Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit.

Critically ill patients with requirement of continuous renal replacement therapy (CRRT) represent a growing intensive care unit (ICU) population. Optimal CRRT delivery demands continuous communication between stakeholders, iterative adjustment of therapy, and quality assurance systems. This Quality Improvement (QI) study reports the development, implementation and outcomes of a quality assurance system to support the provision of CRRT in the ICU. This study was carried out at the University of Kentucky Medical Center between September 2016 and June 2019. We implemented a quality assurance system using a step-wise approach based on the (a) assembly of a multidisciplinary team, (b) standardization of the CRRT protocol, (c) creation of electronic CRRT flowsheets, (d) selection, monitoring and reporting of quality metrics of CRRT deliverables, and (e) enhancement of education. We examined 34-month data comprising 1185 adult patients on CRRT (~ 7420 patient-days of CRRT) and tracked selected QI outcomes/metrics of CRRT delivery. As a result of the QI interventions, we increased the number of multidisciplinary experts in the CRRT team and ensured a continuum of education to health care professionals. We maximized to 100% the use of continuous veno-venous hemodiafiltration and doubled the percentage of patients using regional citrate anticoagulation. The delivered CRRT effluent dose (~ 30 ml/kg/h) and the delivered/prescribed effluent dose ratio (~ 0.89) remained stable within the study period. The average filter life increased from 26 to 31 h (p = 0.020), reducing the mean utilization of filters per patient from 3.56 to 2.67 (p = 0.054) despite similar CRRT duration and mortality rates. The number of CRRT access alarms per treatment day was reduced by 43%. The improvement in filter utilization translated into ~ 20,000 USD gross savings in filter cost per 100-patient receiving CRRT. We satisfactorily developed and implemented a quality assurance system for the provision of CRRT in the ICU that enabled sustainable tracking of CRRT deliverables and reduced filter resource utilization at our institution.

Clostridium perfringens sepsis following a molar pregnancy.

Clostridium perfringens sepsis is rare since the legalization of abortion in 1973. This is a 49 year old female who developed clostridial sepsis after suction dilation and curettage for a molar pregnancy. A hysterectomy was performed after prompt recognition, and the patient survived.

Mucinous histology is a risk factor for nodal metastases in endometrial cancer.

OBJECTIVES: Mucinous adenocarcinoma of the endometrium (MUC) is a rare histological variant of endometrial carcinoma accounting for 1-9% of endometrioid tumors. Few studies have characterized its clinical behavior. This is a case-control study at a single institution comparing the risk factors and clinical course of MUC relative to endometrioid adenocarcinoma. METHODS: A case-control study was performed including patients treated for endometrial cancer between 1996 and 2006. 41 cases of mucinous adenocarcinoma were identified. Each case was matched with two controls of endometrioid histology by age and histological grade. Cases and controls were compared with regard to known risk factors for endometrial cancer and the extent of disease at diagnosis. Chi-square tests were used to compare proportions and Student's t-tests for the comparison of means. Multivariate regression was used to identify the independent predictors of lymph node metastases. Overall survival was calculated using the Kaplan-Meier method and compared with the Log-rank test. p<.05 was considered significant for all tests. RESULTS: Cases and controls were matched by age and FIGO grade and were found to be similar in regard to ethnicity, body mass index and medical history. No significant difference in myometrial invasion (MI)>50% or the presence of lymph-vascular space invasion was found between cases and controls, however, 17% of patients with MUC had lymph node metastases compared to 3% of controls (p=.01). Multivariate analysis controlling for both tumor grade and depth of MI identified mucinous histology as an independent predictor of lymph node metastasis (p=.02). There was no difference in adjuvant treatment, recurrence rate or survival between the two groups. CONCLUSION: Mucinous differentiation was found to be an independent predictor of lymph node metastasis in the study population. Comprehensive surgical staging including retroperitoneal node dissection should be strongly considered in all endometrial cancer patients with predominantly mucinous histology.

Are age cutoffs still used to identify candidates for invasive testing for chromosomal abnormalities?

OBJECTIVE: Our objective was to determine whether women > or = age 35 are more likely to undergo invasive testing after risk adjustment as compared with younger women at similar adjusted risk. STUDY DESIGN: Results of first-trimester combined aneuploidy risk assessment of singleton pregnancies from 2007-2008 were reviewed. For each level of adjusted risk, the rate of invasive testing (CVS or amniocentesis) was compared for those < age 35 and those > or = age 35. Spearman correlation, Fisher's exact test, and chi2 for trend were used for statistical comparison. RESULTS: For all categories except adjusted risk of 1 in < or = 250, women > or = age 35 were significantly more likely to undergo invasive testing as compared with younger women of similar risk. In women > or = age 35 with low adjusted risk, we observed a trend towards lower rates of invasive testing over time. CONCLUSION: The higher rate of invasive testing in those > or = 35 indicates that women are still being categorized based on age, though our data suggest this may be decreasing.

Embryonal rhabdomyosarcoma of the cervix and appendiceal carcinoid tumor.

BACKGROUND: Rhabdomyosarcomas, particularly those of gynecologic origin, are very rare in adults. As a result, there is little literature on the optimal staging procedure and treatment modalities for this population. CASE: A 43-year-old woman presented with a long-standing history of menorrhagia and was subsequently diagnosed with embryonal rhabdomyosarcoma of the cervix. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, omentectomy, and appendectomy, which also revealed a synchronous tubular carcinoid tumor of appendiceal origin. Plans for treatment involve adjuvant chemotherapy with vincristine, dactinomycin, and cyclophosphamide. CONCLUSION: This case adds to the small body of literature surrounding cervical embryonal rhabdomyosarcoma in women over the age of 40 years and proposes that appendectomy be considered during surgical management.

Adolescent comprehension of emergency contraception in New York City.

OBJECTIVE: To estimate comprehension of the over-the-counter emergency contraception label among female adolescents aged 12 through 17 years, and to compare the results with a similar study that focused on adults. METHODS: Surveys were administered to female adolescents in New York City in public venues such as malls, movie theaters, and parks. Participants were asked to read the emergency contraception (levonorgestrel) label before answering survey questions. Comparisons were made in SPSS version 13.0 using chi tests of independence and Fisher exact tests for sparse data. RESULTS: One thousand eighty-five girls between the ages of 12 and 17 participated in the study. Overall, adolescents demonstrated high comprehension of the key points of emergency contraception: (1) that it is a method of preventing pregnancy 92% (confidence interval [CI] 91-94%); (2) that it has to be taken within the first 72 hours after unprotected intercourse 83% (CI 83-87%); (3) that if you are already pregnant emergency contraception will not be effective 87% (CI 85-89%); (4) that emergency contraception will not protect against human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) 95% (CI 94-96%); and (5) that emergency contraception should not be used as a method of long-term birth control 85% (CI 83-87%). CONCLUSION: After reading the emergency contraception (levonorgestrel) label, female adolescents aged 12 to 17 understood the information necessary to use emergency contraception safely and effectively as well as their adult counterparts. LEVEL OF EVIDENCE: III.