Nursing standards, language and age as variables associated with clinical competence for nurses in long-term care facilities: A cross-sectional study.

AIM: To identify and examine the explanatory variables associated with clinical competence among registered nurses (RNs) and practical nurses (PNs) working in long-term care facilities (LTCF) for older adults. DESIGN AND METHODS: This was a cross-sectional study. The competence test, 'the Ms. Olsen test', was used for data collection. A convenience sample of 337 nursing staff working in LTCFs for older adults was selected between December 2020 and January 2021. A quantitative, non-experimental approach with multiple linear regression analysis examined the explanatory variables associated with clinical competence and the outcome variables. RESULTS: The main findings of the linear regression analysis show that the nursing staff's increasing age, use of Swedish as a working language and use of the Finnish nursing practice standards had statistically significant relationships with clinical competence among the participating nursing staff. CONCLUSION: This is the first knowledge test that has been developed to test nursing staff's clinical competence in elderly care. In this study in Finland, the highest clinical competence was among the nursing staff who were Swedish-speaking RNs working in institutional care homes caring for patients according to national practice standards. IMPLICATIONS: These results may be useful to nursing staff and managers working in elderly care to understand the explanatory variables associated with clinical competence in elderly care in Finland and in bilingual settings. The study highlights the importance of using national nursing standards in elderly nursing care. Knowing the explanatory variables associated with clinical competence can provide guidance for the further education of nursing staff in these settings. IMPACT: Caring according to national practice standards and caring for severely ill patients are associated with clinical competence. REPORTING METHOD: The authors adhered to the EQUATOR network guidelines Appendix S1 STROBE to report observational cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION: Registered and PNs completed a questionnaire for the data collection.

Health care services for older people in COVID-19 pandemic times - A Nordic comparison.

OBJECTIVE: To explore the Nordic municipal health and care services' ability to promote principal goals within care for older people during the COVID-19 pandemic. DESIGN AND SETTING: Two surveys were conducted among managers of municipal health care services for older people in Denmark, Finland, Norway and Sweden; the first around 6 months into the pandemic (survey 1), and the second around 12 months later (survey 2). Data were analysed through descriptive statistics, and multiple regression (OLS). SUBJECTS: 1470 (survey 1, 2020) and 745 (survey 2, 2021) managers. 32% in home care, 51% in nursing homes, 17% combined. RESULTS: In all countries the pandemic seems to have had more negative impact on eldercare services' ability to promote an active and social life, than on the ability to promote or enhance older people's mental and physical health. The regression analysis indicates that different factors influence the ability to promote these goals. Managers within nursing homes reported reduced ability to promote mental and physical health and an active social life to a significantly lower degree than managers of home care. The effect of three prevention strategies (lock down, testing, and/or organisational change), were explored. Organisational change (reorganize staff and practice, restrict use of substitutes) tended to impact the units' ability to promote a social life in a positive direction, while lock down (areas, buffets etc) tended to impact both the ability to promote mental/physical health and a social life in a negative direction. CONCLUSION: Measures that can improve opportunities for an active and social life during a pandemic should have high priority, particularily within home care.

It is important to learn from how the COVID-19 outbreak in 2020 affected the municipal health and care services' ability to achieve principal goals within care for older people.The pandemic had a more negative impact on the services' ability to promote an active and social life, than on their ability to promote or enhance mental and physical health.Measures that can improve opportunities for an active and social life during a pandemic situation should have high priority, particularily within home-based care.

Understanding Health, Subjective Aging, and Participation in Social Activities in Later Life: A Regional Finnish Survey.

To understand health and well-being in later life, it is vital to consider the meaning of subjective aging. This study aimed to explore how perceived health, self-perceptions of aging, and participation in social activities relate to each other among older persons in the Bothnia region and Åland islands in Finland. Data were analyzed using Spearman's and polychoric correlation and multinomial logistic regression analyses. The perceived good health and the younger physical, psychological, and social dimensions of subjective age were found to be associated with each other and with participation in social activities outside one's home.

Revealing a gap in the clinical competence of nursing staff in nursing homes: a cross-sectional study with the Ms. Olsen test.

