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Minimising central-line infections in vulnerable children
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A retrospective cohort study of more than 37 000 residents of Xuanwei County in China’s Yunnan Province has concluded that the domestic use of smoky (bituminous) coal substantially increases the risk of lung cancer. The study—led by scientists at the National Cancer Institute (NCI), Bethesda, MD, USA—found that male users of smoky coal had an 18% absolute risk of dying from lung cancer before they reached the age of 70 years. Female users, nearly all of whom were non-smokers, had a 20% risk. Male and female users of smokeless coal (anthracite), by contrast, had a lung cancer risk of less than 0·5%. “Lung cancer alone accounted for about 40% of all deaths before age 60 among individuals using smoky coal”, wrote the authors. About half the world’s population relies on solid fuels or coal for cooking
and heating. The International Agency for Research on Cancer (IARC; Lyon, France) classifies indoor emissions from the combustion of coal as a group 1 carcinogen. 2 years ago the UN Foundation launched the Global Alliance for Clean Cook Stoves, aiming to ensure universal access to such devices. In China, where most people live in rural areas, the use of coal is especially prevalent. Moreover, households in Xuanwei, which has some of the highest lung cancer rates in the world, are poorly ventilated, so the internal concentration of coal smoke is particularly intense. “There are several factors that come together in Xuanwei, but the risk for lung cancer in using smoky coal, compared with smokeless coal, is much higher”, co-author Qing Lan (NCI) told The Lancet Oncology. The study period (1976–96) saw a total
of 8976 deaths, 2377 of which were due to lung cancer. Co-author Nathaniel Rothman (NCI) described the findings as a “striking example of an environmental contribution to cancer”. Lan added that “the use of less carcinogenic types of coal or other fuels would likely translate to a substantial reduction in lung cancer risk in Xuanwei”. However, this strategy might not always be feasible: good quality coal might not be locally available. Fortunately, other interventions can be highly effective. “Construct a chimney and ensure that people’s exposure to coal smoke is reduced”, urges IARC’s Robert Baan. Indeed, an earlier study co-authored by Lan showed that simply installing a household stove with a chimney can halve the risk of lung cancer.
snty-tact (Talk) Wikimedia Commons
The link between lung cancer and indoor air pollution
Published Online September 7, 2012 http://dx.doi.org/10.1016/ S1470-2045(12)70401-1 For the NCI study see BMJ 2012; 345: e5414 For Lan’s previous study see J Natl Cancer Inst 2002; 94: 826–35
Talha Khan Burki
Minimising central-line infections in vulnerable children A three-pronged approach to tackling life-threatening central-line-associated bloodstream infections in children with cancer has shown much promise. Use of a maintenance care bundle with strict protocols, the encouragement of families to be on the lookout for non-compliance, and diligent rootcause analysis prevented one in five infections over a 2-year period, say medics at Johns Hopkins University School of Medicine (Baltimore, MD, USA). But it was not until the second year that the effect was seen. The number of infections dropped by 64%, which, as the researchers wrote in their study published earlier this week, suggests that long introductory periods might be needed to embed the practices in hospital culture. In paediatric oncology, central lines are accessed as much as ten to 30 times a day. The care bundle outlined strict www.thelancet.com/oncology Vol 13 October 2012
device-handling precautions such as frequent and regular changing of dressings, regular changing of the tubes and caps, and cleaning the line before and after each use. Compliance was recorded only if all steps had been completed. Nurses also held monthly briefings to undertake root-cause analysis of every infection. Furthermore, parents were asked to provide additional oversight and were given flash cards to help them spot any deviation from the appropriate routine. The number of central-lineassociated bloodstream infections per 1000 central-line days fell from 2·25 to 1·79 over the 2-year study period, and to 0·81 during the second 12 months. The lead author of the study, Michael Rinke, said: “we really took every infection as an opportunity for learning within a no-blame culture. It
was incredibly difficult but we believe all infections are preventable”. He said whether you considered the US$45 000 cost of treating every infection or the 1% mortality rate, there was a host of reasons to make huge efforts in improving central-line care. “To have a child stay a single day more in hospital than they need to is a tragedy”, he added. Josef Vormoor (Great North Children’s Hospital, Newcastle, UK) said that the care bundle was an excellent idea but that more research was needed into which elements were the most useful and cost-effective— especially because different healthcare systems would have different approaches to central-line care. “This highlights what is a significant problem and risk for patients”, he concluded.
