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BACKGROUND: Occupational self-efficacy (OSE) is an appropriate adaption capability to react to continuous changes in work life today. While self-efficacy is an important component in work context, there is less knowledge regarding older workers’ OSE. OBJECTIVE: This study examined the relationship between work ability, OSE and work engagement among a middle-aged workforce, and whether there were any differences between age groups and between professionals in different work context. METHODS: Data were collected by questionnaire, which included Work Ability Index (WAI), Occupational Self-Efficacy Scale, and Utrecht Work Engagement Scale. RESULTS: A total of 359 home care workers and engineers (response rate 43%) participated. The average age was 54 (SD±5.3) years, 69%were women. The results of logistic regression analyses revealed an association between WAI, OSE (OR 0.66; 95%CI 0.52 to 0.86) and work engagement (OR 0.61; 95%CI 0.47 to 0.78). Higher OSE and work engagement were related to higher work ability. No difference in OSE (5.9; ±0.8) between professional groups was seen, but the home care workers scored considerably higher work engagement (5.1; ±0.9) than the engineers (4.5; ±1.3). CONCLUSIONS: Improving OSE could be worthwhile to support work ability among middle-aged workers, despite dissimilarities in work context and educational level.

Background: The elderly population and their life expectancy have increased, and current long-term care (LTC) for frail older people has limited capabilities because of many diseases among the patients. The nursing staff needs to have a certain level of clinical competence to identify diseases at an early stage and to assess and provide good nursing care to patients with different diseases. In Finland, nursing care in nursing homes is based on evidence-based and high-quality nursing care. However, earlier inspections by the National Supervisory Authority for Welfare and Health showed many discrepancies between the nursing staff’s clinical competence and adequate and continuous education. Aim: This study aimed to explore nursing staff, i.e the clinical competence and decision-making skills of registered and practical nurses in nursing homes for older people in Finland and to analyse the association between nurses’ clinical competence and fundamental background factors Methods: We conducted a cross-sectional study of 337 participants in 50 nursing homes in the western part of Finland. The instrument used was the validated Ms. Olsen test, an extraction of NOP-CET. Statistical analyses were conducted with descriptive statistics and correlations and a cut-off for clinical competence. Results: The clinical competence test, Ms Olsen test was used in Finland for the first time to evaluate the nursing staffs´ clinical competence in nursing homes. This study disclosed that nursing staff showed worrisome limitations in their clinical competence in the LTC in the western part of Finland and the Ms. Olsen test revealed that only one-fourth of the RNs and a third of the PNs passed the cut-off for the clinical competence test. In the self-evaluation, almost all (98.9%) of the participants evaluated themselves as having pretty good to very good clinical competence, which differed remarkably from the results of the Ms. Olsen test. The Finnish Current Care Guidelines were used on a daily basis by 7.4% and weekly by 30%. A statistically significant moderate correlation was found for the nursing staff between Swedish as a working language and mother tongue and the score for clinical competence. No statistically significant correlations were found between the nursing staff’s clinical competence and their use of the Finnish Current Care Guidelines. Previous research has argued that continuous education will enhance nursing staff’s status and clinical competence; however, according to our study, continuous education was not prioritised.

Huolimatta terveydenhuollon kustannus- ja vaikuttavuusmittareiden kansallisesta kehitystyöstä, Suomessa on niukasti vertailukelpoista tietoa sosiaali- ja terveydenhuollon palvelujen asiakas- ja potilasturvallisuudesta. Vuonna 2020 alkaneen valtioneuvoston kanslian selvitys- ja tutkimushankkeen ”Potilas- ja asiakasturvallisuuden kansallinen tilannekuva ja seurantamenettelyt” yhtenä tavoitteena oli selvittää asiakas- ja potilasturvallisuuden mittaamista ja menettelyjä Suomessa. Tässä artikkelissa raportoidaan kyselytutkimuksen havainnot sosiaali- ja kehitysvammaishuollon käyttämistä indikaattoreista. Asiantuntijatyönä selvitettiin kansainvälisiä ja Suomessa käytössä olevia mittareita ja menettelyjä, joita tunnistettiin kaikkiaan noin 200. Joukossa oli 79 RAI-järjestelmän mittaria. Indikaattorit koottiin Webropol-kyselyyn. Sosiaalihuollon kysely kohdennettiin ympärivuorokautisiin laitos- ja asumispalveluihin, kotiin vietäviin palveluihin sekä kehitysvammahuoltoon. Kysely lähetettiin 170 sosiaalipalvelujen organisaatiolle, joista 87 (51%) vastasi. Vastanneissa organisaatioissa oli käytössä keskimäärin 56 asiakas- ja potilasturvallisuusindikaattoria 94:stä; eniten maakunnallisilla hyvinvointikuntayhtymillä (69 kpl), yliopistosairaalakaupungeilla (64 kpl) ja keskussairaalakaupungeilla (61 kpl). Yleisimmin seuratut indikaattorit koskivat johtamista ja organisaatiota, vaaratapahtumien raportointia sekä asiakaspalautteita ja reklamaatioita, mutta seurattujen indikaattorien määrissä oli suurta vaihtelua organisaatioiden välillä. Lisäksi RAI-järjestelmän mittareita käytti noin puolet vastaajista laitoshoidossa ja asumispalveluissa sekä kotiin vietävissä palveluissa. Asiakas- ja potilasturvallisuusindikaattoreita oli käytössä kyselyyn vastanneissa sosiaalipalveluissa kohtalaisesti, omavalvontaohjeiden viitoittamana, mutta seuranta vaikutti epäyhtenäiseltä ja pääasiassa reaktiiviselta. Jatkotutkimusta tarvitaan siitä, kuinka järjestelmällisesti, avoimesti ja terveydenhuollon toimintaan integroituneena indikaattoreita käytetään, sekä siitä, mikä yhteys seurattavien indikaattorien määrällä on asiakasturvallisuuden tasoon.

