Association Between Measurable Residual Disease in Patients With Intermediate-Risk Acute Myeloid Leukemia and First Remission, Treatment, and Outcomes

Importance

Measurable residual disease (MRD) is widely used as a therapy-stratification factor for acute myeloid leukemia (AML), but the association of dynamic MRD with postremission treatment (PRT) in patients with intermediate-risk AML (IR-AML) has not been well investigated.

Objective

To investigate PRT choices based on dynamic MRD in patients with IR-AML.

Design, Setting, and Participants

This cohort study examined 549 younger patients with de novo IR-AML in the South China Hematology Alliance database during the period from January 1, 2012, to June 30, 2016, including 154 who received chemotherapy, 116 who received an autologous stem cell transplant (auto-SCT), and 279 who received an allogeneic SCT (allo-SCT). Subgroup analyses were performed according to dynamic MRD after the first, second, and third courses of chemotherapy. The end point of the last follow-up was August 31, 2020. Statistical analysis was performed from December 1, 2019, to September 30, 2020.

Exposures

Receipt of chemotherapy, auto-SCT, or allo-SCT.

Main Outcomes and Measures

The primary end points were 5-year cumulative incidence of relapse and leukemia-free survival.

Results

Subgroup analyses were performed for 549 participants (314 male participants [57.2%]; median age, 37 years [range, 14-60 years]) according to the dynamics of MRD after 1, 2, or 3 courses of chemotherapy. Comparable cumulative incidences of relapse, leukemia-free survival, and overall survival were observed among participants who had no MRD after 1, 2, or 3 courses of chemotherapy. Participants who underwent chemotherapy and those who underwent auto-SCT had better graft-vs-host disease-free, relapse-free survival (GRFS) than those who underwent allo-SCT (chemotherapy: hazard ratio [HR], 0.35 [95% CI, 0.14-0.90]; P = .03; auto-SCT: HR, 0.07 [95% CI, 0.01-0.58]; P = .01). Among participants with MRD after 1 course of chemotherapy but no MRD after 2 or 3 courses, those who underwent auto-SCT and allo-SCT showed lower cumulative incidence of relapse (auto-SCT: HR, 0.25 [95% CI, 0.08-0.78]; P = .01; allo-SCT: HR, 0.08 [95% CI, 0.02-0.24]; P < .001), better leukemia-free survival (auto-SCT: HR, 0.26 [95% CI, 0.10-0.64]; P = .004; allo-SCT: HR, 0.21 [95% CI, 0.09-0.46]; P < .001), and overall survival (auto-SCT: HR, 0.22 [95% CI, 0.08-0.64]; P = .005; allo-SCT: HR, 0.25 [95% CI, 0.11-0.59]; P = .001) vs chemotherapy. In addition, auto-SCT showed better GRFS than allo-SCT (HR, 0.45 [95% CI, 0.21-0.98]; P = .04) in this group. Among participants with MRD after 1 or 2 courses of chemotherapy but no MRD after 3 courses, allo-SCT had superior cumulative incidence of relapse (HR, 0.10 [95% CI, 0.06-0.94]; P = .04) and leukemia-free survival (HR, 0.18 [95% CI, 0.05-0.68]; P = .01) compared with chemotherapy, but no advantageous cumulative incidence of relapse (HR, 0.15 [95% CI, 0.02-1.42]; P = .10) and leukemia-free survival (HR, 0.23 [95% CI, 0.05-1.08]; P = .06) compared with auto-SCT. Among participants with MRD after 3 courses of chemotherapy, allo-SCT had superior cumulative incidences of relapse, leukemia-free survival, and overall survival compared with chemotherapy (relapse: HR, 0.16 [95% CI, 0.08-0.33]; P < .001; leukemia-free survival: HR, 0.19 [95% CI, 0.10-0.35]; P < .001; overall survival: HR, 0.29 [95% CI, 0.15-0.55]; P < .001) and auto-SCT (relapse: HR, 0.25 [95% CI, 0.12-0.53]; P < .001; leukemia-free survival: HR, 0.35 [95% CI, 0.18-0.73]; P = .004; overall survival: HR, 0.54 [95% CI, 0.26-0.94]; P = .04). Among participants with recurrent MRD, allo-SCT was also associated with advantageous cumulative incidence of relapse, leukemia-free survival, and overall survival compared with chemotherapy (relapse: HR, 0.12 [95% CI, 0.04-0.33]; P < .001; leukemia-free survival: HR, 0.24 [95% CI, 0.10-0.56]; P = .001; overall survival: HR, 0.31 [95% CI, 0.13-0.75]; P = .01) and auto-SCT (relapse: HR, 0.28 [95% CI, 0.09-0.81]; P = .02; leukemia-free survival: HR, 0.30 [95% CI, 0.12-0.76]; P = .01; overall survival: HR, 0.26 [95% CI, 0.10-0.70]; P = .007).

