Assessing Confidence and Competence of Student Pharmacists in a Virtual Medication Adherence Training Program

OBJECTIVE

To assess the impact of a virtual medication adherence training (VMAT) program on students' perceived confidence and perceived competency in delivering medication adherence services via telehealth.

METHODS

This pilot pre-/post-observational study consisted of 2 subsequent sections: (1) 4 asynchronous self-study modules via Canvas (Instructure, Inc.) learning management system, and (2) 2 live application-based sessions involving virtual and telephonic standardized patients. A pre-/post-survey was given to first-, second-, and third-year Doctor of Pharmacy students to assess perceived confidence and perceived competence. Participants completed a 5-question multiple-choice quiz before and after each module to assess knowledge.

RESULTS

Students' overall perceived confidence and perceived competency significantly increased upon completing VMAT. Knowledge in each module assessment also significantly improved. During the assessment of performance throughout the live sessions, most participants lost points when resolving issues within the interaction, addressing the need for patient follow-up, and assessing patient knowledge of medication adherence.

CONCLUSION

This novel VMAT suggests that this or similar programs would be beneficial to improve pharmacy students' perceived confidence, perceived competence, and knowledge in delivering virtual medication adherence services in the telehealth setting. The incorporation of such training within the didactic curriculum of doctoral pharmacy programs should be considered to improve patient care skills for future medication experts.

Use trends of chlorthalidone and hydrochlorothiazide among United States adults with hypertension: National Health and Nutrition Examination Survey 2009-2018

OBJECTIVES

To estimate the national prevalence of chlorthalidone and hydrochlorothiazide use among adults diagnosed with hypertension by sociodemographic subgroup, healthcare access status, and clinical factors.

METHODS

Data was extracted from the National Health and Nutrition Examination Survey for 2009-2010 through 2017-2018 survey waves. Patients at least 20 years old, diagnosed with hypertension, and on hydrochlorothiazide or chlorthalidone were included. Uni-variable logistic regression models estimated the odds of being on chlorthalidone compared with hydrochlorothiazide use by sociodemographic and clinical factors. Analyses were adjusted for multi-stage complex survey design and are nationally representative.

RESULTS

Two thousand five hundred and eighty-five participants were included with 95.2% participants using hydrochlorothiazide and 4.8% using chlorthalidone. Participants over 65 years were more likely to be on chlorthalidone compared with younger counterparts [odds ratio (OR) 1.8; 95% confidence interval (CI) 1.12-2.88]. Participants with hypokalemia (OR 2.62; 95% CI 1.56-4.42) or hyponatremia [OR 2.298; 95% CI 1.23-4.30) were more likely to be using chlorthalidone compared with patients with normal levels.

CONCLUSION

Chlorthalidone, a potent and effective first-line antihypertensive agent and thoroughly studied thiazide diuretic with substantial cardiovascular benefits, continues to be underutilized in patients with hypertension. Findings demonstrated that individuals receiving chlorthalidone were more likely to be 65 years or older and to experience hyponatremia or hypokalemia. Sociodemographic factors, healthcare access and use, clinical factors, and medical conditions did not appear to sway the choice in thiazide diuretic use.

Earthquakes, Hurricanes, Pandemics: Pharmacy Students Impacting Pharmacy Practice in Puerto Rico Through Medication Therapy Management Services During Disasters

BACKGROUND

Community-based medication therapy management advanced pharmacy practice experiences (MTM APPE) can engage pharmacy students in public health initiatives, including emergency response preparedness, to successfully impact patient care. This study aimed to evaluate pharmacy students' perceptions of their experience on an MTM APPE during disasters in Puerto Rico.

METHODS

After completing the MTM APPE during times of hurricanes, earthquake or pandemic, pharmacy students were asked to voluntarily participate in a questionnaire about their perception of assisting during a disaster. The survey consisted of 5 questions. Four questions were based on a Likert scale with answers choices ranging from Agree, Not Sure, Disagree, or Not Applicable. One question requested free text comments from participants.

RESULTS

Sixteen students completed the survey. Pharmacy students agreed that the MTM APPE taught them the clinical skills needed to assist and educate individual patients and the community that suffered from a disaster, and that the role of the pharmacist is vital when a disaster disrupts a community's health-care system.

CONCLUSIONS

Training in emergency response to disasters should be a considered component of MTM APPE.

Evaluating Pharmacist-Driven Interventions in a Primary Care Setting to Improve Proportion of Days Covered and Medication Adherence

Background: Medication nonadherence is the leading cause of poor health outcomes and increased risk of hospitalizations. Previous studies have shown that pharmacist interventions can help improve medication adherence and CMS quality measures. Objective: The purpose of this study was to examine the impact of clinical pharmacists' interventions on medication adherence and PDC scores for ACEi/ARBs, statins, and noninsulin antidiabetic medications in the primary care setting. Methods: This observational study was conducted at four primary care clinics to evaluate PDC scores pre- and post-pharmacist interventions from April 2020 to December 2020. Eligible patients were Humana Part D beneficiaries with a baseline PDC score <85%. The primary outcome of this study was to evaluate the average change in final PDC scores, and 1-month change in PDC scores following a pharmacist intervention. Secondary outcomes were number and types of adherence barriers identified, interventions provided by the pharmacist, and barriers and interventions category (pharmacy, patient or physician-related). Results: A total of 89 barriers were identified and 208 interventions were completed. A statistically significant difference in the average change of final PDC score from baseline was seen among those on ACEi/ARBs (72.5 to 78.0, p = 0.004) and statins (73.3 to 76.6, p < 0.001). Similarly, a statistically significant change was observed from baseline to 1-month PDC among those on ACEi/ARBS (72.5 to 75.4, p = 0.001) and statins (73.3 to 74.9, p < 0.001). Conclusion: Pharmacists located in a primary care setting improved medication adherence and PDC score for patients on ACEIs/ARBs and statins.

