Evaluation of the impact of a quality improvement program and intensivist-directed ICU team on mortality after cardiac surgery.

OBJECTIVE: Quality improvement is an important pursuit for critical care teams. DESIGN: The authors performed an observational cohort study with historic control. SETTING: Eight-bed cardiac surgery ICU in a tertiary university hospital. PARTICIPANTS: A total of 4,866 patients undergoing cardiac surgery over a 6-year period between January 2005 and December 2010. INTERVENTIONS: In this study, the influence of the introduction of a quality improvement program under the supervision of a newly appointed intensivist on patient outcomes after cardiac surgery was evaluated. Patients were further divided into three 2-year periods: Period I, 2005-2006, before appointment of an intensivist; Period II, 2007-2008, after appointment of an intensivist and initial introduction of a quality improvement program; and Period III, 2009-2010, after implementation of the program and introduction of Critical Care Information Systems. MEASUREMENTS AND MAIN RESULTS: There were 1,633, 1,690, and 1,543 patients in each period, respectively. There was no significant difference in the severity of patient illness between the groups. Unadjusted in-hospital mortality decreased from 6.37% (104 patients) in Period I to 4.32% (73 patients) and 3.3% (51 patients) in Periods II and III, respectively (p< 0.01). CONCLUSIONS: Appointment of an intensivist-directed team model and introduction of quality improvement interventions were associated with decreased mortality after cardiac surgery.

Neurolymphomatosis: an International Primary CNS Lymphoma Collaborative Group report.

Neurolymphomatosis (NL) is a rare clinical entity. The International Primary CNS Lymphoma Collaborative Group retrospectively analyzed 50 patients assembled from 12 centers in 5 countries over a 16-year period. NL was related to non-Hodgkin lymphoma in 90% and to acute leukemia in 10%. It occurred as the initial manifestation of malignancy in 26% of cases. The affected neural structures included peripheral nerves (60%), spinal nerve roots (48%), cranial nerves (46%), and plexus (40%) with multiple site involvement in 58%. Imaging studies often suggested the diagnosis with 77% positive magnetic resonance imaging, and 84% (16 of 19) positive computed tomography-positron emission tomography studies. Cerebrospinal fluid cytology was positive in 40%, and nerve biopsy confirmed the diagnosis in 23 of 26 (88%). Treatment in 47 patients included systemic chemotherapy (70%), intra-cerebrospinal fluid chemotherapy (49%), and radiotherapy (34%). Response to treatment was observed in 46%. The median overall survival was 10 months, with 12- and 36-month survival proportions of 46% and 24%, respectively. NL is a challenging diagnosis, but contemporary imaging techniques frequently detect the relevant neural invasion. An aggressive multimodality therapy can prevent neurologic deterioration and is associated with a prolonged survival in a subset of patients.

Recommendations From the Professional Advisory Committee on Nursing Practice in the Care of ECMO-Supported Patients.

BACKGROUND: By July 2020, the Extracorporeal Life Support Organization had documented more than 133 000 extracorporeal membrane oxygenation (ECMO) implementations, with more than 61 000 implementations in adult patients. No clear policies regarding the authority and responsibility of nursing staff in the treatment of ECMO-supported patients are currently available. OBJECTIVE: To formulate evidence-based recommendations for nursing care of ECMO-supported patients. METHODS: The National Head Nurse's office and the Professional Guidelines Department in the Nursing Division of Israel's Ministry of Health formed the Professional Advisory Committee on Nursing Practice in the Care of ECMO-Supported Patients to address concerns regarding the current state of professional nursing practice in the care of these patients. The Professional Advisory Committee brought together 15 senior Israeli ECMO nursing experts who explored the potential of registered nurses in caring for ECMO-supported patients, considered the competencies of nurses treating ECMO-supported patients, discussed training programs and health care policy, and examined nursing outcomes for quality assurance. RESULTS: The Professional Advisory Committee formulated recommendations regarding the following priority issues: (1) determining boundaries of professional authority and nurses' responsibilities, including designated activities for different professional ranks of registered nurses; (2) providing appropriate content for the training programs offered, such as generic/basic, above-basic, and clinical specialization nursing programs; and (3) defining relevant quality measures for nursing treatment of ECMO-supported patients. CONCLUSIONS: Introducing international standards would ensure the safety and effectiveness of nursing care for ECMO-supported patients through quality and risk management and establishment of new evidence-based nursing practices.

Serum DNA can define tumor-specific genetic and epigenetic markers in gliomas of various grades.