Conclusions and Relevance

This study suggests that clinical decisions based on dynamic MRD might be associated with improved therapy stratification and optimized PRT for patients with IR-AML. Prospective multicenter trials are needed to further validate these findings.

Hematology and oncology clinical care during the coronavirus disease 2019 pandemic

New York City has been at the epicenter of the coronavirus disease 2019 (COVID-19) pandemic that has already infected over a million people and resulted in more than 70,000 deaths as of early May 2020 in the United States alone. This rapid and enormous influx of patients into the health care system has had profound effects on all aspects of health care, including the care of patients with cancer. In this report, the authors highlight the transformation they underwent within the Division of Hematology and Medical Oncology as they prepared for the COVID-19 crisis in New York City. Under stressful and uncertain conditions, some of the many changes they enacted within their division included developing a regular line of communication among division leaders to ensure the development and implementation of a restructuring strategy, completely reconfiguring the inpatient and outpatient units, rapidly developing the ability to perform telemedicine video visits, and creating new COVID-rule-out and COVID-positive clinics for their patients. These changes allowed them to manage the storm while minimizing the disruption of important continuity of care to their patients with cancer. The authors hope that their experiences will be helpful to other oncology practices about to experience their own individual COVID-19 crises.

Multidisciplinary exams in medical studies : Interest of docimologic analysis

Docimology has allowed the development of evaluative processes assuring valid, reliable and objective assessments. It was adopted within the faculty of Medicine of Tunis since  2007. The aim of this study was to analyze the docimological survey results of hematology-oncology exams, to evaluate the interest of this analysis in the elaboration of exams and the construction of an item bank, and propose some corrections  in order to improve assessment.     Methods :We have analyzed the hematology-oncology exams of SCMS1 (Second cycle of Medical Studies 1) from educational year 2008-2009 to 2013-2014. The data input was already done with Excel. The test includes 4 disciplines (Hematology, Oncology, Genetics and the Anatomic Pathology). We have calculated docimological parameters allowing global analysis, by discipline and by item. Results : A total of 3281 papers and 1004 questions were analyzed. The average success rate per year was 91,54% ± 7,12. The highest average success rate was found in hematology (80,51% ± 10,18). The lowest rate was found in the anatomic pathology (51,61% ± 23,76). The average rate of students succeeding the test without having average note in hematology was 5,36%. It was 42,29% in the anatomic pathology. Average difficulty index was 0,57 ± 0,05. Items analysis showed that 38,04% were easy and 19,02% were difficult. Average discrimination index was 0,25 ± 0,02. Discrimination was very good in 20,51% of items and good in 17,13%. Useless and bad discrimination items were about 40,53%. The average of Cronbach Alpha coefficient was 0,84 ± 0,03, showing a good internal-consistency. Conclusion :This study allowed an objective evaluation of "contributive disciplines" in multidisciplinary evaluation and showed the interest of integrating questions. Question analysis with teachers would be important to reevaluate and improve these items.

Analyzing the impact of systems-based hematologist in the healthcare system at an academic medical center

Over the next decade, there is a predicted shortage of nonmalignant hematologist to maintain the workforce in the United States. To address this, the American Society of Hematology described the creation of the healthcare systems-based hematologist (SBH). The role of SBH has the potential to provide high-value, cost-conscious care to the healthcare system. In 2011, an Anticoagulation and Bleeding Management Medical Directorship position for a SBH was created at our healthcare system. We described our 6-year experience as SBH at a 750-bed tertiary academic medical center to improve clinical outcomes while reducing costs. Via four different initiatives, we were able to provide high-value, cost-conscious care as SBH by reducing cost of heparin-induced thrombocytopenia management, optimizing blood product utilization using goal-directed algorithms, reducing inappropriate thrombophilia testing and improving inferior vena cava filter retrieval rates. To ensure continuing success as a SBH, business plans need to include education, enforcement, monitoring, feedback, validation of safety and outcomes and a shared vision among leadership.

