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Background Serious mental illnesses (SMI) such as schizophrenia and bipolar disorder first develop between ages 14 and 25. Once diagnosed, young peoples’ health can deteriorate, and it is therefore vital to detect this early to prevent severe outcomes including hospitalisations and deaths by suicide. The main study aim is to describe and discuss observational studies that examine signs of deterioration in young patients with SMI. Methods A systematic review guided by the published protocol was conducted. Cumulative Index to Nursing and allied Health Literature (CINAHL), MEDLINE, Embase, PsycINFO, Health Management Information Consortium (HMIC) and Web of Science were searched against pre-defined criteria until 1 March 2021. Observational studies were extracted according to design, country, participant, indicator, outcome and main finding categories. Quality was assessed independently using the Newcastle Ottawa Scale (NOS). Results Of the 15,788 publications identified, 5 studies were included and subjected to narrative synthesis. Two indicators of mental health deterioration were identified: cognitive functioning (decline, worsening and poor school/academic performance) and expressed emotion status. Indicators revealed mixed views on predicting deterioration. Worsening cognitive functioning and expressed emotion status significantly predicted medication non-adherence and relapse respectively. However, a decline in cognitive functioning (poor academic performance) was not found to significantly correlate to deaths by suicide. Study quality was mostly poor and associations between indicators and varied outcomes were weak. The heterogeneous nature of the data made comparisons difficult and did not allow for further statistical analysis. Conclusion To our knowledge, this is the first review of observational studies to identify indicators of deterioration in young patients with SMI. Worsening cognitive functioning and expressed emotion status could indicate non-adherence and relapse in young patients with SMI but larger sample sizes in good quality studies are needed. The dearth of observational studies means further research is required to ascertain other indicators of deterioration before serious outcomes occur. Funding This work was supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre via an NIHR programme grant. The authors are also grateful for support from the NIHR under the Applied Health Research programme for North West London and the NIHR Imperial Biomedical Research Centre. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Trial registration This systematic review has been registered on PROSPERO (registration number: CRD42017075755).

Until recently, no drug was labeled for AL amyloidosis. In 2011, the Italian Medicines Agency started a program to grant access to upfront bortezomib to patients with AL amyloidosis. All subjects were enrolled in a prospective online registry. Response was evaluated after two cycles to assess the possibility of continuing treatment. A total of 764 patients were included until 2019, and 615 were evaluable. Sixteen percent of patents had advanced (stage-IIIb) heart involvement, and 27% had severe or end-stage renal failure. Bortezomib delivery was possible in stage-IIIb patients at a reduced dose. Bortezomib discontinuation was associated with increasing age, advanced heart involvement and bi-weekly administration. Fifty-nine percent of subjects attained a hematologic response and 14% a cardiac response. Bortezomib-based therapy tends to be discontinued early in elderly patients and in advanced disease. Nevertheless, early response to therapy is possible in this challenging population.

OBJECTIVE: Parental severe mental illness (SMI) increases the lifetime risk of mental and pediatric disorders in the offspring but little is known about specific disorders during early childhood. The primary aim was to investigate the incidence of mental and pediatric disorders among children 0-6 years old exposed to parental SMI, and secondarily to investigate the distribution of disorders on specific child age.METHODS: A nationwide, register-based cohort study of 1,477,185 children born in Denmark between 1994.01.01 and 2016.12.31. Incidence rate ratios were calculated using Poisson Regression analysis for any and specific mental and pediatric disorders.RESULTS: IRR for any psychiatric disorder was elevated by a factor 2-5 among SMI offspring. Maternal schizophrenia resulted in the highest IRR=5.23 (4.80-5.69) of any child psychiatric disorder. The risk of anxiety/OCD and attachment disorder among offspring exposed to parental, and in particular maternal, SMI was markedly raised with IRRs for anxiety/OCD between 7.59-17.02 and attachment disorders between 6.26-15.40. IRRs of mental disorders were highest at age 0-1 year and declined with age. IRR for any pediatric disorder was also elevated with IRRs between 1.01-1.28. Disorders of the digestive system and ill-defined symptoms were associated with the highest IRRs. Maternal (vs. paternal) SMI was associated with higher IRRs. IRRs declined slightly with child age.CONCLUSION: children exposed to parental SMI are at increased risk of mental and pediatric disorders during early childhood, particularly anxiety/OCD and attachment disorders. If associations are estimates of a modifiable causal relationship, our results indicate a need for early intervention to promote mental and pediatric health among SMI offspring.

Background The sensitivity to endocrine therapy assay (SET2,3) predicts treatment outcomes in Stage II-III breast cancer. SET2,3 measures transcription related to estrogen and progesterone receptors (SETER/PR index) and the molecular subtype (RNA4: ESR1, PGR, ERBB2, AURKA) from formalin-fixed paraffin-embedded (FFPE) tissue sections. Methods We designed a nested study across 3 pathology laboratories, each testing 60 breast cancers twice in controlled batches. Laboratories macrodissected and directly homogenized the unstained FFPE tumor sections, then performed the QuantiGene Plex bead-based hybridization assay. SET2,3 was calculated centrally using predefined statistical R-scripts and applying pre-defined cutpoints. Concordance correlation coefficient (CCC) was calculated from continuous measurements and Kappa statistic from categorical results. A mixed-effects model estimated contributions to bias (fixed effects) and variance (random effects) from the replicated design. Results Intralaboratory (CCC 0.96–0.99) and interlaboratory (CCC 0.98–0.99) SET2,3 results were concordant, with rates of agreement for high/low categorization within (Kappa 0.83–0.93) and between laboratories (Kappa 0.87–0.88). The relative contributions to overall variance of SET2,3 measurements were 96.90% from biological differences between cancers, 0.67% from interlaboratory variability, and 2.44% from residual causes including intralaboratory replicates. Similar results were obtained with SETER/PR, the baseline prognostic index calculated using pathological or clinical tumor and nodal staging information, and the 4 individual genes (ESR1, PGR, ERBB2, and AURKA). Conclusion Intra- and interpathology laboratory measurements of SET2,3 and its components were highly reproducible when tested from FFPE tumor sections.

INTRODUCTION: In 2018, nearly 20% of Americans aged 12 years and older reported using illicit substances, with higher rates in rural areas. Federally Qualified Health Centers (FQHCs) provide health care to one in five rural Americans. However, estimates suggest that only 13.6% of patients in rural FQHCs receive substance use (SU) screening compared with 42.6% of patients in urban FQHCs. AIMS: This quality improvement (QI) project aimed to improve patient quality and safety and meet Health Resources and Services Administration reporting requirements. These aims were achieved through the design and implementation of a new SU screening protocol in four FQHCs in rural Indiana. METHOD: Deming’s plan–do–study–act model was used to implement QI interventions to increase SU screening rates. A new SU screening tool, the National Institute on Drug Abuse –Modified Alcohol, Smoking, and Substance Involvement Screening Testwas implemented, and staff were trained on its use. the screening, brief intervention, and referral to treatment model was used as a guiding framework. Outcome measures included a comparison of SU screening rates from the first quarter of 2019 to the first quarter of 2020, as well a pretest–posttest designed to measure staff knowledge and attitudes regarding SU. RESULTS: Baseline SU screening rate in 2019 was 0.87%. This increased to 24.8% by March 2020. Additionally, posttest results demonstrated improvement from staff on all indices, and an approval rating of 77% of the new SU screening practices. CONCLUSIONS: This project demonstrated that a low-cost QI intervention can increase SU screening rates in rural FQHCs, as well as improve staff knowledge and attitudes regarding SU.

