Quality improvement in tracheostomy care: A multidisciplinary approach to standardizing tracheostomy care to reduce complications.

PURPOSE: Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications. METHODS: This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters. RESULTS: Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04). CONCLUSIONS: An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.

Extended use of perioperative antibiotics in head and neck microvascular reconstruction.

PURPOSE: Many head and neck surgical procedures are considered clean-contaminated wounds and antibiotic prophylaxis is recommended. Despite prophylaxis, the incidence of surgical site infections remains significant - especially in the setting of free tissue transfer. The antibiotic course is often of a longer duration after free tissue transfer than the recommended 24hour post-operatively. Currently, there is no consensus on appropriate antibiotic regimen or duration at this time. This study investigates the outcomes of a 7-day perioperative antibiotic regimen after microvascular reconstruction of the head and neck at our institution. MATERIALS AND METHODS: A retrospective review was performed of 72 patients undergoing microvascular free tissue at our institution between 09/2011 and 03/2014. The antibiotic regimen, post-operative surgical (including surgical site infections) and medical complications were noted. Our rates of complications and adverse events were compared to all surgical patients, as well as all inpatients hospital-wide with use of the University Health System Consortium database. RESULTS: Seventy-two subjects met inclusion criteria for this study. The majority of subjects received cefazolin/metronidazole (69.4%). Subjects with beta-lactam allergy received clindamycin (12.5%). The remainder received an alternative regimen (18.1%). All received at least 7days of antibiotics. The rate of hospital acquired C. difficile diarrhea was 0.57% hospital-wide, 1.13% in Otolaryngology patients, and 1.4% in this study. There were no instances of a multi-drug resistant infection or any adverse reactions to the administration of antibiotics. When compared with other antibiotic regimens, clindamycin was associated with a significantly increased rate of either medical or surgical infections (OR 14.38, p=0.02) and longer hospital stay (average=18days, p<0.05). CONCLUSION: The use of a 7-day prophylactic antibiotic regimen is not associated with an increased risk of antibiotic-associated infections, multi-drug resistant infections, or antibiotic-associated complications. The use of clindamycin is associated with increased risk of medical and surgical infections post-operatively and should be avoided in the prophylactic perioperative phase after free tissue transfer of the head and neck.

Molecular signatures of maturing dendritic cells: implications for testing the quality of dendritic cell therapies.

BACKGROUND: Dendritic cells (DCs) are often produced by granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-4 (IL-4) stimulation of monocytes. To improve the effectiveness of DC adoptive immune cancer therapy, many different agents have been used to mature DCs. We analyzed the kinetics of DC maturation by lipopolysaccharide (LPS) and interferon-gamma (IFN-gamma) induction in order to characterize the usefulness of mature DCs (mDCs) for immune therapy and to identify biomarkers for assessing the quality of mDCs. METHODS: Peripheral blood mononuclear cells were collected from 6 healthy subjects by apheresis, monocytes were isolated by elutriation, and immature DCs (iDCs) were produced by 3 days of culture with GM-CSF and IL-4. The iDCs were sampled after 4, 8 and 24 hours in culture with LPS and IFN-gamma and were then assessed by flow cytometry, ELISA, and global gene and microRNA (miRNA) expression analysis. RESULTS: After 24 hours of LPS and IFN-gamma stimulation, DC surface expression of CD80, CD83, CD86, and HLA Class II antigens were up-regulated. Th1 attractant genes such as CXCL9, CXCL10, CXCL11 and CCL5 were up-regulated during maturation but not Treg attractants such as CCL22 and CXCL12. The expression of classical mDC biomarker genes CD83, CCR7, CCL5, CCL8, SOD2, MT2A, OASL, GBP1 and HES4 were up-regulated throughout maturation while MTIB, MTIE, MTIG, MTIH, GADD45A and LAMP3 were only up-regulated late in maturation. The expression of miR-155 was up-regulated 8-fold in mDCs. CONCLUSION: DCs, matured with LPS and IFN-gamma, were characterized by increased levels of Th1 attractants as opposed to Treg attractants and may be particularly effective for adoptive immune cancer therapy.

Plasma circulating tumor DNA as a potential tool for disease monitoring in head and neck cancer.

