Construction of a Nomogram for Identifying Refractory Mycoplasma pneumoniae Pneumonia Among Macrolide-Unresponsive Mycoplasma pneumoniae Pneumonia in Children

OBJECTIVE

The individualized prediction of treatment regimens of macrolide-unresponsive Mycoplasma pneumoniae pneumonia (MUMPP) is scarce. The aim of this study was, therefore, to evaluate the relevant data of patients and construct a nomogram for identifying refractory Mycoplasma pneumoniae pneumonia (RMPP) among children continued to be treated with macrolide after the confirmation of MUMPP, providing a reference for the choice of treatment regimen.

METHODS

We performed a retrospective study involving 162 children who continued to be treated with macrolide (azithromycin) after the confirmation of MUMPP without antibiotic changes between January 2020 and January 2022. We collected data on clinical feature, hospitalization period, treatments, laboratory data, extrapulmonary symptoms, parapneumonic effusion, and connections with other respiratory pathogens. In addition, the independent risk factors for RMPP were determined through univariate and multivariate analyses, and then a nomogram was constructed and validated.

RESULTS

In this study, the multivariate logistic regression analysis showed that age, leukocyte count, neutrophil proportion, serum procalcitonin, and lactate dehydrogenase were independent risk factors for RMPP. Using the five independent associated factors, the nomogram for identification of RMPP was constructed. Moreover, the area under the ROC curve (AUC) was 0.925 (95% CI: 0.882-0.968) for the nomogram showing excellent discrimination. The calibration curve, close to the 45-degree line, exhibited good calibration of nomogram.

CONCLUSION

We constructed and validated a visual and user-friendly nomogram for individualized prediction of RMPP risk in children who continued to be treated with macrolide after the confirmation of MUMPP based on five variables. According to the nomogram model, continuation of macrolide should be considered rather than second-line antibiotics including tetracyclines (doxycycline or minocycline) and fluoroquinolones for MUMPP children with low predictive values.

Low-dose IL-2 improved clinical symptoms by restoring reduced regulatory T cells in patients with refractory rheumatoid arthritis: A randomized controlled trial

Background

Regulatory T cells (Tregs) have been found to play crucial roles in immune tolerance. However, the status of Tregs in refractory rheumatoid arthritis (RA) is still unclear. Moreover, low-dose interleukin-2 (IL-2) has been reported to selectively promote the expansion of Tregs. This study investigated the status of CD4⁺ Tregs and low-dose IL-2 therapy in patients with refractory RA.

Methods

The absolute number of CD4⁺CD25⁺FOXP3⁺ Treg (CD4 Treg), CD4⁺IL17⁺ T (Th17), and other subsets in peripheral blood (PB) from 41 patients with refractory RA and 40 healthy donors was characterized by flow cytometry combined with an internal microsphere counting standard. Twenty-six patients with refractory RA were treated with daily subcutaneous injections of 0.5 million IU of human IL-2 for five consecutive days. Then, its effects on CD4 Treg and Th17 cells in PB were analyzed.

Results

A decrease in the absolute number of PB CD4 Tregs rather than the increase in the number of Th17 was found to contribute to an imbalance between Th17 and CD4 Tregs in these patients, suggesting an essential role of CD4 Tregs in sustained high disease activity. Low-dose IL-2 selectively increased the number of CD4 Tregs and rebalanced the ratio of Th17 and CD4 Tregs, leading to increased clinical symptom remission without the observed side effects.

Conclusions

An absolute decrease of PB CD4 Tregs in patients with refractory RA was associated with continuing disease activation but not the increase of Th17 cells. Low-dose IL-2, a potential therapeutic candidate, restored decreased CD4 Tregs and promoted the rapid remission of patients with refractory RA without overtreatment and the observed side effects.

Clinical trial registration

http://www.chictr.org.cn/showproj.aspx?proj=13909, identifier ChiCTR-INR-16009546.

Incidence, Management Experience and Characteristics of Patients with Giardiasis and Common Variable Immunodeficiency

Common variable immunodeficiency (CVID) is an antibody immunodeficiency with a wide variety of clinical and immunological manifestations, and whose genetic cause is found in about 25% of diagnosed cases. Giardia lamblia is one of the main causes of gastrointestinal infections in CVID. 5-Nitroimidazoles are the most used first-line treatment, but nitroimidazole-refractory giardiasis is increasing. Nevertheless, only a few cases of refractory giardiasis in CVID have been reported. This study aimed to determine the incidence of Giardia infection in our CVID cohort, shows our management experience and describes patients' phenotypic features. Clinical data collection, immunological, immunogenetics and microbiology assays were performed, and previous cases of giardiasis in CVID were reviewed. The incidence of symptomatic giardiasis was 12.9%. The main immunological features were undetectable or decreased IgA levels and reduced switched memory B cells. A probable PTEN pathogenic variant was detected in one. Three patients responded to metronidazole but suffered reinfections, and one was a refractory giardiasis eradicated with innovative quinacrine plus paromomycin combination. This work could contribute to the decision-making and therapeutic management of future patients with CVID and giardiasis, highlighting the importance of the early detection and treatment of infections in patients with CVID to ensure a good quality of life.

Efficacy and safety of belantamab-mafodotin in triple-refractory multiple myeloma patients: A multicentric real-life experience

Belantamab-mafodotin is an innovative and selective treatment for multi-refractory/relapsed multiple myeloma (MM) patients; however, available real-life experiences on efficacy and safety are limited. In this real-world multicentric retrospective study, we enrolled 28 MM patients treated in four Hematology units of Campania region, Italy, who received a median of six treatment lines prior to belantamab-mafodotin. The overall response rate (ORR) was 40% (complete remission, CR, 11%; very good partial remission, VGPR, 11%; and partial remission, PR, 18%), with a median progression-free survival (PFS) and overall survival (OS) of 3 and 8 months, respectively. One of the most frequent drug-related adverse events was keratopathy observed in nine (32%) patients, leading to therapy discontinuation in only three (11%) of them. Moreover, 22 out of 28 total patients who were treated with at least two administrations achieved an ORR of 50% (CR, 14%; VGPR, 14%; and PR, 22%) with a median PFS and OS of 5 and 11 months, respectively. In conclusion, our multicentric study confirmed efficacy and safety of belantamab-mafodotin in triple-refractory MM patients even in the real-life setting.

Effectiveness of Dual Biologic or Small Molecule Therapy for Achieving Endoscopic Remission in Refractory Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic autoimmune disease with relapse-remission courses. A number of patients may present with a refractory disease with partial or no response to treatment. Others may present with extra-intestinal manifestations that makes the treatment with one biologic challenging. Dual target therapy (DTT), combining biologics and/or small molecule drugs, may offer a chance to achieve remission in these cases and improve patients' quality of life despite the limited evidence regarding this approach. We present a case series of refractory inflammatory bowel disease cases managed with DTT. Seven patients with refractory IBD achieved steroid free, clinical, and endoscopic remission by using DTT. These results support that DTT could be an effective approach in selected patients with refractory IBD or with concomitant extra-intestinal manifestations (EIM). Larger studies, ideally randomized controlled trials, are needed to further support the evidence and confirm the efficacy and safety of DTT for IBD.

Case report: Stereotactic body radiation therapy with 12 Gy for silencing refractory ventricular tachycardia

BACKGROUND

Encouraging results have been reported for the treatment of ventricular tachycardia (VT) with stereotactic body radiation therapy (SBRT) with 25 Gy. SBRT with 12 Gy for refractory VT was designed to reduce long-term cardiac toxicity.

METHODS

Stereotactic body radiation therapy-VT simulation, planning, and treatment were performed using standard techniques. A patient was treated with a marginal dose of 12 Gy in a single fraction to the planning target volume (PTV). The goal was for at least ≥ 95% of the PTV to be covered by at least 95% of 12 Gy radiation.

RESULTS

From April 2021 through June 2022, a patient with refractory VT underwent treatment. The volume for PTV was 65.8 cm3. The mean radiation dose administered to the heart (the heart volume excluding the PTV) was 2.2 Gy. No acute or late toxicity was observed after SBRT. Six months after SBRT, the patient experienced new monomorphic right ventricular outflow tract (RVOT) VT. Interestingly, the substrate of the left ventricular basal to middle posteroseptal wall before SBRT was turned into scar zones with a local voltage < 0.5 mV. Catheter ablation to treat RVOT VT was performed, and the situation remains stable to date.

CONCLUSION

This study reports the first patient with refractory VT successfully treated with 12.0 Gy SBRT, suggesting that 12 Gy is a potential dose to treat refractory VT. Further investigations and enrollment of more patients are warranted to assess the long-term efficacy and side effects of this treatment.

Efficacy and safety of galcanezumab as a treatment of refractory episodic and chronic cluster headache: Case series and narrative review

BACKGROUND

Galcanezumab, a monoclonal antibody targeting calcitonin gene-related peptide (CGRP), has demonstrated clinical benefit as a preventive treatment of episodic cluster headache (ECH) but not in chronic cluster headache (CCH) to this date. Our objective was to analyze our clinical experience of the compassionate use of galcanezumab in cluster headache and to conduct a narrative review of the published literature.

