Outpatient Hematopoietic Stem Cell Transplantation Research Articles

Results of treating relapsed and refractory acute myeloid leukemia at a reference center in Latin America: the importance of outpatient hematopoietic stem cell transplantation

Results of treating relapsed and refractory acute myeloid leukemia at a reference center in Latin America: the importance of outpatient hematopoietic stem cell transplantation

Feasibility of Utilizing a Virtual Health Assistant during Inpatient Reduced-Intensity Allogeneic Transplantation

Background:Artificial intelligence (AI) promises to revolutionize hematology care.Patients undergoing inpatient allogeneic hematopoietic stem cell transplantation (HCT) often experience psychological consequences, some of which may be attributed to anxiety about how to optimally care for themselves when returning home.Care.coach Avatar TM is a tablet-based ‘human-in-the-loop’ virtual health assistant (VHA) that utilizes generative AI and deterministic software to provide psychosocial support and health coaching to inpatients. It has been shown to improve loneliness, depression, anxiety, hospital delirium, and falls in older adults in the hospital (Chi, Geriatr Nurs 2017; Bott, J Med Internet Res 2019). Methods: We adapted the care.coach Avatar TM VHA for inpatient HCT, designing an education program to prepare patients for safe return to the home setting. The VHA engages patients with reminders for hydration, medications, food, or activity; education modules adapted for HCT; playing games such as jeopardy, chess, blackjack, trivia, or bingo; playing the news or music; having free-form conversations; going through therapeutic activities and exercises; and practicing mindfulness and guided meditation. Avatar protocols were updated based on feedback from a structured focus group (n=10) of nurse navigators, inpatient HCT nurses, and HCT physicians at the Dana-Farber/Harvard Cancer Center that was convened to discuss perspectives on implementation of care.coach Avatar TM VHA for HCT. Seven HCT-specific educational modules were created. A feasibility pilot was then performed in 3 sequential cohorts of 6 patients receiving reduced intensity conditioning (RIC) HCT. In the first cohort, patients were given the VHAs without any recommendations for how long to use them. The second cohort was given a recommendation for 30 minutes per day, and the third cohort was offered a $20 gift card for completion of at least 4 modules. Responses were measured through patient surveys and engagement data analysis. The predefined retention rate for feasibility was 67%, a standard for introduction of a novel AI technology (Teresi, Med Care 2022). Dissatisfaction rate for the overall VHA experience was defined as responding “disagree” or “strongly disagree” with recommending the VHA to others. Results: The study included 18 patients, with a majority female (61%) and white (72%; Table). The median age of the patients was 63 (interquartile range [IQR] 56-66). The retention rate from enrollment to discharge or three weeks (whichever came first) was 78% (95% exact confidence interval: 52-94%). The median length of use was 9 days (IQR 6-11). A post-pilot survey was completed by 16 patients (90%), revealing a dissatisfaction rate of 28%. The dissatisfaction rates decreased from 50% to 20% to 0% across the 3 cohorts. Frequency of completion of the post-pilot survey for the full study was 72% within 1 week of disenrollment, and 90% overall. Average completion rate was 52% for all seven HCT modules in the whole study population. Across cohorts, module completion rates changed from 5% to 88% to 62%, reflecting evolving guidance to patients at study initiation. The median average daily interaction time with the avatar for all 18 patients was 28 minutes with an interquartile range from 20 to 38 minutes. The most frequently used VHA functions by time of usage were music (35%), exercise (20%), and education (15%; Figure). The least frequently used VHA functions were the rounds optimizer (a tool to remind patients of their questions during rounds; 1%) and humor (1%). Overall, 52% of time using the VHA was spent on social engagement activities. Conclusions: The pilot study demonstrated the feasibility of implementing the care.coach Avatar TM VHA for inpatient HCT patients. Despite modest dissatisfaction and variability in completion rates, the VHA showed promise in providing HCT education, social, and emotional support for inpatient RIC HCT. Further research is needed to assess the impact of this novel technologic intervention on HCT outcomes and quality of life, as well as application to the outpatient HCT setting.

