SARS-CoV-2 Testing for Asymptomatic Patients with Cancer Prior and during Treatment: A Single Centre Experience.

Patients with cancer are more vulnerable to severe COVID-19. As a result, routine SARS-CoV-2 testing of asymptomatic patients with cancer is recommended prior to treatment. However, there is limited evidence of its clinical usefulness. The objective of this study is to evaluate the value of routine testing of asymptomatic patients with cancer. Asymptomatic patients with cancer attending Odette Cancer Centre (Toronto, ON, Canada) were tested for SARS-CoV-2 prior to and during treatment cycles. Results were compared to positivity rates of SARS-CoV-2 locally and provincially. All 890 asymptomatic patients tested negative. Positivity rates in the province were 1.5%, in hospital were 1.0%, and among OCC's symptomatic cancer patients were 0% over the study period. Given our findings and the low SARS-CoV-2 community positivity rates, we recommend a dynamic testing model of asymptomatic patients that triggers testing during increasing community positivity rates of SARS-CoV-2.

Enhancing Nurses' Oral Therapy Practice in 4 Latin American Countries: A Collaborative and Participatory Approach.

BACKGROUND: Oral therapy (OT) use for cancer is increasing globally. Yet, nurses in 4 Latin American countries lacked knowledge and educational opportunities to safely care for people receiving OTs. Global partnerships to contextualize education and create local capacity may enhance nursing practice. OBJECTIVE: Within 4 Latin American countries, this study aims to (1) develop, deliver, and evaluate an OT cancer nursing education program and (2) evaluate the feasibility and efficacy of using an integrated knowledge translation (iKT) framework to develop the program and foster nurses' capacity for OT care. METHODS: Using the iKT framework, a "train the trainer" model was used to develop, contextualize, pilot test, implement, and evaluate the OT education program. An online survey evaluated nurses' perceived benefits, ease of use, barriers, facilitators, and recommendations for improvement. Nurses' self-reported OT practices were evaluated 9 months after the final workshop. RESULTS: One hundred nineteen nurses across 4 countries participated in a pilot and/or final OT educational workshop, facilitated by 6 local nurse champions. The nurse champions found the program easy to use and modify. Participants reported using the curriculum to teach other nurses and patients and networking opportunities for problem solving. Barriers included nurses' role clarity and time for education. CONCLUSIONS: The iKT approach was an effective method to develop the OT curriculum and build OT capacity among nurses and leaders within the 4 countries. IMPLICATIONS FOR PRACTICE: The iKT approach may be useful in low- or middle-income countries to enhance nursing education and practice. Future OT education projects should strengthen strategies for ongoing support after education intervention.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

BACKGROUND: Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. OBJECTIVE: The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. METHODS: The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. RESULTS: Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. CONCLUSIONS: Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

Cytokine gene polymorphisms and outcome after traumatic brain injury.

Clinical outcome after traumatic brain injury (TBI) is variable and cannot easily be predicted. There is increasing evidence to suggest that there may be genetic influences on outcome. Cytokines play an important role in mediating the inflammatory response provoked within the central nervous system after TBI. This study was designed to identify associations between cytokine gene polymorphisms and clinical outcome 6 months after head injury. A prospectively identified cohort of patients (n=1096, age range 0-93 years, mean age 37) was used. Clinical outcome at 6 months was assessed using the Glasgow Outcome Scale. In an initial screen of 11 cytokine gene single nucleotide polymorphisms (SNPs) previously associated with disease susceptibility or outcome (TNFA -238 and -308, IL6 -174, -572 and -597, IL1A -889, IL1B -31, -511 and +3953, and TGFB -509 and -800), TNFA -308 was identified as having a likely association. The TNFA -308 SNP was further evaluated, and a significant association was identified, with 39% of allele 2 carriers having an unfavorable outcome compared with 31% of non-carriers (adjusted odds ratio 1.67, confidence interval 1.19-2.35, p=0.003). These findings are consistent with experimental and clinical data suggesting that neuroinflammation has an impact on clinical outcome after TBI and that tumor necrosis factor alpha plays an important role in this process.

Inflammation and white matter degeneration persist for years after a single traumatic brain injury.

