Improving Pain Self-Efficacy in Orthopedic Surgery Patients Through Video-Based Education: A Quality Improvement Project.

BACKGROUND: Effective pain management following discharge is critical for postoperative recovery, with pain self-efficacy serving as a crucial component in this process. Patient education plays a key role in enhancing self-efficacy. Among various educational modalities, a growing body of evidence supports the efficacy of video-based methods. LOCAL PROBLEM: A lack of evidence-based pain education programs for patients undergoing elective orthopedic surgery was identified at an urban academic hospital on the East Coast of the United States. This quality improvement project aimed to develop and assess a video-based pain education program, focusing on pain self-efficacy and self-reported preparedness among adult patients prescribed opioids for postsurgical pain. METHODS: This project adopted a pretest-posttest design, utilizing the knowledge-to-action framework. Data collection spanned 3 months. Among the 69 patients screened for eligibility, 13 participants were included in the analysis. The primary intervention consisted of a 15-minute educational video covering essential pain management aspects. Following the intervention, pain self-efficacy and self-reported preparedness were evaluated using the Pain Self-Efficacy Questionnaire and a five-point Likert scale, respectively. RESULTS: Median (IQR) scores on the Pain Self-Efficacy Questionnaire increased significantly from 20 (16) to 32 (14) (p < .01). Mean (SD) scores for patients' self-reported preparedness also increased from 21.92 (6.53) to 31.85 (2.41) (p < .01). All participants reported being satisfied or very satisfied with the educational intervention. CONCLUSION: Video-based education is a time-efficient and cost-effective approach. Healthcare providers can consider integrating video education to enhance pain self-efficacy in the postoperative phase, thus enhancing postsurgical pain outcomes and overall recovery experience.

Improving Perioperative Pain Education for Patients Prescribed Opioids: An Integrative Review.

BACKGROUND: Postoperative pain is still inadequately managed for a significant number of patients despite the extensive use of opioids. Among several pain management strategies, patient education is a vital component of perioperative pain management. However, perioperative education practices remain inconsistent and incomplete in many hospital settings. AIM: This integrative review aims to synthesize current evidence regarding pain education interventions across all phases of perioperative care in order to promote the safe use of opioids among patients prescribed opioids. METHODS: The literature search identified 443 records published since 2016 through Cochrane Library, PubMed, the Cumulative Index of Nursing and Allied Health Literature Plus, and Embase. This review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 12 articles met the inclusion criteria. RESULTS: The study settings varied from a general surgery center to multiple settings in the United States or Canada, with sample sizes ranging from 27 to 536. The main themes from the analysis include the key components of education, the optimal timing and frequency of education, education delivery methods, and a multidisciplinary team approach. CONCLUSION: The findings from this review will help nursing professionals across surgical specialties identify effective educational approaches for patients prescribed opioids during the perioperative period. Developing education interventions based on these findings would enhance the quality and effectiveness of pain education, improve patient understanding and their preparedness to manage pain at home, and, ultimately, promote the safe use of opioids postoperatively.

Alcohol-impregnated caps and ambulatory central-line-associated bloodstream infections (CLABSIs): A randomized clinical trial.

