Comparison of venous thromboembolism incidence in newly diagnosed multiple myeloma patients receiving bortezomib, lenalidomide, dexamethasone (RVD) or carfilzomib, lenalidomide, dexamethasone (KRD) with aspirin or rivaroxaban thromboprophylaxis.

Incidence of venous thromboembolism (VTE) varies across different regimens in newly diagnosed multiple myeloma (NDMM) patients. Limited data exist on the use of direct oral anticoagulants as thromboprophylaxis in the setting of haematologic malignancies, specifically multiple myeloma. In this retrospective study of 305 NDMM patients, VTE rates in those treated with carfilzomib, lenalidomide, dexamethasone (KRD) + aspirin (ASA), bortezomib, lenalidomide, dexamethasone (RVD) + ASA, and KRD + rivaroxaban were statistically significant, 16·1%, 4·8%, and 4·8%, respectively. The findings confirm a higher incidence of VTE when using KRD induction compared to RVD induction and reveal that the use of low-dose rivaroxaban thromboprophylaxis can mitigate this risk without an observable increase in bleeding rates.

Outpatient clinical pharmacy practice in the face of COVID-19 at a cancer center in New York City.

PURPOSE: With the rapid spread of COVID-19 in New York City since early March 2020, innovative measures were needed for clinical pharmacy specialists to provide direct clinical care safely to cancer patients. Allocating the workforce was necessary to meet the surging needs of the inpatient services due to the COVID-19 outbreak, which had the potential to compromise outpatient services. We present here our approach of restructuring clinical pharmacy services and providing direct patient care in outpatient clinics during the pandemic. DATA SOURCES: We conducted a retrospective review of electronic clinical documentation involving clinical pharmacy specialist patient encounters in 9 outpatient clinics from March 1, 2020 to May 31, 2020. The analysis of the clinical pharmacy specialist interventions and the impact of the interventions was descriptive. DATA SUMMARY: As hospital services were modified to handle the surge due to COVID-19, select clinical pharmacy specialists were redeployed from the outpatient clinics or research blocks to COVID-19 inpatient teams. During these 3 months, clinical pharmacy specialists were involved in 2535 patient visits from 9 outpatient clinics and contributed a total of 4022 interventions, the majority of which utilized telemedicine. The interventions provided critical clinical pharmacy care during the pandemic and omitted 199 in-person visits for medical care. CONCLUSION: The swift transition to telemedicine allowed the provision of direct clinical pharmacy services to patients with cancer during the COVID-19 pandemic.

Selinexor: A First-in-Class Nuclear Export Inhibitor for Management of Multiply Relapsed Multiple Myeloma.

Objective: To review the pharmacology, pharmacokinetics, efficacy, and safety of selinexor for management of relapsed multiple myeloma (MM). Data Sources: A literature search was performed of PubMed and MEDLINE databases (January 1, 2000, to November 14, 2019), abstracts from the American Society of Hematology and the American Society of Clinical Oncology, and ongoing studies from US National Institutes of Health ClinicalTrials.gov. Queries were performed using key words selinexor, SINE, XPO1, and Xpovio.Study Selection/Data Extraction: Human and animal studies related to the pharmacology, pharmacokinetics, efficacy, and safety of selinexor were identified. Data Synthesis: Although numerous advances have been made in MM management, there remains an unmet need for treatment of heavily relapsed/refractory disease. Selinexor is a first-in-class selective inhibitor of nuclear export, which, through inhibition of exportin-1, causes accumulation of tumor suppressor proteins, reduction in oncoproteins, and apoptosis of plasma cells. Selinexor exhibited an overall response in 26% of patients with multiply relapsed MM. Median progression-free survival was 3.7 months, and overall survival was 8.6 months. Common adverse effects include thrombocytopenia, neutropenia, fatigue, and nausea. Ongoing studies are investigating combination therapies utilizing selinexor. Relevance to Patient Care and Clinical Practice: This review describes the efficacy, safety, and clinical applicability of selinexor, a novel agent with potential to meet an unmet need in refractory MM. Conclusion: Selinexor has demonstrated activity in a heavily refractory patient population. Given the adverse effect profile and associated costs, additional studies are needed to further elucidate the appropriate clinical scenario and combinations for selinexor use.

