Penthrox enables quicker management of fractures, dislocations and more: learning lessons from expedited care of trauma patients during the COVID-19 pandemic

INTRODUCTION

Methoxyflurane is an historical anaesthetic agent that has undergone a renaissance with the introduction of a smaller dose in a handheld 'Penthrox' device. The benefits of Penthrox include its ease of use, with disposable individual packets, and the need for less monitoring and staff, when compared with deeper sedation. The literature acknowledges its use for analgesia and in the management of anterior shoulder dislocation but in no other procedural orthopaedic circumstance.

METHODS

Following institutional approval, we undertook a retrospective review of all incidences of Penthrox use to facilitate minor procedures within a 2-month period starting 24 March 2020. Time to procedure and success were recorded using the surrogate markers of patient attendance and x-Ray occurrence times.

RESULTS

Some 101 Penthrox doses were given to 89 patients over 97 unique episodes between 24 March and 26 May 2020. No complications were recorded following the use of Penthrox during this period. Patient demographics were explored. Fracture manipulations and casting (n=54) had a 100% success rate in achieving adequate and safe reduction. Joint dislocations (n=34) were treated with varying success. Native elbow dislocations were reduced most successfully (4/4, 100%). Native shoulder dislocations were seen in 17 patients and successful relocation was seen in 11 cases, giving a success rate of 65%.

CONCLUSIONS

This is the first study, outside anterior shoulder dislocations, to report on the efficacy of Penthrox within emergent orthopaedic scenarios. We have demonstrated Penthrox to be a safe tool for helping to manage trauma procedures in the emergency department.

Demographic differences among patients treated with chimeric antigen receptor T-cell therapy in the United States

BACKGROUND

It is not clear if all Americans have benefitted equally from the availability of chimeric antigen receptor T-cell (CART) therapy. We aimed to evaluate if demographic differences existed among adult patients who received CART therapy and to assess predictors of CART treatment outcomes.

METHODS

Records of patients ≥18 years who received CART therapy for non-Hodgkin's lymphoma, acute lymphoblastic leukemia, and multiple myeloma in 2018 were evaluated in the National Inpatient Sample. Acute complications and inhospital mortality were compared between two groups of CART recipients: Whites and non-Whites. Logistic regression analysis was used to evaluate the association between sociodemographic factors and inhospital mortality.

RESULTS

Of 1275 CART recipients that met inclusion criteria, there were 40.4% of females, 66.9% of Whites, Blacks (4.2%), Hispanics (13.3%), Asians or Pacific Islanders (4.2%), and Native Americans (1.3%). Up to 96.8% of CART procedures were performed in urban teaching hospitals, and 85.3% of CART recipients lived in metropolitan counties. Non-Whites, compared to Whites, were younger at the time of CART therapy (p < 0.001). The inhospital mortality rate was higher in non-Whites, though not statistically significant (5.4% vs. 4.4%, p = 0.764). There were no differences in length of hospital stay, hospital charges, or rates of acute toxicities between the two race groups. We found no association between race and treatment outcomes. Gender, neurotoxicity, and Charlson Comorbidity Index were significant predictors of inhospital mortality.

CONCLUSIONS

CART therapy recipients in the United States were more likely to be Whites and more likely to be residents of metropolitan areas. These observed demographic differences were not associated with treatment outcomes or inhospital mortalities.

Male-specific late effects in adult hematopoietic cell transplantation recipients: a systematic review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation

Male-specific late effects after hematopoietic cell transplantation (HCT) include genital chronic graft-versus-host disease (GvHD), hypogonadism, sexual dysfunction, infertility, and subsequent malignancies. They may be closely intertwined and cause prolonged morbidity and decreased quality of life after HCT. We provide a systematic review of male-specific late effects in a collaboration between transplant physicians, endocrinologists, urologists, dermatologists, and sexual health professionals through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research, and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. The systematic review summarizes incidence, risk factors, screening, prevention and treatment of these complications and provides consensus evidence-based recommendations for clinical practice and future research.

Cytogenetically cryptic PML::RARA fusion in acute promyelocytic leukemia: Testing strategies in the modern era

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Cytogenetically cryptic PML::RARA fusions is an exceedingly rare phenomenon in acute promyelocytic leukemia

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Multiple methodologies may be employed for detecting the cryptic PML::RARA fusion

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Concurrent mutations can be identified in cases of acute promyelocytic leukemia with a cryptic PML::RARA fusion; however, a unifying genomic feature remains elusive

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For cases with a high clinical suspicion of acute promyelocytic leukemia and no cytogenetic evidence of a PML::RARA fusion, complementary techniques should be employed for further analysis

Acute promyelocytic leukemia (APL) is a unique leukemia that is characterized by the PML::RARA fusion. This fusion is often detected by conventional karyotype and fluorescence in situ hybridization (FISH); however, rare cases are cryptic and require molecular techniques to identify the PML::RARA fusion. Furthermore, as the incidence of these cases is rare, analysis by a targeted next-generation sequencing (NGS) panel of myeloid associated genes has never been reported. Herein, a clinical APL case is reported where the PML::RARA fusion was detected only by reverse transcriptase-polymerase chain reaction (RT-PCR), thus underscoring the necessity of utilizing complementary techniques when suspicion for APL is present.

Improving the preparedness against an oil spill: Evaluation of the influence of environmental parameters on the operability of unmanned vehicles

When an oil spill occurs, a prompt response reduces significantly the impact. The preparedness and contingency plans are essential to identify the most appropriate technologies. Unmanned and autonomous vehicles (UAVs) is emerging as a powerful tool of strategic potential in the observation, oil tracking and damage assessment of an oil spill. The SpilLess project explored the suitability of these devices to be the first-line response to an oil spill. This work analyses the operational requirements related to environmental parameters following a two steps approach: 1) Environmental characterization from long wind and waves time series and modelling; 2) Definition of the optimal periods for operating each UAVs. We have defined the periods in which each of these facilities acts best, confirming that the operational limits of UAVs are not significantly more restrictive than the traditional operations. UAVs should be included in contingency plans as available tools to fight against oil spills.

