Outpatient initiation of venetoclax in patients with acute myeloid leukemia.

INTRODUCTION: Venetoclax is a treatment option in patients with acute myeloid leukemia (AML) in both the front-line and relapsed/refractory settings. Initiation of therapy has been previously restricted to the inpatient setting at some institutions due to a risk of tumor lysis syndrome (TLS) and limitations in medication access efficiency given the high cost of therapy. METHODS: We assessed the safety of initiating venetoclax in the outpatient setting through a single-arm, retrospective study of adult AML patients between April 1, 2019 and June 30, 2020. RESULTS: Eighty-two patients started venetoclax during this time, with 47 (57%) patients initiated in the outpatient setting. Fifty-five percent of patients received venetoclax as first-line treatment for AML (n = 45) and 45% of patients received venetoclax for relapsed/refractory AML (n = 37). Successful initiation, defined as no hospitalizations secondary to TLS within seven days of therapy initiation, occurred in 98% of patients. The rate of TLS was 2.1% (n = 1) following venetoclax initiation. TLS symptoms were managed during hospitalization, requiring only one day of missed AML therapy. Median turnaround time for medication access was three days. Hospitalizations within seven days occurred in 17% of patients (n = 8), with the majority due to febrile neutropenia. CONCLUSIONS: The results of our study provide further evidence for the safety and feasibility of initiating venetoclax in the outpatient setting with a pharmacist-led interdisciplinary protocol.

Safety of Intravenous Bisphosphonates for the Treatment of Hypercalcemia in Patients With Preexisting Renal Dysfunction.

BACKGROUND: Although intravenous (IV) bisphosphonates are first-line medications for the management of hypercalcemia, studies examining their use in patients with preexisting renal dysfunction are limited. OBJECTIVE: The objective of this study is to describe the safety and efficacy of pamidronate and zoledronic acid in the treatment of hypercalcemia in patients with baseline renal dysfunction. METHODS: A retrospective analysis was conducted of IV pamidronate and zoledronic acid in adult patients with hypercalcemia and creatinine clearance (CrCl) <60 mL/min. The primary endpoint was incidence of all-grade serum creatinine (SCr) elevations. Secondary endpoints included refractory hypercalcemia, hypocalcemia, osteonecrosis of the jaw (ONJ), corrected serum calcium (CSC) decrease ≥1.0 mg/dL by day 7 of bisphosphonate administration, and normalization of CSC ≤10.5 mg/dL by days 10 and 30. RESULTS: A total of 113 patients were included (n = 55 pamidronate, n = 58 zoledronic acid). The primary endpoint of all-grade SCr elevation occurred in 28 (24.8%) patients. Grades 3/4 SCr elevations occurred in 10.9% of patients treated with pamidronate and 1.7% of patients receiving zoledronic acid. Approximately 16% and 14% of patients developed grades 1 and 2 hypocalcemia, respectively, and there were no cases of ONJ. Overall, 64.6% of patients achieved normalization of CSC by day 10, and there were no statistical differences between bisphosphonate type and renal function. CONCLUSIONS AND RELEVANCE: The analysis suggests an association between IV bisphosphonates and increased rates of SCr elevations among patients with preexisting renal dysfunction. Future prospective studies are necessary to elucidate these findings.

Meditation alters representations of peripersonal space: Evidence from auditory evoked potentials.

Meditation commonly gives rise to the feeling that the self and the surrounding world are no longer separate, as if the boundary between them has dissolved. We propose this may occur due to alterations in representations of peripersonal space (PPS), the reachable space surrounding the body which is integral to a sense of where one's bodily "self" is located in space. Thirty-one participants completed an auditory oddball paradigm before and after a guided meditation, during which we measured their P3 evoked potential, a marker of attentional salience. Pre-meditation, participants exhibited an enhanced attentional response to stimuli presented within PPS, relative to beyond PPS. Post-meditation, this PPS attentional enhancement was negated, with no distinction between responses to stimuli within versus beyond PPS. The results suggest that meditation leads to a constriction of PPS boundaries, even in novice meditators, elucidating one potential cause of the perceptual changes associated with meditation.

Impact of an electronic health record transition on chemotherapy error reporting.