BACKGROUND: Nursing staff, caring for frail older people in long-term care, needs to have a certain level of clinical competence to identify diseases at an early stage and to assess and provide good nursing care. In Finland, nursing care is based on evidence-based and high-quality nursing care. However, earlier inspections by the National Supervisory Authority for Welfare and Health showed many discrepancies between the nursing staff's clinical competence and adequate and continuous education. AIM: This study aimed to explore nursing staff, i.e. the clinical competence and decision-making skills of registered and practical nurses in nursing homes for older people in Finland and to analyse the association between nurses' clinical competence and fundamental background factors. METHODS: We conducted a cross-sectional study of 337 participants in 50 nursing homes in the western part of Finland, between December 2020 and January 2021. The instrument used was the validated Ms. Olsen test, an extraction of NOP-CET. Statistical analyses were conducted with descriptive statistics and correlations and a cut-off for clinical competence. RESULTS: This study with the Ms. Olsen test revealed that only one-fourth of the RNs and a third of the PNs passed the clinical competence test. In the self-evaluation, almost all participants evaluated themselves with good clinical competence. The Finnish Current Care Guidelines were used on a daily basis by 7.4% and weekly by 30%. Significant correlation was found between Swedish as a working language and mother tongue and the score for clinical competence. CONCLUSION: The clinical competence test, the Ms. Olsen test, was used in Finland for the first time to evaluate the nursing staffs´ clinical competence in nursing homes. We found gaps in the clinical competence in Finnish nursing homes, both for PNs and RNs. The result differed remarkably from their self-assessments and the staff did not use the national nursing guidelines as required to develop their nursing skills and knowledge. Gaps in the clinical competence have been identified and can be used to develop targeted continuous education.

Efficacy of conventional-dose cytarabine, idarubicin and thioguanine versus intermediate-dose cytarabine and idarubicin in the induction treatment of acute myeloid leukemia: Long-term results of the prospective randomized nationwide AML-2003 study by the Finnish Leukemia Group.

OBJECTIVES: AML-2003 study sought to compare the long-term efficacy and safety of IAT and IdAraC-Ida in induction chemotherapy of acute myeloid leukemia (AML) and introduce the results of an integrated genetic and clinical risk classification guided treatment strategy. METHODS: Patients were randomized to receive either IAT or IdAraC-Ida as the first induction treatment. Intensified postremission strategies were employed based on measurable residual disease (MRD) and risk classification. Structured questionnaire forms were used to gather data prospectively. RESULTS: A total of 356 AML patients with a median age of 53 years participated in the study. Long-term overall survival (OS) and relapse-free survival (RFS) were both 49% at 10 years. The median follow-up was 114 months. No significant difference in remission rate, OS or RFS was observed between the two induction treatments. Risk classification according to the protocol, MRD after the first and the last consolidation treatment affected the OS and RFS significantly (p < .001). CONCLUSIONS: Intensified cytarabine dose in the first induction treatment was not better than IAT in patients with AML. Intensification of postremission treatment in patients with clinical risk factors or MRD seems reasonable, but randomized controlled studies are warranted in the future.

Which factors are associated with COVID-19 infection incidence in care services for older people in Nordic countries? A cross-sectional survey.

AIMS: To investigate the differences between Sweden, Denmark, Finland and Norway regarding residential/home care units' and frontline managers' background factors, the resources allocated and measures taken during the initial phases of the COVID-19 pandemic, and whether and how these differences were associated with COVID-19 among older people in residential/home units. METHODS: Register- and survey-based data. Responses from managers in municipal and private residential/home units. Number of municipal COVID-19 cases from national registries. Multilevel logistic multivariate regression analysis with presence of COVID-19 among older people in residential/home units as the outcome variable. RESULTS: The proportions of residential/home units with client COVID-19 cases, mid-March-April 2020 were Denmark 22.7%, Finland 9.0%, Norway 9.7% and Sweden 38.8%, most cases found in clusters. The proportions were similar among employees. Client likelihood of having COVID-19 was six-fold higher if the employees had COVID-19. Mean client cases per residential/home unit were Denmark 0.78, Finland 0.46, Norway 0.22 and Sweden 1.23. For the same municipal infection incidence class, Sweden's mean client infection levels were three-fold those of other countries. The regression analysis variables country, municipal COVID-19 incidence proportion, and care type were associated with client cases at p ⩽ .001. Compared with Denmark, the odds ratios (ORs) for Sweden, Norway and Finland were 1.86, 0.41 and 0.35 respectively. The variable difficulties in preventive testing had an OR of 1.56, p ⩽ .05. CONCLUSIONS: Municipal COVID-19 incidence, employee cases, and the lack of testing resources somewhat explained the confirmed COVID-19 cases among older people in residential/home units. A two- to five-fold unexplained inter-country difference in ORs in the multivariate analyses was notable. The level of protection of vulnerable older clients in municipal and private residential/home units differed between the included countries.

