Using digital storytelling to understand service users' mental health recovery and address stigma among nursing students.

PURPOSE: Stigmatized attitudes towards people with mental illness from healthcare providers continues to be a problem affecting recovery in people with mental illness. The process of recovery was explored through digital stories created by service users, with support from nursing students. Stigmatized attitudes in nursing students and stigma resistance in service users were also investigated. DESIGN AND METHODS: A quasi-experimental, mixed-methods, pilot study in which service users/nursing student teams created digital stories. Surveys testing stigmatized attitudes and stigma resistance were employed. FINDINGS: Statistical significance was not found, however, qualitative analysis revealed recovery elements and greater appreciation of individuals with mental illness by the nursing students. PRACTICE IMPLICATIONS: Digital story-telling assists service users in doing the internal work of making meaning from experience. Nursing students benefit from involvement in the activity.

Twice-daily intravenous bolus tacrolimus infusion: A safe and effective regimen for graft-versus-host disease prophylaxis.

OBJECTIVE/BACKGROUND: Among patients undergoing allogeneic hematopoietic cell transplant, continuous intravenous (IV) tacrolimus infusion is frequently used for graft-versus-host disease (GvHD) prophylaxis. Twice-daily intermittent IV tacrolimus dosing may confer safety and convenience benefits. METHODS: We performed a retrospective chart review of 66 patients who received twice-daily IV bolus tacrolimus for GvHD prophylaxis. The primary end point of the study was safety, as measured by renal toxicity. The secondary end points included mean tacrolimus serum concentrations, incidence of grades II-IV acute GvHD, electrolyte abnormalities, hyperglycemia, hypertension, and neurologic toxicity. RESULTS: There was acceptable, possibly favorable, incidence of renal toxicity (42%) and no significant difference in grades II-IV GvHD (37%), compared with published data. Mean tacrolimus blood concentrations were not affected by occurrence of renal toxicity. CONCLUSION: We conclude that administration of IV tacrolimus twice daily over 4 h may be safe and effective in preventing GvHD in allogeneic hematopoietic cell transplant.

Clinical Outcomes Using Mycophenolate and Tacrolimus for Graft-versus-Host Disease Prophylaxis in Patients Undergoing Allogeneic Stem Cell Transplant: A Single Institution Experience.

For recipients of allogeneic hematopoietic stem cell transplant (HSCT), mycophenolate mofetil (MMF) plus tacrolimus combination is mostly used in reduced-intensity (RIC), and nonmyeloablative conditioning (NMAC) whereas methotrexate and tacrolimus combination is preferred in myeloablative conditioning (MAC). We present single institution outcomes in patients undergoing allogeneic HSCT with both MAC and NMAC/RIC regimen using MMF and tacrolimus for graft-versus-host disease (GVHD) prophylaxis. Data from all adult patients who underwent allogeneic HSCT from 2007 to 2017 was collected from Data Back to Centers web-based application of Center for International Blood and Marrow Transplant Research (CIBMTR). A total of 150 patients were included with the mean age of 46.9 years. For the patients who received MAC (n=109), the cumulative incidence of grade II-IV acute GVHD at day 100 was 37%, grade II-IV acute GVHD at one year was 51%, and chronic GVHD at one year was 38%. For the patients who received NMAC/RIC (n=41), the cumulative incidence of grade II-IV acute GVHD at day 100 was 31%, grade II-IV acute GVHD at one year was 28%, and chronic GVHD at one year was 36%. This institutional analysis shows that the combination of MMF and tacrolimus yields acceptable outcomes for the prevention of acute and chronic GVHD.

Randomized Trial of Lenalidomide Versus Observation in Smoldering Multiple Myeloma.