The impact of mitral regurgitation grade on exercise capacity following cardiac rehabilitation program after transcatheter aortic valve implantation

Introduction

Severe aortic stenosis (AS) and mitral regurgitation (MR) often coexist. Transcatheter aortic valve implantation (TAVI) is becoming widely used for the treatment of patients (pts) with symptomatic severe AS. However, conflicting data reside concerning the impact of MR on outcomes after TAVI. Also, very few data exist regarding the benefits of a cardiac rehabilitation program (CRP) following TAVI in pts with MR.

Purpose

To evaluate the effect of a CRP in functional parameters after TAVI, particularly in pts with MR grade ≥ II.

Methods

Retrospective study which included all pts submitted to TAVI between 2014 and 2020 that completed a CRP following the procedure. Cardiopulmonary exercise tests (CPET) were performed after TAVI at baseline (pre-CRP) and post-CRP. We evaluated pre- and post-CRP peak oxygen consumption (pVO2), pVO2 at the anaerobic threshold (AT), respiratory exchange ratio (RER), VE/VCO2 and CPET duration. The exercise protocol included low/medium intensity exercises and consisted of sessions 3 times per week carried over 3 months. MR grading severity was assessed with transthoracic echocardiography performed after TAVI and was divided into 2 groups (grade &lt; II vs grade ≥ II).

Results

Fifty-two pts were included, 59,6% were male, mean age of 78,6±8,6 years-old. Mean Society of Thoracic Surgery (STS) risk score was 4,9. Mean pre-TAVI aortic valve area was 0,68 cm2, with a mean gradient of 45,5 mmHg and a mean ejection fraction (EF) of 51%. The majority of pts implanted a self-expandable prosthesis (55,8%).

Twenty-seven (51,9%) pts had MR grade ≥ II. Baseline characteristics were similar between pts with MR grade &lt; II vs MR grade ≥ II, with the exception of the prevalence of coronary artery disease which was higher in MR grade ≥ II (p=0,036). Patients with MR grade &lt; II had higher maximum and median aortic gradients before TAVI (p&lt;0,05 for all). The mean number of cardiac rehabilitation sessions was 21±7, without differences between both groups. In pts with MR grade ≥ II, there was an improvement in CPET duration after CRP (HF protocol from 03:57 min to 05:02 min; p=0,017 and modified Bruce protocol from 06:03 min to 06:41 min; p=0,049) but without significant changes in pVO2 (14,7 mL/kg/min to 14,9 mL/kg/min; p=0,990), RER or VEVCO2/VO2 ratio. Patients with MR grade &lt; II significantly improved pVO2 (13,8 mL/kg/min to 14,7 mL/kg/min; p=0,015), and CPET duration with HF protocol from 05:04 min to 06:23 min; p=0,006 after CRP. There was also an improvement in VEVCO2/VO2 ratio, although not statically significant.

Conclusions

Patients with MR grade &lt; II after TAVI who underwent a CRP significantly improved pVO2 and CPET duration. Although pts with MR grade ≥ II did not improved pVO2 after a CRP, an improvement in CPET duration may translate into a clinical benefit in these pts. These results highlight the importance of further research and personalization among this potentially higher risk subset of pts.

Funding Acknowledgement

Type of funding sources: None.

Impact of depth of clinical response on outcomes of acute myeloid leukemia patients in first complete remission who undergo allogeneic hematopoietic cell transplantation

Acute myeloid leukemia (AML) patients often undergo allogeneic hematopoietic cell transplantation (alloHCT) in first complete remission (CR). We examined the effect of depth of clinical response, including incomplete count recovery (CRi) and/or measurable residual disease (MRD), in patients from the Center for International Blood and Marrow Transplantation Research (CIBMTR) registry. We identified 2492 adult patients (1799 CR and 693 CRi) who underwent alloHCT between January 1, 2007 and December 31, 2015. The primary outcome was overall survival (OS). Multivariable analysis was performed to adjust for patient-, disease-, and transplant-related factors. Baseline characteristics were similar. Patients in CRi compared to those in CR had an increased likelihood of death (HR: 1.27; 95% confidence interval: 1.13-1.43). Compared to CR, CRi was significantly associated with increased non-relapse mortality (NRM), shorter disease-free survival (DFS), and a trend toward increased relapse. Detectable MRD was associated with shorter OS, shorter DFS, higher NRM, and increased relapse compared to absence of MRD. The deleterious effects of CRi and MRD were independent. In this large CIBMTR cohort, survival outcomes differ among AML patients based on depth of CR and presence of MRD at the time of alloHCT. Further studies should focus on optimizing post-alloHCT outcomes for patients with responses less than CR.

Acceptance and commitment therapy for chronic pain: A systematic review

Introduction

Chronic pain is common, costly, and associated with significant disability and negative effects on well-being and mental health. The treatment is challenging, requiring a multidisciplinary approach. Acceptance and commitment therapy (ACT) aims to help patients in engaging in a flexible and persistent pattern of values-directed behavior while in contact with continuing pain and discomfort.

Objectives

To provide an updated review on the efficacy of ACT for the management of chronic pain.

Methods

We conducted a systematic review based on the PubMed® and EBSCO databases up to April 2020.

Results

Fifteen trials were included. The results were in favour of ACT in pain acceptance, functioning and pain intensity with small to large effect sizes. Few studies evaluated quality of life, but half of those were favourable to ACT. We also focused our analysis on ACT online interventions, considering the current demands due to the COVID-19 pandemic.

Conclusions

The current systematic review points in favour of ACT for the management of chronic pain conditions, though the studies included suffered from methodological limitations, which may have led to overestimated effects. Methodologically robust trials are required to further understand the clinical efficacy of ACT for chronic pain and which patients most benefit from this intervention.