Background: This project explores the impact of an educational in-service on nurses' knowledge and attitudes toward pain on a postoperative cardiovascular unit. Method: A convenience sample of nurses employed on the postoperative cardiovascular intensive care unit ( n = 82) were asked to participate in this project, with 74 nurses attending the in-service training. Surveys that were 70% complete were used for analysis (preeducation, n = 22; posteducation, n = 24). Results: The results from this project demonstrated that the use of a brief educational in-service is effective and efficient in increasing nurses' knowledge and attitudes related to pain management in this group of nurses. Posteducation survey scores were significantly higher than preeducation survey scores ( p < .001). Conclusion: These findings suggest that a brief educational in-service on pain management can improve nurses' knowledge and attitudes on pain management in this postoperative cardiovascular unit. [ J Contin Educ Nurs . 2020;51(8):377–383.]

Newly diagnosed AL amyloidosis patients were evaluated to develop a model for early assessment of treatment benefit at 6 months, integrating both hematologic (HR) and organ response (OR) assessment (testing cohort, Mayo: n = 473; validation cohort, Pavia: n = 575). Multiple OR were assessed as follows: All OR (AOR): response in all organs, mixed OR (MOR): response in some organs, no OR (NOR)]. AOR rates at 6 months improved with deepening HR; complete response (CR; 38%, 35%), very good partial response (VGPR; 30%, 26%), and partial response (PR; 16%, 21%), respectively. A composite HR/OR (CHOR) model was developed using incremental scoring based on hazard ratios with scores of 0–3 for HR (0—CR, 1—VGPR, 2—PR, 3—no response) and 0–2 for OR (0—AOR, 1—MOR, 2—NOR). Patients could be divided into two distinct CHOR groups (scores 0–3 and 4–5), with median OS in group 1 and group 2: Not reached vs. 34 months, p p

The authors report on the subset of AL amyloidosis patients with nonlymphoplasmacytic lymphoma, emphasizing a predominance of marginal zone lymphoma, frequent delay in diagnosis, and a generally poor prognosis.

Introduction: Teenage pregnancies have serious consequences for the health of mothers and their children. The aim of this work was to study the circumstances of the onset of teenage pregnancy. Methodology: This was a cross-sectional and descriptive study, which took place from July 1st to 31st, 2019 at the Peripheral Care Unit (USP) of Gbodjome in Togo. Results: A total of 100 adolescent girls were interviewed (12.6%). The average age of adolescent girls was 17.2 years (12 - 19 years). Adolescent girls were predominantly in primary school (42.0%) and single status (58.0%). Forty-two decimal zero percent of adolescent girls (42.0%) were living with their partners. In 5.0% of cases, adolescent girls were victims of sexual harassment. The pregnancy was the result of rape in 10.0% of cases. Ten decimal zero percent of adolescent girls (10.0%) had more than one sexual partner. Nearly half of the respondents (49.0%) knew at least one method of contraception, but only 8.0% used it. Financial help from the partner (57.0%) was the leading cause of sex. Conclusion: Teenage pregnancies have a negative impact on both the young mother and the unborn child. The ideal would be to make schooling for girls free, from primary school to the A-level.

PURPOSE Oral melphalan and dexamethasone (MDex) were considered a standard of care in light-chain (AL) amyloidosis. In the past decade, bortezomib has been increasingly used in combination with alkylating agents and dexamethasone. We prospectively compared the efficacy and safety of MDex and MDex with the addition of bortezomib (BMDex). METHODS This was a phase III, multicenter, randomized, open-label trial. Patients were stratified according to cardiac stage. Patients with advanced cardiac stage (stage IIIb) amyloidosis were not eligible. The primary end point was hematologic response rate at 3 months. This trial is registered with ClinicalTrials.gov identifier NCT01277016 . RESULTS A total of 109 patients, 53 in the BMDex and 56 in the MDex group, received ≥ 1 dose of therapy (from January 2011 to February 2016). Hematologic response rate at 3 months was higher in the BMDex arm (79% v 52%; P = .002). Higher rates of very good partial or complete response rates (64% v 39%; hazard ratio [HR], 2.47; 95% CI, 1.30 to 4.71) and improved overall survival, with a 2-fold decrease in mortality rate (HR, 0.50; 95% CI, 0.27 to 0.90), were observed in the BMDex arm. Grade 3 and 4 adverse events (the most common being cytopenia, peripheral neuropathy, and heart failure) were more common in the BMDex arm, occurring in 20% versus 10% of cycles performed. CONCLUSION BMDex improved hematologic response rate and overall survival. To our knowledge, this is the first time a controlled study has demonstrated a survival advantage in AL amyloidosis. BMDex should be considered a new standard of care for AL amyloidosis.

Background: The UK asthma mortality rate has risen by 33% over a decade. The national enquiry into 195 asthma-related deaths revealed that most of these deaths were preventable. The Asthma Discharge Care Bundle (ADCB) is recommended for use when discharging patients with an acute asthma attack and/or exacerbation. Aim: To review the implementation of the British Thoracic Society (BTS) bundle in a teaching hospital. Methods: A 12-month retrospective audit was conducted on 86 adult patients treated for asthma attacks. Findings: The results of the audit indicated that the hospital has complied with the ADCB. In total, 85% of patients had their inhaler technique checked, but 62% of them were not provided with any written inhaler use instructions. The respiratory clinical nurse specialists were more compliant with most of the bundle statements than the medical team. Conclusion: The findings highlighted the need for asthma education sessions for all health professionals with emphasis on record-keeping skills.

Segundo a Organização Pan-Americana de Saúde (OPAS), o envelhecimento é definido como um processo sequencial, individual, acumulativo, irreversível, universal, não patológico, de deterioração de um organismo maduro. Considerando o aumento progressivo da população idosa e todas as alterações funcionais envolvidas no processo do envelhecimento, destacam-se as alterações provenientes por declínio imunológico, como doenças por contaminações fúngicas, como onicomicose e Tinea pedis. Os fungos possuem características oportunistas e utilizam fatores como doenças sistêmicas, deficiência imunológica e uso de medicamentos, que são muito comuns aos idosos, e acabam por predispor a contaminação. As doenças causadas por fungos em idosos são frequentes e necessitam de tratamentos e orientações adequadas [6]. No entanto, observa-se a falta de orientação e cuidados básicos que são essenciais e atuam tanto na prevenção, quanto no tratamento dessas doenças. Segundo Pinto, 2018, [8], o podólogo possui um importante papel através dos serviços prestados pela podologia, demonstrando a importância dos cuidados básicos, associados a prática de higiene diária. Objetivo deste trabalho foi demonstrar que a correta orientação de higiene e cuidados com os pés podem auxiliar na prevenção de podopatias relacionadas a contaminação de fungos em idosos. Este estudo se caracterizou por uma revisão da literatura. Foi feita uma Pesquisa de Campo através de questionário, com aprovação do Comitê de Ética da Universidade Anhembi Morumbi.

