Telerheumatology: The VA Experience.

OBJECTIVES: We sought to characterize the correlation between diagnoses made during telerheumatology and face-to-face visits and to document patients' satisfaction with telerheumatology visits. METHODS: This quality assurance study of the use of telerheumatology evaluated new patients referred to a Veterans Affairs rheumatology clinic. Patients were seen at a community clinic by a nurse practitioner with a rheumatologist participating in the encounter via telelink. All of the patients had a second face-to-face visit with the same rheumatologist. Diagnoses made during telerheumatology and face-to-face visits were compared. Patients' satisfaction with telerheumatology was ascertained. RESULTS: Thirty-eight patients were included in the study. Initially, 23 were diagnosed as having an inflammatory or rheumatic condition; 15 were subsequently confirmed at the face-to-face visits. All of the patients with inflammatory, rheumatic conditions were identified at the telerheumatology visits. The overall correlation was 79% between the telerheumatology and face-to-face visits. Among patients with inflammatory, rheumatic conditions, 66% preferred a face-to-face visit compared with 41% among those without such conditions (not significant). Immediately after the telerheumatology visit, all of the patients gave a 10 out of 10 rating for satisfaction. During the subsequent telephone survey, 30 remained highly satisfied with the telemedicine encounter (10 out of 10 rating). CONCLUSIONS: Telerheumatology at the Palo Alto Veterans Affairs was well received by patients; provided an accurate diagnosis of noninflammatory, nonrheumatic conditions; and may be appropriate for screening and prioritizing patients for in-person rheumatology clinics.

Tonsillar pseudotumor: complications of chronically-administered temozolomide.

The current standard of care for patients with Glioblastoma multiforme (GBM) is surgery, followed by radiation in combination with Temozolomide (TMZ), followed by adjuvant TMZ. The most appropriate length of treatment of adjuvant TMZ after the completion of radiation is unclear. We present the case of a 45 year old female with GBM who received adjuvant TMZ on an experimental study for 24 1-month cycles (150 mg/M(2) 7 days on/7 days off continuously-a higher TMZ dose than standard). After 24 months on study she was stable without GBM regrowth, but presented with a right tonsil and pharynx mass consistent with a new primary malignancy. Tonsillar biopsy was positive for Epstein-Barr virus, Cytomegalovirus and Herpes Simplex Virus, but no tumor. This case highlights the risks and possible complications of immunosuppression associated with long term TMZ use.

Window-of-opportunity clinical trial of pembrolizumab in patients with recurrent glioblastoma reveals predominance of immune-suppressive macrophages.

BACKGROUND: We sought to ascertain the immune effector function of pembrolizumab within the glioblastoma (GBM) microenvironment during the therapeutic window. METHODS: In an open-label, single-center, single-arm phase II "window-of-opportunity" trial in 15 patients with recurrent (operable) GBM receiving up to 2 pembrolizumab doses before surgery and every 3 weeks afterward until disease progression or unacceptable toxicities occurred, immune responses were evaluated within the tumor. RESULTS: No treatment-related deaths occurred. Overall median follow-up time was 50 months. Of 14 patients monitored, 10 had progressive disease, 3 had a partial response, and 1 had stable disease. Median progression-free survival (PFS) was 4.5 months (95% CI: 2.27, 6.83), and the 6-month PFS rate was 40%. Median overall survival (OS) was 20 months, with an estimated 1-year OS rate of 63%. GBM patients' recurrent tumors contained few T cells that demonstrated a paucity of immune activation markers, but the tumor microenvironment was markedly enriched for CD68+ macrophages. CONCLUSIONS: Immune analyses indicated that pembrolizumab anti-programmed cell death 1 (PD-1) monotherapy alone can't induce effector immunologic response in most GBM patients, probably owing to a scarcity of T cells within the tumor microenvironment and a CD68+ macrophage preponderance.

A multicenter phase II trial of intrathecal topotecan in patients with meningeal malignancies.

