Impact of institutional interventions on the rate of paclitaxel hypersensitivity reactions.

PURPOSE: Paclitaxel is associated with hypersensitivity reactions (HSRs). Intravenous premedication regimens have been devised to decrease the incidence and severity of HSRs. At our institution oral histamine 1 receptor antagonists (H1RA) and histamine 2 receptor antagonists (H2RA) were adopted as standard. Standardizations were implemented for consistent premedication use in all disease states. The purpose of this retrospective study was to compare the incidence and severity of HSRs before and after standardization. METHODS: Patients who received paclitaxel from 20 April 2018 to 8 December 2020 having an HSR were included in analysis. An infusion was flagged for review if a rescue medication was administered after the start of the paclitaxel infusion. The incidences of all HSR prior to and post-standardization were compared. A subgroup analysis of patients receiving paclitaxel for the first and second time was performed. RESULTS: There were 3499infusions in the pre-standardization group and 1159infusions in the post-standardization group. After review, 100 HSRs pre-standardization and 38 HSRs post-standardization were confirmed reactions. The rate of overall HSRs was 2.9% in the pre-standardization group and 3.3% in the post-standardization group (p = 0.48). HSRs, during the first and second doses of paclitaxel, occurred in 10.2% of the pre-standardization and 8.5% of the post-standardization group (p = 0.55). CONCLUSIONS: This retrospective interventional study demonstrated that same-day intravenous dexamethasone, oral H1RA, and oral H2RA are safe premedication regimens for paclitaxel. No change in the severity of reactions was seen. Overall, better adherence to premedication administration was seen post-standardization.

Central Line Patency: Management With Normal Saline Flushes for Adult Patients With Cancer.

BACKGROUND: Central venous catheter (CVC) maintenance is critical in administering chemotherapy, transfusions, and high-frequency laboratory draws. Although normal saline (NS) flushes have been associated with similar incidences of irreversible port occlusions as heparin among adult patients with cancer and ports, additional research is needed regarding NS efficacy in other central line maintenance within large populations with cancer. OBJECTIVES: The aim of this study was to analyze changes in reported CVC line patency via tissue plasminogen activator (tPA) administration rates in ports and other central lines because of an institutional switch from heparin to NS as preferred flushes in adult ambulatory patients with cancer. METHODS: Retrospective data were collected from patients with ports (3,706 prepolicy, 3,402 postpolicy) and nonport CVCs (816 prepolicy, 694 postpolicy). FINDINGS: Patients with nonport CVCs experienced similar tPA usage pre- versus postpolicy, versus an increased rate of tPA usage for ports. This policy resulted in institutional savings of $28,695.92. NS flushes are as effective as heparin for maintaining patency in ports and other CVCs for adult outpatients with cancer and address safety concerns with heparin-associated complications.

Unhealthy Lifestyle and Gut Dysbiosis: A Better Understanding of the Effects of Poor Diet and Nicotine on the Intestinal Microbiome.

The study of the intestinal or gut microbiome is a newer field that is rapidly gaining attention. Bidirectional communication between gut microbes and the host can impact numerous biological systems regulating immunity and metabolism to either promote or negatively impact the host's health. Habitual routines, dietary choices, socioeconomic status, education, host genetics, medical care and environmental factors can all contribute to the composition of an individual's microbiome. A key environmental factor that may cause negative outcomes is the consumption of nicotine products. The effects of nicotine on the host can be exacerbated by poor dietary choices and together can impact the composition of the gut microbiota to promote the development of metabolic disease including non-alcoholic fatty liver disease. This review explores the contribution of nicotine, poor dietary choices and other unhealthy lifestyle factors to gut dysbiosis.

The Zipperator! A Novel Model to Simulate Penile Zipper Entrapment.

