| 2010-07-26 16:30:32 |
ONS Stephanie |
Welcome to the ONS Virtual Journal Club chat!! Today we have Infusion Reactions: Diagnosis, Assessment, and Management with Wendy Vogel. |
| 2010-07-26 16:30:45 |
ONS Stephanie |
Wendy H. Vogel, MSN, FNP, AOCNP, is an oncology nurse practitioner from Kingsport, Tennessee. Ms. Vogel received her Masters of Science in Nursing from East Tennessee State University in Johnson City, Tennessee. She is board certified as a family nurse practitioner and as an Advanced Oncology Nurse Practitioner. Ms. Vogel is one of the editors of the recently published Advanced Oncology Nursing Certification Review and Resource Manual. She is also the co-author of the book, Advanced Practice Guidelines for Oncology and Palliative Care and is published in peer-reviewed journals such as the Clinical Journal of Oncology Nursing and The Oncology Nursing Forum. For the past 5 years, Ms. Vogel has been a co-recipient of a Susan G. Komen Breast Cancer Foundation grant for a High Risk Breast Cancer clinic that offers preventative services and genetic counseling and testing to indigent women in East Tennessee. |
| 2010-07-26 16:31:29 |
whvogel |
Thanks everyone so much for joining us this afternoon. Hope you enjoyed the article on Infusion reactions. So what kind of questions do you have or discussion do you want to have today? |
| 2010-07-26 16:32:22 |
judysykes |
I just joined last-minute, was not able to read the article. We've had a lot of Carboplatin rx's lately. Is it common practice to do skin-testing for carbo? |
| 2010-07-26 16:32:51 |
whvogel |
Hi Judy! We do not routinely do skin testing for carbo...does your practice? |
| 2010-07-26 16:32:58 |
whvogel |
Anyone else on the chat? Do you? |
| 2010-07-26 16:33:17 |
judysykes |
No, but I sure would like to have a way to prevent some of these severe rx's, involving n&v and diarrhea. |
| 2010-07-26 16:33:25 |
whvogel |
Carboplatin has a reaction rate of about 2 %. |
| 2010-07-26 16:33:44 |
whvogel |
Tell me about this reaction......Is it during the infusion? |
| 2010-07-26 16:34:08 |
whvogel |
The 2% has to do with infusion reactions like allergic/anaphylactic |
| 2010-07-26 16:35:16 |
judysykes |
Usually after they've had at least 7 or 8 carbos, during the end or after the completion but while still in chemo. Itching palms is most common. nausea and diarrhea sometimes. Some respiratory problems, needing O2. |
| 2010-07-26 16:35:59 |
whvogel |
Hmmm..Allergic or anaphylactic reactions almost always have some sort of cutaneous manifestations like itching and rash/welts. |
| 2010-07-26 16:36:27 |
whvogel |
Also they are more common with subsequent infusions, not the first, unlike monoclonal antibody infusions... |
| 2010-07-26 16:36:32 |
judysykes |
What is the most common protocol for treatment of reactions? |
| 2010-07-26 16:37:10 |
whvogel |
True allergic reactions get worse with repeated exposures...sometimes, nausea/vomiting occur...have seen diarrhea with some of the medications used to treat the reaction or with premeds... |
| 2010-07-26 16:37:20 |
ONS Stephanie |
Welcome to the chat ellenfparks and mgilligan! Do you have any questions for Wendy on infusion reactions? |
| 2010-07-26 16:37:28 |
whvogel |
How often are you have this Judy? |
| 2010-07-26 16:38:35 |
whvogel |
you asked about the most common protocol.......of course - stop the offending agent, open up fluids, assess the ABCs - determine what, if any, emergent medications are needed. If it is a true allergic reaction epinephrine should be given... |
| 2010-07-26 16:38:35 |
judysykes |
Oh, once every few weeks, the older our practice gets the more common carboplatin rx's are. Normally we give Benadryl and dexamethasone as pre-med, then give more Benadryl to treat the rx. If it becomes severe we'll give more dexamethasone. |
| 2010-07-26 16:38:54 |
whvogel |
those are all good meds to use - |
| 2010-07-26 16:39:09 |
whvogel |
for less severe reactions - |
