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Patient Case Studies and Panel Discussion: Leukemia – Rare and Emerging Subtypes

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Rare and emerging subtypes of leukemia can be incredibly challenging to diagnose and even more challenging to treat. At the NCCN 2019 Annual Congress: Hematologic Malignancies, a panel of experts, moderated by Andrew D. Zelenetz, MD, PhD, were presented with particularly challenging cases in these malignancies and asked to discuss best approaches to treatment.

• Patient Case Study 1

In the first case study, a 77-year-old woman presented with multiple nodular lesions and plaques on her face, chest, and back. She had a history of type 2 diabetes, stage 3 hypertension, hyperlipidemia, coronary heart disease, cerebral infarction, glaucoma, lens extracapsular extraction and posterior chamber intraocular lens implantation, Sjögren syndrome, rheumatoid arthritis, and left axillary vein and brachial vein thrombosis.

She had previously received a conventional therapy of Chinese medicine, but her condition did not improve. Her clinicians performed a bone marrow biopsy and an aspiration biopsy of a nodule on the right side of her face, and immunostaining results revealed the following immunophenotype: CD4+, CD123+, CD43+, CD56+, with Ki-67 level of 30% to 40%.

The patient was diagnosed with blastic plasmacytoid dendritic cell neoplasm, which is a rare blood cancer in the myeloid malignancies family. Andrew D. Zelenetz, MD, PhD, Memorial Sloan Kettering Cancer Center, noted that this disease used to be classified as a variant of acute lymphoblastic leukemia (ALL) and has a distinctive immunophenotype and clinical appearance, characterized by purple skin lesions.

He said a helpful tool for remembering the immunophenotype of this disease is to think “123456”: CD123, CD4, and CD56. Conversely, Nitin Jain, MD, The University of Texas MD Anderson Cancer Center, noted that although this rule of thumb can be helpful, it is important to keep in mind that approximately 10% of patients with this malignancy are actually CD56-negative.

Daniel A. Pollyea, MD, MS, University of Colorado Cancer Center, emphasized the unique phenotypic expression pattern in this malignancy, and the risk of cytopenias due to bone marrow involvement. “Certainly there are patients with bone marrow involvement who don't have cytopenias and have predominant expression of these skin manifestations,” he said. “But I think the CD123 is really the key, because this is a very, very difficult diagnosis to make, and that can be the linchpin.” He added that CD123 expression status is important to know not only for diagnostic purposes but also from a therapeutic perspective. However, many clinical pathologists do not possess the capabilities to test for CD123, so if a diagnosis of blastic plasmacytoid dendritic cell neoplasm is even being entertained, a discussion with a pathologist regarding testing for CD123 is critical.

The nodule on the right side of the patient’s face was surgically excised, and she was treated with gemcitabine, nedaplatin (a second-generation platinum drug used in China that is not approved by the FDA; it is similar to carboplatin and cisplatin), and bleomycin. The patient experienced an initial response to therapy but subsequently developed additional nodular lesions on her arm.

According to Dr. Pollyea, regardless of what transpired with this particular patient, surgical resection of skin lesions did not have a role in this case. “Typically, if the disease is going to respond, the skin lesions are very, very sensitive,” he said. “So there are issues with wound healing if you perform a large resection.”

The panel then discussed tagraxofusp-erzs, a recently approved drug for the treatment of this disorder that has been shown to be highly effective. 1 Dr. Pollyea noted that the mechanism of action of this drug is “quite brilliant.”

“You're taking one of nature's most potent toxins and delivering it directly to a cell population of critical importance in this disease, and potentially the precursor or primitive population of the disease,” he said.

A trial of tagraxofusp treatment in patients with blastic plasmacytoid dendritic cell neoplasms led to durable responses and high complete response rates, particularly in the first-line setting (72%). 1 In relapsed/refractory disease, it was less effective, but “still very effective,” according to Dr. Zelenetz, with a complete response rate of 38%. However, significant toxicity was seen, with capillary leak syndrome a fatal toxicity.

Jae Park, MD, Memorial Sloan Kettering Cancer Center, noted that because of the limited clinical experience with this agent, it is critical to administer the drug in an inpatient setting whenever possible and to closely monitor any patient-related physical changes, including weight fluctuations, kidney function, and respiratory status.

William G. Wierda, MD, PhD, The University of Texas MD Anderson Cancer Center, agreed, adding that he actually treated patients with this compound on a clinical trial before its approval. “During the trial, we were closely monitoring daily weight, albumin, and [liver function], and making daily adjustments in dosing based on what was happening with patients clinically,” he said. “So it's important to be very familiar with the prescribing information.”

Given this particular patient’s age, history, and comorbidities, stem cell transplantation was not an option. However, according to Dr. Park, allotransplant should be considered in these cases whenever possible, and earlier rather than later. “Even with a good response, it becomes difficult to continue this regimen,” he said. “And after [patients] relapse, there are very few treatment options available.”

• Patient Case Study 2

A 28-year-old woman presented with fatigue and lymphadenopathy. Her initial WBC count was 11.1 k/uL with 40% blasts, and she showed hypercellular bone marrow. Her immunophenotype included the following: 88.0% CD45+/–, CD34+, CD19+, CD10+ (variable), CD20– (∼4% of cells stain), sCD22+, CD13–, CD33–, CD38+, CD56–, CD2+/–, CD3–, CD4–, CD8–, CD7–, CD5–, CD117, HLA-DR+, sIg light chain–, cCD79a+, cCD22+, MPO–, cIgM+, and TdT+. After noting the complexity of the patient’s immunophenotype, Dr. Pollyea emphasized the importance of working with a skilled hematopathologist in cases such as this.

The patient was diagnosed with B-cell ALL and treated with the CALGB 10403 regimen. 2 At day 30, bone marrow biopsy showed residual disease with 16% blasts by flow. As her next course of treatment, the patient received blinatumomab for one cycle.

Dr. Jain agreed that this was a reasonable next step, but added that an additional cycle of chemotherapy would also have been feasible. Although the patient was high-risk, he would not yet say treatment had failed after only one treatment cycle.

“I think on the adult side we have to take our cues from the pediatricians who have been so incredibly successful with this disease,” said Dr. Pollyea. “And CALGB 10403 is a regimen that attempts to apply the pediatric regimens to an adolescent/young adult population.” 2

He added that pediatricians tend to stick to protocol, and the protocol for this particular regimen allows for a more extended induction period. “So at this point you should have a lot of concerns about this patient, but I think the protocol allows you to continue.”

About 4 weeks after starting blinatumomab, the patient experienced complete remission confirmed by bone marrow biopsy. She also received 6 cycles of intrathecal chemotherapy throughout the course of her treatment and showed no evidence of central nervous system involvement.

A month later, she presented with enlarged lymph nodes in her groin and neck, and bone marrow biopsy confirmed 63% blasts with an ALL phenotype. A same-day inguinal lymph node biopsy was consistent with lymphoblastic leukemia involvement.

Although the patient experienced a complete remission initially, Dr. Park noted that minimal residual disease (MRD) status was never confirmed. This factor is critical in assessing a patient’s depth of remission, and MRD-positive patients should receive additional therapy sooner rather than later to get to MRD-negative status, he said.

Dr. Jain said that additional diagnostic testing in the form of RNA sequencing would be appropriate in this case, but noted a caveat of the limited availability of this type of testing. The patient underwent next-generation sequencing (NGS), which revealed the following: DIAPH1-PDGFRB fusion; CDKN2A/B - p14 ARF loss exon 1 and CDKN2b loss; PIK3R1 splice site 1746-2A>6; and TP53 N288fs*60.

According to Dr. Park, interpreting NGS data can be difficult, and misinterpretation can lead to the wrong choice of treatment. This again underlines the importance of consulting with a skilled pathologist or other experienced ALL expert to assist in interpreting mutation profiles.