METHODS

We present a case series of patients with refractory ECH and CCH treated with 240 mg galcanezumab monthly in an outpatient headache clinic. We recorded epidemiologic and clinical data and analyzed the disease evolution after 3 and 6 months. The review was performed following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

We included three patients with ECH who were treated during a refractory cluster bout (mean duration of 83.7 days since the first attack, range 46.0-105.0 days) and six patients with CCH who had a high frequency of attacks (mean 35.8 attacks/week, range 7-56) and refractory to a mean of 5.2 preventive treatments (range, 3-9). In the CCH group, >50% frequency reduction was seen in 83% (5/6 patients) and the number of attacks per week showed a mean reduction of -24.2 at month 3 (range, -6 to -49) and -27.6 at month 6 (range, -7 to -49). In the ECH group, the bout ended a mean 17.3 days (range, 10-28) after galcanezumab administration. One third of patients reported mild adverse events, none of them leading to discontinuation.

CONCLUSION

In conclusion, our clinical experience supports the use of galcanezumab in patients with refractory cluster headache. These results might encourage the possibility of continuing clinical development with randomized controlled trials of anti-CGRP treatments in patients with cluster headache.

Refractory Hypokalemia in Secretory Diarrhea Phenotype of Colonic Pseudo-Obstruction (Ogilvie's Syndrome)

Colonic pseudo-obstruction is an acute non-obstructive colonic dilation associated with constipation or secretory diarrhea. The secretory diarrhea phenotype is associated with refractory hypokalemia that may require different interventions to treat. We present a case of a 51-year-old male who was admitted with a hemorrhagic stroke whose hospital course was complicated by severe abdominal distension, diarrhea, and hypokalemia. Initial investigations excluded infectious causes. Imaging confirmed colonic pseudo-obstruction. The hypokalemia was severe and refractory, requiring daily potassium replacement along with rectal tube decompression and spironolactone. Despite these interventions, the hypokalemia persists and requires nearly 100 days to resolve completely.

Refractory glossopharyngeal neuralgia successfully treated with onabotulinumtoxinA: A case report

BACKGROUND

Glossopharyngeal neuralgia is a rare but severe and disabling pain condition often caused by vascular compression of the glossopharyngeal nerve. Treatment is similar to that of trigeminal neuralgia, but some patients may be refractory to both medical and surgical approaches. Here we present a case of refractory glossopharyngeal neuralgia that responded well to onabotulinumtoxinA (BTX-A).

CASE

We report a case of a 65-year-old man with well-controlled human immunodeficiency virus disease with glossopharyngeal neuralgia symptoms since 2015. He had partial response to medications but was limited by side-effects. He underwent microvascular decompression twice with initial relief both times, but experienced recurrence of attacks 1-3 years after each surgery. He was treated with BTX-A using the chronic migraine PREEMPT protocol (i.e., 31-39 injection sites in head and neck muscles), which led to significant relief of his glossopharyngeal neuralgia pain.

CONCLUSIONS

This is the first case to our knowledge of glossopharyngeal neuralgia treated with BTX-A. BTX-A can be an effective treatment for glossopharyngeal neuralgia, even when injections are not administered directly over the sensory distribution of the glossopharyngeal nerve.

Refractory angiolymphoid hyperplasia with eosinophilia: Complete resolution with low dose thalidomide

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a difficult-to-treat and rare benign vascular proliferative condition which presents as painless, solitary, or multiple vascular papules or nodules in the head and neck area, with predilection for the ear. We report a case of ALHE that failed multiple therapeutic interventions but achieved complete resolution when treated with thalidomide.

Optimized therapeutic strategy for patients with refractory or relapsed acute myeloid leukemia: long-term clinical outcomes and health-related quality of life assessment

BACKGROUND

Patients with refractory or relapsed acute myeloid leukemia (AML) have poor survival, necessitating the exploration of optimized therapeutic strategy. Here, we aimed to investigate clinical outcomes and health-related quality of life (HR-QoL) after total therapy, which included allogeneic hematopoietic stem cell transplantation (allo-HSCT), and prophylactic donor lymphocyte infusion (DLI) in the early phase after transplantation, followed by multiple measurable residual disease (MRD) and graft-versus-host disease (GvHD)-guided DLIs.

METHODS

Consecutive patients who had refractory or relapsed AML and had received non-T-cell-depleted allo-HSCT at Peking University Institute of Hematology were included in the study. If the patients achieved complete remission at 30 days after transplantation and had no evidence of relapse, severe infection, organ failure, and active GvHD at the time of planned DLI, prophylactic DLI was administered at 30 days after transplantation for human leukocyte antigen (HLA)-matched related HSCT or at 45-60 days after transplantation for haploidentical or unrelated HSCT. Subsequently, multiple DLIs were administered based on MRD results and whether they developed GvHD after transplantation.

RESULTS

A total of 105 patients were eligible. Eighty-seven patients received prophylactic DLI (group B), while 18 did not receive prophylactic DLI (group A). Among 105 patients, the cumulative incidence of grade 2-4 acute GvHD and chronic GvHD was 40.6% (95% confidence interval [CI] = 30.6%-50.6%) and 73.3% (95% CI = 67.4%-79.2%), respectively. The cumulative incidence of relapse (CIR), transplant-related mortality (TRM), and leukemia-free survival (LFS) at 5 years after transplantation were 31.5% (95% CI = 21.9%-41.1%), 22.1% (95% CI = 11.3%-32.9%), and 46.4% (95% CI = 36.8%-56.0%), respectively. In group B, the CIR, TRM, and LFS at 5 years after transplantation were 27.6% (95% CI = 17.6%-37.6%), 21.6% (95% CI = 11.2%-32.0%), and 50.8% (95% CI = 40.0%-61.6%), respectively. At the end of follow-up, 48 patients survived, and more than 90% of survivors had satisfactory recoveries of HR-QoL.

CONCLUSIONS

Our study indicated that total therapy is not only associated with decreased CIR, comparable TRM, and better long-term LFS, but also with satisfactory HR-QoL for refractory or relapsed AML, compared with those of standard of care therapy reported previously. Therefore, total therapy may be an optimized therapeutic strategy for refractory or relapsed AML.

Refractory Behçet's disease treated with low-dose interleukin-2: A case report

RATIONALE

Behçet's disease (BD) is an autoimmune disease presented with recurrent oral aphthous ulcers, genital ulcers, uveitis and skin lesions. The cutaneous manifestations are often refractory and more resistant to conventional therapy. This report provides a new treatment of low-dose interleukin-2 (IL-2) with refractory BD patient.

PATIENT CONCERNS

A 37-year-old female patient experienced oral ulcer and erythema nodosum on the right leg for over 12 months and resisted to Methylprednisolone and Thalidomide.

DIAGNOSES

The patient suffered from recurrent painful oral ulceration and an erythema nodosum. Pathergy test is also positive. Thus, we diagnosed her as BD according to the International Criteria for Behçet's Disease (ICBD).

INTERVENTIONS

The patient took Methylprednisolone 8 mg qd, Thalidomide 50 mg qn and Hydroxychloroquine 200 mg bid successively as treatment. However, the medicine didn't take effect. Finally, this patient was given low-dose IL-2 intramuscular injection qod for 3 months.

OUTCOMES

Oral ulcers and the erythema disappeared and the patient has been symptom-free for 6 months.

LESSONS

low-dose IL-2 is a safe and effective treatment for refractory BD.

The efficacy and safety of thalidomide in the treatment of refractory Crohn's disease in adults: a double-center, double-blind, randomized-controlled trial

Background

Thalidomide is applied in therapy for refractory Crohn's disease (CD) in adults, but systematic and rigorous clinical evidence is scant. The aim was to provide theoretical references for the efficacy of thalidomide in the therapy for refractory CD in adults.

Methods

A double-center, double-blind, placebo-controlled, randomized clinical trial of refractory CD in adults in two inflammatory bowel disease centers in China. In the double-blind trial, patients were randomly assigned to 100 mg of thalidomide or placebo daily for 8 weeks. The primary outcome was considered as the clinical remission rate calculated based on the Crohn's disease activity index at the eighth week following thalidomide or placebo treatment. In open label, non-response to placebo was additionally treated with 8 weeks of thalidomide; all responders were continuously treated with thalidomide until the 48th week.

Results

Twenty-five patients were randomly assigned to each group. At the eighth week, the clinical remission rate in the thalidomide group was significantly higher than that in the placebo group (68.0% [17/25] vs 16.0% [4/25]; relative risk, 4.2; 95% confidence interval, 1.8-10.9, P < 0.001). After a 48-week follow-up, the continuous treatment rate of thalidomide was 46.3% (19/41). Adverse events during the whole process were reported in 58.5% of patients, mainly involving drowsiness, rash, and peripheral neuropathy that were mild and tolerable.