BackgroundIncident reporting systems are being implemented throughout the world to record safety incidents in healthcare. The quality of the recording and analysis of reporting systems is important for the development of safety promotion measures. MethodsTo assess the reliability of incident reporting ratings collected in a hospital setting, a three-level interrater comparison was undertaken. The routine ratings of the frontline event handlers responsible for evaluating safety incident reports (n=495) were compared with the parallel ratings of two trained patient safety coordinators. The two patient safety coordinators then each separately reviewed about half of the 495 reports, followed by reclassification of a random sample (a random data subset of 60 reports) previously reclassified by the other coordinator during the first reclassification. The following seven patient safety variables were included: nature of the incident, type of incident, patient impact, treating unit impact, circumstances and contributory factors, immediate actions taken, risk category. Interrater agreement was tested with kappa, weighted kappa or iota.ResultsFor the seven variables examined, event handlers had an average of 1.36 missing answers, patient safety coordinators 0.32. For the first interrater comparison, the average change between the three ordinal scale variables for all variables together was towards more serious in 29 % (95%CI: 27%, 32%) and towards less serious in 2 % (95%CI: 0%, 5%) of incidents. The net change for the first interrater comparison was 27% (95%CI: 25%, 30%) towards a more serious incident. The average selection of several categories, when allowed, increased from 7 % (95%CI: 6%, 8%) to 33% (95%CI: 31%, 35%). For all three paired interrater comparisons, the average interrater agreements were in the range of 0.44 to 0.53 and considered moderate. While patient safety coordinators should in theory represent a ‘golden standard’, the coordinator interrater agreement seen in this study was moderate. ConclusionConsensus at national level on how to classify high-risk incidents is needed to develop incident reporting reliability. Also, continuous training in common practices, terminology and rating systems should be given more attention. Having a patient safety coordinator reclassify incident reports can improve reporting accuracy and thereby corrective actions and learning.

The role of allogeneic hematopoietic stem cell transplantation (allo-SCT) in multiple myeloma is controversial. We analyzed the results of 205 patients transplanted in one center during 2000–2017. Transplantation was performed on 75 patients without a previous autologous SCT (upfront-allo), on 74 as tandem transplant (auto-allo), and on 56 patients after relapse. Median overall survival (OS) was 9.9 years for upfront-allo, 11.2 years for auto-allo, and 3.9 years for the relapse group (p = 0.015). Progression-free survival (PFS) was 2.4, 2.4, and 0.9 years, respectively (p < 0.001). Non-relapse mortality at 5 years was 8% overall, with no significant difference between the groups. Post-relapse survival was 4.1 years for upfront-allo and auto-allo, and 2.6 years for the relapse group (p = 0.066). Survival of high-risk patients was reduced. In multivariate analysis, the auto-allo group had improved OS and chronic graft-versus-host disease was advantageous in terms of PFS, OS, and relapse incidence. Late relapses occurred in all groups. Allo-SCT resulted in long-term survival in a small subgroup of patients. Our results indicate that auto-allo-SCT is feasible and could be considered for younger patients in the upfront setting.

Aims To evaluate the implementation of advanced practice nursing for patients with minor orthopedic injuries, including comparison of outcomes in relation to advanced practice nurse versus standard (physician-led) care models. Design A non-inferiority study was performed in an emergency department in Norway, where advanced practice nursing is in an initial stage of implementation. The non-inferiority design was chosen to test whether the new advanced practice nursing model does not compromise quality of care compared to the standard care model already in use. Methods Patients with minor orthopedic injuries were assessed and treated by either advanced practice nursing or standard (physician-led) care models. Participating patients were assigned to the professional available at presentation. In the nursing model, registered nurses worked at an advanced level/applied advanced practice nursing following in-house-training. Senior orthopedic specialists evaluated the diagnostic and treatment accuracy in both models. Data were collected in a tool developed for this study, from May to October 2019. Results In total, 335 cases were included, of which 167 (49.9%) were assessed and treated in the nursing model. Overall, correct diagnosis was found in 97.3% (n = 326) of the cases, and correct treatment was found in 91.3% (n = 306) of the cases. In comparison of missed diagnosis between advanced practice nurse and the standard (physician-led) care model showed inconclusive results (risk ratio: 0.29, 95% CI: 0.06–1.36). In comparison of treatment outcomes, the results showed that the advanced practice nursing model was non-inferior (risk ratio: 0.45, 95% CI: 0.21–0.97). Conclusion Advanced practice nursing care models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. Further implementation of the advanced practice nurse care model is encouraged.

