scholarly journals Collaborative Physician-Pharmacist Managed Multiple Myeloma Clinic Decreases Polypharmacy, Improves Guideline Adherence, and Prevents Treatment Delays

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3542-3542
Author(s):  
Karen Sweiss ◽  
Gregory Sampang Calip ◽  
Scott Wirth ◽  
Damiano Rondelli ◽  
Pritesh Patel
Keyword(s):  
Multiple Myeloma ◽  
Supportive Care ◽  
Patient Care ◽  
Complex Disease ◽  
Medication Management ◽  
Median Number ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Collaborative Model ◽  
Vte Prophylaxis ◽  
Care Guidelines

Abstract Multiple myeloma is a complex disease requiring adherence to treatment and supportive care guidelines, patient education, medication management, and timely delivery of anti-myeloma drugs to achieve optimal patient care. Clinical pharmacists play an important role in the management of cancer patients and could potentially assist in several aspects of care. We hypothesized that a multidisciplinary collaborative physician-pharmacist multiple myeloma (MM) clinic would reduce polypharmacy, improve adherence to MM guidelines as well as reduce delays in receiving oral anti-myeloma therapy. Under the collaborative model, an oncology pharmacist provided consultation on all patients in a specialist myeloma clinic. This included reviewing medications, providing medications lists. ensuring physician adherence to supportive care guidelines, managing treatment-related side effects and navigating issues involving access to oral specialty medications. Outcome measures were compared to those of patients being treated by the same physician during the previous year, where ad-hoc pharmacist consultation was available (traditional clinic). The collaborative clinic led to significant improvements in adherence to supportive medications such as bisphosphonates (96% vs. 68%, p=0.0002), calcium and vitamin D (100% vs. 41%, p<0.001), acyclovir (100% vs. 58%, p=0.0009), and Pneumocystis jirovecii pneumonia (PJP) prophylaxis (100% vs. 50%, p<0.0001). Appropriate VTE prophylaxis in immunomodulatory agent (IMiD)-treated patients was prescribed in 100% vs. 83% of patients (p=0.0035). The median time to initiation of bisphosphonate (5.5 vs. 97.5 days, p<0.001) and PJP prophylaxis (11 vs. 40.5 days, p<0.0001) after autologous transplant was shortened in the collaborative clinic. Furthermore, the number (85% vs. 21%, p<0.0001) and duration (7 days vs. 15 days, p=0.002) of delays in obtaining IMiD therapy, was also significantly reduced. We also observed improved medication management in patients treated in the collaborative clinic. These patients took fewer medications on average (9 vs. 7, p=0.045). Although the median number of myeloma-related medications (medications related to treatment or supportive care for MM) was higher (2 vs. 4, p<0.0001), the number of non-myeloma-related medications was lower (7 vs. 3, p<0.0001) in patients seen in the collaborative clinic. We then compared minor (5 to 9 medications) and major (≥10 medications) polypharmacy overall and specific to non-myeloma-related medications between the two clinics. Any type of polypharmacy (≥5 medications) was highly prevalent among patients in both the traditional and collaborative clinics (93% and 84% respectively, p=0.22). Despite this, the collaborative clinic was successful in reducing any type of polypharmacy (71 vs. 33%, p=0.0003), including both minor (48 vs. 28%, p=0.06) and major (23 vs. 5%, p=0.02) polypharmacy of non-myeloma-related medications. We used modified Poisson regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) with adjustment for age, gender, race, ISS stage, protein subtype, new diagnosis, prior or current IMiD, PI or ASCT, and total number of prior treatments. We found significantly reduced risk of having a higher number of medications among patients in the collaborative clinic (RR 0.79, 95% CI 0.67-0.93; p=0.004). Risk of major polypharmacy in all medications was not significantly different between the two clinics (RR 0.67, 95% CI 0.35-1.28; p=0.226); although, there was a significantly lower risk of having any polypharmacy of non-myeloma-related medications (RR 0.41, 95% CI 0.25-0.67; p<0.001) in the collaborative clinic. Here we show that incorporating another sub-specialized individual such as a clinical pharmacist into the care of multiple myeloma patients resulted in increased adherence to core supportive care measures and a reduction in delays in acquiring oral IMiDs. Importantly, although we illustrate a high incidence of polypharmacy among patients in both clinics, consultation by a pharmacist led to a significant reduction in the number of non-myeloma-related medications. The collaborative model may be of benefit in the management of other complex malignant diseases and further studies in other cancer clinics are warranted. Impact on long term clinical outcomes will also highlight the potential benefits of this collaborative model of patient care. Disclosures Patel: Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Honoraria.

