Perceived Needs Among Healthcare Providers Caring for Seriously Ill Adults Regarding Electronic Health Record Triggers for Palliative Care Referral.

Many healthcare facilities in the United States currently utilize electronic health record triggers to promote and facilitate palliative care referral. The purpose of this study was to explore perceived needs regarding electronic health record trigger criteria for palliative care referral among healthcare providers caring for seriously ill adult hospitalized patients in a teaching hospital in New York State. A qualitative descriptive approach was utilized with use of individual semistructured interviews. Braun and Clarke's Reflexive Thematic Analysis method was used to analyze data. Data analysis generated one overarching theme, I'm in Favor of an Electronic Health Record Automatic Trigger for Palliative Care , and three key themes, Build a Checklist Screening Tool Into Epic With Predefined Conditions and a Palliative Consult in the Admission Order Set , If Providers Call a Palliative Care Consult Sooner, We Give Patients a Better Quality of Life , and Providers Need to Be Aware of the Different Facets of What Palliative Care Actually Does. Findings revealed that all participants supported incorporating electronic health record palliative care triggers. Future research is needed exploring provider palliative care education approaches to promote understanding of palliative care services and to address personal and/or professional bias.

School-Based Nurse Practitioners' Perceptions of the Health Care Needs of Transgender and Gender Nonconforming Adolescents.

School-based nurse practitioners (NPs) can reduce health disparities for transgender and gender nonconforming (TGNC) adolescents. However, research is limited regarding their understanding of TGNC health. This study aimed to explore school-based NPs' perceptions of the health needs of TGNC adolescents. A qualitative, descriptive analysis utilizing a demographic survey and semi-structured interview questionnaire was conducted. School-based NPs (N = 6) were recruited via the New York School-Based Health Alliance listserv and through clinical networking. An essentialist, reflexive approach utilizing inductive thematic analysis was utilized. Four key themes and an overarching theme were identified. The overarching theme was the following: School-based NPs are primary resources-or "point people"-for TGNC adolescents seeking support, safety, and accessibility to health care. Findings identified the need for improvements in the areas of TGNC advocacy and education.

Development of a survivorship screening tool in survivors of hematopoietic cell transplant.

PURPOSE: This study describes the development of a screening measure focused on the potential needs of hematopoietic cell transplant (HCT) survivors at least 1-year post-transplant. METHODS: A multidisciplinary team met regularly to develop a screening measure to better understand the ongoing medical and clinical symptoms experienced by survivors of HCT. This measure was given to 299 patients presenting to an HCT survivorship clinic, with referrals offered for any issues reaching clinical threshold. A factor analysis was performed to examine the underlying factor structure of the measure. RESULTS: Analyses indicated a 3-factor underlying structure, including physical, emotional, and practical concerns. Areas most consistently endorsed as ongoing areas of concern included fatigue, financial concerns, and worry about their future. Interestingly, while many patients were interested in referrals for these issues, some patients did not wish to have their symptoms managed at our center. CONCLUSIONS: Survivors of hematopoietic cell transplant continue to experience symptoms well after their treatment has ended, including issues related to the emotional, physical, and practical impact of their illness and treatment regimen. It is vital that their providers understand the frequency of these concerns as well as patients' preference for intervention. IMPLICATIONS FOR CANCER SURVIVORS: While HCT has become increasingly successful in treating hematologic cancers, many survivors experience a range of issues post-transplant. Survivorship care for these patients must include ongoing thorough assessment related to the practical, emotional, and medical symptoms experienced post-transplant, with appropriate intervention provided in-house where possible or in the community according to patient preference.

Burnout, Moral Distress, Work-Life Balance, and Career Satisfaction among Hematopoietic Cell Transplantation Professionals.