The patient was determined to have Ph-like ALL (a newly recognized entity of Ph-negative ALL with a poor prognosis) and was enrolled in the KTE-CA19 CAR-T (axicabtagene ciloleucel [axi-cel]) trial ( ClinicalTrials.gov identifier: NCT02614066). She received cytoreductive chemotherapy with hyperCVAD part A before apheresis for CAR-T generation, and experienced favorable cytoreduction (she received fludarabine/cyclophosphamide for lymphodepletion). She then received a post–CAR-T infusion and showed no response; her blast count increased from 0.42 to 80.35 within a week.

“This is just a tough case,” said Dr. Park, noting the unusually refractory nature of the disease. “Initial response rates to CAR-T cell therapy are approximately 80%, so she’s already in the very unlucky 20% of cases,” he said.

Dr. Jain described 2 subtypes of Ph-like ALL: approximately half are CRLF2 -rearranged, 3 and these patients should ideally be referred to a clinical trial. The other half are nonrearranged, 3 and these patients should be referred for RNA sequencing to determine fusion genes.

No response was seen to further treatment, and the patient chose to continue care in hospice.

According to Dr. Zelenetz, incorporation of comprehensive genetic analysis and fluorescence in situ hybridization testing is important to identify high-risk patients (such as those with Ph-like phenotype) and plan for allogeneic hematopoietic stem cell transplantation (alloHSCT) or referral to clinical trials as early as possible.

MRD assessment by flow and/or NGS is critical to assess depth of response, modification of therapy, and candidacy for early alloHSCT. Dr. Park noted that both gene sequencing tests are validated, so patient preference should take priority.

Incorporation of tyrosine kinase inhibitors (TKIs) in Ph-like ALL is being investigated in clinical trials, and patients with this disease should be referred earlier rather than later, added Dr. Zelenetz. “But the nuance to that is understanding how to integrate TKIs into this entity, which is going to be dependent on understanding the mechanisms involved in the disease,” he said. “It won’t be just one TKI [that everyone receives]; it's much more complicated than that, unfortunately.”

Dr. Jain added that although Ph-like ALL has been established as high risk in the setting of chemotherapy, its classification remains to be determined in the new era of targeted therapies. “Some emerging data suggest that blinatumomab, inotuzumab, and CAR-T-cell therapy may overcome the negative prognostication of Ph-like ALL,” he said. “So those are some data we’ll hopefully see at the ASH Annual Meeting.”

Jarrod Holmes, MD, Annadel Medical Group, also participated in the panel discussion.

Pemmaraju N , Lane AA , Sweet KL , et al. . Tagraxofusp in blastic plasmacytoid dendritic-cell neoplasm . N Engl J Med 2019 ; 380 : 1628 – 1637 .

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Stock W , Luger SW , Advani AS , et al. . A pediatric regimen for older adolescents and young adults with acute lymphoblastic leukemia: results of CALGB 10403 . Blood 2016 ; 133 : 1548 – 1559 .

Jain N , Roberts KG , Jabbour E , et al. . Ph-like acute lymphoblastic leukemia: a high-risk subtype in adults . Blood 2017 ; 129 : 572 – 581 .

Disclosures: Dr. Zelenetz has disclosed that he receives research support from Genentech/Roche, Gilead, MEI, and BeiGene; he has been a consultant for Celegene/JUNO, Genentech/Roche, Gilead, BeiGene, Pharmacyclics, Jansen, Amgen, Astra‐Zeneca, Novartis, and MEI Pharma; and he is on the Scientific Advisory Board of the Lymphoma Research Foundation and Adaptive Biotechnologies. Dr. Jain has disclosed that he is a consultant for AbbVie, Inc., AstraZeneca Pharmaceuticals LP, Genentech, Inc., Janssen Pharmaceutica Products, LP, Adaptive Biotechnologies, Precision Biosciences, Verastem, and Pharmacyclics; receives grant/research support from AbbVie, Inc., AstraZeneca Pharmaceuticals LP, Bristol-Myers Squibb Company, Genentech, Inc., Incyte Corporation, Adaptive Biotechnologies, ADC Therapeutics, Cellectis, Precision Biosciences, Servier, Verastem, Pfizer, Inc., and Pharmacyclics; is a scientific advisor for AbbVie, Inc., AstraZeneca Pharmaceuticals LP, Genentech, Inc., Janssen Pharmaceutica Products, LP, Adaptive Biotechnologies, Precision Biosciences, Verastem, and Pharmacyclics; and has received honoraria from AbbVie, Inc., AstraZeneca Pharmaceuticals LP, Genentech, Inc., Janssen Pharmaceutica Products, LP, Adaptive Biotechnologies, Precision Biosciences, Verastem, and Pharmacyclics. Dr. Park has disclosed that he receives grant/research support from Amgen Inc., Genentech, Inc., Incyte Corporation, Juno Therapeutics, Inc., Kite Pharma, Novartis Pharmaceuticals Corporation, and Servier; and is a scientific advisor for from Amgen Inc., AstraZeneca Pharmaceuticals LP, GlaxoSmithKline, Incyte Corporation, Kite Pharma, Novartis Pharmaceuticals Corporation, Allogene Therapeutics, Autolus Therapeutics plc, and Takeda Pharmaceuticals North America, Inc. Dr. Pollyea has disclosed that he is a scientific advisor for AbbVie, Inc., Agios, Inc., Celgene Corporation, Daiichi-Sankyo Co., Forty Seven, Inc., Janssen Pharmaceutica Products, LP, Pfizer Inc., and Takeda Pharmaceuticals North America, Inc. Dr. Wierda has disclosed that he is a consultant for Genzyme Corporation and receives grant/research support from AbbVie, Inc., Acerta Pharma, Genentech, Inc., Gilead Sciences, Inc., Janssen Pharmaceutica Products, LP, Juno Therapeutics, Inc., Karyopharm Therapeutics, Kite Pharma, Cyclacel Pharmaceuticals, Inc., GlaxoSmithKline/Novartis Pharmaceuticals Corporation, Loxo Oncology, Inc., miRagen Therapeutics, Inc., Oncternal Therapeutics, Inc., Xencor, Inc., Pharmacyclics, and Sunesis Pharmaceuticals, Inc. Dr. Holmes has disclosed that he has no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.

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Acute Lymphocytic Leukemia

• Acute lymphocytic leukemia (ALL), also known as acute lymphoblastic leukemia,  refers to an abnormal growth of lymphocyte precursors or lymphoblasts.

Table of Contents

• What is Acute Lymphocytic Leukemia? 

Pathophysiology

Statistics and incidences, clinical manifestations, complications, assessment and diagnostic findings, medical management, pharmacologic therapy, surgical management, nursing assessment, nursing diagnosis, nursing care planning & goals, nursing interventions, discharge and home care guidelines, documentation guidelines, practice test: acute lymphocytic leukemia, what is acute lymphocytic leukemia.

Acute leukemias have large numbers of immature leukocytes  and overproduction of cells in the blast stage of maturation.

• Acute leukemia is a malignant proliferation of white blood cell precursors in bone marrow or lymph tissue, and their accumulation in peripheral blood, bone marrow, and body tissues.
• About 20% of leukemias are acute.

Pathogenesis isn’t clearly understood, but the pathophysiology may be explained by the following:

• Accumulation . Due to the precipitating factors, immature, non-functioning WBCs appear to accumulate first in the tissue where they originate ( lymphocytes in lymph tissue, granulocytes in bone marrow).
• Infiltration . These immature WBCs then spill into the bloodstream and from there infiltrate other tissues.
• Malfunction . Eventually, this infiltration results in organ malfunction because of encroachment and hemorrhage .
• Schematic diagram and pathophysiology

One of the most common forms of acute leukemia is acute lymphocytic leukemia.