| 2010-07-26 16:39:18 |
mgilligan |
We would like to have standardized pre-meds and standardized orders for treatment of reactions- Any recommendations? |
| 2010-07-26 16:39:25 |
whvogel |
Do your patients with these reactions go on to receive subsequent infusions Judy? |
| 2010-07-26 16:40:01 |
whvogel |
Good question mgilligan - it is often hard to get clinicians to agree on standardized protocols as every patient is different |
| 2010-07-26 16:40:02 |
judysykes |
No no no. Some of our MD's would like to do de-sensitization but these would usually be done in the hospital and haven't had very good results. |
| 2010-07-26 16:40:06 |
ellenfparks |
We see over 100 pts per day- see at least one reaction per day /every other day. We have a reaction protocol to follow so we don't have to call for orders |
| 2010-07-26 16:40:06 |
whvogel |
also every reaction is different |
| 2010-07-26 16:40:44 |
mgilligan |
will you share your reaction protocol?...please |
| 2010-07-26 16:40:56 |
whvogel |
it is very important to determine what type of infusion reaction is occurring...whether a true allergic reaction or a cytokine release reaction |
| 2010-07-26 16:41:00 |
judysykes |
I would just like to forestall these carbo reactions. I wonder if skin testing would help. |
| 2010-07-26 16:41:05 |
whvogel |
very different in terms of treatment, retreatment |
| 2010-07-26 16:41:24 |
judysykes |
How would you determine which is a true allergic tx? |
| 2010-07-26 16:41:29 |
whvogel |
I just looked up skin testing for carbo and haven’t' found anything on it. |
| 2010-07-26 16:42:11 |
ellenfparks |
reaction rated mild. Moderate/severe based on s/s, mild=Benadryl 25mg, if resp s/s add solumedrol |
| 2010-07-26 16:42:19 |
whvogel |
I would suggest heavier premedication’s and also good preassessment of patients more likely to react - i.e. have had previous reactions, have skin reactions a lot, rashes, etc. anxiety level - |
| 2010-07-26 16:42:48 |
whvogel |
Judy good question about a true allergic reaction? |
| 2010-07-26 16:43:06 |
whvogel |
Well, first of all consider if the first infusion? if yes, less likely to be anaphylactic |
| 2010-07-26 16:43:28 |
whvogel |
if there is a rash or derm manifestation - more likely to be true allergic or anaphylactic |
| 2010-07-26 16:43:45 |
whvogel |
How sick is the patient? Is there stridor? Wheezing? |
| 2010-07-26 16:44:02 |
whvogel |
These happen more often with allergic than cytokine release... |
| 2010-07-26 16:44:13 |
judysykes |
the last one we had there was wheezing |
| 2010-07-26 16:44:24 |
whvogel |
BUT sometimes - you just aren’t' sure....and if you aren't treat like an allergic reactions - epi if severe |
| 2010-07-26 16:44:43 |
ellenfparks |
we have resp therapy on call in our bldg- call in to dept for infusion for high risk pt- so they are right there to tx resp s/s |
| 2010-07-26 16:44:44 |
whvogel |
if cytokine release, often just slowing or stopping the infusion makes the reaction stop...not so with anaphylaxis |
| 2010-07-26 16:44:58 |
whvogel |
good idea Ellen - you are fortunate! |
| 2010-07-26 16:45:08 |
judysykes |
really |
| 2010-07-26 16:45:48 |
whvogel |
Cytokine release most occurs with the first infusion... |
| 2010-07-26 16:46:06 |
whvogel |
It happens because of tumor cells literally "explode" releasing cytokines. |
| 2010-07-26 16:46:24 |
whvogel |
Cytokines cause fever, chills, hypotension, rigors, etc... |
| 2010-07-26 16:47:01 |
janie |
What is your protocol or suggested protocol for respiratory reactions to Erbitux? |
| 2010-07-26 16:47:07 |
whvogel |
this is like what you get when you get the flu....it's not actually the flu virus that causes these symptoms, but your body's own release of cytokines that cause the symptoms as your body fights the virus. |
| 2010-07-26 16:48:13 |
whvogel |
We do not have a set protocol...however we would use Benadryl, a corticosteroid, perhaps zantac or pepcid, and epi if it is a severe reaction...We also give a nebulized albuterol |