A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work-life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale-Revised) were examined to identify work-related distress. Additional questions addressed demographics, work-life balance, and career satisfaction. Of 5759 HCT providers who received an individualized invitation to participate, 914 (16%) responded; 627 additional participants responded to an open link survey. Significant differences in demographic and practice characteristics existed across disciplines (P < .05). The prevalence of burnout differed across disciplines (P < .05) with an overall prevalence of 40%. Over one-half of pharmacists had burnout, whereas social workers had the lowest prevalence at less than one-third. Moral distress scores ranged from 0 to 336 and varied by discipline (P < .05); pharmacists had the highest mean score (62.9 ± 34.8) and social workers the lowest (42.7 ± 24.4). In multivariate and univariate analyses, variables contributing to burnout varied by discipline; however, moral distress was a significant contributing factor for all providers. Those with burnout were more likely to report inadequate work-life balance and a low level of career satisfaction; however, overall there was a high level of career satisfaction across disciplines. Burnout, moral distress, and inadequate work-life balance existed at a variable rate in all HCT disciplines, yet career satisfaction was high. These results suggest specific areas to address in the work environment for HCT health professionals, especially the need for relief of moral distress and a greater degree of personal time. As the creation of healthy work environments is increasingly emphasized to improve quality care and decrease costs, these findings should be used by HCT leadership to develop interventions that mitigate work-related distress and in turn foster recruitment and retention of HCT providers.

Ascertainment of Unmet Needs and Participation in Health Maintenance and Screening of Adult Hematopoietic Cell Transplantation Survivors Followed in a Formal Survivorship Program.

This study aimed to ascertain unmet needs in autologous and allogeneic hematopoietic cell transplantation (HCT) recipients actively followed in an established long-term survivorship clinic at Roswell Park Cancer Institute from 2006 to 2012. The Survivor Unmet Needs Survey (SUNS) was mailed to 209 eligible patients and returned by 110 (53% participation rate). SUNS includes 89 items covering 5 domains: Emotional Health, Access and Continuity of Care, Relationships, Financial Concerns, and Information. The top 5 specific unmet needs for autologous HCT patients were inability to set future goals/long-term plans, changes in appearance, bad memory/lacking focus, losing confidence in abilities, and paying household or other bills. For allogeneic HCT patients these 5 unmet needs were tied at 21% of respondents: ability to earn money, pay bills, feeling tired, feeling depressed, and dealing with others' expectations of "returning to normal." The top 5 needs reported by females were all from the emotional health domain, whereas males reported financial domain unmet needs. Self-reported participation in health maintenance and screening tests varied greatly from 88% of patients having routine annual bloodwork to 13% of patients having an exercise stress test in the past year. Our findings demonstrate unmet needs in emotional health and financial burden in HCT survivors and variable compliance with survivorship screening.

Metabolic Syndrome and Cardiovascular Disease after Hematopoietic Cell Transplantation: Screening and Preventive Practice Recommendations from the CIBMTR and EBMT.

Metabolic syndrome (MetS) is a constellation of cardiovascular risk factors that increases the risk of cardiovascular disease, diabetes mellitus, and all-cause mortality. Long-term survivors of hematopoietic cell transplantation (HCT) have a substantial risk of developing MetS and cardiovascular disease, with an estimated prevalence of MetS of 31% to 49% among HCT recipients. Although MetS has not yet been proven to impact cardiovascular risk after HCT, an understanding of the incidence and risk factors for MetS in HCT recipients can provide the foundation to evaluate screening guidelines and develop interventions that may mitigate cardiovascular-related mortality. A working group was established through the Center for International Blood and Marrow Transplant Research and the European Group for Blood and Marrow Transplantation with the goal to review literature and recommend practices appropriate to HCT recipients. Here we deliver consensus recommendations to help clinicians provide screening and preventive care for MetS and cardiovascular disease among HCT recipients. All HCT survivors should be advised of the risks of MetS and encouraged to undergo recommended screening based on their predisposition and ongoing risk factors.

Doctor of Nursing Practice Education: Impact on Advanced Nursing Practice.

OBJECTIVE: To discuss how doctoral education, specifically the doctorate of nursing practice (DNP) can promote changes in advanced practice nursing. DATA SOURCES: Medline, CINAHL, PubMed. CONCLUSION: Variations continue to exist in educational curricula, program plans, and scholarly projects, leading to a lack of consistency in experiential learning. At this point in time it is too early in the DNP implementation process to determine ultimate impact. IMPLICATIONS FOR NURSING PRACTICE: Continuous program self-assessment and evaluation of DNP education programs will be of paramount importance to assure program quality and optimization of health trajectories.

Fludarabine and cyclophosphamide provides a nonmyeloablative alternative conditioning regimen with low transplant-related mortality and control of high risk disease.