TO THE EDITOR: Diagnosis of amyloidosis, with the possible exception of cardiac transthyretin amyloidosis (ATTR) in patients without monoclonal components,[1][1] requires demonstration of tissue amyloid deposits and identification of the amyloidogenic protein.[2][2],[3][3] The gold standard for

Background Nurses and midwives play important roles in educating the public on cervical cancer prevention strategies. Aim This study sought to assess nurses’ and midwives’ knowledge of, attitudes towards, and acceptance of human papillomavirus (HPV) vaccination in relation to their background characteristics. Methods A descriptive cross-sectional study using questionnaires was conducted with a convenience sample of 318 female nurses and midwives, ages 20 to 59, at the Korle-Bu Teaching Hospital in Ghana. The data were summarised using frequencies, percentages, chi-square tests, and Fisher’s exact tests. Results The results indicated that 41.5% (n = 132) of the participants had high levels of knowledge about cervical cancer risk factors, and 17.6% (n = 56) of the respondents had received at least one dose of the HPV vaccine. Reasons for receiving the HPV vaccination included advice from a colleague (12.9%, n = 41) and perceived threat of cervical cancer (11.7%, n = 37). Of the 262 respondents who had not been vaccinated, 24.45% (n = 78) strongly agreed and 28.0% (n = 89) agreed with the statement that there was limited information on HPV vaccination. Also, there were statistically significant associations between age (X2 = 23.746, p = 0.001), marital status (X2 = 14.758, p = 0.005), completed level of education (X2 = 21.692, p = 0.001), and duration of working at the hospital (X2 = 8.424, p = 0.038) and acceptance of HPV vaccination. Conclusions This study demonstrated gaps in knowledge about cervical cancer risk factors and attitudes towards HPV vaccination, indicating the need for targeted measures to improve knowledge and attitudes. Also, measures to increase acceptance of HPV vaccination among nurses and midwives should consider their sociodemographic characteristics.

© The Author(s) 2021., Light chain (AL) amyloidosis is caused by a small B-cell clone producing light chains that form amyloid deposits and cause organ dysfunction. Chemotherapy aims at suppressing the production of the toxic light chain (LC) and restore organ function. However, even complete hematologic response (CR), defined as negative serum and urine immunofixation and normalized free LC ratio, does not always translate into organ response. Next-generation flow (NGF) cytometry is used to detect minimal residual disease (MRD) in multiple myeloma. We evaluated MRD by NGF in 92 AL amyloidosis patients in CR. Fifty-four percent had persistent MRD (median 0.03% abnormal plasma cells). There were no differences in baseline clinical variables in patients with or without detectable MRD. Undetectable MRD was associated with higher rates of renal (90% vs 62%, p = 0.006) and cardiac response (95% vs 75%, p = 0.023). Hematologic progression was more frequent in MRD positive (0 vs 25% at 1 year, p = 0.001). Altogether, NGF can detect MRD in approximately half the AL amyloidosis patients in CR, and persistent MRD can explain persistent organ dysfunction. Thus, this study supports testing MRD in CR patients, especially if not accompanied by organ response. In case MRD persists, further treatment could be considered, carefully balancing residual organ damage, patient frailty, and possible toxicity., This study was supported by a grant from CARIPLO “Molecular mechanisms of Ig toxicity in age-related plasma cell dyscrasias no. 2015-0591”, by a grant from the Black Swan Research Initiative from the International Myeloma Foundation “Automated multidimensional flow cytometry for high-sensitive screening and to monitor response in AL amyloidosis”, by a grant from CARIPLO “Structure–function relation of amyloid: understanding the molecular bases of protein misfolding diseases to design new treatments no. 2013-0964”, by a grant from the Amyloidosis Foundation “Investigating new therapies to treat AL amyloidosis”, and by a grant from Cancer Research UK, FCAECC and AIRC under the Accelerator Award 2017 Program “Early detection and intervention: understanding the mechanisms of transformation and hidden resistance of incurable hematological malignancies”, by a grant from CARIPLO “Harnessing the plasma cell secretory capacity against systemic light chain amyloidosis” (no. 2018-0257), by a grant from the Italian Ministry of Health “Towards effective, patient-tailored anti-plasma cell therapies in AL amyloidosis: predicting drug response and overcoming drug resistance” (GR-2018-12368387). This study has also supported the Centro de Investigación Biomédica en Red—Área de Oncología—del Instituto de Salud Carlos III (CIBERONC; CB16/12/00369, CB16/12/00400, and CB16/12/00489) and the Instituto de Salud Carlos III/Subdirección General de Investigación Sanitaria (FIS No. PI13/02196). G.P. is supported in part by the Bart Barlogie Young Investigator Award from the International Myeloma Society (IMS). P.M. is supported in part by a fellowship grant form Collegio Ghislieri (Pavia). We acknowledge the study coordinator and data manager Anna Carnevale Baraglia.

Deposition of misfolded proteins as extracellular amyloid aggregates is the pathological hallmark of systemic amyloidoses. Subcutaneous fat acquired by fine needle aspiration is the preferred screening tissue in suspected patients. In this study we employed Fourier transform infrared (FTIR) spectroscopy in attenuated total reflection (ATR) to investigate human abdominal fat aspirates with the aim of detecting disease-related changes in the molecular structure and composition of the tissue and exploiting the potentiality of the method to discriminate between amyloid-positive and -negative samples. The absorption and second-derivative spectra of Congo Red (CR) positive and CR-negative specimens were analyzed by three multivariate methods in four spectral regions. The proposed ATR-FTIR method is label-free, rapid, and relatively inexpensive and requires minimal sample preparation. We found that the ATR-FTIR approach can differentiate fat aspirates containing amyloid deposits from control specimens with high sensitivity and specificity, both at 100 [89-100]%. It is worth noting that the wavenumbers most important for discrimination indicate that changes both in the protein conformation and in resident lipids are intrinsic features of affected subcutaneous fat in comparison with the CR-negative controls. In this proof of concept study, we show that this approach could be useful for assessing tissue amyloid aggregates and for acquiring novel knowledge of the molecular bases of the disease.