Published Online September 7, 2012 http://dx.doi.org/10.1016/ S1470-2045(12)70400-X For the study by Rinke and colleagues see Pediatrics 2012; published online Sept 3. DOI:10.1542/peds.2012-0295
Emma Wilkinson e415
A retrospective cohort study of more than 37 000 residents of Xuanwei County in China’s Yunnan Province has concluded that the domestic use of smoky (bituminous) coal substantially increases the risk of lung cancer. The study—led by scientists at the National Cancer Institute (NCI), Bethesda, MD, USA—found that male users of smoky coal had an 18% absolute risk of dying from lung cancer before they reached the age of 70 years. Female users, nearly all of whom were non-smokers, had a 20% risk. Male and female users of smokeless coal (anthracite), by contrast, had a lung cancer risk of less than 0·5%. “Lung cancer alone accounted for about 40% of all deaths before age 60 among individuals using smoky coal”, wrote the authors. About half the world’s population relies on solid fuels or coal for cooking
and heating. The International Agency for Research on Cancer (IARC; Lyon, France) classifies indoor emissions from the combustion of coal as a group 1 carcinogen. 2 years ago the UN Foundation launched the Global Alliance for Clean Cook Stoves, aiming to ensure universal access to such devices. In China, where most people live in rural areas, the use of coal is especially prevalent. Moreover, households in Xuanwei, which has some of the highest lung cancer rates in the world, are poorly ventilated, so the internal concentration of coal smoke is particularly intense. “There are several factors that come together in Xuanwei, but the risk for lung cancer in using smoky coal, compared with smokeless coal, is much higher”, co-author Qing Lan (NCI) told The Lancet Oncology. The study period (1976–96) saw a total
of 8976 deaths, 2377 of which were due to lung cancer. Co-author Nathaniel Rothman (NCI) described the findings as a “striking example of an environmental contribution to cancer”. Lan added that “the use of less carcinogenic types of coal or other fuels would likely translate to a substantial reduction in lung cancer risk in Xuanwei”. However, this strategy might not always be feasible: good quality coal might not be locally available. Fortunately, other interventions can be highly effective. “Construct a chimney and ensure that people’s exposure to coal smoke is reduced”, urges IARC’s Robert Baan. Indeed, an earlier study co-authored by Lan showed that simply installing a household stove with a chimney can halve the risk of lung cancer.
snty-tact (Talk) Wikimedia Commons
The link between lung cancer and indoor air pollution
Published Online September 7, 2012 http://dx.doi.org/10.1016/ S1470-2045(12)70401-1 For the NCI study see BMJ 2012; 345: e5414 For Lan’s previous study see J Natl Cancer Inst 2002; 94: 826–35
Talha Khan Burki
Minimising central-line infections in vulnerable children A three-pronged approach to tackling life-threatening central-line-associated bloodstream infections in children with cancer has shown much promise. Use of a maintenance care bundle with strict protocols, the encouragement of families to be on the lookout for non-compliance, and diligent rootcause analysis prevented one in five infections over a 2-year period, say medics at Johns Hopkins University School of Medicine (Baltimore, MD, USA). But it was not until the second year that the effect was seen. The number of infections dropped by 64%, which, as the researchers wrote in their study published earlier this week, suggests that long introductory periods might be needed to embed the practices in hospital culture. In paediatric oncology, central lines are accessed as much as ten to 30 times a day. The care bundle outlined strict www.thelancet.com/oncology Vol 13 October 2012
device-handling precautions such as frequent and regular changing of dressings, regular changing of the tubes and caps, and cleaning the line before and after each use. Compliance was recorded only if all steps had been completed. Nurses also held monthly briefings to undertake root-cause analysis of every infection. Furthermore, parents were asked to provide additional oversight and were given flash cards to help them spot any deviation from the appropriate routine. The number of central-lineassociated bloodstream infections per 1000 central-line days fell from 2·25 to 1·79 over the 2-year study period, and to 0·81 during the second 12 months. The lead author of the study, Michael Rinke, said: “we really took every infection as an opportunity for learning within a no-blame culture. It
was incredibly difficult but we believe all infections are preventable”. He said whether you considered the US$45 000 cost of treating every infection or the 1% mortality rate, there was a host of reasons to make huge efforts in improving central-line care. “To have a child stay a single day more in hospital than they need to is a tragedy”, he added. Josef Vormoor (Great North Children’s Hospital, Newcastle, UK) said that the care bundle was an excellent idea but that more research was needed into which elements were the most useful and cost-effective— especially because different healthcare systems would have different approaches to central-line care. “This highlights what is a significant problem and risk for patients”, he concluded.
Published Online September 7, 2012 http://dx.doi.org/10.1016/ S1470-2045(12)70400-X For the study by Rinke and colleagues see Pediatrics 2012; published online Sept 3. DOI:10.1542/peds.2012-0295
Emma Wilkinson e415