Clinical perspective: Linking psychosocial care to the disease continuum in patients with multiple myeloma.

OBJECTIVE: A model of psychosocial care specific for patients with multiple myeloma and their caregivers has not yet been proposed. We sought to develop a model of care that considers the specific profile of this disease. METHOD: The authors, representing a multidisciplinary care team, met in December of 2012 to identify a model of psychosocial care for patients with multiple myeloma and their caregivers. This model was determined by consensus during the meeting and via total agreement following the meeting. The meeting was sponsored by Onyx Pharmaceuticals. RESULTS: The need for targeted psychosocial care for the multiple myeloma patient and caregiver throughout the disease process is essential to ensure quality of life and optimal treatment outcomes. We propose herein the first known model of care for the treatment of multiple myeloma that engages both the patient and their caregivers. SIGNIFICANCE OF RESULTS: Innovative partnerships between psychosocial providers and other entities such as pharmaceutical companies can maximize resources for comprehensive program development. This manuscript proposes a model of care that promotes active engagement in therapies for multiple myeloma while engaging the individual patient and their family caregivers. This treatment approach must be evidence based in terms of distress screening tools, comprehensive psychosocial assessments, and, most importantly, in the interventions and measurements of response that clinicians apply to this population.

Real-world experience with clinical management of talquetamab in relapsed/refractory multiple myeloma: a qualitative study of US healthcare providers.

OBJECTIVE: Talquetamab is the first-in-class GPRC5DxCD3 bispecific antibody for relapsed/refractory multiple myeloma. Given limited real-world data, this study was conducted with US healthcare providers (HCPs) to understand real-world talquetamab dosing and symptom management. METHODS: In February/March 2024, individual in-depth interviews (IDIs; n = 10) were conducted with HCPs administering talquetamab in real-world settings. A subsequent expert panel (n = 6) further discussed current practices. RESULTS: The IDIs reported a variety of settings for step-up dosing (SUD), including inpatient (n = 5), outpatient (n = 3), and hybrid models (n = 2), with a trend toward shorter SUD length to reduce healthcare resource utilization. Most HCPs used a biweekly (Q2W) schedule in SUD (n = 7) and treatment phases (n = 8). Six participants explored reducing dose frequency to every 4 weeks (Q4W) in patients following positive disease response to treatment, considering patient convenience and relieving GPRC5D-related symptoms. Panelists recommended symptom management and prophylactic strategies, such as dexamethasone and nystatin mouthwash or zinc and vitamin B complex for oral symptoms, and topical steroids and cosmetic products for skin and nail symptoms. CONCLUSION: This study outlines current real-world practices for talquetamab. Findings indicate variation in the SUD care setting. The 0.8 mg/kg Q2W dosing schedule was most common, although switching to Q4W is a real-world symptom management strategy for some patients with responses to therapy. GPRC5D-related symptom management approaches are evolving; prophylactic use of dexamethasone and nystatin mouthwash or zinc and vitamin B complex may be effective strategies to alleviate oral symptoms. Further real-world evidence is needed to inform optimal dosing schedules while mitigating symptom impact.

Talquetamab is a new treatment that was approved in the United States in 2023 for a type of blood cancer called multiple myeloma. This drug is administered at one of two doses, each of which includes a defined step-up dosing schedule where patients first receive smaller amounts of the drug to help avoid serious side effects. Because talquetamab is new and associated with treatment-related symptoms not normally seen with other multiple myeloma treatments, doctors and patients need more guidance on drug administration and symptom management. In this study, we describe findings from interviews and an expert panel discussion with healthcare professionals who have experience using talquetamab. This study found that most healthcare professionals administered step-up dosing with patients staying overnight in the hospital, while other providers administered these doses during outpatient visits. Most providers administered talquetamab once every 2 weeks after utilizing the associated step-up dosing schedule. Additionally, healthcare providers described transitioning some patients, who had responded positively to treatment, to a less frequent dosing schedule of once per month to help reduce the effect of treatment-related symptoms. Participants in the expert panel described approaches for managing or preventing these symptoms, such as dexamethasone and nystatin mouthwashes or zinc and vitamin B complex for oral symptoms, and topical steroids and cosmetic products for skin and nail symptoms. In summary, this study provides valuable real-world information from healthcare providers who have experience treating patients with multiple myeloma with talquetamab.

Management of Ocular Toxicity in Patients Receiving Belantamab Mafodotin.