| 2010-07-26 16:48:30 |
whvogel |
(that was in regard to janies question re erbitux) |
| 2010-07-26 16:48:45 |
judysykes |
gotcha |
| 2010-07-26 16:48:45 |
whvogel |
O2, and fluids.. |
| 2010-07-26 16:48:51 |
whvogel |
Do you have a set protocol? |
| 2010-07-26 16:49:01 |
whvogel |
Or does anyone else? |
| 2010-07-26 16:49:22 |
janie |
No, we have to call each time. |
| 2010-07-26 16:49:41 |
whvogel |
Who do you call? (not Ghostbusters....lol) |
| 2010-07-26 16:49:53 |
janie |
we do the same as you with the exception of albuterol |
| 2010-07-26 16:50:16 |
janie |
the doctor |
| 2010-07-26 16:50:36 |
whvogel |
Do the nurses have to call the physician or is one on site? Any APNs? |
| 2010-07-26 16:51:01 |
judysykes |
We have a mid-level on call, either NP or PA. |
| 2010-07-26 16:51:23 |
whvogel |
That is an advantage of set protocols for reaction - but nurses must be able to assess and make decisions and then give appropriate meds. All our chemo nurses are ACLS certified. |
| 2010-07-26 16:51:26 |
janie |
he is across the hall and yes we do have a APN down the hall |
| 2010-07-26 16:51:49 |
whvogel |
I always hate getting paged to the chemo room!!! |
| 2010-07-26 16:52:19 |
judysykes |
That’s why you're getting paid the big bucks ;) |
| 2010-07-26 16:52:23 |
janie |
We have two ACLS certified but no crash cart on unit |
| 2010-07-26 16:52:36 |
whvogel |
How about premeds....your clinicians pretty good about ordering adequate premedication’s...the best way to avoid reactions is to prevent them.... |
| 2010-07-26 16:52:38 |
whvogel |
haha Judy |
| 2010-07-26 16:52:54 |
whvogel |
Janie do you have emergent meds available? |
| 2010-07-26 16:53:02 |
whvogel |
Or do you call 911? |
| 2010-07-26 16:53:40 |
judysykes |
We pretty much order our own premeds, 10 of dex for most everyone, Benadryl and pepcid for taxanes/doxil, Benadryl if risky for carbo rx. |
| 2010-07-26 16:53:50 |
janie |
Yes, we do give pre-meds: Benadryl, solu., pepcid. Call 911. No emergent meds avail. |
| 2010-07-26 16:54:00 |
whvogel |
Benadryl for erbitux... |
| 2010-07-26 16:54:16 |
janie |
Yes, we do. |
| 2010-07-26 16:54:21 |
judysykes |
We’re a gyn/onc practice so don't give erbitux. Thank goodness. |
| 2010-07-26 16:54:27 |
whvogel |
I would definitely push for the availability of emergent meds such as epi be available... |
| 2010-07-26 16:54:42 |
janie |
We agree. |
| 2010-07-26 16:54:56 |
whvogel |
That is manufacturers guidelines for many chemotherapy meds AND is in the chemotherapy guidelines recommendations as well. |
| 2010-07-26 16:55:00 |
judysykes |
We have epi but don't remember the last time we gave it. maybe we should go with that more for severe rx's |
| 2010-07-26 16:55:11 |
ellenfparks |
We have the same standing orders/protocol for all reactions- works really well. Still always call MD too, but at least we can start treating the reaction immediately |
| 2010-07-26 16:55:18 |
whvogel |
I think you would be at legal risk if emergent meds were not available and you had a bad outcome. |
| 2010-07-26 16:55:26 |
judysykes |
yes |
| 2010-07-26 16:55:28 |
whvogel |
that is good Ellen |
| 2010-07-26 16:55:37 |
whvogel |
nurses are afraid to use epi |
| 2010-07-26 16:56:19 |
whvogel |
but it is a good drug....we need to get over our fear...in studies done on epi and anaphylactic reactions - the patients more likely to survive were those that got epi sooner |
| 2010-07-26 16:56:29 |
judysykes |
I used it once 14 yrs ago with OK outcome but my CNS acted shocked that I used it on my own so I've never used it since |
| 2010-07-26 16:56:40 |
janie |
We do have epi avail in acute dose but we still have to call to get orders to pull it. |
| 2010-07-26 16:56:44 |
whvogel |
That’s a shame Judy.... |
| 2010-07-26 16:56:57 |
whvogel |
Nurses can certainly be capable of deciding when to use epi!!!!! |
| 2010-07-26 16:57:00 |
ellenfparks |