OBJECTIVE: To evaluate the effect of 70% isopropyl alcohol-impregnated central venous catheter caps on ambulatory central-line-associated bloodstream infections (CLABSIs) in pediatric hematology-oncology patients. DESIGN: This study was a 24-month, cluster-randomized, 2 period, crossover clinical trial. SETTING: The study was conducted in 15 pediatric healthcare institutions, including 16 pediatric hematology-oncology clinics. PARTICIPANTS: All patients with an external central line followed at 1 of the 16 hematology-oncology clinics. INTERVENTION: Usual ambulatory central-line care per each institution using 70% isopropyl alcohol-impregnated caps at home compared to usual ambulatory central-line care in each institution without using 70% isopropyl alcohol-impregnated caps. RESULTS: Of the 16 participating clinics, 15 clinics completed both assignment periods. As assigned, there was no reduction in CLABSI incidence in clinics using 70% isopropyl alcohol-impregnated caps (1.23 per 1,000 days) compared with standard practices (1.38 per 1,000 days; adjusted incidence rate ratio [aIRR], 0.83; 95% CI, 0.63-1.11). In the per-protocol population, there was a reduction in positive blood culture incidence in clinics using 70% isopropyl alcohol-impregnated caps (1.51 per 1,000 days) compared with standard practices (1.88 per 1,000 days; aIRR, 0.72; 95% CI, 0.52-0.99). No adverse events were reported. CONCLUSIONS: Isopropyl alcohol-impregnated central-line caps did not lead to a statistically significant reduction in CLABSI rates in ambulatory hematology-oncology patients. In the per-protocol analysis, there was a statistically significant decrease in positive blood cultures. Larger trials are needed to elucidate the impact of 70% isopropyl alcohol-impregnated caps in the ambulatory setting. REGISTRATION: ClinicalTrials.gov; NCT02351258.

Cardiopulmonary Bypass and Infant Vaccination Titers.

BACKGROUND: Infants with congenital heart disease remain vulnerable to potentially preventable pathogens. Although immunization can significantly reduce this risk, it is unknown how immunization status can be affected by cardiac surgery with cardiopulmonary bypass (CPB). The objective was to evaluate the effect of CPB on infant vaccination status after cardiac surgery. METHODS: We conducted a prospective observational study of patients between 2 and 14 months of age who had received at least their first round of infant vaccinations and who required cardiac surgery with CPB. Antibody titers were measured before CPB and again the following morning. Demographic and surgical variables were assessed via regression methods for their effects on the change in titers. RESULTS: Among the 98 patients followed, there was no demonstrated difference between the pre- and postoperative values in regard to diphtheria, tetanus, polio 1, polio 3, or Haemophilus influenzae titers. Bordetella (1.03 vs 0.84, P < .001), and hepatitis B (log 2.10 vs 1.89, P = .001) titers did reduce after CPB but did not fall below the immunized threshold. Changes in antibody titers were not associated with time between immunization and surgery, age or weight at surgery, blood products administered, number of previous doses, time on CPB, or heterotaxy diagnosis for most of the vaccines. CONCLUSIONS: Infant vaccine antibody titers were minimally affected by CPB and not associated with any easily modifiable surgical variables. Although antibody titers are only 1 marker of immunity, deviation from the recommended vaccination schedule may be unnecessary for children requiring congenital heart surgery.

Implementation of a Novel Medical School Multidisciplinary and Interprofessional Oncology Curriculum: a Mixed Method Study.

As the population of patients with cancer and survivors grows, physician knowledge of oncology clinical care and research is increasingly important. Despite this patient population growth, medical students and non-oncology physicians report insufficient oncologic and survivorship care training. First-year students at a single US medical school completing a summer research experience were invited to participate in integrated Scholars in Oncology-Associated Research (SOAR) program. SOAR seeks to broaden students' understanding of multidisciplinary and interprofessional oncology clinical care and research. SOAR consists of three components: structured didactics, multidisciplinary tumor board attendance, and interprofessional shadowing. A mixed-methods approach investigated whether student knowledge improved after SOAR. Thirty-three students enrolled in SOAR (20 in 2015, 13 in 2016) and completed pre-assessments. Twenty-five (75.8%) students completed SOAR and post-assessments. Self-reported understanding of clinical (2[2, 3] vs. 4[4], p < 0.01) and research oncology (2[2, 3] vs. 4[4], p < 0.01) improved after SOAR. Understanding of individual disciplines also significantly improved. When describing clinical oncology, responses written post-SOAR were more comprehensive, averaging 3.7 themes per response vs. 2.8 on pre-assessments (p = 0.03). There were more references to "survivorship" as a component of oncology on post-assessments (0[0.0%] vs. 7[28.0%], p < 0.01) and "screening/prevention" (2[6.1%] vs. 7[28.0%], p = 0.03). Additionally, students more often described cancer care as a continuum on post-assessments (4[12.1%] vs. 11[44.0%], p = 0.01). A structured didactic and experiential introduction to oncology, SOAR, was successfully piloted. SOAR improved participant understanding of oncology and its distinct clinical and research disciplines. Future work will focus on expanding SOAR into a longitudinal oncology curriculum.

Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety.

BACKGROUND: Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. METHODS: We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy. Study quality was determined by consensus. Investigators developed a framework for defining the level of patient engagement: informing patients about medications (Level 1), informing about engagement with health care providers (Level 2), empowering patients with communication tools and skills (Level 3), partnering with patients in their care (Level 4), and integrating patients as full care team members (Level 5). RESULTS: We included 19 studies that mostly targeted older adults taking multiple medications. The median level of engagement was 2, ranging from 2-4. We identified no level 5 studies. Key themes for patient engagement strategies impacting medication safety were patient education and medication reconciliation, with a subtheme of patient portals. Most studies (84%) reported implementation outcomes. The most commonly reported medication safety outcomes were medication errors, including near misses and discrepancies (47%), and medication safety knowledge (37%). Most studies (63%) were of medium to low quality, and risk of bias was generally moderate. Among the 11 studies with control groups, 55% (n = 6) reported statistically significant improvement on at least one medication safety outcome. Further synthesis of medication safety measures was limited due to intervention and outcome heterogeneity. CONCLUSIONS: Key strategies for engaging patients in medication safety are education and medication reconciliation. Patient engagement levels were generally low, as defined by a novel framework for determining levels of patient engagement. As more patient engagement studies are conducted, this framework should be evaluated for associations with patient outcomes.

A 2015-2016 Survey of American Board of Cardiovascular Perfusion Certified Clinical Perfusionists: Perfusion Profile and Clinical Trends.

To document the current perfusion workforce status and to anticipate the future demands of an ever-changing perfusion workplace environment, a valid survey is needed to help guide the future of the perfusion workforce. The American Board of Cardiovascular Perfusion (ABCP) sponsored a survey of Certified Clinical Perfusionist (CCP) demographic and clinical trends that was linked electronically to the 2015-2016 ABCP online recertification process. Of 3,875 eligible CCP's, 3,056 (78.9%) responded to the survey. The 12 survey questions covered the topics of gender, age, education levels, years of clinical experience, annual clinical activity exposure, high fidelity simulation experience, recertification requirement satisfaction and professional activity requirement contentment. The results of the ABCP annual survey are being published in accordance with the ABCP's commitment to establish and maintain interactive communication with the community of CCPs. The goal of this survey is to present the perfusion and health-care community with important statistics related to the current field of perfusion and establish trends to guide the future of perfusion.

Becoming Parent and Nurse: High-Fidelity Simulation in Teaching Ambulatory Central Line Infection Prevention to Parents of Children with Cancer.

BACKGROUND: Ambulatory central-line infections in children with cancer are life-threatening. Infections are two to three times more frequent in outpatients than inpatients, for whom evidence-based bundles have decreased morbidity. Most cancer care now takes place at home, where parents perform many of the same tasks as nurses. However, parents often feel stressed and unprepared. To address this, high-fidelity simulation, which has been effective for teaching novice nurses, was evaluated for parent central-line education. METHODS: In a feasibility study using a pretest/posttest design, after completion of usual central-line education, parents participated in a high-fidelity simulation practice session. Parents were assessed in three domains: (1) knowledge of infection prevention; (2) psychomotor skill competence; and (3) ability to recognize health care provider nonadherence to best practices. Parents also completed a 5-point Likert simulation experience survey. RESULTS: A convenience sample of 17 parents participated between December 2015 and March 2016. Knowledge median scores increased from pre- to posttest from 10 to 15 of 16 points possible (p ≤ 0.001; Wilcoxon signed rank test). Median skills scores increased from pre- to posttest from 8 to 12 points of 12 possible (p ≤ 0.001). Following simulation, median recognition scores increased from 3 to 6 with 6 points possible (p ≤ 0.001). For the parent experience survey, 100% of participants strongly agreed or agreed that simulation was meaningful for learning central-line care. CONCLUSIONS: As an adjunct to usual care central-line education, translation of high-fidelity simulation to parent education is a novel approach that shows promise for improving central-line care at home in children with cancer.