BACKGROUND: Incident reporting systems allow for frontline employees to report errors and are a critical component of healthcare patient safety programs. Although incident reporting systems cannot quantify total errors, organizations can utilize incident reporting systems to help identify risks and trends to act upon. The objective of this article is to utilize incident reporting systems to evaluate trends in medication error reporting before and after implementation of a new electronic health record system. METHODS: A five-month pre- and post-analysis was completed in a cancer hospital following electronic health record conversion by reviewing medication errors reported via the institution's voluntary incident reporting systems. Error reports included medication error category, date error was reported/occurred, patient location at time of error, harm severity score, medication(s) involved, medication use system node error originated/discovered in, medication source, narrative summary, and contributing factors. Data were analyzed using descriptive statistics within Office Excel. RESULTS: Oncology medication error reports submitted pre- and post-electronic health record were 68 vs. 57, respectively. During the pre- and post-electronic health record conversion, a majority of errors had a harm severity index of 0 or 1; 12 (18%) in pre-electronic health record and 3 (5%) in post-electronic health record were level 2, and one (1%) in pre-electronic health record vs. 0 in post-electronic health record were level 3. Reported medication errors originated most commonly during the prescribing, administration, and preparation/dispensing phase and were primarily identified in the administration phase of the medication use process. The most frequently reported error category was 'wrong dose' followed by 'other' and 'overdose' in the pre-electronic health record phase and 'missing dose/delayed delivery' and 'order incorrect' in the post-electronic health record phase. The most frequently reported medications included methotrexate, chemotherapy (unspecified), and cisplatin. CONCLUSION: Analyzing data from incident reporting system reports allowed our institution to understand different trends of reporting in the cancer hospital following electronic health record adoption. Utilization of incident reporting systems must be combined with proactive risk identification approaches to enable systems-focused improvements to improve patient safety.

N1-p2 recordings to gaps in broadband noise.

BACKGROUND: Normal temporal processing is important for the perception of speech in quiet and in difficult listening situations. Temporal resolution is commonly measured using a behavioral gap detection task, where the patient or subject must participate in the evaluation process. This is difficult to achieve with subjects who cannot reliably complete a behavioral test. However, recent research has investigated the use of evoked potential measures to evaluate gap detection. PURPOSE: The purpose of the current study was to record N1-P2 responses to gaps in broadband noise in normal hearing young adults. Comparisons were made of the N1 and P2 latencies, amplitudes, and morphology to different length gaps in noise in an effort to quantify the changing responses of the brain to these stimuli. It was the goal of this study to show that electrophysiological recordings can be used to evaluate temporal resolution and measure the influence of short and long gaps on the N1-P2 waveform. RESEARCH DESIGN: This study used a repeated-measures design. All subjects completed a behavioral gap detection procedure to establish their behavioral gap detection threshold (BGDT). N1-P2 waveforms were recorded to the gap in a broadband noise. Gap durations were 20 msec, 2 msec above their BGDT, and 2 msec. These durations were chosen to represent a suprathreshold gap, a near-threshold gap, and a subthreshold gap. STUDY SAMPLE: Fifteen normal-hearing young adult females were evaluated. Subjects were recruited from the local university community. DATA COLLECTION AND ANALYSIS: Latencies and amplitudes for N1 and P2 were compared across gap durations for all subjects using a repeated-measures analysis of variance. A qualitative description of responses was also included. RESULTS: Most subjects did not display an N1-P2 response to a 2 msec gap, but all subjects had present clear evoked potential responses to 20 msec and 2+ msec gaps. Decreasing gap duration toward threshold resulted in decreasing waveform amplitude. However, N1 and P2 latencies remained stable as gap duration changed. CONCLUSIONS: N1-P2 waveforms can be elicited by gaps in noise in young normal-hearing adults. The responses are present as low as 2 msec above behavioral gap detection thresholds (BGDT). Gaps that are below BGDT do not generally evoke an electrophysiological response. These findings indicate that when a waveform is present, the gap duration is likely above their BGDT. Waveform amplitude is also a good index of gap detection, since amplitude decreases with decreasing gap duration. Future studies in this area will focus on various age groups and individuals with auditory disorders.

Correlation of Engraftment and Time from Melphalan Administration to Stem Cell Infusion.