we are fortunate to catch the reactions early,& tx immediately so they aren’t as severe- we use epi only for severe resp s/s, but again, respiratory therapy is here also to help |
| 2010-07-26 16:57:06 |
judysykes |
probably just my own over-reaction to her surprise |
| 2010-07-26 16:57:27 |
whvogel |
When minutes (seconds) count....being able to give that epi quickly is important. |
| 2010-07-26 16:58:08 |
whvogel |
other ways we can assess our patients who might be at risk for anaphylaxis include the patient with asthma, if their lymphocyte counts are high (> 25,000) |
| 2010-07-26 16:58:38 |
whvogel |
or if they are on concomitant B-adrenergic blockers, if they have autoimmune disease, have seafood or iodine allergies, |
| 2010-07-26 16:58:56 |
whvogel |
FEMALES!! higher than normal chemo/MOA doses, older age, |
| 2010-07-26 16:59:15 |
judysykes |
name a b-adrenergic blocker please |
| 2010-07-26 16:59:22 |
whvogel |
those with hem malignancies, or those with cardiac or lung dysfunction |
| 2010-07-26 17:00:28 |
whvogel |
metoprolol, bisoprolol |
| 2010-07-26 17:00:43 |
judysykes |
ok |
| 2010-07-26 17:00:55 |
whvogel |
That was metoprolol (spelling!!!) |
| 2010-07-26 17:01:05 |
judysykes |
I knew that |
| 2010-07-26 17:01:35 |
whvogel |
What about monoclonal antibody reactions....had any of those? |
| 2010-07-26 17:02:03 |
whvogel |
There are some sections of the country that have had higher reactions to erbitux than others....no one really sure why... |
| 2010-07-26 17:02:15 |
judysykes |
We had one severe rx to avastin, treated it like a taxol tx, she did OK. Only one, give a lot of avastin. |
| 2010-07-26 17:02:38 |
whvogel |
Great article on that in JCO....especially in TN NC and these patients often had a atopic history... |
| 2010-07-26 17:02:52 |
whvogel |
Did you retreat the avastin patient with avastin Judy? |
| 2010-07-26 17:03:09 |
judysykes |
yes I think we're in that reaction belt (Western North Carolina) No we did not re challenge her |
| 2010-07-26 17:03:14 |
whvogel |
avastin has a very low infusion reaction rate, less than 3% ----- I have not seen one (yet) |
| 2010-07-26 17:03:49 |
ellenfparks |
I'm in NC- we see them, along with taxol, erbitux |
| 2010-07-26 17:03:51 |
whvogel |
We often have rituxan reactions....though....it pays to warn the patient... |
| 2010-07-26 17:04:36 |
whvogel |
The article if you are interested on erbitux reactions is JCO 25(24):3644-3648...author O'Neil, et al... |
| 2010-07-26 17:05:36 |
whvogel |
It’s a very interesting happening - the authors really emphasize preassessment of patients regarding allergic history.... |
| 2010-07-26 17:05:54 |
whvogel |
In those areas, more premeds besides Benadryl might be useful. |
| 2010-07-26 17:06:08 |
whvogel |
Anyone had a rituxan reaction? |
| 2010-07-26 17:06:55 |
judysykes |
I know some of my colleagues in med/onc have, but being gyn/onc we've not |
| 2010-07-26 17:07:08 |
whvogel |
we have some standing orders in my previous practice for rituxan and taxol reactions |
| 2010-07-26 17:07:10 |
ellenfparks |
yes, we def see rituxan reactions, along with IVIG, we usually just see rigors, chills with that- tx with Demerol |
| 2010-07-26 17:07:30 |
whvogel |
We premed differently for these drugs in my current practice.... |
| 2010-07-26 17:07:32 |
whvogel |
same with us Ellen |
| 2010-07-26 17:07:38 |
ONS Stephanie |
Why is it important for nurses to grade the infusion reaction? |
| 2010-07-26 17:07:46 |
whvogel |
Good question!! |
| 2010-07-26 17:08:12 |
whvogel |
Grading is very important because we all see things differently...what might scare me ...wouldn't scare you and vice versa... |
| 2010-07-26 17:08:30 |
mgilligan |
What about reactions to ferrlicet? |
| 2010-07-26 17:08:33 |
whvogel |
Grading a reaction gives us a less subjective way to define the reaction severity... |
| 2010-07-26 17:09:08 |
whvogel |
That way we don’t' deny the patient the opportunity to receive a drug with more premeds, or slower infusion because we are fearful....if it isn't a true allergic reaction... |
