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Updates on Therapeutic Strategies in the Treatment of Relapsed/Refractory Multiple Myeloma
No full textMultiple myeloma is a heterogeneous condition characterized by the proliferation of monoclonal B-cells, for which there is currently no curative treatment available. Relapses are, unfortunately, common after first-line treatment. While the prognosis for relapsed refractory multiple myeloma is generally poor, advances in the treatment of relapsed or refractory multiple myeloma offer hope. However, the expansion of effective options in targeted treatment offers renewed optimism and hope that patients who fail on older therapies may respond to newer modalities, which are often used in combination. We review currently approved and novel investigational agents classified by mechanisms of action, efficacy, approved setting, and adverse events. We delve into future directions of treatment for relapsed/refractory multiple myeloma, reviewing novel agents and therapeutic targets for the future.
Keywords: CAR-T; bispecific antibodies; celmods; monoclonal antibodies; multiple myeloma; proteasome inhibitors; relapsed refractory
CARE Unit RN Competency Evaluation for High-Risk Low Volume Procedures
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2024/1001/thumbnail.jp
Effectiveness of the original monovalent mRNA COVID-19 vaccination series against hospitalization for COVID-19-associated venous thromboembolism
No full textBackground: COVID-19 is a strong risk factor for venous thromboembolism (VTE). Few studies have evaluated the effectiveness of COVID-19 vaccination in preventing hospitalization for COVID-19 with VTE.
Methods: Adults hospitalized at 21 sites between March 2021 and October 2022 with symptoms of acute respiratory illness were assessed for COVID-19, completion of the original monovalent mRNA COVID-19 vaccination series, and VTE. Prevalence of VTE was compared between unvaccinated and vaccinated patients with COVID-19. Vaccine effectiveness in preventing COVID-19 hospitalization with VTE was calculated using a test negative design. Vaccine effectiveness was also stratified by predominant circulating SARS-CoV-2 variant.
Results: Among 18,811 patients (median age 63 [IQR:50-73], 49% women, 59% non-Hispanic White, 20% non-Hispanic Black, 14% Hispanic, and median of 2 comorbid conditions [IQR:1-3]), 9,792 were admitted with COVID-19 (44% vaccinated) and 9,019 were test-negative controls (73% vaccinated). Among patients with COVID-19, 601 were diagnosed with VTE by hospital day 28, of whom 170 were vaccinated. VTE was more common among unvaccinated than vaccinated COVID-19 patients (7.8% versus 4.0%; p=0.001). Vaccine effectiveness against COVID-19 hospitalization with VTE was 84% (95% CI: 80-87%) overall. Vaccine effectiveness stratified by predominant circulating variant was 88% (73-95%) for alpha, 93% (90-95%) for delta, and 68% (58-76%) for omicron variants.
Conclusions and relevance: Vaccination with the original monovalent mRNA series was associated with a decrease in COVID-19 hospitalization with VTE, though data detailing prior history of VTE and use of anticoagulation were not available. These findings will inform risk-benefit considerations for those considering vaccination.
Keywords: COVID-19; SARS-CoV-2; deep venous thrombosis; pulmonary embolus; vaccine; venous thromboembolism
Sprayable inflammasome-inhibiting lipid nanorods in a polymeric scaffold for psoriasis therapy
No full textLocalized delivery of inflammasome inhibitors in phagocytic macrophages could be promising for psoriasis treatment. The present work demonstrates the development of non-spherical lipid nanoparticles, mimicking pathogen-like shapes, consisting of an anti-inflammatory inflammasome inhibiting lipid (pyridoxine dipalmitate) as a trojan horse. The nanorods inhibit inflammasome by 3.8- and 4.5-fold compared with nanoellipses and nanospheres, respectively. Nanorods reduce apoptosis-associated speck-like protein and lysosomal rupture, restrain calcium influx, and mitochondrial reactive oxygen species. Dual inflammasome inhibitor (NLRP3/AIM-2-IN-3) loaded nanorods cause synergistic inhibition by 21.5- and 59-folds compared with nanorods and free drug, respectively alongside caspase-1 inhibition. The NLRP3/AIM-2-IN-3 nanorod when transformed into a polymeric scaffold, simultaneously and effectively inhibits RNA levels of NLRP3, AIM2, caspase-1, chemokine ligand-2, gasdermin-D, interleukin-1β, toll-like receptor 7/ 8, and IL-17A by 6.4-, 1.6-, 2.0-, 13.0-, 4.2-, 24.4-, 4.3-, and 1.82-fold, respectively in psoriatic skin in comparison to Imiquimod positive control group in an in-vivo psoriasis-like mice model
Recommendations for permanent sleep telehealth: an American Academy of Sleep Medicine position statement
No full textTelehealth use greatly expanded under the Centers for Medicare and Medicaid Services (CMS) waivers at the start of the COVID-19 pandemic; however, the uncertainty and limitations of continued coverage risks loss of this momentum. Permanent coverage with adequate reimbursement is essential for the long-term acceptance and expansion of telehealth services. Telehealth supports both the current and future need for sleep health management by expanding patient access, increasing clinician efficiency, improving patient safety, and addressing health care equity. Sleep medicine is an ideal field for telehealth due to limited provider access, safety concerns with sleepy patients, availability of remote patient monitoring for treatment management, and the minimal need for repeated physical examinations. Telehealth is non-inferior for delivery of cognitive behavioral therapy for insomnia (CBT-I) and can enhance obstructive sleep apnea (OSA) treatment adherence. It is the position of the American Academy of Sleep Medicine (AASM) that telehealth is an essential tool for the provision of high quality, patient-centered care for patients with sleep disorders. We encourage all stakeholders including legislators, policymakers, clinicians, and patients to work together to address payment models, interstate care, technology access, prescribing practices, and ongoing research to ensure that sleep telehealth services are permanently available and accessible for all patients seeking sleep medicine care.