• Acute lymphocytic leukemia is more common in males than in females, in whites (especially in people of Jewish descent), in children ( between ages 2 and 5 ), and in people who live in urban and industrialized areas.
• 80% of all leukemias between 2 and 5 years old are ALL.
• Acute leukemias account for 20% of adult leukemias.
• Among children, however, it is the most common form of cancer .
• Incidence is 6 out of every 100, 000 people.

Research on predisposing factors isn’t conclusive but points to some combination of viruses, immunologic factors, genetic factors, and exposure to radiation and certain chemicals.

• Congenital disorders. Down syndrome , Bloom syndrome, Fanconi anemia , congenital agammaglobulinemia, and ataxia-telangiectasia usually predisposes to ALL.
• Familial tendency. Genetics also play a part in the development of ALL.
• Viruses. Viral remnants have been found in leukemic cells, so they are likely one of the causes of ALL.

Signs of acute lymphocytic leukemia may be gradual or abrupt.

• High fever . High fever accompanied by thrombocytopenia and abnormal bleeding (such as nosebleeds and gingival bleeding) manifests in the patient.
• Bruising. Easy bruising after minor trauma is a sign of leukemia.
• Dyspnea. A decrease in the mature blood components leads to dyspnea .
• Anemia. Anemia is present in ALL because of a decrease in mature RBCs.
• Fatigue . The patient experiences fatigue more frequently than normal.
• Tachycardia. As the oxygen-carrying component of the blood decreases, the body compensates by pumping out blood faster than normal.

Untreated, acute leukemia is invariably fatal, usually because of complications that result from leukemic cell infiltration of the bone marrow and vital organs.

• Infection.  Immature WBCs are not fit to defend the body against pathogens, so infection is always a possible complication to watch out for.
• Organ malfunction. Encroachment or hemorrhage occurs when immature WBCs spill into the bloodstream and other tissues and eventually lead to organ or tissue malfunction.

The diagnosis of ALL can be confirmed with a combination of the following:

• Bone marrow aspiration . Typical clinical findings and bone marrow aspirate showing a proliferation of immature WBCs confirm ALL.
• Bone marrow biopsy. A bone marrow biopsy, usually of the posterior superior iliac spine, is part of the diagnostic workup.
• Blood counts. Blood counts show severe anemia , thrombocytopenia, and neutropenia.
• Differential leukocyte count. Differential leukocyte count determines cell type.
• Lumbar puncture . Lumbar puncture detects meningeal involvement.
• Uric acid levels. Elevated uric acid levels and lactic dehydrogenase levels are commonly found.

With treatment, the prognosis varies.

• Systemic chemotherapy. Systemic chemotherapy aims to eradicate leukemic cells and induce remission (less than 5% of blast cells in the marrow and peripheral blood are normal).
• Radiation therapy. Radiation therapy is given for testicular infiltrations .
• Platelet transfusion is performed to prevent bleeding and RBC transfusion to prevent anemia.

ALL chemotherapy includes the following drugs and also other drugs included in the treatment:

• Vincristine.  Vincristine is an anti-cancer (antineoplastic or cytotoxic) chemotherapy drug and is classified as a plant alkaloid.
• Prednisone. This drug works is by altering the body’s normal immune system responses.
• Cytarabine.  Cytarabine belongs to the category of chemotherapy called antimetabolites, wherein When the cells incorporate these substances into the cellular metabolism, they are unable to divide and they attack cells at very specific phases in the cycle.
• L-asparaginase.  Asparaginase breaks down asparagine in the body, so since the cancer cells cannot make more asparagine, they die.
• Daunorubicin .  Daunorubicin is classified as an antitumor antibiotic which is made from natural products produced by species of the soil fungus Streptomyces, and these drugs act during multiple phases of the cell cycle and are considered cell-cycle specific.
• Antibiotic, antifungal , and antivirals . These control infection, a common complication of acute leukemias.

Aggressive treatment may include surgical management through:

• Bone marrow transplant. Bone marrow transplant is a choice that can be considered for a patient with ALL.
• Stem cell transplant. Stem cell transplant in ALL is one of the latest development in the treatment of acute leukemias

Nursing Management

The care plan for the leukemic patient should emphasize comfort, minimize the adverse effects of chemotherapy, promote preservation of veins, manage complications, and provide teaching and psychological support.

The clinical picture varies with the type pf leukemia as well as the treatment implemented, so the following must be assessed:

• Health history. The health history may reveal a range of subtle symptoms reported by the patient before the problem is detectable on physical examination.
• Physical examination. A thorough, systematic assessment incorporating all body systems is essential.
• Laboratory results. The nurse also must closely monitor the results of laboratory studies and culture results need to be reported immediately.

Based on the assessment data, major nursing diagnoses for the patient with ALL may include:

• Risk for infection related to overproduction of immature WBCs.
• Risk for impaired skin integrity related to toxic effects of chemotherapy, alteration in nutrition , and impaired immobility .
• Imbalanced nutrition, less than body requirements , related to hypermetabolic state, anorexia , mucositis, pain, and nausea .
• Acute pain and discomfort related to mucositis, leukocyte infiltration of systemic tissues, fever, and infection.
• Hyperthermia related to tumor lysis or infection.
• Fatigue and activity intolerance related to anemia, infection, and deconditioning.

Main Article:   5 Leukemia Nursing Care Plans

The major goals for the patient may include:

• Absence of pain.
• Attainment and maintenance of adequate nutrition.
• Activity tolerance.
• Ability to provide self-care and to cope with the diagnosis and prognosis.
• Positive body image .

The interventions included in the care plan of the patient follows.

Before treatment:

• Education. The nurse should explain the disease course, treatment, and adverse effects.
• Infection. The nurse should teach the patient and his family how to recognize symptoms of infection such as fever, chills, cough , and sore throat .
• Bleeding. The nurse should educate the patient and the family how to recognize abnormal bleeding through bruising and petechiae and how to stop it with direct pressure and ice application.
• Promote good nutrition. The nurse should explain that chemotherapy causes weight loss and anorexia, so the patient must be encouraged to eat and drink high-calorie and high-protein foods and beverages.
• Rehabilitation. The nurse should help establish and appropriate rehabilitation program for the patient during remission.

Plan meticulous, supportive care:

• Meningeal leukemia. Watch out for meningeal leukemia ( confusion , lethargy, headache) and know how to manage care after intrathecal chemotherapy.
• Hyperuricemia. Prevent hyperuricemia, a possible result of rapid, chemotherapy-induced leukemia cell lysis through encouraging fluids to 2000 ml daily, giving acetazolamide and sodium bicarbonate tablets, and allopurinol.
• Infection control. Control infection by placing the patient in a private room and instituting neutropenic precautions.
• Skincare. Provide thorough skin care by keeping the patient’s skin and perianal area clean, applying mild lotions and creams to keep skin from cracking and drying, and thoroughly cleaning skin before all invasive skin procedures.
• Constipation . Prevent constipation by providing adequate hydration, a high-residue diet, stool softeners, and mild laxatives, and by encouraging walking.
• Mouth ulcers. Control mouth ulceration by checking often for obvious ulcers and gum swelling , and by providing frequent mouth care and saline rinses.
• Psychological support. Provide psychological support by establishing a trusting relationship to promote communication.
• Manage stress. Minimize stress by providing a calm, quiet atmosphere that is conducive to rest and relaxation.

Expected patient outcomes may include:

• Shows no evidence of infection.
• Experiences no bleeding.
• Attains optimal level of nutrition.
• Reports satisfaction with pain and comfort levels.
• Has less fatigue and increased activity.
• Copes with anxiety and grief .
• Absence of complications.

Most patients cope better when they have an understanding of what is happening to them.

• Education. Based on the patient’s education, literacy level, and interest, teaching of the patient and family should focus on the disease, its treatment, and certainly the resulting significant risk of infection and bleeding.
• Vascular access device. Management of a vascular access device can be taught to most patients or family members , and the nurses may need to provide follow-up care for the patient.
• Home care services. Coordination of home care services and instruction can help alleviate anxiety about managing the patient’s care at home.

