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Gladwin MT, Gordeuk VR, Desai PC, Minniti C, Novelli EM, Morris CR, Ataga KI, De Castro L, Curtis SA, El Rassi F, Ford HJ, Harrington T, Klings ES, Lanzkron S, Liles D, Little J, Nero A, Smith W, Taylor JG, Baptiste A, Hagar W, Kanter J, Kinzie A, Martin T, Rafique A, Telen MJ, Lalama CM, Kato GJ, Abebe KZ. Riociguat in patients with sickle cell disease and hypertension or proteinuria (STERIO-SCD): a randomised, double-blind, placebo controlled, phase 1-2 trial. Lancet Haematol 2024:S2352-3026(24)00045-0. [PMID: 38554715 DOI: 10.1016/s2352-3026(24)00045-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Although nitric oxide based therapeutics have been shown in preclinical models to reduce vaso-occlusive events and improve cardiovascular function, a clinical trial of a phosphodiesterase 5 inhibitor increased rates of admission to hospital for pain. We aimed to examine if riociguat, a direct stimulator of the nitric oxide receptor soluble guanylate cyclase, causes similar increases in vaso-occlusive events. METHODS This was a phase 1-2, randomised, double blind, placebo-controlled trial. Eligible patients were 18 years or older, had confirmed sickle cell disease documented by haemoglobin electrophoresis or HPLC fractionation (haemoglobin SS, SC, Sβ-thalassemia, SD, or SO-Arab), and stage 1 hypertension or proteinuria. Participants were randomly assigned 1:1 to receive either riociguat or matching placebo via a web-based system to maintain allocation concealment. Both treatments were administered orally starting at 1·0 mg three times a day up to 2·5 mg three times a day (highest tolerated dose) for 12 weeks. Dose escalation by 0·5 mg was considered every 2 weeks if systolic blood pressure was greater than 95 mm Hg and the participant had no signs of hypotension; otherwise, the last dose was maintained. The primary outcome was the proportion of participants who had at least one adjudicated treatment-emergent serious adverse event. The analysis was performed by the intention-to-treat. This trial is registered with ClinicalTrials.gov (NCT02633397) and was completed. FINDINGS Between April 11, 2017, and Dec 31, 2021, 165 participants were screened and consented to be enrolled into the study. Of these, 130 participants were randomly assigned to either riociguat (n=66) or placebo (n=64). The proportion of participants with at least one treatment-emergent serious adverse event was 22·7% (n=15) in the riociguat group and 31·3% (n=20) in the placebo group (difference -8·5% [90% CI -21·4 to 4·5]; p=0·19). A similar pattern emerged in other key safety outcomes, sickle cell related vaso-occlusive events (16·7 [n=11] vs 21·9% [n=14]; difference -5·2% [-17·2 to 6·5]; p=0·42), mean pain severity (3·18 vs 3·32; adjusted mean difference -0·14 [-0·70 to 0·42]; p=0·69), and pain interference (3·15 vs 3·12; 0·04 [-0·62 to 0·69]; p=0·93) at 12 weeks were similar between groups. Regarding the key clinical efficacy endpoints, participants taking riociguat had a blood pressure of -8·20 mm Hg (-10·48 to -5·91) compared with -1·24 (-3·58 to 1·10) in those taking placebo (-6·96 mm Hg (90% CI -10·22 to -3·69; p<0·001). INTERPRETATION Riociguat was safe and had a significant haemodynamic effect on systemic blood pressure. The results of this study provide measures of effect and variability that will inform power calculations for future trials. FUNDING Bayer Pharmaceuticals.
