Hematopoietic stem cell transplantation nursing: a practice variation study

PURPOSE/OBJECTIVES

To examine practice variation in hematopoietic stem cell transplantation (HSCT) nursing and to identify the gap between recommended standards of practice and actual practice across settings. Additional practices relevant to HSCT nursing also were explored.

RESEARCH APPROACH

Cross-sectional, descriptive survey.

SETTING

National and international cancer centers.

PARTICIPANTS

A convenience sample was obtained from the 2006 Oncology Nursing Society Blood and Marrow Stem Cell Transplant Special Interest Group membership list (N = 205). Most participants were women (94%) with a median age of 45 years. The primary role was bedside nurse (46%), with an adult-only population (78%) in an academic (84%), inpatient (68%-88%) center. 39 (94%) U.S. states and 7 (6%) non-U.S. countries were represented.

METHODOLOGIC APPROACH

Survey development was guided by Dillman Mail and Internet survey design. Electronic questionnaires were conducted with Zoomerang Market Tools.

MAIN RESEARCH VARIABLES

Infection control practices across bone marrow transplantation settings.

FINDINGS

Descriptive statistics revealed minimal practice variation regarding infection control across transplantation types or conditioning regimens. Practices regarding implementation of restrictions on patients' hygiene, diet, and social interactions varied by phase of transplantation, with the greatest variations occurring during the post-transplantation phase. Sixty-two percent of respondents reported using published guidelines; 72% reported using organization-specific policies.

CONCLUSIONS

Although published standards are under consideration, practice variation exists across transplantation centers. Whether the variation is caused by a lack of compliance with published guidelines or by the poor delineation of details for providers to translate the guidelines into practice is not known.

INTERPRETATION

Identifying gaps in the literature and inconsistencies in HSCT practices is an important first step in designing evidence-based projects that can be used to standardize practice and link best practices to improved patient outcomes.

Analytical diagnosis methodology to evaluate nitrate impact on historical building materials

Nitrate salts have become of greater importance in the decay of materials from historical buildings due to changes in the environment. This work presents an analytical diagnosis methodology to evaluate the impact of nitrate salts in mortars and bricks, combining noninvasive and microdestructive analytical techniques together with chemometric and thermodynamic data analyses. The impact of nitrate salts cannot be well ascertained if other soluble salts are not taken into account. Therefore, the principal results from this work relate to nitrate salts but some results for other kinds of salts are included. Data from Raman microprobe spectroscopy and micro X-ray fluorescence (micro-XRF) are used to characterise the original composition and a first approximation of the nature of the decay compounds, mainly nitrates. The soluble salts are extracted and the anions and cations are quantified by means of ion chromatography with conductimetric detection for anions/cations and inductively coupled plasma mass spectrometry (ICP/MS) for cations. The values obtained allow two different data treatments to be applied. First, chemometric analysis is carried out to search for correlations among anions and cations. Second, thermodynamic modelling with the RUNSALT program is performed to search for environmental conditions of soluble salt formation. All the results are finally used to diagnose the impact of nitrates.

Care for patients undergoing extracorporeal photopheresis to treat chronic graft-versus-host disease: review of the evidence

Late immune dysregulation following allogeneic hematopoietic cell transplantation (HCT) is known as chronic graft-versus-host disease (GVHD), which is a major cause of mortality and morbidity after HCT, and a rise in its incidence is predicted. Better therapies are being sought to manage chronic GVHD and limit patients' exposure to corticosteroids. Extracorporeal photopheresis (ECP), an immune-modulating therapy, has shown preliminary safety and efficacy in treating chronic GVHD. However, access to ECP is limited, care is costly, and the optimal frequency, duration, and durability of response are unknown. Although nurses who care for patients with chronic GVHD recognize its adverse impact on patients' quality of life, limited evidence exists about the selection of patients most likely to benefit from ECP therapy and from the supportive care provided to them. A multidisciplinary approach is needed to define the desired outcomes of ECP therapy and to determine the evidence base for nursing management approaches.

