Case Report: Lymphodepletion followed by CAR-T cell therapy with Idecabtagen vicleucel in a patient with severe renal impairment

Acute kidney injury and chronic kidney disease is common in multiple myeloma. Fludarabine which is part of lymphodepletion before CAR-T cell therapy is renally eliminated and its use is not recommended for patients with severe renal impairment defined as a glomerular filtration rate below 30ml/min/1.73m2. We administered fludarabine to a 58-year-old female patient with myeloma-associated severe renal impairment as part of lymphodepletion before Idecabtagen vicleucel infusion. Fludarabine was administered in reduced dose (15mg/m2) and cyclophosphamide with a dose of 300mg/m2 followed by hemodialysis over six hours using a larger filter (FX-100). The therapy was well tolerated with excellent CAR-T cell expansion and complete remission which is ongoing now beyond 12 months.

A Unified Data Architecture for Assessing Motor Symptoms in Parkinson's Disease

INTRODUCTION

The diagnosis and treatment of Parkinson's disease depend on the assessment of motor symptoms. Wearables and machine learning algorithms have emerged to collect large amounts of data and potentially support clinicians in clinical and ambulant settings.

STATE OF THE ART

However, a systematical and reusable data architecture for storage, processing, and analysis of inertial sensor data is not available. Consequently, datasets vary significantly between studies and prevent comparability.

CONCEPT

To simplify research on the neurodegenerative disorder, we propose an efficient and real-time-optimized architecture compatible with HL7 FHIR backed by a relational database schema.

LESSONS LEARNED

We can verify the adequate performance of the system on an experimental benchmark and in a clinical experiment. However, existing standards need to be further optimized to be fully sufficient for data with high temporal resolution.

Development of an immediate release excipient composition for 3D printing via direct powder extrusion in a hospital

3D printing offers the possibility to prepare personalized tablets on demand, making it an intriguing technology for hospital pharmacies. For the implementation of 3D-printed tablets into the digital Closed Loop Medication Management system, the required tablet formulation and development of the manufacturing process as well as the pharmaceutical validation were conducted. The goal of the formulation development was to enable an optimal printing process and rapid dissolution of the printed tablets for the selected model drugs Levodopa/Carbidopa. The 3D printed tablets were prepared by direct powder extrusion. Printability, thermal properties, disintegration, dissolution, physical properties and storage stability were investigated by employing analytical methods such as HPLC-UV, DSC and TGA. The developed formulation shows a high dose accuracy and an immediate drug release for Levodopa. In addition, the tablets exhibit high crushing strength and very low friability. Unfortunately, Carbidopa did not tolerate the printing process. This is the first study to develop an immediate release excipient composition via direct powder extrusion in a hospital pharmacy setting. The developed process is suitable for the implementation in Closed-Loop Medication Management systems in hospital pharmacies and could therefore contribute to medication safety.

Individualized busulfan dosing improves outcomes compared to fixed-dose administration in pre-transplant minimal residual disease-positive acute myeloid leukemia patients with intermediate-risk undergoing allogeneic stem cell transplantation in CR

Pre-transplant minimal residual disease (MRD) impacts negatively on post-transplant relapse risk in acute myeloid leukemia (AML). Therapeutic drug monitoring by calculating area under the curve (AUC) was developed to optimize busulfan (Bu) exposure. Here, we compared post-transplant outcomes after individualized versus fixed busulfan dosage in intermediate-risk AML who achieved CR prior to allograft focusing on pre-transplant flow-MRD. Eighty-seven patients (median, 56 years) with intermediate-risk AML and pre-transplant flow-MRD ("different from normal") were included. Thirty-two patients received individualized busulfan; 54 fixed dosages. Individualized dosage was adjusted in 25/32 patients: increased, n = 18/25 (72%); decreased: n = 7/25 (28%). After median follow-up of 27 months, we observed lower 3-year relapses (6%, 2%-19% vs. 35%, 23%-49% p = 0.02), improved 3-year leukemia-free survival (LFS) (78%, 54%-91% vs. 55%, 40%-70% p = 0.009) and - overall survival (OS) (82%, 60%-93% vs. 69%, 54%-81% p = 0.05) after individualized compared to fixed Bu. Non-relapsed mortality (NRM) and acute graft versus host disease (GvHD) were not different. In multivariate analysis, fixed Bu showed unfavorable impact on OS (hazard ratio [HR] 4.6, p = 0.044), LFS (HR 3.6, p = 0.018) and relapses (HR 3.6, p = 0.033). Fixed Bu also had unfavorable impact on LFS (3.6, 1.1-12.6, p = 0.041) in pre-transplant MRD-positive patients. Individualized, AUC-based, busulfan is associated with lower relapses in intermediate-risk AML patients allografted in CR and may overcome pre-transplant MRD-positivity.