PURPOSE: Observation is the current standard of care for smoldering multiple myeloma. We hypothesized that early intervention with lenalidomide could delay progression to symptomatic multiple myeloma. METHODS: We conducted a randomized trial that assessed the efficacy of single-agent lenalidomide compared with observation in patients with intermediate- or high-risk smoldering multiple myeloma. Lenalidomide was administered orally at a dose of 25 mg on days 1 to 21 of a 28-day cycle. The primary end point was progression-free survival, with disease progression requiring the development of end-organ damage attributable to multiple myeloma and biochemical progression. RESULTS: One hundred eighty-two patients were randomly assigned-92 patients to the lenalidomide arm and 90 to the observation arm. Median follow-up is 35 months. Response to therapy was observed in 50% (95% CI, 39% to 61%) of patients in the lenalidomide arm, with no responses in the observation arm. Progression-free survival was significantly longer with lenalidomide compared with observation (hazard ratio, 0.28; 95% CI, 0.12 to 0.62; P = .002). One-, 2-, and 3-year progression-free survival was 98%, 93%, and 91% for the lenalidomide arm versus 89%, 76%, and 66% for the observation arm, respectively. Only six deaths have been reported, two in the lenalidomide arm versus four in the observation arm (hazard ratio for death, 0.46; 95% CI, 0.08 to 2.53). Grade 3 or 4 nonhematologic adverse events occurred in 25 patients (28%) on lenalidomide. CONCLUSION: Early intervention with lenalidomide in smoldering multiple myeloma significantly delays progression to symptomatic multiple myeloma and the development of end-organ damage.

Rare case of Bing-Neel syndrome treated successfully with ibrutinib.

Waldenstrom's macroglobulinaemia (WM) is a lymphoproliferative disorder of the B cell origin. It is characterised by the presence of IgM paraprotein in the serum and lymphoplasmacytic lymphoma cells in the bone marrow with extranodal involvement relatively uncommon. Bing-Neel syndrome (BNS) is a neurological complication of WM that results from infiltration of the central nervous system by malignant lymphoplasmacytic cells. We present an interesting case of BNS that responded remarkably to ibrutinib monotherapy.

Assessing the Relationship Between Religious Involvement and Health Behaviors.

A growing body of research suggests that people who are more deeply involved in religion may be more likely to adopt beneficial health behaviors. However, religion is a complex phenomenon, and as a result, religion may affect health behaviors in a number of ways. The purpose of the current study was to see whether a sacred view of the body (i.e., belief that the body is the temple of God) is associated with better health behavior. It was proposed that the relationship between a sacred body view and health behavior will emerge only among study participants who have a stronger sense of religiously oriented control (i.e., stronger God-mediated control beliefs). Five positive health behaviors were evaluated: more frequent strenuous exercise, more frequent moderate exercise, more frequent consumption of fruits and vegetables, higher quality sleep, and the adoption of healthy lifestyles. Data from a recent nationwide sample reveal that a sacred body view is associated with each health behavior, but only among study participants who have a strong religiously oriented sense of control.

Health and Well-Being Among the Non-religious: Atheists, Agnostics, and No Preference Compared with Religious Group Members.

Although recent research suggests that the proportion of the US population identifying as non-religious has been rapidly expanding over the course of the last decade, relatively little research has examined the implications of this development for health and well-being. This study uses data from a large representative survey study of religion and health in the adult US population (N = 3010) to examine group differences among religious group members (N = 2401) and three categories of non-religious individuals: atheists (N = 83), agnostics (N = 189), and those stating no religious preference (N = 329). MANCOVA was used to analyze group differences on five outcome dimensions, incorporating 27 outcome variables. Religious non-affiliates did not differ overall from affiliates in terms of physical health outcomes (although atheists and agnostics did have better health on some individual measures including BMI, number of chronic conditions, and physical limitations), but had worse positive psychological functioning characteristics, social support relationships, and health behaviors. On dimensions related to psychological well-being, atheists and agnostics tended to have worse outcomes than either those with religious affiliation or those with no religious preference. If current trends in the religious composition of the population continue, these results have implications for its future healthcare needs.

Benevolent Images of God, Gratitude, and Physical Health Status.

This study has two goals. The first is to assess whether a benevolent image of God is associated with better physical health. The second goal is to examine the aspects of congregational life that is associated with a benevolent image of God. Data from a new nationwide survey (N = 1774) are used to test the following core hypotheses: (1) people who attend worship services more often and individuals who receive more spiritual support from fellow church members (i.e., informal assistance that is intended to increase the religious beliefs and behaviors of the recipient) will have more benevolent images of God, (2) individuals who believe that God is benevolent will feel more grateful to God, (3) study participants who are more grateful to God will be more hopeful about the future, and (4) greater hope will be associated with better health. The data provide support for each of these relationships.

Gratitude as a psychotherapeutic intervention.