scholarly journals Collaborative Physician-Pharmacist–Managed Multiple Myeloma Clinic Improves Guideline Adherence and Prevents Treatment Delays

2018 ◽  
Vol 14 (11) ◽  
pp. e674-e682 ◽  
Author(s):  
Karen Sweiss ◽  
Scott M. Wirth ◽  
Lisa Sharp ◽  
Irene Park ◽  
Helen Sweiss ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Supportive Care ◽  
Ad Hoc ◽  
Autologous Transplantation ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Thromboembolism Prophylaxis ◽  
Time To Initiation ◽  
Care Guidelines ◽  
Immunomodulatory Drug ◽  
Physician Adherence

Purpose: We hypothesized that a multidisciplinary collaborative physician-pharmacist multiple myeloma clinic would improve adherence to treatment and supportive care guidelines as well as reduce delays in receiving oral antimyeloma therapy. Methods: From March 2014 to February 2015, an oncology pharmacist provided consultation for all patients in a specialist myeloma clinic. This included reviewing medications, ensuring physician adherence to supportive care guidelines, managing treatment-related adverse effects, and navigating issues involving access to oral specialty medications (collaborative clinic). Results: Outcome measures were retrospectively compared with those of patients being treated by the same physician during the previous year, in which ad hoc pharmacist consultation was available upon request (traditional clinic). The collaborative clinic led to significant improvements in adherence to supportive medications, such as bisphosphonates (96% v 68%; P < .001), calcium and vitamin D (100% v 41%; P < .001), acyclovir (100% v 58%; P < .001), and Pneumocystis jirovecii pneumonia prophylaxis (100% v 50%; P < .001). Appropriate venous thromboembolism prophylaxis in immunomodulatory drug–treated patients was prescribed in 100% versus 83% of cases ( P = .0035). The median time to initiation of bisphosphonate (5.5 v 97.5 days; P < .001) and P jirovecii pneumonia prophylaxis after autologous transplantation was shortened in the collaborative clinic (11 v 40.5 days; P < .001). Furthermore, the number (85% v 21%; P < .001) and duration (7 v 15 days; P = .002) of delays in obtaining immunomodulatory drug therapy were also significantly reduced. Conclusion: Our collaborative clinic model could potentially be applied to other practice sites to improve the management of patients with multiple myeloma. Prospective studies analyzing clinical outcomes, patient satisfaction, and cost effectiveness of this approach are warranted.

Clarithromycin, pomalidomide, and dexamethasone (ClaPD) in relapsed or refractory multiple myeloma.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 8036-8036
Author(s):  
Adriana C. Rossi ◽  
Tomer Martin Mark ◽  
Melissa Rodriguez ◽  
Manan Shah ◽  
Ryann Quinn ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Partial Response ◽  
Median Number ◽  
Phase 2 ◽  
Disease Response ◽  
Vte Prophylaxis ◽  
Phase 2 Trial ◽  
Chain Analysis ◽  
Grade 3 ◽  
Number Of Cycles