We evaluated whether cell-free circulating DNA can be used as a noninvasive approach for detection of genetic/epigenetic alterations in brain tumors during the course of the disease. Paired tumor-serum samples from 70 patients with either high-grade astrocytomas (n = 41) or oligodendrogliomas of various grades were analyzed. The median interval between surgery and serum sampling was 1 month (range 0.5-168 months). DNA was extracted from whole blood, serum, and paraffin-embedded tumor sections. Loss of heterozygosity (LOH) in chromosomes 1p, 19q, and 10q was assessed by polymerase chain reaction (PCR)-based microsatellite analysis. The methylation status of O(6)-methyl guanine methyltransferase (MGMT) and phosphatase and tensin homolog promoters was studied by methylation-specific PCR. LOH and/or methylation that could identify DNA as tumor-specific was found in 80.5% of astrocytic tumors and in all oligodendrogliomas. The rate of serum detection of these biomarkers was 51% and 55%, respectively, with specificity around 100%. The rate of serum detection did not differ between low- and high-grade oligodendrogliomas. Statistically significant tumor-serum concordance was found for MGMT methylation in both astrocytic tumors (83%; P < .001) and oligodendroglial tumors (72%; P < .003) and for LOH of 10q (79%; P < .002) and 1p (62%; P < .03) in oligodendrogliomas. We conclude that serum DNA in glial tumors is informative for both LOH and aberrant gene promoter methylation analysis during the course of the disease. The sensitivity is moderate and specificity is high for both low- and high-grade tumors. Future studies should identify a panel of biomarkers that bear the highest potential for clinical application.

Blood-brain barrier disruption and intra-arterial methotrexate-based therapy for newly diagnosed primary CNS lymphoma: a multi-institutional experience.

PURPOSE Primary CNS lymphoma (PCNSL) is confined to the CNS and/or the eyes at presentation and is usually initially treated with intravenous methotrexate-based chemotherapy and whole-brain radiotherapy (WBRT). However, the intact blood-brain barrier (BBB) can limit diffusion of methotrexate into brain and tumor. With BBB disruption (BBBD), enhanced drug delivery to the tumor can be achieved. PATIENTS AND METHODS This report summarizes the multi-institutional experience of 149 newly diagnosed (with no prior WBRT) patients with PCNSL treated with osmotic BBBD and intra-arterial (IA) methotrexate at four institutions from 1982 to 2005. In this series, 47.6% of patients were age > or = 60 years, and 42.3% had Karnofsky performance score (KPS) less than 70 at diagnosis. Results The overall response rate was 81.9% (57.8% complete; 24.2% partial). Median overall survival (OS) was 3.1 years (25% estimated survival at 8.5 years). Median progression-free survival (PFS) was 1.8 years, with 5-year PFS of 31% and 7-year PFS of 25%. In low-risk patients (age < 60 years and KPS > or = 70), median OS was approximately 14 years, with a plateau after approximately 8 years. Procedures were generally well tolerated; focal seizures (9.2%) were the most frequent side effect and lacked long-term sequelae. CONCLUSION This large series of patients treated over a 23-year period demonstrates that BBBD/IA methotrexate-based chemotherapy results in successful and durable tumor control and outcomes that are comparable or superior to other PCNSL treatment regimens.

High incidence of thromboembolism in patients with central nervous system lymphoma.

BACKGROUND: Venous thromboembolism (VTE) is a frequent complication in patients with cancer throughout the course of the disease. Patients with brain tumors are at particularly high risk for VTE, and several risk factors were found in patients with malignant glioma. To the authors' knowledge, the incidence of VTE in patients with central nervous system (CNS) lymphoma is not known, and possible risk factors have not been identified to date. The objective of this study was to evaluate the frequency and risk factors of VTE in patients with CNS lymphoma. METHODS: The authors retrospectively evaluated the medical records of 42 patients with CNS lymphoma who were treated at their center between 1992 and 2001. RESULTS: It was found that 25 patients (59.5%) had VTE, and, in 3 patients (7%), the VTE was fatal. The authors could not demonstrate that age or ambulatory status could predict VTE in this group of patients, but almost all VTE events occurred during the early period of intensive therapy. CONCLUSIONS: The high incidence of VTE found in this study indicates that anticoagulant prophylaxis with low-molecular-weight heparin probably outweighs the risk and cost of such therapy. A prospective evaluation of newly diagnosed patients with CNS lymphoma is underway at the authors' center.