Background Due to vague, initial symptoms, persons with Parkinson’s disease (PD) usually receive a definitive diagnosis after a prolonged period of time. At the time of diagnosis, they have already experienced limitations in activities of daily living and quality of life and are thus in need of immediate rehabilitation. Objective To describe the existing knowledge on the rehabilitation of persons with PD suitable to a home environment and to describe the person-centeredness, interprofessionality and clinical effectiveness of existing rehabilitation activities. Sources of evidence 67 full-text papers from the EBSCO, CINAHL, Medline, Google and Google Scholar databases, published in English, Swedish or Finnish between January 2010 and October 2018, were charted (type of rehabilitation, sample, instrumentation, reported effects) and summarized. Results Rehabilitation through physical activities still appears to be the most common form of rehabilitation, varying from walking to individually tailored exercise programs. The majority of physical rehabilitation activities were conducted outside the home even though they were suitable for a home setting. Physical activities not only improved several physical outcomes but also quality of life, well-being and activities of daily living functions, especially when digital devices were used. Cognitive and psychosocial rehabilitation were much less researched but seen to be an emerging area of research. The focus of rehabilitation seems to lie on persons with PD, not their near-ones. The majority of interventions were planned without discussing in advance with the persons with PD about their preferences, needs or values. Very few interventions were individually tailored or conducted in a home setting, and many studies included patient-recorded outcome measures, but only as secondary to clinical measures. Only a few studies focused on an interprofessional approach to PD rehabilitation, despite the approach being found effective in regard to quality of life for persons with PD. Conclusions There appears to be a focus on physical outcomes and symptom management in the rehabilitation of persons with PD, even though cognitive and psychosocial well-being are often explored as secondary outcomes. Very few rehabilitation interventions were planned with persons or conducted in a home setting, and no interventions were seen that included near-ones. The majority of interventions were planned without the involvement of persons with PD. Still, many of the studies included patient-recorded outcome measures. Digital devices that assist in physical rehabilitation and an interprofessional approach to rehabilitation yield positive clinical outcomes, which in turn promotes a person-centered and holistic approach to rehabilitation.

Infections greatly influence the outcome of acute myeloid leukemia (AML) patients receiving intensive treatment. The aim of this study was to establish the incidence, microbial etiology, risk factors and prognosis of bloodstream infections (BSIs) in patients with AML and compare the results with the previous treatment protocol (AML-92).Registery data were gathered prospectively from 357 patients aged 16-65 years recruited on the AML-2003 treatment protocol between November 2003 and November 2011 during different treatment cycles.Blood culture data were available on 977 treatment episodes, in which there were 503 BSIs (51%). The overall incidence rate (IR) for BSIs (per 1000 hospital days) was 16.7. Twenty patients (5.6%) died due to an infection and 16 of them (80%) had a BSI. The most commonly detected microbes (polymicrobial episodes included) in blood cultures were coagulase-negative staphylococci (CoNS, 24.7%), viridans group streptococci (VGS, 19.1%), enterococci (13.9%) and Enterobacteriacae group (25.9%). The etiology of BSIs varied greatly from treatment cycle to cycle.Enterococcal BSIs have increased compared to our previous treatment protocol, and they represent significant pathogens in blood cultures. Infection-related mortality has decreased despite the increase in the IR of BSIs. Enterococci seem to be an increasingly prominent pathogen underlying BSIs in the AML patients, especially during induction therapy (20%).

There is no consensus on treatment strategies for elderly patients with mantle cell lymphoma (MCL). In this prospective phase II study we investigated whether the poor outcome could be improved, with reasonable toxicity, by prolonging the immunochemotherapy. Ten cycles of alternating cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP)/cytarabine (AraC) with eight doses of rituximab (R) were given as induction. The potential synergism of intermediate-dose AraC and fludarabine was tested in cycles 6-8. Induction was followed by bimonthly rituximab maintenance for 2 years. The median age of the 60 included patients was 74 years, and the Mantle Cell Lymphoma International Prognostic Index (MIPI) was intermediate or high risk in 98% of the patients. The overall response rate was 95% (complete response/complete response unconfirmed 87%). The response of 11 patients improved with cycles 6-8 (R-fludarabine-AraC). Progression-free survival was 70% and overall survival 72% at 4 years, respectively. Treatment related mortality was 2%. Severe infections were rare, with only one grade 4 infection. More dose reductions were needed during fludarabine-containing courses as compared to R-AraC. In 20 patients a transient grade 4 neutropenia without severe infections was recorded during maintenance. In conclusion, elderly patients with MCL can be treated relatively intensively with acceptable toxicity.

Achievement of complete response (CR) is a new goal of therapy for multiple myeloma (MM). By sensitive methods, the depth of response can be measured even among the patients in CR. We used a sensitive real-time quantitative polymerase chain reaction by allele-specific primers (qASO-PCR) to assess the level of minimal residual disease (MRD) in bone marrow of 37 patients with myeloma who had achieved CR/near-to-CR after autologous or allogeneic stem cell transplantation (SCT). Allele-specific primers could be successfully designed for 86% of patients. Three to six months after autotransplantation, the PCR target was not detectable in 53% of patients (16/30 patients), and the respective figure after allotransplantation was 71 % (5/7 patients); the median sensitivity of PCR assay was