Multidisciplinary care in the hematology clinic: Implementation of geriatric oncology

Multidisciplinary care is believed to provide benefits to patients with cancer. Tumor board conferences as well aspalliative care or psycho-oncological services have not only become common in oncology, but also in hematology clinics dedicated to the treatment of hematological cancers. Malignant hematological diseases are highly prevalent among older persons. Demographic changes in many countries worldwide are prompting the integration of geriatric principles, methodology, and expertise into existing procedures and infrastructure of multidisciplinary care in hematology clinics. Achieving this goal requires the close collaboration or even incorporation of multiple new professions in the hematology clinic in order to meet the needs of older patients with hematological malignancies who also have comorbidities and functional impairments. We here review the rationale, current evidence, and practical approaches of integrating geriatric oncology into multidisciplinary care in the hematology clinic.

Development and implementation of an academic cancer therapy stewardship program

OBJECTIVES

Antibiotic stewardship is an integral aspect of hospital care, limiting the potential for resistance while working to minimize waste. A similar system is needed in oncology, given the rapid proliferation of new therapies and the challenges of navigating a complicated reimbursement environment. A "cancer therapy stewardship program" has never been described in the literature. Here, we detail our efforts to design and implement such a program and share lessons learned to inform future projects.

STUDY DESIGN AND METHODS

For 1 year, a hematologist-oncologist (the "cancer therapy steward") at Mount Sinai Hospital was in charge of addressing all requests for nonformulary or off-label chemotherapeutic and supportive medications and regimens. Requests consisted of the rationale for use and supporting data from medical journal articles. This pilot initiative was focused mainly on inpatient malignant hematology.

RESULTS

Sixty-seven requests were made by 23 physicians, and all requests were ultimately approved. Requests tended to fall into 3 categories: 1) use of a single drug in a setting not approved by the FDA, 2) use of multiple drugs in novel combinations not approved by the FDA, and 3) adding novel drugs to existing FDA-approved regimens.

CONCLUSIONS

Our cancer therapy stewardship program yielded many useful insights into how our physicians face challenging clinical situations. It also helped to improve overall clinical quality and patient care by emphasizing the importance of value-based care and evidence-based medicine. Expanding this program will likely lead to many interesting experiments aimed at improving medical education and research, patient safety outcomes, and clinical quality.

Setting up your own research group

As an early career investigator, starting one's own research group is often the next important step towards a tenured academic position. As a clinical epidemiologist who has recently moved from Leiden in the Netherlands, where I obtained my PhD, to become a group leader in Berlin, Germany, I have been through this transition. In the first few months as a group leader, I encountered several new situations, as might be expected for any other novice group leader. This paper, which describes my own experiences of dealing with these new situations, may help other early career researchers in their preparations and efforts to find their own approach to handling the new situations typically encountered as a group leader.

Infectious diseases in allogeneic haematopoietic stem cell transplantation: prevention and prophylaxis strategy guidelines 2016

Infectious complications after allogeneic haematopoietic stem cell transplantation (allo-HCT) remain a clinical challenge. This is a guideline provided by the AGIHO (Infectious Diseases Working Group) of the DGHO (German Society for Hematology and Medical Oncology). A core group of experts prepared a preliminary guideline, which was discussed, reviewed, and approved by the entire working group. The guideline provides clinical recommendations for the preventive management including prophylactic treatment of viral, bacterial, parasitic, and fungal diseases. The guideline focuses on antimicrobial agents but includes recommendations on the use of vaccinations. This is the updated version of the AGHIO guideline in the field of allogeneic haematopoietic stem cell transplantation utilizing methods according to evidence-based medicine criteria.

Early career professionals: the mission of a task force

Early career researchers and clinicians face unique challenges in comparison with more senior colleagues, for instance connecting with expert leaders outside of their own institution to enhance their expertise. As the largest international thrombosis and hemostasis professional society, the ISTH can play a central role in supporting the development of early career professionals. The ISTH Early Career Task Force was formed to improve support for, and encourage collaboration between early career thrombosis and hemostasis researchers and clinicians. These activities include (1) maintaining an online forum for early career ISTH members to connect, promote clinical, research, funding and educational activities, and to generate a sense of community; (2) broaden ISTH's reach with early career professionals in the developing world through promotion of the Reach-the-World fellowships and translating ISTH websites into six languages; (3) encourage early career engagement with ISTH activities, such as guidelines and guidance document processing and online webinar series; and (4) establishing this early career forum series in this journal. The JTH Forum series will highlight the early career perspective on a wide range of issues relevant to this group, and all ISTH early career members are encouraged to contribute.

Macmillan lead acute oncology/haematology nurse

Michelle Samson discusses her professional background that has led to her current role, and the projects she has developed over the course of her career.

