Allan D. Siefkin

Failure Mode and Effect Analysis for Delivery of Lung Stereotactic Body Radiation Therapy

PURPOSE To improve the quality and safety of our practice of stereotactic body radiation therapy (SBRT), we analyzed the process following the failure mode and effects analysis (FMEA) method. METHODS The FMEA was performed by a multidisciplinary team. For each step in the SBRT delivery process, a potential failure occurrence was derived and three factors were assessed: the probability of each occurrence, the severity if the event occurs, and the probability of detection by the treatment team. A rank of 1 to 10 was assigned to each factor, and then the multiplied ranks yielded the relative risks (risk priority numbers). The failure modes with the highest risk priority numbers were then considered to implement process improvement measures. RESULTS A total of 28 occurrences were derived, of which nine events scored with significantly high risk priority numbers. The risk priority numbers of the highest ranked events ranged from 20 to 80. These included transcription errors of the stereotactic coordinates and machine failures. CONCLUSION Several areas of our SBRT delivery were reconsidered in terms of process improvement, and safety measures, including treatment checklists and a surgical time-out, were added for our practice of gantry-based image-guided SBRT. This study serves as a guide for other users of SBRT to perform FMEA of their own practice.

Survival of Patients Undergoing Nd:YAG Laser Therapy Compared With Nd:YAG Laser Therapy and Brachytherapy for Malignant Airway Disease

Brachytherapy in combination with Nd:YAG laser therapy may add to the duration of survival of the palliative period when compared with laser alone. A retrospective study of patients with inoperable squamous cell carcinoma (SCC) was undertaken to determine if there was a difference in survival between those patients treated with Nd:YAG laser alone and those treated with Nd:YAG laser and brachytherapy. Twenty-two patients were treated with brachytherapy for malignant airway disease at our institution of which 13 had SCC. All patients had previously received treatment with Nd:YAG laser for exophytic disease. Survival was compared with those patients treated with Nd:YAG laser alone for SCC involving the airway. There was no statistical difference between the two groups with regard to age. The duration of survival of patients with SCC of the airway from the first Nd:YAG laser treatment was determined. A significant difference between those patients treated with Nd:YAG laser alone and those patients treated with combined therapy was found (p < 0.001). Brachytherapy may potentiate the duration of survival in patients with SCC involving the airway compared to palliation with Nd:YAG laser alone.

Emergency airway clot removal in acute hemorrhagic respiratory failure

Three cases of respiratory failure and severe hypoxemia caused by blood clot obscuring the central airway are described. A technique to clear the airway using a no. 6 Fogarty balloon-tip embolectomy catheter inserted through a flexible fiberoptic bronchoscope was used in all three cases. Marked improvement and stabilization occurred while definitive therapy was undertaken.

A case of fatal sodium azide ingestion

A fatal case of sodium azide poisoning in which exchange blood transfusions, charcoal hemoperfusion, hemodialysis and potent vasopressor agents failed to prevent the development of circulatory collapse associated with a wide complex cardiac rhythm is presented. The cellular toxin sodium azide resulted in the development of an altered mental status, profound metabolic acidosis, cardiac arrhythmia (atrial fibrillation and terminal wide complex arrhythmias), a relative decrease in cardiac output, hypotension and non-cardiogenic pulmonary edema. Further animal studies are needed to gain new approaches for the treatment of this rare cause of human poisoning.

Optimal pharmacologic treatment of the critically ill patient with obstructive airways disease

There are few experimental data evaluating the effect of inhaled bronchodilator treatment in the critically ill patient in the intensive care unit. Extrapolating from the data that are available in chronic and acute asthma and chronic obstructive pulmonary disease (COPD) studies, it appears that both agents may be beneficial. Beta-adrenergic receptor agonists are first-line agents in asthma. However, anticholinergics may be valuable as additive agents or as single agents if the patient is intolerant of beta-adrenergic side effects. This may be especially important in the critically ill patient with multiple organ failure in whom excessive tachycardia may reduce oxygen delivery. Anticholinergics and beta 2-adrenergic agonists both appear to be beneficial in smoking-related chronic bronchitis. Finally, because of the severity of illness in the critical care setting, both drugs should be titrated to maximal effect when possible, monitoring closely for adverse effects of the larger than normal doses that are used.