Background Cardiac wild type transthyretin (ATTRwt) amyloidosis, formerly known as senile systemic amyloidosis, is an increasingly recognized, progressive, and fatal cardiomyopathy. Two biomarkers staging systems were proposed based on NT-proBNP (in both cases) and troponin or estimated glomerular filtration rate, that are able to predict survival in this population. The availability of novel effective treatments requires large studies to describe the natural history of the disease in different populations. Objective To describe the natural history of the disease in a large, prospective, national series. Methods Starting in 2007, we protocolized data collection in all the patients diagnosed at our center (n=400 up to 7/2019). Results The referrals to our center increased over time: 5 cases (1%) between 2007–2009, 33 (9%) in 2010–2012, 90 (22%) in 2013–2015 and 272 (68%) in 2016–2019. Median age was 76 years [interquartile range (IQR): 71–80 years] and 372 patients (93%) were males. One hundred and seventy-three (43%) had atrial fibrillation, 63 (15%) had a history of ischemic cardiomyopathy and 64 (15%) underwent pacemaker or ICD implantation. NYHA class was I in 58 subjects (16%), II in 225 (63%) and III in 74 (21%). Median NT-proBNP was 3064 ng/L (IQR: 1817–5579 ng/L), troponin I 0.096 ng/mL (IQR: 0.063–0.158 ng/mL), eGFR 62 mL/min (IQR: 50–78 mL/min). Median IVS was 17 mm (IQR: 15–19 mm), PW 16 mm (IQR: 14–18 mm) and EF 53% (IQR: 45–57%). One-hundred and forty-eight subjects (37%) had a concomitant monoclonal component in serum and/or urine and/or an abnormal free light chain ratio. In these patients, the diagnosis was confirmed by immunoelectron microscopy or mass spectrometry. In 252 (63%) the diagnosis was based on bone scintigraphy. DNA analysis for amyloidogenic mutations in transthyretin and apolipoprotein A-I genes was negative in all subjects. The median survival of the whole cohort was 59 months. The Mayo Clinic staging based on NT-proBNP (cutoff: 3000 ng/L) and troponin I (cutoff: 0.1 ng/mL) discriminated 3 different groups [stage I: 131 (35%), stage II: 123 (32%) and stage III: 127 (33%)] with different survival between stage I and II (median 86 vs. 81 months, P=0.04) and between stage II and III (median 81 vs. 62 months, P Conclusions This is one of the largest series of patients with cardiac ATTRwt reported so far. Referrals and diagnoses increased exponentially in recent years, One-third of patients has a concomitant monoclonal gammopathy and needed tissue typing. Both the current staging systems offered good discrimination of staging and were validated in our independent cohort. Funding Acknowledgement Type of funding source: None

In AL amyloidosis complete response (aCR) is defined as negative serum and urine immunofixation with normalized free light chain ratio (FLCR). However, achievement of low levels of involved FLC (iFLC) or difference between iFLC and uninvolved FLC (dFLC) are also relevant endpoints for treatment. We divided 434 consecutive patients with AL amyloidosis into five groups according to response 6 months after treatment initiation: aCR, iFLC

Daratumumab demonstrated activity in the treatment of AL amyloidosis in two recently concluded phase II clinical trials in relapsed and refractory patients. Its role in upfront therapy is under evaluation in a phase III study. In this report we evaluated the safety and efficacy of 28-day cycles of daratumumab (single agent or combined with bortezomib or lenalidomide) in 72 previously treated patients with multiple myeloma and AL amyloidosis. Fifty (69%) were refractory to the last line of therapy. After eight infusions of daratumumab, 59 patients (82%) achieved a hematologic response, with 12 (16%) complete responses (CRs) and 30 (42%) very good partial responses (VGPRs). After 16 infusions, the quality of response improved with 22 patients (30%) achieving CR and 21 (29%) attaining VGPR. Cardiac response was observed in 11 of 37 evaluable patients (29%) and renal response in 23 of 38 patients (60%). Daratumumab is highly effective in heavily pretreated patients with relapsed/refractory AL amyloidosis and high bone marrow plasma cell burden. Renal responses, which are usually rare in this setting, were frequently observed.

Pomalidomide demonstrated activity in the treatment of AL amyloidosis in three phase II clinical trials. We evaluated the safety and efficacy of 28-day cycles of pomalidomide and dexamethasone in 153 previously treated patients with systemic AL amyloidosis. Ninety-nine (65%) were refractory to the last line of therapy and 54 (35%) had relapsed. The median number of previous lines of therapy was 3 (range: 2–7): 143 patients (93%) previously received bortezomib, 124 (81%) lenalidomide, 114 (75%) oral melphalan, and 37 (24%) underwent autologous stem cell transplant. At the completion of cycle 6, 68 (44%) patients obtained at least partial haematologic response, with 5 complete responses (CR, 3%), 35 very good partial responses (VGPR, 23%). Haematologic response resulted in improved overall survival (median survival 50 vs. 27 months, p = .033) in a 6 months landmark analysis. Obtaining at least partial response was also associated with a significant improvement of the progression-free survival (median PFS 37 vs. 18 months, p

With a wide spectrum of severity, osteogenesis imperfecta (OI) is a connective tissue disease resulting in bone fragility. Approximately 25,000–50,000 Americans are afflicted with OI; 50% of these cases are classified as type I. Type I does not discriminate regarding ethnicity, race, or sex. The disease symptoms change across the life span and vary among patients; therefore, diagnosis is often missed. The aim of this article is to briefly explain etiology, clinical manifestations, common assessment findings, and recommended health promotion activities to recognize individuals with OI type I, thereby facilitating an early diagnosis and appropriate referrals.

AIM We investigated children's counter regulatory hormone profiles during a hyperinsulinaemic hypoglycaemic clamp procedure at day and night. METHODS In 2013, we assessed the counter regulatory response to hypoglycaemia in eight outpatients with type 1 diabetes, recruited from the Herlev Hospital, Denmark, at a mean age of 9.6 ± 2.3 years. Hyperinsulinaemic 80 mU/m2 /min clamps were performed with a stepwise reduction in plasma glucose from euglycaemia (7-9 mmol/L) to hypoglycaemia (

The article considers clinical manifestations, pathogenesis and therapy of complex regional pain syndrome. The historical reference on this issue is provided. The description of clinical case of complex regional pain syndrome with positive effect against the background of applied therapy is presented. It is emphasized that besides complications related to monitoring of this category of patients, the presented case is an evidence of inadequate studying of pathogenesis of complex regional pain syndrome. The pathophysiologic concepts explaining development of complex regional pain syndrome are presented: activation of neurogenous inflammatory alterations, development of pathologic sympathetic afferent links and neuroplastic alterations in central nervous system. The focus is made on mal-adaptive character of neuroplastic alterations of sensory and motor cortex. The results of modern neuro-visual methods of study are analyzed permitting to look from a new perspective on origin of clinical disorders in this condition. The significance of disorders of cerebral links in case of complex regional pain syndrome. These results are based on analysis of functional links («connectom in rest»), temporarily and space characteristics of which are altered in presence of chronic pain. The conclusion is made that the very impact of functional links altered under complex regional pain syndrome provides possibilities for new methods of treatment of this state.