While significant strides have been made in the treatment of multiple myeloma, treatment options remain limited and definite, and most patients ultimately succumb to their disease. The urgency for more treatment modalities remains, as patients who are refractory to proteasome inhibitors, immunomodulatory agents, and anti-CD38 monoclonal antibodies have a median survival of only 5.8 to 13 months. Belantamab mafodotin, a first-in-class antibody-drug conjugate, was approved by the US Food and Drug Administration in 2020 for patients with relapsed or refractory myeloma who have received at least four prior therapies, including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent. It produced an overall response rate of 31%, and the median progression-free survival was 2.9 months when administered as a single agent. While generally well tolerated, ocular toxicities were a notable adverse event reported. In this article, we discuss the response data, toxicity profile including ocular toxicities, and treatment management.

A Focus on Waldenström Macroglobulinemia and AL Amyloidosis.

Waldenström macroglobulinemia (WM) is a lymphoplasmacytic lymphoma that is characterized by the overproduction of an IgM monoclonal protein. It may cause adenopathy, hepatomegaly, splenomegaly, as well as other disease-related complications such as cold agglutinin anemia, cryoglobulinemia, hyperviscosity, and neuropathy. While light chain amyloidosis in patients with WM only occurs in about 10% of patients, it is important that advanced practitioners are able to recognize concurrent AL amyloidosis, which will affect the patient's treatment trajectory. Diagnosis of WM with AL amyloidosis is based on bone marrow biopsy and a fat pad biopsy. If AL amyloidosis is suspected, the bone marrow and fat pad biopsy should undergo Congo red staining. If it is negative, and there is a strong suspicion of AL amyloidosis, then an organ biopsy can be considered. Treatment of WM uses rituximab-based therapy in combination with a variety of other agents, including proteasome inhibitors, alkylating agents, and BTK inhibitors. Treatment of light chain amyloidosis uses bortezomib as the backbone of therapy and can be administered with cyclophosphamide, dexamethasone, and now daratumumab, which was recently approved. Waldenström macroglobulinemia and light chain amyloidosis are both rare diseases and can lead to a variety of disease-related complications. Fortunately, many options exist for both diseases. This article will highlight a case of WM with amyloidosis and a case of a patient with relapsing WM with considerations for advanced practitioners managing this patient population.

A Focus on CAR T-Cell Therapy and Bispecific Antibodies in Multiple Myeloma.

Significant strides have been made in the management of patients living with myeloma. However, patients with multiply relapsed or refractory multiple myeloma (MM) have a shorter overall survival; therefore, new treatments with novel mechanisms of action are needed in this patient population. Patients with relapsing disease require a full restaging workup, including whole body imaging to evaluate for extramedullary disease and lytic bone lesions, as well as bone marrow biopsy with fluorescence in situ hybridization to determine if the patient has any new chromosomal changes that are present. Therapies utilizing the patient's immune cells, in particular T cells, provide a new option in relapsed/refractory myeloma. Treatment utilizing chimeric antigen receptor (CAR) T cells and/or bispecific antibody therapy provide excellent response rates. As such, advanced practitioners need to be aware of the potential toxicities associated with these newer treatments and how to manage them. This article will focus on the management of patients with relapsed and/or refractory disease who are undergoing treatment with either CAR T-cell therapy or bispecific T cell engager therapy.

Food security in African Canadian communities: a scoping review.

OBJECTIVE: The objective of this review is to chart the evidence relating to food security among African Canadian communities to inform future research and offer insight related to food security in African Canadian communities. INTRODUCTION: Achieving food security is of global importance to meet the United Nations Sustainable Development Goals. As a social determinant of health, food security, which refers to the unrestricted physical, economic, and timely access to safe and nutritious foods, impacts more than 4 million Canadians. Yet, little is known about food security and the differential impacts of food insecurity among African Canadians. This scoping review sought to describe the current state of food security among African Canadians. INCLUSION CRITERIA: Sources were considered for inclusion if they: i) focused on Canada, ii) involved African Canadians, and iii) examined food security. METHODS: This scoping review was conducted in accordance with JBI methodology. Databases and relevant websites containing peer-reviewed, unpublished, and gray literature were searched. Ancestry searching and forward citation tracing were completed. No restrictions were placed on date of publication. Language restrictions were limited to English and French. In instances where articles were unavailable, authors of potential sources were contacted at the full-text review phase to request access to their article. Data were extracted independently by two team members, and are presented narratively and in tabular format. RESULTS: The search of databases yielded a total of 1183 records. Ancestry tracing yielded 287 records. After removing duplicates, 1075 titles and abstracts were screened for eligibility and 80 advanced to full-text screening. Seventy-five full-text articles were excluded for not meeting the inclusion criteria, leaving five articles that underwent data extraction. All five included studies involved African Canadian participants in Canada. All studies focused on adults; one study included women and men participants, while four focused exclusively on women. One study involving women participants included cisgender and transgender women as well as those identifying as queer. Study designs reflected qualitative (n = 2), quantitative (n = 1), and mixed methods (n = 2) designs. CONCLUSIONS: This review begins to fill a gap in understanding the current evidence available on food security as it impacts African Canadians. The findings of this review represent existing research, describing the type of evidence available and methodologies used, before suggesting implications for research and practice. The inclusion of only five studies reveals the limited evidence regarding the current state of food security among African Canadians. Further, included studies were exclusively conducted in urban settings and predominantly in one province. There is a need for further research in rural communities, in other provinces and territories, as well as with younger and older participants. The urgent need to collect race-disaggregated data in Canada is evident.