| 2010-07-26 17:09:36 |
whvogel |
this is more and more important as we give more monoclonal antibodies and have more cytokine release reactions that are not TRUE ALLERGIC reactions |
| 2010-07-26 17:09:49 |
whvogel |
ok, ferrlicet - |
| 2010-07-26 17:10:02 |
whvogel |
yes, we can see reactions to that...anyone else had some...we do occasionally |
| 2010-07-26 17:10:24 |
mgilligan |
we've had 2 in the past 2 weeks |
| 2010-07-26 17:11:01 |
whvogel |
we have less reactions with ferrlicit than with Infed by far |
| 2010-07-26 17:11:17 |
janie |
What kind of reaction are you seeing with ferrlicet? |
| 2010-07-26 17:11:20 |
whvogel |
We premed all our iron infusions and preassess the patient... |
| 2010-07-26 17:11:39 |
whvogel |
Hypotension...SOB, fear... |
| 2010-07-26 17:11:54 |
whvogel |
nausea occasionally....what about you mgilligan? |
| 2010-07-26 17:12:18 |
whvogel |
tachycardia also |
| 2010-07-26 17:12:44 |
whvogel |
Interestingly those are all listed as common reactions to ferrlicit!!! |
| 2010-07-26 17:13:12 |
judysykes |
I would like a printout of this chat is that possible, this has been interesting, I 'd like to discuss it with my co-workers. gotta go soon. |
| 2010-07-26 17:13:31 |
whvogel |
yes, it is...Stephanie will tell you about that |
| 2010-07-26 17:14:21 |
ONS Stephanie |
We will have all of the chat transcripts posted on the ONS website. You can find them under Publications/Virtual Journal Club. |
| 2010-07-26 17:14:36 |
whvogel |
there is also a great article on anaphylaxis at www.medscape.com/viewarticle/707607_print |
| 2010-07-26 17:14:47 |
mgilligan |
one pt immediately lost control of bowel...started with SOB, The other one after infusion was complete...pt didn't feel well, had pt sit for 30 min then pt felt worse, very nauseous, then SOB, hypotension, |
| 2010-07-26 17:15:00 |
whvogel |
What did you do? |
| 2010-07-26 17:15:45 |
mgilligan |
oxygen, Benadryl, solu medrol, sent to the ED, it was the second pt's third dose |
| 2010-07-26 17:15:52 |
whvogel |
the ONS chemotherapy and biotherapy guidelines are an excellent resource as well |
| 2010-07-26 17:15:57 |
judysykes |
gotta go, thanks so much : ) |
| 2010-07-26 17:16:00 |
whvogel |
How did patient outcome? |
| 2010-07-26 17:16:05 |
whvogel |
welcome Judy |
| 2010-07-26 17:16:35 |
whvogel |
Did the clinician choose to treat the patient again mgilligan? |
| 2010-07-26 17:16:47 |
whvogel |
I probably would change to a different from of iv iron.. |
| 2010-07-26 17:16:59 |
whvogel |
Maybe venofer? |
| 2010-07-26 17:17:01 |
mgilligan |
She was ok.....we had not pre medicated her for the other 2 infusions, so no pre meds for that one... |
| 2010-07-26 17:17:18 |
mgilligan |
no routine premeds for ferrlicet |
| 2010-07-26 17:17:48 |
mgilligan |
don't know about retreatment yet....this happened Friday |
| 2010-07-26 17:17:49 |
whvogel |
right...ferrlicet and venofer are supposed to have less reactions |
| 2010-07-26 17:18:05 |
whvogel |
we do give Benadryl and Tylenol before iron |
| 2010-07-26 17:18:27 |
whvogel |
in our practice although you don’t' have to |
| 2010-07-26 17:18:39 |
whvogel |
we also test dose infed prior to first dose |
| 2010-07-26 17:19:19 |
whvogel |
I like venofer because you can easily dose it (100 mg) and give once, twice or three times a week for max of 10 doses... |
| 2010-07-26 17:19:28 |
whvogel |
Easier to figure dose than for infed!! |
| 2010-07-26 17:19:48 |
mgilligan |
I'm thinking we should test dose and pre med everyone :) |
| 2010-07-26 17:20:01 |
whvogel |
Haha...i like that idea too!!! |
| 2010-07-26 17:20:17 |
whvogel |
Some bean counter would think that would be too much chair time though!!! lol |
| 2010-07-26 17:20:39 |
ONS Stephanie |
Michelle or Steph199 do you have any questions for Wendy? |
| 2010-07-26 17:20:54 |
mgilligan |
Great article in the CJON although I must admit I haven't read it all.......I do plan to use it to develop some nursing ed and standing orders |