Impact of Pretransplantation Renal Dysfunction on Outcomes after Allogeneic Hematopoietic Cell Transplantation

Renal dysfunction is a recognized risk factor for mortality after allogeneic hematopoietic cell transplantation (alloHCT), yet our understanding of the effect of different levels of renal dysfunction at time of transplantation on outcomes remains limited. This study explores the impact of different degrees of renal dysfunction on HCT outcomes and examines whether the utilization of incremental degrees of renal dysfunction based on estimated glomerular filtration rate (eGFR) improve the predictability of the hematopoietic cell transplantation comorbidity index (HCT-CI). The study population included 2 cohorts: cohort 1, comprising patients age ≥40 years who underwent alloHCT for treatment of hematologic malignancies between 2008 and 2016 (n = 13,505; cohort selected given a very low incidence of renal dysfunction in individuals age <40 years), and cohort 2, comprising patients on dialysis at the time of HCT (n = 46). eGFR was measured using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) method. The patients in cohort 1 were assigned into 4 categories-eGFR ≥90 mL/min (n = 7062), eGFR 60 to 89 mL/min (n = 5264), eGFR 45 to 59 mL/min (n = 897), and eGFR <45 mL/min (n=282)-to assess the impact of degree of renal dysfunction on transplantation outcomes. Transplantation outcomes in patients on dialysis at the time of alloHCT were analyzed separately. eGFR <60 mL/min was associated with an increased risk for nonrelapse mortality (NRM) and requirement for dialysis post-HCT. Compared with the eGFR ≥90 group, the hazard ratio (HR) for NRM was 1.46 (P = .0001) for the eGFR 45 to 59 mL/min group and 1.74 (P = .004) for the eGFR <45 mL/min group. Compared with the eGFR ≥90 mL/min group, the eGFR 45 to 59 mL/min group (HR, 2.45; P < .0001) and the eGFR <45 mL/min group (HR, 3.09; P < .0001) had a higher risk of renal failure necessitating dialysis after alloHCT. In addition, eGFR <45 mL/min was associated with an increased overall mortality (HR, 1.63; P < .0001). An eGFR-based revised HCT-CI was also developed and shown to be predictive of overall survival (OS) and NRM, with predictive performance similar to the original HCT-CI. Among 46 patients on dialysis at alloHCT, the 1-year probability of OS was 20%, and that of NRM was 67%. The degree of pretransplantation renal dysfunction is an independent predictor of OS, NRM, and probability of needing dialysis after alloHCT. An eGFR-based HCT-CI is a validated index for predicting outcomes in adults with hematologic malignancies undergoing alloHCT. The outcomes of alloHCT recipients on dialysis are dismal; therefore, one should strongly weigh the significant risks of being on hemodialysis as a factor in determining alloHCT candidacy.

1100. Outcomes of HIV-Associated Lymphoma Treatments: A Contemporary Single Center Cohort Study

Background

There is a paucity of outcome studies on HIV-associated lymphoma treated with chemotherapy with or without autologous hematopoietic stem cell transplantation (autoHSCT) in comparison to HIV-uninfected individuals with similar histology.

Methods

In our retrospective matched cohort study, we enrolled adult HIV-positive patients with lymphoma treated with chemotherapy with (group 2) or without autoHSCT (group 1) between January 1, 2007 to December 31, 2018 at the University of Kansas Medical Center and followed until May 1, 2020. Group 1 were matched 1:1 to HIV-negative patients based on age, gender, lymphoma histology, stage at diagnosis, year of lymphoma diagnosis, and Group 2 were matched 1:2 to HIV-negative patients based on age at autoHSCT, gender, lymphoma histology, stage at diagnosis and year of transplantation. Overall survival (OS) and progression-free survival (PFS) at 2 years were calculated using Kaplan-Meier (KM) analysis, and adjustment for ECOG and IPI/IPS scores was done using multivariate Cox model.

Results

We had 37 HIV+ patients with lymphoma in our cohort: 9 Hodgkin’s disease (HD), 28 Non Hodgkin’s Lymphoma (NHL). Eleven underwent autoHSCT (3 HD, 8 NHL). The majority were white (76.2%), non-hispanic (92.9%), males (90.5%) and mean age was 46 years. Median CD4 was 172.5, HIV viral load was &lt; 50 copies/mL in 43..2%, and 76.2% were on antiretroviral therapy (ART) at diagnosis. ART was interrupted in 14.6% and adjusted in 40.5% of patients. After excluding rare histological types, 22 in group 1 and 9 in group 2 were included in the matched analysis. On KM survival at 2-years, group 1 had worse OS (75% vs 95%, p=0.02), and a trend for worse PFS (75% vs 90%, p=0.07) than the matched referent group, while group 2 had similar OS (100% vs 94%, p= 0.47) and better PFS (100% vs 70%, p=0.02) than the matched referent group. On Cox models adjusting for ECOG and IPI/IPS, HIV status was no longer independently associated with OS in group 1 or PFS in group 2.

Group 1 HIV lymphoma cases and controls characteristics

Conclusion

In patients with HIV and lymphoma treated with chemotherapy with or without autoHSCT, the outcomes are comparable to those without HIV in our single center contempory cohort.

Disclosures

Wissam El Atrouni, MD, ViiV (Advisor or Review Panel member)

1153. Characterization of Invasive Mold Infections in Acute Leukemia and Hematopoietic Stem Cell Transplant Recipient Patients and Risk Factors for Mortality - a Single Center Experience

Background

Invasive mold infections (IMIs) remain a significant cause of morbidity and mortality in patients with acute leukemia (AL) and those undergoing hematopoietic stem cell transplantation (HSCT). We describe the epidemiology of IMIs, the incidence of IMI in patients with acute myelogenous Leukemia (AML) post HSCT, and risk factors for mortality.

Methods

Patients were identified using ICD9 and ICD10 codes using a University of Kansas internal database from 2009-2019, microbiology records, and an AML HSCT database and were followed through May 1^st, 2020. Patients’ electronic medical records were reviewed for inclusion. IMI was defined as proven or probable using the 2009 National Institute of Allergy and Infectious Diseases Mycoses Study Group (MSG) guidelines. Incidence was calculated as IMI cases/100-person-years. Risk factors for overall mortality were evaluated using a Cox regression model.