Conclusion

Thalidomide can be used in the induction and maintenance therapy of refractory CD in adults. And it could be one of the treatment options for refractory CD.

A Case of a Seven-Year-old boy with Epilepsy with Myoclonic Absence: Importance of Seizure Semiology, Genetic Etiology, and Electroencephalogram Correlation for Timely Intervention

Epilepsy with myoclonic absence (EMA) is a rare disorder with a mean age of onset of 7 years. It is characterized clinically by rhythmic, myoclonic jerking of the head, extremities or both, with impairment of consciousness and an ictal electroencephalogram (EEG) pattern of 3 Hz bilateral, synchronous and symmetrical spike and wave discharges. Prognosis is guarded and most patients are pharmaco-resistant. We present a case of EMA, found to have a FOXP1 gene pathogenic variation and a variance of unknown significance in the MBD5 gene, who was admitted to the intensive care unit in super-refractory status epilepticus. Given the overlap in symptoms of syndromes including myoclonic-astatic epilepsy, childhood absence epilepsy and juvenile myoclonic epilepsy, a detailed seizure semiology with EEG correlation, cannot be over emphasized. In this case, the genetic etiology may lend an interesting insight to the severity and prognosis.

Partial Gastric Resection for Symptomatic Anemia following Diagnosis of Merkel Cell Carcinoma (MCC) of the Skin with Gastric Metastasis

Merkel Cell Carcinoma (MCC) is a rare dermatologic malignancy with significant morbidity and mortality associated with metastatic disease. In this case, we discuss and extremely rare presentation of MCC with metastasis to the stomach in a patient that presented with profound anemia. Unfortunately, mortality following diagnosis of MCC with gastric metastasis approaches 67% at 4 months based on available published reports. Due to its rarity and high rate of mortality, there is a lack of available research and literature to help guide treatment of this rare presentation of MCC. This case report presents a positive outcome associated with a partial gastrectomy for the treatment of symptomatic MCC with gastric metastasis and continued survival with persistently stable hemoglobin at 12 months.

Early characterisation of difficult-to-treat rheumatoid arthritis by suboptimal initial management A multicentre cohort study

OBJECTIVES

To demonstrate that unsuccessful treatment optimisation in early disease is associated with difficult-to-treat rheumatoid arthritis (D2T-RA).

METHODS

In this retrospective multicentre cohort study conducted from 09/2021-03/2022, we enrolled individuals fulfilling the 2010 ACR/EULAR RA criteria diagnosed 2000-2019. The outcome was D2T-RA by the EULAR definition. We used robust regression to examine the associations with delay, dose, duration of methotrexate, and discontinuation of glucocorticoids. We tested through multinomial regression which factors were associated with persistent inflammatory refractory RA (PIRRA) or non-inflammatory refractory RA (NIRRA). Sensitivity analysis included a case-control study matching the year of diagnosis.

RESULTS

We enrolled 48 D2T-RA patients and 145 non-D2T-RA controls. Methotrexate was started within 3 months in 16.7% of D2T-RA vs 33.1% of non-D2T-RA (p= 0.011). Adequate duration of methotrexate was obtained in significantly fewer D2T-RA patients (70.8% vs 85.5%). Glucocorticoids were continued beyond 6 months in a higher proportion of D2T-RA patients (70.8% vs 33.8%, p< 0.001). In multiple regression, treatment delay beyond 3 months (OR 0.3; 95% CI 0.1; 0.9) and non-discontinuation of glucocorticoids after 6 months (OR 4.6; 95% CI 2.2; 9.5) were significantly associated with D2T-RA. Treatment delay was significantly associated with PIRRA only, whilst non-discontinuation of glucocorticoids was significantly associated with PIRRA and NIRRA. Results were replicated in sensitivity analyses.

CONCLUSION

Failure to start methotrexate within 3 months and not being off glucocorticoids within 6 months are early predictive features of D2T-RA.

Knowledge gaps in the management of refractory reflux-like symptoms: Healthcare provider survey

BACKGROUND

Refractory reflux-like symptoms have a substantial impact on patients and healthcare providers. The aim of the survey was to qualitatively assess the needs and attitudes of practicing clinicians around the management of refractory reflux symptoms and refractory gastroesophageal reflux disease (rGERD).

METHODS

An International Working Group for the Classification of Oesophagitis (IWGCO) steering committee invited clinicians to complete an online survey including 17 questions.

KEY RESULTS

Of the 113 clinicians who completed the survey, 70% were GIs, 20% were primary care physicians, and 10% were other specialties. Functional heartburn was considered the most common reason for an incomplete response to proton pump inhibitor (PPI) therapy (82%), followed by stress/anxiety (69%). More GIs identified esophageal hypersensitivity as a cause, while more non-GIs identified esophageal dysmotility and non-reflux-related esophageal conditions. As the first step, most clinicians would order investigations (70-88%). Overall, 72% would add supplemental therapy for patients with partial response, but only 58% for those with non-response. Antacid/alginate was the most common choice overall, while non-GIs were more likely to add a prokinetic than were GIs (47.8 vs. 24.1%). Approximately 40% of clinicians would switch PPIs in patients with partial response, but only 29% would do so in non-responders. Preferences for long-term therapy were highly variable. The most common initial investigation was upper endoscopy. Choice of esophageal manometry and pH monitoring was more variable, with no clear preference for whether pH monitoring should be conducted on, or off, PPI therapy.

CONCLUSIONS AND INFERENCES

The survey identified a number of challenges for clinicians, especially non-GI physicians, treating patients with refractory reflux-like symptoms or rGERD on a daily basis.

TCL-323 Outcome of Relapsed and Refractory Peripheral T-Cell Lymphoma (PTCL) With Intention for Curative Therapy Incorporating High-Dose Chemotherapy and Hematopoietic Stem Cell Transplant (HDC/SCT)

INTRODUCTION

Salvage therapy with high-dose chemotherapy and hematopoietic stem cell transplant (HDC/SCT) is recommended for patients with relapsed/refractory (R/R) PTCL. We evaluated the outcomes of R/R PTCL from the time of first relapse/progression in patients intended for SCT (ITT).

METHODS

The BC Cancer Lymphoid Cancer Database was reviewed, and patients ≥18 years with R/R PTCLs, such as systemic anaplastic large cell lymphoma (ALCL), angioimmunoblastic T-cell lymphoma (AITL), and PTCL-not otherwise specified (PTCL-NOS), were included. Outcomes were assessed from the time of first relapse/progression and from the time of SCT.

RESULTS

Of 114 included patients with ITT R/R PTCL, 60% had refractory disease and were more likely to have a high secondary IPI score, poor performance status, or advanced-stage disease. For second-line therapy, the majority received multi-agent chemotherapy (n = 83, 73%) with GDP, (gemcitabine, dexamethasone, and cisplatin) the most used regimen (n = 59, 52%), whereas 15 patients (13%) received novel agents (brentuximab vedotin [BV] = 12; romidepsin=2; pralatrexate=1). The overall response rate (ORR) to second-line therapy was 61% (24% complete response [CR]; 37% partial response [PR]). The ORR to GDP was 61% (17% CR; 44% PR), with higher responses observed in relapsed patients (81% vs. 41%, p=0.002). Seventy-three patients (63%) received HDC/SCT. Those who underwent allo-SCT were younger and more likely to have refractory disease (50% vs. 16%, p=0.001). Third-line therapy was required in 17/67 (25%), including novel agents in 9 cases. The median follow-up for living patients was 6.8 years. The 5-year progression-free survival (PFS) and overall survival (OS) from the time of first relapse/progression were 28% and 38%, respectively. The 5-year PFS from auto and allo-SCT were 34% and 52% (p = 0.3), and 5-year OS were 44% and 67% (p=0.5), respectively.

CONCLUSIONS

Overall, outcomes for patients with ITT R/R PTCL remain suboptimal, with long-term survival in only one-third of patients; however, over half remained alive at 5 years if they were able to receive an SCT. A third line of therapy may serve as a successful bridge to SCT, and novel agents should be considered. Despite a higher proportion of refractory patients, results are encouraging with allo-SCT.

Refractory Pyoderma Gangrenosum: Stabilized on Colchicine and Tumor Necrosis Factor (TNF) Inhibitor

Pyoderma gangrenosum (PG) is a rare ulcerative, painful inflammatory skin condition that is categorized among neutrophilic dermatoses. We report an otherwise healthy female who initially presented to a dermatology clinic with erythematous nodules and pustules scattered over her legs and thigh, which progressed later to multiple painful ulcers. Upon further investigation, it was diagnosed as idiopathic PG. Prednisone was an initial mainstay of treatment. While tapering, mycophenolate mofetil was started as adjunctive therapy but failed to maintain remission. A tumor necrosis factor inhibitor was initiated alongside colchicine with a significant clinical response.