| 2010-07-26 17:21:17 |
mgilligan |
that was for Wendy |
| 2010-07-26 17:21:22 |
whvogel |
for those who are looking to develop protocol - the algorithm in article might be helpful ....also ONS chemo guidelines |
| 2010-07-26 17:21:27 |
whvogel |
thanks mgilligan |
| 2010-07-26 17:21:44 |
whvogel |
Standing orders are ALWAYS great!!! |
| 2010-07-26 17:21:55 |
Michelle |
Was just reviewing the algorithm for management of reaction in the article...is it something we can use as a citation? |
| 2010-07-26 17:22:03 |
mgilligan |
our chemo dept is getting ready to move another building so the nursing staff will be further away from the MDs and they are getting nervous |
| 2010-07-26 17:22:11 |
Michelle |
(Great minds think alike!) |
| 2010-07-26 17:22:26 |
whvogel |
sure as citation...have to get ONS permission to copy |
| 2010-07-26 17:22:58 |
mgilligan |
We are considering using our rapid response team.......does anyone else that is hospital based do that? |
| 2010-07-26 17:23:09 |
whvogel |
I think there would need to be a MD or APN or PA on site during infusions |
| 2010-07-26 17:23:13 |
whvogel |
Will there be? |
| 2010-07-26 17:23:43 |
mgilligan |
Yes, they are on site, they are just a little further away......depends on what "on site" means |
| 2010-07-26 17:23:44 |
whvogel |
lots of literature on rapid response teams right now...does anyone here have one for their clinic> |
| 2010-07-26 17:24:00 |
whvogel |
Haha on the onsite....many different "interpretations".... |
| 2010-07-26 17:25:32 |
whvogel |
I would think rapid response a great idea...but nurses still need to be prepared to give emergent meds AND be able to direct response team if this is a cytokine release reaction not a true allergic reaction - in that case the RR team would probably not be needed.... |
| 2010-07-26 17:25:34 |
mgilligan |
Our hospital and clinic are somewhat in the same building so the hospital rapid response team is willing to answer our calls and see how it works....I've been looking for an EVP project....think I just found it :) |
| 2010-07-26 17:25:39 |
Michelle |
Do you recommend removing the tubing for the medication causing the reaction from the primary tubing, or is stopping the infusion adequate? |
| 2010-07-26 17:25:59 |
whvogel |
YEA!!!! And you should write it up and submit to CJON or ONF!!!! |
| 2010-07-26 17:26:22 |
mgilligan |
I was thinking that the rapid response team would help give the nursing staff the experience and confidence they need |
| 2010-07-26 17:26:40 |
whvogel |
We piggyback all meds into a central iv line so that we can just stop the offending med and run fluids...what does everyone else do? |
| 2010-07-26 17:27:04 |
whvogel |
otherwise you have to remove bag and replace with a new bag of fluids...time issue |
| 2010-07-26 17:27:17 |
whvogel |
I have never removed the tubing... |
| 2010-07-26 17:27:23 |
ONS Stephanie |
We are coming to the end of our time. What last questions do you have for Wendy? Don't forget the transcripts will be posted. |
| 2010-07-26 17:27:29 |
mgilligan |
IVPB |
| 2010-07-26 17:27:33 |
whvogel |
yes |
| 2010-07-26 17:27:48 |
whvogel |
What a great discussion today!!! |
| 2010-07-26 17:27:51 |
mgilligan |
Thanks- enjoyed the chat...and the transcript will be....... |
| 2010-07-26 17:28:20 |
ONS Stephanie |
It will be up by Wednesday. |
| 2010-07-26 17:28:34 |
mgilligan |
Where are they posted? sorry I know you mentioned earlier |
| 2010-07-26 17:29:15 |
ONS Stephanie |
They will be on the ONS site under Publications/Virtual Journal Club |
| 2010-07-26 17:29:31 |
whvogel |
Thanks to everyone for joining us today!!!! i have enjoyed talking with you!! I always learn something from all of you!!! Thanks again and have a great day!!!!! |
| 2010-07-26 17:29:51 |
ONS Stephanie |
Thank you all for coming to chat! Thank you Wendy for your great article and expertise. Join us next month. |
| 2010-07-26 17:29:59 |
Michelle |
Thank you... |