Social Media and the Practicing Hematologist: Twitter 101 for the Busy Healthcare Provider

Social media is a relatively new form of media that includes social networks for communication dissemination and interaction. Patients, physicians, and other users are active on social media including the microblogging platform Twitter. Many online resources are available to facilitate joining and adding to online conversations. Social media can be used for professional uses, therefore, we include anecdotes of physicians starting on and implementing social media successfully despite the limits of time in busy practices. Various applications demonstrating the utility of social media are explored. These include case discussions, patient groups, research collaborations, medical education, and crowdsourcing/crowdfunding. Social media is integrating into the professional workflow for some individuals and hematology/oncology societies. The potential for improving hematology care and research is just starting to be explored.

Bridging the Distance in the Caribbean: Telemedicine as a means to build capacity for care in paediatric cancer and blood disorders

Over the past 50 years, survival for children in high-income countries has increased from 30% to over 80%, compared to 10-30% in low and middle income countries (LMIC). Given this gap in survival, established paediatric cancer treatment centres, such as The Hospital for Sick Children (SickKids) are well positioned to share clinical expertise. Through the SickKids Centre for Global Child Health, the SickKids-Caribbean Initiative (SCI) was launched in March 2013 to improve the outcomes and quality of life for children with cancer and blood disorders in the Caribbean. The six participating Caribbean countries are among those defined by the United Nations as Small Island Developing States, due to their small size, remote location and limited accessibility. Telemedicine presents an opportunity to increase their accessibility to health care services and has been used by SCI to facilitate two series of interprofessional rounds. Case Consultation Review Rounds are a forum for learning about diagnostic work-up, management challenges and treatment recommendations for these diseases. To date, 54 cases have been reviewed by SickKids staff, of which 35 have been presented in monthly rounds. Patient Care Education Rounds provide nurses and other staff with the knowledge base needed to safely care for children and adolescents receiving treatment. Five of these rounds have taken place to date, with over 200 attendees. Utilized by SCI for both clinical and non-clinical meetings, telemedicine has enhanced opportunities for collaboration within the Caribbean region. By building capacity and nurturing expert knowledge through education, SCI hopes to contribute to closing the gap in childhood survival between high and low-resource settings.

[From JSLH (The Japanese Society for Laboratory Hematology): An Active Team Approach to Medicine as Laboratory Technologists, through Showing Bone Marrow and Peripheral Blood Samples Directly to Patients with Hematological Malignancy]

The clinical path for the treatment of acute myeloid leukemia (AML) patients has been in practice in our hospital since 2003. In the clinical path, laboratory technologists take on the role of explaining the microscopic findings in bone marrow and peripheral blood samples to patients (with or without their families) using the view-sharing microscope in our laboratory. From July 2003 to October 2014, 56 patients were enrolled in the AML clinical path and given an explanation of their bone marrow and peripheral blood samples. The patients' median age was 62, and the median time spent for explanation was 40 minutes. We conducted a questionnaire feedback survey involving those who enrolled, and the results showed significant improvement in the recognition of the disease pathophysiology, treatment efficacy, and the importance of precautions against infectious diseases. Based on the feedback, we have made marked efforts to provide patients with an improved environment during the explanatory session. This includes installing a special display for the patients, drawing a schematic illustration that shows how the blood cells differentiate, and putting them into operation in a hematology ward to promote patient privacy and precautions against infectious diseases. Hematological laboratory technologists have played an important role in patient care in our hospital. To perform their role as effectively as possible, hematological laboratory technologists participate in the conferences of the Department of Hematology and Oncology regularly, in which medical staff members can discuss the conditions and clinical courses of patients. We aim to contribute to patient satisfaction by sophisticating specialized knowledge as hematological laboratory technologists and cooperate with other medical staff members.

It takes a team: creating a hematology/hematopoietic cell therapy day hospital

It is anticipated that by the year 2020, the United States will double the number of hematopoietic cell therapy transplants completed in this country. As a freestanding cancer hospital with one of the largest hematopoietic cell therapy transplant programs in the country, City of Hope embarked on an innovative strategy to address current capacity issues and prospectively plan for future expansion of transplant volumes. This article describes the planning process that was undertaken using various content-specific focused teams to address all components of designing and opening an outpatient day hospital suitable for management of patients undergoing transplant in an ambulatory setting. The deliverables of the 11 teams that drove this planning process are addressed.