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Affiliation(s)
- Mark T Gladwin
- University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Victor R Gordeuk
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Payal C Desai
- Levine Cancer Institute, Atrium Health, Wake Forest School of Medicine, Charlotte, NC, USA
| | | | - Enrico M Novelli
- Department of Medicine, Division of Hematology and Oncology, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Claudia R Morris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kenneth I Ataga
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Laura De Castro
- Department of Medicine, Division of Hematology and Oncology, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA; Georgia Comprehensive Sickle Cell Clinic at Grady Health System, Atlanta, GA, USA
| | - Hubert James Ford
- Pulmonary Hypertension Program, Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas Harrington
- Division of Hematology, Department of Medicine, University of Miami, Miami, FL, USA
| | - Elizabeth S Klings
- The Pulmonary Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sophie Lanzkron
- Sickle Cell Center for Adults, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Darla Liles
- Brody School of Medicine East Carolina University, Greenville, NC, USA
| | - Jane Little
- University of North Carolina Comprehensive Sickle Cell Disease Program and Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alecia Nero
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wally Smith
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - James G Taylor
- Center for Sickle Cell Disease, Departments of Medicine (Hematology and Oncology) and Microbiology and Immunology, Howard University College of Medicine, Washington, DC, USA; Department of Food and Human Nutrition Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ayanna Baptiste
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Ward Hagar
- Internal Medicine, Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Julie Kanter
- Hematology Oncology, Department of Internal Medicine, University of Alabama Birmingham, Birmingham, AL, USA
| | - Amy Kinzie
- Sickle Cell Center of Southern Louisiana, Tulane University School of Medicine, New Orleans, LA, USA
| | - Temeia Martin
- Medical University of South Carolina, Charleston, SC, USA
| | - Amina Rafique
- Sickle Cell Center of Southern Louisiana, Tulane University School of Medicine, New Orleans, LA, USA
| | - Marilyn J Telen
- Division of Hematology, Department of Medicine, Duke University School of Medicine, and Duke Comprehensive Sickle Cell Center, Durham, NC, USA
| | - Christina M Lalama
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Clinical Trials & Data Coordination, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gregory J Kato
- Department of Medicine, Division of Hematology and Oncology, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kaleab Z Abebe
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Clinical Trials & Data Coordination, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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2
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Nakahara H, Cheedarla N, Verkerke HP, Cheedarla S, Wu SC, Hendrickson JE, Chang A, McLemore ML, El Rassi F, Roback JD, Neish AS, Fasano RM, Stowell SR. Enhanced IgG immune response to COVID-19 vaccination in patients with sickle cell disease. Br J Haematol 2023; 202:937-941. [PMID: 37287128 PMCID: PMC10751105 DOI: 10.1111/bjh.18899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/09/2023]
Abstract
Patients with sickle cell disease (SCD) are considered to be immunocompromised, yet data on the antibody response to SARS-CoV-2 vaccination in SCD is limited. We investigated anti-SARS-CoV-2 IgG titres and overall neutralizing activity in 201 adults with SCD and demographically matched non-SCD controls. Unexpectedly, patients with SCD generate a more robust and durable COVID-19 vaccine IgG response compared to matched controls, though the neutralizing activity remained similar across both cohorts. These findings suggest that patients with SCD achieve a similar antibody response following COVID-19 vaccination compared to the general population, with implications for optimal vaccination strategies for patients with SCD.
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Affiliation(s)
- Hirotomo Nakahara
- Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Narayanaiah Cheedarla
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hans P Verkerke
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suneethamma Cheedarla
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shang-Chuen Wu
- Joint Program in Transfusion Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeanne E Hendrickson
- Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andres Chang
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Morgan L McLemore
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - John D Roback
- Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrew S Neish
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ross M Fasano
- Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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3
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Clarke K, Shin YM, Hall MAK, Moussa M, McLemore M, El Rassi F. Presentations and outcomes among sickle cell disease patients with COVID-19 at a large southern healthcare system. Expert Rev Hematol 2023; 16:151-156. [PMID: 36562409 DOI: 10.1080/17474086.2023.2162500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Compared with the general population, patients with sickle cell disease (SCD) typically have substantially reduced life expectancies. It is unclear whether SCD patients who acquire COVID-19 have higher rates of complications and mortality than the general population. We sought to elucidate COVID-19 presentation and outcomes in patients with SCD. METHODS Using retrospective chart review, we evaluated demographic characteristics, presenting symptoms, chest imaging findings, blood transfusion requirements, need for mechanical ventilation or pressor support, medication administration (including remdesivir and dexamethasone), and survival among individuals with SCD hospitalized with COVID-19 from March 2020 to December 2021. RESULTS Among 72 SCD patients, increased pain was the most common presenting symptom followed by cough, fever, and dyspnea. Thirty-seven (44%) received simple transfusion and 14 (17%) underwent exchange transfusion. Lung imaging findings suggestive of COVID-19 were observed in 27 (37%) patients; 21 (29%) patients were treated with remdesivir and 26 (35%) received dexamethasone. Three patients (4%) required mechanical ventilation and pressor support; all three died from COVID complications. CONCLUSIONS Pain is the most common presenting symptom in SCD patients with COVID-19. We observed a mortality rate higher than that among the general population among patients who required mechanical ventilation and pressor support.