The validated criteria of hematologic response in light-chain (AL) amyloidosis are based on the measurement of circulating free light chains (FLCs). Patients with a difference between involved and uninvolved FLC (dFLC)50 mg/L cannot be assessed for response and are excluded from clinical trials. We compared the clinical characteristics and outcome of 203 newly diagnosed patients with dFLC50 mg/L (low dFLC) with 866 patients with measurable dFLC (high dFLC) evaluated between 2004 and 2015. Heart involvement was significantly less common and less advanced in the low-dFLC group (43% vs 83% and Mayo stage III 45% vs 15%, both

Background: There is a high variability in the reasons for cancellation of elective urological surgery cases. Case cancellation rate is expected to be high in the Public Health System with perceived inefficiencies compared to private facilities in the same developing economy. Aims and Objectives: This comparative analysis was to determine the case cancellation rate and the reasons for cancellation of elective urological surgeries in a public tertiary hospital and a private specialist hospital in Accra. This is intended to form a basis for interventions aimed at reducing the case cancellation rate. Methods: This was a retrospective analysis of prospectively collected data on Day of Surgery cancelled elective urological cases from September 2014 to October 2015 at the urology unit of the Korle-Bu Teaching Hospital (KBTH), a public Tertiary Hospital and the Trust Specialist Hospital (TSH), a privately managed hospital in Accra. The reasons for case cancellation were categorized into structural factors, patient factors and process factors. Results: There was no significant difference between the case cancellation rate for elective urological cases at KBTH and the TSH which were 20.8% and 17.1% respectively (p = 0.317). For KBTH, the reasons for cancellation of elective urological cases were due to structural factors in 11/117 (9.4%), patient factors in 15/117 (12.8%) and process factors in 91/117 (77.8%) which was due mainly to surgery running late. At the TSH, the reasons were due to structural factors in 1/29 (3.4%), patient factors in 27/29 (93.1%) mainly due to patient not turning up and process factors in 1/29 (3.4%). Conclusion: The case cancellation rate of elective urological surgeries in both the Public Tertiary Hospital and the Private Specialist Hospital were high with no significant difference between the two. However, in the Public Tertiary Hospital, process factors predominated as the cause of these cancellations while patient factors were the predominant cause in the privately managed facility. Exposure of theater managers in public facilities to management practices in privately run facilities should be encouraged to help improve the efficiency of the public facilities.

Background Children born to parents with severe mental illness like schizophrenia, bipolar disorder or recurrent major depression have been shown to have a higher risk, not only for developing a mental illness themselves in adulthood (Rasic) but also in childhood and adolescence. Less is known about the offspring’s somatic health and very early development processes. Increasing knowledge demonstrate the importance of the very early years of life from birth to age 6 for a healthy and natural brain development and for good life outcomes in general. Thus, more knowledge is needed about this vulnerable period in life, especially for children, who are born with a familial high risk for severe mental illness in order to develop relevant interventions for these children. Methods We used Danish registries to evaluate the incidence and the frequencies of early (i.e. age 0–6 years) psychiatric diagnoses of a nationwide cohort of children born to parents with severe mental illness. Further we calculated the frequencies of somatic health problems and compared them to population-based controls. Results We found increased ORs for children in all three FHR-groups for having received any diagnosis of a mental disorder before age 7 (e.g.: mother depressed, N=1223): OR:2.82 (CI:2.65–2.99), mother bipolar (N=98): OR: 3.06 (CI 2.50–3.76), mother schizophrenia (N=574): OR 5.23 (CI: 4.80–5.69), and similar although a bit smaller ORs if it was the father, who had a diagnosis. Especially ORs for attachment disorder and anxiety were increased but also ORs for eating disorders and sleep disorders were found to be significantly higher than for controls. Odd ratios for somatic disorders were marginally increased for all disorders and also for intoxications and injuries. Discussion Our results document that children born to parents with severe mental illnesses are vulnerable from the beginning of life, mainly in terms of their mental health but to some extent also in terms of somatic health. Parents who have a severe mental disorder may need extra support in the parenting role to ensure good health for the child.

Background: Gemcitabine and cisplatin combined with conventional radiotherapy in treating patients with cervical cancer, resulted in a favourable conclusion but accompanied with high toxicity. The objective of our research was to assess the tolerability, efficacy and feasibility of dual chemotherapy in addition to image-guided adaptive brachytherapy and highly conformal external beam radiation therapy. Methods & Materials: From June 2011 to November 2013, 81 cervical cancer patients with FIGO stage IB2-IIIB medical records were retrospectively reviewed. All patients received whole pelvic radiotherapy (WPRT) to a total dose of 50.4 Gy/ 1.8 Gy Chemoradiotherapy prescription objectives were: concurrent gemcitabine (125 mg/m2) and cisplatin (30 mg/m2) during the 6 weeks of external beam radiation therapy (EBRT) followed by two cycles of gemcitabine (1 g/m2, d1, d8) and cisplatin (25 mg/m2 d1-d3) on the tenth week. External beam radiotherapy was followed by image-guided brachytherapy of 24 Gy/ 4 fractions. Version 4 of the common terminology criteria for adverse events (CTCAE v 4.0) was used in grading the toxicities. Results: Sixty-nine patients obtained complete response (CR), six had a partial response (PR), and five patients had stable disease (SD). The disease control rate (DCR= SD and ORR) and overall response rate (ORR= PR, CR or PR) were 92.6% and 85.2% respectively. The 3-year and 5-year estimated overall survival (OS) was 75.4% and 66.3%, and the 3-year and 5-year estimated progression-free survival (PFS) were 78.2% and 65.4%. The median PFS time and OS time were 36.8 months and 45.5 months, respectively. Distance metastasis was evident in the lung (3 patients), pelvic wall (2 patients), liver (3 patients) and bone (2 patients). Six (6) had a local relapse, and two (2) patients had local relapse plus simultaneous systemic metastatic tumour. Conclusions: Unlike past results, gemcitabine and cisplatin appear to be tolerable, efficient and feasible when combined with conformal radiotherapy.

Background: Neck pain is a common complaint worldwide and ranked seventh in 2010 as the cause of ‘years lived with disability’ in Ghana. Proprioceptive dysfunction, measured by joint position error (JPE) tests, indicates an association with neck pain frequency, dizziness and balance problems in patients. Objectives: To examine proprioceptive deficits of the neck using a laser pointer attached to the head. Methods: Twenty patients within the age group 21–60 years, with at least five points on the neck disability index (NDI), and 20 age- and sex-matched controls with less than five points on the NDI were recruited for this study. The JPE was determined wearing a headlight laser pointer directed towards a Cartesian coordinate system adjusted to x / y = 0/0, placed on a wall after returning from left and right rotation, flexion and extension. From starting in an upright sitting position, facing the Cartesian coordinate system, each participant performed five repetitions for each movement direction. The mean of five repetitions for each movement direction was calculated as absolute error (AE), constant error (CE) and variable error (VE). Results: Control participants showed larger JPE values for nearly all AE, CE and VE. After repositioning from flexion controls showed an approximately 0.6 ° larger median JPE, and the opposite for extension, with median differences between 1 ° and 2 °. Conclusion: The results of this study do not reveal any meaningful differences between patients with mild disabled neck movement compared with controls. Clinical implications: Joint position error testing does not seem useful for patients with mild neck disability.

