High-dose therapy and autologous hematopoietic stem cell transplantation for patients with primary systemic amyloidosis: a Center for International Blood and Marrow Transplant Research Study

OBJECTIVE: To determine the outcome of high-dose therapy with autologous hematopoietic stem cell transplantation (HSCT) in patients with primary systemic amyloidosis reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). PATIENTS AND METHODS: A total of 107 recipients of autologous HSCT for amyloidosis from 48 transplantation centers were reported to the CIBMTR between 1995 and 2001. Hematologic and organ responses were assessed at 100 days and 1 year. Transplantation-related mortality (TRM) was assessed at day 30 after HSCT. A multivariate analysis assessed factors that influenced overall survival. RESULTS: Improvement at day 100 was seen in 1 or more amyloidosis-affected sites (bone marrow, kidney, liver, and/or heart) in 28 (36%) of 77 patients; the 1-year responses included complete response (16%), partial response (16%), stable disease (31%), and disease progression (10%). With a median follow-up of 30 months, the 1- and 3-year survival rates were 66% (95% confidence interval [CI], 56%-75%) and 56% (95% CI, 45%-66%), respectively. The day 30 TRM was 18% (95% CI, 11%-26%). In the multivariate analysis, only the year of transplantation (patients who most recently underwent transplantation) was associated with post-HSCT survival (P-.02). CONCLUSION: In this multi-institutional CIBMTR study, the 3-year survival rate was comparable to single-center results, with patients who more recently underwent transplantation faring better. Of note, the TRM was higher than that reported by single centers, which may reflect differences in patient selection and/or experience in treating this challenging disease. We hope that a better understanding of the recently recognized prognostic factors and more stringent patient selection will result in lower TRM and improved survival.     

骨髓干细胞移植治疗骨不连及骨缺损临床研究

目的观察自体骨髓干细胞移植治疗骨不连及骨缺损的疗效。方法140例患者随机分为自体髂骨移植组(A组)及自体骨髓干细胞移植组(B组)各70例,均行手术治疗,并行简单有效的内外固定。结果术后平均愈合时间A组为(7.0±2.0)个月,B组为(5.0±1.5)个月,两组间有显著性差异(P<0.05);治疗期间患者无明显不良反应。结论自体骨髓干细胞移植较传统植骨治疗骨不连及骨缺损疗程短、疗效好,无不良反应。     

社区医务人员对居家脑卒中患者分级护理认知的质性研究

目的 了解社区医务人员对居家脑卒中患者分级护理的体验。方法 对郑州市中原区3个社区的15名医务人员进行半结构式访谈,并用Colaizzi 7步法分析资料。结果 提炼出3个主题,主题1:家庭照护为主,专业照护为辅,专业化照护需求参差不齐,照护现状不容乐观;主题2:科学分级,有效照护;主题3:分级之路,任重道远。其中主题3包括4个次主题:分级护理符合我国深化医药卫生体制改革要求,但缺乏有效政策支持;缺乏相应的分级护理评估工具;社区医疗资源不足,医务人员核心能力需提高;缺乏连续信息平台,无法做到医院-社区-家庭的连续照护。结论 整合医疗资源,合理界定分级,规范分级照护内容,提升医务人员的核心能力,保证居家照护效果,完善共享信息平台,实现管理监督是居家脑卒中患者分级护理继续发展的主要任务。     

Prospective Study of Candida Species in Patients at a Comprehensive Cancer Center