Diagnosis and Treatment of AL and ATTR Amyloidosis.

At JADPRO Live Virtual 2020, Beth Faiman, PhD, RN, MSN, APRN-BC, AOCN®, FAAN, and Tiffany Richards, PhD, ANP-BC, AOCNP®, differentiated between AL and ATTR amyloidosis, discussed key considerations in selecting therapy, and identified ways that advanced practitioners can manage the supportive care needs of this patient population.

Rescue of postcompaction-stage mouse embryo development from hypertonicity by amino acid transporter substrates that may function as organic osmolytes.

Early preimplantation embryos are sensitive to external osmolarity and use novel mechanisms to accumulate organic osmolytes and thus control their cell volumes and maintain viability. However, these mechanisms are restricted to the cleavage stages of development, and it was unknown whether postcompaction embryos use organic osmolytes. Mouse embryos developing from the 8-cell stage formed blastocoel cavities in vitro at osmolarities up to 360 mOsM. Above this range, several putative organic osmolytes (alanine, glutamine, glycine, and beta-alanine) rescued blastocyst development, but several effective osmoprotectants in cleavage-stage embryos (such as betaine and proline) did not. At physiological osmolarities, each of these compounds resulted in significantly larger blastocysts. This was not due to increased cell numbers, which were unaffected in blastocysts by osmolarity in the range where blastocyst size was rescued by potential organic osmolytes, although cell number was decreased at higher osmolarities and was rescued by each osmolyte. The effective osmolytes were accumulated intracellularly by embryos developing in vitro from the 8-cell stage to blastocysts. However, unlike conventional organic osmolytes in somatic cells or those in cleavage-stage embryos, their intracellular concentrations were not increased with increasing external osmolarity. With the exception of beta-alanine, which is taken up via the beta-amino acid transport system, the effective osmolytes were transported by the B(0,+) system, which becomes highly active in blastocysts. The intracellular accumulation of these osmolytes in postcompaction embryos thus appears to support optimal development and blastocyst expansion at physiological osmolarities and may contribute to the embryo's ability to withstand stress.

AL Amyloidosis: Unfolding a Complex Disease.

Light chain (AL) amyloidosis is a rare plasma cell dyscrasia. An estimated 12,000 people live with the disease in the United States. AL amyloidosis occurs from the misfolding of proteins that deposit in organs (heart, kidneys, digestive tract, tongue, lungs, and nervous system), leading to progressive organ damage and impairment of quality of life. The treatment of AL amyloidosis has improved greatly over the past several years, with new treatments currently in development. This article will focus on the pathophysiology, diagnosis, and treatment of AL amyloidosis.

Novel Speed-Controlled Automated Ladder Walking Device Reveals Walking Speed as a Critical Determinant of Skilled Locomotion after a Spinal Cord Injury in Adult Rats.

The horizontal ladder task is an established method to assess skilled locomotor recovery after neurological dysfunction. Walking speed is often used as a standardized measure in locomotor assessment of overground walking in human and pre-clinical studies, but the assessment of walking speed is typically ignored during skilled locomotor tasks. Ample empirical evidence indicates that walking speeds on the horizontal ladder are largely non-uniform after central nervous system trauma, suggesting that it could pose a potential source of variability in assessing motor deficits. Here, we investigate whether walking speed influences the assessment of motor recovery during skilled walking after a spinal cord injury (SCI). We hypothesized that if rats walk at imposed walking speeds, motor deficits and recovery after an SCI will be more reliably assessed than when not controlling walking speeds. To address this, we developed a novel speed-controlled Automated Device for the Assessment and Training of Skilled locomotion (ADATS) as a surrogate device to the horizontal ladder. The ADATS allows testing at user-defined speeds, thereby forcing the rats to step consistently. Our results demonstrate that: 1) the ability to walk (or not) at one or multiple speeds on the ADATS serves as a gross measure of motor dysfunction/recovery after a spinal cord injury and 2) skilled motor deficits are more readily detected at lower than higher walking speeds. We conclude that walking speed is an important factor in the analyses of skilled locomotion and testing at multiple speeds is useful in accurately measuring recovery after neurotrauma in rats.