Unique abnormalities of CD4(+) and CD8(+) central memory cells associated with chronic graft-versus-host disease improve after extracorporeal photopheresis

Chronic graft-versus-host disease (cGVHD) remains a problematic complication of allogeneic hematopoietic stem cell transplantation. Laboratory parameters correlated with cGVHD have not been fully defined, although changes in CD4/CD8 ratios occur and a decrease in CD4(+) central memory T cells has been noted. Extracorporeal photopheresis (ECP) is an effective therapy for steroid-refractory cGVHD. We have noted changes in lymphocyte subsets after ECP. CD4(+) and CD8(+) T-cell central and effector memory populations were enumerated by flow cytometry in a cohort of 37 patients postallogeneic transplantation with symptomatic cGVHD. Of the patients with symptomatic cGVHD, 7 were treated with ECP over 6 months and prospectively assessed for changes in lymphocyte subsets. There was a highly significant correlation of an increase in CD8(+) central memory cells and a concomitant decrease in CD4(+) central memory cells in patients with symptomatic cGVHD. These changes were not detected in patients without cGVHD posttransplantation. In all, 7 patients with cGVHD followed up prospectively during ECP treatment showed a statistically significant normalization of the pattern of CD4(+) and a trend toward normalization of CD8(+) central memory T cells coincident with improvement of cGVHD. These data indicate a high correlation between disturbances in the balance of central and effector memory populations and cGVHD suggesting use in following up responses to therapy. The normalization of central and effector memory populations in response to ECP coincident with clinical improvement of cGVHD support a correlation between these laboratory parameters and cGVHD. Further studies are needed to demonstrate whether laboratory measurements of the magnitude of changes in central and effector memory populations are useful prognostically or can be used to guide response to therapy. The contrasting change in central memory cells (CD8(+) increased versus CD4(+) decreased) in cGVHD provide support for recent reports suggesting unique differences in the differentiation pathways for CD8(+) versus CD4(+) T cells.

Improvements in the wallpaper industry during the second half of the 19th century: micro-Raman spectroscopy analysis of pigmented wallpapers

Scientific studies of the pigments used in the manufacturing process of some pigmented wallpapers are presented in this work. Non-destructive micro-Raman spectroscopy was selected for this purpose, and provides important information about how the 19th century wallpaper industry incorporated new materials in their works and designs. At the same time, analysis can help to date the samples of uncatalogued wallpapers. Chrome yellow, burnt Sienna, Prussian blue, ultramarine blue, red lead, carbon black, calcium carbonate, red iron oxide and a red organic pigment were identified. According to the palette used, as well as to the manufacturing process, the wallpapers in this study can be dated to the second half of the 19th century.

On-line FT-Raman and dispersive Raman spectra database of artists’ materials (e-VISART database)

Raman spectroscopy has been widely applied in the analysis of different types of artwork. This technique is sensitive, reliable, non-destructive and can be used in situ. However, there are few references in the literature regarding specific Raman spectra libraries for the field of artwork analysis. In this paper, the development of two on-line databases with Fourier transform Raman (FT-Raman; 1064 nm) and dispersive Raman (785 nm) spectra of materials used in fine art is presented; both are implemented in the e-vibrational spectroscopic databases of artists' materials database (e-VISART). The database provides not only spectra, but also information about each pigment. It must be highlighted that for each pigment or material several spectra are available from different dealers. Some of the FT-Raman spectra available in the e-VISART database have not been published until now. Some examples in which the e-VISART database has been successfully used are presented.

Targeted pretransplant host lymphocyte depletion prior to T-cell depleted reduced-intensity allogeneic stem cell transplantation

Mixed chimaerism and graft rejection are higher after reduced-intensity allogeneic stem cell transplantation (RIST) with T-cell depleted (TCD) allografts. As host immune status before RIST affects engraftment, we hypothesized that targeted depletion of host lymphocytes prior to RIST would abrogate graft rejection and promote donor chimaerism. Lymphocyte-depleting chemotherapy was administered at conventional doses to subjects prior to RIST with the intent of decreasing CD4(+) counts to <0.05 x 10(9)cells/l. Subjects (n = 18) then received reduced-intensity conditioning followed by ex vivo TCD human leucocyte antigen-matched sibling allografts. All evaluable patients (n = 17) were engrafted; there were no late graft failures. At day +28 post-RIST, 12 patients showed complete donor chimaerism. Mixed chimaerism in the remaining five patients was associated with higher numbers of circulating host CD3(+) cells (P = 0.0032) after lymphocyte-depleting chemotherapy and was preferentially observed in T lymphoid rather than myeloid cells. Full donor chimaerism was achieved in all patients after planned donor lymphocyte infusions. These data reflect the importance of host immune status prior to RIST and suggest that targeted host lymphocyte depletion facilitates the engraftment of TCD allografts. Targeted lymphocyte depletion may permit an individualized approach to conditioning based on host immune status prior to RIST.