Since most nosocomial systemic yeast infections arise from the endogenous flora of the patient, we prospectively evaluated the species stratification and antifungal susceptibility profile of Candida spp. associated with heavy colonization and systemic infection in patients at Memorial Sloan-Kettering Cancer Center in New York. A total of 349 Candida isolates were obtained from 223 patients during the later half of 1998. Cancer was the most common underlying disease, occurring in 91% of the patients, including 61.8% with organ and 23.7% with hematological malignancies; 4.4% of the patients had AIDS. Candida albicans was the predominant species (67.3%); among 114 non-albicans Candida spp., C. glabrata (45.6%) was the most frequent, followed by C. tropicalis (18.4%), C. parapsilosis (16.6%), and C. krusei (9.6%). The overall resistance to triazole-based agents among all yeast isolates was 9.4 and 10.8% for fluconazole and itraconazole, respectively. A total of 5% of C. albicans strains were resistant to triazole antifungals, whereas 30.8 and 46.2% of C. glabrata strains were resistant to fluconazole (MIC > or = 64 microg/ml) and itraconazole (MIC > or = 1 microg/ml), respectively. A significant association was observed between prior treatment with triazole and isolation of fluconazole-resistant C. albicans (P = 0.005, OR 36), although this relationship was not seen in C. glabrata isolates (P = 0.4). This study reinforces the importance of periodic, prospective surveillance of clinical fungal isolates to determine appropriate prophylactic, empiric, and preemptive antifungal therapy for the highly susceptible patient population.     

癌症治疗功能评价-骨髓移植分量表的汉化及信效度检验

目的对第4版癌症治疗功能评价-骨髓移植分(Functional Assessment of Cancer Treatment-Bone Marrow Transplant,FACT-BMT)量表进行汉化,初步验证量表在中国骨髓移植后患者中的适用性。方法依据量表翻译方法学对第4版FACT-BMT量表进行翻译和文化调试,以137例北京某三级甲等医院骨髓移植后患者作为研究对象,检验量表内部一致性信度;成立专家委员会,验证量表内容效度。结果量表的Cronbach'sα系数为0.71～0.90,总体Cronbach'sα系数为0.83;内容效度为0.87,22个条目的内容效度高于0.80。结论国内骨髓移植患者能够较好地理解第4版FACT-BMT量表中的内容,量表具备较高的内部一致性和内容效度,可应用于我国骨髓移植治疗患者的躯体健康、心理情绪及社会角色等方面的测量。     

医护人员对ICU日记认知和态度的质性研究

目的探究重症监护医护人员对ICU日记的真实态度和认知,为我国开展ICU日记项目提供参考.方法运用现象学研究方法,在2019年4-6月期间,目的抽样选取某三级医院重症监护室的15名医护人员进行半结构式深入访谈,采用Colaizzi 7步法对资料进行分析.结果提炼出三个主题:认可实施ICU日记的意义、实施ICU日记阻力因素、实施ICU日记相关建议.结论医护人员认可开展ICU日记的意义;建议医院出台相关支持政策,制定标准化模板,加强培训,积极推动ICU日记的开展,以期降低患者及家属ICU后综合征的发生.     

70例肾移植术后受者血清生化指标水平的调查

目的 调查肾移植术后患者血清生化指标水平,探讨肾移植手术的临床应用效果、意义。方法 用全自动OLYMPUS AU600生化分析仪分别对肾移植术后患者及正常对照组的血清生化指标进行分析比较。结果 肾移植组血清中ALT、AST、URIC基本正常（P〉0.05）,TP、ALB、GLOB水平明显低于对照组（P〈0.01）,BUN、CR的水平虽在正常参考范围内,但与对照组比存在显著性差异（P〈0.01）。心肌酶谱中的CK、CK-MB水平也在正常参考范围内,但与对照组相比存有差异（P〈0.05）。LDH、HBDH水平明显高于对照组（P〈0.01）。血脂中的CHOL、TG、HDL-C、AproA的水平两组无显著性差异（P〉0.05）,移植组中LDL-C、AproB水平升高,（P〈0.05）,Lp（a）水平明显升高（P〈0.01）。结论 肾移植术后受者肾功能有明显改善,但不能恢复到与正常对照组完全一致,其血清中蛋白水平低于对照组,肝功能基本正常,血脂代谢部分紊乱。     

Prevalence and Quantity of Parvovirus B19 DNA Among Blood Donors from a Regional Blood Center in Turkey