The focus of documentation should include:

• Recent or current antibiotic therapy.
• Signs and symptoms of infectious process.
• Individual risk factors that may potentiate blood loss.
• Baseline vital signs, mentation, urinary output, and subsequent assessments.
• Results of laboratory tests or diagnostic procedures.
• Client’s description of response to pain, specifics of pain inventory, expectations of pain management , and acceptable level of pain.
• Caloric intake.
• Individual cultural or religious restrictions and personal preferences.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcome.
• Modifications to plan of care.
• Discharge needs.
• Specific referrals made.

Here are some practice questions for this study guide . Please visit our nursing test bank page for more NCLEX practice questions .

1. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?

A. Instituting infection control precautions. B. Encouraging adequate intake of iron-rich foods. C. Assisting with coping with chronic illness. D. Administering medications via IM injections.

1. Answer: A. Instituting infection control precautions.

Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL, therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection.

• Option B: Iron-rich foods help with anemia , but dietary iron is not an initial intervention.
• Option C: The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion.
• Option D: Injections should be discouraged, owing to increased risk of bleeding due to thrombocytopenia.

2.  Which of the following complications are three main consequences of leukemia?

A. Bone deformities, spherocytosis, and infection. B. Anemia, infection, and bleeding tendencies. C. Lymphocytopoiesis, growth delays, and hirsutism. D. Polycythemia, decreased clotting time, and infection.

2. Answer: B. Anemia, infection, and bleeding tendencies.

The three main consequences of leukemia are anemia, caused by decreased erythrocyte production; infection secondary to neutropenia; and bleeding tendencies, from decreased platelet production.

• Option A: Bone deformities don’t occur with leukemia, Although bones may become painful because of the proliferation of cells in the bone marrow. Spherocytosis refers to erythrocytes taking on a spheroid shape and isn’t a feature in leukemia.
• Option C: Mature cells aren’t produced in adequate numbers, and hirsutism and growth delay can be a result of large doses of steroids but isn’t common in leukemia.
• Option D: Anemia, not polycythemia, occurs. Clotting times would be prolonged.

3.  A client with leukemia has neutropenia. Which of the following functions must be frequently assessed?

A. Blood pressure . B. Bowel sounds. C. Heart sounds. D. Breath sounds.

3. Answer: D. Breath sounds.

Pneumonia , both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required.

• Options A, B, C: Although assessing blood pressure , bowel sounds, and heart sounds are important; it won’t help detect  pneumonia .

4.  A child is seen in the pediatrician’s office for complaints of bone and joint pain. Which of the following other assessment findings may suggest leukemia?

A. Abdominal pain. B. Increased activity level. C. Increased appetite. D. Petechiae.

4. Answer: D. Petechiae.

The most frequent signs and symptoms of leukemia are a result of infiltration of the bone marrow. These include fever , pallor, fatigue , anorexia, and petechiae, along with bone and joint pain.

• Option A:  Abdominal pain may be caused by areas of inflammation from normal flora within the GI tract or any number of other causes.
• Option B: Activity level is decreased in patients with leukemia as they experience fatigue more frequently than normal.
• Option C: Increased appetite can occur but it usually isn’t a presenting symptom.

5.  What are the three most important prognostic factors in determining long-term survival for children with acute leukemia?

A. Histologic type of disease, initial platelet count, and type of treatment. B. Type of treatment and client’s sex. C. Histologic type of disease, initial WBC count, and client’s age at diagnosis. D. Progression of illness, WBC at the time of diagnosis, and client’s age at the time of diagnosis.

5. Answer: C. Histologic type of disease, initial WBC count, and client’s age at diagnosis.

The factor whose prognostic value is considered to be of greatest significance in determining the long-range outcome is the histologic type of leukemia.

• Option A: The platelet count is not essential in the prognosis of leukemia.
• Option B: The type of treatment and client’s sex do not necessarily affect the prognosis.
• Option D: The progression of illness does not determine the prognosis at all times.

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Clinical efficacy and safety of comprehensive nursing intervention in acute leukemia patients with myelosuppression after chemotherapy

Objective: To investigate the clinical efficacy and safety of comprehensive nursing intervention in acute leukemia patients with myelosuppression after chemotherapy. Methods: Eighty acute leukemia patients with myelosuppression after chemotherapy admitted to our hospital from April 2018 to December 2021 were selected and divided, according to the nursing mode, as the conventional group (n=40) with routine nursing mode and the comprehensive group (n=40) with the comprehensive nursing mode. Patients’ anxiety (Self-Rating Anxiety Scale, SAS) scores, depression (Self-Rating Depression Scale, SDS) scores, occurrence of complications, nursing satisfaction, nursing experience, complaint rate, and Visual Analogue Scale (VAS) score were compared between the two groups so as to analyze the efficacy and safety of comprehensive nursing intervention. The improvement of quality of life in the two groups was observed and analyzed using the short form of quality of life measurement (WHOQOL-BREF). Logistic regression analysis was performed to analyze the risk factors for nosocomial infection in patients with comprehensive nursing intervention. Results: No statistically significant differences in SAS and SDS scores between the two groups were found prior nursing (P>0.05), while after nursing, scores in the two groups both decreased, with those in the comprehensive group significantly lower than in the conventional group (P<0.05). The incidence of complications after nursing in the comprehensive group was significantly lower than that in the conventional group, and the difference was statistically significant (P<0.05). Nursing satisfaction of patients in the comprehensive group were significantly higher than that in the conventional group (P<0.05). After nursing, the nursing experience of the comprehensive group was significantly better than that of the conventional group (P<0.05); the complaint rate of the comprehensive group was significantly lower than that of the conventional group (P<0.05); before nursing, there was no significant difference in the VAS scores between the two groups of patients (P>0.05); after nursing, the VAS score of the comprehensive group was significantly lower than that of the conventional group (P<0.05). Before nursing, there was no significant difference in WHOQOL-BREF scores between the two groups (P>0.05); after nursing, the comprehensive group was higher than the conventional group. Among the 40 patients in the comprehensive nursing group, 15 patients developed infection. The number of neutrophils, age above 40, white blood cell count, hemoglobin content, high-intensity chemotherapy and glucocorticoid therapy were independent risk factors for nosocomial infection in patients with comprehensive nursing intervention (P<0.05). Conclusion: Comprehensive nursing intervention for patients with myelosuppression after chemotherapy for acute leukemia can effectively improve the patient’s nursing experience, reduce the patient’s complaint rate, alleviate the patient’s physical pain, relieve the patient’s anxiety, depression and other negative emotions, and reduce the patient’s complications, suggesting that comprehensive nursing intervention exerts better clinical efficacy and has high safety, which merits promotion clinically.