Results

We included 138 patients: 79 developed IMI after HSCT (8 autologous, 71 allogeneic) and 59 developed IMI after AL diagnosis. Seventeen of the AL patients underwent HSCT after IMI diagnosis (12 within 100 days of IMI). Proven IMI occurred in 45 (32.6%) and probable IMI occurred in 93 (67.4%) patients. The most common prophylactic agent prior to IMI diagnosis was fluconazole (31.2%), with 21.0% receiving none. Aspergillus was the most commonly identified mold with 91 (65.9%) cases. The average treatment duration was 101 (range 0 - 799) days. The incidence of IMI in patients with AML who underwent HSCT was 2.35 cases/100 person-years. All-cause mortality among patients with AL or HSCT who developed IMI was 23.1% at 6 weeks, 34.1% at 12 weeks, and 61.2% at 1 year. On univariate Cox model, Karnofsky performance status > 70 was associated with lower mortality (hazard ratio (HR) 0.317, 95% confidence interval (CI) [0.110, 0.914]) among HSCT recipients. ICU admission within 7 days prior to IMI diagnosis (HR 6.469, 95% CI [1.779, 23.530]) and each one point increase in BMI (HR 1.051, CI [1.001, 1.103]) were associated with increased mortality in the AL group.

Figure 1 - Invasive mold infections by pathogen in HSCT-recipients and acute leukemia patients from 2009-2019.

Figure 2 - Antifungal prophylactic agents prescribed for at least one week at time of IMI diagnosis

Table 1 - Univariate survival analysis calculated using a Cox proportional-hazards regression model among patients who developed IMI after HSCT and patients who developed IMI after acute leukemia diagnosis

Conclusion

IMIs are associated with significant mortality in HSCT recipients and AL patients; patients at higher risk for mortality include those with lower baseline Karnofsky scores, recent ICU admissions, and higher BMI at time of IMI diagnosis.

Disclosures

Wissam El Atrouni, MD, ViiV (Advisor or Review Panel member)

1088. Extracorporeal Photopheresis and Infectious Complications in Patients with Chronic Graft Versus Host Disease

Background

Extracorporeal photopheresis (ECP), is a cell-based immune-modulatory therapy used in the treatment of steroid refractory chronic graft versus host disease (cGHVD). It is unclear whether ECP is associated with an increased risk of infections compared to alternative treatment. We aimed to study the infectious complications in patients who are on ECP post allogeneic hematopoietic stem cell transplant (alloHSCT).

Methods

We conducted a retrospective cohort study of adult patients with cGVHD post alloHSCT who were initiated on ECP or second line immunosuppressive agents (SLIS). The study period was from March 1, 2014 to October 1, 2018. Each subject in the ECP arm was matched to the SLIS arm according to gender, age, underlying disease, and date of diagnosis of cGVHD. All subjects were followed for one-year post treatment. The main outcome was incidence of each type of infection (event rate/ person-years). Kaplan Meier analysis was used, evaluating time to infection with log rank test. The spectrum of infectious complications was described.

Results

Seventy-seven patients were included (36 in ECP and 41 in SLIS arm). Median age was 57.4 years (18.1 -73.4), and 59.7% of patients were male. The most common underlying diseases were acute myeloid leukemia (45.4%), myelodysplastic syndrome (20.8%) and non-Hodgkin’s lymphoma (15.6%). A total occurrence of 94 infections was observed in the ECP arm, compared to 118 in SLIS arm. Bacterial infections accounted for majority of the infections in ECP arm (50%) compared to SLIS arm in which viruses were most common (49.2%). Bacterial pneumonia was the most common clinical syndrome (34% and 27.3%, in the ECP and SLIS arms, respectively). Bacteremia accounted for 12.8% of infections in the ECP arm compared to 16.4% in the SLIS arm. There was no difference in the event rates of infections among the two groups [2.58/ person-years in ECP group vs 3.60/person-years, p = 0.3766], or the probability of infection at any time between the ECP and SLIS group on Kaplan Meier (log rank test, p-value=0.36)(Figure 1).

Kaplan-Meier plot of time to the earliest infection diagnosis between ECP and control group

Conclusion

Bacterial and viral pneumonia were the most common infections in patients undergoing ECP. Overall, ECP does not confer an increased risk of infectious complications compared to second line IS agents.

Disclosures

Wissam El Atrouni, MD, ViiV (Advisor or Review Panel member)

Early discharge after TAVI: should we still be afraid of conduction disturbances?

Introduction

Conduction disturbances (CD) after TAVI remains the most frequent complication of the procedure, frequently increasing the length of hospital stay. A lack of consensus exists regarding in-hospital management of CD post-TAVI.

Purpose

To evaluate if an early discharge (ED) protocol could be safely implemented in patients (pts) with CD post-TAVI.

Methods

Retrospective study of all pts submitted to TAVI between 2016 and 2018. Pts with prior permanent pacemaker (PP) and non-transfemoral approach were excluded. ECG data before, immediately after the procedure and at day 3 post-TAVI were collected, and continuous telemetry monitoring was recorded. We applied a recently proposed ED algorithm (adapted from Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement - JACC Scientific Expert Panel; JACC 2019; 74(8):1086–106) to identify which pts could have been candidates for ED. ED was defined as discharge in the first 72 hours (h) after the procedure. We evaluated if an ED strategy would have been safe at 1-year follow-up (FUP), as defined by the absence of need for PP, syncope and mortality.

Results

242 pts were included, 44,8% males, mean age 80,4 years, mean Euroscore II 5,4 and the majority implanted a self-expandable prosthesis (64,1%). Mean hospital stay after TAVI was 7,7 days. The most frequent CD after TAVI were: new onset left bundle brunch block (36%) and high degree atrioventricular block (HAVB) (16,3%). During hospital stay 21,6% needed PP, mainly because of HAVB (mainly implanted in the first 72h).

