A High-reliability Organization Mindset.

In 2020, the US Department of Veterans Affairs Connecticut Healthcare System began its journey to becoming a high-reliability organization as part of Veterans Affairs efforts to become an enterprise-wide high-reliability organization through the Veterans Health Administration. The initiative was launched to create safe enterprise-wide health care systems and environments with robust continuous process improvements as a method for providing patients with safer and higher quality care. In this article, the authors describe a continuous process improvement initiative aimed at implementing system-wide initiatives along the journey to becoming a high-reliability organization. The initiatives are described from the perspectives of individuals representing staff from the frontline to executive leadership. The authors believe that the processes, strategies, and example initiatives described can be readily adopted and implemented in other health care organizations along the journey to high reliability.

Disseminated visceral Kaposi´s sarcoma in a pediatric bilateral lung transplant recipient.

Cancer is a major adverse outcome of solid organ transplantation, and risks are especially high for malignancies caused by viral infections. HHV-8 is the etiologic agent of Kaposi´s sarcoma (KS). We report a case of visceral KS occurring in a 15-year-old patient after lung transplantation. The evolution was dramatically fast and interestingly, KS lesions were diffusely observed, but not in the skin. The autopsy showed the presence of numerous tumoral lesions in many organs. Microscopically, they all had very similar features, regardless of the organ affected. KS presented without cutaneous involvement. The girl was not tested for HHV-8 prior to transplantation as it was not part of our protocol. The donor was negative. The aim of the report is to alert other teams, especially those working in pediatrics, about this rare but potential complication in the setting of solid organ transplantation.

Diversity of human herpesvirus 8 genotypes in patients with AIDS and non-AIDS associated Kaposi's sarcoma, Castleman's disease and primary effusion lymphoma in Argentina.

HHV-8 genotypes are distributed heterogeneously worldwide. The variable K1 gene and the conserved ORF26E region serve to genotype. The aim of the study was to characterize HHV-8 isolates from patients with AIDS, classical, and iatrogenic KS, primary effusion lymphoma and Castleman's disease and one organ donor from Argentina by analysis of ORFK1 and ORF26E regions. DNA was extracted from fresh or paraffin embedded biopsies, blood, and saliva samples and submitted to HHV-8 PCR. Phylogenetic analyses of ORFK1 showed that subtypes C (C1, C2, and C3), B1 and A (A1, A2, and A3) were present in 70.8%, 16.7%, and 12.5% of cases, respectively. Analyses of ORF26E fragment revealed that most strains (45.8%) were subtype A/C while the remaining fall into K, J, B2, R, and D subtypes. Linkage between ORFK1-ORF26E subtypes corresponded to reported relationships, except for one strain that clustered with B1 (K1 African) and D (ORF26E Asian-Pacific) subtypes. This research reveals predominance of subtype C, a broad spectrum of HHV-8 genotypes and reports the first isolation of the African B genotype in Argentina.

[Human herpesvirus 8 related Kaposi's sarcoma in a pediatric liver transplant recipient: case report]. / Sarcoma de Kaposi por virus del herpes humano de tipo 8 en un receptor de trasplante hepático pediátrico: Caso clínico.

Patients under immunosuppressive treatment are at risk of developing malignant tumors. Primary infection or reactivation of human herpesvirus 8 (HHV-8) may predispose to Kaposi's sarcoma (KS) after solid organ transplantation. KS in pediatric liver transplant recipients has low incidence and poor prognosis. We report the clinical presentation of a KS in lymph node following HHV-8 infection in a pediatric patient presenting four months after liver transplantation. He had a good outcome with suspension of tacrolimus and conversion to sirolimus one month after diagnosis. To our knowledge, this is the frst KS reported case in our country after liver transplant in a pediatric recipient and we believe that this entity should be taken into consideration in the differential diagnosis of post-transplant complications.

Sarcoma de Kaposi por virus del herpes humano de tipo 8 en un receptor de trasplante hepático pediátrico: Caso clínico / Human herpesvirus 8 related Kaposi's sarcoma in a pediatric liver transplant recipient: Case report

Los pacientes que reciben tratamiento inmunosupresor están en riesgo de desarrollar tumores malignos. La infección primaria o reactivación del virus del herpes humano de tipo 8 (HHV-8) puede predisponer al sarcoma de Kaposi después del trasplante de un órgano sólido. En los receptores de trasplantes pediátricos, este sarcoma tiene baja incidencia y mal pronóstico. Se informa la presentación clínica de un sarcoma de Kaposi en un ganglio linfático luego de una infección por HHV-8 en un niño a los 4 meses del trasplante hepático. El paciente tuvo buena evolución con suspensión del tacrolimus y conversión a sirolimus un mes después del diagnóstico. En nuestro conocimiento, este es el primer caso de sarcoma de Kaposi en un receptor pediátrico de trasplante hepático informado en nuestro país y creemos que esta entidad debería considerarse como diagnóstico diferencial en las complicaciones postrasplante.