Introduction

Acute leukemia is a commonly seen clinical malignant tumors caused by the malignant increase of hematopoietic stem cells [ 1 ], the pathogenic mechanism of which is the proliferation of bone marrow blasts and immature cells that widely infiltrate into the liver, spleen, lymph nodes and other external organs and inhibits normal hematopoietic function [ 2 ]. Clinical manifestations of patients with acute leukemia are anemia, hemorrhage, infection and infiltration [ 3 ]. Chemotherapy is the major treatment regimen for acute leukemia, but bone marrow suppression afterwards is a common complication [ 4 ]. Myelosuppression refers to the declined viability of blood cell precursors in the bone marrow which decreases patients’ immune function and triggers infection and other adverse reactions. Frequently encountering myelosuppression during chemotherapy, patients with acute leukemia are susceptible to skin and digestive system infections that result in bleeding and threaten their recovery [ 5 ]. How to effectively control myelosuppression has become the focus as well as the difficulty to help the patients successfully pass through the myelosuppression phase and reduce the incidence of adverse reactions. Clinical studies have pointed out that active and reasonable nursing programs for acute leukemia patients with myelosuppression after chemotherapy can effectively avoid the occurrence of infection [ 6 ]. With the rapid development in the economy and medical quality, patients and their families have increasing demands for high-quality nursing, which is also a key factor to improve nursing satisfaction [ 7 ]. Comprehensive nursing intervention, in addition to conventional nursing, aims to reduce the possibility of complications on the basis of modifying the patients’ psychological state so as to fully motivate their initiative and activeness in treatment, and encourage them as well as their families to participate in the whole nursing process [ 8 ]. Acute leukemia patients may experience bone myelosuppression and agranulocytosis due to reduced organ function, abnormal immune function, decreased body resistance, weakened defense function, and coupled with the use of hormones, especially after high-dose chemotherapy, they are easily further invaded by pathogens, causing severe infection. Infection is the most common and serious complication after chemotherapy in patients with acute leukemia, and it is also one of the causes of death. Therefore, we analyzed the influencing factors of infection in patients with myelosuppression after chemotherapy for acute leukemia with a purpose to take early prevention during comprehensive nursing intervention and to reduce the incidence of infection after myelosuppression following chemotherapy. In this study, 80 acute leukemia patients with myelosuppression after chemotherapy admitted to our hospital from August 2020 to June 2021 were selected as the research subjects to explore the clinical outcome and safety of comprehensive nursing intervention and provide clinical reference.

Materials and methods

General information.

A total of 80 acute leukemia patients with myelosuppression after chemotherapy treated at our hospital from August 2020 to June 2021 were selected and divided, according to the nursing mode, as the conventional group (n=40) with conventional nursing intervention and the comprehensive group (n=40) with comprehensive nursing intervention. The conventional group consisted of 20 males and 20 females, aged 41-94 years old (average: 58.90±11.73 years old), with the course of illness of 3 h-45 d (average 24.62±3.67 days). The comprehensive group had 19 males and 21 females, aged 15-84 years old (average: 57.23±18.86 years old), with the course of illness 5 h-44 d (average 24.70±3.62 days). This study has been reviewed and approved by the Ethics Review Committee of the Lujiang County People’s Hospital, No. LJH70091. And all participants signed informed consent forms.

Inclusion and exclusion criteria

Inclusion criteria: (1) Patients with acute leukemia that were diagnosed according to the relevant criteria for leukemia in the Chinese Guidelines for the Diagnosis and Treatment of Adult Acute Lymphoblastic Leukemia (2016 Edition) [ 3 ] and the Chinese Guidelines for the Diagnosis and Treatment of Acute Myeloid Leukemia (2011 Edition) [ 4 ]; (2) Patients with no history of mental illness or cognitive dysfunction; (3) Patients with good compliance in cooperating with the study; (4) Patients with myelosuppression that occurred after chemotherapy in our hospital; (5) Patients with blast cells in bone marrow images ≥30% of bone marrow nucleated cells.

Exclusion criteria: (1) Patients with a history of drug allergy; (2) Patients with poor compliance that were unable to complete the study; (3) Patients with acute cardiovascular and cerebrovascular diseases; (4) Pregnant or lactating patients; (5) Patients with severe mental disorders or communication disorders; (6) Patients with cancer; or (7) Patients with poor nursing compliance.

Patients in the conventional group received conventional nursing intervention, in which the nursing staff popularized health education, advised precautions during treatment and implemented various routine nursing measures in accordance with the doctor’s instructions.

Patients in the comprehensive group received comprehensive nursing intervention as follows: hierarchical managements were implemented in the ward: head nurse - responsible team leader - responsible nurse - assistant nurse - assistant/training nurse - practice nurse - nursing worker. Nurses were in charge of different numbers of patients according to their abilities. The head nurse and responsible team leaders were responsible for patients with severe and difficult conditions; Nursing tasks included treatment, communication and health coaching etc. Nurses clearly defined the responsibility, and actively took care of patients, carefully handed over shifts, and made patients feel cared for throughout the period from admission to discharge. Nurses timely understood the thoughts and needs of patients, found problems and solved them in time, and enhanced their sense of mission and responsibility. Nursing management was more humanized, and the nurse’s initiative and the initial operation of the work process were harmonious. The performance appraisal of the management department was easily quantified and managed, thereby mobilizing the enthusiasm of nurses.

(1) Psychological nursing: nursing staff evaluated the patients’ psychological condition to grasp their psychological dynamics, listened patiently to their complaints and regularly invited those in remission to return to the hospital for face-to-face communication and guidance for the purpose of providing psychological support and enhancing their confidence in treatment. Nursing staff gave feedback to the patients in timely manner on treatment and examination to eliminate their anxiety and fear, built up their confidence and improved their initiative and compliance. (2) Fever nursing: nursing staff strictly implemented aseptic operations, disinfected the ward and maintained its air circulation, mobilized high-risk patients with serious infections to enter the laminar flow room for preventive isolation, and controlled the access of visitors and family members into the wards. Moreover, the nurses disinfected during chemotherapy in strict accordance with regulations, and closely monitored the patients’ vital signs afterwards. For those with higher body temperature, the nurses instructed them to stay in bed to reduce heat generation and provided ice packs for physical cooling, and if necessary, supplied antipyretic and analgesic drugs following the doctor’s instructions and guided them to reasonably replenish water to maintain electrolytes balance. (3) Gastrointestinal infection care: nursing staff adjusted the patients’ diets based on their eating habits, and closely monitored their water and electrolytes; The patients were instructed to use warm water to wash their perianal area and apply ointment after defecation, and in case of constipation, the patients were told to increase fiber intake, have abdominal massage, and if necessary, take drug intervention. (4) Oral care: patients were asked to rinse with 3% hydrogen peroxide every 3 h, and for bacterial infected patients, 0.02% Bitai Mouthwash were given; the patients were trained with phlegmy cough and breathing, deep breathing 3-8 times/day, 10-15 minutes each time, and for those who couldn’t voluntarily cough and sputum, assistance were given, and if necessary, care givers implemented nebulization inhalation to avoid pressure ulcers or other complications while follow the doctor’s advice. (5) Health education: the nurses explained the causes and treatment procedures of bone marrow suppression after chemotherapy using videos, brochures and image-texts to consequently promote the patients to actively coordinate with treatment and nursing measures. Both groups of patients received nursing for three months.

Infection prevention: patients with neutrophils <0.5×10 9 /L were admitted to a laminar flow room or single ward, and the visitors and time were strictly controlled. Ward windows were opened twice a day for ventilation, about 30 minutes each time. When necessary, the air in the ward was disinfected. The surfaces of the objects in the ward were wiped with chlorine-containing disinfectant. The patient’s vital signs were closely observed. For patient with chills, high fever and other uncomfortable symptoms, the nurses took precations accordingly such as keeping the patients warm, lower the body temperature by physical means, and gave antipyretic drugs as prescribed by the doctor. They observed the patient’s skin and mucous membranes for bleeding. The patient’s consciousness and limb activity were observed to determine whether there was cerebral hemorrhage, the color of the patient’s vomit and stool were observed to determine whether there was gastrointestinal bleeding, and the color of the urine were observed to determine whether there was urinary tract bleeding. The nails of patients were cut frequently to avoid scratching the skin, and the patients were asked to wear loose and soft clothes, and keep the skin clean. In addition, the patients were advised not to pick the nostrils but apply paraffin oil to keep the patient’s nasal mucosa moist, and not to use a hard-bristled toothbrush or eat hard or irritating foods. For patients with splenomegaly, the nurse pinched the skin to avoid stabbing the spleen when injecting subcutaneously in the abdomen. Also, extending the needle compression time after injection and bone puncture to avoid local bleeding. Once a patient developed myelosuppression, the nursing staff strengthened the care of the catheter, replace the film regularly, and disinfect the local skin. Abnormal conditions such as redness, swelling, heat, pain, etc. were dealt with in time, and bacterial culture was performed in parallel, and extubation may be performed if necessary.

