David Baer

Medication Errors Among Adults and Children With Cancer in the Outpatient Setting

PURPOSE Outpatients with cancer receive complicated medication regimens in the clinic and home. Medication errors in this setting are not well described. We aimed to determine rates and types of medication errors and systems factors associated with error in outpatients with cancer. METHODS We retrospectively reviewed records from visits to three adult and one pediatric oncology clinic in the Southeast, Southwest, Northeast, and Northwest for medication errors using established methods. Two physicians independently judged whether an error occurred (kappa = 0.65), identified its severity (kappa = 0.76), and listed possible interventions. RESULTS Of 1,262 adult patient visits involving 10,995 medications, 7.1% (n = 90; 95% CI, 5.7% to 8.6%) were associated with a medication error. Of 117 pediatric visits involving 913 medications, 18.8% (n = 22; 95% CI, 12.5% to 26.9%) were associated with a medication error. Among all visits, 64 of the 112 errors had the potential to cause harm, and 15 errors resulted in injury. There was a range in the rates of chemotherapy errors (0.3 to 5.8 per 100 visits) and home medication errors (0 to 14.5 per 100 visits in children) at different sites. Errors most commonly occurred in administration (56%). Administration errors were often due to confusion over two sets of orders, one written at diagnosis and another adjusted dose on the day of administration. Physician reviewers selected improved communication most often to prevent error. CONCLUSION Medication error rates are high among adult and pediatric outpatients with cancer. Our findings suggest some practical targets for intervention, including improved communication about medication administration in the clinic and home.

Intravenous Bisphosphonate-Related Osteonecrosis of the Jaw: Bone Scintigraphy as an Early Indicator

PURPOSE Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is recognized as a serious complication among patients receiving bisphosphonate therapy. However, methods for early detection and identification of patients at risk for osteonecrosis of the jaw (ONJ) need further investigation. The purpose of this study was to characterize BRONJ among patients receiving intravenous bisphosphonates and to examine bone scintigraphy findings that preceded manifestation of frank ONJ. MATERIALS AND METHODS We identified all known cases of BRONJ (defined according to 2006 American Association of Oral and Maxillofacial Surgeons criteria) diagnosed between January 2004 and September 2008 among patients who received intravenous bisphosphonate therapy (IVBP). The medical records were abstracted, and the clinical and radiographic features of BRONJ and relevant comorbidities were characterized. Technetium Tc 99 bone scintigrams were systematically reviewed among the subset of patients who received these imaging studies for oncologic care and imaging findings were correlated with the temporal development of ONJ. RESULTS We identified 59 cases of intravenous BRONJ (median age, 61.4 +/- 10.7 years; 57.6% female), of whom 44.1% had breast cancer, 33.9% had multiple myeloma, and the remainder had metastatic prostate cancer (15.3%) or other cancers (6.8%). One third (32.2%) of the cohort was diabetic. In addition to IVBP, the vast majority (86.4%) had also received prior systemic glucocorticoid therapy. The median cumulative number of IVBP doses was 25 (interquartile range, 16-39) at the time of BRONJ diagnosis. Half of the patients had prior invasive dental procedures; ONJ developed spontaneously in 27.1%, and in the remainder ONJ developed in the setting of periodontal disease (10.1%) or local trauma (8.4%). Most patients presented with painful stage 2 disease involving the mandible (75%), and Actinomyces was present in more than 77% of available histologic specimens. During the median follow-up of 1.5 years, 15 patients (25.4%) regressed to a less severe stage, with healing in 6 patients; 16 (27.1%) worsened; and the remainder stayed within the same stage, but in almost half of these patients, the extent of involvement progressed. Of the 38 patients who had 99Tc bone scintigraphy, 35 had bone scans before development of BRONJ, and among these patients, 23 (67.5%) had positive tracer uptake in areas that subsequently developed BRONJ. CONCLUSIONS In this study bone scintigraphy showed positive tracer uptake before the development of BRONJ in almost 66% of patients who had these scans before clinical evidence of frank osteonecrosis. BRONJ subsequently developed in the areas identified on scintigraphy in these patients. Further studies should explore the role of bone scintigraphy in the detection of early subclinical BRONJ.