Real-World Analysis of Long-Acting and NPH-Containing Insulins on Glycemic Control

Introduction Affordability of insulin products has become a concern in the past several years as the average price of various insulin products has increased. While awaiting legislation at the federal level that would address issues leading to high insulin costs, providers may have shifted prescribing practices to prescribe the lowest-priced insulin products to achieve patients' treatment goals. Objective To compare the prevalence of hypoglycemic events between patients receiving lower-cost neutral protamine Hagedorn (NPH)-containing human insulins and higher-cost long-acting insulin analogs in Medicare Part D enrollees within a management services organization, as well as assessing glycemic control and changes in body mass index. Methods This was a multicenter, retrospective study conducted at three primary care clinics. The co-primary outcomes were percent difference of documented mild and severe hypoglycemic events between individuals receiving NPH-containing human insulin and long-acting insulin. Results A total of 72 patients met inclusion criteria and were receiving NPH-containing human insulins or the long-acting insulin analogs, 15 and 57 patients, respectively. Severe hypoglycemic events occurred in 3.5% vs 0% of the long-acting insulin analog and NPH-containing human insulin group, respectively (P = 0.999). Mild hypoglycemic episodes were experienced by 31.6% versus 33.3% of long-acting insulin analog and NPH, respectively (P = 0.539). For secondary outcomes, no difference was observed in glycemic control outcomes across insulin groups. Conclusion Among Medicare Part D patients with type 2 diabetes mellitus, the use of NPH-containing human insulins was not associated with an increased risk of mild or severe hypoglycemia-related episodes or reduced glycemic control compared with long-acting insulin. Study findings suggest that lower-cost, NPH-containing human insulins may be an alternative to higher-cost, long-acting insulin analogs.

Utilizing Pharmacist-Led Telehealth Services in Ambulatory Patients with Heart Failure

Background: Heart failure is one of the leading causes of hospital admissions. Non-adherence to medications and poor dietary management for patients who suffer from this condition can lead to worsening of symptoms and hospitalization. Pharmacist interventions via telehealth have demonstrated a beneficial impact on disease management and adherence outcomes in patients with chronic conditions. Methods: This retrospective, descriptive cohort study reviewed subjects from a single-centered primary care office. Data was collected via electronic chart review between January and December 2021. Subjects eligible for inclusion were adults who were diagnosed with heart failure by their primary care provider and referred to a pharmacist for a telehealth visit. The primary outcome was the number of heart failure-related hospitalizations post-pharmacist intervention via telehealth. The secondary outcome was the number of cardiovascular-related hospitalizations post-pharmacist intervention via telehealth. Results: 37 patients were included for analysis. Only two patients were admitted for heart failure post-pharmacist intervention. Fifteen patients were admitted post-pharmacist intervention for a cardiovascular-related hospitalization. Conclusion: This report illustrates the employment of pharmacist-led telehealth services in the chronic heart failure population. This study encourages pharmacist-based interventions via telehealth in the ambulatory setting as few HF-related hospitalizations occurred in this cohort.

The Impact of Pharmacists on Telehealth During Transitions of Care: A Literature Review

Purpose: To provide a review of pharmacists' impact during transitions of care (TOC) visits utilizing telehealth. Methods: An electronic literature review was conducted on studies that addressed pharmacists' impact on telehealth during TOC. Articles included in the review were randomized or observational studies, cohort studies, case series or case reports, literature reviews, or pilot studies conducted on adults. Articles investigating children were excluded from the review. Results: Of the articles identified, 14 studies met the eligibility criteria and were selected for the literature review. All of the studies were published in English between 2013 and 2021. Most were conducted in the United States of America (n = 12) with 1 conducted in Ireland (n = 1) and 1 in Australia (n = 1). The majority of telehealth monitoring was conducted via phone (n = 8), video conferencing (n = 3), or both (n = 2) in patients' homes by pharmacists alone (n = 8) while the remaining studies involved telemonitoring by a combination of pharmacy fellows, residents, and/or students. These findings showed that pharmacist intervention in patient care showed improved patient outcomes and goal markers for a variety of health conditions as well as lower rates of 30 day, 60 day, and 90 day hospital readmissions. Conclusion: Pharmacist involvement in telehealth monitoring had a positive impact on TOC interventions and overall patient outcomes including decreased hospital readmissions and increased patient medication adherence.

Impact of Student Pharmacist-Led Transition-of-Care Services on 30-Day Hospital Readmissions at a University Call Center

Background: Transition of care (TOC) refers to the movement of patients between different health care settings due to changes in medical conditions and needs. Pharmacists can play an important role in TOC services as polypharmacy is a common reason for hospital readmission that costs the US taxpayers an average of $17 billion annually. Objective: The purpose of this study is to evaluate the impact of TOC telehealth services provided by pharmacy students at a university-based call center on 30-day hospital readmission. Methods: In this retrospective observational study, an electronic chart review was conducted for patients who were discharged from the hospital and received a telephone call from pharmacy students. Patients were referred to the pharmacy team from a primary care provider office. The co-primary endpoints were the number of 30-day all-cause hospital readmissions (including emergency department visits) and 30-day readmission due to initial admission diagnosis in patients who received a telephonic TOC call from a pharmacy student compared with patients who declined or were unable to be reached. Types of pharmacy-related TOC interventions provided by students were also collected. Results: A total of 84 patients were included in this study. All-cause 30-day readmission was similar between groups (13% vs 15.8%), whereas 30-day readmission due to initial admission diagnosis was much lower in the intervention group (5.9% vs 11.1%). Although a positive trend was observed in favor of the intervention group, a statistically significant difference was not observed for both 30-day all-cause readmission and 30-day readmission due to initial admission diagnosis. Medication reconciliation, adherence counseling, and lifestyle education (diet, exercise) are the most common topics discussed with the patients during TOC interventions. Conclusion: Using student pharmacists to provide postdischarge TOC calls can be a benefit to the patient and the health care team while offering pharmacy students valuable learning experience prior to graduation.

Considerations of management and marketing courses within pharmacy curricula in the United States

INTRODUCTION

To assess the extent pharmacy programs are offering courses in management and marketing.

METHODS

We sampled the extent of management and marketing coursework in the doctor of pharmacy (PharmD) curricula in the United States (US) by examining website descriptions of the best pharmacy schools in 2020 (N = 134) as ranked by the US News and World report. Links to curriculum descriptions and catalogs were reviewed for coursework having the words, marketing, management, entrepreneurship, or business plan in the title.

RESULTS

Of the 134 PharmD curricula reviewed, 36 (27%) had no required or elective management courses, and 101 (75%) had no required or elective marketing courses in their curriculum. Most schools did offer a core (n = 89) or elective (n = 9) management course. However, of those, about half (n = 46) provided only a single management course over the entire curriculum. Only 33 (25%) schools offered a marketing course, of which most (n = 27) were elective.

CONCLUSIONS

Many pharmacy schools in the US are not providing pharmacy graduates with the business management and marketing education required for the role of a pharmacist. Pharmacy education should consider curriculum changes that equip pharmacy students with sufficient business knowledge and skills to be innovative and entrepreneurial in all practice settings.