Occupational self-efficacy and work engagement associated with work ability among an ageing work force: A cross-sectional study.

BACKGROUND: Occupational self-efficacy (OSE) is an appropriate adaption capability to react to continuous changes in work life today. While self-efficacy is an important component in work context, there is less knowledge regarding older workers' OSE. OBJECTIVE: This study examined the relationship between work ability, OSE and work engagement among a middle-aged workforce, and whether there were any differences between age groups and between professionals in different work context. METHODS: Data were collected by questionnaire, which included Work Ability Index (WAI), Occupational Self-Efficacy Scale, and Utrecht Work Engagement Scale. RESULTS: A total of 359 home care workers and engineers (response rate 43%) participated. The average age was 54 (SD±5.3) years, 69%were women. The results of logistic regression analyses revealed an association between WAI, OSE (OR 0.66; 95%CI 0.52 to 0.86) and work engagement (OR 0.61; 95%CI 0.47 to 0.78). Higher OSE and work engagement were related to higher work ability. No difference in OSE (5.9; ±0.8) between professional groups was seen, but the home care workers scored considerably higher work engagement (5.1; ±0.9) than the engineers (4.5; ±1.3). CONCLUSIONS: Improving OSE could be worthwhile to support work ability among middle-aged workers, despite dissimilarities in work context and educational level.

Long-term outcome after allogeneic stem cell transplantation in multiple myeloma.

The role of allogeneic hematopoietic stem cell transplantation (allo-SCT) in multiple myeloma is controversial. We analyzed the results of 205 patients transplanted in one center during 2000-2017. Transplantation was performed on 75 patients without a previous autologous SCT (upfront-allo), on 74 as tandem transplant (auto-allo), and on 56 patients after relapse. Median overall survival (OS) was 9.9 years for upfront-allo, 11.2 years for auto-allo, and 3.9 years for the relapse group (p = 0.015). Progression-free survival (PFS) was 2.4, 2.4, and 0.9 years, respectively (p < 0.001). Non-relapse mortality at 5 years was 8% overall, with no significant difference between the groups. Post-relapse survival was 4.1 years for upfront-allo and auto-allo, and 2.6 years for the relapse group (p = 0.066). Survival of high-risk patients was reduced. In multivariate analysis, the auto-allo group had improved OS and chronic graft-versus-host disease was advantageous in terms of PFS, OS, and relapse incidence. Late relapses occurred in all groups. Allo-SCT resulted in long-term survival in a small subgroup of patients. Our results indicate that auto-allo-SCT is feasible and could be considered for younger patients in the upfront setting.

Implementation of advanced practice nursing for minor orthopedic injuries in the emergency care context: A non-inferiority study.

AIMS: To evaluate the implementation of advanced practice nursing for patients with minor orthopedic injuries, including comparison of outcomes in relation to advanced practice nurse versus standard (physician-led) care models. DESIGN: A non-inferiority study was performed in an emergency department in Norway, where advanced practice nursing is in an initial stage of implementation. The non-inferiority design was chosen to test whether the new advanced practice nursing model does not compromise quality of care compared to the standard care model already in use. METHODS: Patients with minor orthopedic injuries were assessed and treated by either advanced practice nursing or standard (physician-led) care models. Participating patients were assigned to the professional available at presentation. In the nursing model, registered nurses worked at an advanced level/applied advanced practice nursing following in-house-training. Senior orthopedic specialists evaluated the diagnostic and treatment accuracy in both models. Data were collected in a tool developed for this study, from May to October 2019. RESULTS: In total, 335 cases were included, of which 167 (49.9%) were assessed and treated in the nursing model. Overall, correct diagnosis was found in 97.3% (n = 326) of the cases, and correct treatment was found in 91.3% (n = 306) of the cases. In comparison of missed diagnosis between advanced practice nurse and the standard (physician-led) care model showed inconclusive results (risk ratio: 0.29, 95% CI: 0.06-1.36). In comparison of treatment outcomes, the results showed that the advanced practice nursing model was non-inferior (risk ratio: 0.45, 95% CI: 0.21-0.97). CONCLUSION: Advanced practice nursing care models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. Further implementation of the advanced practice nurse care model is encouraged.