Reaction Mechanism of CA6, Al2O3 and CA6-Al2O3 Refractories with Refining Slag

In this study, to clarify the corrosion mechanism of CA₆ based refractory by refining slag, the static crucible tests for CA₆, CA₆-Al₂O₃, and Al₂O₃ refractory, were carried out and the detail reaction processes were analyzed from the perspective of thermodynamic simulation and structural evolution. From the results, CaAl₄O₇ plays a vital role in the slag corrosion resistance of the three refractories. Regarding CA₆ refractory, the double pyramid module in CA₆ crystal structure was destroyed very quickly, leading to the rapid collapse of its structure to form the denser CaAl₄O₇ in high amounts. As a result, a reaction layer mainly composed of CaAl₄O₇ formed, which effectively inhibited the slag corrosion, so CA₆ refractory exhibits the most excellent slag corrosion. Meanwhile, the formation of CaAl₄O₇ can also avoid CA₆ particles entering the molten steel to introduce exogenous inclusions. For Al₂O₃ refractory, the generation of CaAl₄O₇ is much slower than that of CA₆ and CA₆-Al₂O₃ refractory, and the amount generated is also quite small, resulting in its worst slag corrosion among the three crucibles. Therefore, CA₆ based refractory has excellent application potential in ladle refining and clean steel smelting.

Tofacitinib as an alternative therapy for refractory intestinal Behçet's syndrome

Background:

Intestinal Behçet’s syndrome is a major cause of morbidity and mortality in Behçet’s syndrome.

Objectives:

Current treatment challenges remain in refractory intestinal Behçet’s syndrome, when patients failed first and second-line therapies.

Design:

We reported the efficacy and safety profiles of tofacitinib in patients with moderate-severe intestinal Behçet’s syndrome in a retrospective single-center study.

Methods:

Treatment with glucocorticoids, immunosuppressors, or even anti-TNFα monoclonal antibodies (mAbs) had previously failed. Primary outcomes were clinical remission or low disease activity and endoscopic healing.

Results:

We included 13 patients; 11 were administered tofacitinib 5 mg twice daily, and 2 took tofacitinib 5 mg once daily. Nine patients achieved clinical remission after a mean treatment duration of 10.1 ± 7.0 months, and the other four had low disease activity. Follow-up endoscopy was available in 11 patients: 5 had achieved mucosal healing; the other 4 achieved marked mucosal improvement. Prednisone dosage was significantly reduced, from 30 (interquartile range: 20–30) mg/d to 2.5 (interquartile range: 0–12.5) mg/d (p < 0.001). No serious adverse event was observed.

Conclusion:

Tofacitinib could be an efficacious and generally well-tolerated option in patients with intestinal Behçet’s syndrome refractory to conventional agents, even anti-TNFα mAbs.

An update on the management of refractory cutaneous lupus erythematosus

Management of cutaneous lupus erythematosus (CLE) involves a combination of preventive measures, topical and systemic drugs, fairly similar for the different subtypes. Although guidelines exist, to date, no specific drugs have been specifically licensed for CLE. Antimalarials remain the first-line systemic treatment, but many patients do not respond, making refractory lupus a challenge for clinicians. The choice of alternative medication should be based on effectiveness, safety and cost. Most of the available drugs for CLE have been adapted from systemic lupus erythematosus (SLE) treatment but the existing literature is limited to small studies and evidence often lacks. As knowledge of pathogenesis of both CLE and SLE is improving, promising new therapies are emerging. In this review, we discuss the available medications, focusing on the novelties under development for CLE.

Efficacy of long-term repeated rituximab treatment in refractory phospholipase A2 receptor-antibody-related membranous nephropathy

Aims: To evaluate the efficacy of long-term repeated rituximab treatment in refractory PLA2R-Ab-related membranous nephropathy (MN). Materials & methods: Rituximab was administered at a single dose of 375 mg/m² and repeated if peripheral B-cell levels were >5/ul in 46 patients with refractory PLA2R-Ab-related MN. Results: The median frequency of rituximab treatment was 3 (IQR 2.0-4.0). A total of 32 (32/46) patients achieved remission (completed remission [CR] or partial remission [PR]) over a median time of 17.0 months, and 10 patients eventually progressed to CR. The proportion of serum PLA2R-Ab depletion was 73.91% (34/46) over a median time of 9 months. Antibody depletion preceded proteinuria remission. Conclusions: Long-term repeated rituximab treatment achieved high kidney and immunological response rates in refractory PLA2R-Ab related MN, and antibody depletion was a prerequisite for proteinuria remission.

JAK Inhibition with Ruxolitinib in Relapsed or Refractory Classical Hodgkin Lymphoma: Final Results of A Phase II, Open Label, Multicenter Clinical Trial (JeRiCHO)

OBJECTIVES

Patients with classical Hodgkin Lymphoma (cHL) relapsing after second-line therapy have a dismal prognosis and novel approaches are required for this patient group. Based on promising (pre-)clinical data and the favorable toxicity profile, we performed a phase II clinical trial with the JAK inhibitor ruxolitinib in patients with relapsed or refractory cHL (r/r cHL).

METHODS

Patients ≥18 years with histologically confirmed r/r cHL who failed second-line treatment were included. Ruxolitinib was given orally at a dose of 25mg twice daily in continuous 28-day cycles until progression or unacceptable toxicity. Primary endpoint was the PET/CT-based overall response rate (ORR; complete response (CR) or partial response (PR)) after 2 cycles; secondary endpoints included progression-free (PFS) and overall survival (OS) as well as feasibility. The Jericho Trial adopted a 2-stage phase 2 design (Simon 1989).

RESULTS

Among the 12 included patients in stage 1, 2 had a PR, 3 had a stable disease (SD) and 6 had progressive disease (PD) after two treatment cycles (ORR: 2/12 evaluable patients, 16.7%). Median PFS was 3.6 months, the 1-year OS estimate was 50.6% (median not reached). The toxicity profile was favorable with only one grade IV adverse event (7.1%) reported.

CONCLUSION

Ruxolitinib exhibited a favorable side effect profile but modest activity in r/r cHL. Although the formal stopping criterion after stage 1 was not met, the trial did not continue to stage 2 due to the low response and PFS rates observed in stage 1. This article is protected by copyright. All rights reserved.

Peculiarities of the Phase Formation during Electroconsolidation of Al2O3-SiO2-ZrO2 Powders Mixtures

This paper is devoted to the sintering process of Al₂O₃-SiO₂-ZrO₂ ceramics. The studied method was electroconsolidation with directly applied electric current. This method provides substantial improvements to the mechanical properties of the sintered samples compared to the traditional sintering in the air. The research covered elemental and phase analysis of the samples, which revealed phase transition of high-alumina solid solutions into mullite and corundum. Zirconia was represented mainly by tetragonal phase, but monoclinic phase was present, too. Electroconsolidation enabled samples to reach a density of 3.0 g/cm³ at 1300 °C, while the sample prepared by traditional sintering method obtained it only at 1700 °C. For the composite Al₂O₃-20 wt.% SiO₂-10 wt.% ZrO₂ fabricated by electroconsolidation, it was demonstrated that fracture toughness was higher by 20-30%, and hardness was higher by 15-20% compared to that of samples sintered traditionally. Similarly, the samples fabricated by electroconsolidation exhibited elastic modulus E higher by 15-20%. The hypothesis was proposed that the difference in mechanical and physical properties could be attributed to the peculiarities of phase formation processes during electroconsolidation.

CD123 Antagonistic Peptides Assembled with Nanomicelles Act as Monotherapeutics to Combat Refractory Acute Myeloid Leukemia

Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults. Due to the development of drug resistance to traditional chemotherapies and high relapse rate, AML still has a low survival rate and there is in an urgent need for better treatment strategies. CD123 is widely expressed by AML cells, also associated with the poor prognosis of AML. In this study, we fabricated nanomicelles loaded with a lab-designed CD123 antagonistic peptide, which were referred to as ^mPO-6. The antagonistic and therapeutic effects were investigated with CD123⁺ AML cell lines and a refractory AML mouse (AE and CKIT^D816V) model. Results show that ^mPO-6 can specifically bind to the CD123⁺ AML cells and inhibit the cell viability effectively. Intravenous administration of ^mPO-6 significantly reduces the percentage of AML cells' infiltration and prolongs the median survival of AML mice. Further, the efficiency of ^mPO-6 is demonstrated to interfere with the axis of CD123/IL-3 via regulating the activation of STAT5, PI3K/AKT, and NF-κB signaling pathways related to cell proliferation or apoptosis at the level of mRNA and protein in vivo and in vitro. In conclusion, the novel CD123 antagonistic peptide micelle formulation ^mPO-6 can significantly enhance apoptosis and prolong the survival of AML mice by effectively interfering with the axis of CD123/IL-3 and therefore is a promising therapeutic candidate for the treatment of refractory AML.