Effects of a Therapeutic Interchange Between Branded and Generic Inhaled Therapy on Chronic Obstructive Pulmonary Disease

Objective To evaluate the difference in the occurrence of chronic obstructive pulmonary disease (COPD) exacerbations six months preconversion compared with six months postconversion from the branded inhaled corticosteroid/long-acting beta 2-agonist inhalers to the generic fluticasone/salmeterol inhalers. Design Retrospective cohort study using a six-month pre-/post-test design Setting Three primary care offices within a Management Service Organization (MSO) in South Florida. Patients, Participants Patients were included in the study if they had a diagnosis of COPD (in electronic medical record [EMR]), were at least 18 years of age, were under the care of a provider at one of the three primary care clinics within an MSO, and were switched from a branded ICS/LABA inhaler to a generic ICS/LABA inhaler between May 2019 and February 2020. This study included a total of 22 patients. Interventions Not applicable; this was a retrospective chart review. Main Outcome Measure The prevalence of COPD exacerbations leading to hospitalizations, emergency room visits, urgent care visits, or clinic visits. Results In this study, 10 (45.5%) patients experienced at least one exacerbation while on generic inhaler therapy compared with four (18.2%) patients while on branded inhaler therapy (P = 0.05). Those on a generic inhaler were 3.8 times more likely to have a COPD exacerbation. Conclusion While changing patients from branded to generic inhalers may be appealing because of the potential benefits in cost-reduction, the results of this study conclude that the inhaler switch may lead to increased exacerbations. Prescribers need to be aware of potential complications that may be related to a therapeutic interchange.

Destigmatizing public health concerns and supply of COVID-19 vaccines

The end of the global pandemic caused by COVID-19 and a future without masks and restrictions are promising with the discovery of a vaccine. Still, there is much worry about the vaccine itself. Fears about what is inside the vaccine, how quickly it was created and plans for distribution are major concerns. This article aims to address these concerns to relieve vaccine hesitancy. Methods for distribution within the United States as well as different strategies to ensure proper and equitable allocation of COVID-19 vaccine worldwide is also described.

Evaluating a Pharmacist-Led Intervention on Cardiovascular- and Diabetes-Related Quality Measures in a Primary Care-Based Accountable Care Organization

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) publishes quality measures to gauge performance in Accountable Care Organizations (ACOs). ACO-27 (Diabetes Mellitus: Hemoglobin A1c Poor Control) and ACO-41 (Diabetes: Eye Exam), are 2 components for the Diabetes Composite measure. ACO-42 focuses on Statin Therapy for the Prevention and Treatment of Cardiovascular (CV) Disease. There are limited studies regarding the pharmacist role in CV and Diabetes Management in the ACO primary care setting.

OBJECTIVE

To evaluate the impact of pharmacist-led interventions on CV- and diabetes-related CMS quality measures within a primary care-based ACO.

METHODS

This retrospective pre-post intervention study included 3 primary care-based ACO offices. Patients who met eligibility criteria for CMS quality measures ACO-27, -41 and -42 were included. Pharmacist interventions occurred in December 2018. The study co-primary outcomes were the percentage of patient meeting ACO-27/-41 (composite diabetes-related) and -42 (statin-related) CMS quality measures in the pre-intervention compared to the post-intervention phases.

RESULTS

Of 105 patients meeting study inclusion criteria, 77.1% were on statin therapy prior to intervention. After pharmacist intervention, the prevalence of patients on statin therapy increased to 80.0% (p = 0.083). All patients had a HbA1c less than 9% pre-intervention. Sixty-one (58.1%) patients had a documented dilated eye exam prior to intervention. Post-intervention, the prevalence of exams increased to 73.3% (p < 0.0005).

CONCLUSIONS

Pharmacists can assist primary care providers in the ACO setting meet CV- and diabetes-related CMS quality measures, demonstrating the value of the pharmacist in value-based health care settings.

Management of Partial Hydatidiform Mole and Subsequent Intrauterine Adhesions: A Case Report and Literature Review

Background:

Gestational trophoblastic disease (GTD) originates from placental tissue and is among rare human tumors that can be cured even in the presence of widespread metastases. The most common form of GTD is hydatidiform mole (HM), commonly referred to as molar pregnancy. Molar pregnancies have the potential to locally invade the uterus and metastasize and result as a result ofgestational trophoblastic neoplasia. Intrauterine adhesions (IUAs) is a condition where scar tissue develops within the uterine cavity, often following a procedure. Hysteroscopy has been established as the criterion standard for the diagnosis of IUAs, although the optimal adjuvant treatment after surgical intervention remains unclear. ‎

Case:

A 35-year-old-female underwent suction curettage a week after the detection of a molar pregnancy. Two months later, she suffered from amenorrhea and hormonal therapy was initiated. Saline-infusion sonogram was tried and failed due to cervical stenosis. IUAs leading to scar tissue developed along with uterine polyps. Hysteroscopy successfully lysed IUAs and uterine polyps. The patient conceived two months after stopping hormonal therapy and proceeded to a pregnancy which resulted in a healthy live birth.

Conclusion:

Although the etiology of the patient’s molar pregnancy is still unknown, this report demonstrates the need to utilize hysteroscopy as a primary and early mode of treatment if IUAs are found in patients along with providing adjuvant treatment while utilizing clinical judgement in order to prevent IUAs recurrence. The patient conceived four months after the hysteroscopy resulting in a healthy live birth.

Improving Medication Adherence in an ACO Primary Care Office With a Pharmacist-Led Clinic: A Report From the ACORN SEED

BACKGROUND

As health care moves into the era of value-based medicine, both ambulatory and acute settings are being held accountable for the quality of care provided to patients. Previous studies have shown improved clinical outcomes through medication therapy management (MTM) due to improved medication adherence.

OBJECTIVE

The purpose of this study is to assess the effects of a pharmacist-led MTM clinic in an accountable care organization (ACO) affiliated primary care office on adherence to renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported through Healthcare Effectiveness Data and Information Set (HEDIS) Medicare Star Ratings.

METHODS

In this retrospective cohort study, data were collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated with a RAS antagonist, statin, or diabetic medication. The primary outcome of this investigation was a change in Star Rating scores for medication adherence to RAS antagonists, diabetic medications, and statins from pre- and postpharmacist MTM intervention.

RESULTS

A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25 interventions. One year prior to MTM clinic implementation, most Star Ratings were consistently 3 (out of 5) for RAS antagonists, diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Conclusion: Implementing a pharmacist-led MTM clinic in the ACO primary care setting improves Medicare Star Ratings in patients with chronic conditions.

