Models of care and the advanced practice nurse role in caring for children and adolescents with a cancer predisposition syndrome: a scoping review protocol.

OBJECTIVE: This scoping review will examine the literature describing models of care, barriers and facilitators of care, and gaps in care delivery for children and adolescents with a cancer predisposition syndrome (CPS). It will also explore how advanced practice nurses contribute to the delivery of care for children and adolescents with a CPS. INTRODUCTION: Cancer remains a leading cause of death in children and adolescents. Pediatric CPS clinics proactively aim for early diagnosis or prevention of cancer in children and adolescents with a CPS. Additionally, the holistic well-being of individuals requires a multidisciplinary team, including advanced practice nurses, to manage their complex health care needs. INCLUSION CRITERIA: This review will consider both published and unpublished literature exploring aspects of models of care and the role of the nurse in pediatric CPS clinics. Literature published in English from 1991 will be considered. METHODS: This scoping review will follow the JBI methodology for scoping reviews. The review will include searches in MEDLINE, Embase, and CINAHL Complete. Gray literature searches will be conducted in OAIster and Social Science Research Network (SSRN), as well as websites of hospitals in the USA and the UK with large pediatric cancer centers. Two reviewers will screen titles, abstracts, and full-text articles. An extraction table will be used to extract relevant data from all included articles and facilitate data analysis. Results will be presented in narrative and tabular format. REVIEW REGISTRATION: Open Science Framework osf.io/axkp7/.

Rethinking Blood Testing in Pediatric Cancer Patients: A Quality Improvement Approach.

Introduction: The overuse of blood tests burdens the healthcare system and can detrimentally impact patient care. Risks of frequent blood sampling include infection and clinician-induced anemia, which can negatively impact patients and their families. Pediatric cancer patients are particularly vulnerable as they are immunocompromised with a small blood volume. Four blood tests had become a daily practice. Therefore, we aimed to reduce the number of blood tests taken per bed day within the inpatient pediatric cancer unit by 15% within 8 months. Methods: This quality improvement project combined several strategies to reduce test frequency and empower clinicians on the rationale for blood test ordering. Recommendations were developed collaboratively presented in a summary table. Targeted behavior-change methodology built engagement and momentum for the change. All clinicians were challenged to STOP and THINK about why a test is necessary for each patient. The primary outcome measure was the frequency of the tests taken per bed day. Frequency was compared between pre- and postimplementation plus follow-up periods across 2019-2021. Results: 26,941 blood tests were captured in 1,558 admissions. The intervention led to an overall blood test reduction of 37% over 8 months. Liver Function Tests were the standout, with a 52% decrease in test frequency. Conclusions: A strategy incorporating education and culture change, combined with clear guidance on testing frequency, significantly reduced the ordering frequency of blood tests without increased patient harm.

Rationalised premedication practice for blood product transfusions: A single-centre quality initiative.

AIM: Blood and platelets are scarce resources that are an essential part of the supportive care for paediatric cancer patients. There are many inherent risks involved with transfusions including acute transfusion reactions (ATRs). Following an initial ATR, prophylactic medications are commonly given prior to subsequent transfusions. However, there are risks with medication administration as well as negative implications for the health system. Our aim was to prevent the automatic prescribing of premedications prior to blood and platelet transfusions for ATRs. We hypothesised this would not increase the risk of harm. METHODS: Our intervention was to eliminate automatic prescribing of intravenous corticosteroids and intravenous promethazine prior to a transfusion. This was approached through a behaviour change model and the implementation of recommended prescribing guidelines. Three Plan Do Study Act (PDSA) cycles refined the guidelines to align with clinicians' needs and build support through co-design. Data gathered on individual patients receiving transfusions and reaction rates during the trial were compared to international data. RESULTS: A total of 100 patients received a transfusion during the trial. Eleven patients either had a previous reaction or experienced their first reaction during this time. All patients followed the guidelines and had either no premedication or an oral antihistamine premedication. There were no breakthrough reactions using oral antihistamines. The overall reaction rate was 1.33%, which aligns with the reported data on ATRs internationally. CONCLUSION: A restricted prescribing approach to pharmaceutical cover prior to blood and platelet transfusions can be implemented effectively in a paediatric cancer population, without an increase in the risk of harm to the patients.

Topic maps for exploring nosological, lexical, semantic and HL7 structures for clinical data.

A topic map is implemented for learning about clinical data associated with a hospital stay for patients diagnosed with chronic kidney disease, diabetes and hypertension. The question posed is: how might a topic map help bridge perspectival differences among communities of practice and help make commensurable the different classifications they use? The knowledge layer of the topic map was generated from existing ontological relationships in nosological, lexical, semantic and HL7 boundary objects. Discharge summaries, patient charts and clinical data warehouse entries rectified the clinical knowledge used in practice. These clinical data were normalized to HL7 Clinical Document Architecture (CDA) markup standard and stored in the Clinical Document Repository. Each CDA entry was given a subject identifier and linked with the topic map. The ability of topic maps to function as the infostructure ;glue' is assessed using dimensions of semantic interoperability and commensurability.

Evaluation of clinical innovation: a gray zone in the ethics of modern clinical practice?