Development and Testing of Castables with Low Content of Calcium Oxide

Colloidal silica is used in many kinds of industry. It is an aqueous dispersion of SiO₂ nanoparticles. SiO₂ colloidal solutions are commercially available in different concentrations, with different particle sizes and are stabilized with different ions. Colloidal SiO₂ was used in this study as a cement replacement in refractory castable. The present study, in its first stage, offers an assessment of five different SiO₂ colloidal solutions. The particle size of the solutions was 15 nm, the particle concentration was 30% and 40% and the colloidal solutions were stabilized with Na⁺, OH^- and Cl^- ions. The effect of the colloidal solutions on selected characteristics of the refractory pastes and on their mineralogical composition after firing at 1000 °C and 1500 °C was described. The most suitable SiO₂ colloidal solution from the first stage was subsequently used for the refractory castable test samples' preparation in the second stage. Refractory castables, unlike paste, contain a coarse aggregate (grog) up to a grain size of 6 mm. Four types of coarse refractory grog were evaluated. Their effect on selected characteristics of the refractory castable and on its mineralogical composition after firing at 1000 °C and 1500 °C was described. The selected characteristics, within the scope of this study, include bulk density, apparent porosity, cold modulus of rupture and linear changes after firing. Finally, the study describes the effect of the sol particle concentration and the effect of pore size distribution on corrosion resistance and on the internal structure of the material. Mineral and chemical compositions and microstructures of both the raw materials and designed aggregates were thoroughly investigated by the means of X-ray fluorescence spectroscopy, powder X-ray diffraction and scanning electron microscopy. An analysis of the transition zone between corrosive media (K₂CO₃) and tested castables showed better corrosion resistance for a sol-gel castable than an ultra-low cement castable.

Corrosive Effect of Wood Ash Produced by Biomass Combustion on Refractory Materials in a Binary Al-Si System

In terms of its chemical composition, biomass is a very complex type of fuel. Its combustion leads to the formation of materials such as alkaline ash and gases, and there is evidence of the corrosive effect this process has on refractory linings, thus shortening the service life of the combustion unit. This frequently encountered process is known as "alkaline oxidative bursting". Corrosion is very complex, and it has not been completely described yet. Alkaline corrosion is the most common cause of furnace-lining degradation in aggregates that burn biomass. This article deals with an experiment investigating the corrosion resistance of 2 types of refractory materials in the Al₂O₃-SiO₂ binary system, for the following compositions: I. (53 wt.% SiO₂/42 wt.% Al₂O₃) and II. (28 wt.% SiO₂/46 wt.% Al₂O₃/12 wt.% SiC). These were exposed to seven types of ash obtained from one biomass combustion company in the Czech Republic. The chemical composition of the ash is a good indicator of the problematic nature of a type of biomass. The ashes were analyzed by X-ray diffraction and X-ray fluorescence. Analysis confirmed that ash composition varies. The experiment also included the calculation of the so-called "slagging/fouling index" (I/C, TA, Sr, B/A, Fu, etc.), which can be used to estimate the probability of slag formation in combustion units. The corrosive effect on refractory materials was evaluated according to the norm ČSN P CEN/TS 15418, and a static corrosion test was used to investigate sample corrosion.

Lateralized subgenual ACC metabolic connectivity patterns in refractory melancholic depression: does it matter?

Although treatment resistance to antidepressant pharmacotherapy is quite common, the phenomenon of refractory major depressive disorder (rMDD) is not well understood. Nevertheless, the metabolic activity of the subgenual anterior cingulate cortex (sgACC) has been put forward as a possible metabolic biomarker of clinical prediction and response, albeit sgACC lateralization differences in functional connectivity have not yet been extensively examined. Also not in the refractory depressed state. To examine sgACC lateralization differences in metabolic connectivity, we recruited 43 right-handed antidepressant-free unipolar melancholic rMDD patients and 32 right-handed healthy controls to participate in this 18FDG PET study and developed a searchlight-based interregional covariance connectivity approach. Compared to non-depressed individuals, sgACC covariance analysis showed stronger metabolic connections with frontolimbic brain regions known to be affected in the depressed state. Furthermore, whereas the left sgACC showed stronger metabolic connections with ventromedial prefrontal cortical regions, implicated in anhedonia, suicidal ideation, and self-referential processes, the right sgACC showed significantly stronger metabolic connections with posterior hippocampal and cerebellar regions, respectively specialized in memory and social processing. Overall, our results substantiate earlier research that the sgACC is a metabolic key player when clinically depressed and that distinct lateralized sgACC metabolic connectivity patterns are present.

Metronomic Cyclophosphamide With Cisplatin and Bevacizumab for Refractory Anaplastic Ependymoma: A Retrospective Study

BACKGROUND/AIM

Anaplastic ependymoma is a rare cancer of the central nervous system. The treatment includes optimal resection with focal radiotherapy. Some case reports or retrospective studies have suggested efficacy of regimens containing platinum or bevacizumab. We describe the feasibility and clinical benefit of the cisplatin-bevacizumab-cyclophosphamide treatment of anaplastic ependymoma.

PATIENTS AND METHODS

Patients were identified through the Adolescent and Young Adults (AYAS) brain tumor national Web conference. We estimated the median progression-free (PFS) and overall survival (OS).

RESULTS

There were eight patients with anaplastic ependymoma, with a median age of 36 years. The median OS was 19.9 months and median PFS was 12.3 months. Three patients obtained partial response, four stable disease, and one patient had disease progression during induction. Six patients received maintenance with a median duration of 224 days.

CONCLUSION

This study confirms the tolerance of bevacizumab-cyclophosphamide-cisplatin treatment of anaplastic ependymoma. The clinical benefit seems even superior to that described in the literature.

Non-Iodine-Avid Disease Is Highly Prevalent in Distant Metastatic Differentiated Thyroid Cancer With Papillary Histology

CONTEXT

Patients with radioactive iodine (RAI) refractory metastatic differentiated thyroid cancer (DTC) have poor prognosis. Early identification of RAI refractoriness may improve care.

OBJECTIVE

This work aimed to characterize DTC patients with distant metastases (DM) at diagnosis who presented with non-iodine-avid disease.

METHODS

Retrospective analyses of DTC patients with DM at diagnosis who presented between 2012 and 2020 were performed. Iodine uptake in DM was correlated with tumor histology and mutational profile. The difference in uptake between BRAFV600E-like (BVL) and RAS-like (RL) cancers based on insights from The Cancer Genome Atlas was evaluated.

RESULTS

Among 78 patients, 48.7% had negative uptake in DM on the first posttherapy scan. Negative scans were highly prevalent in papillary thyroid carcinoma (PTC) with papillary architecture, PTC with BRAFV600E mutation, and PTC with both BRAFV600E and TERT promoter mutations (71.1%, 80.9%, and 100%, respectively). BVL and RL tumors exhibited distinct uptake patterns with negative scan prevalence of 76.9% and 14.3% (P = .005). Multivariate logistical regression confirmed high odds of negative uptake in BVL tumors with either BVL mutations or papillary architecture, 19.8 (95% CI, 2.72-144), and low odds of negative uptake in RL tumors with either RL mutations or follicular architecture, 0.048 (95% CI, 0.006-0.344), after adjusting for age, sex, race, RAI preparation method, bone metastases, and RAI dose. Patients with negative scans were significantly older (62.4 vs 47.0 years, P = .03).

CONCLUSION

Among DTC patients with DM at diagnosis, non-iodine-avid disease is highly prevalent in patients with BVL cancers, particularly with BRAFV600E and TERT promoter mutations, and is associated with an older age. Better strategies are needed to improve RAI treatment response for these patients.

Bevacizumab-containing regimens for children with relapsed or refractory tumors

Background

We aimed to evaluate the effect of bevacizumab-containing regimens (BCRs) on the survival of children with relapsed or refractory solid tumors.

Materials and Methods

Files of children with relapsed or refractory solid tumors treated with BCR were retrospectively reviewed for age, gender, follow-up time, histopathological diagnosis, adverse events observed with BCR, number of chemotherapy protocols used before BCR, the best overall response obtained with BCR, time to progression, number of BCR courses given to patients, the status of patient at last visit, and outcome.

Results

Thirty patients (16 boys, 14 girls) were treated with BCR. The median age at diagnosis was 8.5 (2 - 17) years and at the time of the study was 11 (3-21) years. The median follow-up time was 25.7 (5-79.4) months. The median follow-up time after the start of BCR was 3.2 (1-27) months. Histopathological diagnosis was central nervous system tumors in 25, Ewing sarcoma in two, osteosarcoma in two, and rhabdomyosarcoma in one patient. BCR was given as second-line in 21, third-line in six, and fourth-line protocol in three patients. No chemotherapy toxicity was observed in 22 (73.3%) patients. The best overall response was progressive disease in 17 (56.7%), partial response in seven (23.3%), and stable disease in 6 (20%) patients at first-response evaluation. The median time until progression was 77 (12-690) days. During the study period, 17 patients died of progressive disease.