The value of serial serum angiotensin converting enzyme determinations in hospitalized patients with lung disease.

Abnormal serum angiotensin converting enzyme (ACE) activity has been reported in various human lung disorders and in laboratory animals with acute lung injuries. To test the value of serum ACE activity as an indicator of lung damage and its assistance in diagnosis or prognosis, 328 serum samples were obtained from 108 hospitalized patients with lung disease and 26 normal subjects. When patients were clinically grouped by disease entity, only the sarcoidosis group showed elevated mean serum ACE. Significantly increased serum ACE was found in 17 patients with various lung diseases (15% of hospitalized patients) 12 of whom also had concomitant liver disease. It is hypothesized that the liver may play a role in the normal metabolism of ACE being released by lung endothelial injury. Significantly low levels were seen in many acute and chronic lung injuries; specifically the groups with chronic obstructive lung disease, lung cancer, acute pneumonia, aspiration pneumonitis, gram-negative sepsis, acute myocardial infarction, and congestive heart failure. Serial measures of ACE in 71 patients with lung injuries showed that significantly decreasing levels over successive days were associated with a very high mortality. A single ACE measurement did not predict the presence or extent of lung injury, or aid in diagnosis or prognosis, but serial levels are of value prognostically. [Am J Med Sci 1984; 288(5):200–207.]

Combined Paraquat and Acetaminophen Toxicity

A case of combined paraquat and acetaminophen ingestion is reported with accompanying serial serum levels (including pre- and postcharcoal hemoperfusion) and autopsy tissue levels of both toxins. An increased lethality (time until death) is suggested in rats receiving both toxins as compared to either toxin alone. A proposed mechanism for the combined toxicity of the two drugs is hypothesized.

Does “Mainstreaming” Guarantee Access to Care for Medicaid Recipients with Asthma?

OBJECTIVE: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated.DESIGN: Cross-sectional survey.SETTING/PARTICIPANTS: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group.MEASUREMENTS AND MAIN RESULTS: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patiens covered by the state’s Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Ca1 patients were more likely to report at least one access problem compared to non-Medi-Ca1 patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction.CONCLUSIONS: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.

A Randomised Comparative Trial of Aztreonam Plus Cefazolin versus Ceftazidime for the Treatment of Nosocomial Pneumonia

SummaryA multicentre prospective randomised open-label controlled trial was conducted to compare the efficacy and safety of aztreonam (1 to 2g every 8 hours) plus cefazolin (1g every 8 hours) with that of ceftazidime (1 to 2g every 8 hours) in patients with nosocomial pneumonia. 66 adults were enrolled who had a presumptive diagnosis of pneumonia made at least 48 hours after hospitalisation. Patients exhibited the classic clinical picture of pneumonia and/or fever and/or leucocytosis and a newly developed or expanding infiltrate on chest x-ray.Among 48 evaluable patients treated, clinical cure or improvement was reported in 18 of 20 (90%) aztreonam patients as compared with 24 of 28 (85.7%) patients treated with ceftazidime. Bacteriological eradication or presumptive eradication was reported in 11 of 13 (84.6%) aztreonam patients and 15 of 19 (78.9%) ceftazidime recipients. Five patients with positive blood cultures prior to therapy (2 aztreonam, 3 ceftazidime) had negative blood cultures at study completion.Superinfection was reported in 2 patients randomised to aztreonam (both Staphylococcus aureus) and in 3 ceftazidime patients (2 with Pseudomonas aeruginosa and 1 with β-haemolytic Streptococcus). Colonisation was observed following ceftazidime (n = 4) and aztreonam (n = 2) therapy. Six aztreonam and 3 ceftazidime recipients experienced adverse events, which were possibly related to study therapy.Aztreonam plus cefazolin appears to be as effective as ceftazidime for the treatment of adults with nosocomial pneumonia.

Using pulmonary function testing in the diagnosis and treatment of asthma.

Asthmatics have remarkable changes in their pulmonary function in response to numerous external stimuli and internal controls. Serial pulmonary function testing in the office, hospital, at home, or the work place allows the objective measurement that is necessary to intelligently diagnose and treat these patients. Once the patient and the physician understand how to use the techniques for monitoring the degree of airways obstruction, they become a key in medical management decisions.