Gratitude practice can be a catalyzing and relational healing force, often untapped in clinical practice. In this article, we provide an overview of current thinking about gratitude's defining and beneficial properties, followed by a brief review of the research on mental health outcomes that result from gratitude practice. Following an analysis of our case study of the use of gratitude as a psychotherapeutic intervention, we present various self-strategies and techniques for consciously choosing and cultivating gratitude. We conclude by describing ways in which gratitude might be capitalized upon for beneficial outcomes in therapeutic settings.

Spontaneous graft versus host disease occurring in a patient with multiple myeloma after autologous stem cell transplant.

Graft versus host disease (GVHD) is a common complication of allogeneic transplant. Acute GVHD primarily affects the skin, liver, and GI tract generally within the first 100 days after transplant. GVHD following an allogeneic transplant occurs as a result of donor T-cell recognition of host alloantigens. In contrast, patients undergoing ASCT are not subjected to the genetic disparity that occurs with allogeneic transplant, and in principal, should not develop this proinflammatory response. A clinical syndrome, however, has been described in patients following autologous transplant that shares the same features as GVHD occurring in recipients post-allogeneic transplant [1-3]. Previously reported cases have described skin, liver, and GI tract manifestations consistent with what is seen in allogeneic GVHD. Biopsies of the skin and GI tract mucosa have demonstrated similar histological features as well. Interestingly, the majority of reported cases seem to occur in patients with multiple myeloma undergoing consolidative ASCT. Historically, however, these patients have been described as having a relatively benign course with mild skin rash, nausea, vomiting, and/or diarrhea that is responsive to immunosuppression. In this article, we present a case of fatal, spontaneous GVHD in a patient with multiple myeloma following ASCT.

Relational humility: conceptualizing and measuring humility as a personality judgment.

The study of humility has progressed slowly due to measurement problems. We describe a model of relational humility that conceptualizes humility as a personality judgment. In this set of 5 studies, we developed the 16-item Relational Humility Scale (RHS) and offered initial evidence for the theoretical model. In Study 1 (N = 300), we developed the RHS and its subscales--Global Humility, Superiority, and Accurate View of Self. In Study 2, we confirmed the factor structure of the scale in an independent sample (N = 196). In Study 3, we provided initial evidence supporting construct validity using an experimental design (N = 200). In Study 4 (N = 150), we provided additional evidence of construct validity by examining the relationships between humility and empathy, forgiveness, and other virtues. In Study 5 (N = 163), we adduced evidence of discriminant and incremental validity of the RHS compared with the Honesty-Humility subscale of the HEXACO-PI (Lee & Ashton, 2004).

Measuring gratitude in youth: assessing the psychometric properties of adult gratitude scales in children and adolescents.

Before the developmental trajectory, outcomes, and related interventions of gratitude can be accurately and confidently studied among the youth, researchers must ensure that they have psychometrically sound measures of gratitude that are suitable for this population. Thus, considering that no known scales were specifically designed to measure gratitude in youth, this study aimed to answer an important question: Are the existing gratitude scales used with adults valid for use with youth? The present study is an empirical investigation, based on a large youth sample (N = 1,405) with ages ranging from 10 to 19 years old, of the psychometric properties of scores of the Gratitude Questionnaire-6 (GQ-6; M. E. McCullough, R. A. Emmons, & J.-A. Tsang, 2002), the Gratitude Adjective Checklist (GAC; M. E. McCullough, R. A. Emmons, & J.-A. Tsang, 2002), and the Gratitude Resentment and Appreciation Test (GRAT)-short form (M. Thomas & P. Watkins, 2003). Single-group and multiple-group confirmatory factor analyses indicated that the factor structures of these gratitude scales resemble those found with adults and were invariant across age groups. Scores of all three gratitude scales revealed acceptable internal consistency estimates (i.e., >.70) across age groups. Results showed that whereas scores of all three gratitude scales were positively correlated with each other for 14- to 19-year-olds, GRAT-short form scores tended to display relatively low correlations with scores of the other two measures for younger children (10-13 years old). Furthermore, the nomological network analysis showed that scores of all three gratitude scales were positively correlated with positive affect and life satisfaction scores across the age groups. The relationships with negative affect and depression scores, however, seemed dependent on the child's age. Pending results from subsequent research recommendations for researchers interested in studying gratitude in youth are offered.