Pegfilgrastim (PEGFIL) has been found to be comparable to daily filgrastim (FIL) in managing chemotherapy-induced neutropenia. In the present study, we evaluated the ability of PEGFIL to mobilize stem cells in 38 consecutive patients with lymphoproliferative diseases (multiple myeloma, n = 18; lymphomas, n = 15; chronic lymphocytic leukemia, n = 5). Patients were mobilized using PEGFIL (6-18 mg as a single dose) during 2005-2006; 32 then received high-dose chemotherapy followed by autologous stem cell transplantation. PEGFIL-mobilized patients were matched by age, disease, and treatment line at a ratio of 1:2 to historical FIL-mobilized controls. The primary study endpoint was the blood CD34(+) concentration at onset of leukapheresis. Leukapheresis began a median of 10 days from the beginning of mobilization chemotherapy in both groups. At the onset of leukapheresis, median blood CD34(+) cell counts did not differ significantly in the FIL group compared with the PEGFIL group (79 x 10(6)/L vs 64 x 10(6)/L, respectively; p = 0.44). In the different disease categories, the respective CD34(+) cell counts after FIL and PEGFIL mobilization were 72 x 10(6)/L vs 123 x 10(6)/L (p = 0.08) in myeloma, 51 x 10(6)/L vs 62 x 10(6)/L (p = 0.6) in lymphomas, and 27 x 10(6)/L vs 30 x 10(6)/L (p = 0.62) in CLL, respectively. The target CD34(+) cell yield was harvested with one leukapheresis in 53% of PEGFIL-mobilized patients. Engraftment after autografting did not differ significantly in the two groups. Stem cell mobilization with a single dose of PEGFIL was, therefore, comparable to that achieved using daily FIL in patients with lymphoproliferative diseases. PEGFIL is a more practical way to mobilize stem cells than daily FIL.

A total of 178 bone marrow samples were taken for minimal residual disease (MRD) analysis after 34 stem cell transplantations for poor-risk chronic lymphocytic leukemia, and 86 of them were analyzed in parallel by flow cytometry and allele-specific oligonucleotide-PCR (ASO-PCR). ASO primer was successfully designed for all patients whose frozen diagnosis samples were available. Flow cytometry and ASO-PCR were concordant, i.e. both either positive or both negative, in 78% of the analyses. Flow cytometry did not detect MRD in any of the samples that were PCR-negative cases. In contrast, ASO-PCR detected MRD in samples that were negative for MRD by flow cytometry in 22% of the analyses. In one patient, the immunophenotype but not the IgV H gene sequence had changed during a course of the disease, and MRD could not be followed by flow cytometry. In the remaining cases, the discrepancy was due to a higher sensitivity of ASO-PCR. Autologous stem cell transplantation resulted in clinical complete response in 87% (20/23) of the patients. By flow cytometry, 35% (8/23) of autotransplanted patients became MRD-negative, but only 12.5% (2/16) PCR-negative (sensitivity of ASO-PCR

In the article a new method is presented for allocation of staff resources, 'Professional Assessment of Optimal Nursing Care Intensity Level' (PAONCIL). This method is presented as an alternative to classical time study, which has traditionally been considered to belong to systems for patient classification. By means of this method the optimal nursing care intensity level for individual wards can be established. The study comprised 8 wards, and the nurses working in these wards provided a total of 8,458 professional assessments of optimal nursing care intensity levels. The material was analysed by means of simple linear regression analysis. The nursing care intensity scores per nurse in a single ward were used as independent variables and the average PAONCIL score for the same calendar day was used as a dependent variable. The average determination coefficient for different wards were 0.37; the PAONCIL instrument thus explained 37% of the nursing care intensity/nurse variation. This corresponded to a linear correlation of 0.60. In five out of six wards for adults the optimal nursing care intensity/nurse scores were close to each other, ranging from 3.0 to 3.6. The advantage of the PAONCIL method is that it can be easily implemented in a ward, can be used time and again, is advantageous and is based on quality aspects. The PAONCIL method has been developed on the basis of a caring science perspective and can be seen as an administrative method for the nurse manager, with whose help 'good care' can become possible.

At Vasa Central Hospital in Western Finland a further development of the Oulu Patient Classification (OPC) has been made by the development of weight coefficients and by estimating the nursing care intensity per nurse. The daily level of nursing care intensity of a ward is expressed by the number of nursing care intensity points per nurse. This article presents results from a validity test of the OPC at Vasa Central Hospital. The test was carried out by comparing the daily patient classifications by means of the OPC against measurements made by means of a new measuring instrument, the 'Professional Assessment of Optimal Nursing Care Intensity Level' (PAONCIL) developed at the Vasa Central Hospital. The study was implemented in eight wards during a period of 3 months. The data material consisted of two parts, the daily patient classifications based on the OPC (n = 19 324) and the measurements by means of the PAONCIL forms (n = 8458). Simple and multiple linear regression analyses were used as statistical methods in quantifying the linear relationship between the two interval-scaled variables. In the test of concurrent validity the coefficient of determination was 0.366, i.e. the association between these two indicators is fairly strong (36.6%). The testing of construct validity showed that the construct validity of the indicator hardly deteriorates as a result of the patients being placed in separate nursing care intensity categories. There was a clear correlation between the scores allotted by the indicator to the six different sub-areas of nursing care. When examining the construct validity of the OPC, no factors with independent explanatory power in predicting PAONCIL values were discovered other than those of the OPC. The OPC proved on the basis of this research material and these statistical methods to possess fairly adequate validity, and thus there is a good basis for further research and a development of nursing care.