Substance use disorders (SUDs) in nursing have individual well-being, patient safety, and licensure/regulatory implications. Literature is scarce related to predicting SUDs in registered nurses; this study included specific items surrounding nurses’ psychological trauma. An online survey, consisting of validated scales and investigator-generated items was distributed to 4,000 registered nurses in Indiana with a yield of 1,478 surveys. The World Health Organization: Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was used as the dependent variable to assess risk of SUDs. Three multivariate regression models with predictive variables for risk of tobacco ( R2 = 0.08), alcohol ( R2 = 0.09), and other substances ( R2 = 0.10) use were found. Of concern, nurses are at moderate risk for tobacco use at 11.6%; alcohol use at 11.6% and for other substances at 10.4%. Each regression model contained distinct predictor variables; however, variables occurring in all three models were: depression, anxiety, and items surrounding psychological trauma (adverse childhood experiences, life events, lateral workplace violence).

Ulcerative colitis (UC) is a lifelong disease that peaks in diagnosis between the ages of 15 to 25 years, making UC a significant chronic disease among adolescents that could affect the adolescents throughout their life. This article provides an overview of the role of nurse practitioners as health care providers in managing adolescent patients with UC with a holistic approach that encompasses the physical aspects of the disease, as well as developmental and psychosocial needs. By describing the influence that developmental stage and psychological stress have on patients with UC, the nurse practitioners can facilitate evidence-based and holistic care for adolescents and promote self-management.

How to Obtain Contact Hours by Reading This Article Instructions 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf . To obtain contact hours you must: 1. Read the article, “Familism and Health Care Provision to Hispanic Older Adults” found on pages 21–29, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until December 31, 2018. Contact Hours This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Activity Objectives 1. Explain familism and its potential effect on health care provision to Hispanic older adults. 2. Describe cultural considerations with decision making and caregiving within Hispanic families. Disclosure Statement Neither the planners nor the authors have any conflicts of interest to disclose. The Hispanic older adult population's rapid growth calls for an awareness of values that can affect the rendering and receipt of care. Familism, or familismo , a traditional Hispanic value, places importance of family over the self and can potentially affect health care perceptions and practices for Hispanic older adults. The current article discusses familism, which is upheld by some Hispanic older adults, and the potential for underuse of health care services. The traditional feminine role, marianismo , and masculine role, machismo , are considered, as well as implications for how decision making may be made by family members rather than the patient. Clinical implications for the provision of health care to Hispanic older adults are provided, along with the importance of considering acculturation and ethnic heterogeneity. Health care management strategies that reflect recognition and respect of familism, yet emphasize optimization of adherence and self-care, are described. [ Journal of Gerontological Nursing, 42 (1), 21–29.]

Background: Forgotten ureteral stent is defined as prolong indwelling ureteral stent whose function is no longer desired. Ureteral stents are used in the management of upper urinary tract pathologies. Prolonged indwelling ureteral stents may be complicated by urosepsis or renal failure, encrustation, stone formation, spontaneous fracture which may either be retained or voided in the urine (stenturia). Hitherto, these complications were managed by open procedures alone in our center. We report our recent experience in endourology with the management of three cases of forgotten ureteral stents with durations of ten years and two years (two cases) and review endourological practice in West Africa. Conclusion: Although encrusted stents can be managed successfully by minimally invasive approaches in the majority of cases, the best treatment is prevention. Urology units should have preferably an electronic stent register such that when the time for removal is due, the patient's name and details are flagged red. If electronic register is not available, then a hard paper/book register should be made to prevent situations of forgotten stents. Also, efforts must be made to improve endourological services in the West Africa subregion to allow patients to have the benefit of endourology in the management of upper urinary tract pathologies including that of stones originating from an encrusted or fractured forgotten ureteral stent.

Background: There is no licensed therapy for light chain (AL) amyloidosis; however, bortezomib (B) is considered standard upfront treatment. Existing data on safety and efficacy of B in AL amyloidosis derive from clinical trials and retrospective series from few referral centers and only partly reflect real-world practice. In 2011, the Italian Medicines Agency (AIFA) started a program to grant access to upfront B to patients with AL amyloidosis. Treated patients had to be enrolled in an online registry and prospectively followed during therapy. We report the treatment experience in this real-world setting. Methods: AL amyloidosis diagnosis required tissue typing with mass spectrometry or immuno-electron microscopy. Patients samples could be sent to the Pavia specialized center for typing, but patients were not treated under the supervision of the referral center. Subjects with multiple myeloma were excluded. Variables were collected at baseline and hematologic and cardiac responses were assessed after 8 weeks (approximately 2 cycles) according to the International Society of Amyloidosis criteria. The cox proportional model has been adopted to assess the risk of treatment discontinuation according to the baseline characteristics. Results: A total of 754 patients were treated between May 2011 and October 2019 and 605 were included in the analysis. Most common reasons for exclusion were retrospective data collection (45%), and incomplete data set (31%). Median age was 67 years (range 26-89 years). 82% of patients had heart involvement. Cardiac stage was I in 18% of subjects, II in 45%, IIIa in 21%, and IIIb, in 16%. Sixty-seven percent of patients had renal involvement, and 13% and 14% had severe (glomerular filtration rate [eGFR] between 30 and 15 mL/min) and end-stage (eGFR 180 mg/L in 41% of cases. Bortezomib was administered with dexamethasone (D) alone in 41% of patients, with cyclophosphamide and D (CyBorD) in 44%, and with melphalan and D (BMDex) in 13% of subjects. Other combinations were used in 2% of patients. In the overall population, the initial dose of B was attenuated ( Conclusions: Patients with AL amyloidosis start treatment at an advanced stage and early deaths are common. The rate of severe/end-stage renal failure was higher (27%) than expected, possibly indicating that these patients are less likely to be referred to specialized centers. Remarkably, outside referral centers B is commonly administered with D alone. Dose reductions are frequently applied, but dosage can be escalated during therapy. Response rates at 8 weeks are comparable to those reported in other large studies and early cardiac responses are possible. To the best of our knowledge this is the only study prospectively evaluating treatment with B in a real-world setting. Treatment registries under the supervision of regulatory agencies are precious tools to assess common therapeutic practice in rare disease, to evaluate candidate comparators for future trials, and to assess unmet medical needs. Disclosures Palladini: Celgene: Other: Travel support; Jannsen Cilag: Honoraria, Other. Milani:Janssen: Other: Speaker honoraria; Celgene: Other: Travel support; Pfizer: Other: Speaker honoraria. Nuvolone:Janssen: Honoraria. OffLabel Disclosure: Bortezomib in AL amyloidosis

The combination of cyclophosphamide/bortezomib/dexamethasone (CyBorD) showed early promise of high rates of hematologic responses tempered by studies showing the inability to overcome poor prognosis of advanced cardiac amyloidosis. Large studies are needed to clarify its role in light chain (AL) amyloidosis. We report the outcome of 230 patients treated frontline with CyBorD. Overall hematologic response rate was 60%, and in the 201 patients with measurable disease it was 62%, with 43% achieving at least very good partial response (VGPR). Cardiac response was reached in 17% of patients and renal response in 25% of patients. Advanced cardiac stage III patients (amino-terminal pro-natriuretic peptide type B >8500 ng/L) had lower response rates (42%, ≥ VGPR 23%) and poorer survival (median, 7 months). Nevertheless, hematologic response improved survival in these subjects (67% at 2 years), showing the importance of striving for a good response even in this group.