To determine the therapeutic efficacy (13-week and 26-week CNS progression-free survival [PFS], response rate, and overall survival) and safety of intraventricular (IVent) topotecan in patients with neoplastic meningitis (NM), we conducted a phase II, open-label, nonrandomized, single-arm trial of IVent topotecan in patients with NM using 400 mug of topotecan IVent twice weekly for 6 weeks, followed by evaluation with imaging, cerebrospinal fluid (CSF), and physical examinations. In the absence of disease progression, patients were then treated with IVent topotecan weekly for 6 weeks, twice monthly for 4 months, and monthly thereafter. Sixty-two patients (23 males and 39 females) were enrolled from April 2001 through March 2006. Median age and KPS at enrollment were 56 (range 5-83) and 80 (range 60-100), respectively. Primary cancers included breast (19), lung (13), CNS (14), and others (16). Forty patients (65%) completed the 6-week induction period, among whom 13 (21%) had CSF clearance of malignant cells. Kaplan-Meier estimates of PFS at 13 and 26 weeks were 30% (95% confidence interval [CI], 20%-45%) and 19% (95% CI, 11%-34%). Overall median survival (50 deaths) was 15 weeks (95% CI, 13-24 weeks). The most common side effect was chemical meningitis in 32% of patients (5% grade 3); 32% experienced no drug side effects. IVent topotecan is well tolerated, but provides no added benefit over other IVent therapies. Because of its modest side effect profile, combining IVent topotecan with other IVent or systemic interventions should be considered.

Position paper on the development of a middle level provider in nuclear medicine: the nuclear medicine practitioner.

The development of an educational program and credentialing structure to support and recognize an advanced level of the practice of nuclear medicine technology is now underway. This work parallels the efforts in many, if not most, health care disciplines as they seek to achieve the twin goals of developing enhanced career paths and providing the best possible patient care in an environment where science and technology can run roughshod over concepts taught in the classroom a mere decade ago. Education is key to both goals. A master's level degree in nuclear medicine technology, coupled with an advanced practice credential recognizing both the educational achievement and a level of clinical expertise, will give nuclear medicine practitioners the knowledge and the right to practice their profession at a high level of autonomy, leading to more efficient and higher quality health care services. To that end the following position paper was prepared by members of the Advance Practice Task Force of the SNMTS and presented to the SNMTS Executive Council and the SNM Board of Directors. In June 2005, the executive council and the board of directors approved a resolution supporting the establishment of a middle level provider in nuclear medicine known as the nuclear medicine practitioner.

Competency Skills Assessment: Successes and Areas for Improvement Identified During Collaboration Between Informaticists and a National Organization.

The Association of periOperative Registered Nurses (AORN) approached the Nursing Informatics Research Team (NIRT) with a request to collaborate and conduct a competency assessment for their organization. An online tool was developed to determine current technology in perioperative settings. This presentation shares the process used to conduct research that led to a method for assessing perioperative nurses' competencies skills in their practice as well as identified gaps in curricula that faculty could address. Both successes and areas for improvement are detailed. The outcome of the process demonstrated a need to understand what skills are being assessed as AORN did not know what technology existed or how existing equipment was being used.

Operationalizing the TANIC and NICA-L3/L4 Tools to Improve Informatics Competencies.

Two tools were developed for nurses to self-assess different levels of informatics competencies. The TANIC is used for all nurses to self-assess; the NICA-L3/L4 is a tool for the informatics nurse specialist (INS) to self-assess skill levels. There are 167 informatics items in the TANIC and 178 advanced informatics items in the NICA-L3/L4. These tools were piloted; the results presented here. Based on the evaluation, the tools have been integrated into informatics courses at the BSN and MSN programs at Chamberlain College of Nursing, and presented in two AACN webinars and other national conferences. Numerous requests have been honored to provide the tools for other schools of nursing to use in their courses, including DNP programs. Other requests include those from CNIOs and managers to include in their job descriptions for informatics nurses.

Evaluation and management of polymyositis.