[The Onco-hematology clinical research unit at the Geneva University Hospital: example of a fruitful public-private partners]

A better understanding of the molecular deregulation leading to carcinogenesis allows the development of numerous novel targeted therapeutic candidates. Clinical research in oncology is a critical step to evaluate in a thorough manner the safety and efficacy of these innovative compounds. During the last four years the fruitful partnership between the Geneva University Hospitals and the Dr. Henri Dubois-Ferriere Dinu Lipatti Foundation lead to a dedicated clinical research unit for cancer patients with a staff of ten people. Since 2010, more than 300 patients were enrolled in more than 70 distinct clinical trials evaluating novel therapies for both solid tumors and hematologic malignancies. Interestingly, classical cytostatic drugs now represent only a small fraction of the new anti-cancer therapies in the pipeline.

Management of neutropenic fever during a transition from traditional hematology/oncology service to hospitalist care

OBJECTIVES

Increasingly, hospitalists across the United States provide primary inpatient care for almost all subspecialty patients, including hematology and medical oncology. Febrile neutropenia (FN) is a serious condition often seen as a complication of cytotoxic chemotherapy or in patients with underlying bone marrow defects. The purpose of this study was to document the change of inpatient management of a common admission diagnosis during a transition of providers from hematologists/oncologists to the use of hospitalists in a tertiary care medical center, and to compare the appropriateness of treatment and outcomes over a period of 5.5 years of this transition.

METHODS

The medical records of all patients with neutropenia at a community-based teaching hospital during a period of conversion from hematologist/oncologist to hospitalist coverage were retrospectively reviewed. Patients with fever and absolute neutrophil counts of less than 500/ microL (.5 x 10(9)/L) on admission were included. Study cases were divided into 3 groups by admission date, roughly demarcating the nascent hospitalist era, the era of transition to hospitalist, and the mature hospitalist era. Management of FN during these eras was compared.

RESULTS

Three hundred ninety-nine inpatients were identified as neutropenic. Of these, 184 did not meet case-inclusion criteria. The remaining 215 cases were included in the study. The internal medicine hospitalist service admitted less than 10% of this population in 2003, but by 2007-2008 it admitted over 90%. The use of 4th-generation cephalosporins and carbapenems increased over time (P = .027), and the infectious disease service was consulted more frequently over time (P = .007). Outcomes varied due to changes in underlying disease states, use of hospice services, and changes in the types of patients hospitalized with FN. Morbidity decreased due to the change in the type and nonantibiotic therapy of cases, but inappropriate antimicrobial treatment was unusual, and septic morbidity or mortality related to inappropriate therapy was too rare to compare through these eras.

CONCLUSION

Over the 3 eras compared, care of most neutropenic fever patients was transferred from specialists to hospitalists. Care became more uniform, guideline based, and used more infectious disease consultation, and mortality decreased. Complex changes in the types and treatments of cancer, neutropenia therapy, and in the types of patients hospitalized with FN prevent any conclusion of added value for this change in the type of primary provider management.

Molecular epidemiology of a Pseudomonas aeruginosa hospital outbreak driven by a contaminated disinfectant-soap dispenser

BACKGROUND AND OBJECTIVE

Pseudomonas aeruginosa infection represents a main cause of morbidity and mortality among immunocompromised patients. This study describes a fatal epidemic of P. aeruginosa that occurred in a hematology unit in Italy.

METHODS

Retrospective cohort study, prospective surveillance, auditing, extensive testing on healthcare workers and environmental investigation were performed to define the dynamics and potential causes of transmission. RAPD, macrorestriction analyses and sequence typing were used to define relationships between P. aeruginosa isolates.

RESULTS

Eighteen cases of infection were identified in the different phases of the investigation. Of these, five constitute a significant molecular cluster of infection. A P. aeruginosa strain with the same genetic fingerprint and sequence type (ST175) as clinical isolates strain was also isolated from a heavily contaminated triclosan soap dispenser.

DISCUSSION AND CONCLUSIONS

Our results are consistent with the hypothesis that patients became indirectly infected, e.g., during central venous catheter handling through contaminated items, and that the triclosan soap dispenser acted as a common continuous source of P. aeruginosa infection. Since P. aeruginosa is intrinsically unsusceptible to triclosan, the use of triclosan-based disinfectant formulations should be avoided in those healthcare settings hosting patients at high risk of P. aeruginosa infection.

[From disease's treatment to global care of the child with acute lymphoblastic leukemia]

The history of the treatment of childhood acute leukemia is a meaningful model of the ethical, bioethical and organizational implications of the technical progress in medicine. This experience provides indications and very useful tools to face the main topics of modern medicine: the risk of intense medicalization to the detriment of the quality of the care, the importance of psycho-emotive, ethical and spiritual aspects in the doctor-patient relationship, etc. The Authors report the difficulties and progresses until and after the first cures of children with leukemia in the Pediatric Clinic of the University "La Sapienza" of Rome (1964), the new features of treated leukemia (the real disease of cured child") and the psycho-emotive involvement of the pediatric staff a "parallel disease"). The necessity of a continuous activity aimed at the adaptation of services to scientific and medical progress and to the necessity of humanization of procedures and environment is stressed.