Aim The aim of this analysis was to define survivor in the cancer context. Background Cancer survivor has been used in the cancer lexicon, but may not represent the individuals it defines. Design This concept analysis was completed according to Walker and Avant's method. Data sources PubMed, PsychInfo, CINAHL, JSTOR, Google and medical and public health websites. Review methods Thirty sources from multiple disciplines, published between 1987–2013, were analysed for recurrent themes and conceptual meaning. Critical attributes, antecedents and consequences were extrapolated. Model, related and contrary cases were developed based on an amalgamation of clinical observations. Illegitimate, borderline and invented cases were excluded for this reason. Results Survivor in the cancer context is an individual with a history of malignancy, who has lived through a personalized challenge and has ongoing positive and negative consequences. Not all cancer survivors would identify themselves using the term survivor. Conclusions This contributes to the paradigm shift of cancer as a chronic disease as it establishes the unique nature of the cancer experience while highlighting the long-term concerns related to this set of diseases. The Theory of Uncertainty in Illness provides a framework to understand the individualized nature of being a cancer survivor. Nursing research and practice should address the personal experiences of cancer survivors while still focusing on general survivorship needs.

The purpose of this clinical concept report is to describe a public health project in rural Indiana that addressed the complex social issue or "wicked problem" of childhood trauma. The project was implemented through a unique partnership between nursing faculty and Cooperative Extension Educators, community-based workers who are associated with fulfilling the mission of Land Grant Universities. The core focus of the project entailed a nurse and a Cooperative Extension Educator co-teaching trauma-informed parenting classes to rural dwelling, kinship caregivers. Kinship caregivers are often grandparents who assume the parenting role after the child has been removed from the birth parents' care. The trauma-informed curriculum was developed by experts in child trauma and is available through the National Child Traumatic Stress Network. The unique partnership provided insight into the different missions of the two organizations, different values and workflow metrics, and different schedules, which at times proved to be barriers to implementation. This discussion focuses on deconstructing the goals and objectives of the project and retrospectively, describing recommendations so that public health nurses may partner with Extension Educators in their communities for optimal project success.

According to the American Cancer Society, 1 in 23 Americans will be diagnosed with colorectal cancer (CRC) in their lifetime. Screening for CRC is an effective, yet underused preventive approach. This is especially true in rural areas, where only 35% of patients were found to be up to date on their screenings in 2014. Increasing CRC screening can produce positive patient outcomes by early recognition and removal of precancerous polyps. The purpose of this project was to use quality improvement (QI) interventions to increase CRC screening rates at a nurse-managed clinic in rural Indiana. Using Deming's Plan-Do-Study-Act QI model, multiple interventions were implemented which resulted in a 37% increase in the number of screenings ordered on eligible patients and an overall increase of 28% in the completion of the screenings. This project contributes to healthcare quality knowledge by also suggesting that the fundamental principles of encouraging staff feedback to gain buy-in, improving processes informed by patient data, and valuing frequent performance feedback to staff, strengthened this QI project and ensured adoption and sustainability of these results.

Amyloidosis is a disorder caused by misfolding of autologous protein and its extracellular deposition as fibrils, resulting in vital organ dysfunction and eventually death. Pulmonary amyloidosis may be localised or part of systemic amyloidosis.Pulmonary interstitial amyloidosis is symptomatic only if the amyloid deposits severely affect gas exchange alveolar structure, thus resulting in serious respiratory impairment. Localised parenchymal involvement may be present as nodular amyloidosis or as amyloid deposits associated with localised lymphomas. Finally, tracheobronchial amyloidosis, which is usually not associated with evident clonal proliferation, may result in airway stenosis.Because the treatment options for amyloidosis are dependent on the fibril protein type, the workup of all new cases should include accurate determination of the amyloid protein. Most cases are asymptomatic and need only a careful follow-up. Diffuse alveolar-septal amyloidosis is treated according to the underlying systemic amyloidosis. Nodular pulmonary amyloidosis is usually localised, conservative excision is usually curative and the long-term prognosis is excellent. Tracheobronchial amyloidosis is usually treated with bronchoscopic interventions or external beam radiation therapy.

Immunoglobulin light chain (AL) amyloidosis is caused by a misfolded light chain that deposits in tissue and causes organ dysfunction. Although alternative approaches are being designated, the main...

In patients with light chain (AL) amyloidosis, clinical benefit depends on profound hematologic response translating into organ, especially cardiac or renal, response. Treatment is aimed at rapidly...

The kidney is involved in 70% of patients with immunoglobulin light-chain (AL) amyloidosis. Kidney involvement does not have a major effect on survival, but limits quality of life and access to eff...

Depression is a common comorbid condition experienced by children with type 1 diabetes that, if undiagnosed, can lead to deterioration in glycemic control and other serious health complications. Although it is documented that children with type 1 diabetes experience high rates of depression, a comprehensive clinical guide does not exist to help direct the pediatric provider on how to best care for these children. The purpose of this article is to synthesize current evidence to aid the pediatric primary care provider in the detection and management of depression in the school-aged child with type 1 diabetes.

Background:The measurement of circulating free light chain (FLC) is essential in the diagnosis, prognostic stratification and evaluation of response to therapy in light chain (AL) amyloidosis. For more than 10 years, this has been done with an immunonephelometric assay based on polyclonal antibodies (Freelite), and cutoffs for staging and response assessment have been validated with this method. Recently, a new assay based on monoclonal antibodies (N latex FLC) has been marketed in Europe.Methods:We evaluated and compared the clinical performance of the two assays in 426 patients with newly diagnosed AL amyloidosis.Results:We found suboptimal agreement between the two methods, with differences between values obtained with the Freelite and N latex FLC assays increasing with the concentration of clonal FLC. The diagnostic sensitivity of the Freelite (82%) and N latex FLC (84%) assays was similar, and both improved to 98% in combination with serum and urine immunofixation. The concentration of FLC measured with both methods had prognostic significance. Less pronounced decreases in FLC best predicted improved survival with the N latex FLC assay (33% vs. 50%), and there was poor concordance (84%) in discrimination of responders.Conclusions:The two assays have similar diagnostic and prognostic performance. However, they are not interchangeable, and follow-up should be done with either one. New response criteria are needed for the N latex FLC assay.