Evaluation of Pharmacist Impact Within an Interdisciplinary Inpatient Heart Failure Consult Service

Background: Heart failure (HF) is highly prevalent in the Veterans Affairs (VA) health care system and the leading cause of hospital discharges in the VA. Despite guideline-specific recommendations of drug therapy, many patients are not on optimal medication regimens. Objective: To examine and quantify pharmacist impact in an interdisciplinary HF consult (IC) service on increasing use of guideline-directed medical therapy (GDMT). The 30-day readmission rates before and after the implementation of an IC service are reported. Methods: This was a single-center retrospective analysis of veterans admitted with a HF diagnosis between August 2008 and August 2015 in 2 distinctive cohorts: pre-IC (August 2008 to November 2011) and IC (November 2011 to August 2015). Results: Four-hundred patients were included, with 200 in each cohort. All-cause readmissions at 30 days were not different between pre-IC and IC groups: 33.5% versus 28.5%, respectively. Secondary outcomes of HF readmission and 1-year mortality were not different between groups. Significant increases in medication use rates were observed from admission to discharge in both cohorts; however, greater increases were observed in the IC group in which the pharmacist role was clearly defined in recommending GDMT optimization, especially in patients with HF with reduced ejection fraction. Conclusion and Relevance: Although the implementation of an IC service did not significantly change 30-day readmission rates, increases in GDMT use are evident with increased pharmacist involvement. Longer-term outcomes associated with this intervention warrant future investigation.

Chronic Obstructive Pulmonary Disease and Heart Failure Self-Management Kits for Outpatient Transitions of Care

OBJECTIVE

To develop heart failure (HF) and chronic obstructive pulmonary disease (COPD) self-management kits in an accountable care organization (ACO) to facilitate patients' self-care and prevent hospital readmissions.

SETTING

Pharmacists practice in an outpatient-based ACO. They participate in interprofessional office visits with providers and independently manage maintenance pharmacotherapies.

PRACTICE DESCRIPTION

Pharmacists collaborate with an interprofessional team within the ACO including physicians, nurses, case managers, and paramedics. Two commonly encountered diseases are chronic COPD and HF. Reducing preventable readmissions for these conditions are important quality benchmarks and cost-saving strategies.

PRACTICE INNOVATION

Pharmacists were responsible for developing HF and COPD self-management kits containing patient education materials and prescriptions to facilitate self-care. Prior to kit development, pharmacists performed a literature review to determine the presence of previously published findings on these topics.

MAIN OUTCOME MEASUREMENTS

The interprofessional team continually evaluates the successes and limitations of this initiative. Pharmacists developed training and instructions for ACO allied health professionals in an effort to incorporate the self-management kits in clinical practice.

RESULTS

The initial literature search revealed no studies describing the intervention of interest. Innovative programs designed to help reduce preventable readmissions are lacking in primary care. Implementation of the self-management kits was accepted by interprofessional ACO leadership and is currently being integrated into allied health workflow.

CONCLUSION

Patients at risk for having an exacerbation of COPD or HF should receive self-management strategies. Prompt therapy prior to exacerbations reduces hospital admissions and readmissions, speeds recovery, and slows disease progression. Pharmacist-facilitated implementation of self-management kits may be developed by interprofessional health care teams.

Oral anticoagulation therapy upon discharge in hospitalized patients with nonvalvular atrial fibrillation: a retrospective cohort study

OBJECTIVES

Availability of direct oral anticoagulants and CHA₂DS₂VASc/HAS-BLED scoring tools underscore the importance of appropriate and safe use of oral anticoagulation therapy (OACT). The purpose of this study was to evaluate stroke prevention pharmacotherapy in adult patients with nonvalvular atrial fibrillation (NVAF) discharged from a large, community-based hospital.

METHODS

A retrospective cohort study was conducted using a de-identified data collection sheet for data extraction (demographics, admitting diagnosis, OACT prior to admission and at discharge, concomitant medications that could increase bleed risk and/or acid-suppressive therapies). CHA₂DS2VASc and HAS-BLED scores were calculated. Descriptive statistics were generated to describe all parameters. Frequency counts and percentages summarized categorical variables while mean ± standard deviation were determined for continuous variables.

RESULTS

Data from 180 patients were evaluated and of these 177 (98.3%) received OACT regardless of stroke risk upon discharge, as determined by CHA₂DS₂VASc scoring tool. The mean CHA₂DS₂VASc and HAS-BLED scores were 3.61 ± 1.7 and 2.13 ± 1.26, respectively. At discharge, eight patients at low-stroke risk received OACT for unclear reasons, one intermediate-stroke risk patient received aspirin only, and two patients at high-stroke risk did not receive OACT due to concerns about bleeds. In 66 patients at high-bleed risk, only half received concomitant acid-suppressive therapy.

CONCLUSIONS

Decision to add OACT is often guideline-driven, however, individualized circumstances in which clinicians and patients find themselves are also important considerations. Determination of ischemic stroke risk should be performed with CHA₂DS₂VASc scoring tool to exclude patients who may not benefit from OACT. HAS-BLED scoring tool should be used to identify any modifiable bleeding risk factors present with subsequent initiation of management strategies. Availability of complete medical histories and meticulous documentation are necessary for multiple clinicians to continuously determine optimal pharmacotherapy during follow-up visits.

Acclimating to the Increase in Statin Use in Accountable Care Organizations Based on Changes in Quality Measures: A Report from the Accountable Care Organization Research Network, Services, and Education

The Accountable Care Organization Research Network, Services, and Education (ACORN SEED), founded by faculty members at Nova Southeastern University College of Pharmacy, is a group of pharmacists that provides unique pharmacy services to accountable care organizations (ACOs), patient-centered medical homes, and management services organizations to help maximize shared savings and target medication-related issues, while promoting the pharmacy profession and unique learning experiences for pharmacy students within these settings. In this report, ACORN SEED investigators provide a brief overview of the ACO benchmark measures in relation to statin use. Historically, hyperlipidemia treatment was tailored to meet certain cholesterol levels as a surrogate marker in preventing major adverse cardiovascular events, specifically a low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL as a target goal. In addition, Medicare assessed a health care provider's performance based on this target goal in specific populations (i.e., diabetes and ischemic vascular disease). In 2013, the American College of Cardiology and American Heart Association published updated recommendations removing these LDL-C treatment goals. Rather than treating with cholesterol-lowering medications in an effort to reduce cholesterol levels, patients are now being evaluated for statin therapy use based on 4 benefit groups that focus on the risk of atherosclerotic cardiovascular disease. In 2015, Medicare's shared savings program removed the previous LDL-C goals from its quality measures and now assesses positive performance from the updated guidelines. Currently, under ACO benchmark measure #42, health care providers are being rewarded for prescribing statin therapy for the prevention and treatment of cardiovascular disease, which reflects updated evidence-based recommendations. With the increase in statin use, randomized controlled trials or ACO validation studies are important in determining future implications on cardiovascular outcomes.

