Quality Improvement at the Laboratory’s Specimen Reception Station

Introduction/Objective

In our 1000-bed acute care tertiary hospital, physicians order laboratory tests via the computerized-provider-order-entry (CPOE) system and print barcode labels (patient demographics/tests ordered) at the computer-on-wheel printer. When tubes with unsuitable barcodes (misaligned, poor quality) are received at the laboratory specimen reception area a fresh barcode is re-printed by our laboratory staff. An incident involving a re- printed barcode label pasted on the wrong blood tube prompted an investigation into the quality of barcodes.

Methods/Case Report

We initiated ‘an opportunity for improvement (OFI) project’ at the laboratory specimen reception station. The OFI team involved Nursing, Information Technology (IT) and Pathology departments aimed to eliminate re-printing of barcode labels by 75% within 6 months. We collated and analyzed reasons for re-printing of barcodes on 3 separate 48-hour periods (27-28 April 2020, 24-25 June 2020, and 13-14 June 2022). A series of interventions and initiatives were implemented.

Results (if a Case Study enter NA)

Re-printed barcodes were from the Emergency Department (56%), Out-patient clinics (7%) and Wards (57%). Root cause analysis(RCA) using the “5 whys” technique categorized re-print causes into staff-related (misaligned barcodes) and printer-related (faint barcodes lines/truncated un-verifiable patient demographics). The team mass-emailed clinicians an educational “Do-You-Know” guide on proper pasting of barcodes on blood tubes and instructions on how to obtain help for printer rectification. These guide documents were placed in the hospital-wide document-sharing portal - Docupedia. Immediate close follow-up with sites that had poor barcodes was done in real-time. Barcode reprints decreased 83% within 2 months - from 174 (27-28 Apr 2020) to 30 (24-25 Jun 2020). A recent audit showed sustained elimination of barcode re-printing: 25 cases (13-14 Jun 2022).

Conclusion

The OFI project has successfully raised the quality of CPOE labels on specimen tubes contributing to process efficiency and safer patient care. Close communication with all care sites and their representatives on the OFI team are critical success factors.

Advanced necrotizing enterocolitis part 1: mortality

AIM OF THE STUDY

The aim of this study was to investigate the factors associated with mortality in infants referred for the surgical treatment of advanced necrotizing enterocolitis (NEC).

METHODS

Retrospective review of all infants with confirmed (Bell stage II or III) NEC treated in our unit during the past 8 years (January 2002 to December 2010). Data for survivors and nonsurvivors were compared using Mann-Whitney test and Fisher's exact test and are reported as median (range).

RESULTS

Of the 205 infants with NEC, 35 (17%) were medically managed; 170 (83%) had surgery; 66 (32%) infants died; all had received surgery. Survivors and nonsurvivors were comparable for gestational age, birth weight, and gender distribution. Overall mortality was 32%, the highest mortality was in infants with pan-intestinal disease (86%) but remained significant in those with less severe disease (multifocal 39%; focal disease 21%). The commonest cause of mortality was multiple organ dysfunction syndrome and nearly half of the nonsurvivors had care withdrawn.

CONCLUSION

Despite improvement in neonatal care, overall mortality (32%) for advanced NEC has not changed in 10 years. Mortality is significant even with minimal bowel involvement.

First-line physician’s choice (PC1) or standard of care (SOC) then second-line PC2 chemotherapy (CT) in metastatic esophago-gastric adenocarcinoma (MEGA): BC Cancer Agency experience