Achievement of complete response (CR) is a new goal of therapy for multiple myeloma (MM). By sensitive methods, the depth of response can be measured even among the patients in CR. We used a sensitive real-time quantitative polymerase chain reaction by allele-specific primers (qASO-PCR) to assess the level of minimal residual disease (MRD) in bone marrow of 37 patients with myeloma who had achieved CR/near-to-CR after autologous or allogeneic stem cell transplantation (SCT). Allele-specific primers could be successfully designed for 86% of patients. Three to six months after autotransplantation, the PCR target was not detectable in 53% of patients (16/30 patients), and the respective figure after allotransplantation was 71% (5/7 patients); the median sensitivity of PCR assay was0.002%. The proportion of patients without detectable PCR target was 22% of all autotransplanted patients. A threshold level of 0.01% in the qASO-PCR assay 3-6 months after SCT was found to be a useful cut-off limit to divide the patients into two prognostic groups: MRD low/negative vs. MRD high. Low/negative MRD after SCT was a significant predictive factor for the prolongation of progression free (70 vs. 19 months; P = 0.003) and suggestively also for overall survival. We conclude that not only CR but also its depth is important for the long-term outcome in MM.

Dasatinib, a wide-spectrum tyrosine kinase inhibitor (TKI), has shown notable clinical activity in Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) patients carrying a 9;22 translocation and the resulting BCR-ABL1 fusion gene.[1][1] In other subtypes of ALL, its clinical

The RAFAELA Patient Classification System offers tools for the managers to follow the adequacy of resourcing through the Nursing Care Intensity per Nurse (NCI/N). The basic idea of the RAFAELA system is that the workload expressed as NCI/N is compared with the optimal NCI level for the ward. By creating systematic reporting on this indicator, managers can follow the workload level on different wards. The measurement tool is available to all nurses as well as to managers. Thus the staff can follow the results of the daily use of patient classification. Managers can use the data for staff allocation between different wards. As a result, the workload can be discussed and analyzed, and the consequences of challenging situations can be resolved. Together with the staff the managers can look for different solutions for the problems. The overall workload can be too high or too low or the variations of the workload can be too large. The overall aim is a workload on an optimal level. RAFAELA offers a multitude of solutions finding new ways to allocate working hours, networking with different wards, discussions with the persons who guide patient flow in the hospital or changing the number of nurses in the ward.

Benchmarking is a fashionable word within manybranches today, but within nursing care and nursingresearch, systematic benchmarking is fairly undevel-oped and has not been researched. The basic idea withbenchmarking as a method for developing an organ-ization is to learn from others and preferably from thebest of the organizations that can show the best resultswithin the area (Camp 1993, Kaivos et al. 1995). Whatcould be a good resource allocation within nursingcare?During the period from 1994 to 2000 a new patientclassification system (PCS), the so-called RAFAELAsystem, was developed in Finland. Already at the endof the 1990s, the RAFAELA system had spread toapproximately 15 hospitals. To standardize, test thecredibility of the system, the Association of FinnishRegional and Local Authorities decided to start alarge research project (Fagerstro¨m & Rauhala 2001).One important aim during the project time was todevelop and commence a systematic benchmarkingactivity within nursing care (Fagerstro¨m & Rauhala2003). Today, information is collected biannuallyfrom the units participating (about 15 hospitals and250 wards) in the national benchmarking system,according to the concept presented in this study.Benchmarking reports are made and are thenavailable for the users, executives and politicians ondifferent levels of the organizations.

Valproic acid (VPA), an inhibitor of histone deacetylases, inhibits the growth of leukemia cells and induces their differentiation in vitro. In the present study, VPA in combination with two differentiating agents, 13-cis retinoic acid and 1,25-dihydroxyvitamin D3, was given to 19 previously untreated patients with MDS or CMML. Eight patients had to discontinue treatment before week 16 due to toxicity. According to international working group criteria, three patients (16%) responded to treatment. No correlation between VPA serum level, histone acetylation or clinical response was observed.

Aims To identify (1) the contribution of non-patient factors to patient classification systems and (2) the explanatory power of nursing care intensity and non-patient factors to Professional Assessment of Optimal Nursing Care Intensity Level workload. Background In the Rainio, Fagerstrom and Rauhala (RAFAELA) patient classification system, nursing care intensity per nurse is measured daily by the Oulu Patient Classification/Qualisan instrument. The optimal nursing care intensity is determined using Professional Assessment of Optimal Nursing Care Intensity Level instrument. However, nurses’ workload may be affected by factors other than nursing care intensity. Therefore, RAFAELA contains 12 non-patient questions. Methods A retrospective study of all 22 somatic wards of a secondary healthcare hospital in Finland. Results Non-patient questions were answered in 26% of 4870 questionnaires. They added to workload in 62%. Eight questions were grouped into four factors: administration; staff resources and mental stress; co-operation within and between units. The explanatory value between Oulu Patient Classification/Qualisan and Professional Assessment of Optimal Nursing Care Intensity Level had a median of 0.45. Including the non-patient questions raised it to 0.55. Conclusions Non-patient factors affect the nurses’ assessments of their workload, but less than nursing care intensity. They contribute valuable information on the functioning and problems of wards.