Single-agent, high-dose melphalan continues to be the most commonly used conditioning regimen for transplantation-eligible patients with multiple myeloma undergoing autologous stem cell transplantation. The timing of melphalan administration with respect to stem cell infusion has not been clearly defined. Many institutions require a minimum of 24 hours between melphalan administration and stem cell infusion; however, some institutions have adopted shorter intervals based on melphalan's short half-life. Some studies have suggested that shortening the interval between melphalan administration and stem cell infusion may contribute to delays in engraftment, but this correlation has not been clearly evaluated or defined. This multicenter retrospective cohort study evaluated the times to neutrophil and platelet engraftment in patients who received stem cells at least 24 hours after melphalan (≥24 hours cohort) compared with those who received stem cells within 24 hours of melphalan (<24 hours cohort. The study included a total of 723 adult patients, 502 patients in the ≥24 hours cohort and 221 in the <24 hours cohort, treated at 3 transplantation centers between January 1, 2016, and September 30, 2019. Patient characteristics were summarized using descriptive statistics. The Fisher exact test was used to compare nominal categorical variables between the 2 cohorts, and the nonparametric van der Waerden test or Mood median test was used to compare ordinal or continuous variables. The median time to neutrophil engraftment was 12 days for both the ≥24 hours cohort (interquartile range [IQR], 11 to 12 days) and the <24 hours cohort (IQR, 11 to 13 days) (P = .07). The median time to platelet engraftment was 19 days for both the ≥24 hours cohort (IQR, 17 to 22 days) and <24 hours cohort (IQR, 17 to 20 days) (P = .25). The median time between melphalan administration and stem cell infusion in the <24 hours cohort was 18 hours, with a minimum time of 12 hours. The existing literature has not clearly defined the impact of the timing between melphalan administration and stem cell infusion on engraftment in autologous transplantation. The ability to safely shorten the interval between chemotherapy and transplantation could increase logistical flexibility and/or decrease the length of hospital stay. This large multicenter retrospective study did not identify a statistical or clinical impact on engraftment when melphalan was infused <24 hours or ≥24 hours before autologous stem cell infusion.

Utility of Urine Cultures During Febrile Neutropenia Workup in Hematopoietic Stem Cell Transplantation Recipients Without Urinary Symptoms.

The utility of obtaining screening urine cultures for febrile neutropenia (FN) during hematopoietic stem cell transplant (HCT) is unknown. In 667 adult HCT patients with FN, only 40 (6%) were found with bacteriuria. Antibiotics were modified in 3 patients (0.4%) based on urine cultures and none developed urinary-associated infectious complications.

Reliability of presynaptic inhibition in patients with diabetic peripheral neuropathy.

There has been rising interest in evaluating spinal reflex activity within the clinical population, however no study has yet investigated the reliability of presynaptic inhibition (PI) on patients with diabetic peripheral neuropathy (DPN). Because neuropathy is closely related to central nervous system modification, it is important to understand the mechanism of spinal reflex activity in the DPN population. Therefore, the purpose of the study was to evaluate the reliability of PI in patients with DPN. Eight participants (58.24 ± 6.38 yrs.) diagnosed with either type I or type II diabetes and peripheral neuropathy were recruited for the study. Each subject's H-reflex was measured using an EMG to elicit and record a series of 10 paired reflex depression trials. Reliability was measured by calculating Intra Class Correlation Coefficients (ICCs) with a 95% confidence interval. The results showed excellent reliability in both intraday (0.94) and interday (0.88) reliability. Therefore, analyzing PI in the central nervous system allows for an accurate evaluation of spinal cord circuitry in a non-invasive manner.

Impact of Oncology Pharmacists on the Knowledge, Attitude, and Practices of Clinicians to Enhance Patient Engagement of Self-Administered Oral Oncolytics.

Oncology clinical pharmacists are uniquely positioned to make interventions to impact the knowledge, attitudes, and practices of clinicians as well as patient activation and engagement. To accomplish this goal, pharmacists can target health system-related, provider-related, and patient-related factors to enhance patient-centered care and drive behavioral health changes. Interventions that pharmacists must tackle include educating team members and patients on the medication acquisition process, communicating urgency of treatment, optimizing workflows, facilitating guideline recommendations, preventing, and managing treatment toxicities, and promoting patient self-advocacy through education and shared decision-making. As crucial members of the healthcare team, oncology pharmacists can simplify highly complex treatment regimens to facilitate and optimize patients' ownership of their care. This narrative review will focus on the example of venetoclax treatment in acute myeloid leukemia to demonstrate the impact that pharmacists provide that leads to behavioral change of patients and clinicians.