Observation of indexes

(1) Anxiety and depression scores of the two groups were compared. The Self-Rating Anxiety Scale (SAS) was used to evaluate the degree of anxiety on a scale of 0-100 points with a cut-off score of 50 points, of which 50-59 points were mild anxiety, 60-69 points were moderate anxiety, and over 69 points were severe anxiety. The Self-Rating Depression Scale (SDS) was used to analyze the patients’ degree of depression on a scale of 0-100 points with a cut-off score of 53 points, of which 53-62 points were mild depression, 63-72 points were moderate depression, and over 73 points were severe depression.

(2) The occurrence of complications related to myelosuppression in the two groups were compared, including stomatitis, syncope, infection of upper respiratory tract, high fever, etc.

(3) Nursing satisfaction of the two groups were compared by patients filling out the Nursing Satisfaction Questionnaire made by our hospital, its reliability and validity is 0.863, and the test-retest consistency is 0.854, with 20 questions, 5 points for each. Total score <70 indicates unsatisfied, 70-89 indicates satisfied, and ≥90 indicates very satisfied. Satisfaction = (very satisfied + satisfied)/total number of cases ×100%.

(4) The nursing experience of the two groups of patients was compared. Good: the patient was in a happy mood during the treatment; modest: the patient was in a calmer mood during the treatment; poor: the patient was in a poor mood during the treatment; good experience rate = (good + modest)/total number of cases ×100%.

(5) The complaint rates of the two groups of patients were compared and recorded by the medical staff of our hospital.

(6) The VAS score of the two groups of patients was compared. A score of 0 points means that the patient has no pain; a score of less than 3 points indicates mild pain; a score of 4-6 points indicates moderate pain; a score of 7-10 points indicates severe pain; the higher the score, the more severe the pain.

(7) The improvement of quality of life in the two groups was compared. The quality of life was evaluated using World Health Organization Quality of Life Questionnaire abbreviated version (WHOQOL-BREF), which mainly includes four aspects: physiology, psychology, society and environment, with a total score of 100 points, and the score is proportional to the patient’s quality of life.

(8) The patients in the comprehensive nursing group developed infection during the period of chemotherapy and myelosuppression, and were single-site infection, were regarded as the infection group; their clinical data were recorded, and the factors affecting the nosocomial infection of the patients were analyzed, including the positive level of serum endotoxin, calcitonin serum hemoglobin content, chemotherapy intensity, neutrophil count in peripheral blood, white blood cell count, presence or absence of glucocorticoid therapy, serum hemoglobin content, etc. Limulus reagent chromogenic matrix method was used to detect serum endotoxin, and fluorescence quantitative was used to detect serum procalcitonin content.

Statistical methods

SPSS 20.0 software was used for data analysis, measurement data was expressed as ( x ̅ ±s), and independent samples t tests were used, while enumeration data was presented as number of cases (rate), and X 2 test was used. Logistic regression analysis was performed on the factors of nosocomial infection in patients with comprehensive nursing intervention. P<0.05 indicated statistical significance.

Comparison of the general data between the two groups

The general information of the two groups, such as gender, age, and disease course, was compared and no statistically significant difference was found (P>0.05) (See Table 1 ).

Comparison of general information between the two groups (n (%))

Comparison of Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS)

Prior to nursing, the SAS and SDS scores of the two groups were not statistically significant (P>0.05) while after nursing, both scores in the two groups decreased, with those in the comprehensive group were lower than in the conventional group (P<0.05) (See Table 2 ).

Comparison of anxiety (SAS) and depression (SDS) scores between the two groups (x ± s)

Comparison of incidence of complications between the two groups

The incidence of complications after nursing in the comprehensive group was significantly lower than that in the conventional group, and the difference was statistically significant (P<0.05) (See Table 3 ).

Comparison of incidence of complications between the two groups (n (%))

Comparison of nursing satisfaction between the two groups

Nursing satisfaction in the comprehensive group was significantly higher than that in the conventional group, and the difference was statistically significant (P<0.05) (See Table 4 ).

Comparison of nursing satisfaction between the two groups (n (%))

Comparison of nursing experience of two groups of patients

After nursing, the nursing experience of the patients in the comprehensive group was significantly better than that of the patients in the conventional group (P<0.05), as shown in Table 5 .

Comparison of nursing experience of two groups of patients (n (%))

Comparison of complaint rates between the two groups of patients

The complaint rate of the patients in the comprehensive group was significantly lower than that of the patients in the conventional group (P<0.05, Table 6 ).

Comparison of complaint rates between the two groups of patients (n (%))

Comparison of VAS scores between the two groups of patients

Before nursing, there was no significant difference in the VAS scores between the two groups of patients (P>0.05); after nursing, the VAS scores of the comprehensive group were significantly lower than those of the conventional group (P<0.05), as shown in Figure 1 .

Comparison of VAS scores between the two groups of patients (n (%)). Note: *means P<0.05.

Comparison of WHOQOL-BREF score

Before nursing, there was no significant difference in WHOQOL-BREF scores between the two groups (P>0.05); after nursing, the score in the comprehensive group was higher than that in the conventional group (P<0.05, Table 7 ).

Comparison of quality of life before and after nursing in the two groups (x ± s)

Univariate analysis of risk factors for nosocomial infection in patients after comprehensive nursing intervention

There were 40 patients in the comprehensive nursing group, of them 15 patients developed infection and were enrolled in the infection group, and the remaining 25 patients without infection were the non-infection group. There were statistical differences between the infection group and the non-infection group in terms of age, glucocorticoid treatment or not, hemoglobin content, white blood cell content, chemotherapy intensity, procalcitonin content, neutrophil count and endotoxin positive level (P<0.05), see Table 8 .

Multivariate analysis of independent risk factors for nosocomial infection in patients after comprehensive nursing intervention

Logistic regression analysis showed that the number of neutrophils, age above 40, white blood cell count, hemoglobin content, high-intensity chemotherapy and glucocorticoid therapy were independent risk factors for nosocomial infection in patients with comprehensive nursing intervention (P<0.05), see Table 9 .

Multivariate analysis of risk factors for nosocomial infection in patients after comprehensive nursing intervention

Chemotherapeutic drugs are a class of cytotoxic drugs, which can be administered intravenously or orally to achieve the purpose of systemic anti-tumor therapy. Cytotoxic drugs have a certain impact on the bone marrow hematopoiesis, resulting in decreased bone marrow hematopoiesis, and eventually leading to myelosuppression. The clinical manifestations of bone marrow suppression are generally manifested as a decrease in red blood cells and neutrophils. Severe patients may develop grade IV reduction, or granulocytopenia and agranulocytosis-like manifestations. Some patients may have a decrease in red blood cells, resulting in anemia with clinical symptoms such as dizziness, fatigue and other anemia-related symptoms, which can be further judged according to the specific degree of anemia. In addition, patients may even experience thrombocytopenia (degree I-IV), which is relatively serious and may cause bleeding. Therefore, after chemotherapy, myelosuppression needs to be taken into consideration and dealt with as soon as possible to avoid serious adverse events.

