Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative.

OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia. Undiagnosed and poorly managed AF increases risk of stroke. The Hounslow AF quality improvement (QI) initiative was associated with improved quality of care for patients with AF through increased detection of AF and appropriate anticoagulation. This study aimed to evaluate whether there has been a change in stroke and bleeding rates in the Hounslow population following the QI initiative. METHODS: Using hospital admissions data from January 2011 to August 2018, interrupted time series analysis was performed to investigate the changes in standardised rates of admission with stroke and bleeding, following the start of the QI initiative in October 2014. RESULTS: There was a 17% decrease in the rate of admission with stroke as primary diagnosis (incidence rate ratio (IRR) 0.83; 95% CI 0.712 to 0.963; p<0.014). There was an even larger yet not statistically significant decrease in admission with stroke as primary diagnosis and AF as secondary diagnosis (IRR 0.75; 95% CI 0.550 to 1.025; p<0.071). No significant changes were observed in bleeding admissions. For each outcome, an additional regression model including both the level change and an interaction term for slope change was created. In all cases, the slope change was small and not statistically significant. CONCLUSION: Reduction in stroke admissions may be associated with the AF QI initiative. However, the immediate level change and non-significant slope change suggests a lack of effect of the intervention over time and that the decrease observed may be attributable to other events.

Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices.

Objective: Atrial fibrillation (AF) is a growing problem internationally and a recognised cause of cardiovascular morbidity and mortality. The London borough of Hounslow has a lower than expected prevalence of AF, suggesting poor detection and associated undertreatment. To improve AF diagnosis and management, a quality improvement (QI) initiative was set up in 48 general practices in Hounslow. We aimed to study whether there was evidence of a change in AF diagnosis and management in Hounslow following implementation of interventions in this QI initiative. Methods: Using the general practice information system (SystmOne), data were retrospectively collected for 415 626 patients, who were actively registered at a Hounslow practice between 1 January 2011 and 31 August 2018. Process, outcome and balancing measures were analysed using statistical process control and interrupted time series regression methods. The baseline period was from 1 January 2011 to 30 September 2014 and the intervention period was from 1 October 2014 to 31 August 2018. Results: When comparing the baseline to the intervention period, (1) the rate of new AF diagnoses increased by 27% (relative risk 1.27; 95% CI 1.05 to 1.52; p<0.01); (2) ECG tests done for patients aged 60 and above increased; (3) CHA2DS2-VASc and HAS-BLED risk assessments within 30 days of AF diagnosis increased from 1.7% to 19% and 0.2% to 8.1%, respectively; (4) among those at higher risk of stroke, anticoagulation prescription within 30 days of AF diagnosis increased from 31% to 63% while prescription of antiplatelet monotherapy within the same time period decreased from 17% to 7.1%; and (5) average CHA2DS2-VASc and HAS-BLED risk scores did not change. Conclusion: Implementation of interventions in the Hounslow QI initiative coincided with improved AF diagnosis and management. Areas with perceived underdetection of AF should consider similar interventions and methodology.

A der(19)t(12;19)(q12;p13.3) in a case of pediatric acute leukemia with unusual immunophenotype.

We describe a case of acute leukemia in a child with an unusual immunophenotype and a novel cytogenetic abnormality. The leukemia blasts expressed myeloid, natural killer and B-lineage associated antigens. Cytogenetics showed the presence of a novel unbalanced chromosomal translocation, der(19)t(12;19)(q12;p13.3). The patient achieved and maintained remission with myeloid-directed chemotherapy. The differential diagnosis of the immunophenotype and the potential fusion genes are discussed.

Sweet syndrome developing during treatment with all-trans retinoic acid in a child with acute myelogenous leukemia.

Acute febrile neutrophilic dermatosis (Sweet syndrome) has been reported in a few adults receiving all-trans retinoic acid for acute promyelocytic leukemia. The authors report a case of Sweet syndrome associated with the administration of all-trans retinoic acid for acute promyelocytic leukemia in a pediatric patient.

Folic acid food fortification is associated with a decline in neuroblastoma.

BACKGROUND: Neuroblastoma, an embryonic tumor, is the second most common pediatric tumor and is the most prevalent extracranial solid tumor in children. Results of previous studies have suggested that maternal vitamin intake may decrease the risk of several childhood cancers. In January 1997, Canada began fortifying flour with folic acid for the prevention of neural tube defects. The effect of folic acid fortification on the rate of neuroblastoma in offspring is not known. METHODS: We investigated the rates of neuroblastoma (<1 year), acute lymphoblastic leukemia, and hepatoblastoma registered by the Pediatric Oncology Group of Ontario, which captures 95% of all pediatric cancers in Ontario, before and after the introduction of folate fortification. RESULTS: An interventional time series analysis showed that the incidence of neuroblastoma declined from 1.57 cases per 10,000 births before to 0.62 case per 10,000 births after folic acid fortification (P <.0001). The crude incidence rate ratio (0.40; 95% confidence interval, 0.25-0.64) remained significant after adjustment for both age and disease stage at diagnosis (adjusted incidence rate ratio, 0.38; 95% confidence interval, 0.23-0.62). In contrast, there was no significant change in the rate of infant acute lymphoblastic leukemia (incidence rate ratio, 0.97; 95% confidence interval, 0.41-2.27) or hepatoblastoma (incidence rate ratio, 0.81; 95% confidence interval, 0.35-1.89). CONCLUSIONS: Folic acid fortification was associated with a 60% reduction in neuroblastoma but was not associated with any change in the rate of infant acute lymphoblastic leukemia or hepatoblastoma. Further investigation is needed into the role of metabolism in the formation and prevention of neuroblastoma and other embryonically determined cancers.

Phase I study of fotemustine in pediatric patients with refractory brain tumors.

BACKGROUND: Fotemustine is a nitrosourea with theoretic and preclinical advantages over the original analogs, carmustine and lomustine, in the treatment of brain tumors. This is the first pediatric Phase I study of fotemustine. METHODS: Patients younger than 21 with recurrent/resistant brain tumors were enrolled in a conventional Phase I study. Fotemustine was administered intravenously every 3 weeks at increasing dose levels starting at 100 mg/m(2). Toxicity and response data were monitored closely. RESULTS: Fifteen evaluable patients entered the study and received a total of 45 courses of fotemustine (dose range, 100-175 mg/m(2)). Myelosuppression was observed, with the dose-limiting toxicity being Grade 4 neutropenia and thrombocytopenia. Toxicity was delayed and cumulative. The maximum tolerated dose was 150 mg/m(2) every 3 weeks. There were three documented radiologic responses (20% of patients) comprising one partial response and two minor responses in patients with a sarcoma, medulloblastoma, and ependymoma, respectively. CONCLUSIONS: Fotemustine administered at a dose of 150 mg/m(2) every 3 weeks is well tolerated in children and has antitumor activity in several brain tumors. This is the first dedicated Phase I study of a single agent nitrosourea in a pediatric population. More comparative studies should be undertaken to define the optimum nitrosourea analog for use in children with brain tumors.