According to the proposed algorithm, 70,7% of our pts were ED-candidates. ED-candidates had lower prevalence of predilation (18,5% vs 36,8%, p=0,008) with no significant differences between type of prosthesis or baseline ECG. ED-candidates had smaller PR interval post-TAVI (184,5 vs 202,5 ms, p=0,044) and smaller PR and QRS at 72h (p&lt;0,001 in both).

At 1-year FUP, only 2,3% of ED-candidates needed a PP (vs 37,7% non-ED, p&lt;0,001). It is noteworthy that in those ED-candidates who needed a PP during FUP, the percentage of ventricular pacing was less than 2% at 6 months. In the FUP period, 3,2% of ED candidates presented at the ER because of syncope, with no significant differences to non-ED pts. No differences between groups were found in 30-days and 1-year ER presentation because of syncope or all-cause mortality.

Conclusions

According to the proposed algorithm for ED in pts with CD post-TAVI, pts with specific ECG characteristics and without rhythm events during continuous telemetry monitoring can be early discharged with long-term safety.

Funding Acknowledgement

Type of funding source: None

Myeloablative Conditioning for Allogeneic Transplantation Results in Superior Disease-Free Survival for Acute Myelogenous Leukemia and Myelodysplastic Syndromes with Low/Intermediate but not High Disease Risk Index: A Center for International Blood and Marrow Transplant Research Study

Compared with reduced-intensity conditioning (RIC), myeloablative conditioning (MAC) is generally associated with lower relapse risk after allogeneic hematopoietic cell transplantation (HCT) for acute myelogenous leukemia (AML) and myelodysplastic syndromes (MDS). However, disease-specific risk factors in AML/MDS can further inform when MAC and RIC may yield differential outcomes. We analyzed HCT outcomes stratified by the Disease Risk Index (DRI) in 4387 adults (age 40 to 65 years) to identify the impact of conditioning intensity. In the low/intermediate-risk DRI cohort, RIC was associated with lower nonrelapse mortality (NRM) (hazard ratio [HR], .74; 95% confidence interval [CI], .62 to .88; P < .001) but significantly greater relapse risk (HR, 1.54; 95% CI, 1.35 to 1.76; P < .001) and thus inferior disease-free survival (DFS) (HR, 1.19; 95% CI, 1.07 to 1.33; P = .001). In the high/very high-risk DRI cohort, RIC was associated with marginally lower NRM (HR, .83; 95% CI, .68 to 1.00; P = .051) and significantly higher relapse risk (HR, 1.23; 95% CI, 1.08 to 1.41; P = .002), leading to similar DFS using either RIC or MAC. These data support MAC over RIC as the preferred conditioning intensity for patients with AML/MDS with low/intermediate-risk DRI, but with a similar benefit as RIC in high/very high-risk DRI. Novel MAC regimens with less toxicity could benefit all patients, but more potent antineoplastic approaches are needed for the high/very-high risk DRI group.

Simultaneous Synthesis and Nitrogen Doping of Free-Standing Graphene Applying Microwave Plasma

An experimental and theoretical investigation on microwave plasma-based synthesis of free-standing N-graphene, i.e., nitrogen-doped graphene, was further extended using ethanol and nitrogen gas as precursors. The in situ assembly of N-graphene is a single-step method, based on the introduction of N-containing precursor together with carbon precursor in the reactive microwave plasma environment at atmospheric pressure conditions. A previously developed theoretical model was updated to account for the new reactor geometry and the nitrogen precursor employed. The theoretical predictions of the model are in good agreement with all experimental data and assist in deeper understanding of the complicated physical and chemical process in microwave plasma. Optical Emission Spectroscopy was used to detect the emission of plasma-generated ‘‘building units’’ and to determine the gas temperature. The outlet gas was analyzed by Fourier-Transform Infrared Spectroscopy to detect the generated gaseous by-products. The synthesized N-graphene was characterized by Scanning Electron Microscopy, Raman, and X-ray photoelectron spectroscopies.

Acute myeloid leukemia or myelodysplastic syndrome with chromosome 17 abnormalities and long-term outcomes with or without hematopoietic stem cell transplantation

INTRODUCTION

Chromosome 17 abnormalities, especially disorders of the 17p region and including TP53 gene mutations, result in very low rates of cure for patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) treated with conventional chemotherapy or allogeneic hematopoietic cell transplant (allo-HCT). Our retrospective study analyzed outcomes in patients with chromosome 17 (ch17) abnormalities who received conventional chemotherapy followed by allo-HCT versus those who did not receive a transplant. We analyzed whether poor outcomes extend to patients with all types of ch17 abnormalities and the impact of concomitant TP53 gene mutations assessed by next-generation sequencing (NGS) on prognosis.

METHODS

We retrospectively analyzed diagnostic and outcome data on 98 patients treated at our institution from 2012 to 2018 with AML or MDS who possessed ch17 abnormalities by cytogenetic analysis. The presence of TP53 mutations was analyzed by NGS. Primary endpoint of our study was overall survival (OS).

RESULTS

61 patients with AML and 37 with MDS were included. Complete remission (CR) with first line treatment was similar between induction chemotherapy or hypomethylating agents (HMA), 22.9 % versus 21.6 % (p = 0.33). Median OS for all patients (with or without transplant) was 10 months. Patients with abnormal ch17 in conjunction with any TP53 mutation(s) exhibited worse OS compared to patients without a TP53 mutation (10 versus 23 months, p = 0.02). 30 patients (19 AML, 11 MDS) underwent HCT, with a median OS of 11 months. For AML patients who underwent allo-HCT, 18 were in CR (13 with cytogenetic remission) and 1 had persistent disease at transplant. In the MDS cohort, 3 patients were in CR (2 with cytogenetic remission) and 8 had stable disease. Post allo-HCT survival of AML and MDS cohorts did not differ (p = 0.6), although cytogenetic CR at time of HCT trended towards improved OS (17 versus 8 months; p = 0.6).

CONCLUSIONS

AML/MDS patients with ch17 abnormalities have poor outcomes with or without HCT. Our results show that patients with ch17 abnormalities and TP53 mutations have a significantly poorer survival compared to patients who have ch17 abnormalities but no TP53 mutations. Drugs targeting abnormalities of the p53 pathway, improvement in depth of response prior to HCT, and novel maintenance strategies are needed for improved outcomes in these patients.