Identifying Educational Needs of the Multidisciplinary Cancer Team in the Treatment of Metastatic Breast Cancer.

Background: Rapid advancements in the field of metastatic breast cancer (mBC) add to the complexity of managing patients with this disease. An educational needs assessment of multidisciplinary mBC clinicians was executed to identify practice performance gaps and recommend educational strategies aimed at closing these gaps. Methods: To ensure a collection of reliable data for assessment, a systematic process was used to design, develop, and validate the tools that were used. This grounded theory approach included assessment and confirmation by clinical experts and validation testing within the target audiences. A mixed-methods approach was used to identify practice performance gaps in care, using both qualitative in-depth interviews and quantitative surveying. The quantitative survey assessment consisted of 2 main sections: the Clinician Change Readiness Inventory tool and a Clinical Knowledge and Practice Assessment. Results: The study included 42 clinicians in the interview phase and 186 clinicians in the survey phase from 36 different states. Five key practice performance gaps were identified: (1) selecting optimal treatment, (2) personalizing therapy, (3) monitoring mBC, (4) engaging in effective communication, and (5) balancing patient access and time. Most of the gaps overlap and are related to the integral role communication plays in management decision-making in mBC. Conclusions: Awareness of the key practice performance gaps is critical to inform improvements in quality care.

Promotion of self-management for post treatment cancer survivors: evaluation of a risk-adapted visit.

PURPOSE: The LIFE Cancer Survivorship Program at NorthShore University HealthSystem provides risk-adapted visits (RAV) facilitated by an oncology nurse during which a survivorship care plan (SCP) is provided and discussed. In this report, we describe and evaluate RAV in promoting individualized health care and self-management during survivorship transition. METHODS: Patients complete a post-RAV questionnaire at their RAV and another ≥1 year after their RAV. RESULTS: One thousand seven hundred thirteen (1713) RAVs, majority for breast cancer, occurred from January 2007 to March 2014. One thousand six hundred fifteen (1615) "day-of" post-RAV questionnaires were completed. Respondents scaled statements as strongly agree/agree/disagree/strongly disagree. Combined strongly agree/agree ratings are 94 % felt more confident in communicating information about their treatments to other health care providers, 90 % felt more comfortable recognizing signs/symptoms to report to providers, and 98 % had a better appreciation for community programs/services. Of 488 respondents (RAV January 2007 to December 2012 n = 1366) to a questionnaire at least 1 year after the RAV, nearly 100 % found SCP useful to summarize medical information, 97 % to reinforce follow-up, 85 % to recognize symptoms of recurrence, 93 % to identify healthy lifestyle practices, 91 % to assist in identifying resources for support, 72 % discussed their SCP with their healthcare provider, and 97 % made at least one positive lifestyle change. CONCLUSIONS: Participation in LIFE RAV following treatment helps survivors to guide future self-care behavior. Data suggest that benefits may persist 1 year after the visit and support the feasibility of a nurse-led RAV to establish a SCP in cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Combined provision and discussion of SCPs help survivors construct a useful understanding of their cancer experience and may promote long-term self-management.

Medical Student Knowledge of Oncology and Related Disciplines: a Targeted Needs Assessment.