Raman fibre optic approach to artwork dating

Raman micro-probe spectroscopy has been applied to the analysis of a non catalogued hand-crafted wallpaper during its restoration process. The analysis has been totally non-destructive without the necessity of taking any sample. The artwork showed a great chromatic palette having been detected the presence of calcium carbonate, Prussian blue, ultramarine blue, gypsum (CaSO4.2H2O), minium (Pb3O4), vermilion (HgS), chrome orange (CaCO3), chrome yellow (PbCrO4), barium sulphate and carbon black (C). From the spectroscopic analysis the date of its manufacturing has been set between 1828 and 1830, introduction of chrome yellow and orange, as well as artificial ultramarine blue, and 1840, when continuous industrial wallpapers were extensively manufactured in Europe.

Allogeneic lymphocytes induce tumor regression of advanced metastatic breast cancer

PURPOSE

Allogeneic T lymphocytes can induce regression of metastatic breast cancer through an immune-mediated graft-versus-tumor (GVT) effect in murine models. To determine if a clinical GVT effect exists against metastatic breast cancer, allogeneic lymphocytes were used as adoptive cellular therapy after a reduced-intensity chemotherapy conditioning regimen and allogeneic hematopoietic stem-cell transplantation (HSCT) from human leukocyte antigen-matched siblings.

PATIENTS AND METHODS

Sixteen patients with metastatic breast cancer that had progressed after treatment with anthracyclines, taxanes, hormonal agents, and trastuzumab, received allogeneic HSCT. The reduced-intensity transplant conditioning regimen consisted of cyclophosphamide and fludarabine. To distinguish an immunological GVT effect from any antitumor effect of cytotoxic chemotherapy in the transplant-conditioning regimen, allogeneic T lymphocytes were removed from the stem-cell graft and were subsequently administered late postallogeneic HSCT. Allogeneic lymphocytes containing 1 x 10(6), 5 x 10(6), and 10 x 10(6) CD3(+) cells/kg were infused on days +42, +70, and +98 post-allogeneic HSCT, respectively.

RESULTS

Objective tumor regressions occurred after day +28 post-allogeneic HSCT in six patients and were attributed to allogeneic lymphocyte infusions. Two of these responding patients had disease progression post-allogeneic HSCT before subsequent tumor regression. Tumor regressions occurred concomitantly with the establishment of complete donor T-lymphoid engraftment, were associated with the development of graft-versus-host disease (GVHD), and were abrogated by subsequent systemic immunosuppression for GVHD.

CONCLUSION

Allogeneic lymphocytes can induce regression of advanced metastatic breast cancer. These results indicate that an immunological GVT effect from allogeneic lymphocytes exists against metastatic breast cancer and provide rationale for further development of allogeneic cellular therapy for this largely incurable disease.

Micro-Raman analysis of coloured lithographs

Raman micro-spectroscopy was chosen for analysis and identification of the pigments present in four nineteenth-century hand-coloured lithographs, as this technique has several advantages over others for this purpose. The possibility of performing completely non-destructive analysis without any sampling is probably one of its most favourable qualities for art analysis. Raman spectroscopy can also be used to determine some pigments that cannot be detected using FTIR, such as vermilion, carbon blacks, cadmium pigments, etc. Among others, Prussian blue, ultramarine blue, carbon black, chrome yellow, yellow ochre, red lead, red iron oxide, burnt Sienna, indigo blue, chrome orange, phthalocyanine green, and some other organic pigments, were determined in the specimens. The results obtained have led to doubts about the age of the lithographs.

Analysis of bulk and inorganic degradation products of stones, mortars and wall paintings by portable Raman microprobe spectroscopy

This work reports the use of a portable Raman microprobe spectrometer for the analysis of bulk and decaying compounds in carbonaceous materials such as stones, mortars and wall paintings. The analysed stones include limestone, dolomite and carbonaceous sandstone, gypsum and calcium oxalate, both mono- and dihydrated, being the main inorganic degradation products detected. Mortars include bulk phases with pure gypsum, calcite and mixtures of both or with sand, soluble salts being the most important degradation products. The pigments detected in several wall paintings include Prussian blue, iron oxide red, iron oxide yellow, vermilion, carbon black and lead white. Three different decaying processes have been characterised in the mortars of the wall paintings: (a) a massive absorption of nitrates that reacted with calcium carbonate and promoted the unbinding of pigment grains, (b) the formation of black crusts in the vault of the presbytery and (c) the thermodecomposition of pigments due to a fire.