A single traumatic brain injury is associated with an increased risk of dementia and, in a proportion of patients surviving a year or more from injury, the development of hallmark Alzheimer's disease-like pathologies. However, the pathological processes linking traumatic brain injury and neurodegenerative disease remain poorly understood. Growing evidence supports a role for neuroinflammation in the development of Alzheimer's disease. In contrast, little is known about the neuroinflammatory response to brain injury and, in particular, its temporal dynamics and any potential role in neurodegeneration. Cases of traumatic brain injury with survivals ranging from 10 h to 47 years post injury (n = 52) and age-matched, uninjured control subjects (n = 44) were selected from the Glasgow Traumatic Brain Injury archive. From these, sections of the corpus callosum and adjacent parasaggital cortex were examined for microglial density and morphology, and for indices of white matter pathology and integrity. With survival of ≥3 months from injury, cases with traumatic brain injury frequently displayed extensive, densely packed, reactive microglia (CR3/43- and/or CD68-immunoreactive), a pathology not seen in control subjects or acutely injured cases. Of particular note, these reactive microglia were present in 28% of cases with survival of >1 year and up to 18 years post-trauma. In cases displaying this inflammatory pathology, evidence of ongoing white matter degradation could also be observed. Moreover, there was a 25% reduction in the corpus callosum thickness with survival >1 year post-injury. These data present striking evidence of persistent inflammation and ongoing white matter degeneration for many years after just a single traumatic brain injury in humans. Future studies to determine whether inflammation occurs in response to or, conversely, promotes white matter degeneration will be important. These findings may provide parallels for studying neurodegenerative disease, with traumatic brain injury patients serving as a model for longitudinal investigations, in particular with a view to identifying potential therapeutic interventions.

Repetitive mild traumatic brain injury in a mouse model produces learning and memory deficits accompanied by histological changes.

Concussion or mild traumatic brain injury (mTBI) represents the most common type of brain injury. However, in contrast with moderate or severe injury, there are currently few non-invasive experimental studies that investigate the cumulative effects of repetitive mTBI using rodent models. Here we describe and compare the behavioral and pathological consequences in a mouse model of single (s-mTBI) or repetitive injury (r-mTBI, five injuries given at 48 h intervals) administered by an electromagnetic controlled impactor. Our results reveal that a single mTBI is associated with transient motor and cognitive deficits as demonstrated by rotarod and the Barnes Maze respectively, whereas r-mTBI results in more significant deficits in both paradigms. Histology revealed no overt cell loss in the hippocampus, although a reactive gliosis did emerge in hippocampal sector CA1 and in the deeper cortical layers beneath the injury site in repetitively injured animals, where evidence of focal injury also was observed in the brainstem and cerebellum. Axonal injury, manifest as amyloid precursor protein immunoreactive axonal profiles, was present in the corpus callosum of both injury groups, though more evident in the r-mTBI animals. Our data demonstrate that this mouse model of mTBI is reproducible, simple, and noninvasive, with behavioral impairment after a single injury and increasing deficits after multiple injuries accompanied by increased focal and diffuse pathology. As such, this model may serve as a suitable platform with which to explore repetitive mTBI relevant to human brain injury.

Determining resource intensity weights in ambulatory chemotherapy related to nursing workload.

Ontario cancer programs aim to deliver high-quality nursing care and treatment that is safe for patients and staff. The reality of health care is that financial constraints, inherent in the delivery of care, require that funding mechanisms count not only the cost of drugs, but factors such as pharmacy and nursing human resource costs. While some organizations have developed patient classification systems to measure nursing intensity and workload, these systems apply primarily to inpatient populations, and are fraught with numerous challenges, such as the need for nurses to document to justify the workload required for care. The purpose of this paper is to outline the methodology and engagement of nurses to develop regimen-based resource intensity weights that can be applied to ambulatory chemotherapy suites. The methodology included determination of workload related to nursing time to prepare, teach, counsel and assess patients, as well as time to gather supplies, access lines, monitor, manage adverse reactions, manage symptoms and document care. Resource intensity weights provide better measures of the complexity of care required by cancer patients in ambulatory settings.

Improving the patient experience through design.

Toronto's Princess Margaret Hospital (PMH) received a major financial gift to redesign its chemotherapy daycare and transfusion facilities, which were over capacity and in need of improvement, both functionally and aesthetically. PMH's vision was to create a new space and experience that was truly patient centric and world class. Meanwhile, a research team at the University of Toronto's Rotman School of Management had also received a gift from a corporate donor with a patient-focused mandate to examine ways in which healthcare in Canada could be made more patient centric. The Rotman research team was invited to work with the hospital's staff, physicians, patients and families to explore a more patient-centered approach to care.

Interruptions during the delivery of high-risk medications.

OBJECTIVE: The goal of this study was to assess the nature and frequency of interruptions during medication administration and the interruptions' effects on task efficiency to guide healthcare managers/executives in improving patient safety and staff productivity. BACKGROUND: Interruptions have been identified as causal factors in medication administration errors. Research, however, is needed to assess the nature and frequency of interruptions throughout specific stages of the medication administration process and to develop mitigation interventions. METHOD: A direct observation study was conducted to document the nature, frequency, and timing of interruptions during specific stages of medication administration in a chemotherapy daycare unit. RESULTS: Nurses were interrupted, on average, 22% of their time and were frequently interrupted while performing safety-critical tasks. Task completion times were greater for interrupted tasks than for uninterrupted tasks. CONCLUSION: Nurses are frequently interrupted during safety-critical stages of medication administration, which decreases task efficiency and could lead to adverse events.