8036 Background: Clarithromycin has been shown to enhance anti-myeloma activity of lenalidomide+dexamethasone in the upfront treatment of multiple myeloma (MM). Pomalidomide is an immunomodulatory agent effective in relapsed/refractory MM (RRMM). We hypothesized that clarithromycin may similarly enhance pomalidomide + dexamethasone in RRMM. We now report updated results from a phase 2 trial of ClaPD in RRMM. Methods: 73 patients with RRMM were enrolled in a single-institution phase 2 study of ClaPD. All subjects had ≥ 3 prior lines of therapy, one of which must have included lenalidomide. ClaPD is clarithromycin 500mg twice daily; dexamethasone 40mg weekly; and pomalidomide 4mg for days 1-21 of a 28-day cycle. All patients had VTE prophylaxis with aspirin. Monthly disease response evaluation included immunoelectrophoresis and free light chain analysis; bone marrow biopsy with skeletal imaging was used to confirm MM responses. Treatment continued as tolerated until disease progression. Results: The 66 patients who completed ≥ 1 cycle of ClaPD are reported. Median number of cycles was 6 (range 1-17). Responses were progressive disease: 10%, stable disease: 21%, minimal response: 12%, partial response: 33%, very good partial response: 18%, stringent complete remission: 5%, for an overall response rate (ORR) of 56% and ≥VGPR rate of 23%. Median time to PR was 1.25 cycles (range 1-8). Median PFS was 5 months. Response and PFS were not different in patients refractory to lenalidomide (85%), bortezomib (82%), or double-refractory patients (76%). After a median follow up of 12 months,28 pts (42%) remain on study without progression and 56pts (85%) are alive. Two pts withdrew due to toxicity (1 Grade 3 fatigue, 1 Grade 4 muscular weakness). One patient withdrew consent. Conclusions: ClaPD is highly effective for heavily pre-treated RRMM, particularly in lenalidomide-refractory disesase and compares favorably to previously published Phase 2 data of Pom/Dex (ORR 56% vs 40% - Lacy et. al JCO 2009) without excess toxicity. Response to ClaPD is rapid, well tolerated, and sustained over 7 months in most subjects. These data support the clinical efficacy of pomalidomide based regimens in RRMM.

Policy Considerations for the Design and Use of Web Portals for Researchers, Clinicians, and Patients: A Scoping Literature Review (Preprint)

2020 ◽  
Author(s):  
Michael Lang ◽  
Sébastien Lemieux ◽  
Josée Hébert ◽  
Guy Sauvageau ◽  
Ma'n H. Zawati
Keyword(s):  
Patient Care ◽  
Health Research ◽  
Complex Disease ◽  
Patient Empowerment ◽  
Patient Portals ◽  
Research Results ◽  
Online Systems ◽  
The Public ◽  
Online Tools ◽  
Research Findings

BACKGROUND Medical care and health research are jointly undergoing significant changes brought about by the Internet [1,2,3]. New online tools, apps, and programs are helping to facilitate unprecedented levels of data sharing and collaboration, potentially enabling more precisely targeted treatment and rapid research translation [4,5,6]. Patient portals have been a significant part of this emerging online health ecosystem, providing patients a mechanism for accessing electronic health records, managing appointments and prescriptions, even communicating directly with care providers [7]. Much has been written about the technical and ethical challenges associated with the development and integration of patient portals into the clinic [8,9]. But portal technology might also be used to connect health researchers to clinicians, patients, and the public. Online systems could be a useful platform for broadly and rapidly disseminating research results while also promoting patient empowerment. OBJECTIVE The aim of this study is to assess the potential use of online portals that facilitate the sharing of health research findings among researchers, clinicians, patients, and the public. It will also summarize the potential legal, ethical, and policy implications associated with such tools for public use and in the management of patient care for complex disease. METHODS We systematically consulted three databases, PubMed, Scopus, and WestLaw Next for sources describing online portals for sharing health research findings among clinicians, researchers, and patients and their associated legal, ethical, and policy challenges. raised by the integration of online tools into patient care for complex disease. Of 719 source citations, we retained 22 for review. RESULTS We found a varied and inconsistent treatment of online portals for sharing health research findings among clinicians, researchers, and patients. While the literature supports the view that portals of this kind are potentially highly promising, they remain novel and are not yet being widely adopted. We also found a wide-ranging discussion on the legal, ethical, and policy issues related to the use of online tools for sharing research data. We identified five important policy challenges: privacy & confidentiality, health literacy & patient empowerment, equity, training, and decision making. Each of these, we contend, have meaningful implications for the increased integration of online tools into clinical care. CONCLUSIONS As online tools become increasingly important mechanisms for sharing health research with clinicians, patients, and the public, it is vital that these developments are met with ethical and conceptual scrutiny. Therapeutic portals as they are presented in this paper may become a more widespread feature of precision and translational medicine. Our findings suggest that online portals are already being used to disseminate research results among clinicians, patients, and the public. But much of the ethical and conceptual debate is framed in terms of the patient portal, a concept that does not adequately reflect the potentially broader scope of therapeutic portals. It may be useful to clarify this distinction in future research and to underscore the unique ethical, legal, and policy challenges raised when online systems are used as a platform for disseminating research to as wide an audience as possible. CLINICALTRIAL n/a

scholarly journals Drug therapy problems identified among older adults placed in a nursing home: the Croatian experience