Patients under immunosuppressive treatment are at risk of developing malignant tumors. Primary infection or reactivation of human herpesvirus 8 (HHV-8) may predispose to Kaposi's sarcoma (KS) after solid organ transplantation. KS in pediatric liver transplant recipients has low incidence and poor prognosis. We report the clinical presentation of a KS in lymph node following HHV-8 infection in a pediatric patient presenting four months after liver transplantation. He had a good outcome with suspension of tacrolimus and conversion to sirolimus one month after diagnosis. To our knowledge, this is the frst KS reported case in our country after liver transplant in a pediatric recipient and we believe that this entity should be taken into consideration in the differential diagnosis of post-transplant complications.

Sarcoma de Kaposi por virus del herpes humano de tipo 8 en un receptor de trasplante hepático pediátrico: Caso clínico / Human herpesvirus 8 related Kaposis sarcoma in a pediatric liver transplant recipient: Case report

Los pacientes que reciben tratamiento inmunosupresor están en riesgo de desarrollar tumores malignos. La infección primaria o reactivación del virus del herpes humano de tipo 8 (HHV-8) puede predisponer al sarcoma de Kaposi después del trasplante de un órgano sólido. En los receptores de trasplantes pediátricos, este sarcoma tiene baja incidencia y mal pronóstico. Se informa la presentación clínica de un sarcoma de Kaposi en un ganglio linfático luego de una infección por HHV-8 en un niño a los 4 meses del trasplante hepático. El paciente tuvo buena evolución con suspensión del tacrolimus y conversión a sirolimus un mes después del diagnóstico. En nuestro conocimiento, este es el primer caso de sarcoma de Kaposi en un receptor pediátrico de trasplante hepático informado en nuestro país y creemos que esta entidad debería considerarse como diagnóstico diferencial en las complicaciones postrasplante.(AU)

Patients under immunosuppressive treatment are at risk of developing malignant tumors. Primary infection or reactivation of human herpesvirus 8 (HHV-8) may predispose to Kaposis sarcoma (KS) after solid organ transplantation. KS in pediatric liver transplant recipients has low incidence and poor prognosis. We report the clinical presentation of a KS in lymph node following HHV-8 infection in a pediatric patient presenting four months after liver transplantation. He had a good outcome with suspension of tacrolimus and conversion to sirolimus one month after diagnosis. To our knowledge, this is the frst KS reported case in our country after liver transplant in a pediatric recipient and we believe that this entity should be taken into consideration in the differential diagnosis of post-transplant complications.(AU)

Sarcoma de Kaposi por virus del herpes humano de tipo 8 en un receptor de trasplante hepático pediátrico: Caso clínico. / [Human herpesvirus 8 related Kaposis sarcoma in a pediatric liver transplant recipient: case report].

Patients under immunosuppressive treatment are at risk of developing malignant tumors. Primary infection or reactivation of human herpesvirus 8 (HHV-8) may predispose to Kaposis sarcoma (KS) after solid organ transplantation. KS in pediatric liver transplant recipients has low incidence and poor prognosis. We report the clinical presentation of a KS in lymph node following HHV-8 infection in a pediatric patient presenting four months after liver transplantation. He had a good outcome with suspension of tacrolimus and conversion to sirolimus one month after diagnosis. To our knowledge, this is the frst KS reported case in our country after liver transplant in a pediatric recipient and we believe that this entity should be taken into consideration in the differential diagnosis of post-transplant complications.

Correlations between synthetic peptide-based enzyme immunoassays and immunofluorescence assay for detection of human herpesvirus 8 antibodies in different Argentine populations.

Human herpesvirus 8 (HHV-8) antibody tests vary in sensitivity and specificity, depending on the population tested and on the type of assay. In this study, we evaluated the sensitivity and specificity of two peptide enzyme immunoassays using a multiple antigenic peptide (PK8.1-MAP) or a chimeric peptide (PK8.1-orf65) as the antigens and determined the HHV-8 seroprevalence in different Argentine populations using an immunofluorescence assay (IFA) as reference. For analysis, when either or both of the peptide EIAs were positive, the specimen was considered positive (PEIA). We estimated the sensitivity and specificity of PEIA to be 97% using Kaposi's sarcoma (KS) patients and healthy individuals as positive and negative controls respectively. Then, we expanded the control groups to include IFA positive men who have sex with men (MSM) and IFA negative blood donors. The sensitivity decreased to 83% but specificity remained high at 98%. Concordance between PEIA and IFA was 77% for 1/40 IFA titers and increased to 90% for titers >or=1/160. Seroprevalences for HHV-8 performed in the HIV positive MSM were (IFA 73.1%; PEIA55.2%); heterosexuals (52.5%, 22.2%), which includes injecting drug users (IDU) (54.0%, 32.4%) and non-IDU (51.6%, 16.1%). The inclusion of non-KS HHV-8 IFA positive individuals to the positive controls may be a substantial improvement towards the realistic assessment of assay sensitivity. These peptide EIAs can be used for trends in populations with high probability of being HHV-8 infected and negative results should be confirmed by IFA. IFA test is still the most suitable test for populations with low probabilities of being infected.