Management of Mantle Cell Lymphoma in the Era of Novel Oral Agents.

Objectives: To discuss (1) recent and emerging data for pharmacological management of untreated and relapsed/refractory (R/R) mantle cell lymphoma (MCL) with agents approved in the United States, (2) important considerations for toxicity monitoring and management, and (3) preliminary data and ongoing studies for agents in MCL-specific clinical trials. Data Sources: PubMed/MEDLINE, EMBASE, Google Scholar, product labeling, National Comprehensive Cancer Network, American Cancer Society, and ClinicalTrials.gov were searched for studies published between January 1, 2017, and January 31, 2020, and key historical trials. Study Selection and Data Extraction: Relevant studies conducted in humans and selected supporting preclinical data were reviewed. Data Synthesis: MCL is a rare but usually aggressive non-Hodgkin lymphoma that most commonly affects the older population. Traditionally, the treatment of MCL has been determined based on transplant eligibility. Newer data suggest that more tolerable frontline therapy may produce outcomes similar to intensive historical induction regimens, possibly precluding fewer patients from autologous stem cell transplant and producing better long-term outcomes in transplant-ineligible patients. In the R/R setting, novel regimens are improving outcomes and changing the landscape of treatment. Relevance to Patient Care and Clinical Practice: This review summarizes and discusses recent and emerging data for management of newly diagnosed and R/R MCL; key supportive care considerations for agents are also discussed. Conclusions: Recent study results are changing management of MCL. Although these data have complicated the picture of regimen selection, increasingly effective and tolerable therapy and additional anticipated data point to a brighter future for patients with MCL.

Associations between professional development benefits and PA career satisfaction.

OBJECTIVE: This study investigated how professional development benefits offered by employers directly correlate to self-perceptions of leadership potential, committee involvement, and career satisfaction among physician assistants (PAs). METHODS: A retrospective analysis of the 2015 AAPA National Survey and 2016 AAPA Salary Survey explored the associations between the aforementioned variables. Bivariate correlations were used to evaluate the associations between variables. RESULTS: Self-perceived leadership attributes were found to be mildly and positively correlated with the number of committees a PA was involved in (P < .001; correlation coefficient (CC) = 0.245). Of the investigated factors, only leadership potential was significantly correlated with career satisfaction (P ≤ .001; CC = 0.059). The proportion of professional development fees, memberships, and expenses covered by employers had no bearing on career satisfaction (P = .438). CONCLUSIONS: Irrespective of the benefits received, PAs were satisfied with their careers. Intrinsic rewards may have a greater positive association with career satisfaction than extrinsic benefits alone.

Deep venous thrombosis after saphenous endovenous radiofrequency ablation: is it predictable?