2020 ◽  
Vol 48 (6) ◽  
pp. 030006052092879
Author(s):  
Katarina Fehir Šola ◽  
Iva Mucalo ◽  
Andrea Brajković ◽  
Ivona Jukić ◽  
Donatella Verbanac ◽  
...  
Keyword(s):  
Nursing Home ◽  
Drug Therapy ◽  
Medication Management ◽  
Institutional Care ◽  
Nursing Home Residents ◽  
Median Number ◽  
Cross Sectional ◽  
High Prevalence ◽  
Care Facilities ◽  
Drug Therapy Problems

Objective The aim of this study was to determine the frequency and type of drug therapy problems (DTPs) in older institutionalized adults. Method We conducted a cross-sectional observational study from February to June 2016 at a 150-bed public nursing home in Croatia, where comprehensive medication management (CMM) services were provided. A rational decision-making process, referred to as the Pharmacotherapy Workup method, was used to classify DTPs. Results Data were prospectively collected from 73 residents, among which 71% were age 75 years or older. The median number of prescribed medications per patient was 7 (2–16) and polypharmacy (> 4) was recorded for 54 (74.0%) patients. A total 313 DTPs were identified, with an average of 4.3 ± 2 DTPs per patient. The most frequent DTP was needing additional drug therapy (n = 118; 37.7%), followed by adverse drug reaction (n = 55; 17.6%). Lactulose (14.4%), tramadol (6.7%), and potassium (6.4%) were the medications most frequently related to DTPs. Conclusion The high prevalence of DTPs identified among older institutionalized adults strongly suggests the need to incorporate new pharmacist-led CMM services within existing institutional care facilities, to improve the care provided to nursing home residents.

scholarly journals Pegfilgrastim for primary prophylaxis of febrile neutropenia in multiple myeloma

2021 ◽  
Author(s):  
Claudio Cerchione ◽  
Davide Nappi ◽  
Giovanni Martinelli
Keyword(s):  
Multiple Myeloma ◽  
Febrile Neutropenia ◽  
Supportive Care ◽  
Survival Rates ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Novel Agents ◽  
Severe Side Effect ◽  
Maximum Benefit ◽  
Long Acting

AbstractMultiple myeloma (MM) survival rates have been substantially increased thanks to novel agents that have improved survival outcomes and shown better tolerability than treatments of earlier years. These new agents include immunomodulating imide drugs (IMiD) thalidomide and lenalidomide, the proteasome inhibitor bortezomib (PI), recently followed by new generation IMID pomalidomide, monoclonal antibodies daratumumab and elotuzumab, and next generation PI carfilzomib and ixazomib. However, even in this more promising scenario, febrile neutropenia remains a severe side effect of antineoplastic therapies and can lead to a delay and/or dose reduction in subsequent cycles. Supportive care has thus become key in helping patients to obtain the maximum benefit from novel agents. Filgrastim is a human recombinant subcutaneous preparation of G-CSF, largely adopted in hematological supportive care as “on demand” (or secondary) prophylaxis to recovery from neutropenia and its infectious consequences during anti-myeloma treatment. On the contrary, pegfilgrastim is a pegylated long-acting recombinant form of granulocyte colony-stimulating factor (G-CSF) that, given its extended half-life, can be particularly useful when adopted as “primary prophylaxis,” therefore before the onset of neutropenia, along chemotherapy treatment in multiple myeloma patients. There is no direct comparison between the two G-CSF delivery modalities. In this review, we compare data on the two administrations’ modality, highlighting the efficacy of the secondary prophylaxis over multiple myeloma treatment. Advantage of pegfilgrastim could be as follows: the fixed administration rather than multiple injections, reduction in neutropenia and febrile neutropenia rates, and, finally, a cost-effectiveness advantage.