Title. What degree of work overload is likely to cause increased sickness absenteeism among nurses? Evidence from the RAFAELA patient classification system Aim. This paper reports a study examining whether nurses’ work overload is associated with increased sick leave and quantifying the loss of working days from work overload. Background. The RAFAELA patient classification system indicates nursing care intensity in relation to an optimum and is one of the few validated monitoring instruments of patient-associated workload among nurses. However, it is not clear whether work overload is a risk factor for increased sickness absenteeism, an important occupational problem in health care. Method. An observational cohort study was carried out with 877 nurses, 31 wards and five Finnish hospitals. Patient-associated workload scores from the RAFAELA system were based on a 6-month monitoring period in 2004. Records of 12-month self certified (1–3 days) and medically certified (>3 days) periods of sick leave in the same year were obtained from employers’ registers. Findings. The mean workload was 9% (SD ¼ 8%) above the optimum. There was a linear trend between increasing workload and increasing sick leave (P £ 0AE006). Among nurses with workload ‡30% above the optimum the rate of self certified periods of sick leave was 1AE44 (95% CI 1AE13–1AE83) times higher than among those with an optimum workload. The corresponding rate ratio for medically certified sick leave was 1AE49 (1AE10–2AE03). These excess rates of sickness absence resulted in 12 extra sick leave days per person-year. Conclusion. Measuring nurses’ workload may be an important part of strategic human resource management of nurses to reduce sick leave among nurses.

One hundred patients with newly diagnosed multiple myeloma (MM) were treated with high-dose chemotherapy followed by single or double autologous stem cell transplantation (ASCT). Up-front treatment with a double ASCT tended to prolong progression-free and overall survival.

Background. RAFAELA is a modern system of patient classification. In the last few years the system has become widely used in Finland and has aroused international interest. It comprises three parts: (1) The Oulu Patient Classification (OPC) instrument and (2) a file on nurse resources. Using these, the daily nursing care intensity, expressed as OPC points per nurse, can be calculated. The existing nursing care intensity can then be compared with the optimal by using the third instrument, (3) the Professional Assessment of Optimal Nursing Care Intensity Level (PAONCIL). This is a daily questionnaire that nurses complete in a 2-month period at intervals every few years. The daily workload is scored from −3 to +3, where zero is the optimal level. The optimal nursing care intensity per nurse is then defined by using linear regression analysis. No expensive time studies are needed. Aims. This paper reports on a study which aimed to identify the minimum requirements for determining optimal nursing care intensity that allow the results to be accepted as correct, in terms of: length of the PAONCIL examination period, PAONCIL questionnaire response rate, explanatory power of the regression analysis and mean values of the OPC and PAONCIL instruments. Design. The results of analyses of optimal nursing care intensity from 61 wards in eight Finnish hospitals for the period 1997–2001 are presented. The data do not contain any information about the identity of the patients. Methods. Linear regression analysis, one-way analysis of variance, t-tests and correlation analysis were used, as well as parameters of distribution of the data. Results. The results of the analysis of optimal nursing care intensity can be regarded as reliable if the PAONCIL response rate is above 70%, the period of examination is at least 3–4 weeks, the mean PAONCIL value is below 0·65 and the explanatory power is above 25%. Conclusion. On the basis of the RAFAELA system, the optimal nursing care intensity of a ward can be reliably determined. The prerequisites for achieving reliable results were clear and mostly fulfilled. Because a study period shorter than that which has previously been the practice is enough, the use of this system will be easier than before. The credibility and usefulness of the RAFAELA system have thus received considerable additional confirmation.