Outpatient allogeneic hematopoietic stem-cell transplantation: a review.

Hematopoietic stem-cell transplantation (HSCT) is usually performed in well-equipped units inside a hospital. The cost of this in-hospital transplant is usually very high; therefore, this procedure is more difficult to perform in low- and middle-income countries. Autologous outpatient HSCT is now a common procedure; however, outpatient allogeneic transplants are more complicated. Only a few centers in the world have incorporated outpatient HSCT. This transplant requires special adaptation, like a day hospital, careful selection of patients, oral medications, and the patient must live relatively close to the hospital. The results until now suggest that this outpatient transplant is factible and similar to inpatient HSCT. The objective was to review and describe the different methods and results following an outpatient allogeneic-HSCT strategy.

Outpatient Based Autologous Hematopoietic Stem Cell Transplantation Is a Feasible Therapeutic Option for Patients with Chronic Inflammatory Demyelinating Polyneuropathy: The Mexican Experience

IntroductionSeveral autoimmune disorders such as multiple sclerosis, Stiff man syndrome or chronic inflammatory demyelinating polyneuropathy (CIDP) can benefit from autologous hematopoietic stem cell transplantation (HSCT) due to its immunomodulatory effects at short- and long-term. Here we present the results from the conduction of an outpatient HSCT procedures in 16 patients with CIDP.MethodsProspective study of HSCT in persons with CIDP recruited since 2015. Patients with and without previous immunomodulatory therapy were enrolled and a 3-month wash-out period was recquired; previous or current use of walking support was not a contraindication. All patients signed a consent before starting the study and the study protocol was approved by Clínica Ruiz IRB. Before the conditioning, all participants underwent a comprehensive evaluation. On day -11 and -10, patients received cyclophosphamide (Cy) at 50 mg/kg, followed by a 7-day course of G-CSF previous to cell collection (day -2) through apheresis using a Mahurkar catheter. Then, on day -2 and -1 a second round of Cy at 50 mg/kg was given (Figure 1). Transfusions and antimicrobial prophylaxis were administered per local protocol. Upon hematological recovery (>500 ANC) all patients received a rituximab infusion at 1000 mg.ResultsSixteen patients with CIDP underwent screening for transplantation clearance and all of them proceeded to HSCT. Of those, 8 (50%) patients were male. Median age at transplantation was found to be 44 years (SD 10.5). Walking support was employed at the time of HSCT by 7 (44%) patients and most frequent previous therapy was intravenous immunoglobulin in 4 (25%) patients. On average a mean 8.5x10 6/kg (SD 4.2) of CD34 + cells were infused. The mean nadir neutropenia was found to be 0.11x10 9/L (SD 0.13) and the median time of granulocytes recovery was 7.0 days (SD 2.9) while median time of platelet recovery was 5.5 days (SD 3.0). One (6%) patient was admitted to hospital due to febrile neutropenia and 4 (25%) patients required red-blood cell and platelet transfusion support. In 3 of 5 persons the need of walking support reverted.ConclusionsOur experience suggests that people with CIDP may undergo HSCT with no major complications on an outpatient basis. Hospital admissions, hematological recovery, and infectious complications seem to be relatively low-severity complications that could be manage with standard protocols. [Display omitted] DisclosuresGomez-Almaguer: Bristol-Myers-Squibb: Honoraria, Speakers Bureau; Roche: Honoraria, Speakers Bureau; Takeda: Honoraria, Speakers Bureau; Janssen: Honoraria, Speakers Bureau.