Comparison of Rewatching Class Recordings versus Retrieval Practice as Post-Lecture Learning Strategies.

Objective. To assess the relative effectiveness of two study strategies, rewatching a recorded lecture and retrieval practice, on Doctor of Pharmacy (PharmD) students' long-term retention of lecture material presented in a pharmacotherapeutics class. Methods. One hundred two first-year pharmacy students were recruited for the study. All students attended two in-class lectures on different topics. The following week, students either re-studied from the recorded lecture on one of the two topics or, on the other topic, retrieved information about class content by responding to the course objectives. Half of the students were quizzed immediately after studying both topics. One week later, all students were required to complete an unannounced quiz to measure long-term retention. Finally, students were surveyed regarding their perceptions of the two learning strategies. Time on task was recorded to assess the efficiency of each learning strategy. Results. The primary outcome was student performance on the unannounced quiz administered one week after restudy of the lecture. No difference in performance was found between students who restudied the recorded lecture versus students who retrieved information about the lecture. However, immediately after restudying the material, students who studied from the recorded lecture performed better than students who retrieved information on the lecture. In terms of efficiency, the retrieval learning method required less time for the same gain in students' long-term retention of knowledge. Conclusions. Testing may be more efficient (ie, cost-effective) for long-term performance. Students who attend class may want to avoid rewatching course recordings in favor of practice testing.

The Effect of Varying Test Administration and Scoring Procedures on Three Tests of (Central) Auditory Processing Disorder.

BACKGROUND: There is currently no widely accepted objective method used to identify (central) auditory processing disorder ([C]APD). Audiologists often rely on behavioral test methods to diagnose (C)APD, which can be highly subjective. This is problematic in light of relevant literature that has reported a lack of adequate graduate-level preparation related to (C)APD. This is further complicated when exacerbated by the use of inconsistent test procedures from those used to standardize tests of (C)APD, resulting in higher test variability. The consequences of modifying test administration and scoring methods for tests of (C)APD are not currently documented in the literature. PURPOSE: This study aims to examine the effect of varying test administration and scoring procedures from those used to standardize tests of (C)APD on test outcome. RESEARCH DESIGN: This study used a repeated-measures design in which all participants were evaluated in all test conditions. The effects of varying the number of test items administered and the use of repetitions of missed test items on the test outcome score were assessed for the frequency patterns test (FPT), competing sentences test (CST), and the low-pass filtered speech test (LPFST). For the CST only, two scoring methods were used (a strict and a lax criterion) to determine whether or not scoring method affected test outcome. STUDY SAMPLE: Thirty-three native English-speaking adults served as participants. All participants had normal hearing (as defined by thresholds of 25-dB HL or better) at all octave band frequencies from 500 to 4000 Hz, with thresholds of 55-dB HL or better at 8000 Hz. All participants had normal cognitive function as assessed by the Mini-Mental State Examination. DATA COLLECTION AND ANALYSIS: Paired samples t-tests were used to evaluate the differences in test outcome when varying the CST scoring method. A 3 × 2 × 2 repeated-measures factorial analysis of variance (ANOVA) was used to determine the effects of test, length, and repetitions on outcome score for all three tests of auditory processing ability. Individual 2 × 2 repeated-measures two-way ANOVAs were subsequently conducted for each test to further evaluate interactions. RESULTS: There was no effect of scoring method on the CST outcome. There was a significant main effect of repetition use for the FPT and LPFST, in that test scores were greater when corrected for repetitions. An interaction between test length and repetitions was found for the LPFST only, such that there was a greater effect of repetition use when a shorter test was administered compared with a longer test. CONCLUSIONS: Test outcome may be affected when test administration procedures are varied from those used to standardize the test, lending itself to the broader possibility that the overall diagnosis of (C)APD may be subsequently affected.

Assessing metacognition in the classroom: Student help-seeking behavior.

