Staff Experiences with a Team-based Approach to Sleep Medicine Referrals: A Qualitative Evaluation.

Rationale: Sleep disorders are highly prevalent, and the volume of referrals sent to sleep specialists frequently exceeds their capacity. To manage this demand, we will need to consider sustainable strategies to expand the reach of our sleep medicine workforce. The Referral Coordination Initiative (RCI) takes a team-based approach to streamlining care for new specialty care referrals by 1) incorporating registered nurses into initial decision-making, 2) integrating administrative staff for coordination, and 3) sharing resources across facilities. Although prior work shows that the RCI can improve access to sleep care, we have a limited understanding around staff experiences and perspectives with this approach. Objectives: To assess staff experiences with a team-based approach to sleep medicine referrals. Methods: From June 2019 to September 2020, we conducted semistructured interviews with staff members who interacted with the RCI in sleep medicine. We recruited a variety of staff, including RCI team members (nurses and medical support assistants), sleep specialists, and referring providers. Two analysts used content analysis to identify themes. Results: We conducted 48 interviews among 35 unique staff members and identified six themes: 1) efficiency, in which staff described the impacts of the RCI program regarding efficient use of staff time and resources; 2) patient access and experience, in which staff noted improvements to patients' ability to receive care; 3) staff well-being and satisfaction, in which specialists and RCI staff described how the RCI mitigated the adverse impact of triage volume on staff well-being; 4) sharing specialty knowledge, in which nurses and specialists discussed the challenges of sharing specialty knowledge and training nurses to triage; 5) nurse autonomy, in which staff discussed nurses' ability to make triage decisions in the RCI system and highlighted the crucial role that decision support tools play in supporting that autonomy; and 6) coordination and communication, in which staff noted the importance, challenges, and facilitators of coordination and communication across facilities and at the interface of primary and specialty care. Conclusions: Staff endorsed positive and negative experiences around the RCI system, identifying opportunities to further streamline the referral process in support of access, patient experience, and staff well-being.

Spontaneous autologous graft-versus-host disease in plasma cell myeloma autograft recipients: flow cytometric analysis of hematopoietic progenitor cell grafts.

Nine plasma cell myeloma patients spontaneously developed histologically proven autologous graft-versus-host disease (GVHD) limited predominantly to the gastrointestinal tract within 1 month of initial autologous hematopoietic cell transplantation (AHCT) using high-dose melphalan conditioning. All recipients responded promptly to systemic and nonabsorbable oral corticosteroid therapy. All patients previously received systemic therapy with thalidomide, lenalidomide, or bortezomib before AHCT. Using enzymatic amplification staining-enhanced flow cytometry, we evaluated expression of selected transcription regulators, pathway molecules, and surface receptors on samples of the infused hematopoietic cell grafts. We demonstrated significantly enhanced expression of GATA-2, CD130, and CXCR4 on CD34(+) hematopoietic progenitor cells of affected patients compared with 42 unaffected AHCT controls. These 3 overexpressed markers have not been previously implicated in autologous GVHD. Although we did not specifically evaluate T cells, we postulate that exposure over time to the various immunomodulating therapies used for induction treatment affected not only the CD34(+) cells but also T cells or relevant T cell subpopulations capable of mediating GVHD. After infusion, the affected hematopoietic progenitor cells then encounter a host that has been further altered by the high-dose melphalan preparative regimen; such a situation leads to the syndrome. These surface markers could be used to develop a model to predict development of this syndrome. Autologous GVHD potentially is a serious complication of AHCT and should be considered in plasma cell myeloma patients with otherwise unexplained gastrointestinal symptoms in the immediate post-AHCT period. Prompt recognition of this condition and protracted treatment with nonabsorbable or systemic corticosteroids or the combination may lead to resolution.

The rise, fall and subsequent triumph of thalidomide: lessons learned in drug development.

Perhaps no other drug in modern medicine rivals the dramatic revitalization of thalidomide. Originally marketed as a sedative, thalidomide gained immense popularity worldwide among pregnant women because of its effective anti-emetic properties in morning sickness. Mounting evidence of human teratogenicity marked a dramatic fall from grace and led to widespread social, legal and economic ramifications. Despite its tragic past thalidomide emerged several decades later as a novel and highly effective agent in the treatment of various inflammatory and malignant diseases. In 2006 thalidomide completed its remarkable renaissance becoming the first new agent in over a decade to gain approval for the treatment of plasma cell myeloma. The catastrophic collapse yet subsequent revival of thalidomide provides important lessons in drug development. Never entirely abandoned by the medical community, thalidomide resurfaced as an important drug once the mechanisms of action were further studied and better understood. Ongoing research and development of related drugs such as lenalidomide now represent a class of irreplaceable drugs in hematological malignancies. Further, the tragedies associated with this agent stimulated the legislation which revamped the FDA regulatory process, expanded patient informed consent procedures and mandated more transparency from drug manufacturers. Finally, we review recent clinical trials summarizing selected medical indications for thalidomide with an emphasis on hematologic malignancies. Herein, we provide a historic perspective regarding the up-and-down development of thalidomide. Using PubMed databases we conducted searches using thalidomide and associated keywords highlighting pharmacology, mechanisms of action, and clinical uses.

Approaches to the early treatment of invasive fungal infection.

Invasive fungal infections account for significant morbidity and mortality in the seriously immunocompromised host, especially those suffering from hematologic malignancies and the recipients of hematopoietic cell transplant. One of the reasons for the continuing high mortality rates due to invasive fungal infection is the delay in administering appropriate therapy. As preemptive antifungal therapy is not feasible for lack of a predictive test, early empiric therapy is currently the only approach likely to result in improvement in survival. Here, we present our approach to both invasive candidiasis and invasive mold infection. Therapy should be initiated at the first signs and symptoms of disease, utilizing knowledge of local fungal epidemiology, the patient's recent antifungal agent exposure, and the diagnostic tests immediately available, to select an appropriate antifungal agent most likely to be effective against the suspected fungal species.

Second hematopoietic stem cell transplantation in myeloid malignancies.

PURPOSE OF REVIEW: Hematopoietic stem cell and umbilical cord blood transplantation can be a life-saving procedure for many patients with myeloid malignancies. The posttransplant period, however, can be complicated by graft failure and disease relapse, prompting the need for further therapy. Herein, we review and examine the data of second allogeneic stem cell transplant after autologous, allogeneic and umbilical cord blood transplantation. RECENT FINDINGS: Although large, prospective, multicenter trials are lacking, certain factors such as younger patient age, lower disease burden and a longer interval between first transplantation and relapse appear to portend a better prognosis for second transplant. SUMMARY: Currently, only a selected group of patients without important comorbidities should be considered for second allogeneic transplantation. Strategies such as new immunosuppressive agents, antileukemia monoclonal antibodies, graft modification and use of molecularly targeted therapy are needed to decrease the morbidity and increase the efficacy of transplantation.