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Affiliation(s)
- Karen Clarke
- Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Yoo Mee Shin
- Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Mary Ann Kirkconnell Hall
- Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohamad Moussa
- Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Morgan McLemore
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
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4
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Amarapurkar P, Roberts L, Navarrete J, El Rassi F. Sickle Cell Disease and Kidney. Adv Chronic Kidney Dis 2022; 29:141-148.e1. [PMID: 35817521 DOI: 10.1053/j.ackd.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/01/2022] [Accepted: 03/10/2022] [Indexed: 11/11/2022]
Abstract
Sickle cell disease causes several kidney manifestations. They include defects in urine concentration, impaired handling of potassium and hydrogen ion, albuminuria, acute kidney injury, and chronic kidney disease to name a few. Glomerular hyperfiltration, tubular hyperfunctioning, endothelial damage from repeated sickling and vaso-occlusive episodes, and iron-induced proinflammatory changes in the glomerular mesangium and tubulointerstitium are some of the mechanisms of kidney damage. Albuminuria is one of the most and common clinical features of kidney disease and progresses with age. Kidney disease in patients with sickle cell is associated with increased mortality. Annual screening for proteinuria starting at age 10 years and limiting the use of nonsteroidal anti-inflammatory agents and the use of angiotensin-converting enzyme inhibitors may help in early detection and delaying the progression of kidney disease. Adequate hydration, angiotensin-converting enzyme inhibitors, and adequate control of sickle cell are the main stay of treatment for albuminuria. The hemoglobin goal for patients with sickle cell nephropathy is lesser (10 g/dL) than that for patients with chronic kidney disease due to other causes given that a higher hemoglobin level increases viscosity and the risk of precipitating vaso-occlusive episodes. A multidisciplinary approach is recommended for managing patients with sickle cell and kidney diseases.
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Affiliation(s)
- Pooja Amarapurkar
- Division of Renal Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Levard Roberts
- Division of Renal Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jose Navarrete
- Division of Renal Medicine, Emory University School of Medicine, Atlanta, GA
| | - Fuad El Rassi
- Associate Professor of Hematology and Medical Oncology, Emory University School of Medicine, Director of Sickle Cell Research, Georgia Comprehensive Sickle Cell Center at Grady Health System, Winship Cancer Institute of Emory University, Atlanta, GA
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5
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Clarke K, Benameur K, Wiley Z, Shin YM, Moussa M, El Rassi F, McLemore M. Catastrophic Neurological Complications in 2 Patients With Sickle Cell Disease and COVID-19. J Investig Med High Impact Case Rep 2022; 10:23247096221111778. [PMID: 35850596 PMCID: PMC9301110 DOI: 10.1177/23247096221111778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/11/2022] [Accepted: 06/18/2022] [Indexed: 11/25/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection is commonly associated with neurological complications. Patients with sickle cell disease are at increased risk of developing neurologic complications throughout their lifetimes and often have underlying cardiopulmonary comorbidities that may predispose them to poor outcomes during serious infections. In this case series, we describe 2 patients with sickle cell disease who developed devastating neurologic complications following SARS-CoV-2 infection, which ultimately led to brain edema and death. We highlight the unusual manifestations of coronavirus disease 2019 in patients with sickle cell disease and address the risk of these patients to develop catastrophic neurologic injury due to COVID-19, if not recognized promptly.
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Affiliation(s)
- Karen Clarke
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Karima Benameur
- Department of Neurology, Emory University
School of Medicine, Atlanta, GA, USA
| | - Zanthia Wiley
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Yoo Mee Shin
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Mohamad Moussa
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Fuad El Rassi
- Department of Hematology and Medical
Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Morgan McLemore
- Department of Hematology and Medical
Oncology, Emory University School of Medicine, Atlanta, GA, USA
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6
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Osunkwo I, Andemariam B, Minniti CP, Inusa BPD, El Rassi F, Francis‐Gibson B, Nero A, Trimnell C, Abboud MR, Arlet J, Colombatti R, Montalembert M, Jain S, Jastaniah W, Nur E, Pita M, DeBonnett L, Ramscar N, Bailey T, Rajkovic‐Hooley O, James J. Impact of sickle cell disease on patients' daily lives, symptoms reported, and disease management strategies: Results from the international Sickle Cell World Assessment Survey (SWAY). Am J Hematol 2021; 96:404-417. [PMID: 33264445 PMCID: PMC8248107 DOI: 10.1002/ajh.26063] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 11/26/2020] [Accepted: 11/29/2020] [Indexed: 12/20/2022]
Abstract
Sickle cell disease (SCD) is a genetic disorder, characterized by hemolytic anemia and vaso‐occlusive crises (VOCs). Data on the global SCD impact on quality of life (QoL) from the patient viewpoint are limited. The international Sickle Cell World Assessment Survey (SWAY) aimed to provide insights into patient‐reported impact of SCD on QoL. This cross‐sectional survey of SCD patients enrolled by healthcare professionals and advocacy groups assessed disease impact on daily life, education and work, symptoms, treatment goals, and disease management. Opinions were captured using a Likert scale of 1‐7 for some questions; 5‐7 indicated “high severity/impact.” Two thousand one hundred and forty five patients (mean age 24.7 years [standard deviation (SD) = 13.1], 39% ≤18 years, 52% female) were surveyed from 16 countries (six geographical regions). A substantial proportion of patients reported that SCD caused a high negative impact on emotions (60%) and school achievement (51%) and a reduction in work hours (53%). A mean of 5.3 VOCs (SD = 6.8) was reported over the 12 months prior to survey (median 3.0 [interquartile range 2.0‐6.0]); 24% were managed at home and 76% required healthcare services. Other than VOCs, fatigue was the most commonly reported symptom in the month before survey (65%), graded “high severity” by 67% of patients. Depression and anxiety were reported by 39% and 38% of patients, respectively. The most common patient treatment goal was improving QoL (55%). Findings from SWAY reaffirm that SCD confers a significant burden on patients, epitomized by the high impact on patientsʼ QoL and emotional wellbeing, and the high prevalence of self‐reported VOCs and other symptoms.