Background Rituximab (R) maintenance therapy bimonthly until progression has been shown in a recent randomized study to prolong duration of remission (with median follow-up of 37 months) and overall survival in elderly patients (pts) with MCL after R-CHOP, but not after R-FC, induction therapy (Kluin-Nelemans et al, N Engl J Med 2012; 367:520-31). We have previously reported initial results of 60 elderly pts with MCL treated with induction therapy consisting of 10 cycles of alternating standard CHOP and intermediate-dose AraC (combining fludarabine in 3 cycles) with 8 doses of R, followed by bimonthly R maintenance for 2 years (yrs) (Räty et al. Leuk Lymphoma 2012; 53:1920-8). High response rate to induction therapy with ORR of 95% (CR/CRu 87%) was seen. PFS was 70% and OS 72% at 4 yrs with the median follow-up of 40 months. Herein, we update our results of this prospective study with completed maintenance therapy in all pts with a median follow-up time of 6 yrs for surviving pts. Methods The pts were recruited at 10 Finnish centres during Dec 2004 and Aug 2010. Eligible pts were > 65 yrs old with histologically confirmed newly diagnosed (WHO criteria, CD5+, CD19/20+, Cyclin D1+) and previously untreated stage II-IV MCL with adequate organ functions and performance status (WHO) Results At the time of diagnosis the median age of 60 recruited pts was 74 yrs (range 65-83), 62% were males, 97% had advanced disease (stage III-IV), 77% had good performance status (PS 0-1). Most (87%) had a history of some other notable illness, most typically cardiovascular disease. Another cancer had been diagnosed earlier in 9 pts (prostate n=3, breast n=3, other n=3). The MIPI risk was low in 2%, intermediate in 45% and high in 53% of the pts, respectively. ORR was 95% (CR/CRu n= 52, PR n=5, PD n=2). One patient could not be evaluated for response due to withdrawal of consent after the first cycle. Seven pts did not receive R maintenance (died/progressed/relapsed during induction n=5, withdrawal of consents n= 2). All 12 doses were given to 34 of 53 pts (64%, CR/CRu n=32, PR n=2). Four pts discontinued maintenance due to recurrent infections / neutropenia,10 pts due to relapse and 5 due to other reasons (secondary MDS n=1, general fatigue n=2, unknown n=2). A transient grade 4 neutropenia was seen in 20 pts during maintenance with no serious infections. HZV or VZV infections were recorded in 9 pts. Altogether 22 of responding pts have progressed/relapsed (during induction n=2, during maintenance n=10, during follow-up n=10), 6 of them with isolated CNS relapse. Twenty-one pts have died (sudden cardiac death during induction n=1, progressive MCL n=17, secondary MDS/AML n=1, unknown n=2). At 6 yrs (intention to treat) PFS was 64% (median 97 months, 95% CI 75 – 120 months), EFS 59% (median 95 months, 95% CI 75 – 114 months) and OS 62% (median not reached), respectively. DFS was 72% at 6 yrs (median 91 months, 95% CI 89 – 93 months) for 52 pts in CR/CRu. Two pts have developed secondary MDS (at 27 and 67 months). Eight new cancers (prostate n=3, breast n=1 and skin n=4) have been recorded in 6 patients during maintenance or follow-up. Conclusions Long PFS and OS over 60% at 6 yrs with median DFS of more than 7 yrs can be achieved with prolonged cytarabine-containing immunochemotherapy followed by 2 yrs R maintenance in elderly pts with MCL. Maintenance therapy was well tolerated in general. Transient neutropenia during maintenance was not uncommon, but serious infections were not seen and only 4 pts discontinued maintenance therapy because of recurrent neutropenia or infections. Attention for second malignancies is requested as 9 pts had cancer before MCL diagnosis, MDS/AML was developed in 2 pts and 6 pts showed carcinomas during follow-up in this elderly patient population. Disclosures Räty: Roche Ltd: Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline Ltd: Honoraria; Mundipharma: Honoraria. Mikkola:Roche Ltd: Honoraria. Poikonen:Celgene: Speakers Bureau; Amgen: Speakers Bureau; Baxter: Speakers Bureau; Novartis: Speakers Bureau; GlaxoSmithKline: Consultancy; Mundipharma: Honoraria; Novartis: Honoraria. Räsänen:Novartis: Honoraria; Roche Ltd: Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy; Janssen-Cilag: Honoraria; Amgen: Honoraria; Mundipharma: Honoraria.

Tyrosine kinase inhibitors (TKIs) targeting the BCR-ABL fusion protein are an effective therapy for Philadelphia chromosome positive (Ph+) leukemia. Dasatinib, a 2nd generation pan-TKI, also inhibits wild-type kinases, which may result in unexpected clinical responses. Recent data suggest that dasatinib has a potent immunosuppressive effect on T- and NK-cells in vitro. In contrast, we have noticed a marked expansion of lymphocytes in blood in a subset of dasatinib patients, but its clinical significance and molecular mechanisms are unclear. In this multicenter study, 19 Ph+ leukemia patients with marked lymphoproliferation in blood while on dasatinib (9 CML CP, 2 CML AP, 2 CML BC, 6 Ph+ALL) were identified. Clonality, immunophenotype, and intracellular signaling was analyzed and related clinical information was collected. In addition, prevalence and prognostic significance of the phenomenon was retrospectively assessed in a Phase II clinical study on 46 Ph+ ALL patients. An abrupt lymphocytosis (peak count range 4–20×109/L) with large granular lymphocyte (LGL) morphology was observed after a median of 3 months from the start of therapy (range 1–8 months). In most patients, LGL lymphocytosis was long-lasting and continued throughout dasatinib therapy, albeit with marked fluctuations in absolute lymphocyte count (Fig. 1a). In all evaluable patients (n=4), lymphocyte counts normalized after drug discontinuation. All patients were previously exposed to imatinib without similar changes in lymphocyte count or morphology. By immunophenotyping, 14 patients had a cytotoxic T-cell and 5 patients a NK-cell phenotype. After initiation of dasatinib therapy, the CD4/CD8 ratio shifted, expression of activation antigens HLA-DR and CD57 increased, expression of homing antigen CD62L decreased and relative numbers of regulatory T-cells were significantly decreased (p Figure Figure