In-Hospital Feeding Practices of Infants Born to Mothers With Gestational Diabetes Mellitus or Type 2 Diabetes Mellitus: Evaluating Policy Implementation Effectiveness.

OBJECTIVES: Women with diabetes in pregnancy may experience unique breastfeeding challenges. Few studies have examined the effectiveness of hospital policy to support breastfeeding in this patient population. This study aimed 1) to describe infant feeding practices of mother-infant pairs with gestational diabetes mellitus (GDM) or type 2 diabetes in pregnancy before and after introduction of an in-hospital policy and, 2) to compare feeding practices before and after policy introduction. METHODS: A retrospective chart audit of mother-infant pairs (n=120) was performed: 60 at 1 year before and 60 after policy introduction. The primary outcome was provision of breast milk at discharge; a chi-square test was completed to compare pre- and postpolicy groups. Secondary outcomes included participant and infant feeding characteristics. RESULTS: There was no significant difference in the number of infants receiving breast milk at discharge between pre- (58% [35 of 60]) and postpolicy (58% [35 of 60]) groups (p=0.64). The number of infants receiving breast milk exclusively throughout the hospital stay also did not differ by group (37% [22 of 60] before; and 43% [26 of 60] after; p=0.39). Information for each feed was infrequently recorded in charts for the method of feeding (34% [704 of 2,064]), infant state (96% [1,991 of 2,064]) and feeding description (96% [1,987 of 2,064]). CONCLUSIONS: This practice-based research has highlighted a need for continuation of this work, examining an in-hospital policy to support breastfeeding in those with GDM or type 2 diabetes in pregnancy. Initially, feedback could be collected from health-care providers to understand perceived facilitators and barriers to policy application and the use of job aids (e.g. record keeping tools).

Lenalidomide in multiple myeloma.

For many years the treatment of multiple myeloma was limited to such regimens as melphalan-prednisone, high-dose dexamethasone, and vincristine-doxorubicin-dexamethasone (VAD). These combinations provided response rates of 45-55%, with complete remission rates of up to 10%. With the advent of thalidomide- and bortezomib-based combinations, response rates to induction therapy have risen to 85-95% in previously untreated patients and are associated with complete remission rates up to 25%. However, these agents are associated with such side-effects as somnolence, constipation and neuropathy. Lenalidomide, a thalidomide analog, was developed with the hope of improving both the efficacy and toxicity profile of thalidomide, and has subsequently shown significant clinical activity in patients with multiple myeloma. We describe the role of lenalidomide in patients with symptomatic multiple myeloma that is newly diagnosed, relapsed and/or refractory to other therapies, or concurrent with primary amyloidosis.

Strategies for Selecting the Optimal Treatment in Newly Diagnosed Multiple Myeloma Patients.

OBJECTIVE: To review the current evidence on strategies for selecting the optimal treatment for newly diagnosed patients with multiple myeloma (MM). DATA SOURCES: Journal articles, research reports, state of the science papers, and clinical practice guidelines. CONCLUSION: Despite the plethora of drugs to effectively treat MM, the optimal induction regimen for patients with newly diagnosed MM is unknown. Rapid control of the disease, appropriate treatment selection and effective supportive care strategies remain integral to prevention and management of the disease. Strategies for selecting the optimal treatment include considering inherent patient characteristics, frailty, and existing clinical practice guidelines. IMPLICATIONS FOR NURSING PRACTICE: Nurses should provide patients with disease- and treatment-related education to enhance patient and caregiver understanding of the disease and treatment options, taking into consideration clinical data and overarching goals of treatment.

Distress, Fatigue, and Sexuality: Understanding and Treating Concerns and Symptoms in Patients With Multiple Myeloma 
.

BACKGROUND: The psychological needs of patients and caregivers may be inadvertently overlooked, contributing to the patient's distress and possibly compromising outcomes. Untreated, these psychological needs may impair the patient's ability to make decisions and adhere to treatment. 
. OBJECTIVES: This article aims to present consensus statements to guide oncology nurses in the recognition and management of distress, fatigue, and sexual dysfunction in patients with multiple myeloma (MM). 
. METHODS: Members of the International Myeloma Foundation Nursing Leadership Board reviewed the current literature and clinical experience regarding interventions related to distress, fatigue, and sexual dysfunction in patients with MM.
. FINDINGS: Ongoing patient education and attention to medical and psychological care is important to assess and address patients' needs, such as cancer-related fatigue, sexual dysfunction, and distress.

