St. Mary-Corwin Medical Center

The recent introduction of clinically available next generation sequencing (NGS) cancer panels has presented new challenges for genetic counselors. Determining which patients are appropriate for NGS panel testing is complex. Due to the large number of genes included in the NGS panels, thorough and appropriate pre-test counseling and interpretation of NGS results can be a time-consuming and difficult process. Many of the genes associated with increased cancer risk lack published clinical management guidelines and estimates of cancer risk for individuals with deleterious mutations. In order to efficiently and effectively review the clinical utility of NGS panels, Colorado cancer genetic counselors formed a working group to gain a better understanding of the genes included in NGS cancer panels. This publication reports on the approach of this group, the process used to evaluate a selected NGS panel, future directions for this collaboration, and ideas for other genetic counselors to form similar groups to efficiently evaluate new technologies and improve practice.

Acute stroke can result in neurological impairment or death. The Colorado Stroke Alliance and the Colorado Stroke Registry have made progress toward improving stroke care through their statewide quality improvement efforts. This report is a follow-up to a previous publication in the Journal of Neuroscience Nursing. The previous report focused on the organization and structure of the Colorado Stroke Alliance. The present report describes some of the successes and insights that have been achieved, including adherence to stroke quality indicators, gender disparities, process times for intravenous recombinant tissue plasminogen activator/alteplase, the impact of emergency medical services, and the role that nurses continue to have as agents of change in improving hospital care.

The validity of death certification of stroke was studied in the general population cohort at Framingham, MA. During the last 30 years, 5106 people aged 30 to 62 and free of CHD and stroke at entry have been followed for the development of cardiovascular disease including stroke. Of the 280 decedents with certified stroke 113 (40% false negative rate) had no mention of stroke on the death certificate. THe false negative rate increased significantly with increasing age at death and increasing interval from last stroke to death. Among the 216 certificates listing stroke there were 46 false positives (21%). Analysis by type of stroke disclosed marked over-reporting of cerebral hemorrhage and under-reporting of cerebral embolus. This comparison of prospectively collected data to death certificates should raise questions about the accuracy of studies dependent on ths source of information.

Two cases of nafcillin-induced neutropenia in children are discussed. A seven-year-old girl was referred to the hospital after the pain and swelling in her foot persisted despite five days of oral penicillin VK therapy. Administration of intravenous nafcillin 150 mg/kg/day was started upon admission. The patient's leukocyte count was normal upon admission; further, her leukocyte and neutrophil counts were normal on the 10th and 17th days of hospitalization. After 22 days of nafcillin therapy, her leukocyte and neutrophil counts fell to 2300 and 162/cu mm, respectively. Three days after the nafcillin was discontinued, the leukocyte count was 5800/cu mm. The patient was given dicloxacillin 50 mg/kg/day, and had no recurrence of neutropenia. The second case involved a 28-month-old girl admitted to the hospital with fever, irritability, and skin rash. Her leukocyte count was normal upon admission. She received 10 days of penicillin G 100,000 units/kg/day, followed by 10 days of nafcillin 150 mg/kg/day, before neutropenia was discovered. On the ninth day of nafcillin therapy, here leukocyte and neutrophil counts were 4200 and 822/cu mm, respectively. Nafcillin was discontinued and cefazolin therapy was initiated at 100 mg/kg/day. Blood counts returned to normal, and there was no recurrence of neutropenia. Differential blood cell counts should be performed on patients receiving nafcillin, and, if neutropenia develops, nafcillin should be discontinued and treatment with a nonpenicillin antimicrobial considered.