Research, quality improvement (QI), and evidence-based practice (EBP) are knowledge-based methods used to enhance nursing practice. Nurses need to conduct studies to fill empirical gaps of knowledge (research), continually monitor health care practices and processes (QI), and systematically compile and review evidence (EBP). Research, QI, and EBP are valuable instruments within the health care setting as they can benefit the patient, families, health care team members, and the nursing profession, but it is important to understand when and how to use each method. This article will differentiate between and provide examples of research, QI, and EBP by focusing on the characteristics and purposes of each method. Clinical issues and concerns can transform practices based on evidence through the proper use of these methods. Nurses are highly motivated to create the best possible environment of healing for their patients. Therefore, it is essential that nurses use research, QI, and EBP so pediatric oncology knowledge can continue to evolve.
Nurse practitioners (NPs) and physician assistants (PAs) have an important role in delivery of care in a tertiary children's hospital emergency department (ED). Most NPs and PAs have not had any formal training to work in a pediatric ED; although our NPs and PAs had no formal ED training, some were acute care certified. We describe a curriculum designed to improve knowledge and skills of NPs and PAs in the pediatric ED. The curriculum consists of three modules, namely, online lecture series, procedural workshops, and case scenarios in a simulated setting. Module 1 consisted of online lecture on 10 common ED diagnoses. The second module consisted of procedural workshops on lumbar puncture, incision and drainage of abscesses, gastrostomy insertion, and laceration repair. The third module included simulation scenarios on ED-specific cases of seizure in an infant, bronchiolitis and ruptured appendicitis with shock. Each module was evaluated by a survey. Participants rated each item on the survey using a Likert scale response (1 = disagree completely to 5 = agree completely). Both NPs and PAs demonstrated increase in knowledge scores in posttest 1 vs pretest (p < .001) and did not show a significant decline in posttest 2 (p = .073). The mean ratings of components of the online lecture series, workshops, and simulation scenarios were 4. 5-4.7, 4.4-4.8, and 4.5-4.7, respectively, with positive comments. This novel curriculum meets the educational needs of NPs and PAs at our institution and can be used as a model to train them at other tertiary care pediatric EDs.
TRAEs leading to death occurred in 3.9% of leukemia patients and 2.1% of nonleukemia patients, with the most common being pulmonary hemorrhage (1%/.6%). Conclusions: At Day +100, survival profiles and safety profiles in leukemia and nonleukemia post-HSCT patients were consistent with prior defibrotide studies and with the overall HSCT population in this study. There was a trend toward improved Day +100 survival in the nonleukemia group. Between the AML and ALL subgroups, Day +100 survival rates were similar. Support: Jazz Pharmaceuticals.Dry eye disease (DED) is one of the most common and challenging manifestation of cGVHD and ocular symptoms are largely related to patient's quality of life. This cross-sectional study aimed to describe the incidence, clinical features, outcome of DED, and Meibomian gland dysfunction (MGD) associated with ocular graft-versus-host disease (oGVHD). The patients referred to the oGVHD Unit at University of Campinas, due to ocular surface discomfort any time after allo-HSCT or for routine ocular exam prior to the procedure were included. Patients were diagnosed with cGVHD per NIH Consensus criteria. The ancillary ophthalmological examination, including Schirmer's test, Ocular Surface Disease Index (OSDI), Corneal Fluorescein Staining (CFS), Conjunctival hyperemia (CH), Tear Breakup time (TBUT) and Meibomian Gland Dysfunction (MGD) were compared to NIH ocular score at the onset of the ocular symptoms. All the data was analysed using descriptive tools and Spearman's/Pearson's test using SPSS 21 version software. Forty-one out of fifty (82%) patients had cGVHD. The median month of cGVHD onset was 7 (2-74). The median of organs involved was 3 (1-6). Mouth, skin and liver were the main organs involved (93%, 63% and 63% respectively). The ocular involvement was present in 22/41 (54%) cGVHD patients. Comparing all cGVHD patients, with or without ocular involvement, Schirmer <10 mm (−67% P < .0001), CH > 1 (67% P < .0001), CSF > 1 (43% P = .005) and OSDI > 20 (65% P < .0001) had a significant association with oGVHD. Considering just the patients with oGVHD, the Schirmer <10 mm (−54% P = .01) was the only test associated with NIH ocular score ≥1. Therefore, Schirmer's test, CH, CFS and OSDI might be important tools to refine the evaluation of oGVHD and should be considered in clinical trials addressing ocular involvement.
Pediatric patients with hematologic malignancies undergoing allogeneic hematopoietic stem cell transplantation (aHSCT) comprise a patient cohort at highest risk of developing disseminated fungal infections. Invasive aspergillosis post-HSCT is associated with unacceptably high mortality in pediatric patients with overall survival of only 15-34%. Hospital construction and excavation further potentiate the risk of fungal related morbidity and mortality in the post-HSCT setting. The current standard of care for anti-fungal prophylaxis for children undergoing aHSCT is the use of triazoles. However, 40% of healthcare associated mold infections in pediatric leukemia patients exposed to hospital construction are historically resistant to voriconazole. Methods to optimize prevention of fungal infections in this high-risk population are critical to improving pediatric aHSCT survival outcomes. We hypothesized that pre-emptive ambisome prophylaxis would be tolerated in the post-HSCT setting and would decrease the incidence of voriconazole resistant healthcare-associated fungal infections and resultant morbidity. We explored the use of intermediate dose daily ambisome (3mg/kg/day) as fungal prophylaxis in 5 patients with hematologic malignancies (2=ALL, 2=AML, 1=Lymphoblastic lymphoma) undergoing allogeneic stem cell transplantation in proximity to construction and excavation. Patient demographics, disease, donor source, conditioning regimen, methotrexate course and transplant related morbidity are shown in table 1. We found that 5 of 5 patients experienced delayed clearance of low dose methotrexate (MTX). This delayed clearance resulted in delayed methotrexate dosing in 3 of 5 patients and a missed methotrexate dose in 1 patient who subsequently developed GVHD and complications from high dose steroids. 4 of 5 patients experienced acute kidney injury (AKI), demonstrated by doubling of the pre-HSCT creatinine value following MTX administration. This identified creatinine elevation is increased as compared to historical controls receiving standard anti-fungal prophylaxis with azole agents. It has been described that AKI delays the clearance of high dose methotrexate. Here, we demonstrate that intermediate doses of daily ambisome following allogeneic HSCT is associated with AKI and delayed clearance of low doses of methotrexate used for GVHD prophylaxis in pediatric patients. Delayed methotrexate clearance was associated with development of morbidity including inadequate GVHD prophylaxis and possible resultant development of GVHD. Combined ambisome and low dose MTX is associated with AKI and delayed MTX clearance and thus is a constrained strategy for prevention of invasive fungal disease in the post-HSCT pediatric setting. The implication of these finding can be extrapolated beyond the construction setting implying cautious use of intermediate dose ambisome prophylaxis in combination with low dose MTX GVHD prophylaxis in pediatric patients post aHSCT. Table 1 Table 1. Disclosures Porteus: CRISPR Therapeutics: Consultancy, Equity Ownership.
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