DISCLOSURES

No funding was involved in the preparation of this report. The authors have no conflicts of interest to declare. Both authors contributed equally to data collection, analysis, and manuscript preparation.

Simultaneous measurement of the HT and DT fusion burn histories in inertial fusion implosions

Measuring the thermonuclear burn history is an important way to diagnose inertial fusion implosions. Using the gas Cherenkov detectors at the OMEGA laser facility, we measure the HT fusion burn in a H₂+T₂ gas-fueled implosion for the first time. Using multiple detectors with varied Cherenkov thresholds, we demonstrate a technique for simultaneously measuring both the HT and DT burn histories from an implosion where the total reaction yields are comparable. This new technique will be used to study material mixing and kinetic phenomena in implosions.

Using Inertial Fusion Implosions to Measure the T+^{3}He Fusion Cross Section at Nucleosynthesis-Relevant Energies

Light nuclei were created during big-bang nucleosynthesis (BBN). Standard BBN theory, using rates inferred from accelerator-beam data, cannot explain high levels of ^{6}Li in low-metallicity stars. Using high-energy-density plasmas we measure the T(^{3}He,γ)^{6}Li reaction rate, a candidate for anomalously high ^{6}Li production; we find that the rate is too low to explain the observations, and different than values used in common BBN models. This is the first data directly relevant to BBN, and also the first use of laboratory plasmas, at comparable conditions to astrophysical systems, to address a problem in nuclear astrophysics.

Risks and benefits of low molecular-weight heparin and target-specific oral anticoagulant use for thromboprophylaxis in medically ill patients

Venous thromboembolism is the third most common cardiovascular disease and a major cause of inpatient mortality as over 50 % of deep vein thrombosis and pulmonary embolism are undetected in medically treated patients. Several agents are approved for thromboprophylaxis, including warfarin, unfractionated heparin, low molecular-weight heparins, fondaparinux, and target-specific oral anticoagulants. The purpose of this literature review is to discuss the increased risk of venous thromboembolism in medically ill patients and the literature surrounding the efficacy and tolerability of low molecular-weight heparins and target-specific oral anticoagulants for this indication. PubMed, MEDLINE, EBSCOhost, and clinicaltrials.gov were used as search engines in the literature review. Search limits included articles containing human subjects, scholarly (peer-reviewed) journals written in English, and publication dates from 2004 to 2014. Animal studies, non-English articles, and publications dated prior to 2004 were excluded. Recurrent venous thromboembolism remains an ongoing problem affecting thousands of people in the non-surgical population annually. With limited data, it is not likely that target-specific oral anticoagulants will soon replace low molecular-weight heparins or even be considered an alternative until efficacy and tolerability have been established. Until further evidence is disclosed, low molecular-weight heparins and fondaparinux (in the absence of renal dysfunction and low body weight) should continue to be utilized as first-line agents for thromboprophylaxis in medically ill patients. The use of apixaban and rivaroxaban is discouraged for thromboprophylaxis in medically ill patients.

A pilot study of combination anti-cytokine and anti-lymphocyte biological therapy in rheumatoid arthritis

BACKGROUND

Immunological tolerance in humans using anti-T-cell monoclonal antibodies (mAbs) may be hampered by a pro-inflammatory microenvironment. All clinical trials of such therapies in rheumatoid arthritis (RA), however, have selected patients with active disease at baseline. Concurrent neutralization of inflammation with a TNFalpha antagonist should maximize the potential of anti-T-cell mAbs to induce tolerance in RA.

AIM

To evaluate the safety of combining a TNFalpha antagonist and CD4 mAb in RA.

DESIGN

An iterative pilot study focused on the safety of such combination therapy.

METHODS

Eight poor prognosis, seropositive RA patients were treated with combined CD4 and TNFalpha blockade. Prolonged CD4 blockade was achieved with a humanized mAb, and TNFalpha blockade with a p55 TNF receptor fusion protein.

RESULTS

There was a low incidence of classical first-dose reactions to the CD4 mAb, possibly reflecting concomitant TNFalpha blockade. An unusual anaphylactoid reaction was seen, however, and one patient developed a probable allergic reaction after several infusions. Skin rashes were common, as previously reported with CD4 mAb monotherapy. No serious infections were documented during follow-up, despite CD4+ lymphopenia in some patients. Most patients appeared to demonstrate improved RA disease control after the study. After 17-49 months after therapy, one patient was in remission, one remained off disease modifying anti-rheumatic drugs and five had stable disease, three on previously ineffective doses of methotrexate.

CONCLUSION

We report, for the first time in man, immunotherapy with a combination of an anti-cytokine and an anti-T-cell reagent. We witnessed an unusual first-dose reaction but there were no significant infectious complications.

High nitrogen during growth reduced glucoraphanin and flavonol content in broccoli (Brassica oleracea var. italica) heads

Broccoli (Brassica oleracea var. italica) heads are commonly consumed in the Western diet and frequent consumption is thought to help protect against certain cancers and cardiovascular disease. Broccoli heads contain relatively high levels of glucosinolates and flavonols, thought to be the key phytochemicals that contribute to the health benefits gained upon consumption. In this study, we investigated the effect of applied nitrogen (N) at either 0, 15, 30 or 60 kg/ha, or 30, 60, 90 or 150 kg/ha with applied sulfur (S) at 50 or 100 kg/ha on the glucosinolates glucoraphanin, glucobrassicin and progoitrin, and the flavonols quercetin and kaempferol in broccoli cv. Marathon florets. Trials were conducted in two sites in either heavy clay or sandy loam to also assess the effect of soil type on phytochemical content. Application rates were based around recommended N and S applications for this crop in south-east Australia. N applications over 30 kg/ha caused a decrease in the content of glucoraphanin (18–34%) and both flavonols (20–38%). Progoitrin content was not affected while glucobrassicin increased by up to 44% with N applications >30 kg/ha. S applications of 50 or 100 kg/ha had no significant effect on either glucosinolates or flavonols. Crop yield (fresh weight), however, was significantly depressed (up to 40%) by N applications below 60 kg/ha. Fresh weight was also significantly depressed in plants grown in heavy clay compared with plants grown in a sandy loam, and phytochemical content increased, possibly due to a concentration effect. Therefore, low N applications to optimise phytochemicals may be only commercially useful if growers are producing mini-broccoli heads, as levels required to optimise phytochemical content (<30 kg/ha) also caused a significant decline in yield.