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Background: The BCCA GI Tumor Group supports 1 CT regimen for MEGA: weekly 5FU-cisplatin [FUC] (Shah, ASCO 1992, A530) for first line SOC CT. All other regimens (PC) require “undesignated” approval for public funding. Reasons for PC requests include prior CT, results of modern CT trials, and contra-indications to FUC. Objectives: to examine response, toxicity and survival in pts. receiving either first-line PC1 CT , or SOC and second line PC2 CT. Methods: BCCA Pharmacy records (Dec. 1999 to April 2006) were searched for PC MEGA pts, charts abstracted, database constructed and KM survival analyses undertaken. Treatment responses, serious toxicities and hospitalizations were recorded. Results: Demographic summary (N = 85): 32 esophageal (10 GEJ), 53 (62%) gastric primary, 61 M, 24 F, median age 56.2 (range 28.7 - 81.8) yrs., 68 Caucasian, 15 Asian, 2 Fijian descent, 55 stage M1 at diagnosis. Prior therapy: 14 CTRT, 3 adjuvant CT, 34 radical surgery. 50 pts received PC1 of whom 25, 9 and 2 received 2nd, 3rd and 4th line CT respectively; of 35 SOC/PC2 pts, 35, 10 and 2 received 2nd, 3rd and 4th line CT for a total of 133 patient-courses of PC (including 4 repeat FUC). Docetaxel and irinotecan regimens accounted for 34% and 36%, 5% and 55%, 16% and 32% of 1st, 2nd and 3rd line PC CT regimens respectively. Partial responses were seen with SOC (11/35) and PC1 (6/50) [chi square p = 0.05]. Four responses were seen with 2nd line CT (2 SOC/PC2, and 2 PC1). Grade 3+ toxicity rates: 19/49 (39%) and 6/36 (17%) with SOC and PC1 with initial CT (p = 0.02). There were 20 hospitalizations with PC and 2 with SOC CT (p = 0.02). Median follow-up time was 8.9 months. Survival analyses are presented below. Multivariate analysis results: primary site, SOC, gender, ethnicity, prior CT, p values were 0.15, 0.23, 0.23, 0.25 and 0.25 resp. Conclusions: Benefits and risks of non-SOC chemotherapy in MEGA need careful consideration before routine adoption as primary or subsequent therapy.

[Table: see text]

No significant financial relationships to disclose.

The use of telemedicine to care for cancer patients at remote sites

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Background: At the BC Cancer Agency -CSI we are challenged to provide systemic cancer care to a population of 720,000 widely dispersed over 250,000 square kilometers. Video-link technology (VT) has been used at our centre since April 2004 to help provide distant care and prevent patient and physician travel. Methods: Patients gave consent for the use of VT. We prospectively collected data on patient and physician experiences as part of on-going quality assurance. We retrospectively collected the clinical data on these patients. Results: We performed 104 encounters on 100 patients between April 2, 2004 and October 4, 2006. Patient characteristics: female 62%, male 38%, average age was 66 years with a range of 28 –83. Extent of cancer was 67% curable, 31% advanced and 7% unknown. Visit type and cancer sites are shown below. Patients rated this experience very highly and the vast majority would repeat the experience rather than travel or wait several weeks to see the doctor in person. Physicians were not as satisfied as the patients; and both groups expressed a concern about the need for physical exam. In those having a consult, 54% had an exam within 60 days, and in none of these patients were the treatment recommendations changed. The majority (57%) of those consult patients that didn’t have an exam had either Stage 0 or I breast cancer or Stage II or III colorectal cancer; and it seems unlikely that physical exam would have changed management in these patients. Conclusions: We were able to deliver cancer care at distant sites with VT and patients found the experience very acceptable. There may not be a need for repeat physical exam in these patients, who had previously been examined by other physicians, prior to referral.

No significant financial relationships to disclose.

[Table: see text]

Micropapillary variant of urothelial carcinoma of the urinary bladder; a clinicopathological and immunohistochemical study

AIMS

To investigate whether prognosis in micropapillary urothelial carcinoma is related to the proportion of the micropapillary component (MPC), and to identify the immunohistochemical features of MPC.

