Development of Electronic Chemotherapy Roadmaps for Pediatric Oncology Patients.

A chemotherapy roadmap is a summary of the chemotherapy plan for a pediatric oncology patient. Chemotherapy roadmaps exist as paper documents for most, if not all, pediatric oncology programs. Paper chemotherapy roadmaps are associated with risks that can negatively affect the safety of the chemotherapy process. This institution explored the feasibility of converting paper chemotherapy roadmaps into an electronic form. The pediatric information systems team developed an innovative computer application that can generate electronic chemotherapy roadmaps, and the pediatric oncology program established a novel workflow that can operationalize them. Electronic chemotherapy roadmaps have been produced for 36 treatment protocols, and 369 electronic chemotherapy roadmaps have been used for 352 pediatric oncology patients. They have functioned as designed and have not had any unintended effects. In the 5 years after their implementation, the average proportion of patient safety events involving paper or electronic chemotherapy roadmaps decreased by 78.7%. This report is the first to demonstrate the feasibility of creating and implementing electronic chemotherapy roadmaps. Continued expansion of the current library will be necessary to formally test the hypothesis that electronic chemotherapy roadmaps can decrease the risks associated with their paper counterparts and increase the safety of the chemotherapy process.

Nutritional screening and early intervention in children, adolescents, and young adults with cancer.

Children and adolescents with cancer who receive chemotherapy and/or radiation treatments are at risk for malnutrition due to side effects such as nausea, vomiting, anorexia, and mouth sores. Malnutrition during treatment for childhood cancer increases the risk of infection, decreases tolerance to treatment, and even affects overall survival. A retrospective analysis of 79 children, adolescents, and young adults was conducted to evaluate nutritional screening at baseline and for the first 6 months of treatment. Interventions were also documented. Forty-nine participants had a positive screen for risk of malnutrition. In the patients with a positive screen, 78% had intervention within 24 hours of the identified risk for malnutrition. Thirty-five patients had a nutritional referral, which resulted in a full nutritional assessment and plan. Key independent variables were analyzed to determine if they were associated with an increased risk of malnutrition. In addition, individual risk factors were analyzed to determine their association with malnutrition. Future studies should find whether early intervention is effective in reversing the risk of malnutrition during treatment for childhood cancer.

Delayed vomiting in children with cancer after receiving moderately high or highly emetogenic chemotherapy.

Delayed vomiting is a potentially significant adverse effect of chemotherapy used to treat childhood cancer, but little is known about the experience of delayed vomiting in children and adolescents. An exploratory study was conducted to determine the pattern of delayed vomiting in children and adolescents with cancer after highly emetic chemotherapy and to identify possible risk factors. In a sample of 82 children and adolescents who completed 117 cycles of highly emetic chemotherapy, the overall prevalence of delayed vomiting was 32%. The frequency of delayed vomiting was highest on delayed day 2, with 21% of participants experiencing vomiting. By delayed day 7, only 9% of participants still reported vomiting. The severity of vomiting was moderate to severe in 11% to 12% of subjects. Age and gender had no significant effect on delayed vomiting. The emetic potential of the agent, incomplete protection from acute vomiting, and treatment regimens that lasted 6 or more days significantly affected delayed vomiting. In addition, a history of motion sickness, lack of acute control, and 6 or more days of chemotherapy were predictive of delayed vomiting.

Glycogenin protein and mRNA expression in response to changing glycogen concentration in exercise and recovery.

Glycogenin (GN-1) is essential for the formation of a glycogen granule; however, rarely has it been studied when glycogen concentration changes in exercise and recovery. It is unclear whether GN-1 is degraded or is liberated and exists as apoprotein (apo)-GN-1 (unglycosylated). To examine this, we measured GN-1 protein and mRNA level at rest, at exhaustion (EXH), and during 5 h of recovery in which the rate of glycogen restoration was influenced by carbohydrate (CHO) provision. Ten males cycled (65% VO2 max) to volitional EXH (117.8 +/- 4.2 min) on two separate occasions. Subjects were administered carbohydrate (CHO; 1 g.kg(-1).h(-1) Gatorlode) or water [placebo (PL)] during 5 h of recovery. Muscle biopsies were taken at rest, at EXH, and following 30, 60, 120, and 300 min of recovery. At EXH, total glycogen concentration was reduced (P < 0.05). However, GN-1 protein and mRNA content did not change. By 5 h of recovery, glycogen was resynthesized to approximately 60% of rest in the CHO trial and remained unchanged in the PL trial. GN-1 protein and mRNA level did not increase during recovery in either trial. We observed modest amounts of apo-GN-1 at EXH, suggesting complete degradation of some granules. These data suggest that GN-1 is conserved, possibly as very small, or nascent, granules when glycogen concentration is low. This would provide the ability to rapidly restore glycogen during early recovery.

Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.

BACKGROUND: The administration of chemotherapy to hospitalized children with cancer is a complex and high-risk process. A team divided the process into three areas--prescribing, dispensing, and administration--and used Failure Mode and Effects Analysis (FMEA) to identify the elements of risk and implement appropriate strategies. For each area, potential failures within subprocesses were assigned risk priority numbers (RPNs), reflecting their frequency, severity, and detectability. STRATEGIES FOR RISK REDUCTION: The team made prescribing and administration, the areas with the highest RPNs, the focus of most of its strategies, which were introduced and completed in 2002. POSTIMPLEMENTATION RESULTS: The potential prescribing error rate decreased from 23% to 14%; use of preprinted standard order sets increased from 22% to 45% in 2003 (one year after the FMEA was conducted) and 76% in 2005. Actual dispensing errors decreased from 3 to 1, and the actual administration errors from 4 to 3. FINAL REFLECTIONS: Computerized order entry systems would only affect prescribing, dispensing, and administering, which would still be done manually, resulting in potential for failure. The FMEA project will be an ongoing part of providing safe chemotherapy treatments.

Increases in glycogenin and glycogenin mRNA accompany glycogen resynthesis in human skeletal muscle.

Glycogenin is the self-glycosylating protein primer that initiates glycogen granule formation. To examine the role of this protein during glycogen resynthesis, eight male subjects exercised to exhaustion on a cycle ergometer at 75% Vo2 max followed by five 30-s sprints at maximal capacity to further deplete glycogen stores. During recovery, carbohydrate (75 g/h) was supplied to promote rapid glycogen repletion, and muscle biopsies were obtained from the vastus lateralis at 0, 30, 120, and 300 min postexercise. At time 0, no free (deglycosylated) glycogenin was detected in muscle, indicating that all glycogenin was complexed to carbohydrate. Glycogenin activity, a measure of the glycosylating ability of the protein, increased at 30 min and remained elevated for the remainder of the study. Quantitative RT-PCR showed elevated glycogenin mRNA at 120 min followed by increases in protein levels at 300 min. Glycogenin specific activity (glycogenin activity/relative protein content) was also elevated at 120 min. Proglycogen increased at all time points, with the highest rate of resynthesis occurring between 0 and 30 min. In comparison, macroglycogen levels did not significantly increase until 300 min postexercise. Together, these results show that, during recovery from prolonged exhaustive exercise, glycogenin mRNA and protein content and activity increase in muscle. This may facilitate rapid glycogen resynthesis by providing the glycogenin backbone of proglycogen, the major component of glycogen synthesized in early recovery.

Glycogenin activity and mRNA expression in response to volitional exhaustion in human skeletal muscle.

Glycogenolysis results in the selective catabolism of individual glycogen granules by glycogen phosphorylase. However, once the carbohydrate portion of the granule is metabolized, the fate of glycogenin, the protein primer of granule formation, is not known. To examine this, male subjects (n = 6) exercised to volitional exhaustion (Exh) on a cycle ergometer at 75% maximal O2 uptake. Muscle biopsies were obtained at rest, 30 min, and Exh (99 +/- 10 min). At rest, total glycogen concentration was 497 +/- 41 and declined to 378 +/- 51 mmol glucosyl units/kg dry wt following 30 min of exercise (P < 0.05). There were no significant changes in proglycogen, macroglycogen, glycogenin activity, or mRNA in this period (P > or = 0.05). Exh resulted in decreases in total glycogen, proglycogen, and macroglycogen as well as glycogenin activity (P < 0.05). These decrements were associated with a 1.9 +/- 0.4-fold increase in glycogenin mRNA over resting values (P < 0.05). Glycogenolysis in the initial exercise period (0-30 min) was not adequate to induce changes in glycogenin; however, later in exercise when concentration and granule number decreased further, decrements in glycogenin activity and increases in glycogenin mRNA were demonstrated. Results show that glycogenin becomes inactivated with glycogen catabolism and that this event coincides with an increase in glycogenin gene expression as exercise and glycogenolysis progress.