Mechanisms of Antibody Immunotherapy on Clonal Islet Reactive T Cells

Clinical intervention trials evaluating the efficacy of antibody immunotherapy in type 1 diabetes are in progress. We tested effects on prediabetic islet antigen-specific autoreactive T cells of antithymocyte globulin (ATG) and humanized monoclonal antibodies against CD3 (ChAglyCD3) or CD25 (daclizumab) with regard to downmodulation of the target protein, proliferation, cytokine production, complement-dependent cytotoxicity (CDC), antibody-dependent cell cytotoxicity (ADCC), and survival. ATG leads to depletion of autoreactive CD4+ T cells by ADCC, CDC, and apoptosis, whereas anti-CD3 and anti-CD25 inhibited T-cell autoreactivity in a nondepleting fashion. ATG treatment led to a cytokine burst of Th1- and Th2-associated cytokines. Modulation of cytokine release through humanized monoclonal antibodies was moderate and selective: anti-CD25 led to increased release of IL-2 and reduced production of TNFalpha, whereas anti-CD3 decreased release of interferon-y and IL-5 and increased secretion of IL-10. ATG and the humanized monoclonal antibodies displayed contrasting mechanisms of action.

Different glycoforms of the human GPI-anchored antigen CD52 associate differently with lipid microdomains in leukocytes and sperm membranes

CD52 is a human GPI-anchored antigen, expressed exclusively in the immune system and part of the reproductive system (epididymal cells). Sperm cells acquire the antigen from the epididymal secretions when transiting in the epididymal corpus and cauda. The peptide backbone of CD52, consisting of only 12 aminoacids, is generally considered no more than a scaffold for post-translational modifications, such as GPI-anchor and especially N-glycosylation which occur at the third asparagine. The latter modification is highly heterogeneous, especially in the reproductive system, giving rise to many different glycoforms, some of which are tissue specific. A peculiar O-glycan-containing glycoform is also found in reproductive and immune systems. We determined to locate CD52 in microdomains of leukocytes and sperm membranes using two antibodies: (1) CAMPATH-1G, the epitope of which includes the last three aminoacids and part of the GPI-anchor of glycoforms present in leukocytes and sperm cells; (2) anti-gp20, the epitope of which belongs to the unique O-glycan-bearing glycoform also present in both cell types. Using a Brij 98 solubilization protocol and sucrose gradient partition we demonstrated that the CD52 glycoforms recognized by both antibodies are markers of typical raft microdomains in leukocytes, whereas in capacitated sperm the O-glycoform is included in GM3-rich microdomains different from the cholesterol and GM1-rich lipid rafts with which CAMPATH antigen is stably associated. The importance of the association between GM3 and O-glycans for formation of specialized microdomains was confirmed by heterologous CD52 insertion experiments. When prostasomes from human seminal fluid were incubated with rat sperm from different epididymal regions, the CD52 glycoform recognized by anti-gp20 decorated rat epididymal corpus and cauda sperm, associated with the same low-cholesterol GM3-rich sperm membrane fractions as in human sperm. The glycoforms recognized by CAMPATH-1G were not found in rat sperm. The relationship between this differential insertion and differences in glycosylation of rat and human CD52 is discussed.

Myeloablative conditioning is well tolerated by older patients receiving T-cell-depleted grafts

Older age has been linked to increased transplant-related mortality from graft-versus-host disease (GvHD). Depletion of T cells from stem cell grafts seems to protect from complications of GvHD particularly in older patients. After myeloablative conditioning, patients with haematological malignancies received allogeneic grafts from HLA identical siblings. For GvHD prophylaxis, PBPC grafts were treated ex vivo with anti-CD52, and therapeutic doses of cyclosporin until day +90. Survival of patients younger or older than the population age median was analysed. In all, 62 consecutive patients with a median age of 42.5 years were studied. Death was procedure related in 17% and from relapse of malignancy in five. At a median, follow-up is 662 (7-2316) days, 74% survive disease free. The rate of haematopoietic recovery and treatment-related mortality was similar in both groups. A total of 73% of 30 individuals in the younger group and 75% (P=0.8) in the older cohort survive at a median follow-up of 444 and 806 days (P=0.4). GvHD occurred in 13% and was the only adverse factor for survival (P<0.04). Myeloablative conditioning is well tolerated up to the age of 59 in patients receiving T-cell-depleted grafts. This information is useful to more precisely select patients who would benefit most from reduced intensity conditioning schedules.

Epitope analysis of immunoglobulins against gp20, a GPI-anchored protein of the human sperm surface homologous to leukocyte antigen CD52

Gp20 is a sialylglycoprotein of the human sperm surface related to maturation and capacitation and is homologous to CD52, a glycosyl- phosphatidyl-inositol (GPI)-anchored protein highly expressed in lymphocytes, monocytes, eosinophils, and epididymal cells, described by the monoclonal antibody family CAMPATH. The CAMPATH antigen is characterized by a very short peptide (12 amino acids) and an N-linked oligosaccharide chain bound to the asparagine located in the third position and a GPI anchor bound to the C-terminal serine. The CAMPATH epitope includes three amino acids at the C-terminus and part of the GPI anchor. It has been suggested that anti-gp20 interacts with the same peptide recognized by CAMPATH antibodies but with a different epitope, since it describes the corresponding antigen in a different way. For example, it localizes the corresponding antigen in the equatorial region of the sperm head when sperm are capacitated, whereas CAMPATH antibodies bind all over the sperm surface. Our results indicate that the anti-gp20 epitope does not include the peptide backbone, the GPI anchor, or the N-glycans but consists of O-linked oligosaccharide chains bound to a unique CD52 glycoform present both in sperm and leukocytes. This is suggested by results obtained using many different approaches, such as immunoblot analysis of gp20 after removal of N- and O-glycans and after jacalin (Artocarpus integrifolia agglutinin)-affinity chromatography.