scholarly journals ANZSN Renal Supportive Care Guidelines 2013

Nephrology ◽  
2013 ◽  
Vol 18 (6) ◽  
pp. 401-454 ◽  
Author(s):  
Mark A Brown ◽  
Susan M Crail ◽  
Rosemary Masterson ◽  
Celine Foote ◽  
Jennifer Robins ◽  
...  
Keyword(s):  
Supportive Care ◽  
Care Guidelines

scholarly journals Living with systemic lupus erythematosus in 2020: a European patient survey

2021 ◽  
Vol 8 (1) ◽  
pp. e000469
Author(s):  
Alain Cornet ◽  
Jeanette Andersen ◽  
Kirsi Myllys ◽  
Angela Edwards ◽  
Laurent Arnaud
Keyword(s):  
Systemic Lupus Erythematosus ◽  
Lupus Erythematosus ◽  
Online Survey ◽  
Complex Disease ◽  
Renal Involvement ◽  
Median Number ◽  
Sexual Life ◽  
Diagnosis Delay ◽  
Systemic Lupus ◽  
Organ Systems

ObjectiveThe aim of this study was to analyse the 2020 burden of Systemic Lupus Erythematosus (SLE) in Europe, from the patients’ perspective.MethodsIn May 2020, Lupus Europe, the European umbrella patient association for SLE, designed and disseminated a multilingual anonymous online survey to individuals with a self-reported physician’s diagnosis of SLE living in Europe.ResultsData from 4375 SLE survey respondents (95.9% women, median age: 45 (IQR: 36–54) years, 70.7% Caucasians) from 35 European countries were analysed. The median age at SLE diagnosis was 30 years (IQR: 22–40) and the median diagnosis delay was 2 years (IQR: 0–6). The most commonly affected organ-systems included the joints (81.8%) and skin (59.4%), with renal involvement in 30%. Another diagnosis was given before that of SLE in 45.0%, including psychological/mental disorders in 9.1% and fibromyalgia in 5.9%. The median number of symptoms reported was 9 (IQR: 6–11) out of 21, with fatigue most common (85.3%) and most bothersome. The median number of SLE-related medications was 5 (IQR: 3–7), including antimalarials (75%), oral glucocorticoids (52.4%), immunosuppressants (39.8%) and biologics (10.9%). Respondents reported significant impact over their studies, career and emotional/sexual life in 50.7%, 57.9% and 38.2%, respectively. Appropriate access to care was highly variable across countries and care component.ConclusionThis survey underlines the 2020 burden and strong heterogeneity in the care of SLE across Europe, from the patient’s perspective. Altogether, these data may prove crucial to physicians, patients and policy-makers to improve the diagnosis and management of this rare and complex disease.

scholarly journals Daratumumab, Pomalidomide, and Dexamethasone (DPd) for the Treatment of Relapsed/Refractory Multiple Myeloma: A Single Institution Experience

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5642-5642 ◽  
Author(s):  
Al-Ola Abdallah ◽  
Neil Dunavin ◽  
Brian McClune ◽  
Leyla Shune ◽  
Ajoy L. Dias ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Proteasome Inhibitor ◽  
Research Funding ◽  
Median Number ◽  
Autologous Stem Cell Transplant ◽  
Cell Transplant ◽  
Duration Of Treatment ◽  
Effective Treatment Option ◽  
Refractory Multiple Myeloma ◽  
Overall Response