Outcomes of daratumumab, pomalidomide, and dexamethasone (DPd) followed by high-dose chemotherapy and autologous stem cell transplantation (HDCT/ASCT) in patients with relapsed/refractory myeloma RRMM

e20508

Background: The number of therapeutic options for patients with RRMM has increased significantly. Our institute treated a series of patients with induction therapy consisting of DPd followed by HDCT/ASCT. We present the early outcomes of these patients. Methods: We treated 16 patients with RRMM at the University of Kansas Health System between May 2016 and October 2019, with DPd as induction therapy followed by HDCT/ASCT. DPd was administered as Daratumumab 16 mg/kg weekly for cycles 1 and 2, every 2 weeks for cycles 3-6, and then every 4 weeks; pomalidomide was dosed at 4 mg orally on days 1-21 of a 28-day cycle; and dexamethasone 20 or 40 mg weekly. Responses were evaluated using the 2016 International Myeloma Working Group (IMWG) criteria. Results: Patients had received a median of two prior regimens. Out of the 16 patients: 81% received ASCT prior to this treatment. In addition, 75%,81% and 68% were refractory to proteasome inhibitors (PI), immunomodulatory agents (IMiDs), and double refractory to IMiDs and PI, respectively. Median time from diagnosis to treatment was 12 months. Median number of DPd cycles received was 4 cycles. A median follow-up of 27 (9-39) months, the overall response rate (ORR) after induction treatment with DPd was 100%. ORR on day 100 post ASCT was 100%, 65% achieved ≥CR, and 81% achieved ≥VGPR. There was no treatment related mortality on day 100. Median progression free survival was 34 months (95%, CI = NA), median overall survival was not reached. The most common grade ≥ 3 adverse events were thrombocytopenia 53%, anemia 40%, neutropenia 53%. Conclusions: DPd as induction therapy followed by HDCT/ASCT demonstrated deep, durable, and clinically meaningful responses with manageable safety profile in patients with RRMM. [Table: see text]

Biological effects and bioaccumulation of gold in gilthead seabream (Sparus aurata) - Nano versus ionic form

The question of whether gold (Au) is more toxic as nanoparticles or in its ionic form remains unclear and controversial. The present work aimed to clarify the effects of 96 h exposure to 4, 80 and 1600 μg·L^-1 of 7 nm gold nanoparticles (AuNPs) - (citrate coated (cAuNPs) or polyvinylpyrrolidone coated (PVP-AuNPs)) - and ionic Au (iAu) on gilthead seabream (Sparus aurata). Effects at different levels of biological organization (behaviour, neurotransmission, biotransformation, oxidative stress/damage and genotoxicity) were assessed. cAuNPs induced oxidative stress and damage (lipid peroxidation increase), even at 4 μg·L^-1, and reduced the ability of S. aurata to swim against a water flow at 1600 μg·L^-1. Exposure to cAuNPs induced more adverse effects than exposure to PVP-AuNPs. All tested concentrations of Au (nano or ionic form) induced DNA breaks and cytogenetic damage in erythrocytes of S. aurata. Generally, iAu induced significantly more effects in fish than the nano form, probably associated with the significantly higher accumulation in the fish tissues. No fish mortality was observed following exposure to AuNPs, but mortality was observed in the group exposed to 1600 μg·L^-1 of iAu.

Size-dependent influence of NOx on the growth rates of organic aerosol particles

Atmospheric new-particle formation (NPF) affects climate by contributing to a large fraction of the cloud condensation nuclei (CCN). Highly oxygenated organic molecules (HOMs) drive the early particle growth and therefore substantially influence the survival of newly formed particles to CCN. Nitrogen oxide (NOx) is known to suppress the NPF driven by HOMs, but the underlying mechanism remains largely unclear. Here, we examine the response of particle growth to the changes of HOM formation caused by NOx. We show that NOx suppresses particle growth in general, but the suppression is rather nonuniform and size dependent, which can be quantitatively explained by the shifted HOM volatility after adding NOx. By illustrating how NOx affects the early growth of new particles, a critical step of CCN formation, our results help provide a refined assessment of the potential climatic effects caused by the diverse changes of NOx level in forest regions around the globe.

Ultra-broadband silicon photonics devices based on subwavelength metamaterials -INVITED

Subwavelength structured waveguides provide tailorable optical properties that can be leveraged to overcome bandwidth limitations in a wide range of photonic devices. In this invited talk, we present an overview of recent developments on subwavelength engineered building blocks, including phase shifters, mode multiplexers, polarization beam splitters and zero-birefringence waveguides.

Microwave plasma-based direct synthesis of free-standing N-graphene

Scheme of ethanol/ammonia plasma driven decomposition pathways considering injection of the nitrogen precursor in “hot” and “mild” plasma zone.

P5739Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: exploring prognostic variables and risk prediction tools

Introduction

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to support patients in cardiogenic shock has been increasing in Portugal over the past few years. Nonetheless, epidemiologic, prognostic and clinical outcome data are scarce.

Purpose

We aim to identify clinical variables with prognostic significance in this challenging population, as well as the performance of various risk scores in mortality prediction.

Methods

All patients that underwent VA-ECMO support at our Cardiac ICU between 2011 and 2018 were included in the analysis. Logistic regression analysis was used to assess the relationship between clinical variables and outcomes.

