OBJECTIVE: To explore and describe the implementation of the Royal College of Nursing's approach to audit--the dynamic standard setting system--within the current context of health care, in ...particular to focus on how the system has developed since its inception in the 1980s as a method for uniprofessional and multiprofessional audit. DESIGN: Qualitative design with semistructure interviews and field visits. SETTING: 28 sites throughout the United Kingdom that use the dynamic standard setting system. SUBJECTS: Quality and audit coordinators with a responsibility for implementing the system; clinical staff who practice the system. MAIN MEASURES: Experiences of the dynamic standard setting system, including reasons for selection, methods of implementation, and observed outcomes. RESULTS: Issues relating to four themes emerged from the data: practical experiences of the system as a method for improving patient care; issues of facilitation and training; strategic issues of implementation; and the use of the system as a method for multiprofessional audit. The development of clinical practice was described as a major benefit of the system and evidence of improved patient care was apparent. However, difficulties were experienced in motivating staff and finding time for audit, which in part related to the current format of the system and the level of training and support available for clinical staff. Diverse experiences were reported in the extent to which the system had been integrated at a strategic level of quality improvement and its successful application to multiprofessional clinical audit. CONCLUSIONS: The Royal College of Nursing's dynamic standard setting system can successfully be used as a method for clinical audit at both a uniprofessional and multiprofessional level. However, to capitalise on the strengths of the system, several issues need to be considered further. These include modifications to the system itself, as well as a more strategic focus on resources and support for audit, better integration of quality initiatives in health care, and a continuing focus on ways to achieve true multiprofessional collaboration and involvement of patients in clinical audit.
Background
Metastatic germ cell tumor (mGCT) patients receiving chemotherapy have increased risk of life‐threatening venous thromboembolism (VTE). Identifying VTE risk factors may guide ...thromboprophylaxis in this highly curable population.
Methods
Data were collected from mGCT patients receiving first‐line platinum‐based chemotherapy at 22 centers. Predefined variables included International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification, long‐axis diameter of largest retroperitoneal lymph node (RPLN), Khorana score, and use of indwelling vascular access device (VAD). VTE occurring at baseline, during chemotherapy and within 90 days, was analyzed.
Results
Data from 1135 patients were collected. Median age was 31 years (range 10‐74). IGCCCG risk was 64% good, 20% intermediate, and 16% poor. VTE occurred in 150 (13%) patients. RPLN >3.5 cm demonstrated highest discriminatory accuracy for VTE (AUC 0.632, P < .001) and was associated with significantly higher risk of VTE in univariable analysis (22% vs 8%, OR 3.0, P < .001) and multivariable analysis (OR 1.8, P = .02). Other significant risk factors included, Khorana score ≥3 (OR 2.6, P = .008) and VAD use (OR 2.7, P < .001).
Conclusions
Large RPLN and VAD use are independent risk factors for VTE in mGCT patients receiving chemotherapy. VAD use should be minimized in this population and thromboprophylaxis might be considered for large RPLN.
Venous thromboembolism can cause morbidity in germ cell tumor patients receiving chemotherapy; large retroperitoneal lymphadenopathy (RPLN) and indwelling vascular access devices (VAD) are significant VTE risk factors. VAD insertion should be avoided and thromboprophylaxis can be considered for large RPLN.
Although somatic mutations in Histone 3.3 (H3.3) are well-studied drivers of oncogenesis, the role of germline mutations remains unreported. We analyze 46 patients bearing de novo germline mutations ...in histone 3 family 3A (
) or
with progressive neurologic dysfunction and congenital anomalies without malignancies. Molecular modeling of all 37 variants demonstrated clear disruptions in interactions with DNA, other histones, and histone chaperone proteins. Patient histone posttranslational modifications (PTMs) analysis revealed notably aberrant local PTM patterns distinct from the somatic lysine mutations that cause global PTM dysregulation. RNA sequencing on patient cells demonstrated up-regulated gene expression related to mitosis and cell division, and cellular assays confirmed an increased proliferative capacity. A zebrafish model showed craniofacial anomalies and a defect in Foxd3-derived glia. These data suggest that the mechanism of germline mutations are distinct from cancer-associated somatic histone mutations but may converge on control of cell proliferation.