METHODS AND RESULTS

This study presents a clinicopathological analysis of 20 patients with micropapillary urothelial carcinoma of the bladder with cystectomy specimens for evaluation. Tumours were stratified on the extent of MPC: focal, <10%; moderate, 10-50%; extensive, >50%; and this was correlated with tumour stage and prognosis. Sixteen males and four females were aged 56-81 years (mean 69 years). All cases had high-grade morphology in the micropapillary carcinoma and typical urothelial carcinoma. All cases with extensive MPC (n = 4) were of a high pathological stage (pT3 or pT4) and died of disease (DOD) or other causes. Eighty percent with moderate MPC (eight of 10 cases) were pT3 or pT4 and 50% DOD or are alive with disease. Eighty-four percent with focal MPC (five of six cases) were pT1 or pTa. In high-stage cases, the most invasive component was MPC. High-stage cases had an 85% risk of being advanced at presentation with micropapillary carcinoma. All pT2 or lower stage cases had micropapillary carcinoma on prior transurethral resections of bladder tumour (TURB). High-stage carcinomas had 30% and 54%, respectively, of surface MPC and urothelial carcinoma in situ, in comparison with 85% and 28% in lower stage carcinomas. Immunohistochemical staining was similarly positive in MPC and typical urothelial carcinoma with cytokeratin (CK)7, CK20, epithelial membrane antigen, carcinoembryonic antigen and cytokeratin 34betaE12. CA125 staining was seen only in MPC in 43% of cases.

CONCLUSIONS

Micropapillary urothelial carcinoma is a high-grade carcinoma in which the prognosis is related to the proportion and location of the MPC. Cases with moderate or extensive MPC are at high risk of being advanced at presentation. Cases with <10% MPC and surface MPC have a high chance of detection at an early stage. The morphology and immunohistochemical profile of the MPC suggest that it is a form of glandular differentiation in urothelial carcinoma.

A National Cancer Institute of Canada clinical trials group phase II study of eniluracil (776C85) and oral 5-fluorouracil in patients with advanced squamous cell head and neck cancer

BACKGROUND/PATIENTS AND METHODS: Thirty-two patients with recurrent head and neck cancer (HNC) following radiotherapy and/or surgery were treated with eniluracil (10 mg/m2) and 5-fluorouracil (5-FU) (1 mg/m2) (E5F) orally twice daily for 28 days followed by a seven-day treatment free period. Thirty-five-day cycles were repeated until disease progression, unacceptable toxicity or patient refusal. Doses were modified for toxicity. Standard toxicity and response criteria were used.

RESULTS

Thirty-two patients were accrued; thirty-two and twenty-eight patients were evaluable for toxicity and response, respectively. Twelve patients received three or more cycles of E5F. Drug related toxicities were usually grade 1-2 intensity and included lethargy, nausea or diarrhea (> or = 25% of patients), and anorexia, rash or itch, stomatitis or vomiting (12%-24% of patients). Hematologic toxicity was generally mild; two patients experienced grade 3-5 leukopenia or thrombocytopenia. No significant biochemical toxicity was seen. One patient was withdrawn (severe nausea and vomiting) and one patient died because of drug related toxicity (thrombocytopenia). In the final analysis there were one complete and four partial responses for a 15.6% overall response.

CONCLUSIONS

E5F demonstrates activity in chemotherapy naïve patients with advanced HNC cancer with acceptable toxicity profile. Further investigation of E5F with other active agents is warranted in HNC.

Phase II trial of N,N-diethyl-2-[4-(phenylmethyl)phenoxy]ethanamine.HCl and doxorubicin chemotherapy in metastatic breast cancer: A National Cancer Institute of Canada clinical trials group study

PURPOSE

This multicenter phase II trial investigated the efficacy and toxicity of a combination of the novel intracellular histamine antagonist, N,N-diethyl-2-[4-(phenylmethyl)phenoxy]ethanamine.HCl (DPPE), and doxorubicin in patients with anthracycline-naïve metastatic breast cancer. Preclinical models and early single institutional studies suggested DPPE could potentiate the cytotoxicity of doxorubicin.