Results

Short-term mechanical support with VA-ECMO was given to 40 patients, with a mean age of 52±11 years. At the time of the implant, the mean SOFA score was 11.2±4.0, and mean SAVE score was −4.75±4.6. Mean ECMO support duration was 116±96 hours. In 70% (N=28) of patients, VA-ECMO was successfully weaned. In-hospital mortality was observed in 52.5% of patients, which was in accordance with the predicted mortality by SOFA score (22.5% to 82% in our population risk range) and by SAVE score (60 to 70%). Those who placed the VA-ECMO as a bridge to transplant or to long-term mechanical LV assist device had greater in-hospital mortality rates (91.6 vs 41.9%, p=0.013), as well as those under ≥2 inotropic/vasopressors (69.2 vs 21.4%, p=0.012) or when adrenaline use was needed (100% vs 44.1%, p=0.01). No other between-group differences were observed in what concerns short-term mortality. After logistic regression analysis, independent predictors of in-hospital mortality included AMI setting, number of vasoactive amines used, and necessity of a LV venting device. SAVE score had the greater predictive ability in these patients (AUC = 0.638) among the most utilized clinical risk scores (SOFA score AUC = 0.37; APACHE II score AUC = 0.59; SAPS II score AUC = 0.54).

Conclusion

In our analysis, patients in profound cardiogenic shock on VA-ECMO support had slightly better survival rates than predicted by classical Risk Scores. The SAVE score may be the most accurate tool to predict in-hospital mortality in this specific, and yet heterogeneous, clinical subset. Other well recognized clinical markers of severity may also help refine short-term prognosis, and potentially improve organ transplant or other destination therapy prioritization.

Dose to the interventional radiologist in CTF-guided procedures

The aim of this work was to assess the occupational dose received by an interventional radiologist (IR) during computed tomography fluoroscopy (CTF)-guided procedures; to identify the most exposed areas of the body including the hands and fingers; to suggest recommendations for individual monitoring; and to improve radiation safety of the practice. A total of 53 CTF-guided procedures were studied. Twelve whole-body dosimeters were worn by the IR in each procedure for the assessment of the personal dose equivalent, H_p(10), on the chest, waist, and back, both over and under the lead apron, as well as the personal dose equivalent, H_p(0.07), on both arms, knees, and feet. Special gloves with casings to fit extremity dosimeters were prepared to assess H_p(0.07) to the fingers. The measured chest dose values were higher than those on the waist and back; the dominant hand or the left side was the most exposed. In general, the ring, middle, and index fingers of the dominant hand were the most exposed (maximum in the 36-39 mSv range), while wrist dose was negligible compared to finger doses. Based on the results obtained the following recommendations are suggested: protective devices (lead aprons, thyroid shield, and goggles) should be worn; H_p(10) should be assessed at the chest level both above and below the lead apron; finger doses can be measured on the basis of each middle finger; the arm closer to the beam should be monitored; and finally, a wrist dosimeter will not provide useful information.

Femtosecond laser writing of photonic devices in borate glasses compositionally designed to be laser writable

The design and performance of borate glass samples compositionally pre-designed to be femtosecond laser writable via laser-induced ion migration is reported in this Letter. It is demonstrated that borate glasses modified on purpose with small amounts of La₂O₃ and Na₂O can be straightforwardly used to produce high-index contrast (Δn) waveguides by femtosecond-laser-assisted ion migration. The positive Δn of the waveguides is caused by the local enrichment of La₂O₃ in the guiding region with a slope of 8·10^-3(mol.%)^-1. The value of this is consistent with numerical aperture measurements of the waveguides and local compositional measurements at the guiding region performed by energy-dispersive x-ray micro-analysis. The maximum achievable Δn values can be controlled through the initial La₂O₃ content of the glass. Maximum Δn values >10^-2 for samples with just 5.5 mol. % of La₂O₃ have been produced. This compositional design approach could be potentially used to produce highly efficient femtosecond laser writeable glasses in other glass families.

Utility of Routine Surveillance Imaging for Hodgkin Disease following Autologous Transplant: Experiences from a Single Institution

BACKGROUND

Surveillance scans performed after autologous stem cell transplant (auto-HCT) for patients with Hodgkin disease (HD) have no proven survival benefit.

METHODS

We studied survival differences among patients with HD after auto-HCT whose recurrences were detected on clinical history and exam, versus those detected on routine surveillance scan.

RESULTS

Among the 98 patients with HD that underwent auto-HCT from 2000 to 2014 at our institution, 30 relapsed, of which 21 were detected radiologically and 9 clinically. There were no statistically significant differences in patient characteristics between the 2 groups. The median time to progression was 118 days for the clinical cohort and 284 days for the radiological cohort (p = 0.05). Median overall survival (OS) was 728 days for the clinical cohort, and was not reached for the radiological cohort (p = 0.02).

DISCUSSION

In our review, most patients with HD after auto-HCT were diagnosed radiologically. Patients whose relapse was diagnosed clinically were likely to be detected earlier and have a shorter OS. Patients with aggressive disease may be detected when clinically relevant, regardless of scanning. Routine scanning may not be necessary in the majority of patients with HD following auto-HCT.

Microwave plasma enabled synthesis of free standing carbon nanostructures at atmospheric pressure conditions

Schematic representation of the physico-chemical processes involved in the formation of carbon nanostructures in the microwave plasma environment.

Utility of routine surveillance imaging for diffuse large B-cell lymphoma post autologous transplant: A single center experience

Surveillance scans after autologous stem cell transplant (auto-HCT) for patients with relapsed/refractory (RR) diffuse large B Cell lymphoma (DLBCL) have no proven survival benefit. We studied survival differences among patients with RR DLBCL post auto-HCT whose recurrences were detected clinically versus with routine surveillance imaging. Among the 139 patients with RR DLBCL that underwent auto-HCT from 2000 to 2014 at our institution, 37 relapsed: 21 clinical and 16 radiological. The median time to progression was 167 days for the clinical cohort and 565 days for the radiological cohort (p = 0.03), and median overall survival (OS) was 587 days and not reached, respectively (p = 0.006). Most patients with relapsed DLBCL after auto-HCT were diagnosed clinically and were likely to be detected earlier and have a shorter OS. Relapse in patients with aggressive disease will likely be detected when clinically apparent, and the outcome of these patients is independent of the way the relapse is diagnosed. Thus, universal scanning after auto-HCT appears to have little benefit.