Abstract Background: Daratumumab triplet regimens containing dexamethasone and lenalidomide or bortezomib are an effective treatment option for patients with relapsed/refractory multiple myeloma (RRMM). Daratumumab was recently FDA-approved in combination with the second-generation immunomodulatory drug, pomalidomide, and dexamethasone based (DPd) on results of the EQUULEUS study where overall response rates (ORR) of 60% were seen. The goal of this retrospective study was to analyze clinical outcomes of the DPd triplet regimen in either a daratumumab and pomalidomide naïve or refractory population of heavily pretreated RRMM patients at our institution. Methods: Thirty-two patients with RRMM treated with DPd at the University of Kansas Health System between November 2015 and July 2018 were included in our analysis. DPd consisted of 28-day cycles of daratumumab 16 mg/kg intravenously (weekly for cycles 1 and 2, every 2 weeks for cycles 3-6, and every 4 weeks thereafter until disease progression); pomalidomide 4 mg orally (PO)on Days 1-21 and adjusted for cytopenia or toxicities; and dexamethasone 40 mg PO weekly adjusted based on tolerance. based on age. Responses were evaluated using IMWG criteria. Patient characteristics, disease course, and outcomes were summarized with descriptive statistics. Kaplan-Meier analyses were used to estimate progression-free (PFS) and overall survival (OS). Results:The median age was 64 years (range 44-83). Twenty-three patients (72%) had IgG isotype, 11 patients (34 %) had ISS stage III disease at diagnosis, 13 patients (41%) had high risk cytogenetics, and 13 patients (41%) had extramedullary disease. Median number of previous lines of therapy was 4 (1-9). Twenty-two patients (69%) received ≥3 prior therapies. Twenty-three patients (72%) were proteasome inhibitor refractory, 28 patients (88%) were immunomodulator refractory, 9 patients (28%) were daratumumab refractory, and 3 patients (15%) were double refractory to daratumumab and pomalidomide. Twenty-eight patients (88%) had received autologous stem cell transplant (ASCT) prior to DPd; 12 patients (38%) had ≥2 prior transplants. Median number of DPd cycles received was 6 (2-30) and the median duration of treatment was 5 months (2-30). At a median follow-up of 8.4 months (range: 2-29), the overall response rate (ORR) for all patients was 72% which compares favorably to the ORR of 60% in the EQUULEUS study. However, about half of the responses were partial responses (PR) (47%). The ORR rate for those who were refractory to either pomalidomide or daratumumab was 65%. The PFS was 8.3 months, while the median OS was not reached. Conclusion: DPd was recently approved for the treatment of RRMM. Our ORR compares favorably to the EQUULEUS study, however about half of responses were partial responses or better. Surprisingly, our analysis shows an impressive ORR in patients with previous exposure to proteasome inhibitor and immunomodulatory therapies in RRMM population, suggesting a benefit of DPd even in patients who received prior pomalidomide or daratumumab. Disclosures McGuirk: Astellas Pharma: Research Funding; Gamida Cell: Research Funding; Novartis Pharmaceuticals Corporation: Honoraria, Other: speaker, Research Funding; Pluristem Ltd: Research Funding; Kite Pharma: Honoraria, Other: travel accommodations, expenses, speaker ; Fresenius Biotech: Research Funding; Bellicum Pharmaceuticals: Research Funding. Ganguly:Daiichi Sankyo: Research Funding; Janssen: Consultancy; Amgen: Consultancy; Seattle Genetics: Speakers Bureau.

scholarly journals Macroglossia reveals multiple myeloma

2021 ◽  
Vol 7 (3) ◽  
Author(s):  
Maria Bonvicini ◽  
Davide Crapanzano ◽  
Susanna Fenu ◽  
Marco Giordano ◽  
Lorenzo Palleschi
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Differential Diagnosis ◽  
Arterial Hypertension ◽  
Supportive Care ◽  
Loss Of Weight ◽  
Bright Orange ◽  
History Of ◽  
Congo Red Staining ◽  
One Year

We present an eighty-year old man with a one year history of progressive macroglossia, dysphagia and loss of weight. He had a medical history of arterial hypertension and prostatic hypertrophy which he had under good therapeutic control. The entire tongue was swollen, had hard solidity and was slightly painful upon palpation. A tongue biopsy revealed an amyloid deposition as it coloured bright orange-red on Congo Red staining and lead us subsequently to the diagnosis of amyloidosis; then a bone marrow biopsy confirmed the diagnosis of multiple myeloma. The case was further evaluated by a multidisciplinary team who considered it appropriate to start a lowdose melphalan treatment combined with supportive care. When macroglossia in the tongue is confirmed to be amyloidosis the differential diagnosis should include systemic amyloidosis deposition and multiple myeloma.

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