Despite increasing numbers of cancer survivors, non-oncology physicians report discomfort and little training regarding oncologic and survivorship care. This pilot study assesses medical student comfort with medical oncology, surgical oncology, radiation oncology, hospice/palliative medicine, and survivorship care. A survey was developed with input from specialists in various fields of oncologic care at a National Cancer Institute-designated comprehensive cancer center. The survey included respondent demographics, reports of experience with oncology, comfort ratings with oncologic care, and five clinical vignettes. Responses were yes/no, multiple choice, Likert scale, or free response. The survey was distributed via email to medical students (MS1-4) at two US medical schools. The 105 respondents were 34 MS1s (32 %), 15 MS2s and MD/PhDs (14 %), 26 MS3s (25 %), and 30 MS4s (29 %). Medical oncology, surgical oncology, and hospice/palliative medicine demonstrated a significant trend for increased comfort from MS1 to MS4, but radiation oncology and survivorship care did not. MS3s and MS4s reported the least experience with survivorship care and radiation oncology. In the clinical vignettes, students performed the worst on the long-term chemotherapy toxicity and hospice/palliative medicine questions. Medical students report learning about components of oncologic care, but lack overall comfort with oncologic care. Medical students also fail to develop an increased self-assessed level of comfort with radiation oncology and survivorship care. These pilot results support development of a formalized multidisciplinary medical school oncology curriculum at these two institutions. An expanded national survey is being developed to confirm these preliminary findings.

Design of the standardizing care to improve outcomes in pediatric end stage renal disease collaborative.

The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a North American multi-center quality transformation effort whose primary aim is to minimize exit-site infection and peritonitis rates among pediatric chronic peritoneal dialysis patients. The project, developed by the quality improvement faculty and staff at the Children's Hospital Association's Quality Transformation Network (QTN) and content experts in pediatric nephrology and pediatric infectious diseases, is modeled after the QTN's highly successful Pediatric Intensive Care Unit and Hematology-Oncology central line-associated blood-stream infection (CLABSI) Collaboratives. Like the Association's other QTN efforts, the SCOPE Collaborative is part of a broader effort to assist pediatric nephrology teams in learning about and using quality improvement methods to develop and implement evidence-based practices. In addition, the design of this project allows for targeted research that builds on high-quality, ongoing data collection. Finally, the project, while focused on reducing peritoneal dialysis catheter-associated infections, will also serve as a model for future pediatric nephrology projects that could further improve the quality of care provided to children with end stage renal disease.

Prospective analysis of association between statin use and breast cancer risk in the women's health initiative.

BACKGROUND: Statins are a class of cholesterol-lowering drugs that affect many intracellular pathways that may have implications for chemoprevention against cancer. Epidemiologic data on statins and breast cancer are conflicting. We analyzed updated data from the Women's Health Initiative (WHI) to assess the relationship between statins and breast cancer risk. METHODS: The population included 154,587 postmenopausal women ages 50 to 79 years, with 7,430 pathologically confirmed cases of breast cancer identified over an average of 10.8 (SD, 3.3) years. Information on statins was collected at baseline and years one, three, six, and nine. Self- and interviewer-administered questionnaires were used to collect information on risk factors. Cox proportional hazards regression was used to calculate HRs with 95% confidence intervals (CI) to evaluate the relationship between statin use and cancer risk. Statistical tests were two-sided. RESULTS: Statins were used by 11,584 (7.5%) women at baseline. The annualized rate of breast cancer was 0.42% among statin users and 0.42% among nonusers. The multivariable adjusted HR of breast cancer for users versus nonusers was 0.94 (95% CI, 0.83-1.06). In the multivariable-adjusted, time-dependent model, the HR for simvastatin was 0.87 (95% CI, 0.71-1.07). There was no significant trend by overall duration of use (P value for trend 0.68). There was no effect of tumor stage, grade, or hormone receptor status. CONCLUSION: Overall, statins were not associated with breast cancer risk. IMPACT: Our study is one of the largest prospective observational studies on this topic, and substantially adds to the literature suggesting no relationship between statins and breast cancer risk.

Evaluating application of the National Healthcare Safety Network central line-associated bloodstream infection surveillance definition: a survey of pediatric intensive care and hematology/oncology units.