Towards large-scale in free-standing graphene and N-graphene sheets

One of the greatest challenges in the commercialization of graphene and derivatives is production of high quality material in bulk quantities at low price and in a reproducible manner. The very limited control, or even lack of, over the synthesis process is one of the main problems of conventional approaches. Herein, we present a microwave plasma-enabled scalable route for continuous, large-scale fabrication of free-standing graphene and nitrogen doped graphene sheets. The method's crucial advantage relies on harnessing unique plasma mechanisms to control the material and energy fluxes of the main building units at the atomic scale. By tailoring the high energy density plasma environment and complementarily applying in situ IR and soft UV radiation, a controllable selective synthesis of high quality graphene sheets at 2 mg/min yield with prescribed structural qualities was achieved. Raman spectroscopy, scanning electron microscopy, high resolution transmission electron microscopy, X-ray photoelectron spectroscopy and Near Edge X-ray-absorption fine-structure spectroscopy were used to probe the morphological, chemical and microstructural features of the produced material. The method described here is scalable and show a potential for controllable, large-scale fabrication of other graphene derivatives and promotes microwave plasmas as a competitive, green, and cost-effective alternative to presently used chemical methods.

Mesenchymal Stromal Cells: What Is the Mechanism in Acute Graft-Versus-Host Disease?

After more than a decade of preclinical and clinical development, therapeutic infusion of mesenchymal stromal cells is now a leading investigational strategy for the treatment of acute graft-versus-host disease (GVHD). While their clinical use continues to expand, it is still unknown which of their immunomodulatory properties contributes most to their therapeutic activity. Herein we describe the proposed mechanisms, focusing on the inhibitory activity of mesenchymal stromal cells (MSCs) at immunologic checkpoints. A deeper understanding of the mechanism of action will allow us to design more effective treatment strategies.

Differences in outcomes between patients whose relapse was diagnosed radiologically versus clinically after autologous transplantation for relapsed/refractory diffuse large B-cell lymphoma

e19001

Background: Surveillance scans performed after autologous stem cell transplant (AutoSCT) for patients with relapsed/refractory (RR) diffuse large B Cell lymphoma (DLBCL) have no proven survival benefit. We studied survival differences among patients with RR DLBCL post AutoSCT whose recurrences were detected on clinical history and exam, versus those detected on routine surveillance scan. Methods: We retrospectively identified 139 patients from our institutional database with DLBCL who underwent AutoSCT from 2000 to 2014. All patients had surveillance scans performed at days 100, 180 and at 1-year post AutoSCT. Results: Among the 139 patients with RR DLBCL that underwent AutoSCT, 37 relapsed, of which 21 were clinical and 16 radiological. There were no statistically significant differences in patient characteristics, although more patients in the clinical cohort had extra-nodal and bulky disease (Table 1). The median time to progression was 167 days for the clinical cohort and 565 days for the radiological cohort (p= 0.03). Median follow-up was 587 days for the clinical cohort and 1503 days for the radiological cohort (p=0.002). Median overall survival (OS) was 587 days for the clinical cohort, and was not reached for the radiological cohort (p=0.006). Conclusions: In our review, most patients with relapsed DLBCL after AutoSCT were diagnosed clinically. Patients whose relapse was diagnosed clinically were likely to be detected earlier and have a shorter OS. Our data indicates that patients with aggressive disease may be detected when clinically relevant, regardless of scanning. Given the known risks of excess radiation exposure, our data suggests that routine scanning may not be necessary in the majority of patients with DLBCL following AutoSCT. [Table: see text]

Validation of the Airway-Dyspnoea-Voice-Swallow (ADVS) scale and Patient-Reported Outcome Measure (PROM) as disease-specific instruments in paediatric laryngotracheal stenosis

OBJECTIVE

To validate the Airway-Dyspnoea-Voice-Swallow (ADVS) instrument as a disease-specific Patient-Reported Outcome Measure in paediatric laryngotracheal stenosis.

DESIGN

Prospective observational study.

SETTING

A quaternary referral centre for complex airway disease.

PARTICIPANTS

Forty-eight patients (30 males) with a mean age of 49 ± 49 months who underwent laryngotracheal surgery or microlaryngoscopy and bronchoscopy (MLB) following laryngotracheal surgery.

MAIN OUTCOME MEASURES

Airway-Dyspnoea-Voice-Swallow summary scale and Patient-Reported Outcome Measure (PROM), Paediatric Quality of Life (PedsQL) scale, Paediatric Voice Handicap Index (pVHI) and Lansky performance scale were administered to patients before and 6-8 weeks following airway examination/surgery.

RESULTS

Most patients (73%) had intubation-related subglottic stenosis, and 60% of patients had prior airway treatments. The majority of patients (77%) had more than one major chronic morbidity, and the commonest procedures were diagnostic MLB (49%), followed by airway dilation (29%). Cronbach-α value for the ADVS PROM was 0.71 overall and 0.85, 0.86 and 0.64 for the dyspnoea, voice and swallow domains, respectively. Rank correlations between Dyspnoea, Voice and Swallow summary scale and PROM scores were 0.83, 0.71 and 0.81, respectively (P < 0.0001). For those patients undergoing diagnostic MLB, pre- and post-examination scores were highly correlated (intraclass correlations >0.75). There was a significant rank correlation between ADVS PROM score and Lansky performance score (r = -0.68; P < 0.0001). There were significant correlations between PROM score and PedsQL (r = -0.57; P < 0.0001) and between voice domain of the PROM and pVHI (r = 0.78; P < 0.0001). There were strong correlations between Myer-Cotton stenosis severity and dyspnoea scale and PROM score (r = 0.68; P < 0.0001). There were significant differences in voice and swallow ADVS scales and PROM scores between patients with and without concomitant laryngeal/oesophageal pathology. Patient age and presence of high dyspnoea and swallowing PROM scores were independently associated with poorer quality of life and performance status.

CONCLUSIONS

These series of observations validate the ADVS instrument as a disease-specific outcome measure for paediatric laryngotracheal stenosis. Dyspnoea and swallowing dysfunction appear to have the greatest impact on quality of life. More widespread adoption of the ADVS instrument could help create a shared language for outcomes communication and benchmarking for children with this complex condition.