Increased natural killer cells and decreased regulatory T cells are seen in complex atypical endometrial hyperplasia and well-differentiated carcinoma treated with progestins.

Progestins are used to treat complex atypical hyperplasia and well-differentiated endometrial carcinoma in women who desire fertility preservation and those who are poor surgical candidates. Although sensitivity to progestins is thought to be associated with the presence of estrogen and progesterone receptors, it is known that receptor-negative tumors can also respond to the agent, suggesting that there is another direct antitumor action of progestin. Because tumor immune response is an additional predictor of survival in well-differentiated endometrial carcinoma, it is surprising that the role of progestins in tumor immunity has not been investigated. Regulatory T cells modulate the immune response, whereas cytotoxic T cells directly target tumor cells. In this study, we investigated the effect of progestins on regulatory T cells and cytotoxic T cells. The pre- and posttreatment endometrial samples of 15 progestin-treated patients with complex atypical hyperplasia or well-differentiated endometrial carcinoma were evaluated for therapeutic response and the presence of cytotoxic T cells and regulatory T cells. Immunohistochemical analysis was performed for FOXP3 to identify regulatory T cells and for granzyme B to identify activated cytotoxic T cells. To further characterize the cytotoxic T cell's subpopulations, we performed CD8 (cytotoxic T-cell marker) and CD56 (natural killer cells marker). Ten of 15 patients had normal morphology on follow-up endometrial samplings, and 4 patients had persistence or progression of the disease. Regulatory T-cell counts pretreatment were significantly higher in complex atypical hyperplasia and well-differentiated endometrial carcinoma than in posttreatment normal endometrium. Residual complex atypical hyperplasia and well-differentiated endometrial carcinoma present in posttreatment samples maintained high regulatory T cells and low number of cytotoxic T cells. Progestin treatment was associated with striking increase in cytotoxic T cells in areas with decidual reaction. Before treatment, most of the granzyme B+ cytotoxic T cells in complex atypical hyperplasia and well-differentiated endometrial carcinoma were CD8(+) T cells, whereas after treatment, up to 80% of cytotoxic T cells were natural killer cells. These results suggest that progestin treatment affects subpopulations of lymphocytes in the endometrium and may induce immune suppression of complex atypical hyperplasia and well-differentiated endometrial carcinoma.

Tackling mantle cell lymphoma (MCL): Potential benefit of allogeneic stem cell transplantation.

Mantle cell lymphoma (MCL) is a type of non-Hodgkins lymphoma (NHL) associated with poor progression-free and overall survival. There is a high relapse rate with conventional cytotoxic chemotherapy. Intensive combination chemotherapy including rituximab, dose intense CHOP- (cyclophosphamide-doxorubicin-vincristine-prednisone) like regimens, high dose cytarabine, and/or consolidation with autologous stem cell transplant (autoSCT) have shown promise in significantly prolonging remissions. Data from phase II studies show that even in patients with chemotherapy refractory MCL, allogeneic stem cell transplant (alloSCT) can lead to long term disease control. Most patients with MCL are not candidates for myeloablative alloSCT due to their age, comorbidities, and performance status. The advent of less toxic reduced intensity conditioning (RIC) regimens, which rely more on the graft-versus-lymphoma (GVL) effect, have expanded the population of patients who would be eligible for alloSCT. RIC regimens alter the balance of toxicity and efficacy favoring its use. Treatment decisions are complicated by introduction of novel agents which are attractive options for older, frail patients. Further studies are needed to determine the role and timing of alloSCT in MCL. Currently, for selected fit patients with chemotherapy resistant MCL or those who progress after autoSCT, alloSCT may provide long term survival.

Foxp3-expressing T regulatory cells and mast cells in acute graft-versus-host disease of the skin.