A three-dimensional definition of nodal spaces on the basis of CT images showing enlarged nodes for pelvic radiotherapy.

PURPOSE: To demonstrate that margins of each pelvic chain may be derived by verifying the bony and soft tissue structures around abnormal nodes on computed tomography (CT) slices. METHODS AND MATERIALS: Twenty consecutive patients (16 males, 4 females; mean age, 66 years; range, 43-80 years) with radiologic diagnosis of nodal involvement by histologically proved cervix carcinoma (two), rectum carcinoma (three), prostate carcinoma (four), lymphoma (five), penis carcinoma (one), corpus uteri carcinoma (one), bladder carcinoma (two), cutis tumor (one), and soft-tissue sarcoma (one) were retrospectively reviewed. One hundred CT scans showing 85 enlarged pelvic nodes were reviewed by two radiation oncologists (M.P., S.B.), and two radiologists (C.P., G.A.). RESULTS: The more proximal structures to each enlarged node or group of nodes were thus recorded in a clockwise direction. CONCLUSION: According to their frequency and visibility, craniocaudal, anterior, lateral, posterior and medial margins of common iliac, external and internal iliac nodal chains, obturator and pudendal nodes, and deep and superficial inguinal nodes were derived from CT observations.

Clinical and anatomical guidelines in pelvic cancer contouring for radiotherapy treatment planning.

BACKGROUND AND PURPOSE: Many observations on potential inadequate coverage of tumour volume at risk in advanced cervical cancer (CC) when conventional radiation fields are used, have further substantiated by investigators using MRI, CT or lymphangiographic imaging. This work tries to obtain three dimensional margins by observing enlarged nodes in CT scans in order to improve pelvic nodal chains clinical target volumes (CTVs) drawing, and by looking for corroborative evidence in the literature for a better delineation of tumour CTV. METHOD: Eleven consecutive patients (seven males, four females, mean age 62 years, range 43-78) with CT diagnosis of nodal involvement caused by pathologically proved carcinoma of the cervix (n = 2), carcinoma of the rectum (n = 2), carcinoma of the prostate (n = 2), non-Hodgkin lymphoma (n = 2), Hodgkin lymphoma (n = 1), carcinoma of the penis (n = 1) and carcinoma of the corpus uteri (n = 1) were retrospectively reviewed. Sixty CT scans with 67 enlarged pelvic nodes were reviewed in order to record the more proximal structures (muscle, bone, vessels, cutis or subcutis and other organs) to each enlarged node or group of nodes according to the four surfaces (anterior, lateral, posterior and medial) in a clockwise direction. RESULTS: A summary of the observations of each nodal chain and the number of occurrences of every marginal structure on axial CT slices is presented. Finally, simple guidelines are proposed. CONCLUSIONS: Tumour CTV should be based on individual tumour anatomy-mainly for lateral beams as it results from sagittal T2 weighted MRI images. Boundaries of pelvic nodes CTVs can be derived from observations of enlarged lymph nodes in CT scans.

Seroprevalence of human herpesvirus-8 in blood donors from different geographical regions of Argentina, Brazil, and Chile.

Human herpesvirus-8 (HHV-8) causes Kaposi's sarcoma (KS) and lymphoproliferative disorders in both HIV-infected and uninfected patients. HHV-8 has a worldwide occurrence but infection rates vary according to a combination of geographic and behavioral risks. The main transmission route seems to be sexual, nevertheless, nasal secretions, saliva, blood, and organ graft have been proposed. HHV-8 was postulated as a new infectious agent for screening in blood donors. The aim of this study was to evaluate the prevalence of antibodies against HHV-8 antigens in blood donors of South America. Serum samples from 2,470 blood donors from Argentina, Brazil, and Chile corresponding to five geographic regions were studied by indirect immunofluorescence assay (IFA). Seroprevalence rate was 3.7% (92/2,470; 95% CI 2.9-4.5) in the entire blood donor population distributed as follows: Argentina, 4.0% (Buenos Aires city, 4.3%; Bahia Blanca, 2.4%; and Córdoba, 4.0%), Campinas (Brazil), 2.8%; and Santiago de Chile, 3.0%. There was no difference (P>0.05) between men and women or age related, except in Brazil where positive cases were 30-49-year-old males. The present study, which includes different geographical areas of multiple countries from South America, has not been done before. The results show similar prevalence rates among the studied zones corresponding to low-prevalence regions. South America is a large sub-continent with a wide spectrum of population and geographical characteristics, thus, more HHV-8 prevalence studies should be necessary to establish possible regional differences.