BACKGROUND: Endovenous radiofrequency ablation (RFA) is a safe and effective treatment for varicose veins caused by saphenous reflux. Deep venous thrombosis (DVT) is a known complication of this procedure. The purpose of this study is to describe the frequency of DVT after RFA and the associated predisposing factors. METHODS: A retrospective analysis was performed using prospectively collected data from December 2008 to December 2011; a total of 277 consecutive office-based RFA procedures were performed at a single institution using the VNUS ClosureFast catheter (VNUS Medical Technologies, San Jose, CA). Duplex ultrasonography scans were completed 2 weeks postprocedure in all patients. Risk factors assessed for the development of DVT included: great versus small saphenous vein (SSV) treated, right versus left side treated, number of radiofrequency cycles used, hypercoagulable state, history of DVT, tobacco use, medications (i.e., oral contraceptives, aspirin, warfarin, and clopidogrel), and vein diameter at the junction of the superficial and deep systems. RESULTS: Seventy-two percent of the patients were women, 56% were treated on the right side, and 86% were performed on the great saphenous vein (GSV). The mean age was 54 ± 14 years (range: 23-88 years). Three percent of patients had a preprocedure diagnosis of hypercoagulable state, and 8% had a history of previous DVT. On postprocedural ultrasound, thrombus protrusion into the deep system without occlusion (endovenous heat-induced thrombosis) was present in 11 patients (4%). DVT, as defined by thrombus protrusion with complete occlusion of the femoral or popliteal vein, was identified in 2 patients (0.7%). Previous DVT was the only factor associated with postprocedural DVT (P = 0.018). Although not statistically significant, there was a trend toward a higher risk of DVT in SSV-treated patients. Factors associated with endovascular heat-induced thrombosis alone were male sex (P = 0.02), SSV treatment (P = 0.05), aspirin use (P = 0.008), and factor V Leiden deficiency (P = 0.01). CONCLUSIONS: The use of RFA to treat patients with symptoms caused by saphenous reflux involves a small but definite risk of DVT. This study shows that the risk of post-RFA DVT is greater in patients with previous DVT, with a trend toward an increased risk in patients having treatment of the SSV. Periprocedural anticoagulation may be considered in this subset to reduce the risk of DVT after RFA. Thrombus protrusion without DVT was found to be more likely in patients with hypercoagulability, male sex, SSV treatment, and aspirin use. Additional prospective studies are required to analyze these and other factors that may predict thrombotic events after endovenous RFA.

Histological artifacts associated with laser and electroscalpel gingivectomy: Case series / Artefactos histológicos asociados a gingivectomía con láser y electrobisturí: serie de casos.

Introduction. Over time, efforts have been invested in the design of new instruments that overcome the disadvantages of the gold standard instrument in surgery, the scalpel. As a result, electronic equipment has emerged such as the electric scalpel and laser devices. The available evidence on these instruments suggests that the tissue response is related to each instrument's physical and biological cutting principles. Objective. To compare the histological changes in gingiva samples associated with surgical cutting performed with a 940 nm diode laser, a 2780 nm erbium, chromium: yttriumscandium-gallium-garnet (Er,Cr:YSGG) laser, and an electric scalpel, by presenting a series of cases. Case presentation. We present three cases of healthy patients undergoing cosmetic surgery. The clinical examination revealed exposure of a keratinized gingiva band greater than 4 mm, normal color and texture in gingival tissue, with a firm consistency and no bleeding on periodontal probing. Gingivectomy was indicated with the following protocols: Diode laser of 940 nm at 1 W, in continuous mode; Er,Cr:YSGG laser of 2780 nm at 2.5 W, 75 Hz, H mode, air 20, water 40, gold tip MT4); and electric scalpel in cutting mode at power level four. Gingival tissue samples were taken and stored in 10% formaldehyde for histological analysis. Conclusion. All the evaluated cutting instruments generated histological changes produced by the thermal effect, the main ones being collagen coagulation and carbonization. The depth of thermal damage caused by the 2780 nm Er,Cr:YSGG laser was much lesser than that induced by the electric scalpel and the 940 nm diode laser.

Introducción. Históricamente se ha invertido esfuerzo en el diseño de nuevos instrumentos que superen las desventajas del estándar de referencia en cirugía, el bisturí. Como consecuencia de esto, han surgido equipos electrónicos como el electrobisturí y los diferentes dispositivos de tecnología láser. La información disponible sobre estos instrumentos sugiere que la respuesta del tejido intervenido está influenciada por los principios físicos y biológicos de corte del instrumento. Objetivo. Comparar los cambios histológicos en muestras de encía asociados al corte quirúrgico realizado con láser de diodo de 940 nm, láser de erbio, cromo: itrio-escandiogalio-granate (Er,Cr:YSGG) (2780nm) y electrobisturí mediante una presentación de serie de casos. Presentación de los casos. Se presentan tres casos de pacientes sanos sometidos a cirugía estética. El examen clínico reveló la exposición de una banda gingival queratinizada mayor de 4 mm, tejido gingival de color y textura normales, de consistencia firme y sin sangrado al sondaje periodontal. Se indicó gingivectomía con los siguientes protocolos: láser de diodo de 940 nm a 1 W, en modo continuo; láser de Er,Cr:YSGG de 2780 nm a 2,5 W, 75 Hz, modo H, aire 20, agua 40, punta de oro MT4; y bisturí eléctrico en modo de corte, a nivel de potencia cuatro. Se tomaron muestras de tejido gingival y se almacenaron en formaldehído al 10 % para su análisis histológico. Conclusión. Los tres instrumentos de corte generaron cambios histológicos producidos por el efecto térmico; los principales fueron coagulación del colágeno y carbonización.