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Affiliation(s)
- Ifeyinwa Osunkwo
- Sickle Cell Disease Enterprise The Levine Cancer Institute, Atrium Health Charlotte North Carolina USA
| | - Biree Andemariam
- New England Sickle Cell Institute, University of Connecticut Health Farmington Connecticut USA
| | | | - Baba P. D. Inusa
- Evelina Childrenʼs Hospital Guyʼs and St Thomasʼ NHS Foundation Trust London UK
| | - Fuad El Rassi
- Emory University School of Medicine and Georgia Comprehensive Sickle Cell Center at Grady Health System Atlanta Georgia USA
| | | | - Alecia Nero
- University of Texas Southwestern Medical Center Dallas Texas USA
| | | | | | - Jean‐Benoît Arlet
- Sickle Cell Disease Referral Centre, Internal Medicine Department, Hôpital Européen Georges‐Pompidou, AP‐HP Université de Paris Paris France
| | | | | | - Suman Jain
- Thalassemia and Sickle Cell Society Hyderabad India
| | | | - Erfan Nur
- Academic Medical Center Amsterdam The Netherlands
| | - Marimilia Pita
- Pediatric Hematology, Hospital Samaritano Laureate University‐UAM São Paulo Brazil
| | - Laurie DeBonnett
- Novartis Pharmaceuticals Corporation East Hanover New Jersey USA
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7
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Haydek JP, Taborda C, Shah R, Reshamwala PA, McLemore ML, Rassi FE, Chawla S. Extreme hyperbilirubinemia: An indicator of morbidity and mortality in sickle cell disease. World J Hepatol 2019; 11:287-293. [PMID: 30967906 PMCID: PMC6447425 DOI: 10.4254/wjh.v11.i3.287] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 01/16/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sickle cell disease (SCD) is a disorder that results in increased hospitalizations and higher mortality. Advances in management have resulted in increases in life expectancy and led to increasing awareness of sickle cell hepatopathy (SCH). However, its impact in patients on the natural history and outcomes of SCD is not known. Our study aims to describe the prevalence of extreme hyperbilirubinemia (EH), one form of SCH, its effect on morbidity and mortality, and correlations between sickle cell genotype and SCH type. We hypothesize that EH is associated with higher morbidity and mortality.
AIM To investigate the effects of EH on morbidity and mortality among patients with SCD.
METHODS This retrospective cohort study was performed using a database of patients with SCD treated at Grady Memorial Hospital between May 2004 and January 2017. Patients with EH (defined as total bilirubin above 13.0 mg/dL) were identified. A control group was identified from the same database with patients with total serum bilirubin ≤ 5.0 mg/dL. Electronic medical records were used to extract demographic information, laboratory values, radiology results, current medications, need for transfusions and mortality data. Two samples T-test, chi-squared test and Fisher’s exact test were then used to compare the parameters between the two groups.
RESULTS Out of the database, fifty-seven charts were found of patients with bilirubin > 13 mg/dL. Prevalence of severe SCH as defined by EH was 4.8% (57/1172). There were no demographic differences between patients with and without EH. Significant genotypic differences existed between the two groups, with hemoglobin SS SCD being much higher in the EH group (P < 0.001). Patients with severe EH had a significant elevations in alanine aminotransferase (157.0 ± 266.2 IU/L vs 19.8 ± 21.3 IU/L, P < 0.001), aspartate aminotransferase (256.5 ± 485.9 U/L vs 28.2 ± 14.7 U/L, P < 0.001) and alkaline phosphatase (218.0 ± 176.2 IU/L vs 85.9 ± 68.4 IU/L, P < 0.001). Patients with EH had significantly higher degree of end organ failure measured with quick Sequential Organ Failure Assessment scores (0.42 ± 0.68 vs 0.01 ± 0.12, P < 0.001), increased need for blood products (63% vs 5%, P < 0.001), and exchange transfusions (10.5% vs 1.3%, P = 0.022).
CONCLUSION Among patients with SCD, elevated levels of total bilirubin are rare, but indicative of elevated morbidity, mortality, and need for blood transfusions. Large differences in sickle cell genotype also exist, but the significance of this is unknown.