ObjectiveParvovirus B19 causes a range of diseases and morbidity in humans and is transmissible by transfusion of blood, blood components and plasma derivatives. The objective of the study was to investigate the prevalence and quantity of B19 DNA among blood donors. Method: Totally 1053 samples were collected from March to July 2016 at a blood bank for detection of Parvovirus B19 DNA and serological status of blood donors. Testing of the presence of viral DNA was performed by a quantitative real-time PCR with a 101 copies/ml detection limit. All DNA positive and randomly selected 267 samples were tested for the presence of anti-B19 IgM and IgG by ELISA.ResultsAge distribution of donors was between 18-64; mean age was 27 and median was 23. Among the 1053 samples, 5 (0.47%) had PB19 DNA. All PB19 DNA positive donations had both B19 IgM and IgG antibodies. The DNA level for positive donations were between 0.9 × 102 to 3.1 × 104 copies/ml. IgG and IgM were present in 59.9% (160/267) and 0,74% (2/267) respectively among the healthy donors without PB19 DNA.ConclusionDetected DNA concentration was less than 105 copies/ml. The presence of IgM in low level PB19 DNA positive donors may indicate that there might be a risk in transmission of PB19 to particularly immunosuppressed recipients. The clinical follow-up of blood donation with low level of PB19DNA should be considered to answer the questions about blood safety.     

PICC专科护士对癌症患者开展叙事护理体验的现象学研究

目的 了解经外周静脉置入中心静脉导管(peripherally inserted cen-tral catheters,PICC)专科护士在为癌症患者置管-维护-拔管过程中运用叙事护理方法的工作体验、成长收获和开展叙事护理面临的困难和挑战,为叙事护理的推广及护理专科人才培养提供依据.方法 目的性抽样选择山西省某三级甲等...     

Delivering Virtual Cancer Rehabilitation Programming During the First 90 Days of the COVID-19 Pandemic: A Multimethod Study

ObjectiveTo describe the adaptations made to implement virtual cancer rehabilitation at the onset of the coronavirus disease 2019 pandemic, as well as understand the experiences of patients and providers adapting to virtual care.DesignMultimethod study.SettingCancer center.ParticipantsA total of 1968 virtual patient visits were completed during the study period. Adult survivors of cancer (n=12) and oncology health care providers (n=12) participated in semi-structured interviews.InterventionsNot applicable.Main Outcome MeasuresFramework-driven categorization of program modifications, qualitative interviews with patients and providers, and a comparison of process outcomes with the previous 90 days of in-person care via referrals, completed visits and attendance, method of delivery, weekly capacities, and wait times.ResultsThe majority of program visits could be adapted to virtual delivery, with format, setting, and content modifications. Virtual care demonstrated an increase or maintenance in the number of completed visits by appointment type compared with in-person care, with attendance ranging from 80%-93%. For most appointment types, capacities increased, whereas wait times decreased slightly. Overall, 168 patients (11% of all assessments and follow-ups) assessed virtually were identified by providers as requiring an in-person appointment because of reassessment of musculoskeletal and/or neurologic impairment (n=109, 65%) and lymphedema (n=59, 35%). The interviews (n=24) revealed that virtual care was an acceptable alternative in some circumstances, with the ability to (1) increase access to care; (2) provide a sense of reassurance during a time of isolation; and (3) provide confidence in learning skills to self-manage impairments.ConclusionsMany appointments can be successfully adapted to virtual formats to deliver cancer rehabilitation programming. Based on our findings, we provide practical recommendations that can be implemented by providers and programs to facilitate the adoption and delivery of virtual care.     