Health implications of human trafficking.

Freedom is arguably the most cherished right in the United States. But each year, approximately 14,500 to 17,500 women, men and children are trafficked into the United States for the purposes of forced labor or sexual exploitation. Human trafficking has significant effects on both physical and mental health. This article describes the features of human trafficking, its physical and mental health effects and the vital role nurses can play in providing care to this vulnerable population.

Innovative agents in multiple myeloma.

Multiple myeloma (MM) remains an incurable cancer of the bone marrow plasma cells. However, the overall survival of patients with MM has increased dramatically within the past decade. This is due, in part, to newer agents such as immunomodulatory drugs (lenalidomide, thalidomide, and pomalidomide) and proteasome inhibitors (bortezomib, carfilzomib, MLN9708). These and several other new classes of drugs have arisen from an improved understanding of the complex environment in which genetic changes occur. Improved understanding of genetic events will enable clinicians to better stratify risk before and during therapy, tailor treatment, and test the value of personalized interventions. The ultimate goal in this incurable disease setting is to reduce the impact of cancer- or chemotherapy-related side effects. Nurses and advanced practitioners are integral to the treatment team. Thus, each should be aware of changes to the current drug landscape. Targeted drugs with sophisticated mechanisms of action are currently under investigation. Patients gain access to newer drugs within the context of clinical trials. Awareness of such trials will help accrual and determine if therapeutic benefit exists. In this article, we will describe new agents with unique and targeted mechanisms of action that have activity in patients with relapsed and/or refractory multiple myeloma.

Combining other antihypertensive drugs with ß-blockers in hypertension: a focus on safety and tolerability.

Combining multiple classes of antihypertensive drugs together is one of the most important factors for achieving blood pressure control in most hypertensive patients. The benefits of combination therapy in comparison with monotherapy include: a synergistic enhancement of each drug's hypertensive effects and a potential reduction of side effects if each drug is used at a lower dose. Although long-acting dihydropyridine calcium channel blockers and ß-blockers are a good fit for combination therapy, because of the risk of atrioventricular block and bradycardia, the combination of verapamil and ß-blockers is not advised. In addition, the combination of higher-dose diltiazem and ß-blockers is also not advised. ß-blockers and diuretic agents as initial lone combination therapy are not the preferred combination to be used in uncomplicated hypertension. Using an angiotensin-converting enzyme inhibitor as initial combination therapy with most ß-blockers is not recommended because of a lack of antihypertensive efficacy. Nebivolol, however, appears different in this regard and might provide an opportunity for combining these 2 classes of agents with proven cardiovascular benefits for better blood pressure control. Adding an α-blocker to a ß-blocker is an effective combination.

Survey of experiences of an e-mentorship program: Part II.

Nurse educators (NEs) are responsible for providing continuing education to nurses, who are expected to remain knowledgeble in the diagnosis and management strategies of a range of cancers. Remaining abreast of up-to-date information can be a challenge. Part I of the e-mentorship program was developed in 2009 to provide NEs with the latest updates and educational materials to enhance multiple myeloma (MM) nursing knowledge. The second phase was completed in January 2011. Faculty developed four modules: overview of MM, peripheral neuropathy, bone health, and overview of transplantation. Seventeen MM nurses were identified to participate as mentors and partner with 34 mentees. Mentees were trained through monographs, journal articles, webcasts, and telephone communication, and then they presented the modules to their nurses. All mentees were asked to participate in voluntary pre- and post-test assessments to measure improved knowledge and clinical competence in the management of patients with MM. A significant improvement in post-test scores, as compared to pretest scores, was seen; therefore, nurses who participated in the e-mentorship program demonstrated improved knowledge. In the future, this type of educational program should be expanded to other cancer types.

Sexual dysfunction in multiple myeloma: survivorship care plan of the International Myeloma Foundation Nurse Leadership Board.

The World Health Organization describes sexuality as a "central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors." Currently, no research has been conducted regarding sexual dysfunction in patients with multiple myeloma; therefore, information related to the assessment and evaluation of sexual dysfunction is gleaned from other malignancies and diseases. In this article, members of the International Myeloma Foundation's Nurse Leadership Board discuss the definition, presentation, and causes of sexual dysfunction; provide recommendations for sexual assessment practices; and promote discussion among patients with multiple myeloma, their healthcare providers, and their partners.