Audience: The Zipperator training model is designed for emergency medicine resident physicians and physicians. Introduction: Zipper entrapment injuries are an uncommon cause of penile injury in the emergency department, representing an incidence of less than 0.5% of pediatric emergency department visits.1 However, they are one of the most common causes of genital injuries in young boys.1,2 Various methods proposed for releasing the entrapped tissue range from the use of mineral oil as lubrication to techniques to release the zipper mechanism or, in extreme cases, surgical procedures.3-6 A well-designed simulated task trainer would allow learners to practice these methods in a controlled environment conducive to learning 7,8. Given the low frequency of the chief complaint and with a wide variety of release techniques available, the purpose of this study was to build a simulation model that could improve learner confidence in troubleshooting this rarely performed procedure. Although past studies have designed similar task trainers, this novel model was built using a low-cost device ("Operation") to provide real-time alarm noises that reasonably simulate distress and procedural anxiety for both the patient and provider. Although pain and anxiety are separate outcomes from zipper entrapment release, including a component of these emotions may mimic the same emotional states that patients, their parental unit, and perhaps their provider may experience regarding this chief complaint given its rarity, anatomic vulnerability, and the overall sensitivity of the complaint's nature. Educational Objectives: After training on the Zipperator, learners will be able to:Demonstrate at least two techniques for zipper release and describe how methods would extrapolate to a real patient.Verbalize increased comfort with the diagnosis of zipper entrapment.Present a plan of care for this low-volume, high-anxiety presentation. Educational Methods: As part of a voluntary Emergency Medicine curriculum at two different sites, we constructed an inexpensive model for penile zipper entrapment using a household gameboard, "Operation," and materials that are easily obtainable and assembled in any emergency department. "Operation" was selected for its ability to produce alarm noises in response to excessive movement, which would reasonably simulate distress and procedural anxiety that may be experienced by both the patient and provider. This task trainer was used to teach medical students and post graduate year (PGY) 1-4 resident learners. A brief hypothetical situation was presented to learners, highlighting patient and paternal unit anxiety. Following this, learners were given a survey and asked to complete pre-model training questions immediately prior to using the simulated model. Learners were then given the opportunity for hands-on skills-based practice. Postmodel training questions were made available in the same survey immediately following the exercise. Research Methods: This exercise was offered at two sites over a two-year period. Sixty learners participated in the exercise. Participation was voluntary, was not graded nor shared with the residency director, and all feedback was formative in nature. Selected faculty and research assistants provided asynchronous opportunities for learners to practice on the model. Before the exercise, the faculty or research assistant on site presented a brief hypothetical situation to simulate patient and paternal unit anxiety that could be expected in this chief complaint. Each learner was then allowed to select a variety of tools and methods to practice zipper entrapment release. Learners were asked to begin a survey prior to training on the model, and then complete the survey immediately after training on the model to evaluate its educational value. The survey created for this study consisted of a structured questionnaire that contained close-ended questions. Measures evaluated include experience with prior zipper entrapments, comfort with zipper entrapments before and after training on the simulated model, and user experience. Results: Before the exercise, 68.3% of learners described their comfort with managing future zipper entrapments as very uncomfortable or totally uncomfortable. Although only 8.3% of learners had treated the zipper entrapment complaint prior to the exercise, 100% of those who had experienced treating the complaint felt that the simulated model was at least somewhat reflective of their experience with a real patient. 71.7% of the learners found the experience enjoyable, although 20% found the experience totally unenjoyable, of note, for unclear reasons and with unclear significance or etiology. After the exercise, 71.7% of learners indicated they felt comfortable to very comfortable regarding future cases of zipper entrapment. Discussion: Through the use of a well-known household board game and supplies commonly found in the emergency department, we created a simulated model that could be easily replicated. This simple model provided practice of the hand motions necessary for zipper entrapment release, as well as familiarity with the mental and physical approaches to dislodging the entrapment. The resident physicians who had had a prior zipper entrapment patient reported the model was somewhat similar to actual patient encounters. Overall, this model was well-received by the learners, with most expressing it was enjoyable and feeling it increased their confidence for treating this chief complaint. Some learners had noted the experience was totally unenjoyable. This measure may not be an appropriate endpoint, however, and incongruencies may be addressed by implementing prizes or friendly competition for enjoyment. Another limitation of this study is the leap taken between movement and patient comfort. While possible that learners can manipulate the model to reduce movement of the needle without meaningful reduction in zipper movement, observation by the instructor was sufficient to ensure this finding was not observed in our learner population. We therefore submit this cheap, simple model as a potential method to teach approaches to teaching a low frequency, high anxiety chief complaint. Topics: Penile entrapment model, penile entrapment release, Emergency Medicine, Urology, Clinical/Procedural Skills Training.

Drug Diversion: Best Practices and Support for a Staff Assessment Process.

The characteristics of opioid prescribing and administration in cancer centers include large quantities and less restrictive regulatory mandates governing cancer-related pain, which may increase the risk of drug diversion by staff members. The purpose of this article is to provide a framework for creating respectful investigative processes for staff suspected of drug diversion. Organizations, including cancer centers, need to engage in careful oversight of potential drug diversions while simultaneously promoting a psychologically safe work environment for individuals to successfully seek help.