Iron Chelation with Deferasirox Suppresses the Appearance of Labile Plasma Iron During Conditioning Chemotherapy Prior to Allogeneic Stem Cell Transplantation

During conditioning chemotherapy prior to allogeneic haematopoietic stem cell transplantation (HSCT), non-transferrin-bound iron and its chelatable form, labile plasma iron (LPI), regularly appear in the blood of patients at high levels of transferrin saturation (TfS). As these free iron species potentially favor infection and mediate transplantation-associated toxicities, chelation therapy could be an approach to improve outcome after transplantation. However, data addressing iron chelation in the immediate peritransplantation period are sparse. In this study, we investigated the influence of iron chelation with deferasirox during conditioning chemotherapy on the appearance of LPI, the incidence of infection and toxicities, and the tolerability of this treatment in the peritransplantation period. We conducted this single-center prospective observational study in 25 adults with iron overload (serum ferritin >1000 µg/L) undergoing allogeneic HSCT after myeloablative busulfan-based conditioning chemotherapy. Patients received iron chelation with deferasirox (14 mg/kg) from the start of conditioning until day 3 post-transplantation. Iron parameters, including LPI, were obtained at the chelator's trough level daily until day 0 and then on days 4, 7, and 14. Data on infection (bacteremia or invasive fungal disease) and toxicity, as well as the tolerability of deferasirox, were collected until the end of the follow-up period on day 28. Data were analyzed descriptively. TfS levels exceeded 70% in median on 6 days (range, 4 to 10 days) and in 63.6% (range, 36.4% to 90.9%) of the samples per patient, although in 19 of 25 patients (76%), no elevated LPI values were detected during the intake of deferasirox despite high TfS levels. Only 6 patients (24%) showed mildly increased LPI values (≤0.5 units) during the intake of deferasirox, 3 of whom had presented with elevated LPI values before the start of conditioning. Deferasirox was well tolerated, and no aggravation of toxicities was observed. Infection occurred in 5 patients (20%), including 3 of the 6 patients with elevated LPI values despite chelation therapy. In the present study, we demonstrate that iron chelation with deferasirox safely suppresses the appearance of LPI and might decrease the incidence of infection, whereas the impact on transplantation-associated toxicities remains to be elucidated.

Population Pharmacokinetics of Busulfan and Its Metabolite Sulfolane in Patients with Myelofibrosis Undergoing Hematopoietic Stem Cell Transplantation

For patients with myelofibrosis, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative treatment to date. Busulfan-based conditioning regimens are commonly used, although high inter-individual variability (IIV) in busulfan drug exposure makes individual dose selection challenging. Since data regarding the IIV in patients with myelofibrosis are sparse, this study aimed to develop a population pharmacokinetic (PopPK) model of busulfan and its metabolite sulfolane in patients with myelofibrosis. The influence of patient-specific covariates on the pharmacokinetics of drug and metabolite was assessed using non-linear mixed effects modeling in NONMEM^®. We obtained 523 plasma concentrations of busulfan and its metabolite sulfolane from 37 patients with myelofibrosis. The final model showed a population clearance (CL) and volume of distribution (V_d) of 0.217 L/h/kg and 0.82 L/kg for busulfan and 0.021 L/h/kg and 0.65 L/kg for its metabolite. Total body weight (TBW) and a single-nucleotide polymorphism of glutathione-S-transferase A1 (GSTA1 SNP) displayed a significant impact on volume of distribution and metabolite clearance, respectively. This is the first PopPK-model developed to describe busulfan’s pharmacokinetics in patients with myelofibrosis. Incorporating its metabolite sulfolane into the model not only allowed the characterization of the covariate relationship between GSTA1 and the clearance of the metabolite but also improved the understanding of busulfan’s metabolic pathway.