Conclusion

Our study revealed that adding antiangiogenic agent bevacizumab to cytotoxic chemotherapy provided no survival benefit in children with relapsed or refractory solid tumors.

HLA-haploidentical transplantation for relapsed/refractory AML: better LFS with BM than with PBSC in patients ≥ 55 years of age

The best stem cell source for T-cell replete HLA-haploidentical transplantation with post-transplant cyclophosphamide (PTCy) remains to be determined. In this EBMT retrospective study we analyzed the impact of stem cell source on leukemia-free survival (LFS) in adult patients with primary refractory or relapsed acute myeloid leukemia (AML) given grafts from HLA-haploidentical donors with PTCy as graft-versus-host disease (GVHD) prophylaxis. A total of 668 patients (249 bone marrow (BM) and 419 peripheral blood stem cells (PBSC) recipients) met the inclusion criteria. The use of PBSC was associated with a higher incidence of grade II-IV (HR = 1.59, P = 0.029) and grade III-IV (HR = 2.08, P = 0.013) acute GVHD. There was a statistical interaction between patient age and the impact of stem cell source for LFS (P < 0.01). In multivariate Cox models, among patients <55 years, the use of PBSC versus BM resulted in comparable LFS (HR = 0.82, P = 0.2). In contrast, in patients ≥55 years of age, the use of PBSC versus BM was associated with higher non-relapse mortality (NRM) (HR = 1.7, P = 0.01), lower LFS (HR = 1.37, P = 0.026) and lower overall survival (OS) (HR = 1.33, P = 0.044). In conclusions, our data suggest that in patients ≥55 years of age with active AML at HLA-haploidentical transplantation, the use of BM instead of PBSC as stem cell source results in lower NRM and better LFS. In contrast among younger patients, the use of PBSC results in at least a comparable LFS. This article is protected by copyright. All rights reserved.

Advanced Molecular Characterisation in Relapsed and Refractory Paediatric Acute Leukaemia, the Key for Personalised Medicine

Relapsed and refractory (R/r) disease in paediatric acute leukaemia remains the first reason for treatment failure. Advances in molecular characterisation can ameliorate the identification of genetic biomarkers treatment strategies for this disease, especially in high-risk patients. The purpose of this study was to analyse a cohort of R/r children diagnosed with acute lymphoblastic (ALL) or myeloid (AML) leukaemia in order to offer them a targeted treatment if available. Advanced molecular characterisation of 26 patients diagnosed with R/r disease was performed using NGS, MLPA, and RT-qPCR. The clinical relevance of the identified alterations was discussed in a multidisciplinary molecular tumour board (MTB). A total of 18 (69.2%) patients were diagnosed with B-ALL, 4 (15.4%) with T-ALL, 3 (11.5%) with AML and 1 patient (3.8%) with a mixed-phenotype acute leukaemia (MPL). Most of the patients had relapsed disease (88%) at the time of sample collection. A total of 17 patients (65.4%) were found to be carriers of a druggable molecular alteration, 8 of whom (47%) received targeted therapy, 7 (87.5%) of them in addition to hematopoietic stem cell transplantation (HSCT). Treatment response and disease control were achieved in 4 patients (50%). In conclusion, advanced molecular characterisation and MTB can improve treatment and outcome in paediatric R/r acute leukaemias.

Aberrantly Activated APOBEC3B Is Associated With Mutant p53-Driven Refractory/Relapsed Diffuse Large B-Cell Lymphoma

Tumor protein 53 (TP53) mutation predicts an unfavorable prognosis in diffuse large B-cell lymphoma (DLBCL), but the molecular basis for this association remains unclear. In several malignancies, the cytidine deaminase apolipoprotein B mRNA editing enzyme catalytic subunit 3B (APOBEC3B) has been reported to be associated with the TP53 G/C-to-A/T mutation. Here, we show that the frequency of this mutation was significantly higher in relapsed/refractory (R/R) than in non-R/R DLBCL, which was positively associated with the APOBEC3B expression level. APOBEC3B overexpression induced the TP53 G/C-to-A/T mutation in vitro, resulting in a phenotype similar to that of DLBCL specimens. Additionally, APOBEC3B-induced p53 mutants promoted the growth of DLBCL cells and enhanced drug resistance. These results suggest that APOBEC3B is a critical factor in mutant p53-driven R/R DLBCL and is therefore a potential therapeutic target.

Application of PLASMIC Score in Risk Prediction of Thrombotic Thrombocytopenic Purpura: Real-World Experience From a Tertiary Medical Center in Taiwan

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder caused by severe ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) deficiency (activity <10%). Urgent intervention based on the timely evaluation of ADAMTS13 level is crucial to guide optimal therapy. The recently developed PLASMIC score based on seven items allows the rapid identification of patients at high risk for TTP due to severe ADAMTS13 deficiency. This retrospective study included 31 hospitalized patients with suspicious thrombotic microangiopathy in National Cheng Kung University Hospital from December 2016 to July 2021. Data on ADAMTS13 activity and medical and laboratory information were retrieved from medical records. The PLASMIC score could be calculated in 24 of the 31 patients with available data, and the final cohort was stratified according to the 7-point PLASMIC score. All patients with high PLASMIC score (6-7) exhibited severe ADAMTS13 deficiency (activity ≤10%). One patient with a brain tumor and a PLASMIC score of 6 did not have severe ADAMTS13 activity of ≤10%. The patients in the intermediate- and low risk groups (PLASMIC scores of 5 and 0-4, respectively) exhibited ADAMTS13 activities of above 10%. Given the role of prompt diagnosis in the timely delivery of appropriate therapy, these findings confirm and strengthen the predictive value of the PLASMIC score in patients at high risk for TTP due to severe ADAMTS13 deficiency.

Advanced RAI-refractory thyroid cancer: an update on treatment perspectives

During the last decades, the knowledge on follicular cell-derived thyroid cancer molecular biology has led to the evolution of a number of novel therapies for these tumors, mainly tyrosine kinase inhibitors. Lenvantinib, sorafenib and recently cabozantinib have been approved for differentiated thyroid cancer (DTC), while larotrectinib and entrectinib for neurotrophic-tropomyosin receptor kinase-fusion thyroid cancer. For radioiodine (RAI) refractory DTCs ongoing research aims to identify agents that may restore RAI-avidity via redifferentiation protocols (vemurafenib or dabrafenib and trametinib) or combination treatments. These treatments are based on the tumor molecular signature. The treatment with targeted therapies has changed the therapeutic strategies and the disease prognosis, however drug resistance remains the main reason for treatment failure. Thus, the understanding of both molecular pathways implicated in tumorigenesis, and tumoral escape mechanisms, are of paramount significance for the development of new therapies for DTC. The present review focuses on the molecular landscape of DTC, the approved targeted therapies as well as the mechanisms of drug resistance. Furthermore, it points to the ongoing research and the future perspectives for the development of more efficient drugs for DTC.

Prolonged responses to brentuximab vedotin as last therapy in Hodgkin lymphoma failing autologous transplantation: A case series

The follow-up of the pivotal trial and large case series reports of a proportion of patients, between 5% and 9%, with relapsed or refractory Hodgkin lymphoma failing autologous stem cell transplantation and treated with brentuximab vedotin, achieving and maintaining long lasting complete responses with no further treatment. Very long-term data on the outcomes of such patients are indeed underreported. Our institutional experience with patients meeting these characteristics and in continuous complete response for more than 5 years after brentuximab vedotin was reviewed. Five patients achieved a median duration of complete response of 7.4 (range 5.1-8.1) years, and none of them encountered disease relapse or received any subsequent consolidation, including allogeneic transplantation. A proportion of patients failing autologous transplantation and receiving subsequent brentuximab vedotin may reach a long-lasting complete response with no need of further treatment. These patients are therefore considered cured. The role of allogeneic transplantation in such patients is matter of debate.

The Role of Antimicrobial Resistance in Refractory and Recurrent Bacterial Vaginosis and Current Recommendations for Treatment

Bacterial vaginosis (BV), the most common cause of vaginal discharge, is characterized by a shift in the vaginal microbiota from Lactobacillus species dominance to a diverse array of facultative and strict anaerobic bacteria which form a multi-species biofilm on vaginal epithelial cells. The rate of BV recurrence after therapy is high, often >60%. The BV biofilm itself likely contributes to recurrent and refractory disease after treatment by reducing antimicrobial penetration. However, antimicrobial resistance in BV-associated bacteria, including those both within the biofilm and the vaginal canal, may be the result of independent, unrelated bacterial properties. In the absence of new, more potent antimicrobial agents to eradicate drug-resistant pathogenic vaginal microbiota, treatment advances in refractory and recurrent BV have employed new strategies incorporating combination therapy. Such strategies include the use of combination antimicrobial regimens as well as alternative approaches such as probiotics and vaginal fluid transfer. Our current recommendations for the treatment of refractory and recurrent BV are provided.