PATIENTS AND METHODS

Forty-two women, 32 to 77 years old (median, 59 years), with anthracycline-naïve metastatic breast cancer were treated. Patients may have had one previous regimen of nonanthracycline chemotherapy, either in the adjuvant or metastatic disease treatment setting. DPPE (6 mg/kg) was administered as an 80 minute intravenous infusion with doxorubicin (60 mg/m(2)) given intravenously over the last 20 minutes of the DPPE infusion. Patients were premedicated with an antiemetic and sedating regimen. The DPPE/doxorubicin treatment was given every 21 days for a maximum of seven cycles.

RESULTS

All 42 patients were assessable. Overall, toxicity was comparable to that expected with doxorubicin alone, with the exception of DPPE-related motion sickness, mild hallucinations, and cerebellar signs at the time of the infusion. These CNS side effects were manageable in an ambulatory care setting, improved with subsequent cycles of treatment, and did not usually require hospitalization. Four patients developed febrile neutropenia. Thirty-five patients received four or more cycles of chemotherapy. The overall response rate was 52.5% (95% confidence interval, 36% to 68%), with 9.5% complete responses (n = 4), 43% partial responses (n = 18), and 38% of patients with stable disease (n = 16).

CONCLUSION

The antitumour effects of DPPE/doxorubicin the 52.5% response rate seems encouraging, particularly in consideration of the fact that a recently reported randomized National Cancer Institute of Canada Clinical Trials Group trial using single-agent doxorubicin 60 mg/m(2) in one of the treatment arms achieved a 31% response rate. Thus, a randomized phase III trial of doxorubicin versus doxorubicin plus DPPE is being conducted in this clinical setting.

The utility of bone scans in rheumatology

PURPOSE

Bone scanning is the most common diagnostic imaging service requested by Australian rheumatologists, who order $50,000 (Australian) worth of bone scans annually.

METHODS

To determine why rheumatologists request bone scans and how they affect their patient management, the authors administered a two-part prospective survey before and after every bone scan ordered by four rheumatologists during a 6-month period in 1996.

RESULTS

A total of 136 bone scans were requested. The primary indications for scanning were to confirm a clinical diagnosis (38%), to exclude a diagnosis (34%), and to localize the site of pain (17%). The common diseases that rheumatologists were attempting to confirm or exclude with bone scanning were inflammatory arthritis, malignancy, and fracture. However, the most common provisional and final diagnosis was soft tissue rheumatism (18%), followed by inflammatory arthritis (15%) and osteoarthritis (11%). Bone scans were successful in excluding a diagnosis in 87% and confirming a diagnosis in 80%. In 32%, bone scans altered the clinical diagnosis, and in 43% they changed the course of disease management. Bone scan results prevented further investigations in 60%.

Steroid specificity of the putative DHB receptor: evidence that the receptor is not 11betaHSD

Recently, we identified a novel putative nuclear receptor in colonic crypt cells distinct from both mineralocorticoid receptor and glucocorticoid receptor, with high affinity for 11-dehydrocorticosterone (11-DHB) (33). In the present study, competitive nuclear binding assays demonstrated that this site has a unique steroid binding specificity that distinguishes it from other steroid receptors. Western blot analysis showed the presence of 11beta-hydroxysteroid dehydrogenase-2 (11betaHSD2) but not 11betaHSD1 in colonic crypt cells and showed that 11betaHSD2 was present in the nuclear pellet. Differences in steroid specificity between the putative DHB receptor and inhibition of 11betaHSD activity indicate that binding is not to the enzyme. Furthermore, modified Chinese hamster ovary cells transfected with the 11betaHSD2 gene express nuclear 11betaHSD2 but not a nuclear DHB binding site. In conclusion, these data support the existence of a novel nuclear DHB receptor in rat colon that is distinct from the classic steroid receptors and from both 11betaHSD1 and 11betaHSD2.

Cognitive therapy for multiple sclerosis: a preliminary study

BACKGROUND

Drug treatments for multiple sclerosis are expensive, may cause side effects, and do not have demonstrated efficacy for cognitive deficits associated with this disease.

OBJECTIVE

To test the effectiveness of a multimodal cognitive therapy on cognitive and physical measures known to be affected in multiple sclerosis.

DESIGN

Quasi-experimental wait-list control.