Patient Satisfaction with Pharmacist Video Visits in an Outpatient Hematopoietic Stem Cell Transplant Clinic

<h3>Introduction</h3> The number of HCT recipients and survivors continues to increase worldwide. With this growth, strategies are needed to improve delivery and access to HCT. We implemented video visits for patients and pharmacists in our HCT clinic in 2016 and initiated a cross-sectional, self-administered, descriptive survey study of patient satisfaction in outpatient adult HCT patients. <h3>Objective</h3> To determine if patient satisfaction with a pharmacist video visit is non-inferior to a face-to-face, in-clinic pharmacist visit in HCT patients. <h3>Methods</h3> Patients self-allocated to either face-to-face or video visits for future appointments after having at least one face-to-face pharmacist visit. Survey questions were based on the Health-Systems Alliance for Integrated Medication Management (HAIMM) survey. The primary endpoint to assess if pharmacist video visits are non-inferior to face-to-face visits was based on response to the question "Overall, how would you rate the quality of care and services you received from the pharmacist?" using a Likert-scale from 1 to 5 (excellent to poor). Secondary endpoints include likelihood of medication reconciliation using the medication bottles in patients with video visits compared with face-to-face visits and pharmacist satisfaction with video visits versus face-to-face visits. The average length of visit, delays, and total time spent per patient were captured to describe time efficiency differences between pharmacist video visits and pharmacist face-to-face visits. <h3>Results</h3> To date, 111 patients in the face to face arm and 20 patients in the video arm have completed surveys. The survey response rate to the 15-question survey in the face-to-face arm is 100% and 43% in the video arm. Overall, 95% of patients had high satisfaction (rated excellent or very good) with video visits in comparison to 99% in the control group (p = 0.25). Table 1 summarizes other patient satisfaction responses to the survey. <h3>Conclusion</h3> To our knowledge, this is the first study investigating pharmacist involvement in telemedicine with HCT patients. Our preliminary results indicate patient satisfaction is high with both face-to-face and video appointments. Accrual to the video arm has been slow. We hypothesize enrollment is limited by restriction of patient enrollment to patients physically located in a state where the pharmacist is licensed at the time of the video visit.

Unique Collaboration between Inpatient Hematopoietic Stem Cell Transplant Unit and Outpatient Hematopoietic Stem Cell Transplant Clinic to Address Staffing Challenges

Topic Significance & Study Purpose/Background/Rationale Fluctuating patient census often requires inpatient nurses to float to other units in the hospital. When nurses float to unfamiliar units, it increases stress, anxiety and frustration which can negatively impact quality of care and patient safety. Methods, Intervention, & Analysis Due to concerns voiced by nurses on the hematopoietic stem cell transplant (HSCT) inpatient unit at an academic medical center, a unique collaboration was initiated between the inpatient HSCT unit and the outpatient HSCT clinic. Nurses from the HSCT inpatient unit floated either to a unit in the hospital or to the outpatient HSCT clinic. Staffing assignments were reviewed from January to September of 2019 to identify the frequency of floating in the HSCT inpatient nurse. Surveys regarding floating were constructed and emailed to HSCT inpatient and outpatient nurses and collected for 2 weeks. Findings & Interpretation Inpatient HSCT nurses floated 89 times (65 times to outpatient HSCT clinic, 6 times to different units during day shift, and 18 times to different units during night shift) during the assessment period. Inpatient nurses preferred to float to the outpatient HSCT clinic due to familiar patient population and the feeling of competence and confidence in providing quality nursing care for these patients. Inpatient nurses also experienced less distress with floating to the HSCT outpatient clinic. The outpatient clinic nurses reported that benefits of having HSCT inpatient nurses include familiarity with the HSCT patient population and improved continuity of care. Outpatient nurses added that because inpatient HSCT nurses are familiar with the processes of HSCT, they tend to need less help which takes less time away from patient care. Discussion & Implications When nurses are floated to an environment where they feel competent, the nurses' perception of stress, anxiety and frustration are greatly decreased. Due to the frequency of floating to the outpatient HSCT clinic, the importance of a more structured orientation to the clinic was discussed with leadership. Next steps would include reviewing the safety data over the trial timeframe to explore the number of safety events and developing a more systematic orientation to increase inpatient HSCT nurse competence in the outpatient clinic.