[On the restructuring of the blood service]

The issue of the restructuring of the blood service is discussed. The actuality and and the need of this process is substantiated. Four alternative organizational models of the blood service institutions (the centralized model, the regional model, the model based of the hospital ground and the mix model) acclaimed by the international community are proposed to be adapted to the Russia conditions. The model of the blood service of the Sverdlovsk oblast is discussed.

Improving outcomes for children with cancer in low-income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)-Part I

The difference in survival for children diagnosed with cancer between high- and low-income countries (LIC) continues to widen as curative therapies are developed in the former but not implemented in the latter. In 1996, the Monza International School of Pediatric Hematology/Oncology (MISPHO) was founded in an attempt to narrow this survival gap. During its sixth and seventh meetings, members recognized the problem of lack of affordability of essential drugs to treat childhood cancer in many LIC, and initiated an advocacy program. In 1998, MISPHO spawned a collaboration of Central American pediatric oncology centers: the Asociación de Hemato-Oncología Pediátrica Centroamericana (AHOPCA). AHOPCA members reported preliminary findings from several of the 10 cooperative protocols that are currently in progress. In 2003, a second regional collaborative group was formed that includes seven centers in South America. Twinning programs between MISPHO centers and centers in high-income countries (HIC) have proven invaluable to harness the resources of these centers to improve pediatric oncology care in LIC. MISPHO educational efforts include oncology nursing, supportive care, cancer-specific updates, epidemiology, and clinical research methods. Educational efforts are facilitated by educational content and online conferencing via www.cure4kids.org. Identifying preventable causes of abandonment of therapy and documenting the nutritional status of patients treated at MISPHO centers are areas of active research.

Hurricane Katrina's Impact on Pediatric and Adult Patients with Sickle Cell Disease

OBJECTIVE

Hurricane Katrina, making landfall in the U.S. in late August 2005, disrupted the medical infrastructure of New Orleans. We hypothesized that Hurricane Katrina measurably affected the ability of patients with sickle cell disease (SCD) to receive necessary and adequate health care. Differences in health care delivery among children and adults in New Orleans prior to the hurricane prompted our interest in these two groups.

METHODS

In May 2006, an anonymous survey was administered via either telephone or written questionnaire to patients in the greater New Orleans, Louisiana area with SCD and/or their guardians. The survey was intended to gauge patients' access to and satisfaction with specialized health care in the months following Hurricane Katrina.

CONCLUSIONS

Adult patients with SCD who relied almost exclusively on New Orleans' main public hospital (Charity Hospital) for specialized sickle cell services reported significant frustration/dissatisfaction with their medical care eight months after the storm. In contrast, pediatric patients with SCD and their guardians, who rarely received care within the public hospital system, reported more satisfaction with their care. There was a statistically significant difference between the two groups in their responses to the perception of quality of their health care.

[Centralization versus decentralization. Hematology]

Clinical haematology is the result of teamwork among dedicated specialists in pathology, molecular diagnostics, imaging, radiotherapy and the haematologist, who in turn can focus on only a limited fraction of the various and highly complex diseases that together constitute clinical haematology. The treatment of patients should be centralized in departments large enough to permit internal subspecialization and to provide expert service focused on haematology. No more than three such hematology centers are needed in Denmark.

Safe and efficacious use of procedural sedation and analgesia by non-anesthesiologists in a pediatric hematology-oncology unit

BACKGROUND

Children often require relief of pain and anxiety while undergoing diagnostic and therapeutic procedures. Procedural sedation and analgesia (PSA) is the safe and effective control of pain, anxiety and motion so as to allow a necessary procedure to be performed and to provide an appropriate degree of memory loss or decreased awareness.

OBJECTIVE

To prospectively describe procedural sedation and analgesia as performed in the pediatric oncology unit and to report the success of sedation and the incidence of complications.

METHODS

IV Midazolam and IV Ketamine were used for PSA in pediatric oncology patients undergoing painful procedures.

