODS: Representatives from 10 schools evaluated in 2003 were again evaluated in 2005. They were interviewed by members of the Team Based Learning Collaborative using a semistructured interview process. Data were analysed by 2 researchers using the constant comparative method and were triangulated through sharing results with other interviewers at regular intervals to verify conclusions and form consensus. RESULTS: TBL continued to be used in all but 1 school. At the 9 remaining schools, TBL was added to 18 courses, continued to be used in 19 and was discontinued in 13 courses. At some schools, it was discontinued in single courses in lieu of new, longitudinal integration courses in which TBL was a main instructional strategy. Faculty, student, course and institutional factors were associated with changes in TBL use. CONCLUSION: Faculty, administration/curriculum, students and characteristics of specific courses influence ongoing utilisation of TBL. Those who desire to implement TBL would do well to take these factors into account as they plan implementation efforts at their schools.

A comparison of in-class learner engagement across lecture, problem-based learning, and team learning using the STROBE classroom observation tool.

BACKGROUND: Having recently introduced team learning into the preclinical medical curriculum, evidence of the relative impact of this instructional method on in-class learner engagement was sought. PURPOSE: To compare patterns of engagement behaviors among learners in class sessions across 3 distinct instructional methods: lecture, problem-based learning (PBL), and team learning. METHODS: Trained observers used the STROBE classroom observation tool to measure learner engagement in 7 lecture, 4 PBL, and 3 team learning classrooms over a 12-month period. Proportions of different types of engagement behaviors were compared using chi-square. RESULTS: In PBL and team learning, the amount of learner-to-learner engagement was similar and much greater than in lecture, where most engagement was of the learner-to-instructor and self-engagement types. Also, learner-to-instructor engagement appeared greater in team learning than in PBL. CONCLUSIONS: Observed engagement behaviors confirm the potential of team learning to foster engagement similar to PBL, but with greater faculty input.

Plasma levels of TNF-alpha and IL-6 are inversely related to cytochrome P450-dependent drug metabolism in patients with congestive heart failure.

BACKGROUND: Cytochrome P450 (CYP) enzymes are important mediators of drug metabolism, and activity of these enzymes is a major determinant of the duration and intensity of drug effect. Circulating plasma concentrations of pro-inflammatory cytokines (e.g., tumor necrosis factor [TNF]-alpha and interleukin [IL]-6) are elevated in patients with heart failure and these cytokines have been shown to down-regulate CYP enzyme activity. The purpose of this study was to evaluate the relationship between plasma cytokine concentrations and CYP enzyme activities in patients with heart failure. METHODS AND RESULTS: Sixteen patients with congestive heart failure (New York Heart Association classes II-IV) received a metabolic probe cocktail consisting of caffeine, mephenytoin, dextromethorphan, and chlorzoxazone to assess the activities of the CYP enzymes 1A2, 2C19, 2D6, and 2E1. Blood and urine samples were collected for drug and metabolite determinations by high-performance liquid chromatography (HPLC); cytokine concentrations were measured by enzyme-linked immunosorbent assay (ELISA). We found a striking inverse relationship between both TNF-alpha and IL-6 plasma concentrations and the activity of CYP2C19; metabolism of caffeine (CYP1A2) also had a negative association with IL-6 plasma concentrations. CONCLUSIONS: Cytokine-mediated decreases in drug metabolism may contribute to observed variability in drug response and augment the risk of adverse drug effects in CHF patients.