SETTING

Alternative medicine clinic.

PATIENTS

27 persons with clinically definite multiple sclerosis.

INTERVENTION

Multimodal cognitive therapy.

MAIN OUTCOME MEASURES

Neuropsychological measures of verbal learning and memory, abstraction, vocabulary, and information processing speed; Beck Depression Inventory; tactile sensitivity of the hands; grip strength; and visual acuity.

MAIN RESULTS

12 of 14 patients in the therapy group and 10 of 13 patients in the control group completed 24 weeks of treatment and all assessments. Patients who received therapy showed significantly greater improvement in verbal learning, verbal abstraction, depression, and some measures of grip strength and tactile sensitivity than did patients in the untreated control group. The groups did not differ in the magnitude of change on vocabulary, information processing speed, or visual acuity.

CONCLUSION

Cognitive therapy appears to be a promising treatment for ameliorating some symptoms of multiple sclerosis. A larger study with a randomized design and additional outcome measures is warranted.

Methods of immunosuppression for study of growth and lung colony formation by human tumor cells in mice

Mice that are immune-suppressed by thymectomy and by sequential treatment with 1-beta-D-arabinofuranosylcytosine and whole body irradiation may be used as hosts for generation of human tumor xenografts. We have studied the effect of various additional methods of immune suppression on the formation of tumors after i.m. injection and on the formation of lung colonies after i.v. injection with the human MGH-U1 bladder cancer cell line. Success of transplantation was improved by treatment of immune-suppressed animals with either heterologous antilymphocyte serum or a monoclonal anti-Thy-1.2 antibody. Success of lung colony formation was also improved by antilymphocyte serum but not by monoclonal anti-Thy-1.2 antibody. Admixture of heavily irradiated cells (10(6)) to the viable inoculum of tumor cells in addition to antilymphocyte serum treatment improved the success of i.m. transplantation but not that of lung colony formation. Treatment with corticosteroids or treatment with carrageenan to suppress macrophage activity added toxicity and did not improve the success of xenografting. Immune suppression decreased the natural killer cell activity of normal mice and treatment with antiinterferon to further suppress natural killer cells may also enhance xenograft formation. Administration of cyclosporin A to normal mice allowed the growth of a single xenograft but was not a useful method for immunosuppression. The success of xenografting into immune-deprived mice was superior to that for two strains of nude mice maintained in our laboratory, and i.v. injection of tumor cells did not lead to lung colonies in these nude mice. Immune-deprived mice are a useful alternative to nude mice for the study of xenografts derived from human tumor cell lines and may allow the study of experimental lung metastases.

A new form of residual hexosaminidase activity in infantile Tay Sachs disease fibroblasts

Fibroblast cell lines obtained from five patients with the early onset form of Tay Sachs disease (TSD) possess a species of beta-N-acetylhexosaminidase (Hex) which is more anionic than Hex B but which is stable to heating under conditions which completely inactivate Hex A. This species, which comprised between 3 and 20% of the total hexosaminidase activity in homozygous TSD fibroblasts, appeared to be unstable and upon isoelectric focussing produced a mixture of Hex B (pI = 7.2) and an isozyme with a pI of 6.2. This intermediate form of hexosaminidase was not seen in two normal fibroblast cell lines but was observed following anion exchange chromatography of extracts of fibroblast cell lines obtained from two obligate heterozygotes. A species of hexosaminidase with the same chromatographic properties, thermostability and isoelectric point as the intermediate form found in fibroblasts with the TSD genotypes can be recovered after anion exchange chromatography of a partially purified preparation of human liver Hex A that had been treated with merthiolate. We hypothesize that in TSD cells a form of the beta subunit which is usually incorporated into Hex A accumulates due to the absence of alpha subunits. This form of the beta subunit is more anionic than the beta subunit found in Hex B. In the absence of alpha subunits these anionic beta subunits form tetramers with a pI = 6.2. This form of the enzyme is unstable in the presence of cellular proteases and may be modified to Hexosaminidase B.