With no clinical cure for acute leukemia yet, chemotherapy becomes the main regiment to effectively delay disease progression and significantly prolong survival [ 9 ]. However, chemotherapy can cause bone marrow suppression, which can severely hinder patients’ recovery [ 10 ]. Patients with acute leukemia in the myelosuppressive phase will experience a significant hematopoietic function decrease of bone marrow which needs 2 to 3 weeks for reconstruction [ 11 ]. Myelosuppression also reduces the activity of blood cell precursors in the bone marrow and induces decreased immune function that further leads to adverse reactions such as infection [ 12 ]. Comprehensive nursing intervention, on the basis of routine nursing, is meant to improve the patient’s psychological state and diminish the occurrence of complications [ 13 ] by fully motivating the patients’ subjective initiative and treatment enthusiasm, as well as encourage them and their families to participate in the nursing process. Relevant studies have indicated that active and reasonable nursing programs for acute leukemia patients with myelosuppression after chemotherapy can effectively avoid the occurrence of infection, showcasing the necessity to conduct nursing intervention [ 14 ]. Comprehensive nursing intervention is to implement planned, anticipatory and helpful care measures to improve nursing efficiency and nursing satisfaction [ 15 ], including intensive care on the patients’ oral, respiratory and gastrointestinal complications, psychological care of listening to patients’ complaints and answering their concerns in a timely manner to relieve their psychological pressure, and give health education to improve their knowledge and awareness and ensure smooth treatment [ 16 , 17 ]. In this study, we compared the anxiety (SAS) and depression (SDS) scores of the two groups of patients, and the results suggested that both scores decreased after nursing, with scores in the comprehensive group being lower than those in the conventional group, indicating that comprehensive nursing intervention can significantly reduce the anxiety and depression level of acute leukemia patients with myelosuppression after chemotherapy and alleviate their psychological pressure and enhance their confidence [ 18 ]. We know that patients with myelosuppression after chemotherapy for acute leukemia are prone to immune dysfunction, increasing the risk of infection due to decreased activity of blood cell precursors in the bone marrow [ 19 ]. Therefore, we compared in the study the complications and the VAS score of the two groups, and the results showed that the incidence of complications in the comprehensive group was significantly lower than that in the conventional group, confirming that comprehensive nursing intervention effectively reduced the occurrence of complications in those patients, relieved their pain and indirectly improved their initiative and confidence for treatment [ 20 ]. At last, we compared the nursing experience, complaint rate and nursing satisfaction between the two groups and found a significantly better score in the comprehensive group than in the conventional group in terms of these aspects, promoting recognition among patients and their families, which in turn demonstrated that comprehensive nursing intervention was clinically practical [ 21 ]. Although chemotherapy can inhibit the proliferation of cancer cells, it also damages healthy cells to a certain extent, so patients often experience bone marrow suppression after chemotherapy. The bone marrow suppression stage is a key stage in the treatment of leukemia. In this stage, the activity of blood cell precursors in patients is severely reduced, which affects the division of blood cells, resulting in low immunity of patients. Bacteria and viruses easily invade the body and cause bleeding and infection. It is very important to provide reasonable and effective nursing intervention [ 13 ]. Hou et al. [ 15 ] showed that comprehensive nursing can effectively reduce the risk of adverse reactions in patients with leukemia after chemotherapy in the period of myelosuppression, which is similar with our results. The above data show that comprehensive nursing intervention has a good effect on reducing the occurrence of adverse reactions such as bleeding and infection in patients with leukemia in myelosuppression stage. However, there are still some limitations of this study, such as no long-term follow-up, long-term quality of life or survival time observation.

Neutrophil count, age above 40 years, white blood cell count, hemoglobin content, high-intensity chemotherapy and glucocorticoid therapy were independent risk factors for nosocomial infection, and the levels of serum procalcitonin and endotoxin were high in infected patients compared to those in uninfected patients. Endotoxin is the main component of the inner and outer membranes of gram-negative bacteria, which is also the main factor that affects the pathogenesis of gram-negative bacteria. Procalcitonin is a polypeptide hormone that is low normally in the human body but increases significantly in the condition of serious bacterial infection, which has important diagnostic value for early bacterial infection.

In view of some infection factors of patients, patients are advised to maintain good hygiene and living habits during chemotherapy to avoid cross-infection and overexertion. In terms of diet, the patients guided to eat digestible foods with sufficient energy, but to avoid high grease, spicy and raw foods. If the patient’s body temperature is >38.5°C, secretion and sputum culture should be carried out in time, and blood samples should be collected to find the etiological basis and provide some guidance for the patient to adjust antibiotics. In addition, imaging, endotoxin, β-glucan and procalcitonin and other tests should be performed to distinguish from fungal or bacterial infections [ 16 ]. Carbapenems and other powerful anti-infections can be given to patients with concomitant infection after chemotherapy. Additionally, the changes of skin mucous soft tissues, digestive tract, respiratory tract, and body temperature of the patients should be closely observed, and antifungal therapy should be given if necessary. For symptoms of anemia or severe anemia, bleeding tendency, abnormal coagulation and low platelets, fresh frozen plasma, platelets and red blood cells should be transfused.

In conclusion, comprehensive nursing intervention for patients with myelosuppression after chemotherapy for acute leukemia can effectively improve the patient’s nursing experience, reduce the patient’s complaint rate, alleviate the patient’s physical pain, relieve the patient’s anxiety, depression and other negative emotions, and reduce the patient’s complications, suggesting that comprehensive nursing intervention presented better clinical efficacy and high safety, and merits promotion clinically.

Disclosure of conflict of interest

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Acute Lymphocytic Leukemia Case Study

Leukemia is a cancer of white blood cells. In acute leukemia, the abnormal cells divide rapidly, quickly overtaking functional white and red blood cells. The most common form of cancer in children 0-14 years of age is acute lymphocytic leukemia (ALL). The survival rate in children has improved more than 50% in the last half century. Currently, there is a 65.3% overall survival rate; in children under 5 the survival rate increases to 90.4%. Come experience the cancer journey with 6-year-old Noah.

Module 6: Acute Lymphocytic Leukemia

Noah, 6 years old, was brought back to his pediatrician three weeks following a streptococcal throat infection...

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Upon receiving the results, the physician informed the stunned mother that her child had...

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A spinal tap was ordered to see if the leukemic cells had crossed the blood/brain barrier...

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A sputum culture was obtained and sent to the lab for gram stain, culture, and sensitivities...

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Noah was now in remission. Two weeks after achieving...

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Case Study: New Therapies for Acute Myeloid Leukemia

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A 76-year-old woman presents to the emergency department following two weeks of progressive dyspnea and fatigue, and a new rash. Her medical history is significant for stage 2 chronic kidney disease, coronary artery disease, and diabetes.

Physical examination results are within normal limits, except for skin pallor and a petechial rash on the lower extremities bilaterally. She has an Eastern Cooperative Oncology Group (ECOG) performance status score of 1. Complete blood count with differential is significant for a white blood cell count of 18 × 10 9 /L with 40 percent circulating blasts, hemoglobin 6.7 g/dL, and platelet count of 20 × 10 9 /L. A bone marrow biopsy reveals a hypercellular marrow with 22 percent blasts, consistent with a diagnosis of acute myeloid leukemia (AML). Flow cytometry demonstrates CD33 negativity, and classic cytogenetic analysis revealed a normal karyotype. Molecular markers are pending for FLT3, IDH1, IDH2, and NPM1.

A pre-treatment echocardiogram is performed and is notable for mild global systolic dysfunction and a left-ventricular ejection fraction of 45 percent.

Which of the following is the most appropriate therapy?