Stereology of cerebral cortex after traumatic brain injury matched to the Glasgow outcome score.

Magnetic resonance imaging provides evidence for loss of both white and grey matter, in terms of tissue volume, from the cerebral hemispheres after traumatic brain injury. However, quantitative histopathological data are lacking. From the archive of the Department of Neuropathology at Glasgow, the cerebral cortex of 48 patients was investigated using stereology. Patients had survived 3 months after traumatic brain injury and were classified using the Glasgow Outcome Scale as follows: moderately disabled (n = 13), severely disabled (n = 12) and vegetative state (n = 12); and controls. Some patients from the archive were diagnosed with diffuse axonal injury post-mortem. Comparisons of changes in cortical neuron population across Glasgow Outcome Scale groups between diffuse axonal injury and non-diffuse axonal injury patients were undertaken using effect size analyses. The hypotheses tested were that (i) thinning of the cerebral cortex occurred after traumatic brain injury; (ii) changes in thickness of cortical layers in Brodmann areas 11, 10, 24a and 4 differed; and (iii) different changes occurred for neuronal number, their size and nearest neighbour index across Glasgow Outcome Scale groups. There was a greater loss of large pyramidal and large non-pyramidal neurons with a more severe score on the Glasgow Outcome Scale from all four cortical regions, with the greatest loss of neurons from the prefrontal cortex of patients with diffuse axonal injury. There were differences in the changes of number of medium and small pyramidal and non-pyramidal neurons between different cortical regions, and between patients with and without diffuse axonal injury. Generally, a decrease in the somatic diameter of pyramidal and non-pyramidal neurons was associated with a more severe clinical outcome. However, in the motor cortex a more severe Glasgow Outcome Scale was associated with an increased diameter of medium pyramidal neurons and small non-pyramidal cells. Pyramidal and non-pyramidal neurons did not follow a Poisson distribution within the neuropil of control patients. Pyramidal neurons were usually scattered while medium and small non-pyramidal neurons were clustered. An increased spacing between remaining neurons usually occurred across Glasgow Outcome Scale groups. It is concluded that loss of neurons resulted in reduced executive and integrative capability in patients after traumatic head injury.

A neprilysin polymorphism and amyloid-beta plaques after traumatic brain injury.

Traumatic brain injury (TBI) induces the rapid formation of Alzheimer's disease (AD)-like amyloid-beta (AB) plaques in about 30% of patients. However, the mechanisms behind this selective plaque formation are unclear. We investigated a potential association between amyloid deposition acutely after TBI and a genetic polymorphism of the AB-degrading enzyme, neprilysin (n = 81). We found that the length of the GT repeats in AB-accumulators was longer than in non-accumulators. Specifically, there was an increased risk of AB plaques for patients with more than 41 total repeats (p < 0.0001; OR: 10.1). In addition, the presence of 22 repeats in at least one allele was independently associated with plaque deposition (p = 0.03; OR: 5.2). In contrast, the presence of 20 GT repeats in one allele was independently associated with a reduced incidence of AB deposition (p = 0.003). These data suggest a genetically linked mechanism that determines which TBI patients will rapidly form AB plaques. Moreover, these findings provide a potential genetic screening test for individuals at high risk of TBI, such as participants in contact sports and military personnel.

Glycemic control in diabetic and non-diabetic cardiac surgical patients and length of hospital stay.

BACKGROUND: Maintaining blood glucose levels (BGL) within normoglycemic range has been shown to reduce morbidity and mortality in critically ill patients. However, there is little evidence that maintenance of normoglycemic BGL is beneficial for diabetic and non-diabetic patients who undergo cardiac surgery. PURPOSE: To examine the relationship between BGL and length of stay (LOS) of cardiac surgical patients. METHODS: Data were obtained from the Safer Healthcare Now Project database in the cardiovascular intensive care unit (CVICU) at the Foothills Medical Centre, Calgary, Alberta, and included two BGL from cardiac surgery patients: BGL 1 was collected within four hours preoperatively, BGL 2 was collected postoperatively 24 hours after BGL 1. CVICU LOS and total hospital LOS were obtained from the Tracer database of the Department of Critical Care Medicine, Calgary Health Region. Demographic, clinical, and surgical data were collected from health records. RESULTS: For the 398 patients, no relationship was found between pre- and postoperative BGL and LOS. Although pre- and postoperative BGL were not different between diabetics and non-diabetics, diabetics had longer CVICU LOS and total hospital LOS. Age, preoperative HgbA1C, type of surgery, cross-clamp and cardiopulmonary bypass times, APACHE II scores, and postoperative complications also affected LOS. CONCLUSION: In this cohort of cardiac surgical patients, pre- and postoperative BGL did not affect LOS.