Hemochromatosis screening in asymptomatic ambulatory men 30 years of age and older

OBJECTIVE To perform a cost-benefit analysis of screening for hereditary hemochromatosis. PATIENTS AND METHODS A total of 3,977 consecutive men > or = 30 years of age who presented for routine health checkups at a health maintenance organization medical center were screened for hereditary hemochromatosis by measuring transferrin saturation. Subjects with repeated transferrin saturation > or = 62% and ferritin level > or = 500 ng/mL (> or = 500 micrograms/L) were referred for liver biopsy. Subjects with transferrin saturation < 15% were referred for evaluation. Laboratory testing, screening, and abnormal screening test evaluation procedures were identified by chart review. RESULTS Forty patients had transferrin saturation > or = 62%. One hundred seventy-two had transferrin saturation < 15%. Eight patients with hemochromatosis were identified. The 3 patients most seriously affected had hepatic iron concentrations > 250 mumol/g dry weight. Two of them had hepatic fibrosis. Seven cases of hemochromatosis were found among 1,974 white subjects who were screened. Only 1 case was found among the remaining subjects. CONCLUSIONS Our observations support routine screening with transferrin saturation for white men > or = 30 years of age.

Stanford-Kaiser Permanente G1 study for clinical stage I to IIA Hodgkin's disease: subtotal lymphoid irradiation versus vinblastine, methotrexate, and bleomycin chemotherapy and regional irradiation.

PURPOSE We have demonstrated that a relatively mild chemotherapy regimen, vinblastine, methotrexate, and bleomycin (VBM), and involved-field radiotherapy (IFRT) could substitute for extended-field radiotherapy in patients with favorable Hodgkins disease (HD) who have been laparotomy-staged. The purpose of this study is to determine if VBM and regional radiotherapy can substitute for extended-field radiotherapy in favorable clinical stage (CS) I and II HD. PATIENTS AND METHODS Seventy-eight patients with favorable CS I to II HD were randomly assigned to subtotal lymphoid irradiation (STLI) or VBM chemotherapy and regional radiotherapy. Randomization was stratified on the basis of age, sex, number of Ann Arbor sites, histology, and institution. Patients were evaluated for freedom from progressive HD, survival, and toxicity. Results were compared with the predecessor trial in pathologically staged patients. RESULTS With a median follow-up period of 4 years, the rate of freedom from progressive HD was 92% (95% confidence interval [CI], 88% to 96%) for patients treated with STLI and 87% (95% CI, 81% to 93%) for patients treated with VBM and regional radiotherapy. Six of seven patients who relapsed are alive and in remission following successful second-line therapy. CONCLUSION Given the caveat of a small number of patients, the results of extended-field radiotherapy and VBM and regional radiotherapy are comparable with a median follow-up period of 4 years. VBM serves as a paradigm to reduce late effects in favorable early-stage HD. We do not advocate its routine use in clinical practice, but instead encourage participation in clinical trials with the objective of maintaining efficacy while reducing toxicity in CS I and II HD.

Patient-physician e-mail communication: the kaiser permanente experience.

Kaiser Permanente (KP) is a not-for profit health care organization that provides care for approximately 8.7 million members in nine states and the District of Columbia. In 2004, it began implementation of its current electronic health record (EHR), which by 2010, was in use in all KP regions, in both outpatient and inpatient settings. Over the same period, a suite of online services was also implemented. Among these services was a password-protected e-mail system (referred to as secure messaging) that allowed physicians and patients to communicate electronically. Use of secure messaging has increased rapidly. By 2010, 64% of the 3.6 million KP members in northern California had signed up for online access. In 2010, the 7,000 physicians of Northern California KP received 5.8 million secure messages. Secure messaging has been associated with a decrease in office visits, an increase in measurable quality outcomes (at least in primary care), and excellent patient satisfaction.

Wine, liquor, beer and risk of breast cancer in a large population

Population studies show a relation of alcohol drinking to an increased risk of breast cancer (BrCa). Aiming to investigate uncertainties about a risk threshold, the role of beverage type and interactions with other BrCa predictors, we performed a cohort study among 70,033 women, 2,829 of whom developed BrCa. Using Cox proportional hazards models with 8 covariates, the following relative risks (95% confidence intervals) for BrCa versus lifelong abstainers were found: 1.08 (0.95-1.22) at <1 drink per day, 1.21 (1.05-1.40, p=0.01) at 1-2 drinks daily and 1.38 (1.13-1.68, p=0.002) at > or = 3 drinks daily. Increased BrCa risk was concentrated in women with oestrogen receptor positive tumours with no major disparity related to choice of wine, liquor, beer or type of wine (red, white, etc). We conclude that with a threshold below 1-2 drinks daily, a hormone-related mechanism mediates a relation of alcohol drinking to an increased BrCa risk.

Acquired immune deficiency syndrome in homosexual men with hodgkin's disease. Three case reports

Fatal opportunistic infections developed in three homosexual men with Hodgkins disease. Widely disseminated Kaposis sarcoma developed in one, and another had persistent lymphadenopathy with a biopsy specimen showing benign follicular hyperplasia two years before the diagnosis of Hodgkins disease. Physicians are alerted to the possible association of Hodgkins disease and the acquired immune deficiency syndrome (AIDS). They are cautioned to consider the diagnosis of Hodgkins disease in homosexual men with lymphadenopathy and warned of the risk of serious infections in homosexual men receiving therapy for Hodgkins disease.