Iron Chelation With Deferasirox Increases Busulfan AUC During Conditioning Chemotherapy Prior to Allogeneic Stem Cell Transplantation

The negative effects of iron overload caused by repetitive blood transfusions and iron release during cytotoxic chemotherapy might be ameliorated by early treatment with an iron chelator. However, in the setting of allogeneic hematopoietic stem cell transplantation (HSCT), chelation therapy is often postponed until the late post-transplantation period because of potential drug interactions. We wanted to systematically investigate the influence of iron chelation with deferasirox on the pharmacokinetics of intravenous busulfan in adult patients in the context of routine therapeutic drug monitoring (TDM) before HSCT. We conducted a single-center, prospective, observational study in 25 adult patients with planned allogeneic HSCT after myeloablative, busulfan-based, TDM-guided conditioning chemotherapy. Busulfan was administered intravenously over 3 hours with an initial dose of 3.2 mg/kg once daily (based on adjusted ideal body weight [AIBW] in overweight patients). Four consecutive dosages were planned to achieve a cumulative area under the curve (AUC) of 80 mg · h/L. Patients received deferasirox for transfusional iron overload as per approval from the start of conditioning until day 3 after transplantation. Model-based calculation of the busulfan AUC was carried out by means of Bayesian prediction based on a population pharmacokinetic model after the first or second dose of busulfan, and dose adjustments were performed accordingly. Calculated median cumulative AUC before dose adjustment was 93.7 mg · h/L (65.1-151.4 mg · h/L), which was considerably above the target AUC of 80 mg · h/L ± 10%. Median dose adjustment was -17.1% (-50.0% to 18.2%), and patients ultimately received busulfan with a median cumulative dose of 10.60 mg/kg (6.38-15.62 mg/kg). A busulfan dose reduction was necessary in 19 patients (76%) whereas a dose increase was only necessary in 1 patient. After dose adjustment the median AUC was 79.7 mg/L · h (62.5 - 84.2 mg/L · h). Median busulfan clearance was 0.134 L/h/kg (0.084-0.203 L/h/kg), which is significantly lower than the average clearance of 0.2 L/h/kg reported in the literature, whereas volume of distribution was not altered. We were able to demonstrate, that TDM is the key point to facilitate a safe co-administration of both medications, because the intake of deferasirox leads to a considerable increase in the busulfan AUC of about 35% to 40%. The reason for the increase in busulfan AUC is a reduction in busulfan clearance by about one third; therefore a lower initial dose of busulfan followed by TDM could be considered in this case.

Evaluation of the Robustness of Therapeutic Drug Monitoring Coupled with Bayesian Forecasting of Busulfan with Regard to Inaccurate Documentation

Background

Inaccurate documentation of sampling and infusion times is a potential source of error in personalizing busulfan doses using therapeutic drug monitoring (TDM). Planned times rather than the actual times for sampling and infusion time are often documented.

Therefore, this study aimed to evaluate the robustness of a limited sampling TDM of busulfan with regard to inaccurate documentation.

Methods

A pharmacometric analysis was conducted in NONMEM® 7.4.3 and “R” by performing stochastic simulation and estimation with four, two and one sample(s) per patient on the basis of a one-compartment- (1CMT) and two-compartment (2CMT) population pharmacokinetic model. The dosing regimens consisted of i.v. busulfan (0.8 mg/kg) every 6 h (Q6H) or 3.2 mg/kg every 24 h (Q24H) with a 2 h- and 3 h infusion time, respectively. The relative prediction error (rPE) and relative root-mean-square error (rRmse) were calculated in order to determine the accuracy and precision of the individual AUC estimation.

Results

A noticeable impact on the estimated AUC based on a 1CMT-model was only observed if uncertain documentation reached ± 30 min (1.60% for Q24H and 2.19% for Q6H). Calculated rPEs and rRmse for Q6H indicate a slightly lower level of accuracy and precision when compared to Q24H. Spread of rPE’s and rRmse for the 2CMT-model were wider and higher compared to estimations based on a 1CMT-model.

Conclusions

The estimated AUC was not affected substantially by inaccurate documentation of sampling and infusion time. The calculated rPEs and rRmses of estimated AUC indicate robustness and reliability for TDM of busulfan, even in presence of erroneous records.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11095-021-03115-8.

The changes of social performance with transcranial magnetic stimulation (TMS) in depressed patients

Objectives

The purpose of this study was investigating the effectiveness of rTMS (repetitive transcranial of magnetic stimulation) on increase social performance in patients with recurrent major depression.

Method

It was used a quasi-experimental, pretest–posttest design with control group, a sample consisting of 32 patients who had depression on the basis of DSM-IV diagnostic criteria, SCID and BDI-II scales and were randomly assigned to two groups.

The experimental group underwent 20 sessions of rTMS as the independent factor and both groups (control & experimental) had 12-session psychotherapy and drugs treatment. Upon the intervention, both groups were tested with two tests (BDI-II & SASS). To determine the effect of the independent factor on the dependent factor of rTMS.

Data were analyzed by t-test.