Keywords: health care delivery; sleep; telehealth
Reduced-Dose Tenecteplase in High-Risk Pulmonary Embolism
No full textBackground: Pulmonary embolism (PE) is a venous thromboembolic disease occurring when thrombi detach and embolize to pulmonary arteries, causing substantial morbidity and mortality in older adults yearly. In patients experiencing hemodynamic compromise, systemically administered thrombolytic therapy followed by anticoagulation over anticoagulation alone is recommended for initial management.
Case report: This report describes successful treatment of a patient over 90 years of age presenting to the Emergency Department with an acute, high-risk PE who received low-dose, systemically administered tenecteplase followed by systemic anticoagulation with unfractionated heparin. The patient was initiated on norepinephrine 0.5 µg/kg/min for hemodynamic support. They were administered a reduced dose of tenecteplase (17.5 mg or 0.37 mg/kg) bolus followed by unfractionated heparin and subsequent transfer to the medical intensive care unit. At 1 h post-tenecteplase, norepinephrine was decreased to 0.2 µg/kg/min. At 14 h post-tenecteplase, the norepinephrine requirement was minimal at 0.02 µg/kg/min and resolved with extubation 15 h post-tenecteplase. The patient did not develop any clinically significant bleeding and was discharged to an acute rehabilitation facility on hospital day 7. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Available evidence suggests positive outcomes and dosing guidance for low-dose alteplase for PE treatment, though at the time of this report the authors identified a gap in existing literature surrounding the same concept with reduced-dose tenecteplase. Further studies are needed to investigate this intervention further.
Keywords: critical care; pulmonary embolism; systemic anticoagulation; tenecteplase; thrombolytics
Demographics and Clinical Characteristics of Patients with Neurosyphilis in Rhode Island
No full textThe incidence of syphilis has been steadily rising throughout the United States over the past decade, including Rhode Island. Neurosyphilis is a manifestation of syphilis involving the central nervous system and can present with a multitude of symptoms. We evaluated all cases of syphilis at a single healthcare system in Rhode Island over a 10.5-year period and identified 33 cases of neurosyphilis (24 confirmed and 9 diagnosed clinically). Neurosyphilis was more common in females, older patients, White/Caucasian patients, and non-Latino patients. Patients with neurosyphilis confirmed by cerebral spinal fluid analysis were more likely to have a higher RPR than patients who did not have neurosyphilis. Six patients with HIV were diagnosed with neurosyphilis and were similar to those with HIV and syphilis except for lower rates of drug use. Given increasing trends, clinicians should be familiar with the diagnosis and management of neurosyphilis.
Keywords: HIV; Neurosyphilis; Ocular Syphilis; Otosyphilis; Rhode Island
Clinical trial screening in gynecologic oncology: Defining the need and identifying best practices
No full textBackground: Evidence is limited in gynecologic cancers on best practices for clinical trial screening, but the risk of ineffective screening processes and subsequent under-enrollment introduces significant cost to patient, healthcare systems, and scientific advancement. Absence of a defined screening process makes determination of who and when to screen potential patients inconsistent allowing inefficiency and potential introduction of biases. This is especially germane as generative artificial intelligence (AI), and electronic health record (EHR) integration is applied to trial screening. Though often a requirement of cooperative groups such as the Cancer therapy Evaluation Program (CTEP), and/or the Commission on Cancer (CoC), there are no standard practice guidelines on best practices regarding screening and how best to track screening data.