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Affiliation(s)
- John Paul Haydek
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Cesar Taborda
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Rushikesh Shah
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Preeti A Reshamwala
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Morgan L McLemore
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30329, United States
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Dean CL, Maier CL, Chonat S, Chang A, Carden MA, El Rassi F, McLemore ML, Stowell SR, Fasano RM. Challenges in the treatment and prevention of delayed hemolytic transfusion reactions with hyperhemolysis in sickle cell disease patients. Transfusion 2019; 59:1698-1705. [PMID: 30848512 DOI: 10.1111/trf.15227] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/13/2018] [Accepted: 01/08/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delayed hemolytic transfusion reactions (DHTRs) are serious complications of RBC transfusion that can occur in previously alloimmunized patients. Patients who require episodic transfusions during heightened inflammatory states, such as patients with sickle cell disease (SCD), are particularly prone to alloimmunization and developing DHTRs with hyperhemolysis. While efforts to mitigate these hemolytic episodes via immunosuppressive drugs can be employed, the relative efficacy of various treatment options remains incompletely understood. CASE REPORTS In this study, we explored five patients with SCD and multiple RBC alloantibodies who received various forms of immunosuppressive therapy in an attempt to prevent or treat severe DHTRs. RESULTS The clinical course for these five patients provides insight into the difficulty of effectively treating and preventing DHTRs in patients with SCD with currently available immunosuppressive therapies. CONCLUSION Based on our experience, and the current literature, it is difficult to predict the potential impact of various immunosuppressive therapies when seeking to prevent or treat DHTRs. Future mechanistic studies are needed to identify the optimal treatment options for DHTRs in the presence or absence of distinct alloantibodies in patients with SCD.
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Affiliation(s)
- Christina L Dean
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Cheryl L Maier
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Satheesh Chonat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Andres Chang
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Marcus A Carden
- Department of Pediatrics and Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Morgan L McLemore
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sean R Stowell
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Maier CL, Gross PJ, Dean CL, Chonat S, Ip A, McLemore M, El Rassi F, Stowell SR, Josephson CD, Fasano RM. Transfusion-transmitted malaria masquerading as sickle cell crisis with multisystem organ failure. Transfusion 2018. [PMID: 29524230 DOI: 10.1111/trf.14566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Fever accompanying vaso-occlusive crisis is a common presentation in patients with sickle cell disease (SCD) and carries a broad differential diagnosis. Here, we report a case of transfusion-transmitted malaria in a patient with SCD presenting with acute vaso-occlusive crisis and rapidly decompensating to multisystem organ failure (MSOF). CASE REPORT An 18-year-old African American male with SCD was admitted after multiple days of fever and severe generalized body pain. He received monthly blood transfusions as stroke prophylaxis. A source of infection was not readily identified, but treatment was initiated with continuous intravenous fluids and empiric antibiotics. The patient developed acute renal failure, acute hypoxic respiratory failure, and shock. He underwent red blood cell (RBC) exchange transfusion followed by therapeutic plasma exchange and continuous veno-venous hemodialysis. A manual peripheral blood smear revealed intraerythrocytic inclusions suggestive of Plasmodium, and molecular studies confirmed Plasmodium falciparum infection. Intravenous artesunate was given daily for 1 week. A look-back investigation involving two hospitals, multiple blood suppliers, and state and federal public health departments identified the source of malaria as a unit of RBCs transfused 2 weeks prior to admission. CONCLUSIONS Clinical suspicion for transfusion-related adverse events, including hemolytic transfusion reactions and transfusion-transmitted infections, should be high in typically and atypically immunocompromised patient populations (like SCD), especially those on chronic transfusion protocols. Manual blood smear review aids in the evaluation of patients with SCD presenting with severe vaso-occlusive crisis and MSOF and can alert clinicians to the need for initiating aggressive therapy like RBC exchange and artesunate therapy.