Donor Cell Leukemia in Umbilical Cord Blood Transplant Patients: A Case Study and Literature Review Highlighting the Importance of Molecular Engraftment Analysis

Donor cell neoplasms are rare complications of treatment regimens that involve stem cell transplantation for hematological malignancies, myelodysplastic processes, or certain genetic or metabolic disorders. We report a case of donor cell leukemia in a pediatric patient with a history of acute myeloid leukemia that manifested as recurrent AML FAB type M5 fourteen months after umbilical cord blood transplantation. Although there was some immunophenotypic drift from the patient''s original AML and their posttransplant presentation, the initial pathological impression was of recurrent disease. Bone marrow engraftment analysis by multiplex PCR of short tandem repeat markers performed on the patient''s diagnostic specimen showed complete engraftment by donor cells, with a loss of heterozygosity in the donor alleles on chromosome 7. This led to the reinterpretation of this patient''s disease as donor-derived leukemia. This interpretation was supported by a routine karyotype and fluorescence in situ hybridization analysis showing loss of chromosome 7 and a male (donor) chromosome complement in this female patient. Also noted was a loss of the patient''s presenting chromosomal abnormality, t(11;19)(q23;p13). This case highlights the need for close coordination between all aspects of clinical testing for the transplant patient, including molecular engraftment studies, when distinguishing the very common complication of recurrent disease from the exceedingly rare complication of donor cell leukemia.Unrelated donor umbilical cord blood transplantation (UCBT) is an increasingly used treatment in pediatric patients with a variety of different diseases, including neoplastic hematological diseases such as acute myeloid leukemia and myelodysplastic syndromes^1,2 and inherited disorders of metabolism, including lysosomal and peroxisomal storage diseases.³ The growing adoption of UCBT stems both from its efficacy in treating these diseases and from its two distinct benefits over traditional bone marrow transplantation (BMT) and peripheral blood stem cell (progenitor cell) transplantation (PBPC): the availability of donor umbilical cord blood stem cells and the decrease in certain complications including acute and chronic graft versus host disease.^4,5 In the context of neoplastic indications, an additional devastating complication that occurs in similar frequency in BMT, PBPC, and UCBT is recurrence of the patient''s original disease. In pediatric patients receiving UCBT for acute lymphoblastic leukemia, overall three-year leukemia-free survival ranges from 20 to 35% depending on timing of transplantation (i.e., during the first or second complete remission, CR1 or CR2, or in patients with advanced disease). Similar rates of recurrence have been reported for pediatric patients with AML receiving UCBT (two-year leukemia-free survival of 22% in patients with advanced disease, 43% in patients treated during CR1 and 65% for patients treated during CR2; reviewed in 5).Although very rare compared with recurrent disease, secondary neoplastic complications also occur in transplant patients. The best described are posttransplant lymphoproliferative disorders (PTLD). PTLD is an Epstein-Barr virus–driven neoplastic proliferation, usually of B-cells, in transplant patients that can progress from polymorphic PTLD, which has a good prognosis, to the more frankly malignant monomorphic PTLD, which includes diffuse large B-cell lymphoma, Burkitt lymphoma, plasmacytoma, and myeloma. PTLD is a rare complication in the setting of UCBT, occurring in fewer than 2% of patients.^6,7 Although PTLD in solid organ transplants is usually of recipient origin, in patients who have had successful UCBT, PTLD is usually of donor origin.^6,7,8,9An even less common secondary neoplastic complication seen in BMT and UCBT patients is donor cell leukemia (DCL). Because of its rarity, the exact percentage of stem cell transplant patients that develop DCL is difficult to determine (reviewed in 10). In one large survey study, only 14 cases of donor cell leukemia were identified among approximately 10,000 transplant patients, making the incidence around 0.1%.¹¹ However, some studies suggest the incidence may be much higher (2 of 40 patients in one institutional experience).¹² Given that UCBT is a relatively new approach for stem cell transplantation, donor cell leukemia in UCBT patients is a very rarely reported event. A little more than 50 cases of donor cell leukemia have been reported in the literature in BMT, PBPC, and UCBT patients (reviewed in 10,13–18). Only ten cases of DCL have been previously described in UCBT patients.^{15,16,19,20,21}Here we report a new case of DCL after umbilical cord blood transplantation that manifested as a phenotypic recurrence of acute myeloid leukemia. This case was detected because of two incidental unusual findings on a PCR-based short tandem repeat (STR) analysis for bone marrow engraftment: maintained engraftment in the face of recurrent disease, and a loss of heterozygosity on chromosome 7 in cells of donor origin. The correct diagnosis of DCL in this patient by engraftment analysis was essentially an incidental finding and not the primary objective of the test. This case demonstrates how easily this could have been diagnosed as a simple recurrence and lends further weight to the assertion that donor cell leukemias are likely under-diagnosed. It also highlights the need for close coordination between all aspects of clinical testing for the transplant patient and the need for close attention to unusual or unexpected bone marrow engraftment patterns.     