Development of manuscript: The authors provided a review of current clinical trial screening practices and the effect on enrollment and trial activation across a variety of disease and practice sites. Established clinical trial screening practices and evidence supporting emerging strategies were reviewed and reported. Due to lack of published literature in gynecologic oncology, authors sought to survey the members of current rostered GOG sites to provide perspectives on clinical trial screening practices. Survey results showed a variety of screening practices. Most respondents participate in some type of manual screening process, where approximately 13 % also report incorporating AI or EHR integration. Over half (60 %) of sites track screening data to use for feasibility when opening new trials. The rapid increase in generative AI, EHR integration, and site agnostic screening initiatives could provide a significant opportunity to improve screening efficiency, translating to improved enrollment, but limitations and barriers remain.
Keywords: Artificial intelligence in clinical trial screening; Best practices for clinical trial screening; Clinical trial equity; Clinical trial screening; Clinical trial screening survey in gynecologic oncology
Incorporating systems-level stakeholder perspectives into the Design of Mobile Integrated Health Programs
No full textObjectives: Despite early evidence of effectiveness, cost-savings, and resource optimization, mobile integrated health (MIH) programs have not been widely implemented in the United States. System, community, and organizational-level barriers often hinder evidence-based public health interventions, such as MIH programs, from being broadly adopted into real-world clinical practice. The objective of this study is to identify solutions to the barriers impeding the implementation of MIH through interviews with multilevel stakeholders.
Methods: Using the CENTERing multi-level partner voices in Implementation Theory methodology, the study team recruited stakeholders to participate in semi-structured interviews that were recorded, transcribed, and open-coded. Stakeholders were asked to explore and propose solutions to established barriers to the implementation of MIH programs including poor understanding of the role of MIH, the absence of sustainable reimbursement for MIH programs, and its disruption of existing clinical workflows. The study team used the Consolidated Framework for Implementation Research to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes related to pragmatic solutions for overcoming barriers to the adoption of MIH.
Results: Interviews with Department of Public Health officials, medical directors of MIH programs, non-physician MIH program leaders, community paramedics, health insurance officials, ambulatory physicians, hospital administrators, and hospital contract specialists (n = 18) elicited solutions to address barriers including 1) Developing a consistent identity for the MIH paradigm, 2) adopting an interdisciplinary approach to the development of efficient MIH workflows that utilize informatics to mimic existing clinical work, and 3) implementing capitated fee schedules that are cost-effective by targeting high-risk populations that are already a priority for payors.
Conclusions: An investigation of solutions to barriers that impede the translation of MIH models into sustainable practice elicited several unifying themes including the establishment of a cohesive identity for MIH to improve engagement and dissemination, the use of a strategic approach to program design that aligns with existing healthcare delivery workflows and collaboration with payors to promote a robust reimbursement structure. These findings may help accelerate the implementation of MIH programs into real clinical practice.
Keywords: Community Paramedicine; Implementation Science; Mobile Integrated Health; Public Health
Pediatric to Adult Care Transition in the Hospital Context (PATCH) Tool: A Novel Tool to Assess Pediatric Institutional Guidelines for Inpatient Care of Adults
No full textObjective: The growing number of adults with childhood onset chronic conditions (COCC) is reflected in the increase of adult-aged admissions to pediatric institutions. Despite national bodies advising pediatric institutions to have a pediatric to adult healthcare transition (HCT) policy, little guidance is available on if or how to include inpatient care. We sought to create a framework-based Pediatric to Adult Transitional Care in the Hospital Context (PATCH) tool to assess how inpatient care of adults is addressed in pediatric institutional guidelines or policies (hereafter guidelines) as a first step towards informing future PATCH guideline development.
Methods: We used convenience and snowball sampling to obtain 11 pediatric institutional guidelines. Combining the GotTransition® core elements with Coller et al\u27s inpatient transition conceptual model through iterative consensus building, we developed the PATCH tool. Interrater reliability was assessed by using mean percent agreement amongst raters. A three-phase content validity process utilizing existing guidelines refined the finalized tool.
Results: The PATCH tool included 42 items within nine domains. There was a high degree of agreeability amongst reviewers, and qualitative analysis revealed no missing items. Twenty-five (59%) of our 42 PATCH tool items were present in at least one of the reviewed guidelines, with age being present in all.
Conclusion: We developed the PATCH tool as a guide for pediatric institutions regarding the care of adolescent and adult patients. The PATCH tool, embedded in multidisciplinary stakeholder discussion and patient- and system-specific knowledge, may help institutions incorporate HCT into processes for adolescent and adult patients with COCCs.
Keywords: guideline; inpatient; transition