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
| | - Phillip J Gross
- Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Christina L Dean
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
| | - Satheesh Chonat
- AFLAC Cancer Center and Blood Disorders Services, Department of Pediatrics, Division of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew Ip
- Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Morgan McLemore
- Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Fuad El Rassi
- Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Sean R Stowell
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia.,AFLAC Cancer Center and Blood Disorders Services, Department of Pediatrics, Division of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Ross M Fasano
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
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Kota VK, Kong JH, Arellano M, El Rassi F, Gaddh M, Heffner LT, Winton EF, Jillella AP, McLemore ML, Khoury HJ. Outcomes of Newly Diagnosed Chronic Phase Chronic Myeloid Leukemia Following an Elective Switch From Second-Generation Tyrosine Kinase Inhibitor to Imatinib. Clin Lymphoma Myeloma Leuk 2017; 17:e71-e73. [PMID: 29032022 DOI: 10.1016/j.clml.2017.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/17/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
Abstract
The second-generation tyrosine kinase inhibitors (TKIs) (2G-TKIs) dasatinib (DAS) and nilotinib (NIL) yield faster responses in newly diagnosed chronic phase (CP) chronic myeloid leukemia (CML) as compared with imatinib (IM); however, long-term safety of these agents is a growing concern. We identified 20 patients with CP-CML diagnosed between August 2013 and October 2016 who initiated 2G-TKIs and were then switched after optimal response at 3 months to IM. Second-generation TKIs initiated were DAS (n = 15), NIL (n = 3), or both sequentially due to intolerance (n = 1). One other patient initiated therapy with ponatinib on trial. Response was assessed by quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) for BCR-ABL1 levels every 3 months and in patients with qRT-PCR values less than 10% at 3 months, IM was started at 400 mg/d. IM was well tolerated except in 2 patients who required dose-reduction and discontinuation due to grade 2 skin rash (1) and grade 2 anxiety (1). After initiation of IM therapy, the BCR-ABL1 qRT-PCR levels trended down as expected. At 12 months 16 (84.2%) of 19 evaluable patients showed a 3 log (major molecular remission) or better reduction in their PCR levels. In conclusion, this retrospective analysis shows that IM can be safely and effectively administered following optimal response to 2G-TKIs. A prospective trial exploring this approach is currently enrolling and will be needed to confirm the safety and efficacy of this therapeutic approach.
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Affiliation(s)
- Vamsi K Kota
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA.
| | - Jee Hyun Kong
- Division of Hematology Oncology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei College of Medicine, Wonju, Korea
| | - Martha Arellano
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Leonard T Heffner
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Elliott F Winton
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Anand P Jillella
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Morgan L McLemore
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - H Jean Khoury
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
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DeFilipp Z, Langston AA, Chen Z, Zhang C, Arellano ML, El Rassi F, Flowers CR, Kota VK, Al-Kadhimi Z, Veldman R, Jillella AP, Lonial S, Waller EK, Khoury HJ. Does Post-Transplant Maintenance Therapy With Tyrosine Kinase Inhibitors Improve Outcomes of Patients With High-Risk Philadelphia Chromosome-Positive Leukemia? Clinical Lymphoma Myeloma and Leukemia 2016; 16:466-471.e1. [DOI: 10.1016/j.clml.2016.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/19/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
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12
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Hill BG, Shen AQ, El Rassi F, Khoury HJ. Sustained Complete Molecular Remission After Discontinuation of Tyrosine Kinase Inhibitors in Blast-Phase Chronic Myeloid Leukemia. J Clin Oncol 2016; 34:e68-9. [DOI: 10.1200/jco.2013.50.1221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Ann Qi Shen
- The Winship Cancer Institute of Emory University, Atlanta, GA
| | - Fuad El Rassi
- The Winship Cancer Institute of Emory University, Atlanta, GA
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Saliba AN, El Rassi F, Taher AT. Clinical monitoring and management of complications related to chelation therapy in patients with β-thalassemia. Expert Rev Hematol 2015; 9:151-68. [DOI: 10.1586/17474086.2016.1126176] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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14
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El Rassi F, Bergsagel JD, Arellano M, Gaddh M, Jillella A, Kota V, Heffner LT, Winton EF, Khoury HJ. Predicting early blast transformation in chronic-phase chronic myeloid leukemia: is immunophenotyping the missing link? Cancer 2014; 121:872-5. [PMID: 25387987 DOI: 10.1002/cncr.29142] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 09/11/2014] [Accepted: 10/02/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Flow cytometry (FC) is a commonly requested test in the workup of leukocytosis in community practices. The role of FC in chronic-phase chronic myeloid leukemia (CP-CML) is unknown. We hypothesized that finding aberrant cells with FC in CP-CML may predict early blast-phase (BP) transformation. METHODS Results for FC performed at the time of diagnosis for adult and pediatric patients with CP-CML who were referred to our institution were reviewed, and they were correlated with outcomes. RESULTS FC was performed at the time of diagnosis for 110 of 233 patients (47%) with CP-CML. Aberrant populations, representing a median of 2% (range, 0.3%-15%), were detected with FC in 30% of patients (33 of 110): 2 of these 33 patients expressed lymphoid markers, and 31 expressed aberrant myeloid markers. Patients received imatinib (85%), dasatinib (12%), or nilotinib (3%) as their first-line treatment. With a median follow-up of 43 months (range, 2-113 months), chronic myeloid leukemia transformed to BP in 5 of the 33 patients. The 2 patients with lymphoid markers and the 3 of 31 patients with aberrant myeloid markers experienced a transformation to lymphoid BP at a median of 11 months (range, 4-72 months) after the initiation of tyrosine kinase inhibitor therapy. Although both cases with detectable lymphoid markers rapidly progressed to lymphoid BP, the positive predictive value of BP transformation by the detection of myeloid aberrant cells with FC was only 10% (3 of 31). CONCLUSIONS In contrast to aberrant myeloid markers, the detection of lymphoid markers by FC at the time of the diagnosis of CP-CML appears to be associated with early progression to lymphoid BP.