Acute graft-versus-host disease (aGVHD) limits the effectiveness of allogeneic hematopoietic stem cell transplantation. Foxp3 is required for the development and function of CD4(+)/CD25(+) regulatory T cells (T-regs). Foxp3-expressing T-regs are thought to protect against GVHD. Mast cells are thought to be essential in CD4(+)/CD25(+) regulatory T cell-dependent peripheral tolerance. Twenty biopsies of skin with grades I-III aGVHD were stained for Foxp3 and CD117. Inflammation was quantified by a 4 point scale, 0 = no inflammation, 1 = <25% of 20x field, 2 = 25-50%, and 3 = >50%. T-regs and mast cells were quantified by a 4 point scale, 0 = no cells per 20x field, 1 = <5 cells per 20x field, 2 = 5-10 cells, and 3 = >10 cells. T-regs were positively correlated with both inflammation and aGVHD grade. Twelve cases with low T-regs had mild inflammation and lower grades of aGVHD and 6 cases with high T-regs had dense inflammatory infiltrate and higher grades of aGVHD. The number of T-regs, mast cells and density of the inflammatory infiltrate were positively correlated only in cases with mild inflammation. In aGVHD of the skin, T-regs increased with the degree of inflammation and GVHD grade. Mast cells were present at the same density whether aGVHD was of lower or higher grade.

Expression of indoleamine 2,3-dioxygenase in metastatic malignant melanoma recruits regulatory T cells to avoid immune detection and affects survival.

The mechanism by which malignant melanoma (MM) cells survive in lymph nodes is poorly understood. One possible mechanism by which MM cells can escape immune surveillance is through upregulation of immunomodulatory enzymes such as indoleamine 2,3-dioxygenase (IDO). In this study, 25 cases of MM lymph node metastases from patients with long and short survival were evaluated for expression of IDO and the number of Forkhead box p3 (FOXP3)-expressing regulatory T cells. Moderate to strong cytoplasmic IDO expression was present in all (15/15) MM lymph node metastases in patients with poor survival. Eight of 10 patients with metastatic MM and long survival were negative or only weakly positive for IDO. Upregulation of IDO in metastatic MM cells was associated with an increased number of regulatory T cells (Tregs). There was a statistically significant association between shorter survival and both a stronger IDO expression (p = 0.0019) and a higher number of FOXP3 expressing Tregs (p < 0.001). Using RT-PCR analysis, we showed that IDO expression in MM cells is induced by interferon-gamma. These data support the notion that metastatic MM cells select for expression of IDO to evade immunologic detection. Therefore, inhibition of IDO in MM patients may be a useful treatment strategy.

Counting blessings in early adolescents: an experimental study of gratitude and subjective well-being.

The development and manifestation of gratitude in youth is unclear. We examined the effects of a grateful outlook on subjective well-being and other outcomes of positive psychological functioning in 221 early adolescents. Eleven classes were randomly assigned to either a gratitude, hassles, or control condition. Results indicated that counting blessings was associated with enhanced self-reported gratitude, optimism, life satisfaction, and decreased negative affect. Feeling grateful in response to aid mediated the relationship between experimental condition and general gratitude at the 3-week follow-up. The most significant finding was the robust relationship between gratitude and satisfaction with school experience at both the immediate post-test and 3-week follow-up. Counting blessings seems to be an effective intervention for well-being enhancement in early adolescents.

Lack of effect of donor-recipient Rh mismatch on outcomes after allogeneic hematopoietic stem cell transplantation.

BACKGROUND: A recently published study has reported that donor-recipient Rhesus (Rh)-mismatched allogeneic hematopoietic stem cell transplantation independently led to significantly poorer survival. This suggests that donor-recipient Rh mismatching is a risk factor in allogeneic hematopoietic stem cell transplantation and should be a criterion for donor selection. STUDY DESIGN AND METHODS: To further evaluate this issue, 258 consecutive patients who underwent myeloablative or submyeloablative allogeneic hematopoietic stem cell transplantation at our institution were analyzed to determine the association between the Rh mismatch pattern and 5-year actuarial survival. Secondary endpoints analyzed were the association of donor-recipient Rh mismatch and event-free survival, transplant-related mortality, incidence of acute graft-versus-host disease (GVHD), and incidence of chronic GVHD. RESULTS: In our analysis, there were no significant associations between donor-recipient Rh mismatch pattern and overall survival, event-free survival, transplant-related mortality, incidence of acute GVHD, or incidence of chronic GVHD. On multivariate Cox proportional hazard analyses, the donor-recipient Rh mismatch pattern was not independently predictive of overall survival. CONCLUSION: Donor-recipient Rh mismatch is not a risk factor in allogeneic hematopoietic stem cell transplantation and does not affect transplant outcomes.