Person-centered home-based rehabilitation for persons with Parkinson's disease: A scoping review.

BACKGROUND: Due to vague, initial symptoms, persons with Parkinson's disease (PD) usually receive a definitive diagnosis after a prolonged period of time. At the time of diagnosis, they have already experienced limitations in activities of daily living and quality of life and are thus in need of immediate rehabilitation. OBJECTIVE: To describe the existing knowledge on the rehabilitation of persons with PD suitable to a home environment and to describe the person-centeredness, interprofessionality and clinical effectiveness of existing rehabilitation activities. SOURCES OF EVIDENCE: 67 full-text papers from the EBSCO, CINAHL, Medline, Google and Google Scholar databases, published in English, Swedish or Finnish between January 2010 and October 2018, were charted (type of rehabilitation, sample, instrumentation, reported effects) and summarized. RESULTS: Rehabilitation through physical activities still appears to be the most common form of rehabilitation, varying from walking to individually tailored exercise programs. The majority of physical rehabilitation activities were conducted outside the home even though they were suitable for a home setting. Physical activities not only improved several physical outcomes but also quality of life, well-being and activities of daily living functions, especially when digital devices were used. Cognitive and psychosocial rehabilitation were much less researched but seen to be an emerging area of research. The focus of rehabilitation seems to lie on persons with PD, not their near-ones. The majority of interventions were planned without discussing in advance with the persons with PD about their preferences, needs or values. Very few interventions were individually tailored or conducted in a home setting, and many studies included patient-recorded outcome measures, but only as secondary to clinical measures. Only a few studies focused on an interprofessional approach to PD rehabilitation, despite the approach being found effective in regard to quality of life for persons with PD. CONCLUSIONS: There appears to be a focus on physical outcomes and symptom management in the rehabilitation of persons with PD, even though cognitive and psychosocial well-being are often explored as secondary outcomes. Very few rehabilitation interventions were planned with persons or conducted in a home setting, and no interventions were seen that included near-ones. The majority of interventions were planned without the involvement of persons with PD. Still, many of the studies included patient-recorded outcome measures. Digital devices that assist in physical rehabilitation and an interprofessional approach to rehabilitation yield positive clinical outcomes, which in turn promotes a person-centered and holistic approach to rehabilitation.

Bloodstream infections in acute myeloid leukemia patients treated according to the Finnish Leukemia Group AML-2003 protocol - a prospective nationwide study.

BACKGROUND: Infections greatly influence the outcome of acute myeloid leukemia (AML) patients receiving intensive treatment. The aim of this study was to establish the incidence, microbial etiology, risk factors and prognosis of bloodstream infections (BSIs) in patients with AML and compare the results with the previous treatment protocol (AML-92). METHODS: Registery data were gathered prospectively from 357 patients aged 16-65 years recruited on the AML-2003 treatment protocol between November 2003 and November 2011 during different treatment cycles. RESULTS: Blood culture data were available on 977 treatment episodes, in which there were 503 BSIs (51%). The overall incidence rate (IR) for BSIs (per 1000 hospital days) was 16.7. Twenty patients (5.6%) died due to an infection and 16 of them (80%) had a BSI. The most commonly detected microbes (polymicrobial episodes included) in blood cultures were coagulase-negative staphylococci (CoNS, 24.7%), viridans group streptococci (VGS, 19.1%), enterococci (13.9%) and Enterobacteriacae group (25.9%). The etiology of BSIs varied greatly from treatment cycle to cycle. CONCLUSIONS: Enterococcal BSIs have increased compared to our previous treatment protocol, and they represent significant pathogens in blood cultures. Infection-related mortality has decreased despite the increase in the IR of BSIs. Enterococci seem to be an increasingly prominent pathogen underlying BSIs in the AML patients, especially during induction therapy (20%).

Prolonged immunochemotherapy with rituximab, cytarabine and fludarabine added to cyclophosphamide, doxorubicin, vincristine and prednisolone and followed by rituximab maintenance in untreated elderly patients with mantle cell lymphoma: a prospective study by the Finnish Lymphoma Group.