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Affiliation(s)
- Fuad El Rassi
- Division of Hematology, Department of Hematology and Medical Oncology, the Winship Cancer Institute of Emory University, Atlanta, Georgia
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15
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El Rassi F, Ward KC, Flowers CR, Heffner LT, Waller EK, Winton EF, Vaughn J, Hill BG, Langston A, Nooka A, Arellano M, Khoury HJ. Incidence and geographic distribution of adult acute leukemia in the state of Georgia. South Med J 2014; 107:497-500. [PMID: 25084186 DOI: 10.14423/smj.0000000000000146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We investigated an apparent increase in acute lymphoblastic leukemia (ALL) referrals from northern Georgia to a tertiary care center located in Atlanta. METHODS Cases reported to the Georgia Comprehensive Cancer Registry and the national Surveillance Epidemiology and End Results cancer registry between 1999 and 2008 were analyzed. Age-adjusted incidence rates were calculated for all of the counties and public health regions and were compared with national rates calculated using Surveillance Epidemiology and End Results 17 data. Cases of adult acute myeloid leukemia served as controls. RESULTS Age-adjusted incidence rates of adult ALL (0.8/100,000) and acute myeloid leukemia (4.6/100,000) were comparable to the national rates (0.9 and 5.2, respectively). The age-adjusted incidence rate of ALL in northern Georgia was 1.1 (95% confidence interval 0.8-1.5) and was not affected by race. CONCLUSIONS The observed increase in cases of ALL at our tertiary center results from a referral pattern rather than heterogeneous distribution of adult ALL across Georgia.
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Affiliation(s)
- Fuad El Rassi
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Kevin C Ward
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Christopher R Flowers
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Leonard T Heffner
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Edmund K Waller
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Elliott F Winton
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Jennifer Vaughn
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Brittany G Hill
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Amelia Langston
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Ajay Nooka
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Martha Arellano
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
| | - Hanna Jean Khoury
- From the Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, the Emory University Rollins School of Public Health, Atlanta, Georgia, and the University of Washington, Fred Hutchinson Cancer Research Center, Seattle
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16
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Mitri Z, Siddiqui MT, El Rassi F, Holden JT, Heffner LT, Langston A, Waller EK, Winton E, McLemore M, Bernal-Mizrachi L, Jaye D, Arellano M, Khoury HJ. Sensitivity and specificity of cerebrospinal fluid flow cytometry for the diagnosis of leukemic meningitis in acute lymphoblastic leukemia/lymphoma. Leuk Lymphoma 2014; 55:1498-500. [DOI: 10.3109/10428194.2013.852667] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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17
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Veldman R, El Rassi F, Holloway S, Langston A, Khoury HJ. Advances in hematopoietic stem cell transplantation in chronic myeloid leukemia. Discov Med 2013; 16:179-186. [PMID: 24099673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Treatment of chronic myeloid leukemia (CML) has evolved dramatically with the development of tyrosine kinase inhibitors (TKIs). This past decade also witnessed major advances in the field of allogeneic hematopoietic stem cell transplantation (alloHSCT) that led to better patients' outcomes. Progress in the exploitation of alternative sources of stem cells, development of novel conditioning regimens, discovery of innovative graft-versus-host prophylactic strategies, and advances in supportive care as well as positioning of alloHSCT in the overall management of CML are discussed in this article.
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Affiliation(s)
- Rachel Veldman
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia 30322, USA
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Abstract
Acute myeloid leukemia (AML) represents a malignant accumulation of immature myeloid cells in the marrow, presenting with impaired hematopoiesis and its attendant complications, including bleeding, infection, and organ infiltration. Chromosomal abnormalities remain the most powerful predictors of AML prognosis and help to identify a subgroup with favorable prognosis. However, the majority of AML patients who are not in the favorable category succumb to the disease. Therefore, better efforts to identify those patients who may benefit from more aggressive and investigational therapeutic approaches are needed. Newer molecular markers aim at better characterizing the large group of intermediate-risk patients and to identify newer targets for therapy. A group that has seen little improvement over the years is the older AML group, usually defined as age ≥ 60. Efforts to develop less intensive but equally efficacious therapy for this vulnerable population are underway.