RESULTS

Between June 2004 and December 2004, 55 diagnostic and therapeutic procedures were performed using PSA in 16 children. There were 9 boys and 7 girls with a median age of 11 years. Twelve patients had hematolymphoid malignancies and 4 patients had solid tumors. The indication for PSA were bone marrow aspiration and or biopsy in 7 patients, therapeutic lumbar puncture in 43 patients, bone marrow aspiration and lumbar puncture in 4 patients and skin biopsy in 1 patient. All 55 procedures were successfully completed. Adverse events occurred in 15 (27%) episodes and included transient drop in oxygen saturation, vomiting, dizziness and disinhibition with crying spells. Average time to arousable state and full recovery was 22 minutes and 31 minutes respectively. None of the patients complained of post procedure pain nor recalled the procedure at the follow up visit.

CONCLUSION

Procedural sedation and analgesia using midazolam and ketamine is a safe and efficient method of limiting anxiety and procedure related pain and can be successfully administered by non-anaesthesiologists. The complication rate is low and can be easily managed.

[The Haemolymphopathology Italian Group (H.I.G.): an essential resource for the new technical and organization problems troubling modern haemolymphopathology diagnostics]

Recently, many progresses have been recorded in the molecular and histogenetic characterization of the haematopoietic and lymphoid tumours, resulting in important classifying changes. As a consequence, the exact definition of lymphoma subtype requires an integration between traditional morphologic "expertise" and several bio-functional data obtained from advanced and complex ancillary techniques (immunohistochemistry, molecular biology and cytogenetics). At the same time, the data provided by gene expression profiling studies are going to deeply modify the therapies in haematological cancers. These studies are expected to allow the achievement of single-patient-tailored genic therapy; for this reason it is necessary to get biological samples of good quality. Indeed, while these progresses contribute to highlight the pathologist's diagnostic role, they should make us reflect on the state of the art of the Italian haemolymphopathology diagnostics and on its ability to cope up with the new challanges. The aim of this article is to outline a realistic picture of the present condition, and to explain the reasons for setting up, inside SIAPEC-IAP, the Haemolymphopathology Italian Group (H.I.G.). The purpose of H.I.G. will be twofold: first of all, scheduling of a series of projects so as to the haemolymphopathological diagnostic standardization; secondly, building a national network among all the pathologists involved in this exciting and complex field of the anatomic pathology.

Quality management for clinical trials within the German Competence Network Paediatric Oncology and Haematology

The German 'Competence Network Paediatric Oncology and Haematology' aims at improving the structure of paediatric oncology and haematology as a whole, focussing in particular on the quality of clinical trials and study co-ordinating centres. This comprises the following measures: (1) Employment of research and trial assistants in order to improve the quality of documentation and study management in the participating hospitals. (2) Development of an internet portal to provide medical information for non-professionals, for patients and their families as well as for health professionals. (3) The project group 'Central Trial Support' supports study centres during the process of writing and examining new treatment protocols so that they are in compliance with the Good Clinical Practice criteria, formal criteria, legal requirements and statutory provisions. This group currently produces a structural standardisation of study protocols and case record forms in order to improve their usability. The 'Competence Network Malignant Lymphomas' is a project with similar aims and will be outlined for comparison.

Physicians' attitude and practices in sickle cell disease pain management

Many physicians believe that patients with sickle cell disease (SCD) are more likely to become addicted to pain medication than are other patient populations. This study hypothesizes that physicians' attitudes towards addiction in patients with SCD affects pain management practices. The Physician Attitudes Survey was sent to 286 physicians at seven National Institutes of Health-funded university-based comprehensive sickle cell centres. The survey assessed demographic information; and physician's attitudes toward and knowledge of pain, pain treatment, and drug addiction and abuse. Significant Pearson product-moment correlations were found between attitudes towards pain and beliefs regarding addiction to prescribed opioids. Physicians reported varied pain management strategies, however, many believe that attitudes toward addiction and to patients in pain crises may result in undertreatment of pain. These results indicate that physicians might benefit from additional education regarding sickle cell disease, addiction to pain medication, the pharmacology of opioids, and the assessment and treatment of pain.

A survey of clinical productivity and current procedural terminology (CPT) coding patterns of pediatric hematologist/oncologists

BACKGROUND

Subspecialty-specific normative values for clinical productivity of practicing pediatric hematologist/oncologists have not been well established. This information could be a useful adjunct in administrative decision-making in areas such as necessary levels of physician staffing and development of compensation plans.

METHODS

Current procedural terminology (CPT) coding information was obtained from 27 pediatric hematology/oncology groups. Clinical productivity was assessed by overall number of patient encounters and the total number of physician work relative value units (RVU) as defined by the resource-based relative value scale. The average physician productivity within each individual program was calculated. To determine uniformity of CPT coding, an additional survey solicited mock patient encounter documentation and CPT coding for a simple clinical vignette.