Knowledge and Attitudes Regarding Neonatal Pain Among Nursing Staff of Pediatric Department: An Indian Experience

Neonates receiving care in intensive care units are highly likely to experience pain due to investigations and/or treatments carried out by the health care providers. Neonates are a vulnerable population because they are unable to vocalize their pain. Unaddressed and mismanaged pain can not only affect the child’s comfort, but also may alter the development and cognitive abilities of the child in a later part of his/her life. Therefore it is entirely the caregiver’s responsibility to accurately assess and manage neonatal pain. We assessed and compared the knowledge and attitudes regarding neonatal pain among the nurses posted in the various units of a pediatric department [pediatric ward, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU)]. An appropriately modified Knowledge and Attitudes Survey Regarding Pain questionnaire was consensually validated, pretested, and then administered to the nursing staff of the pediatric department at a department at a hospital in Gujarat. Data were entered in Epi-Info and analyzed with the use of SPSS 14.0. The questionnaire was administered to 41 nurses working in the Department of Pediatrics, and the response rate was 97.5%. Mean age of the nurses in the study sample was 25.75 years (SD 5.513). The mean total score of the participants was 8.75 out of 17 (SD 2.549), which was unsatisfactory. The mean correct answer rate was 49.67% among the staff of NICU and 48.67% among the pediatric ward and PICU staff. The attitudes among the nurses were assessed. It was concluded that the nurses lack knowledge and that their attitudes also were hindering pain management. One of the barriers identified by the nurses was that physicians do not prescribe analgesics for managing neonatal pain. So not only the nursing staff, but all of the caregivers involved in neonatal care may be lacking in knowledge and hold perceptions and attitudes that hamper neonatal pain management.     

The Interaction of Waiting Time and Patient Experience during Radiation Therapy: A Survey of Patients from a Tertiary Cancer Center

PurposeThe logistical burdens of appointment scheduling and travel add to the psychological and emotional distress among patients with a new cancer diagnosis. This may be heightened among patients needing radiation therapy (RT), who must travel to and from a treatment facility daily for several weeks. Here, we studied the association between RT appointment waiting time and patient-reported pain and anxiety and explored additional factors that may influence daily waiting time.MethodsNinety-four patients undergoing RT at a single, academic institution were surveyed in the first and final weeks of treatment. On the day of the survey, patients were asked to report: pain (Likert scale: 0–10), anxiety (0–10), commute mode/time, and estimated waiting time for RT. Actual waiting times were calculated per review of the electronic scheduling system.ResultsIncreased objective waiting time was associated with higher pain scores at the start (P = .05) and end (P = 0.004) of RT, although overall pain scores were low at both time points (mean 1.4 and 1.5, respectively). Anxiety scores were also low (mean 1.2 at both time points) and were not associated with objective waiting time (P > .05). Of note, patients reported perceived waiting times that were considerably shorter than actual waiting times (mean 15 vs. 26 minutes, respectively, at first survey early in the RT course). Time of day and tumor site were not associated with waiting time.ConclusionDaily waiting time may play a role in pain and/or anxiety experienced by patients with cancer during RT. Perceived waiting time may differ substantially from actual waiting time and represents a potential area for intervention to improve patients’ quality of life.