Interdisciplinary Educational Checklist for Allogeneic Stem Cell Transplant Patients.

Allogeneic hematopoietic stem cell transplant (HSCT) has emerged as a unique treatment modality. Patients who receive an allogeneic HSCT report feeling inadequately equipped to manage their postdischarge plan of care. It is essential that interdisciplinary team members prepare HSCT patients with the education needed in order to deal with the overwhelming care needs involved during and after hospital discharge. Targeted interventions that promote effective, meaningful education and behaviors are needed to guide patients and caregivers through this treatment experience together. Health-care checklists have produced dramatic, sustained gains in patient safety and quality of care. Checklists provide an ideal way to comply with standards of evidence-based care and promote good communication among interdisciplinary team members. The main purpose of this project was to investigate the use of an educational checklist for allogeneic stem cell transplant patients by interdisciplinary team members. Provider use of the educational checklist was evaluated at discharge assessing completion of checklist items.

Practical Guide to Bone Marrow Sampling for Suspected Myelodysplastic Syndromes.

Myelodysplastic syndromes (MDS) comprise a group of diverse clonal hematopoietic stem cell malignancies that are characterized by ineffective hematopoiesis and progressive bone marrow failure. Clinical symptoms are generally nonspecific. The diagnosis, classification, and risk stratification of MDS rely on the evaluation of peripheral blood and bone marrow sampling using the Revised International Prognostic Scoring System tool. Accurate diagnosis and risk stratification require a good-quality bone marrow sample. Bone marrow samples are obtained using two complementary techniques: bone marrow aspiration and bone marrow biopsy. Knowledge of what constitutes an adequate bone marrow sample and a proper bone marrow sampling technique may help advanced practitioners obtain quality samples while minimizing patient discomfort and risk. Patient preparation and positioning, site selection, sampling equipment, and sampling technique can help lead to the collection of high-quality bone marrow samples. Postprocedural care and knowledge of potential complications can reduce a patient's pain and optimize recovery.

Practical Strategies for Management of Lenalidomide-Associated Cytopenias in Myelodysplastic Syndromes With del(5q).

CASE STUDY A male patient aged 67 years with a 2-year history of refractory anemia and myelodysplastic syndromes (MDS) with del(5q) started lenalidomide (Revlimid) treatment as a participant in the MDS-001 trial (List et al., 2005). At the time of the study, this patient had been transfusion-dependent since 2001, and at study entry he had received a total of 12 units of red blood cells (RBCs). The patient started lenalidomide at 25 mg daily for 21 days of each 28-day cycle on April 2, 2002. (Please note that as a result of subsequent trials, the approved starting dose for lenalidomide in patients with del[5q] MDS is 10 mg.) The patient developed treatment-related pancytopenia in the first 3 weeks of treatment (see Figure on next page). On day 24, lenalidomide was withheld. Platelet and white blood cell (WBC) counts were recovered during a 21-day period, and treatment was resumed with lenalidomide at 10 mg daily. During this initial dose interruption, the patient's hemoglobin level improved. He achieved RBC-transfusion independence (TI) during week 5 of treatment-his last RBC transfusion was on April 22, 2002. Bone marrow (BM) analysis, including fluorescence in situ hybridization, after 3 months of therapy, did not show the del(5q) abnormality. A repeat BM analysis after 57 months of treatment revealed minimal residual dyspoiesis, normal metaphase cytogenetics, and normal cell morphology. Subsequent BM biopsies showed transient trisomy 8 abnormalities but no del(5q) abnormality. The patient required one additional dose reduction during the first year of treatment. The patient did not require hospitalization during lenalidomide treatment but did have a history of seasonal allergies and a propensity for acute sinusitis. He received a single dose of pegfilgrastim (Neulasta) and a short course of antibiotics for active infections, generally one course of antibiotics per year. This patient continued on lenalidomide at 5 mg daily for 21 days of every 28-day cycle without further dose reduction. The patient achieved durable RBC-TI and continued to receive treatment for more than 11 years. The levels of hemoglobin, platelets, and WBCs for an 11-year period in this patient are shown in the Figure. This patient had one normal platelet count in 11 years of lenalidomide treatment but no bleeding episodes. The average platelet count in the 11-year period was 67 × 1,000/∝L (normal range, 150-425 × 1,000/∝L). Similarly, the WBC count remained below normal, with an average of 3.1 × 1,000/∝L (normal range, 3.4-10.4 × 1,000/∝L). He remained active and continued working as an aerospace engineer until age 75. This case demonstrates how effective management of cytopenias, through dose interruptions and modifications in the early weeks of treatment, helps to enable long-term lenalidomide treatment and a high quality of life. Despite the persistence of moderate, asymptomatic cytopenias, the patient was able to remain on lenalidomide therapy and maintained RBC-TI for more than 11 years. The patient died on October 4, 2014, at age 79.5, due to coronary artery disease and heart failure.

Practical Management of Lenalidomide-Related Rash.

Lenalidomide (LEN) is an immunomodulatory drug with US Food and Drug Administration approval for use in myelodysplastic syndromes (MDS), multiple myeloma (MM), and mantle cell lymphoma (MCL). The toxicity profile for LEN is similar across indications, with the most common adverse events reported in registration trials being hematologic in nature, and Grade ≥ 3 hematologic toxicities the most common reasons for treatment interruption or permanent LEN discontinuation. However, an analysis of the Celgene Global Drug Safety database showed that nonserious rash was the leading cause of permanent early discontinuation of LEN in patients with MDS treated in the postmarketing setting (similar data not available for patients with MM or MCL). In registration trials, rash was reported in up to a third of patients, but Grade ≥ 3 rash was uncommon and rash rarely led to LEN treatment interruption or permanent discontinuation. This suggests differences in management of LEN-related rash in clinical trials versus real-world use. Most LEN-related rash is mild to moderate in severity and might present as patchy, raised, macular skin lesions, sometimes with localized urticaria, which might be associated with pruritus. Mild to moderate rash might be treated with topical corticosteroids and/or oral antihistamines. Any grade LEN-related rash should be appropriately managed through awareness of symptoms, appropriate and prompt intervention, and maximizing patient self-reporting of early signs of rash using upfront educational initiatives. This guide to management of LEN-related rash reviews key clinical data from registration trials, and the incidence and physiology of LEN-related rash, grading of rash, and guidelines for patients and caregivers.

Update on the science of myelodysplastic syndromes.

Scientific research is only just beginning to shed light on the pathobiology underlying the various subtypes of myelodysplastic syndromes (MDS), a heterogeneous group of clonal stem cell disorders characterized by cytopenias that can progress to acute myeloid leukemia. Increased understanding of the disease and prognostic implications of specific clinical features has aided in the development of prescribing guidelines and new treatments for MDS. Because oncology nurses have frequent interactions with patients during diagnostic and therapeutic evaluations, an understanding of the science behind disease classification, prognostic scoring, and the goals of treatment for low- and high-risk disease is important to answer questions regarding diagnostic results, treatment outcomes, and adverse event monitoring.