OBJECTIVE: To evaluate the application of the National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) definition in pediatric intensive care units (PICUs) and pediatric hematology/oncology units (PHOUs) participating in a multicenter quality improvement collaborative to reduce CLABSIs; to identify sources of variability in the application of the definition. DESIGN: Online survey using 18 standardized case scenarios. Each described a positive blood culture in a patient and required a yes- or-no answer to the question "Is this a CLABSI?" NHSN staff responses were the reference standard. SETTING: Sixty-five US PICUs and PHOUs. PARTICIPANTS: Staff who routinely adjudicate CLABSIs using NHSN definitions. RESULTS: Sixty responses were received from 58 (89%) of 65 institutions; 78% of respondents were infection preventionists, infection control officers, or infectious disease physicians. Responses matched those of NHSN staff for 78% of questions. The mean (SE) percentage of concurring answers did not differ for scenarios evaluating application of 1 of the 3 criteria ("known pathogen," 78% [1.7%]; "skin contaminant, >1 year of age," 76% [SE, 2.5%]; "skin contaminant, ≤1 year of age," 81% [3.8%]; [Formula: see text]). The mean percentage of concurring answers was lower for scenarios requiring respondents to determine whether a CLABSI was present or incubating on admission (64% [4.6%]; [Formula: see text]) or to distinguish between primary and secondary bacteremia (65% [2.5%]; [Formula: see text]). CONCLUSIONS: The accuracy of application of the CLABSI definition was suboptimal. Efforts to reduce variability in identifying CLABSIs that are present or incubating on admission and in distinguishing primary from secondary bloodstream infection are needed.

Breast cancer in postmenopausal women after non-melanomatous skin cancer: the Women's Health Initiative observational study.

An increased risk of breast cancer has been reported in patients with non-melanomatous skin cancer (NMSC), but this association has not been studied in a large, multi-geographic population. We utilized data from the Women's Health Initiative observational study to assess whether history of NMSC is associated with breast cancer risk. This analysis included 70,246 postmenopausal White and Hispanic women aged 50-79, in which 4,247 breast cancer cases were identified over a mean (SD) of 11.3 (3.2) years. Baseline information was collected on demographics, medical history, sun exposure, and vitamin D intake. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95 % confidence intervals (CIs). The relationship between NMSC and breast cancer was examined as a time-dependent exposure using updated information on NMSC gathered during follow-up visits. All statistical tests were two sided. There were 5,595 women diagnosed with NMSC at study entry. The annualized rate of breast cancer was 0.64 % among women with a history of NMSC and 0.55 % among women with no history of NMSC. The multivariable-adjusted HR for breast cancer among women with a history of NMSC versus no history of NMSC was 1.07 (95 % CI 0.95-1.20, P = 0.27). Further evaluation stratified by tumor characteristics showed an increased risk of lymph node-positive disease, HR = 1.30 (95 % CI 1.01-1.67, P = 0.04), and regional-stage disease, HR = 1.33 (95 % CI 1.05-1.70, P = 0.02), among women with NMSC. There was no significant overall association between NMSC and breast cancer; however, there was an increased risk of more advanced-stage breast cancer which needs further exploration.

Blood conservation operations in pediatric cardiac patients: a paradigm shift of blood use.

BACKGROUND: Red blood cell transfusion is associated with high morbidity in pediatric patients undergoing cardiac operations. The aim of this study was to evaluate the clinical effects and outcomes of blood conservation for our pediatric patients undergoing cardiac operations. METHODS: We retrospectively analyzed a collected database of 168 pediatric patients who underwent biventricular (BV) and univentricular (UV) cardiac operations from 2006 to 2010. Patients were grouped into no blood conservation (n = 86 [BV = 74, UV = 12]) and blood conservation (n = 82 [BV = 68, UV = 14]) cohorts. There were no statistical differences in age, sex, weight, and preoperative or postoperative hemoglobin levels in the BV groups. RESULTS: Even though the blood conservation group had longer cardiopulmonary bypass (CPB) (p < 0.0001) and cross-clamp times (p < 0.002) with lower hemoglobin levels (p < 0.0001), there was a decreased need for intraoperative (p < 0.0001) and postoperative blood transfusions (p < 0.018), lower inotropic scores (p < 0.0001), a decrease in ventilator days (p < 0.0009), and a shorter length of hospital stay (p < 0.0008). In the UV blood conservation group, there were no statistical differences in age, sex, weight, CPB and cross-clamp times, preoperative and postoperative hemoglobin levels, and red blood cell transfusions despite lower intraoperative hemoglobin levels (p < 0.0009) and blood transfusion (p < 0.01) requirements. There were significantly lower inotropic scores (p < 0.001) and a trend toward a shorter duration of time on the ventilator (p < 0.07) in the blood conservation group. Logistic regression analysis demonstrated a significant correlation between intraoperative blood transfusion and increased inotropic score, longer duration on the ventilator, and increased length of hospitalization. CONCLUSIONS: Blood conservation in pediatric cardiac operations is associated with fewer ventilator days, lower inotropic scores, and shorter lengths of stay. These findings, in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products, justify blood conservation in pediatric cardiac operations.