A cohort study of guselkumab in the treatment of psoriasis refractory to previous biologic therapies: effectiveness, safety and adherence

Background Guselkumab is indicated for moderate-to-severe plaque psoriasis. Data from real-life clinical practice regarding its use are scarce, especially concerning patients who relapse after previous biologic therapies. Aim This study aimed to evaluate the effectiveness, safety, and adherence to guselkumab in psoriasis refractory to biologic therapies. Method This real-life, retrospective study included patients who initiated guselkumab between February 2019 and October 2020. The main objective was to assess effectiveness, expressed as the psoriasis area and severity index (PASI) ≤5, ≤2 and 0, at the first follow-up medical visit. As secondary effectiveness outcomes, we assessed the body surface area (BSA) and dermatology life quality index (DLQI). We also evaluated adverse events and adherence (using the medication possession ratio [MPR]). Results The study included 35 patients who had previously received a median of two biologic drugs. The median basal PASI score (IQR) was 11 (7.3-15.9), decreasing to 0 (0-1.4) at first follow-up medical visit. At this point, 32 patients (94.1%) reached PASI ≤5, 28 (82.4%) PASI ≤2 and 19 (55.9%) PASI 0. We also found statistically significant improvements in PASI, BSA and DLQI at first follow-up (p<0.001). Three patients developed adverse events. Most patients (N=29, 85.3%) had an MPR ≥90%. The MPR was not associated with PASI score at first follow-up. Conclusion Our study supports evidence that guselkumab is an effective and safe drug in psoriasis refractory to biologic therapies. Adherence to treatment is not related to effectiveness, suggesting that, in some cases, the interval between doses could be increased.

Vincristine, Irinotecan, and Temozolomide in Patients With Relapsed/Refractory Neuroblastoma

Purpose

The combination of irinotecan, temozolomide and vincristine has been proposed as an effective salvage regimen for some pediatric malignancies. Thus, we sought to evaluate this combination for patients with relapsed and refractory neuroblastoma (NB).

Patients and Methods

In this retrospective study, forty-six patients with relapsed or refractory NB were treated with the combination of vincristine (1.5 mg/m² i.v. day 1), irinotecan (50 mg/m²/day i.v. days 1–5) and temozolomide (100 mg/m²/day p.o. days 1–5) (VIT) during the period 2011–2019. All toxicities were documented.

Results

A total of 251 cycles (median 6 cycles/patient) were administered. A complete response (CR) was achieved in 5 patients, partial response (PR) in 27 patients, stable disease (SD) in 8 patients, and progression disease (PD) in 6 patients, with an overall objective response rate (CR+PR) of 69.6%. Eighteen patients developed diarrhea with Grade 3 or less. Grade 1-2 hematologic toxicity occurred in 10 patients. Grade 3-4 hematologic toxicity developed in 32 patients. VIT was an effective regimen for different metastatic sites. UGT1A*28 genotyping performed in 7 patients revealed wild type. Diarrhea occurred in 4 of them.

Conclusion

The shorter, 5-day VIT regimen is an active and well-tolerated salvage regimen in relapse/refractory NB.

Brentuximab vedotin in combination with bendamustine in pediatric patients or young adults with relapsed or refractory Hodgkin lymphoma

Although children and young adults with Hodgkin's lymphoma usually have a favorable prognosis, patients with primary refractory disease and some subsets of relapsed patients still have a dismal outcome. Brentuximab vedotin (BV) in combination with bendamustine may represent a suitable salvage therapy; data on 32 patients aged less than 25 years were retrospectively analyzed. Patients received up to six cycles of treatment of BV 1.8 mg/kg on day 1 and bendamustine 90-120 mg/m² on days 2 and 3. At the end of treatment, the overall response rate was 81%. The 3-year overall and progression-free survivals are 78.1% and 67%, respectively.

Relationships between early age at onset of psychotic symptoms and treatment resistant schizophrenia

AIM

Early age at schizophrenia onset (EOS) has been associated with a worse clinical course, although previous studies reported substantial heterogeneity. Despite the relevance of the subject, the relationship between the age of onset and treatment resistant schizophrenia (TRS) is less clear.

METHODS

We screened 197 non-affective psychotic patients. Of these, 99 suffered from schizophrenia and were putative TRS and were included in a prospective 4-to-8-week trial to assess their response to antipsychotics. According to status (TRS/nonTRS) and age-at-onset (early: ≤18 years, EOS; adult: >18 years, adult onset schizophrenia [AOS]) patients were subdivided in EOS-TRS, EOS-nonTRS, AOS-TRS, AOS-nonTRS. Multiple clinical variables were measured and compared by analysis of covariance (ANCOVA), using age as a covariate. Two-way analysis of variance (ANOVA) was used to assess whether significant differences were attributable to TRS status or age-at-onset.

RESULTS

The rate of TRS patients was significantly higher in EOS compared to AOS. At the ANCOVA, EOS-TRS had significantly worse clinical, cognitive, and psychosocial outcomes compared to the other groups. Overall, EOS-TRS were more impaired than EOS-nonTRS, while significant differences with AOS-TRS were less consistent, albeit appreciable. Two-way ANOVA demonstrated that, in the majority of the investigated variables, the significant differences among groups were attributable to the TRS status effect rather than to age-at-onset or combined effects.

CONCLUSIONS

These results suggest that refractoriness to antipsychotics may be strongly linked to the early onset of psychotic symptoms, possibly as a result of common neurobiology.

Use of Venetoclax in Patients with Relapsed or Refractory Acute Myeloid Leukemia: The PETHEMA Registry Experience

Simple Summary

The use of venetoclax combined with hypomethylating agents or low-dose cytarabine in patients with newly diagnosed acute myeloid leukemia unfit for intensive chemotherapy was recently approved. However, the evidence in relapse or refractory patients is still scarce. The cohort of patients included in our study was heavily pretreated and had a poor performance status. It is still necessary to identify those patients at higher risk of early death who would not benefit from this type of treatment. For these ultra-high-risk patients, other treatment strategies should be followed.

Abstract

The effectiveness of venetoclax (VEN) in relapsed or refractory acute myeloid leukemia (RR-AML) has not been well established. This retrospective, multicenter, observational database studied the effectiveness of VEN in a cohort of 51 RR-AML patients and evaluated for predictors of response and overall survival (OS). The median age was 68 years, most were at high risk, 61% received ≥2 therapies for AML, 49% had received hypomethylating agents, and ECOG was ≥2 in 52%. Complete remission (CR) rate, including CR with incomplete hematological recovery (CRi), was 12.4%. Additionally, 10.4% experienced partial response (PR). The CR/CRi was higher in combination with azacitidine (AZA; 17.9%) than with decitabine (DEC; 6.7%) and low-dose cytarabine (LDAC; 0%). Mutated NPM1 was associated with increased CR/CRi. Median OS was 104 days (95% CI: 56–151). For the combination with AZA, DEC, and LDAC, median OS was 120 days, 104 days, and 69 days, respectively; p = 0.875. Treatment response and ECOG 0 influenced OS in a multivariate model. A total of 28% of patients required interruption of VEN because of toxicity. Our real-life series describes a marginal probability of CR/CRi and poor OS after VEN-based salvage. Patients included had very poor-risk features and were heavily pretreated. The small percentage of responders did not reach the median OS.

A Phase II Trial of a Personalized, Dose-Intense Administration Schedule of 177Lutetium-DOTATATE in Children With Primary Refractory or Relapsed High-Risk Neuroblastoma-LuDO-N

Background

Half the children with high-risk neuroblastoma die with widespread metastases. Molecular radiotherapy is an attractive systemic treatment for this relatively radiosensitive tumor. 131I-mIBG is the most widely used form in current use, but is not universally effective. Clinical trials of 177Lutetium DOTATATE have so far had disappointing results, possibly because the administered activity was too low, and the courses were spread over too long a period of time, for a rapidly proliferating tumor. We have devised an alternative administration schedule to overcome these limitations. This involves two high-activity administrations of single agent 177Lu-DOTATATE given 2 weeks apart, prescribed as a personalized whole body radiation absorbed dose, rather than a fixed administered activity. "A phase II trial of 177Lutetium-DOTATATE in children with primary refractory or relapsed high-risk neuroblastoma - LuDO-N" (EudraCT No: 2020-004445-36, ClinicalTrials.gov Identifier: NCT04903899) evaluates this new dosing schedule.

Methods

The LuDO-N trial is a phase II, open label, multi-center, single arm, two stage design clinical trial. Children aged 18 months to 18 years are eligible. The trial is conducted by the Nordic Society for Pediatric Hematology and Oncology (NOPHO) and it has been endorsed by SIOPEN (https://www.siopen.net). The Karolinska University Hospital, is the sponsor of the LuDO-N trial, which is conducted in collaboration with Advanced Accelerator Applications, a Novartis company. All Scandinavian countries, Lithuania and the Netherlands participate in the trial and the UK has voiced an interest in joining in 2022.