Benzodiazepine &amp; Zolpidem Usage in Multiple Myeloma Patients Undergoing Transplantation

Background Multiple myeloma (MM) patients (pts) are older and have poorer quality of life (QOL) compared to pts with other hematologic malignancies (Nielsen et al, Eur J Haematol 2017). Autologous hematopoietic stem cell transplantation (HCT) acutely exacerbates psychosocial distress & insomnia. These symptoms are often treated with benzodiazepines and zolpidem-class drugs (B/Z Rx) that come with serious toxicities in older adults. B/Z Rx patterns in HCT recipients, particularly among MM patients who tend to be older with more co-morbidities, are unknown. Methods We conducted a retrospective cohort study including all pts with MM or light-chain amyloidosis who underwent autologous HCT at our institution from 1/1/17-12/31/18. We identified B/Z Rx at 3 timepoints: (1) pre-HCT baseline; (2) discharge, or D+14 for outpatient HCT; and (3) D+100 follow-up. Results 205 pts (43% female) underwent HCT, 184 (90%) as inpatient (inpt) and 21 (10%) as outpatient (outpt). The median age was 61; 27 pts (13%) were ≥ 70. 174 pts (85%) had received melphalan 200 mg/m2 conditioning; the remainder received 140 mg/m2. 28% of pts (n=58) had ≥ 1 B/Z Rx at all timepoints, while 38% (n=77) had no Rx at any timepoint. As shown in Figures 1 & 2: 33% of pts (n=67) had B/Z Rx at baseline, 57% (n=116) at discharge, and 51% (n=104) at D+100. Among B/Z-naive pts at baseline (n=138), the D+100 B/Z Rx rate was significantly higher among those with any B/Z Rx at discharge than those without (34% vs. 11%, p The most common B/Z Rx's were lorazepam (55% of pts, n=113) and zolpidem (12%, n=24). Of the 113 pts with lorazepam Rx, 35% (n=40) had a specific indication (2nd-line management of nausea/vomiting) without listing a distress-related symptom (e.g., anxiety). After excluding these 40 pts, overall rates of B/Z Rx fell to: 33% (54/165) at baseline, 47% (77/165) at discharge, and 48% (79/165) at D+100. Conclusions 62% of MM pts undergoing HCT received ≥ 1 B/Z Rx peri-HCT, a substantially higher rate than the 13% prevalence in the US population. ∼1/4 of pts experienced escalation of B/Z Rx therapy. Among B/Z-naive pts at baseline, pts prescribed B/Z Rx at discharge were 3x as likely to have continued B/Z Rx at D+100. These findings demonstrate the prevalence and persistence of B/Z Rx use despite their known toxicities. Limitations of our single-center study include an inability to assess how frequently prn Rx were actually taken or prescribed by local oncologists. Nevertheless, we are now investigating non-pharmacologic interventions to improve distress & insomnia in HCT recipients with the eventual goal of lowering B/Z Rx usage.

Adaptation of Coping Together - a self-directed coping skills intervention for patients and caregivers in an outpatient hematopoietic stem cell transplantation setting: a study protocol

BackgroundDespite numerous reports of significant distress and burden for hematopoietic stem cell transplantation (HSCT) patients and caregivers (CGs), HSCT-specific coping interventions remain rare. The few in use lack specificity and are often not easily accessible or cost-effective. Whereas the development of new interventions is resource-intensive, theory-informed adaptation of existing evidence-based interventions is promising. To date, no HSCT-specific intervention has relied on a formal adaptation approach.MethodsUsing the Center for Disease Control and Prevention’s Map of Adaptation, this two-phase qualitative descriptive study seeks to understand the perceptions of HSCT patients, CGs, individually, and in dyads, and clinicians about Coping Together (CT) for the preliminary adaptation (Phase 1), and then explores perceptions of the modified intervention in additional mixed sample (Phase 2). Six to ten participants including outpatients, CGs and dyads and five to seven HSCT clinician participants will be recruited for Phase 1. For Phase 2, 14 to 16 participants including outpatients, CGs and dyads will be recruited. Individual and dyadic semi-structured interviews will take place between 100 and 130 days post-HSCT. Verbatim transcripts will be analyzed using content analysis.DiscussionIt is paramount to have HSCT-specific supportive interventions that address patients’ and CGs’ multidimensional and complex needs. The timely involvement of key stakeholders throughout the adaptation process is likely to optimize the relevance and uptake of such tailored intervention.Trial registrationThis study is registered on October 6, 2016 in ClinicalTrials.gov at (identifier number NCT02928185).