Encephalopathy in pediatric patients after allogeneic hematopoietic stem cell transplantation is associated with a poor prognosis

Encephalopathy is a poorly characterized complication of hematopoietic stem cell transplantation (HSCT). No comprehensive report of encephalopathy exists for children, and the literature contains only a few for adults. We analyzed a large cohort of 405 pediatric patients who underwent allogeneic HSCT during a 10-year period and identified 26 patients (6.4%) who experienced encephalopathy. Identifiable causes of encephalopathy included infection (n=5), single or multiorgan failure (n=4), medication-related complications (n=3), nonconvulsive seizures (n=4), acute disseminated encephalomyelitis (n=2), thrombotic thrombocytopenic purpura (n=2), and stroke (n=1). We were unable to identify the etiology of encephalopathy in five (19%) patients. The prognosis for pediatric patients with encephalopathy was poor: only four (15%) experienced complete neurologic recovery, and 10 (38%) patients experienced partial recovery with residual neurologic deficits. Nine (35%) patients with complete or partial recovery survive long term. A total of 17 patients died; one died of progressive encephalopathy, and 16 died of either relapse of primary disease or toxicity. MRI, CSF analysis including molecular testing for infectious pathogens, and brain biopsy were helpful in obtaining a diagnosis in most of our patients. However, a standardized approach to accurate and timely diagnosis and treatment is needed to improve outcome in these patients.

Design and manufacture of monoclonal antibodies for radioimmunotherapy

antibodies is fundamental to their use for radioimmunotherapy. Besides the right selection of antibody specificity and affinity, recombinant antibodies can be designed to simplify manufacture and minimise unwanted side effects. Although many innovative new technologies have been developed in recent years, antibodies are still most commonly produced from mammalian cells and purified by column chromatography. Purification methods have to be designed and validated to remove potential contaminants, especially retroviruses, which in principle might be present in mammalian cell lines. Adherence to relevant ''Good Manufacturing Practices'' is mandatory in the production of any medicinal product and there are numerous guidelines regarding the manufacture of antibodies. This article outlines some methods used for fermentation, purification and quality control of antibodies intended for radiolabelling.

Radiotherapy-based conditioning is effective immunosuppression for patients undergoing transplantation with T-cell depleted stem cell grafts for severe aplasia

BACKGROUND

We studied the outcome of individuals with aplastic anemia conditioned with a radiation-containing regimen followed by an infusion of stem cell grafts that had been depleted of lymphocytes with CAMPATH-1H (antiCD52; humanised).

METHODS

The conditioning regime consisted of fractionated (f) TBI 8 Gy followed by f total nodal irradiation (TNI) 6 Gy. In addition, patients received CY 60 mg/kg on 2 consecutive days. Cytokine-mobilized peripheral blood grafts from HLA-identical siblings were T-cell depleted with CAMPATH-1H 'in the bag'. CsA was commenced on day -1 and continued until day +90.

RESULTS

Seventeen heavily transfused patients with aplastic anemia, median age 18 years (range 14-56 years), were studied. The median time from diagnosis to transplantation was 172 days (range 34-443 days). The median CD34(+) cell number infused was 3.47 x 10(6)/kg (range 1.03-18.4 x 10(6)/kg). All patients engrafted. Recovery was fast and patients reached 0.5 x 10(9)/L polymorphs by median day 11 (range 9-17 days). Toxicity from the conditioning included grade 4 hematologic toxicity in all patients. Another major toxicity was gastrointestinal mucosal damage, which exceeded grade 2 in two instances. One patient developed thrombotic thrombocytopenic purpura, which responded to substitution of CsA with tacrolimus and plasmapheresis. Another patient, who had normal blood counts, died of infection on day 241. Chimerism studies at 6 months post-transplantation confirmed the donor origin of hematopoiesis in all seven patients tested. None of the patients developed acute or chronic GvHD. There was no delayed graft failure and 94% of patients had survived disease free at a median of 1303.5 days (range 216-2615 days) from graft infusion.

DISCUSSION

In this cohort of multiply transfused patients, the radiation-containing schedules described in this study led to universal engraftment with limited toxicity despite T-cell depletion. No patient developed GvHD or late graft failure. Lower doses of radiation-containing conditioning should be explored further.

Alemtuzumab (Campath-1H) in allogeneic stem cell transplantation: where do we go from here?

Alemtuzumab (Campath-1H) has been widely used for T-cell depletion following both conventional and reduced-intensity conditioning allografts. We studied the impact of alemtuzumab used in vivo and in vitro on infections, immune reconstitution, and allograft outcome. The use of alemtuzumab in vivo following reduced-intensity conditioning and unrelated donor conventional transplantation was associated with durable engraftment and significant reduction in graft-versus-host disease (GVHD) but at the cost of impaired immune reconstitution and increased infectious complications. Alemtuzumab exposure in vitro was associated with durable engraftment and reduced GVHD following conventional transplants without affecting immune recovery to the same extent. Improved results were obtained following a further reduction in the alemtuzumab dose in vitro from 20 mg to 10 mg. Subsequent pharmacokinetic studies on alemtuzumab demonstrated that the antibody persisted at a higher concentration at the time of transplant and for at least 2 months thereafter when used in vivo compared to persistence for less than 30 days when used at 20 mg in vitro. In this context; an antibody with a shorter half-life, like the original rat CD52 antibody Campath-1G, would be preferable. Otherwise, our cumulative experience with alemtuzumab suggests that better results might be achieved by tailoring the dose and mode of antibody use to match the clinical situation. Further studies are needed to optimize the dose of alemtuzumab in vivo and in vitro, determined by the type of conditioning and the graft.

Campath-1 Abs ‘in the bag’ for hematological malignancies: the Cape Town experience

BACKGROUND

We examined the strategy of T-cell depletion of HLA-identical sibling grafts for the prevention of GvHD, as well as disease control and overall survival.

PATIENTS AND METHODS

The myeloablative conditioning was radiation based. The source of stem cells was BM in 62, and cytokine-mobilized PBPC in 68 patients. GvHD prophylaxis was by ex vivo incubation of the stem-cell concentrates with Campath-1G (anti-CD52; n=76) or Campath-1H (n=54).

RESULTS

Patients receiving PBPC grafts were older (median 38.5) than those undergoing BMT (median 31; P=0.002). More patients in the PBPC group developed chronic GvHD (p<0.01). While no post-transplant GvHD prophylaxis was given to BMT recipients, prednisone 30 mg daily was prescribed to 12 and CYA for 90 days to a further 32 patients who had received PBPC grafts. Median follow-up was 1055 (range 28-4867) days. Although there was no difference in the survival between patients who received BMT or PBPC, death was from disease recurrence in 16 and nine (p=0.03; chi(2) test) subjects, respectively. Multivariate analysis showed that outcome was particularly favorable in those who were given<20 mg Campath-1 (survival: 28/39 versus 12/29; P=0.01), and in the subgroup of 30 patients who received Campath-1H and post-transplantation CYA.