Results

The pediatric use of the Investigational Medicinal Product (IMP) 177Lu-DOTATATE, as well as non-IMPs SomaKit TOC® (68Ga-DOTATOC) and LysaKare® amino acid solution for renal protection, have been approved for pediatric use, within the LuDO-N Trial by the European Medicines Agency (EMA). The trial is currently recruiting. Recruitment is estimated to be finalized within 3-5 years.

Discussion

In this paper we present the protocol of the LuDO-N Trial. The rationale and design of the trial are discussed in relation to other ongoing, or planned trials with similar objectives. Further, we discuss the rapid development of targeted radiopharmaceutical therapy and the future perspectives for developing novel therapies for high-risk neuroblastoma and other pediatric solid tumors.

125I Seed Brachytherapy for Refractory Loco-Regional Recurrence of Non-Anaplastic Thyroid Cancer

Purpose

The purpose of this research was to evaluate the feasibility and efficacy of ¹²⁵I seed brachytherapy as salvage treatment for recurrence from non-anaplastic thyroid cancer refractory to other modalities.

Methods

Between June 2006 and September 2019, fifteen patients with recurrent non-anaplastic thyroid cancer were treated with ¹²⁵I seed brachytherapy. ¹²⁵I seeds were implanted into the tumor under the guidance of CT and/or ultrasound images with the median prescription dose of 120 Gy (range, 100-140 Gy). The median seed number was 80 (range 10-214). Clinical efficacy was evaluated with Response Evaluation Criteria in Solid Tumors.

Findings

Fifteen patients were selected, eleven of whom had papillary carcinoma, two suffered from follicular carcinoma, and two were diagnosed with medullary carcinoma. These patients had twenty-four nodes in total. After they received salvage surgery and/or radioactive iodine (RAI) therapy, local recurrence was detected in all of them. No less than one node was observed in everyone’s cervical or supraclavicular areas, and four patients had lung metastatic. The median follow-up period lasted 48 months (range, 5-93 months). All patients did not develop locoregional recurrence after experiencing ¹²⁵I seed brachytherapy. Only three of them formed new metastases in nontarget regional nodes after brachytherapy, and additional brachytherapy can solve all regional failure problems. No significant adverse events were observed in any patient.

Implications

For the chosen patients, 125I seed brachytherapy is feasible for treating refractory local recurrence from non-anaplastic thyroid cancer. Further studies are required to determine the role of 125I seed brachytherapy in the treatment of thyroid cancer.

Immunotherapy for Refractory Autoimmune Encephalitis

Autoimmune encephalitis (AE) is an immune-mediated disease involving the central nervous system, usually caused by antigen-antibody reactions. With the advent of autoantibody-associated diseases, AE has become a hot research frontier in neuroimmunology. The first-line conventional treatments of autoimmune encephalitis consist of steroids, intravenous immunoglobulin (IVIG), plasma exchange (PLEX), and second-line therapy includes rituximab. Despite considerable research and expanding clinical experience, current treatments are still ineffective for a significant number of patients. Although there is no clear consensus, clinical trial evidence limited, and the level of evidence for some of the drugs based on single reports, third-line therapy is a viable alternative for refractory encephalitis patients. With the current rapid research progress, a breakthrough in the treatment of AE is critical. This article aims to review the third-line therapy for refractory AE

Effectiveness of ustekinumab in patients with refractory Crohn's disease: a multicentre real-life study in Italy

BACKGROUND

The effectiveness of ustekinumab in patients with refractory Crohn's disease (CD) has been investigated in several real-world studies. However, very few data concerning the real-life experience in Italy have been reported. Therefore, this study assessed the effectiveness of ustekinumab in a large cohort of Italian patients with refractory CD.

METHODS

All patients who had started on ustekinumab after failure of or intolerance to antitumour necrosis factor-α (TNF-α) treatment at five tertiary centres between November 2018 and February 2020 were retrospectively enrolled. The coprimary outcome was corticosteroid-free clinical remission, defined as a Harvey-Bradshaw Index (HBI) score of ⩽4, at weeks 26 and 52. The secondary outcomes were changes in the HBI and C-reactive protein (CRP) values at weeks 8, 26, and 52 from baseline and the normalization of CRP in patients with initially abnormal values.

RESULTS

Totally, 140 patients who had previously received at least one anti-TNF-α agent were enrolled; 40.0% received two anti-TNF-α agents and 20.0% received vedolizumab. At baseline, 108 patients (77.1%) had HBI scores of >4; of these, 56.5% and 58.3% achieved corticosteroid-free clinical remission at weeks 26 and 52, respectively. Significant decreases in HBI and CRP values were observed at weeks 8, 26, and 52 in the entire study cohort (all p < 0.0001). The CRP values were normalized in 34.9%, 37.8%, and 49.3% of the patients by weeks 8, 26, and 52, respectively. The baseline HBI score of ⩾8 was a negative predictor of corticosteroid-free clinical remission at week 52 (odds ratio: 0.21, 95% confidence interval: 0.08-0.56, p = 0.002). The probability of remaining on ustekinumab after 52 weeks was 92.1%. Eleven (7.9%) patients discontinued ustekinumab (three for adverse events).

CONCLUSION

Our study findings confirm the effectiveness and safety of ustekinumab in patients with CD after failure of or intolerance to anti-TNF-α therapy.

Clinical and therapeutic value of the adjusted Global Antiphospholipid Syndrome Score in primary obstetric antiphospholipid syndrome

OBJECTIVES

(1) To assess the clinical utility of the adjusted global antiphospholipid syndrome score (aGAPSS) to predict new obstetric events during follow-up in primary obstetric antiphospholipid syndrome (POAPS) patients under standard-of-care treatment (SC) based on the use of low-dose aspirin (LDA) + heparin and (2) to study the risk of a first thrombotic event and to evaluate whether stratification according to this score could help to identify POAPS patients who would benefit from long-term thromboprophylaxis.

METHODS

This is a retrospective, multicentre study. 169 women with POAPS were evaluated for the presence of a new obstetric event and/or a first thrombotic event during follow-up [time period: 2008-2020, median: 7 years (6-12 years)]. The outcomes of 107 pregnancies from these POAPS patients with SC were studied to evaluate relapses. Simple and multivariable logistic regression analyses were performed.

RESULTS

Regarding obstetric morbidity, only triple positivity for antiphospholipid antibodies (aPLs) [OR = 8.462 (95% CI: 2.732-26.210); p < 0.0001] was found to be a strong risk factor independently associated with treatment failure. On the other hand, triple positivity for aPLs [OR=10.44 (95% CI: 2.161-50.469), p = 0.004] and an aGAPSS ≥7 [OR = 1.621 (95% CI: 1.198-2.193), p = 0.002] were independent risk factors associated with a first thrombotic event. LDA was marginally associated with a decrease in the risk of thrombosis only in patients with aGAPSS ≥ 7 (p = 0.048).

CONCLUSION

aGAPSS appears to be useful in predicting the occurrence of a first thrombotic event in POAPS patients, and these stratification of patients could be helpful in selecting patients who would benefit from thromboprophylaxis with LDA.

Outcomes of anti-CD38 isatuximab plus pomalidomide and dexamethasone in five relapsed myeloma patients with prior exposure to anti-C38 daratumumab: case series

Objectives: Daratumumab is the first anti-CD38 monoclonal antibody (Mab) used to treat myeloma in the newly diagnosed setting and in the relapsed setting. Isatuximab, another Mab targeting a specific epitope on the CD38 receptor, was recently approved in the UK in combination with pomalidomide and dexamethasone (IsaPomDex) to treat myeloma patients who received three prior lines of therapy. However, there is a lack of understanding of whether using a prior anti-CD38 Mab (e.g. daratumumab) can affect the efficacy of another Mab (e.g. isatuximab), when the latter is used to treat a subsequent relapse.Methods: We performed a UK-wide outcomes study of IsaPomDex in the real-world. In this case series, we report a detailed descriptive analysis of the characteristics and clinical outcomes of five IsaPomDex patients in UK routine practice (Patients I to V), with a prior exposure to daratumumab.Results: Age range was 51-77 years with two patients >70 and three patients <70 years. The cytogenetic risk was standard in two patients, high in two patients and not known in one patient. Prior daratumumab regimen were monotherapy (dara-mono) in one patient (II), and daratumumab with bortezomib and dexamethasone (DVd) in four patients. Responses to prior daratumumab were: very good partial response (VGPR) in two patients (I and III), minor response-stable disease (MR-SD) in one patient (II), and progressive disease (PD) in two patients (IV and V). Median (range) number of IsaPomDex cycles received was 2 (1-4). Outcomes of IsaPomDex were PD in three patients (II, IV and V) and a response in two patients. Response categories were: MR-SD in patient I and PR in patient III.Discussion: Despite the limitations of our case series, we described the first UK real-world report of IsaPomDex outcomes in myeloma patients with a prior exposure to daratumumab.Conclusion: Large prospective studies are required to further evaluate myeloma outcomes in this setting.