PURPOSE/OBJECTIVE The purpose of this study was to examine the relationship between hospitalization cost and discharge blood glucose levels among adult diabetes mellitus type 2 patients hospitalized with uncontrolled glycemia without complications. DESIGN Retrospective cohort analysis examined healthcare billing and laboratory data. SETTING The study was performed in Chicago, Illinois, in a 269-bed medical center between January 1, 2011, and December 31, 2011. SAMPLE Patients were placed into 1 of 2 groups at discharge: blood glucose level less than 250 mg/dL or blood glucose level 250 mg/dL or greater. RESULTS Of the 579 patients with uncontrolled glycemia, 366 met inclusion criteria: diabetes mellitus without complications (International Classification of Diseases, Ninth Revision; 250.0) with abnormal fasting blood glucose (International Classification of Diseases, Ninth Revision; 790.21). Discharge blood glucose levels were 250 mg/dL or greater in 74 patients and less than 250 mg/dL in 292 patients. Mean age of the 2 cohorts was 71.4 (SD, 13.41) years. The majority was male (52.1% and 59.7%, respectively). The median healthcare cost for the entire sample was $3964.34. The mean cost of healthcare for the group with blood glucose of 250 mg/dL or greater at discharge was $4182.65, with a mean length of stay of 8.22 (SD, 3.468) days, while the mean cost of healthcare for the group with blood glucose of less than 250 mg/dL at discharge was $3826.25 and mean length of stay 7.826 (SD, 6.073) days. Analysis of cost was conducted using Pearson χ and was significant for α = .05 (P = .037). The odds ratio of having increased healthcare cost with blood glucose of 250 mg/dL or greater was 1.732 with a 95% confidence interval of 0.998 to 3.012. CONCLUSION The group discharged with blood glucose levels of 250 mg/dL or greater accrued greater cost during hospitalization than did patients who were discharged with blood glucose levels of less than 250 mg/dL. IMPLICATIONS Today's healthcare system is struggling with cost containment, quality control, and standardization of care. Clinical nurse specialists can evaluate current patient care practices and ensure that the practice setting is fiscally beneficial to future patients and healthcare organizations.

Rising healthcare costs and the management of diabetes are financially straining to healthcare organizations. The study purpose was to examine whether a direct relationship existed between the cost of hospitalization, length of stay, excess admission days, and discharge blood glucose (DC-BG) levels and utilizing a standardized glycemic protocol. A retrospective cohort analysis was conducted of adult diabetes mellitus type 2 (DM-2) patients’ pre-diabetic protocol (January 1, 2011-December 31, 2011) and post-diabetic protocol (August 1, 2012-October 31, 2012). The sample included DM-2 inpatients aged ≥18 years admitted without complications and/or with abnormal fasting blood glucose. Pre-protocol sample comprised n = 346 subjects and post-protocol sample comprised n = 149 subjects. Patients who received the diabetic protocol in 2012 experienced a decrease in the DC-BG ( p < .05) and decrease in excess admission days ( p < .05). Evidence supports that utilizing a standardized glycemic protocol improves glycemic control and reduces healthcare cost.

Primary care providers (PCPs) must have accurate information regarding bone marrow donation to effectively educate patients. Since unrelated bone marrow donors are important sources for individuals requiring bone marrow transplant, providers must understand the donation process in order to facilitate it. How bone marrow donations are used, how to join the registry, the process of donation, and the risks and benefits of donation are described. With the increasing need for bone marrow donation, PCPs who are well-educated on this subject can guide their patients in making the potentially life-saving decision to donate.

Introduction: Autologous stem cell transplant (ASCT) is a very effective treatment in AL amyloidosis. However, its role is challenged by novel, powerful, non-transplant therapy, also due to the potentially high treatment-related mortality (TRM) that requires an extremely careful patient selection. Bortezomib-based induction and consolidation preceding and following ASCT have been proposed to improve patient outcomes. Here we report the outcome of 139 patients treated with bortezomib-based induction followed by ASCT in case of unsatisfactory response. Methods: Starting in 2009 we offered upfront therapy with cyclophosphamide (300 mg/m2), bortezomib (1.3 mg/m2) and dexamethasone (40 mg) weekly (CyBorD) to all patients with AL amyloidosis who met the eligibility criteria for transplantation at our institution. Eligibility criteria for ASCT were: age < 65 years, NT-proBNP 50 mL/min per 1.73 m2, NYHA class >3, PS-ECOG, ≤2, left ventricular EF >45%, DLCO >50% (Palladini and Merlini, Blood 2016). Patients who did not achieve a satisfactory response after CyBorD proceeded to ASCT (with melphalan 200 mg/m2), if still eligible. A satisfactory response was defined as complete response (CR), very good partial response (VGPR) with organ response (OR), or partial response (PR) with OR. Patients with overt multiple myeloma were excluded. We assessed response rates (by intent-to-treat), overall survival (OS) and time to next line of treatment or death (TNTD). Results: Between 2009 and 2018, 139 consecutive newly diagnosed patients were eligible for ASCT and received CyBorD as first line treatment. They represented 15% of all patients diagnosed at our center during the study period. Patients' characteristics are reported in Table 1. Treatment with CyBorD continued for 2 cycles in 44 patients (32%), 4 cycles in 64 (46%), 6 cycles in 20 (14%) and 8 cycles in 11 (8%) patients. Only one patient (stage IIIa) died within 100 days from CyBorD initiation due to sudden death. After CyBorD treatment, 26 (20%) patients achieved CR, 45 (32%) VGPR, and 24 (17%) PR (overall hematologic response rate 69%). Sixty-three patients (45%) achieved a satisfactory response after CyBorD and did not proceed to ASCT. Twenty-one patients (15%) who did not reach a satisfactory response after CyBorD did not proceed to ASCT because of organ progression that made them no longer eligible (16 subjects, 12%) or patient refusal (5 cases, 4%). The remaining 55 subjects (40%) received ASCT. No patients died within 100 days from ASCT. Hematologic response after ASCT was obtained in 80% of patients, with CR in 21 subjects (38%), VGPR in 15 (27%) and PR in 8 (15%). In the overall cohort, the hematologic response rate after CyBorD or CyBorD followed by ASCT was 77%, with 47 subjects (34%) attaining CR, 40 (29%) VGPR, and 19 (14%) PR. After a median follow-up of living patients of 48 months, 27 subjects died. In the whole study cohort, overall median survival (OS) was not reached and projected OS was 78% at 4 years and 69% at 10 years. In patients who proceeded to ASCT, median OS was not reached, and projected survival was 90% at 4 years and 77% at 10 years. In patients who achieved a satisfactory response after CyBorD and did not proceed to ASCT, median OS was not reached as well, and projected survival was 84% at 4 years and 72% at 10 years (P=0.438 compared to ASCT). In patients who did not proceed to ASCT despite having failed to achieve a satisfactory response after CyBorD, median survival was 47 months (P Conclusion: This sequential treatment approach granted a high rate of profound hematologic responses and prolonged survival with minimal TRM ( Figure 1 Disclosures Milani: Janssen: Honoraria; Pfizef: Honoraria. Palladini:Sebia: Honoraria; Celgene: Other: Travel grant; Janssen-Cilag: Other: Travel grant; Janssen-Cilag: Honoraria. OffLabel Disclosure: Bortezomib in AL amyloidosis