RESULTS

A broad range of clinical productivity was observed for both numbers of patient encounters and RVU. Evaluation of the CPT coding data of the surveyed groups revealed differences in usage of certain evaluation and management (E/M) codes and procedural and specimen interpretation codes. Within individual categories of E/M service codes, a wide variation in assigned CPT code levels was also observed. This observation was supported by differences in the E/M coding for the clinical vignette.

CONCLUSIONS

Assessment and tracking of physician productivity can provide useful information for the administrative management of pediatric hematology/oncology programs. Caution must be exercised, however, when making productivity comparisons with other subspecialties or even between pediatric hematology/oncology programs. Such comparisons should take into account the number of patient encounters, characteristics of E/M coding patterns, the use of physician extenders, as well as overall RVU production.

The Clinical Thrombosis Center and Clinical Thrombologist: A New US Health Systems Paradigm for the Management of Venous Thromboembolic Disease

New paradigms for the diagnosis, prophylaxis, acute treatment, and ongoing management of patients with venous thromboembolic disease (VTE), a better understanding of the genotypic and phenotypic mechanisms of thrombophilic states, and the possibility of a greatly expanded armamentarium of antithrombotic therapies are necessitating a more formalized and systematic approach to VTE management. This has required many US healthcare institutions to develop piecemeal approaches in management models for VTE utilizing local champions from a variety of subspecialties. Development of a formalized Clinical Thrombosis Center from an already established Anticoagulant Management Service utilizing a clinical thrombologist, a new role for a physician who has developed expertise in anticoagulation and VTE management, presents a new paradigm in which this disease may be approached at a formalized, institutional level. Thus the clinical thrombologist working through a Clinical Thrombosis Center can develop a system-of-care approach to link the rapid advances in the field of thromboembolism to clinical applications, formulate evidence-based disease management guidelines, and conduct patient-oriented translational clinical research in VTE.

[The transfusion medicine program in Cuba]

Cuba's Transfusion Medicine Program (TMP) is a subsystem of the country's National Health System. The TMP's objective is to ensure hemotherapy with blood that is safe and sufficient for all the individuals who need it. The TMP subsystem is made up of the National Commission on Transfusion Medicine, the Institute of Hematology and Immunology, 37 clinical services, 44 blood banks, 120 collection centers, 19 mobile units, and 37 blood certification laboratories. Additional facilities include a laboratory for plasma separation, a laboratory that produces leukocyte interferon and transfer factor, and two laboratories that produce reagents for blood classification and blood diagnosis symptoms. In Cuba, blood donation is voluntary. Since 1997 approximately 5% of the population per year has donated blood, thus meeting the goal recommended by the Pan American Health Organization of one voluntary blood donation annually for every 20 persons. During 2002, 563,204 blood donations were received, and there were 445,898 transfusions of blood or blood components. All donations are individually screened for HIV 1 and 2, hepatitis B, hepatitis C, and syphilis, thus meeting the country's current regulations. In 2002 these screening measures led to discarding, respectively, 0.12%, 0.60%, 0.71%, and 1.8% of the blood donations. Although the prevalence of human T-cell lymphotropic virus I and II in Cuba is very low, this test will soon be added to the screening process.

[Peru's experience with a national blood banking program]

This paper describes Peru's experiences with its National Blood Banking Program. Until the mid-1990s, the country faced a host of problems, including the lack of a legal framework to regulate blood banks, a high maternal mortality rate due to a shortage of blood, virtually no voluntary donations, a high risk of infection from transfusions, the use of only whole blood for transfusion, serious disorganization in the blood banks, deficiencies in blood bank supervision and control, no training programs, indifference on the part of health officials, frequent selling of blood, and limited community awareness. Subsequently, a strategic plan was prepared that made it possible to solve many of those problems. Legal instruments were prepared; the rate of voluntary donations rose from 0% to 19.5%; the safety of the blood was improved through compulsory screening of all donated blood units for seven markers of infectious diseases, as well as by placing a national seal of quality on all screened units. The availability of blood doubled, thus meeting 70% of the need; sales of blood decreased; and the use of blood components was improved, with 80% of the blood being fractionated. In addition, supervisory control of 100% of the blood banks in the country was achieved, a national registry was established, the cost-benefit relationship for blood units was improved through centralized screening, internal and external quality control was made mandatory, and pro-donation campaigns led to commitments from civil society. While important, all these achievements represent just a first step. This is especially true given that developing the National Blood Banking Program required the participation of outside organizations, such as the Pan American Health Organization, whose support, together with the experience provided by other countries, was key. The Program is facing a number of new challenges, and the progress that has been achieved could be threatened if current activities stagnate or if officials become complacent.