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Affiliation(s)
- Fuad El Rassi
- Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
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Abstract
Bosutinib is one of five tyrosine kinase inhibitors commercially available in the United States for the treatment of chronic myeloid leukemia. This review of bosutinib summarizes the mode of action, pharmacokinetics, efficacy and safety data, as well as the patient-focused perspective through quality-of-life data. Bosutinib has shown considerable and sustained efficacy in chronic myeloid leukemia, especially in the chronic phase, with resistance or intolerance to prior tyrosine kinase inhibitors. Bosutinib has distinct but manageable adverse events. In the absence of T315I and V299L mutations, there are no absolute contraindications for the use of bosutinib in this patient population.
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Affiliation(s)
- Fuad El Rassi
- Division of Hematology, Department of Hematology and Medical Oncology, the Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
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20
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Gaddh M, Antun A, Yamada K, Gupta P, Tran H, El Rassi F, Kim HS, Khoury HJ. Venous access catheter-related thrombosis in patients with cancer. Leuk Lymphoma 2013; 55:501-8. [PMID: 23772637 DOI: 10.3109/10428194.2013.813503] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with cancer are at high risk for developing venous thromboembolism (VTE), and the presence of a central venous catheter (CVC) further increases this risk. CVC-related VTE has serious implications related to the loss of vascular access, development of pulmonary embolism, recurrent VTE, infections and post-thrombotic syndrome. The pathogenesis of CVC-related VTE is complex and multifactorial, with risk factors associated with the catheter, the vessel selected for insertion and the underlying cancer as well as the anti-cancer therapy. Clinical presentation of CVC-related VTEs is often non-specific, and ultrasonography is the most commonly used radiological diagnostic test. Management of CVC-related VTE in patients with cancer requires a balance between the need for venous access, the risk of VTE recurrence and the risk of bleeding from treatment-induced thrombocytopenia. Effective VTE prophylaxis methods have yet to be defined. Ongoing studies are evaluating the role of newer oral antithrombotic agents and alternative interventional strategies for the prevention and treatment of CVC-related VTE in patients with cancer.
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Affiliation(s)
- Manila Gaddh
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University , Atlanta, GA , USA
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21
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El Rassi F, Little BP, Holloway S, Roberts D, Khoury HJ. Early Diagnosis of Acute Myeloid Leukemia by Computed Tomography Scan. J Clin Oncol 2012; 30:e207-8. [DOI: 10.1200/jco.2011.41.0506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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22
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Taher A, El Rassi F, Isma'eel H, Koussa S, Inati A, Cappellini MD. Correlation of liver iron concentration determined by R2 magnetic resonance imaging with serum ferritin in patients with thalassemia intermedia. Haematologica 2008; 93:1584-6. [PMID: 18728025 DOI: 10.3324/haematol.13098] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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23
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Isma'eel H, Chafic AHE, Rassi FE, Inati A, Koussa S, Daher R, Gharzuddin W, Alam S, Taher A. Relation between iron-overload indices, cardiac echo-Doppler, and biochemical markers in thalassemia intermedia. Am J Cardiol 2008; 102:363-7. [PMID: 18638603 DOI: 10.1016/j.amjcard.2008.03.066] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 03/17/2008] [Accepted: 03/17/2008] [Indexed: 10/22/2022]
Abstract
Cardiovascular impairment is a major cause of morbidity and mortality in patients with thalassemia intermedia. In this study, echocardiographic assessment of left heart condition was performed in patients with thalassemia intermedia, and its relation to hematologic variables--amino terminal pro-brain natriuretic peptide (NT-proBNP), ferritin, hemoglobin--and liver iron concentration (LIC) was investigated. Echocardiographic assessment was performed using pulse-wave Doppler and tissue Doppler imaging. Data from 74 patients with thalassemia intermedia--35 men, 39 women, mean age 26.5 years (8 to 63)--were randomly selected and evaluated. Blood samples were collected for NT-proBNP levels in a random subgroup of 19 patients. Mean baseline values were hemoglobin 8.4 g/dl (4.9 to 13.1), serum ferritin 902.6 ng/ml (15 to 4,140), LIC 9.0 mg Fe/g (0.5 to 32.1), and NT-proBNP 113.5 pg/ml (16.4 to 371). Correlation between LIC and pulmonary artery systolic pressure was significant, suggesting that iron loading in the liver is indicative of cardiovascular sequelae. NT-proBNP was significantly correlated with the ratio of the left ventricular early rapid filling wave to early diastolic velocity at the mitral annulus (r = 0.50, p = 0.04) and hemoglobin (r = -0.49, p = 0.03), but not with other characteristics assessed. In conclusion, this study has highlighted the importance of using tissue Doppler imaging rather than pulse-wave Doppler to characterize left ventricular diastolic dysfunction in patients with thalassemia intermedia. Demonstration of the correlation of LIC and pulmonary artery systolic pressure independent of left ventricular filling pressures supports our hypothesis that left ventricular diastolic dysfunction does not contribute to the increased pulmonary artery systolic pressure in patients with thalassemia intermedia.
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25
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Affiliation(s)
- Fuad El Rassi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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