There is no consensus on treatment strategies for elderly patients with mantle cell lymphoma (MCL). In this prospective phase II study we investigated whether the poor outcome could be improved, with reasonable toxicity, by prolonging the immunochemotherapy. Ten cycles of alternating cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP)/cytarabine (AraC) with eight doses of rituximab (R) were given as induction. The potential synergism of intermediate-dose AraC and fludarabine was tested in cycles 6-8. Induction was followed by bimonthly rituximab maintenance for 2 years. The median age of the 60 included patients was 74 years, and the Mantle Cell Lymphoma International Prognostic Index (MIPI) was intermediate or high risk in 98% of the patients. The overall response rate was 95% (complete response/complete response unconfirmed 87%). The response of 11 patients improved with cycles 6-8 (R-fludarabine-AraC). Progression-free survival was 70% and overall survival 72% at 4 years, respectively. Treatment related mortality was 2%. Severe infections were rare, with only one grade 4 infection. More dose reductions were needed during fludarabine-containing courses as compared to R-AraC. In 20 patients a transient grade 4 neutropenia without severe infections was recorded during maintenance. In conclusion, elderly patients with MCL can be treated relatively intensively with acceptable toxicity.

Depth of response assessed by quantitative ASO-PCR predicts the outcome after stem cell transplantation in multiple myeloma.

Achievement of complete response (CR) is a new goal of therapy for multiple myeloma (MM). By sensitive methods, the depth of response can be measured even among the patients in CR. We used a sensitive real-time quantitative polymerase chain reaction by allele-specific primers (qASO-PCR) to assess the level of minimal residual disease (MRD) in bone marrow of 37 patients with myeloma who had achieved CR/near-to-CR after autologous or allogeneic stem cell transplantation (SCT). Allele-specific primers could be successfully designed for 86% of patients. Three to six months after autotransplantation, the PCR target was not detectable in 53% of patients (16/30 patients), and the respective figure after allotransplantation was 71% (5/7 patients); the median sensitivity of PCR assay was <0.002%. The proportion of patients without detectable PCR target was 22% of all autotransplanted patients. A threshold level of 0.01% in the qASO-PCR assay 3-6 months after SCT was found to be a useful cut-off limit to divide the patients into two prognostic groups: MRD low/negative vs. MRD high. Low/negative MRD after SCT was a significant predictive factor for the prolongation of progression free (70 vs. 19 months; P = 0.003) and suggestively also for overall survival. We conclude that not only CR but also its depth is important for the long-term outcome in MM.

RAFAELA Patient Classification System as a tool for management.

The RAFAELA Patient Classification System offers tools for the managers to follow the adequacy of resourcing through the Nursing Care Intensity per Nurse (NCI/N). The basic idea of the RAFAELA system is that the workload expressed as NCI/N is compared with the optimal NCI level for the ward. By creating systematic reporting on this indicator, managers can follow the workload level on different wards. The measurement tool is available to all nurses as well as to managers. Thus the staff can follow the results of the daily use of patient classification. Managers can use the data for staff allocation between different wards. As a result, the workload can be discussed and analyzed, and the consequences of challenging situations can be resolved. Together with the staff the managers can look for different solutions for the problems. The overall workload can be too high or too low or the variations of the workload can be too large. The overall aim is a workload on an optimal level. RAFAELA offers a multitude of solutions finding new ways to allocate working hours, networking with different wards, discussions with the persons who guide patient flow in the hospital or changing the number of nurses in the ward.

Single-dose pegfilgrastim is comparable to daily filgrastim in mobilizing peripheral blood stem cells: a case-matched study in patients with lymphoproliferative malignancies.