Getting results for hematology patients through access to the electronic health record.

PURPOSE: To conduct a needs assessment to identify patient and provider perceptions about providing patients with access to their electronic health record in order to develop an online system that is appropriate for all stakeholders. METHODS: Malignant hematology patients were surveyed and health care providers were interviewed to identify issues and validate concerns reported in the literature. Based on the analysed data, a prototype will be designed to examine the feasibility and efficacy of providing patients with access to their electronic health record and tailored information. RESULTS: 61% of patients reported using the internet to find health information; 89% were interested in accessing their electronic health record and 79% stated they would benefit from educational material along with the results. Staff members viewed patient online access to the record favourably, but expressed the importance of providing the necessary patient support and education. A Web-based prototype was developed for patients to review their registration data and blood results. CONCLUSIONS: Hematology oncology patients are more interested in using the internet to monitor their clinical information than to find health information. Using the constructed prototype, the feasibility of this project is currently being tested.

La autonomía en la práctica de enfermería / Enhancing the practice of nursing autonomy

La autonomía ha sido vista como un indicador de la profesionalización de la disciplina. La autonomía de enfermería ha sido identificada como una variable importante que afecta la percepci ón de la enfermera en relación con su satisfacción en el trabajo, los ambientes positivos de su práctica profesional y la calidad del cuidado de enfermería. La suposición de que un aspecto clave de la autonom ía de enfermería es actuar con un juicio y práctica independiente, fue cuestionada en un estudio interpretativo que exploró la forma como las enfermeras entienden la autonomía en su práctica clínica y en su trabajo. Este artículo describe el proyecto de investigación, y explora el énfasis que hacen las enfermeras sobre los aspectos inherentes al ejercicio de la autonomía en su trabajo clínico. Las descripciones de sus relaciones con los médicos, colegas y directores de enfermería, ofrecen muchos ejemplos en los cuales la práctica autó- noma puede ser respaldada y fortalecida. Este artículo también discute estas posibilidades para que este concepto se pueda llevar a cabo en tres áreas claves: crear ambientes de práctica que enriquezcan la pericia clínica y la toma de decisiones; hacer posible que las enfermeras practiquen, aplicando todas sus capacidades educativas, sus experiencias y competencias; y fortalecer la práctica multidisciplinaria con colaboración.

Clinical nurses' understanding of autonomy: accomplishing patient goals through interdependent practice.

OBJECTIVE: The purpose of the study was to enable nurse managers to identify strategies to support and enhance autonomous practice based on clinical nurses' understanding of autonomy. BACKGROUND: Findings from an organizational work-life satisfaction survey led a nursing management team to question how clinical nurses understand autonomy. The nursing literature offers inconsistent definitions of autonomy and interchangeable use of related concepts. METHODS: Twelve focus groups involving 43 nurses working in cardiovascular service units discussed instances of satisfaction and dissatisfaction with autonomy in their clinical practice and work life. Verbatim transcripts of group discussions were interpreted by a research team to identify salient examples and descriptions of autonomy. RESULTS: Nurses described autonomy as their ability to accomplish patient care goals in a timely manner by using their knowledge and skills to understand and contribute to the overall plan of care; assess patient needs and conditions; effectively communicate concerns and priorities regarding patient care; and access and coordinate the resources of the multidisciplinary team. CONCLUSIONS: These findings challenge assumptions about autonomy as independent decision making and practice. They highlight nurses' contributions to patient care goals through knowledge of how to get things done within hospital systems and through interdisciplinary coordination and collaboration.

Involvement of apolipoprotein E in glioblastoma: immunohistochemistry and clinical outcome.

We hypothesised that apolipoprotein E (apoE) influences brain tumours by delivery of lipids to tumour cells and by analogy with other brain insults. APOE gene analysis was performed for 126 glioblastomas, the commonest primary brain tumour. Neither APOE epsilon2 nor epsilon4 alleles were significantly associated with differences in post-operative survival. However, there was apoE immunoreactivity of tumour cells, macrophages in areas of necrosis and astrocytes nearby. The immunohistochemistry findings support the hypothesis that apoE is involved in the delivery of lipids to tumour cells and in the recycling of lipids by macrophages in necrotic areas, raising the possibility that apoE-mediated lipid transport may represent a new therapeutic target in brain tumours.