Polymyositis (PM) is one of the inflammatory myopathies, disorders characterized pathologically by the presence of inflammatory infiltrates in striated muscle. The principal clinical manifestation of PM is proximal muscle weakness. The cause of PM is unknown, but current evidence suggests that it is an autoimmune disorder. PM can affect people of any age, but most commonly presents between the ages of 50 to 70. PM is rarely seen in people younger than 18 years of age, and is twice as common among females than males. PM is more common in blacks than in whites. The overall prevalence of PM is 1 per 100,000. Muscle weakness may develop suddenly or more insidiously over a period of weeks to months. The classic symptom of PM is proximal weakness, which may manifest as difficulty holding the arms over the head, climbing stairs, or rising from a chair. Weakness of the striated muscle of the upper esophagus may result in dysphagia, dysphonia, and aspiration. The chest wall muscles may be affected, leading to ventilatory compromises. Involvement of cardiac muscle may lead to arrhythmias and congestive heart failure. Dermatomyositis (DM) is closely related to PM, and both are distinguished primarily by the occurrence of characteristic skin abnormalities in the former. PM and DM may be associated with a variety of malignancies. PM may also occur as part of the spectrum of other rheumatic diseases like systemic lupus erythematosus and mixed connective tissue disease. Moreover, inflammatory myopathy may be caused by some drugs (procainamide, D-penicillamine), and viruses, most notably the retroviruses. Corticosteroids and immunosuppressive agents are the mainstays of therapy for PM. The principal goals of therapy are to improve strength and improve physical functioning. Many patients require treatment for several years. The 5-year survival rate for treated patients is in the order of 95%. Up to one-third of PM patients may be left with some degree of residual muscle weakness.

Operationalizing TIGER NI Competencies for Online Assessment of Perceived Competency.

Competencies in nursing informatics (NI) are needed by every nurse. The TIGER Initiative published a set of NI competencies for every nurse in 2009. A research project focused on using these competencies is underway. A systematic instrument-development process is used to adapt these competencies for use in an online instrument. Results of a modified Delphi method, content-validity assessment, and pilot testing are related. Plans for ongoing research are shared.

A phase I factorial design study of dose-dense temozolomide alone and in combination with thalidomide, isotretinoin, and/or celecoxib as postchemoradiation adjuvant therapy for newly diagnosed glioblastoma.

External beam radiation therapy (XRT) with concomitant temozolomide and 6 cycles of adjuvant temozolomide (5/28-day schedule) improves survival in patients with newly diagnosed glioblastoma compared with XRT alone. Studies suggest that dose-dense temozolomide schedules and addition of cytostatic agents may further improve efficacy. This factorial design phase I/II protocol tested dose-dense temozolomide alone and combined with cytostatic agents. Patients with newly diagnosed glioblastoma received fractionated XRT to 60 Gy concomitant with temozolomide (75 mg/m²)/day for 42 days). In the phase I portion, patients with stable disease or radiologic response 1 month after chemoradiation were randomized to adjuvant temozolomide alone (150 mg/m²/day, 7/14-day schedule) or with doublet combinations of thalidomide (400 mg/day), isotretinoin (100 mg/m²/day), and/or celecoxib (400 mg twice daily), or all 3 agents. Toxicity was assessed after 4 weeks. Among 54 patients enrolled (median age, 52 years; median Karnofsky performance status, 90), adjuvant treatment was not administered to 12 (22%), primarily because of disease progression (n = 10). All combinations were well tolerated. Grade 3/4 lymphopenia developed in 63% of patients, but no related infections occurred. One patient treated with temozolomide plus isotretinoin plus thalidomide had dose-limiting grade 3 fatigue and rash, and 1 patient receiving all 4 agents had dose-limiting grade 4 neutropenia. Venous thrombosis occurred in 7 patients, 4 of whom received thalidomide. From study entry, median survival was 20 months and the 2-year survival rate was 40%. Multiple cytostatic agents can be safely combined with dose-dense temozolomide. The factorial-based phase II portion of this study is currently ongoing.