Results

The comparison between pre- & posttest of all the tests showed the reduction of signs & symptoms of depression, (a = 0/05) (Beck scale P ≤ 0/001 & F = 30) and increase social performance in participants (P ≤ 0/001 & F = 83).

Conclusion

The rTMS is effect in the reduction of signs & symptoms of depression and increase social functioning in recurrent major depression.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Protective effects of Iranian Achillea wilhelmsii essential oil on acetaminophen-induced oxidative stress in rat liver

CONTEXT

Achillea wilhelmsii C. Koch (Asteraceae) is widely used in Iranian traditional medicine.

OBJECTIVE

This in vivo study evaluates the hepatoprotective role of Iranian A. wilhelmsii oils against acetaminophen-induced oxidative damages in rats.

MATERIALS AND METHODS

The animals were divided into five groups: in negative control and control groups, the DMSO and 500 mg/kg acetaminophen were i.p. injected, respectively. In treatment groups, 100 and 200 mg/kg oils and 10 mg/kg BHT were given i.p. immediately after acetaminophen administration. Then, the hepatic oxidative/antioxidant parameters such as lipid peroxidation (LP), glutathione (GSH), superoxide dismutase (SOD), catalase (CAT), and ferric reducing ability of plasma (FRAP) were measured in time intervals (2, 4, 8, 16, and 24 h) after administrations confirmed by histophatological consideration at 24 h.

RESULTS

The results indicated that acetaminophen caused a significant elevation in SOD activity (8-24 h) and LP and FRAP levels (4 h) paralleled with significant decline in GSH level (4 and 8 h). The apparent oxidative injury was associated with evident hepatic necrosis confirmed in histological examination. The presences of A. wilhelmsii oils (100 and 200 mg/kg) with acetaminophen mitigated significantly the rise in SOD, LP, and FRAP levels and restored the GSH compared with the group treated with acetaminophen. These were confirmed by histological examination indicating the hepatic necrosis reversal by the oils.

DISCUSSION AND CONCLUSION

It can be concluded that concomitant administration of A. wilhelmsii oils with acetaminophen may be useful in reversing the drug hepatotoxicity.

Investigation of STW 5 (Iberogast®) preventive effects in experimental sepsis

CONTEXT

STW 5 (Iberogast(®)) is a well known herbal combination drug containing glycosides and flavonoids for which multiple pharmacological properties have been shown.

OBJECTIVE

In this study, attempts were made to assess whether STW 5, an aqueous ethanol solution, has a preventive effect against liver and lung pathological damage in rats after experimental induction of sepsis [cecal ligation and puncture (CLP)].

MATERIALS AND METHODS

Experimental sepsis was induced in rats using CLP operation. The rats (n = 36) were divided into six groups (six/group): Sham-operated (SOP); CLP; CLP + STW 5 (2.5, 5 and 10 mg/kg) and CLP + indomethacin. The drugs were injected intraperitoneally immediately after sepsis induction.

RESULTS

It was found that induction of sepsis 24 h after CLP was associated with significant liver and lung damage, also remaining after STW 5 administration.

DISCUSSION AND CONCLUSION

It appears that STW 5, which has a pronounced efficacy in functional gastro-intestinal diseases, has no effect on septic liver and lung damage in the CLP rat model.

Inhibitory effects of dietary caraway essential oils on 1,2-dimethylhydrazine-induced colon carcinogenesis is mediated by liver xenobiotic metabolizing enzymes

The effects of dietary essential oils prepared from caraway seeds on colon carcinogenesis induced by 1,2-dimethylhydrazine (DMH) in rats has been studied. The number of aberrant crypt foci (ACF) and aberrant crypt (AC) induced by DMH were found to be significantly inhibited in colon of rats treated with essential oils in diet (0.01 and 0.1%). To find out the mechanism(s) by which the essential oils reduced colon premalignancies, plasma, liver, and colon tissues were collected and analyzed for parameters related to oxidative stress and xenobiotic metabolizing enzymes. Lack of influence of caraway extracts on hepatic lipid peroxidation products, superoxide dismutase (SOD), catalase (CAT) and ferric reducing ability of plasma (FRAP) may suggest that the oils do not interfere with these factors. However, it was clearly shown that DMH-related changes in hepatic and colonic cytochrome P4501A1 (CYP1A1) and glutathione S-transferae (GST) activities were recovered in liver but not in colon tissue in animals treated with caraway oil preparations. In conclusion, histopathological and biochemical data clearly showed that inhibition of colon premalignant lesions induced by DMH is mediated by interference of caraway oil components in the activities of the main hepatic xenobiotic metabolizing enzymes.