Pegfilgrastim (PEGFIL) has been found to be comparable to daily filgrastim (FIL) in managing chemotherapy-induced neutropenia. In the present study, we evaluated the ability of PEGFIL to mobilize stem cells in 38 consecutive patients with lymphoproliferative diseases (multiple myeloma, n = 18; lymphomas, n = 15; chronic lymphocytic leukemia, n = 5). Patients were mobilized using PEGFIL (6-18 mg as a single dose) during 2005-2006; 32 then received high-dose chemotherapy followed by autologous stem cell transplantation. PEGFIL-mobilized patients were matched by age, disease, and treatment line at a ratio of 1:2 to historical FIL-mobilized controls. The primary study endpoint was the blood CD34(+) concentration at onset of leukapheresis. Leukapheresis began a median of 10 days from the beginning of mobilization chemotherapy in both groups. At the onset of leukapheresis, median blood CD34(+) cell counts did not differ significantly in the FIL group compared with the PEGFIL group (79 x 10(6)/L vs 64 x 10(6)/L, respectively; p = 0.44). In the different disease categories, the respective CD34(+) cell counts after FIL and PEGFIL mobilization were 72 x 10(6)/L vs 123 x 10(6)/L (p = 0.08) in myeloma, 51 x 10(6)/L vs 62 x 10(6)/L (p = 0.6) in lymphomas, and 27 x 10(6)/L vs 30 x 10(6)/L (p = 0.62) in CLL, respectively. The target CD34(+) cell yield was harvested with one leukapheresis in 53% of PEGFIL-mobilized patients. Engraftment after autografting did not differ significantly in the two groups. Stem cell mobilization with a single dose of PEGFIL was, therefore, comparable to that achieved using daily FIL in patients with lymphoproliferative diseases. PEGFIL is a more practical way to mobilize stem cells than daily FIL.

Stem cell transplantation in poor-risk chronic lymphocytic leukemia: assessment of post-transplant minimal residual disease using four- and six-color flow cytometry and allele-specific RQ-PCR.

A total of 178 bone marrow samples were taken for minimal residual disease (MRD) analysis after 34 stem cell transplantations for poor-risk chronic lymphocytic leukemia, and 86 of them were analyzed in parallel by flow cytometry and allele-specific oligonucleotide-PCR (ASO-PCR). ASO primer was successfully designed for all patients whose frozen diagnosis samples were available. Flow cytometry and ASO-PCR were concordant, i.e. both either positive or both negative, in 78% of the analyses. Flow cytometry did not detect MRD in any of the samples that were PCR-negative cases. In contrast, ASO-PCR detected MRD in samples that were negative for MRD by flow cytometry in 22% of the analyses. In one patient, the immunophenotype but not the IgV(H) gene sequence had changed during a course of the disease, and MRD could not be followed by flow cytometry. In the remaining cases, the discrepancy was due to a higher sensitivity of ASO-PCR. Autologous stem cell transplantation resulted in clinical complete response in 87% (20/23) of the patients. By flow cytometry, 35% (8/23) of autotransplanted patients became MRD-negative, but only 12.5% (2/16) PCR-negative (sensitivity of ASO-PCR <0.001 and <0.01, respectively). All allotransplanted patients achieved or maintained hematological CR, and five out of nine patients (56%) became PCR-negative (sensitivity of PCR between <0.001 and <0.003), two of them having non-myeloablative conditioning. None of the patients who became PCR-negative after allogeneic transplantation have relapsed.

Benchmarking in nursing care by the RAFAELA patient classification system - a possibility for nurse managers.

AIM: The aim of the study was to explore the possibilities of benchmarking with the RAFAELA system. In this study, comparisons are made between: (1) costs for one nursing care intensity point; (2) the nursing care intensity per nurse; (3) the relationship between nursing care intensity per nurse and (4) the optimal nursing care intensity. BACKGROUND: During the period from 1994 to 2000 a new system for patient classification, the RAFAELA system, was developed in Finland. METHODS: 86 wards from 14 different hospitals in Finland took part in the study. RESULTS: The costs for one nursing care intensity point on the adults' wards were on average 7.80euro. The average workload was 25.2 nursing care intensity points per nurse. The optimal nursing care intensity was exceeded during 49.5% of the days and under during 20% of the days. CONCLUSIONS: The study shows that benchmarking with the RAFAELA system provides many opportunities for the nurse managers' resource allocation and their personnel administration.

Valproic acid combined with 13-cis retinoic acid and 1,25-dihydroxyvitamin D3 in the treatment of patients with myelodysplastic syndromes.

Valproic acid (VPA), an inhibitor of histone deacetylases, inhibits the growth of leukemia cells and induces their differentiation in vitro. In the present study, VPA in combination with two differentiating agents, 13-cis retinoic acid and 1,25-dihydroxyvitamin D3, was given to 19 previously untreated patients with MDS or CMML. Eight patients had to discontinue treatment before week 16 due to toxicity. According to international working group criteria, three patients (16%) responded to treatment. No correlation between VPA serum level, histone acetylation or clinical response was observed.