BACKGROUND: Recommendations for perioperative therapy in head and neck cancer are not explicit and recurrence occurs frequently. Circulating tumor DNA is an emerging cancer biomarker, but has not been extensively explored for detection of recurrence in head and neck cancer. METHODS: Patients diagnosed with head and neck squamous cell carcinoma were recruited into the study protocol. Tumors were sequenced to identify patient-specific mutations. Mutations were then identified in plasma circulating tumor DNA from pre-treatment blood samples and longitudinally during standard follow-up. Circulating tumor DNA status during follow-up was correlated to disease recurrence. RESULTS: Samples were taken from eight patients. Tumor mutations were verified in seven patients. Baseline circulating tumor DNA was positive in six patients. Recurrence occurred in four patients, two of whom had detectable circulating tumor DNA prior to recurrence. CONCLUSION: Circulating tumor DNA is a potential tool for disease and recurrence monitoring following curative therapy in head and neck cancer, allowing for better prognostication, and/or modification of treatment strategies.

Pitfalls in the use of epinephrine for anaphylaxis: patient and provider opportunities for improvement.

BACKGROUND: Epinephrine remains the mainstay of treatment for life-threatening allergic reactions. A number of challenges are encountered with epinephrine, resulting in underutilization and misutilization of epinephrine. The purpose of this study was to identify the scope of epinephrine pitfalls and opportunities for improvement in the management of allergy emergencies. METHODS: A PubMed search from 1990 to 2015 was performed to identify all cases and reports pertaining to the use and misuse of epinephrine for anaphylaxis. Studies were assessed for obstacles or complications related to proper administration of epinephrine for treatment of allergic reactions, and were divided into problems originating with patients compared to healthcare providers. RESULTS: There were 1840 publications related to epinephrine use, of which 61 reports met inclusion criteria for pitfalls in the use of epinephrine. The most common problems reported related to lack of autoinjector availability (22), inadequate education of patients or providers (9), uncertainty about when or how to administer epinephrine (9), concern for systemic effects (13), failure to administer (8), and accidental administration (2). Responsibility for errors was divided among patients (18), providers (39), or both (4). CONCLUSION: Epinephrine is a potent medication with lifesaving indications and is the standard of care for treatment of anaphylaxis. The delivery of epinephrine in both trained and untrained populations carries certain pitfalls and complications that can have serious consequences. Identification of the scope of the problem is an important step in improving education for both providers and patients who are tasked with use of epinephrine for allergy emergencies.

Oral allergy syndrome.

PURPOSE OF REVIEW: Oral allergy syndrome (OAS) is common in patients with allergic rhinoconjunctivitis. OAS may be less recognized in clinical practice leading to unclear diagnosis and treatment plans. Many aspects of OAS remain poorly understood, including a lack of a standard definition, limits in diagnostic tests, and complicated pathophysiology with a multitude of cross-reactivities. Understanding the range of mild-to-severe reactions will assist providers in developing the best approaches for diagnosis and management of patients with OAS. RECENT FINDINGS: A standardized definition of OAS does not exist in the current literature, which can make diagnosis and treatment of OAS difficult. Multiple studies have attempted to better define parameters for diagnosis and treatment; however, the complexity of the cross-reactivity between allergens makes this task difficult. Studies have investigated members in each of the protein families implicated in OAS, but largely without identification of broad candidate markers. Those candidate markers that have been established are typically too specific, which limits generalization. SUMMARY: This review will address current OAS definitions, pathophysiology, diagnosis, and available treatments. Current literature largely focuses on attempts to identify cross-reactivities and markers that may be useful in diagnosis and treatment of patients with OAS.

Degrees of dysplasia based on viral typing in patients with cidofovir use and recurrent respiratory papillomatosis.

OBJECTIVES/HYPOTHESIS: To evaluate the degree of dysplasia following cidofovir injections while documenting human papillomavirus (HPV) type in patients with recurrent respiratory papillomatosis (RRP). STUDY DESIGN: Retrospective chart review. METHODS: Demographic data, operative reports, and pathology results were reviewed from 25 patients with RRP who had had cidofovir injections. All patients included had adult onset RRP, no history of immunosuppression, well-controlled laryngopharyngeal reflux, and no current smoking history. Eight patients were excluded because they did not meet the inclusion criteria. RESULTS: Seventeen patients had adequate data for analysis and 40 subsites were identified with sufficient data for analysis. Patients negative for both low and high risk did not have progressive dysplasia at the conclusion of the study. Of the patients with positive viral typing, 70% had progressive disease at the conclusion of the study. No patients progressed to carcinoma or carcinoma in situ. The average pre- and post-treatment dysplasia scores were analyzed using a Student paired t test. There was no difference in mean dysplasia score, indicating that there was no increased risk of dysplasia following cidofovir treatment. CONCLUSIONS: To our knowledge, this is the first study looking at the degree of dysplasia while documenting HPV types in RRP. Our study suggests that HPV type appears to be relevant in the disease progression of RRP and that cidofovir does not increase the risk of dysplasia.