INTRODUCTION: The study's purpose was to develop an assessment of students' metacognitive monitoring of help-seeking behavior. METHODS: This study piloted an assessment of help-seeking behavior in first-year student pharmacists to answer two questions: (1) Does help-seeking behavior depend on how familiar students are with the content? and (2) When students ask for help, does their performance and metacognition differ from when they do not seek help? As part of their year-end capstone, students answered drug information questions. The drugs within these questions were chosen based on the level of emphasis during the first-year curriculum (i.e. more familiar or less familiar). For each question, students rated their confidence level for their answer's correctness and marked whether they would ask their preceptor for help. Bias scores were calculated under conditions of familiarity based on level of emphasis (more familiar vs. less familiar) and help-seeking (asked for help and did not ask for help). RESULTS: Students performed better on more familiar material (d = 1.2), with a small difference in confidence on more familiar material (d = 0.2). When students asked for help, they scored lower (d = -2.2) and reported lower confidence (d = -3.7). Students were more likely to ask for help from their preceptors on more familiar content than less familiar (odds ratio = 1.25) and less likely to ask for help when they were overconfident (odds ratio = 0.18). CONCLUSIONS: Overall, students were more overconfident for less familiar material and were less likely to ask for help.

Universal Newborn Hearing Screening in Midwifery Education: A Survey.

INTRODUCTION: Universal newborn hearing screening has been adopted by all 50 states in the United States. However, there is currently a lack of knowledge about how health care providers learn about universal newborn hearing screening during their education programs. The purpose of this study was to identify whether midwifery education programs in the United States currently include information regarding universal newborn hearing screening in the standard curricula and, if so, what specific information is covered. METHODS: A survey that assessed whether specific topics related to universal newborn hearing screening are presented during midwifery education was sent to directors of midwifery education programs. RESULTS: Seventy-one midwifery education program directors were contacted, and the response rate was 38% (27 surveys). Most respondents reported that universal newborn hearing screening is discussed in the program, with the amount of time spent covering these topics varying considerably. Programs provide information about the midwife's role in universal newborn hearing screening, legal obligation to provide hearing screening information, and tests used to complete universal newborn hearing screening. How to complete the hearing screening, counseling for parents about results, and follow-up after a newborn does not pass the screening are topics that were not often discussed. There was no influence of program type or program length on the universal newborn hearing screening content discussed. DISCUSSION: The majority of midwifery education program directors that responded indicated that their programs include information about universal newborn hearing screening to midwifery students. There is a need for further information and resources specific to universal newborn hearing screening. Providing additional information to midwifery students about newborn hearing screening may result in increased awareness and education for families.

Electrophysiological gap detection thresholds: effects of age and comparison with a behavioral measure.

BACKGROUND: Temporal processing ability has been linked to speech understanding ability and older adults often complain of difficulty understanding speech in difficult listening situations. Temporal processing can be evaluated using gap detection procedures. There is some research showing that gap detection can be evaluated using an electrophysiological procedure. However, there is currently no research establishing gap detection threshold using the N1-P2 response. PURPOSE: The purposes of the current study were to 1) determine gap detection thresholds in younger and older normal-hearing adults using an electrophysiological measure, 2) compare the electrophysiological gap detection threshold and behavioral gap detection threshold within each group, and 3) investigate the effect of age on each gap detection measure. DESIGN: This study utilized an older adult group and younger adult group to compare performance on an electrophysiological and behavioral gap detection procedure. STUDY SAMPLE: The subjects in this study were 11 younger, normal-hearing adults (mean = 22 yrs) and 11 older, normal-hearing adults (mean = 64.36 yrs). DATA COLLECTION: All subjects completed an adaptive behavioral gap detection procedure in order to determine their behavioral gap detection threshold (BGDT). Subjects also completed an electrophysiologic gap detection procedure to determine their electrophysiologic gap detection threshold (EGDT). RESULTS: Older adults demonstrated significantly larger gap detection thresholds than the younger adults. However, EGDT and BGDT were not significantly different in either group. The mean difference between EGDT and BGDT for all subjects was 0.43 msec. CONCLUSIONS: Older adults show poorer gap detection ability when compared to younger adults. However, this study shows that gap detection thresholds can be measured using evoked potential recordings and yield results similar to a behavioral measure.