Frequency of ABO blood group in peptic ulcer disease in Iranian subjects

The relationship between ABO blood group distribution and Peptic Ulcer Disease (PUD) has been widely evaluated in the past. But data concerning the same evaluation are very limited in Iran. This study sought to determine the distribution of ABO blood group in patients with PUD in Iranian subjects. Eighty-one patients with PUD (51 male and 30 female; mean age: 49 +/- 18 years) who attended our endoscopy section were enrolled. Blood samples were used for ABO/Rhesus (Rh) blood group antigen typing. The ABO blood group phenotype distribution in subjects was as follows: 37.1% (30/81) for group A, 23.4% (19/81) for group B, 35.6% (28/81) for group O and 4.9% (4/81) for group AB. Rh positivity was found in 63% (51/81) of patients. In local healthy population, ABO/Rh blood group distribution was 33.8, 20.7, 34.7, 8.4 and 89.6% for A, B, O, AB and Rh, respectively. AB blood group distribution in healthy population was higher than PUD (8.4 vs 4.9%). In contrast, Rh positivity of PUD in Iran is lower than healthy subjects (63 vs 89.6%). Variation in the results of studies is related to different study communities. According to these results, probably ABO/Rh blood group has an important role in patients with peptic ulceration. The functional significance of ABO blood group distribution might be associated with biological behavior of PUD. The impact of blood group on PUD may be a focus for further studies.

Validity and reliability of Infant Neurological International Battery for detection of gross motor developmental delay in Iran

BACKGROUND

Child development screening is important issue for early detection of developmental delay and disability. Children in different environment acquire developmental abilities at different age. In this paper we report the examination of Infant Neurological International Battery (INFANIB) as a screening tool for early detection of gross motor developmental delay in Iran.

METHODS

In this study, we reported the result of a study which was conducted on 6150 consecutive 4- to 18-month infants who were referred form Karaj Health Network (Tehran Province) over a 12-month period. A questionnaire was filled for each child, and an evaluation was carried out with INFANIB by occupational therapists. Assessed infants had been classified in three categories: normal, transiently abnormal and abnormal neuro-development. The transient group infants were divided to normal and abnormal group after 3 months' follow-up. The abnormal group was referred to developmental centre for neuro-developmental examination. For depicting validity of the test, some of the normal, transient and abnormal group was evaluated randomly by paediatrician for neuro-developmental exam and for reliability of test between paediatrician and occupational therapist 54 infants scored randomly by both of them.

RESULTS

The INFANIB was valid for normal and abnormal group with 90% sensitivity, 83% specificity, 79% positive predictive value and 93% negative predictive value (NPV). Also the reliability coefficient between the examiners (paediatrician and occupational therapists) was calculated, and the intraclass correlation coefficient was 0.90.

CONCLUSIONS

Results indicate that INFANIB is proposed as an appropriate screening test in developing countries such as Iran as a reliable measurement of gross motor developmental delay and short time of performing.

Pattern of social interaction in societies of the Asia-Pacific region

The authors developed an 18-item Social Interaction Inventory that yielded a factorial structure based on the 3 domains of social interaction: interpersonal, personal, and extrapersonal. They administered the inventory to samples from 15 countries of the Asia-Pacific region (N = 146). The participants in the different cultural groups preferred to interact more within the interpersonal (in-group) domain as compared with the personal (individual) and extrapersonal (out-group) domains. The findings reflect a collective pattern, rather than an individualistic pattern, of social interaction in the societies of the Asia-Pacific region.

Body consciousness in Dohsa-hou, a Japanese psychorehabilitative program

To seven cerebral palsied children in a special elementary school, Dohsa-hou, a Japanese psychorehabilitative program, was introduced in a pre-post design. With the help of their mothers in writing they rated on a 5-point scale changes in their body consciousness by applying 8 1-hr. sessions of Dohsa-hou training to each child. Analysis suggests a significant positive change after training in body consciousness of these children especially for private as compared to public body consciousness.

Use of dohsa-hou, a Japanese psychorehabilitative program, to guide motor activity of young adults with cerebral palsy

Dohsa-hou, a Japanese psychorehabilitation method for motor training, was introduced to 10 subjects with cerebral palsy in a pre-post (6-wk.) design. Four expert raters were asked to judge the improvement in range of motion, ease and smoothness of movement, correctness of posture) of these subjects. Findings suggest that the training method had a significant effect on body movement as compared to body posture. Since the effect may be peculiar to this subject group, further studies are suggested.