Non-myeloablative allogeneic transplant (NMAT) has a curative potential for patients who are not myeloablative allogeneic transplant (MAT) candidates. We report a phase II trial of a NMAT regimen with cyclophosphamide and fludarabine in 40 patients; 21 of whom had a prior MAT. Day +100 and 1-year transplant-related mortality (TRM) post-NMAT were 13% and 34%, respectively. Day +100 and 1-year Overall/Progression-Free Survival (OS/PFS) were 80%/65% and 43%/25%, respectively. OS was higher in patients with KPS≥90 and lower in recipient/donor CMV+/- vs. other combinations. FluCy has low TRM and is curative in about 20% of high-risk patients.

Remestemcel-L for acute graft-versus-host disease therapy.

INTRODUCTION: Remestemcel-L (Prochymal®, Osiris) is an off-the-shelf adult mesenchymal stromal cell product that has been applied to acute graft-versus-host disease (aGvHD) for its immunomodulatory properties. AREAS COVERED: This article discusses preclinical and clinical studies supporting the use of remestemcel-L in aGvHD as well as the current regulatory status. This information was based upon a PubMed and Internet search. EXPERT OPINION: Phase II studies suggest remestemcel-L may have clinical activity in aGvHD and confirm tolerability. However, these results must be interpreted cautiously with any use of remestemcel-L optimally occurring in the context of a clinical trial. Further clarity will be obtained when the results of a completed Phase III study are published. There is a small market for remestemcel-L in aGvHD. A possible future scenario is that a more prevalent indication is found and remestemcel-L is approved for that indication, but use continues for aGvHD.

Seeing what's out of sight: wireless capsule endoscopy's unique ability to visualize and accurately assess the severity of gastrointestinal graft-versus-host-disease.

Early recognition of gastrointestinal graft-versus-host disease (GI GVHD) after allogeneic hematopoietic stem cell transplantation (alloHSCT) is vital to initiation of therapy. However, the most common location, the small bowel (SB), is difficult to access with upper and lower endoscopy (UGE/LGE). Wireless capsule endoscopy (WCE) is a noninvasive technology allowing complete SB evaluation. The capsule location can also be tracked to identify motility derangements. From August 2006 to July 2007, 11 alloHSCT patients with GI symptoms underwent WCE, and visual grading was performed. UGE and LGE with biopsies were done when clinically indicated. All patients had evidence of probable acute GVHD (aGVHD) on WCE. WCE revealed lesions of greater severity than those seen by UGE or LGE in most patients. WCE demonstrated that 45% of patients had delayed gastric transit time. WCE is an excellent, noninvasive method for assessing GI GVHD, with the ability to more accurately assess the severity of GVHD, evaluate clinical symptoms, and follow response to treatment.

Arterial thrombosis in four patients treated with thalidomide.

Thalidomide has been associated with venous thrombotic events, as reported in the post-marketing surveillance reports by Celgene Corporation; as well as case reports in the literature. Seven arterial thrombotic events have been reported in patients receiving thalidomide with 3 cases occurring in patients with other predisposing conditions. We report 4 additional cases of arterial thromboses in 1 lymphoma and 3 myeloma patients treated with thalidomide. The mechanism for these events is unclear; however, it is significant that 2 patients were receiving concomitant anticoagulation with aspirin and warfarin.

Long-term survival with allogeneic stem cell transplant and donor lymphocyte infusion following salvage therapy with anti-CD52 monoclonal antibody (Campath) in a patient with alpha/beta hepatosplenic T-cell non-Hodgkin's lymphoma.

Hepatosplenic T-cell non-Hodgkin's lymphoma (HSTCL) is a rare, aggressive form of NHL, with a median survival of approximately 8 months. We were able to successfully induce complete remission in a patient with alpha/beta HSTCL who was refractory to multiple prior chemotherapy regimens, using the humanized anti-CD52 monoclonal antibody alemtuzumab (Campath). Once disease was controlled, the patient was able to undergo allogeneic stem cell transplantation (SCT), which resulted in complete remission. Furthermore, upon relapse, we were able to re-induce complete clinical and molecular remission with donor lymphocyte infusions. At Day 655 (post-SCT), the patient remains in complete remission. These data suggest a potential role for alemtuzumab and allogeneic SCT in the treatment of T-cell NHL.