BACKGROUND: Various stakeholders can have differing opinions regarding ethical review when introducing new procedures with patients. OBJECTIVE: This pilot study examines the way in which Research Ethics Boards (REBs; Institutional Review Boards) and clinical biochemists (CBs; laboratory medicine specialists) differ in their interpretation of what is research and what should be considered common practice versus innovation versus experimentation when introducing new procedures with patients. It also explores whether these groups agree on who is responsible for the ethical review of new procedures. METHODS: A validated case scenario for the introduction of a new diagnostic test into clinical practice was sent to CBs and REBs across Canada. Participants were asked to determine whether the scenario constituted research; whether the test procedure should be considered as experimental, innovative, or commonly accepted care; and whether the project required approval by a REB and, if not, who should be responsible for ethical review. RESULTS: Results showed 81% of 37 CBs and 52% of 27 REBs identified the scenario as research. Responsibility for ethical review was assigned to REBs by 44% of REBs and 54% of CBs. Of all participants, 53% classified the test procedure as 'innovative', 8% as 'experimental', whereas 17% classified it as 'commonly accepted'. CONCLUSIONS: This pilot study indicates a substantial variation in the ethical assessment of innovation in clinical care. This suggests the need to further elaborate on the types of innovation in health care and categorize the nature of the risks associated with each.

When is bioavailable testosterone a redundant test in the diagnosis of hypogonadism in men?

OBJECTIVES: Total testosterone (TT) is frequently prescribed with an SHBG and/or free or bioavailable testosterone measurement. Our objective was to identify a TT range for which subsequent SHBG measurement/calculation adds no additional clinical information. DESIGN AND METHODS: Study data were composed of 3955 sets of TT, SHBG and calculated bioavailable testosterone (cBAT) results from unscreened ambulatory male subjects, aged 18-99. RESULTS: 90% of mismatches between TT and cBAT were observed with TT levels between 6.5 and 13.0 nmol/L, with only slight age variation and no important change with albumin level. SHBG measurement restricted to male patients with TT between 6.5 and 13.0 nmol/L should enable reagent cost savings of over 55%. CONCLUSION: We suggest that a TT level below 6.5 nmol/L or above 13.0 nmol/L provides sufficient useful information for ruling out hypogonadism in ambulatory adult males. This strategy of BAT testing should lead to significant time and cost savings.

Comparison of two methods to assess variability of platelet response to anti-platelet therapies in patients with acute coronary syndrome undergoing angioplasty.

The study investigated the clinical usefulness of a new method to evaluate platelet activation and the variability of platelet response to anti-platelet therapy in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). Platelet activation was assessed in parallel by a new method for platelet density measurements (MPC, Mean Platelet Component Concentration), on the automated ADVIA 120 Hematology System and by the classic measurement of P-selectin (CD62P) expression, on a fluorescence flow cytometer. Patients received a loading dose of clopidogrel (300 mg; n = 29) or a bolus of abciximab (0.25 mg/kg; n = 15). Blood samples were collected before (baseline) and at different times after PTCA and antiplatelet drugs administration. Our data showed a close inverse correlation between the change in MPC and the CD62P fluorescence surface marker expression (r = -0.776, P<0.0001). Individual platelet activation determinations in patients receiving either clopidogrel or abciximab showed a variation in platelet activation as assayed by MPC and CD62P expression. Patients were characterized as having either high platelet activity upon admission and positive response to treatment or no detectable platelet activation before or after treatment. This study demonstrates the heterogeneity of platelet activation states in ACS patients undergoing coronary angioplasty. The present work also illustrates the potential use of the MPC parameter, generated on an automated hematology system, to define high risk patients and to monitor the variability of platelet response to anti-platelet therapies.

Assessment of platelet activation in several different anticoagulants by the Advia 120 Hematology System, fluorescence flow cytometry, and electron microscopy.

In vivo platelet activation results are often confounded by activation induced in vitro during the preparative procedures. We measured ex vivo (basal) and in vitro (thrombin-induced) platelet activation in sodium citrate, ethylenediaminetetraacetic acid (EDTA), and Citrate Theophylline Dipyridamole Adenosine (CTAD) whole blood specimens. Determinations were made by measurements of platelet density (mean platelet component: MPC concentration) on the Advia 120 Hematology System. The MPC has been previously shown to correlate with a fluorescence flow cytometric method, also determined in this study, using the surface expression of CD62P. Moreover, platelet shape and structure changes in EDTA and CTAD anticoagulated whole blood specimens were characterized by transmission electron microscopy (TEM). Observations made using the Advia 120 Hematology System platelet density parameter, MPC, in the absence of thrombin were 25.7 +/- 0.9 g/dl, 27.9 +/- 0.9 g/dl and 24.8 +/- 1.2 g/dl in sodium citrate, EDTA and CTAD whole blood specimens, respectively. Addition of thrombin induced a significant change in platelet MPC for sodium citrate (21.9 +/- 1.9 g/dl; p<0.0001) and EDTA (23.2 +/- 0.9 g/dl; p<0.0001) whole blood specimens. In contrast, thrombin had no effect on MPC measured in whole blood taken into CTAD tubes. In vitro fluorescence flow cytometric platelet activation experiments measuring the percentage of platelets expressing anti-CD62P showed increase in sodium citrate specimens from 9.2 +/- 7.0 to 55.5 +/- 23.1 % (p<0.0001) and in EDTA specimens from 1.9 +/- 1.7 to 64.6 +/- 12.4 % (p<0.0001) after addition of thrombin. However, in blood taken into CTAD tubes, there was no significant change. Studies on platelets isolated from whole blood in CTAD showed activation by thrombin indicating that platelets in CTAD, while protected in its presence remained functional upon its removal. When observed by TEM over time, platelets in EDTA appear more activated and contain fewer granules than platelets in CTAD. We conclude that CTAD demonstrates in vitro platelet activation inhibition and may be useful in stabilizing ex vivo platelet activation. The novel platelet activation parameter, MPC, measured by an automated routine hematology system, using customized proprietary software, may be used in conjunction with CTAD, a stabilizing anticoagulant, to measure the ex vivo platelet activation state in whole blood specimens. TEM studies verify shape modifications and simultaneous retention of intracellular granules at early post-venipuncture time periods in CTAD specimens.