A scoping review of caregiver burden during allogeneic HSCT: lessons learned and future directions.

The extant literature documents burden among caregivers of patients undergoing a hematopoietic stem cell transplantation (HSCT), but little is known about the burden of caregivers of patients receiving outpatient and homebound HSCTs. This scoping study sought to evaluate what is known about the burden of the increasing number of adult caregivers of patients receiving outpatient HSCTs and to create practice guidelines for how to best support this vulnerable group. Online databases were searched for studies that evaluated caregiver burden in adult caregivers of HSCT patients since 2010 (the publication date of the most recent systematic review on HSCT caregiver burden). Of the 1271 articles retrieved, 12 met the inclusion criteria, though none specifically examined outpatient or homebound caregivers. Overall, studies corroborated existing literature on the experience of significant burden among HSCT caregivers across the HSCT trajectory, and highlighted the emotional costs of outpatient transplants on caregivers and the need to identify caregivers at high risk for burden early in the transplant process. Future studies of outpatient caregivers should include a comprehensive assessment of burden and seek to identify points along the transplant trajectory at which caregivers are at particular risk for negative outcomes and when intervention is most appropriate.

Impact of outpatient non-myeloablative haematopoietic stem cell transplantation in quality of life vs. conventional therapy

The role of outpatient hematopoietic stem cell transplantation (HSCT) as a therapeutic tool has been strengthened significantly because of the increasing number of patients undergoing this treatment. Due the very nature of this procedure, one of the aspects that should not be overlooked is the quality of life (QOL) of patients undergoing HSCT. Thus, one must consider not only health status after treatment, but also, the psychosocial implications for the patient. This is an observational, longitudinal, and prospective study to assess QOL in patients undergoing outpatient HSCT vs. similar patients receiving medical treatment (MxTx). By applying the COOP/WONKA charts on five occasions (pre-HSCT/initial, post-HSCT/first month, and at 3, 6, and 9 months), thirty-eight patients were analysed, 19 with HSCT and 19 with MxTx with no differences in age, gender or diagnosis. The initial survey found significant differences only in pain perception, which was higher in the HSCT group (p = .08); at the first month, there was a greater tendency for feelings of depression or anxiety in the HSCT group (p = .016), with more limitations in social (p = .003) and daily (p = .044) activities. From 3 months post-HSCT, the results were very similar. The differences persisted only in the area of social activities. Four patients developed graft-versus-host disease with no significant difference in the scores obtained compared to other transplant patients at 3, 6, and 9 months (p = .26) of follow-up.

A Study of Dietary Intake and the Relationship to Neutrophil Engraftment Among Outpatient Hematopoietic Stem Cell Transplant Patients with Multiple Myeloma

A Study of Dietary Intake and the Relationship to Neutrophil Engraftment Among Outpatient Hematopoietic Stem Cell Transplant Patients with Multiple Myeloma

An outbreak of human parainfluenza virus 3 infection in an outpatient hematopoietic stem cell transplantation clinic

Parainfluenza viruses cause respiratory tract infections in adults and children, with peak activity during the spring and summer months. Human parainfluenza virus type 3 (hPIV-3) can contribute to significant morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). Automated surveillance software was used to identify an hPIV-3 outbreak in an HSCT clinic. Active surveillance for respiratory illness and infection control measures were instituted. A retrospective molecular investigation of outbreak viral strains was performed by direct sequencing. Twelve of 196 HSCT recipients attending the clinic during the outbreak period had hPIV-3; one of these patients died. Sequencing demonstrated highly related strains in 9 of 10 patients studied. Despite the ongoing presence of hPIV-3 outside the inpatient/outpatient care continuum clinic, only 2 cases were observed after institution of respiratory season infection control measures. This investigation demonstrates the utility of surveillance software in the identification of respiratory virus outbreaks and the importance of rapid implementation of infection control/prevention measures for containment of outbreaks.