• Gilternitinib
• Azacitidine and venetoclax
• Liposomal daunorubicin and cytarabine
• Gemtuzumab ozogamicin

Explanation

The best treatment option for this patient is azacitidine and venetoclax. Recently, the U.S. Food and Drug Administration (FDA) approved the BCL-2 inhibitor venetoclax in combination with a hypomethylating agent for patients with newly diagnosed AML who are 75 years or older, or those with comorbidities that preclude the use of intensive induction chemotherapy. 1 Approval was based on preliminary data published in February 2018 from a phase Ib study of 57 patients to evaluate the safety and efficacy of either azacitidine or decitabine in combination with venetoclax. 2

Eligibility criteria included previously untreated patients aged 65 years and older with AML who were ineligible for standard induction therapy, ECOG performance status of 0 to 2, and intermediate-risk or poor-risk cytogenetics. During dose escalation, oral venetoclax was administered daily in combination with either decitabine (days 1-5) or azacitidine (days 1-7). Results from this study population showed a complete remission (CR) or CR with incomplete marrow recovery (CRi) in 61 percent of patients. 2 A follow-up of the same clinical trial was recently published in January 2019 evaluating 145 patients. 3 This study demonstrated a CR + CRi rate at all doses of 67 percent, with notable responses in those with poor-risk cytogenetics and those who were at least 75 years old. The median duration of CR + CRi was 11.3 months, with a median overall survival of 17.5 months. 3

While this patient has newly diagnosed AML, her age and comorbidities, including CKD, borderline heart function, and diabetes, likely preclude her from being able to tolerate a standard induction chemotherapy regimen. 4 Gilteritinib (answer A) is an oral kinase inhibitor that was recently approved for treatment of relapsed or refractory AML, with a FLT3 mutation based on interim analysis of 138 patients in the ADMIRAL trial, showing CR or CRh in 21 percent of patients. 5 Answer D is incorrect because the liposomal form of daunorubicin and cytarabine is approved for indications of newly diagnosed therapy-related AML (t-AML) or AML with myelodysplasia-related changes, 6 which is not the case with this patient. Additionally, the left ventricular dysfunction is a relative contraindication to the danunorubicin. Ivosidenib is an IDH-1 inhibitor approved for patients with relapsed or refractory AML with a mutation in the IDH-1 gene. 7 While gemtuzumab ozogamicin (GO), an anti-CD33 monoclonal antibody, is well tolerated in older patients with newly diagnosed or relapsed AML, its approval is for treatment of CD33+ disease. 8 It would be an inappropriate choice for this patient because her flow cytometry demonstrated CD33 negativity. It is also not used as a single agent for initial induction therapy.

In summary, for older patients with newly diagnosed AML, a hypomethylating agent in combination with venetoclax should be considered when comorbidities preclude the use of standard induction chemotherapy.

Case study submitted by Nicole Held, DO, and Talha Badar, MD, of Medical College of Wisconsin, Milwaukee, WI.

Resources  

• U.S. Food and Drug Administration FDA approves venetoclax in combination for AML in adults. . 2018.
• DiNardo CD, Pratz KW, Letai A, et al Safety and preliminary efficacy of venetoclax with decitabine or azacitidine in elderly patients with previously untreated acute myeloid luekaemia: a non-randomised, open-label, phase 1b study . Lancet Oncol. 2018 19:216-228.
• DiNardo CD, Pratz K, Pullarkat V, et al Venetoclax combined with decitabine or azacitidine in treatment-naïve, elderly patients with acute myeloid leukemia . Blood. 2019 133:7-17.
• Kantarjian H, O’brien S, Cortes J, et al Results of intensive chemotherapy in 998 patients age 65 years or older with acute myeloid leukemia or high-risk myelodysplastic syndrome: predictive prognostic models for outcome . Cancer. 2006 106:1090-1098.
• U.S. Food and Drug Administration FDA approves gilteritinib for relapsed or refractory acute myeloid leukemia (AML) with a FLT3 mutation . 2018.
• Vyxeos (daunorubicin and cytarabine) package insert . Jazz Pharmaceuticals. 2017.
• U.S. Food and Drug Administration FDA approves first targeted treatment for patients with relapsed or refractory acute myeloid leukemia who have a certain genetic mutation . 2018.
• Sievers EL, Larson RA, Stadtmauer EA, et al Efficacy and safety of gemtuzumab ozogamicin in patients with CD33-positive acute myeloid leukemia in first relapse . J Clin Oncol. 2001 19:3244-3254.

American Society of Hematology. (1). Case Study: New Therapies for Acute Myeloid Leukemia. Retrieved from https://www.hematology.org/education/trainees/fellows/case-studies/new-therapies-for-acute-myeloid-leukemia .

American Society of Hematology. "Case Study: New Therapies for Acute Myeloid Leukemia." Hematology.org. https://www.hematology.org/education/trainees/fellows/case-studies/new-therapies-for-acute-myeloid-leukemia (label-accessed April 07, 2024).

"American Society of Hematology." Case Study: New Therapies for Acute Myeloid Leukemia, 07 Apr. 2024 , https://www.hematology.org/education/trainees/fellows/case-studies/new-therapies-for-acute-myeloid-leukemia .

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Mr. Devito is a 48-year-old  male who presents to his Primary Care Provider with left upper abdominal pain and complaints of weakness and fatigue. The nurse immediately notes how pale his skin is.  A full set of vital signs reveals the following:

BP 142/90 mmHg

SpO 2 94% on Room Air

Temp 101.0°F

What furtner nursing assessments would you perform at this time?

• Heart and lung sounds
• Assess abdomen and review details of abdominal pain (OLDCARTS)
• Assess skin condition (color, quality, turgor, etc.)
• Peripheral perfusion (pulses, cap refill, etc.)

Upon further assessment, the nurse notes a palpable mass in the left upper quadrant, possibly an enlarged spleen, that is tender on palpation. The nurse also notes petechiae and bruising to the patient’s arms and legs. When questioned, the patient says “I seem to bruise so easily these days”.  The patient’s lungs have diffuse crackles, heart sounds S1 and S2 present with no murmurs. The patient also reports a slight headache.

What laboratory or diagnostic tests do you anticipate the provider ordering?

• Complete Blood Count (to check for wbc – infection and reason for bruising)
• Full chemistry to ensure no electrolyte abnormalities or renal involvement
• Coagulation studies to determine cause of easy bruising
• Chest X-ray and sputum culture to identify source of infection

The provider orders a complete blood count, chemistry panel, and chest x-ray. The chest x-ray shows the patient has a slight pneumonia. He is sent home with a course of antibiotics while awaiting the test results.

The next day, the lab results show the following:

RBC 4.2 BUN 22

Hgb 8.4 Cr 0.9

Hct 25.2 K 3.9

WBC 144,000 Na 148

Plt 40,000 Ca 7.6

Based on the above lab results, what should the nurse be most concerned about?

• The patient has EXCESSIVE amounts of white blood cells. It would be expected for them to be slightly elevated because of the infection, but this is WAY beyond that.
• The patient is also anemic, with low platelets – this could explain the easy bruising

What do you believe may be going on, physiologically, with Mr. Devito?

• The excessive amounts of White Blood Cells, plus the easy bruising, anemia, and enlarged spleen point to some type of Leukemia.
• The body is excessively making immature, non-functioning white blood cells – hence the patient being susceptible to a pneumonia.

What further diagnostic testing should be performed to confirm a diagnosis?

• A bone marrow biopsy must be done to confirm a leukemia diagnosis
• The provider calls Mr. Devito and explains the results. They set an appointment for Mr. Devito to have a bone marrow biopsy. Biopsy results confirm Mr. Devito has Acute Myeloid Leukemia.  Mr. Devito’s wife says “I don’t understand, I thought you said he just had pneumonia?”

How would you explain this to the patient’s wife?

• Leukemia causes the body to make a bunch of immature, non-functioning white blood cells. So when a patient gets an infection, like a respiratory infection, the body’s white blood cells can’t actually fight it off. So it’s common for patients to be prone to infections like pneumonia.
• Mr. Devito DID have pneumonia – but it was due to the poor immune response caused by the Leukemia.

Mr. Devito will be started on high-dose chemotherapy.

What education topics should be included in teaching for Mr. Devito and his wife?

• Mr. Devito will have a special port implanted in order to receive his chemotherapy
• Mr. Devito will likely also receive medications to manage the symptoms of the chemotherapy
• Mr. Devito may lose his hair, depending on the type of chemotherapy used, because chemo also kills healthy fast-growing cells
• Mr. Devito May experience something called neutropenia. This means he will be highly susceptible to infections. He should avoid having lots of visitors, avoid fresh flowers, and especially avoid being around anybody who is sick. He can even wear a mask in public if he so desires.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

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