It remains unclear which patients with metastatic germ cell tumours (mGCTs) need prophylactic anticoagulation to prevent venous thromboembolic events (VTEs).
To assess the risk and onset of VTEs ...stratified by risk factors.
This multi-institutional retrospective dataset included mGCT patients treated with first-line platinum-based chemotherapy.
Patients with prophylactic anticoagulation were excluded.
A regression analysis was performed to select risk factors for VTEs. The simulated number needed to treat (NNT) and the number needed to harm (NNH) with prophylactic anticoagulation were calculated based on the cumulative incidences retrieved from this study and hazard rates of recently published trials describing the efficacy of prophylactic anticoagulation to prevent VTEs and the risk of bleeding events.
From 1120 patients, 121 (11%) had a VTE, which occurred prior to chemotherapy in 49 (4%) and on or after chemotherapy in 72 (6%). Six patients (<1%) had a bleeding event without anticoagulation. After backward regression, the one risk factor for a VTE during or after chemotherapy was the use of a venous access device. The simulated cumulative VTE incidence from prophylactic anticoagulation for patients on or after chemotherapy would translate into an NNT of 45 (95% confidence interval CI 36–56) and an NNH of 186 (95% CI 87–506). Limitations are mainly related to the retrospective nature of the study.
The mGCTs associated VTEs are most common before and during, but not after, chemotherapy. Avoiding venous access device and/or prophylactic anticoagulation with an acceptable risk-benefit profile may decrease VTE occurring on chemotherapy.
We found that venous thromboembolic events (VTEs) occur rarely after chemotherapy. Based on experience of prophylactic anticoagulation in other cancers, we conclude that the risk of VTE in men undergoing chemotherapy for metastatic germ cell tumours can be decreased by thromboprophylaxis with a reasonable risk-benefit profile and by avoidance of venous access devices.
The results of this study suggest that all metastatic germ cell cancer patients undergoing first-line chemotherapy have an increased risk for venous thromboembolic events (VTEs), specifically before and during chemotherapy. For patients during chemotherapy with an acceptable risk-benefit profile, avoidance of venous access devices and prophylactic anticoagulation are two simple strategies to possibly decrease VTE risk.
Induction of anaesthesia Hool, Alison J; Kitson, Ross M
Anaesthesia and intensive care medicine,
01/2010, Letnik:
11, Številka:
1
Journal Article
Recenzirano
Abstract Induction of anaesthesia aims to produce a rapid, smooth transition from consciousness to unconsciousness by achieving adequate concentration of anaesthetic agents in the central nervous ...system. Careful planning is required, which includes pre-operative assessment, consent and explanation to the patient, and checking of all equipment and drugs. There are two main methods of inducing anaesthesia: inhalational and intravenous. The choice will depend upon patient and surgical factors as well as the anaesthetist's preference and experience. Rapid sequence induction is a modified induction technique (usually intravenous, but can be inhalational) used when there is increased risk of aspiration of gastric contents. At induction of anaesthesia, there is great physiological change; the complications that can occur can be classified into drug-related and airway-related. Once anaesthesia has been induced, the patient's airway must be maintained; a variety of airway maintenance techniques are available, including endotracheal intubation and laryngeal mask airway.
Good Practice in Safeguarding Adults provides an up to date and topical overview of developments in policy, guidance, legislation and practice in the area of adult protection. The book aims to ...broaden thinking about adult abuse, assesses alternative models of practice such as criminal justice and welfare, and covers groups who may be overlooked, such as people with brain injuries, older prisoners and adults within the black and minority ethnic communities. Issues covered include domestic violence and honour-based crime, abuse in institutions, financial abuse, and risk assessment in adult protection. The book is illustrated throughout with case studies, and also gives a voice to the victims of adult abuse who can be forgotten in a working environment that emphasises target performance, indicators, standards, star ratings, paperwork and correct use of terminology. This book will be essential reading for anyone working with vulnerable adults, including social workers, care managers, care workers, health care staff, police, probation officers, staff within the prison system, advocates, volunteers, training officers and students.
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