Damus-Kaye-Stansel procedure 5 years after Fontan operation with ligated main pulmonary artery.

We report a case of tricuspid atresia with transposed great arteries and rudimentary right ventricle owing to which the patient developed severe subaortic stenosis and restrictive bulboventricular foramen 5 years after her extracardiac Fontan operation. She underwent a successful modified Damus-Kaye-Stansel operation using her native pulmonary valve. Spiral cardiac computed tomography with three-dimensional reconstructions was instrumental in pre-operative surgical planning.

Prospective analysis of association between use of statins and melanoma risk in the Women's Health Initiative.

BACKGROUND: Melanoma is the most lethal form of skin cancer, with an estimated 68,130 new cases and 8700 deaths in the United States in 2010. The increasing incidence and high death rate associated with metastatic disease support the need to focus on prevention. The authors used data from the Women's Health Initiative (WHI) to assess whether 3-hydroxy-3 methylglutaryl coenzyme A inhibitors (statins) are associated with a decreased risk of melanoma. METHODS: The study population consisted of 119,726 postmenopausal white women, in which 1099 cases of malignant melanoma were identified over an average (± standard deviation) of 11.6 ± 3.2 years. All diagnoses were confirmed by medical record review and pathology reports. Information on statin use was collected at baseline and during follow-up. Self-administered and interview-administered questionnaires were used to collect information on other risk factors. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Analyses investigated the association of any statin use, type, potency, lipophilic status, and duration of use with melanoma. RESULTS: Statins were used by 8824 women (7.4%) at baseline. The annualized rate of melanoma was 0.09% among statin users and 0.09% among nonusers The multivariable adjusted HR for statin users compared with nonusers was 1.14 (95% CI, 0.91-1.43). There were no significant differences in risk based on statin type, potency, category, duration, or in time-dependent models. CONCLUSIONS: There was no significant association between statin use and melanoma risk among postmenopausal women in the WHI.

Prospective analysis of association between use of statins or other lipid-lowering agents and colorectal cancer risk.

PURPOSE: To determine whether 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) are associated with a decreased risk of colorectal cancer. METHODS: The population included 159,219 postmenopausal women enrolled in the Women's Health Initiative in which 2000 pathologically confirmed cases of colorectal cancer were identified during an average of 10.7 (S.D. 2.9) years. Information on statins was collected at baseline and years 1, 3, 6, and 9. Self- and interviewer-administered questionnaires were used to collect information on other risk factors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated by the use of Cox proportional hazards regression to evaluate the relationship between statin use and risk. Statistical tests were two-sided. RESULTS: Statins were used by 12,030 (7.6%) women at baseline. The annualized colorectal cancer rate was 0.13% among users and 0.12% among nonusers. The multivariable adjusted HR for users versus nonusers was 0.99 (95% confidence interval [CI], 0.83-1.20, p = .95), and 0.79 (95% CI, 0.56-1.11) for users of ≥3 years. In the multivariable adjusted time-dependent model, the HR for lovastatin was 0.62 (95% CI, 0.39-0.99). There was no effect of tumor location, stage or grade. CONCLUSIONS: There was a reduction in colorectal cancer risk associated with lovastatin and a nonsignificant association with longer duration of use.