Axicabtagene Ciloleucel: The First FDA-Approved CAR T-Cell Therapy for Relapsed/Refractory Large B-Cell Lymphoma.

Axicabtagene ciloleucel (axi-cel) is an anti-CD19 CAR T-cell therapy that has demonstrated efficacy in relapsed and refractory diffuse large B-cell lymphoma (DLBCL) patients who have had suboptimal responses to conventional therapies. The immune activation that confers the efficacy of axi-cel comes at the price of potentially devastating adverse phenomena: cytokine release syndrome and neurotoxicity. This article serves as an overview of axi-cel, including a review of the available clinical evidence, mechanism of action, and management of some of the unique toxicities of axi-cel.

Cobimetinib-induced "dropped head syndrome" and subsequent disease management in an Erdheim-Chester patient.

Our rechallenge of cobimetinib in an Erdheim-Chester Disease (ECD) patient for the rare adverse effect, "dropped head syndrome," with a previously unexplored cobimetinib regimen was successful. Similar to other experiences with targeted agents in ECD, dosing of cobimetinib may vary to mitigate toxicity without impairing efficacy.

Assessing Burnout Among Advanced Practice Providers (APPs) Compared with APP Trainees.

BACKGROUND: This study explored the prevalence of burnout syndrome among advanced practice providers (APPs = physician assistants (PAs) and advanced practice nurses (APNs)) and physician assistant students in training to become APPs. While previous research has focused on understanding burnout in a myriad of health professions, burnout among APPs and APP trainees has been underexplored. As such, this work serves as a primer for establishing benchmark levels of burnout in these specific healthcare provider/trainee populations. METHODS: This study distributed a modified Maslach Burnout Inventory (MBI) to a sample of 297 APPs and 1200 PA students. Mean differences in burnout scores were compared against a national reference sample of healthcare professionals using one sample t tests and linear regression explored relationships among demographics and burnout dimension scores. RESULTS: APPs (n = 124) and APP trainees (n = 230) who responded to the survey displayed average levels of burnout, though both populations expressed significantly lower personal accomplishment scores than the national reference sample. No significant differences were detected between APNs and practicing PAs (p = 0.761). Increased age was negatively associated with depersonalization scores suggesting that APP trainees and younger APPs are at higher risk of developing severe burnout and may need additional support in their training and early careers. Furthermore, the prevalence of burnout between APPs and APP trainees was found to be comparable, suggesting that burnout from training may persist into practice. CONCLUSIONS: A small proportion of APPs and APP trainees may be at risk of developing severe burnout. Individuals in these "at risk" populations may need additional support during training and perhaps later on in practice.

Factores relacionados a flebitis química en personas con quimioterapia, revisión sistemática de la literatura / Factors related to chemical phlebitis in patients treated with chemotherapy, a systematic literature review

Objetivo: Describir los factores asociados a la flebitis química en personas con diagnóstico de cáncer que reciben quimioterapia, evidenciados en la literatura. Metodología: Se realizó una revisión sistemática de la literatura, según recomendaciones de Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Resultados: Los factores que aumentaron el riesgo de flebitis química hallados en la evidencia fueron la edad mayor de 57 años, sexo femenino, antecedentes de cáncer, enfermedad metastásica, hipertensión arterial, neutropenia, tabaquismo, vaciamiento ganglionar, hipoalbuminemia, uso de medicamentos citotóxicos, epirrubicina, fosaprepitant, antraciclina y vinorelbina, presentación premezclada de los fármacos, dilución en 50 cc de solución salina normal, tiempo de administración mayor a 60 minutos, catéteres de calibres grandes como 18 G o 20 G y ubicación anatómica del catéter en antebrazo o fosa antecubital. Conclusión: los factores relacionados a la flebitis química hallados en la literatura fueron principalmente elementos inherentes al paciente y a su tratamiento, algunos de estos no son modificables.