HIGH-GRADE NON-HODGKIN'S LYMPHOMA IN PATIENTS WITH AIDSa

An apparent excess of high grade non-Hodgkins lymphoma has been reported among those at risk for acquired immunodeficiency syndrome (AIDS), especially homosexual men. Common to these cases are pre-existing lymphadenopathy, concomitant opportunistic infections or Kaposis sarcoma, and an extremely poor prognosis. The Cancer Registry for the San Francisco Bay Area was reviewed to obtain data on the incidence of undifferentiated non-Hodgkins lymphoma among single men ages 20-50 years in 2 periods: 1975-78 and 1979-82. The Registry recoreded no such cases in the earlier period and 9 cases (6 Burkitts and 3 non-Burkitts) in 1979-82. In addition, descriptive data were obtained from area oncologists on non-Hodgkins lymphomas that developed in 18 single men 20-60 years of age in 1979-83. 17 of these men were homosexual, and the median age was 36 years. Prodromal manifestations associated with AIDS were present in various combinations in all homosexual patients. All 10 patients treated with chemotherapy had complete responses, but relapse occurred quickly in all but 2 patients (including the 1 heterosexual). Only 3 men in this series remain alive, but have other diagnostic criteria for AIDS. The 1-year survival rate for the Bay Area cases was 13%, compared with 48% in heterosexual controls with undifferentiated lymphomas treated at the National Cancer Institute. 3 major differences were noted between the California cases and NCI controls: 1) all homosexual men had prodromal manifestations of either generalized lymphadenopathy or Kaposis sarcoma or opportunistic infections compared to none of the controls: 2) Most Bay Area men had stage D (widespread or central nervous system) lymphoma on presentation; 3) the response to chemotherapy was poorer among cases than controls. Because of these differences, it is argued that malignant lymphomas that occur in members of AIDS risk groups should be a diagnostic criterion for AIDS.

Alcohol consumption and risk of hematologic malignancies.

PURPOSE Limited data suggest that alcohol drinking may have an inverse relation to risk of non-Hodgkins lymphoma (NHL). Prospective data about alcohol, NHL, and other hematologic malignancies (HM) are sparse. METHODS We carried out a cohort study in a multiethnic population of 126,293 adults who supplied baseline information at health examinations. There were subsequent HM diagnoses in 1244 persons. We used Cox proportional hazards models with seven covariates. The role of beverage types was studied by comparing groups with preponderant choices and by studying the role of frequency of drinking beverage types. RESULTS Using lifelong abstainers plus infrequent drinkers as referent, adjusted relative risks (95% confidence intervals) for HM follow: less than one drink per day=1.0 (0.9-1.2), one to two drinks per day=0.9 (0.7-1.0), greater than three drinks per day=0.7 (0.6-0.9, p=0.008). For 673 NHL these were 1.2 (1.0-1.5), 0.9 (0.7-1.2), and 0.9 (0.6-1.2). Persons reporting greater than three drinks/day had inverse relations to lymphocytic (n= 146) and myelocytic (n= 169) leukemias, with relative risk of 0.5 (0.2-1.0, p<0.05) for each. No major independent relation was seen for choice of wine, liquor, or beer. CONCLUSIONS Alcohol drinking is associated with slightly lower risk of HM, due largely to inverse relations to lymphocytic and myelocytic leukemia.

Efficacy of abbreviated Stanford V chemotherapy and involved-field radiotherapy in early-stage Hodgkin lymphoma: mature results of the G4 trial

INTRODUCTION To assess the efficacy of an abbreviated Stanford V regimen in patients with early-stage Hodgkin lymphoma (HL). PATIENTS AND METHODS PATIENTS: with untreated nonbulky stage I-IIA supradiaphragmatic HL were eligible for the G4 study. Stanford V chemotherapy was administered for 8 weeks followed by radiation therapy (RT) 30 Gy to involved fields (IF). Freedom from progression (FFP), disease-specific survival (DSS) and overall survival (OS) were estimated. RESULTS All 87 enrolled patients completed the abbreviated regimen. At a median follow-up of 10 years, FFP, DSS and OS are 94%, 99% and 94%, respectively. Therapy was well tolerated with no treatment-related deaths. CONCLUSIONS Mature results of the abbreviated Stanford V regimen in nonbulky early-stage HL are excellent and comparable to the results from other contemporary therapies.