Gram-negative bloodstream infections in hematopoietic stem cell transplant patients: The roles of needleless device use, bathing practices, and catheter care

Between August 1 and October 30, 1998 (outbreak period), an increased incidence of central venous catheter (CVC)-associated gram-negative bacterial bloodstream infection (GN-BSI) was detected in hematopoietic stem cell transplantation (HSCT) candidates and recipients in an outpatient HSCT unit. The objectives of the present study were to determine strategies for controlling the outbreak and identify risk factors for GN-BSI. Two case-control studies, an assessment of infection control practices, microbiologic studies, and water quality analysis were conducted. A case was defined as any outpatient with a CVC and a primary GN-BSI during the outbreak period. All of the 31 case patients identified had needleless intravenous (IV) access devices. Independent risk factors for CVC-associated GN-BSI were self-administered IV infusion (odds ratio [OR] = 6.2; P = .02), lower frequency of needleless device changes (OR = 15.2; P = .03), and more frequent baths (OR = 1.4; P = .05). Interventions included increased frequency of needleless device change, recommending showers rather than baths, and use of CVC protection during showering/bathing. After these interventions, the CVC-associated GN-BSI rate declined to below the preoutbreak period rate (2.1/1000 vs 0.3/1000 CVC-days; P < .01). This study demonstrated an increased risk of CVC-associated GN-BSIs related to self-IV infusion, bathing habits, and frequency of needleless device change. Infection control practices associated with the use of needleless devices may expose susceptible patients to increased risk for BSI.

Evidence-Based Guidelines for the Management of Neutropenia Following Outpatient Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) involves the transfer of stem cells to establish hematopoiesis in patients who have received myeloablative chemotherapy with or without whole body irradiation. Following high-dose therapy and HSCT, all patients experience a period of neutropenia. Outpatient care delivery models place expanded responsibilities on patients and their families for the management of this treatment side effect. Proactive management of neutropenia is critical to decrease the depth and duration of neutropenia following HSCT, limit exposure to opportunistic and nosocomial pathogens, and ensure prompt intervention should febrile neutropenia or infection develop. Patient and family education, psychosocial support, and coordination of care are key nursing responsibilities.

Reassessing the definition of myeloid engraftment after autotransplantation: it is not necessary to see 0.5 x 10(9)/l neutrophils on 3 consecutive days to define myeloid recovery.

The time to myeloid recovery after autologous hematopoietic stem cell transplantation (HSCT) is usually defined as the first of 3 consecutive days with an absolute neutrophil count (ANC) of >or=0.5 x 10(9)/l (ANC500). Universal documentation of ANC500 for 3 consecutive days, historically required to ensure robust myeloid recovery, has become difficult with a trend towards early discharge and outpatient HSCT. We studied 90 autografted patients to see how frequently ANC declined after having reached >or=0.5 x 10(9)/l. ANC500 was documented on 2 and 3 consecutive days in 14 and 63 patients, respectively. ANC increased by a median of 213% from the 1st to the 2nd day (rise in 75 and unchanged in two), and by a median of 142% from the 2nd day to the 3rd (rise in 60, unchanged in one, and decline in two; higher than the 1st day in the latter three). The increase from the 1st to the 3rd day was 13-3433% (median, 557%). Thus, in all 63 patients, no decline below ANC500 was seen, and the first day with ANC500 was also the first of 3 consecutive days with ANC500. The remaining 13 patients had repeat counts 2-7 days after the 1st day with ANC500 documenting further increase in ANC with no evidence of failed engraftment. These data show that the first day with ANC500 is also consistently the first of 3 consecutive days with ANC500 in autografted patients. Therefore, the traditional definition of myeloid engraftment should be changed to consider the first day with ANC500 as the day of engraftment without necessarily documenting ANC500 on the subsequent 1-2 days. This simple change in definition has significant implications for how data are reported to transplant registries and how peer-review organizations such as the Foundation for the Accreditation of Hematopoietic Cell Therapy (FAHCT) define completeness of data.