Objective: To describe the factors related to chemical phlebitis in patients diagnosed with cancer undergoing chemotherapeutic treatment. Methodology: A systematic review of the literature was carried out, according to recommendations of Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Results: The factors that increase the risk of chemical phlebitis were: age older than 57 years, female sex, history of cancer, metastatic disease, arterial hypertension, neutropenia, smoking, lymph node emptying, hypoalbuminemia, use of cytotoxic drugs, epirubicin, fosaprepitant, anthracycline and vinorelbine, premixed presentation, dilution in 50 cc of Normal Saline Solution, administration time greater than 60 minutes, catheters of large gauges such as 18 G or 20 G and anatomical location of the catheter in the forearm or antecubital fossa. Conclusion: Factors related to chemical phlebitis found in the literature were features inherent to the patient and their treatment. Therefore, some of these are not modifiable.

[Depression and state of nutrition in schoolchildren from Sonora]. / Depresión y estado de nutrición en escolares de Sonora.

BACKGROUND: Pediatric obesity has become a problem of epidemic proportions, due to the inadequate and excessive consumption of food, sedentary lifestyle, and the restricted socio-economic development. This causes a major risk in health complications that have an effect on the psychological and social spheres of the child, which makes him endure such diseases as depression and anxiety. The aim of this study was to determine the association between depression and the nutritional status of schoolchildren from a family medicine unit in Sonora. METHODS: Cross-sectional study performed during 2011 in 101 schoolchildren from Sonora. Kovacs test was applied to detect depressive symptoms; nutritional status was determined by weight and height; body mass index was calculated according to the Center for Disease Control and Prevention (CDC) percentiles. The results were analyzed in SPSS version 18 using Mann-Whitney U and chi-square. RESULTS: Of all the patients with depression, 19 were obese; the other 10 showed a normal nutrition status. Patients with low weight did not show depression. The odds ratio (OR) for depression in students with obesity was 3.16, 95 % CI = 1.13, 7.12. CONCLUSIONS: The detection and management of depression should be considered in the treatment of obesity.

INTRODUCCIÓN: la obesidad infantil se ha convertido en un problema cuyas proporciones son epidémicas, debido al consumo excesivo e inadecuado de alimentos, al sedentarismo y al limitado desarrollo socioeconómico. Esto ocasiona un mayor riesgo en complicaciones en la salud que repercuten en el ámbito psicológico y social del infante, lo cual lo lleva a padecer enfermedades como la depresión y la ansiedad. El objetivo de este estudio fue determinar la asociación entre la depresión y el estado de nutrición en escolares adscritos a una unidad de medicina familiar en Sonora. MÉTODOS: estudio transversal analítico que se llevó a cabo durante el 2011 en 101 escolares de Sonora. Se aplicó el test de Kovacs para detectar síntomas depresivos; se determinó el estado nutricional mediante peso y talla, y el cálculo del índice de masa corporal se hizo de acuerdo con los percentiles de las tablas del Centro para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglés) de Atlanta. El análisis de los resultados se realizó con U de Mann-Whitney y chi cuadrada en el programa SPSS, versión 18. RESULTADOS: del total de pacientes con depresión, 19 presentaron obesidad y el resto presentó estado de nutrición normal (10); los pacientes con bajo peso no presentaron depresión. La razón de momios para depresión en escolares con obesidad fue de 3.16 con un IC al 95 % de 1.13; 7.12. CONCLUSIÓN: la detección y manejo de depresión debe ser considerada dentro del tratamiento de la obesidad.