Severe chronic graft-versus-host disease is characterized by a preponderance of CD4(+) effector memory cells relative to central memory cells

Donor alloreactive CD4(+) T cells are important to the pathogenesis of chronic graft-versus-host disease (cGVHD), but specific subsets of CD4(+) T cells responsible for GVHD have not been defined. We hypothesized that cGVHD might be associated with a preponderance of CD4(+) effector memory cells (CCR7(-)/CD62L(low), CD4(EM)). We analyzed CCR7 and CD62L expression on CD4(+) T cells from stem cell transplantation patients, who did or did not develop cGVHD, and healthy donors. Patients with cGVHD had a higher percentage of CD4(EM) cells (35.5% +/- 2.9%) than healthy donors (13.8% +/- 0.7%; P <.0001) or patients without cGVHD that received a transplant (21.7% +/- 2.1%; P <.01). Using corticosteroid dose as a surrogate marker for cGVHD severity, severe cGVHD was associated with a higher percentage of CD4(EM) cells. The proportion of CD4(EM) cells in corticosteroid-dependent patients with systemic lupus erythematosis or Wegener granulomatosis did not differ from patients without cGVHD that received a transplant. This finding implies that overrepresentation of CD4(EM) cells is a unique feature of cGVHD.

Establishment of early donor engraftment after reduced-intensity allogeneic hematopoietic stem cell transplantation to potentiate the graft-versus-lymphoma effect against refractory lymphomas

Reduced-intensity allogeneic hematopoietic stem cell transplantation (alloHSCT), which typically results in mixed chimerism initially after transplantation, has had limited efficacy in chemotherapy-refractory lymphomas. We hypothesized that the rapid establishment of complete donor chimerism would potentiate a graft-versus-lymphoma effect. Fifteen patients with chemotherapy-refractory lymphoma initially received induction with a conventional chemotherapy regimen (etoposide, prednisone, vincristine, cyclophosphamide, adriamycin, fludarabine [EPOCH-F]) to deplete host T cells and provide disease control prior to alloHSCT. Patients then received conditioning with fludarabine and cyclophosphamide followed by alloHSCT from HLA-matched siblings. Graft-versus-host disease prophylaxis consisted of cyclosporine alone. EPOCH-F resulted in 73% of patients having partial responses or stable disease. EPOCH-F depleted host CD4(+) T cells from a median of 235 cells/microL to 56 cells/microL. Fourteen patients underwent alloHSCT, and all had >95% donor engraftment by day 14 after transplantation. The incidence of Grade II to III acute graft-versus-host disease was 71%. There were two therapy-related deaths. There were 8 partial responses and 3 complete responses (CRs) at day 28. Five additional CRs were observed at day 100 without withdrawal of cyclosporine or donor lymphocyte infusion. The rate of CRs for all 15 patients was 60%. The 1-year progression-free survival rate from time of study entry is 67% with only 1 relapse among 9 CRs. At a median potential follow-up of 28 months, the overall survival rate is 53%. These data demonstrate that a potent and durable graft-versus-lymphoma effect can occur against chemotherapy-refractory lymphomas and suggest that this effect may be associated with rapid, complete donor chimerism after reduced-intensity alloHSCT.

A nosocomial outbreak of multidrug-resistant tuberculosis

BACKGROUND

An outbreak of seven cases (in six patients and one health care worker, all of whom had AIDS) of multidrug-resistant tuberculosis occurred in a hospital in Chicago. The hospital had a respirator-fit testing program but no acid-fast bacilli isolation rooms.

OBJECTIVE

To identify risk factors for transmission of Mycobacterium tuberculosis.

DESIGN

Retrospective cohort study.

SETTING

Private hospital.

PARTICIPANTS

Patients and health care workers exposed to M. tuberculosis.

MEASUREMENTS

Analysis of M. tuberculosis isolates, tuberculin skin testing, assessment of exposure, and assessment of participant characteristics.

RESULTS

All seven M. tuberculosis isolates had matching DNA fingerprints. Of patients exposed to M. tuberculosis, those who developed tuberculosis had lower CD4+ T-lymphocyte counts (P = 0.02) and were more likely to be ambulatory (P = 0.03) than those who did not. Of 74 exposed health care workers, the 11 (15%) who had conversion on tuberculin skin testing were no more likely than those who did not have conversion to report that they always wore a respirator with a high-efficiency particulate air filter.

CONCLUSIONS

Transmission of M. tuberculosis occurred in a hospital that did not have recommended isolation rooms. A respirator-fit testing program did not protect health care workers in this setting.