Background: The Nordic Lymphoma Group has shown that adding cytarabine (AraC) and rituximab (R) to high dose CHOP and autologous stem cell transplantation increases response rate, event free survival (EFS), progression free survival (PFS) and overall survival (OS) of patients (pts) with MCL < 65 years (Geisler et al, Blood 2008). About 50% of pts with MCL are older than 65 years. Most of them are not candidates for high dose chemotherapy or transplantations and no satisfactory standard treatment is known for them. In this prospective pilot trial for elderly pts we explored the feasibility and efficacy of a prolonged standard dose induction treatment (10 cycles) with potentially synergistic combinations followed by R maintenance. Methods: Eligible were pts with histologically confirmed MCL (WHO criteria), CD5+, CD19/20+, cyclinD1+, age > 65 years, with adequate organ functions and performance status < 4. Induction: standard dose R-CHOP (cycles 1, 3, 5), R-AraC (R 375mg/m2 x 1, AraC 1g/m2 4 doses with 12 hrs intervals, cycles 2, 4), R-AraC with fludarabine (F) (2 doses of F 25 mg/m2, cycles 6 – 8), CHOP (cycles 9–10). Maintenance for pts with CR/PR: R 375 mg/m2 bimonthly x 12. Diagnostic workup included physical examination, CT scan, histological lymph node biopsy, bone marrow aspiration and biopsy, and immunohistology or flow cytometry of the diagnostic material. Endoscopies were performed for symptomatic patients. Responses were evaluated according to revised criteria (Cheson et al JCO 2007) after 5th, 8th, 10th cycles and after that every 6 months. Results: Thirty four pts were recruited. Age median 74 years (67–79 years). Performance status 0 n=12, 1 n=16, 2 n=3, 3 n=3. Stage IIA n=1, IVA n=20, IVB n=13. International prognostic index IPI 2 n=10, 3 n=13, 4 n=9, 5 n=2. Response to induction: CR 23, CRu 6, PR 3, PD 1, not evaluable 1. The response of 7 pts improved with cycles 6 to 8 (R-AraC with F). At diagnosis 32 pts had bone marrow involvement. At best response 24/25 pts with bone marrow involvement studied and CR (n=17), CRu (n=6) or PR (CTscan positive, n=1) were negative in flow cytometry (sensitivity 10−3–10−4). One patient with PR had residual MCL in flow cytometry. Median follow-up time of living patients is 26 months, range 6–43 months. There have been 8 events: progression or relapse 4, secondary AML 1, sudden cardiac death in CR 1, and 2 responding patients withdrew their concents. At 30 months EFS is 72%, PFS 77%, time to progression 85%, and OS 80%. Three pts have discontinued induction after 6,7 or 8 cycles due to toxicity but remain in CR. Infections grade 3 occurred in 8 pts and grade 4 in 1 patient. Eight pts have had transient neutropenia < 0.5 x 109/l during maintenance treatment. Conclusions: Elderly patients with MCL and with good performance status could be treated relatively intensively with moderate toxicity when supported with G-CSF. In historical comparison to CHOP, R, AraC and F increase response rate and prolong PFS, TTP and OS. Flow cytometry is a powerful tool to study bone marrow involvement at diagnosis and minimal residual disease. A longer follow-up is needed to evaluate the maintenance treatment but several patients have developed transient grade 4 neutropenia during maintenance treatment after this induction schedule.

In addition to therapeutic efficacy in imatinib-resistant BCR-ABL positive malignancies, dasatinib may have off-target immunomodulatory effects by inhibiting kinases (e.g. SRCs, c-KIT) in immune effector cells. In a proportion of patients, dasatinib treatment is associated with non-infectious pleural effusions and panniculitis, which may reflect aberrant immune reactivity. Here we describe a marked expansion of clonal LGL lymphocytes in blood among 11 BCR-ABL positive patients on dasatinib therapy (5 CML CP, 1 CML AP, 1 CML BC, 4 Ph+ALL). All patients were previously exposed to imatinib without similar changes in lymphocyte count or morphology. The median time to LGL lymphocytosis was 2 months from the start of dasatinib (range 1–8 months). It developed abruptly, with a peak lymphocyte count of 4–20 ×109/L, and was often preceded by low-grade fever. In all evaluable cases, lymphocyte counts normalized after drug discontinuation. By immunophenotyping, 6 patients had a CD3/CD8+ cytotoxic T-cell phenotype and 4 patients had a CD56+ NK-cell phenotype. The LGL lymphocytes were BCR-ABL negative. All CD3-positive cases had a clonal rearrangement of TCR gamma/delta genes by PCR; clonality was not detected in samples prior to dasatinib therapy (n=3). In TCR beta gene repertoire assay, oligoclonal patterns were seen in selected genes. All patients with HLA data had the A2 allele (n=8). Dasatinib-related complications were common: pleural effusions and/or pulmonary infiltrates (n=8), modest CMV reactivation (n=5), severe colitis (n=5), which developed after appearance of LGL lymphocytosis. Immunophenotyping was available from 2 patients with pleural effusions: in both cases the majority of cells were CD3+CD8+ T-cells and no leukemic cells were detected. TCR gamma assay was done from one patient sample and it showed similar clonal pattern as in peripheral blood. However, despite frequent side-effects, response to dasatinib treatment was very good in all cases, including complete molecular responses in 5 advanced phase patients. Transient clonal LGL lymphocytosis has been described in few patient cases with a primary herpesvirus infection. Our patients share striking pheno/genotypic similarities with LGL leukemia, in which an antigen driven expansion of LGLs precedes the occurrence of oncogenic events. However, in our patients LGL lymphocytosis appeared to be a benign phenomenon. We postulate that by virtue of inhibition of key non-BCR-ABL kinases, dasatinib induces a reversible state of autoimmune-like reactivity upon antigen challenge in a proportion of patients with a distinct genetic and/or environmental background. The aberrant immune response may also result in enhanced anti-leukemic control driven by the cytotoxic T/NK LGL cells. Dasatinib could be a valuable tool in uncovering the pathogenesis of LGL lymphoproliferation, putatively related to mutations in kinases targeted by the drug.