DISCUSSION

In patients receiving BMT, Campath-1 Abs effectively prevent GvHD. For those treated with PBPC grafts, the combination of T-cell depletion and post-transplantation CYA is equally effective, without an obvious increase in disease recurrence.

Effective donor lymphohematopoietic reconstitution after haploidentical CD34+-selected hematopoietic stem cell transplantation in children with refractory severe aplastic anemia

Peritransplant toxicity and a delay in effective immune reconstitution have limited the utility of alternate donor transplantation for children with refractory severe aplastic anemia. We have assessed the effectiveness of infusing large numbers of highly purified haploidentical CD34+ cells after immunoablative conditioning in three patients who had failed intensive immunosuppression, lacked unrelated donors, and had active or recent serious infections. One patient rejected the first infusion, but engrafted after a second infusion from the same donor. This patient died 4 months after hematopoietic stem cell transplantation with no evidence of lymphoid reconstitution. Two patients experienced mixed chimerism requiring treatment with antibodies and/or donor lymphocyte infusion. Both currently survive more than 1 year after transplantation with normal blood counts, 100% donor engraftment, effective lymphoid reconstitution, and no chronic graft-versus-host disease. We observed functional thymopoiesis as measured by lymphocyte immunophenotyping, T cell receptor excision circles and T cell receptor Vbeta spectratyping complexity analysis. Further study is required to validate the initial promise of these preliminary observations.

Remission induction in Behçet's disease following lymphocyte depletion by the anti-CD52 antibody CAMPATH 1-H

OBJECTIVE

Behçet's disease (BD) is a multisystem vasculopathy of unknown cause with variable clinical presentation and the outcome of current treatments is often unsatisfactory. There is evidence for T-cell autoreactivity in BD and this study explores the therapeutic response to lymphocyte depletion with a humanized anti-CD52 antibody, CAMPATH-1H.

METHODS

Eighteen patients with active BD received a single course of 134 mg of CAMPATH-1H. Immunosuppressives were withdrawn and prednisolone reduced according to clinical status. Treatment response was assessed by remission of clinical features of disease activity, erythrocyte sedimentation rate, C-reactive protein, prednisolone dose, the need for subsequent immunosuppressives and disease relapse.

RESULTS

By 6 months, 13/18 (72%) had entered remission and average, daily prednisolone dose was reduced from 17.7 to 6.7 mg/day (P < 0.005). At patient follow-up after 37 (6-60) months, seven had relapsed after an average of 25 months, five had required the introduction of an immunosuppressive drug and two had been retreated with CAMPATH-1H; 10 were in stable remission and six were receiving no therapy. Moderate infusion-related adverse effects occurred in five and two developed hypothyroidism. Circulating CD4+ T cells fell to low levels after CAMPATH-1H and remained depressed for at least 1 yr; no opportunistic infections were seen.

CONCLUSIONS

The therapeutic response to CAMPATH-1H suggests a central role for autoreactive lymphocytes in BD. The potential of CAMPATH-1H to induce sustained treatment-free remission in BD poorly controlled by conventional therapy requires further evaluation.

Intensive chemotherapy with hematopoietic stem-cell support for children with recurrent or refractory NHL

BACKGROUND

Children with refractory or recurrent NHL are generally thought to have a poor prognosis. Those with chemosensitive disease are usually considered for an intensification phase, with either autologous or allogeneic hematopoietic stem-cell transplantation (HSCT).

METHODS

From 1990 to 2001 we performed 24 HSCTs in 22 children with refractory (n = 8), recurrent (n = 13), or high-risk in first CR (n = 1) NHL. Among the HSCTs, 19 were autologous and five were allogeneic.

RESULTS

In two children, allogeneic HSCT was performed after failing autologous HSCT. The histologic subtypes comprised large cell, (n = 13), Burkitt's lymphoma (n = 5) and lymphoblastic (n = 4). Among the cases of primary relapse, 10 occurred during therapy and three occurred after completing initial therapy. Among the 22 children in this series, two died of transplant-related toxicity and nine died of progressive disease or relapse after transplant. Among the 11 children who are alive and disease-free, 10 had non-lymphoblastic histology and one had lymphoblastic disease; one relapsed after autologous HSCT, but was successfully salvaged with multi-agent chemotherapy and involved-field irradiation. Among the 22 initial transplanted cases, 10 of 19 children with chemosensitive disease before transplantation and one of three with chemoresistant disease are currently alive and disease-free.

DISCUSSION

Intensive chemotherapy followed by hematopoietic stem-cell support is an effective strategy for children with chemosensitive recurrent non-lymphoblastic NHL.

Impact on T-cell depletion and CD34+ cell recovery using humanised CD52 monoclonal antibody (CAMPATH-1H) in BM and PSBC collections; comparison with CAMPATH-1M and CAMPATH-1G

BACKGROUND

Ex vivo T-cell depletion of allogeneic BM (BM) grafts can effectively reduce graft versus host disease (GvHD) and may also apply to transplantation of allogeneic peripheral blood stem cell (PBSC) transplants.

METHODS

Here we have evaluated T-cell depletion and progenitor cell recovery by antibody-mediated cells lysis using three CD52 monoclonal antibodies (MAbs) at different concentrations and cell densities.

RESULTS

CAMPATH-1M was superior to CAMPATH-1H for T-cell depletion of BM samples. Treatment with CAMPATH-1M resulted in up to 2.55 log depletion of CD3+ cells, with recoveries of >or=45% CD34+ cells, >or=67% CFU-GM and >or=65% BFU-E. CAMPATH-1H treatment resulted in up to 1.64 log depletion of CD3+ cells and similar recoveries of CD34+ cells, CFU-GM and BFU-E as seen with CAMPATH-1M. Depletion of CD19+ cells was similar to that observed for CD3+ cells while natural killer (NK) cells were relatively spared compared with the T and B cell populations. Log depletions of T cells from PBSC, as determined by immunofluorescence studies and limiting dilution analyses, were similar using CAMPATH-1M, -1H, and -1G. There were also no differences in the depletion of CD19+ cells or NK cells using the three MAbs. Similar results were obtained for recoveries of CD34+ cells, CFU-GM and BFU-E using all three MAbs, although the recovery of CD34+ cells using the highest concentration of MAbs was significantly greater in CAMPATH-1H treated samples. Increasing the number of PBSC treated with CAMPATH-1H and -1M had no effect on the log depletion of T, B or NK cells and there were no major differences in the log depletions achieved with CAMPATH-1H or -1M. Likewise, the higher PBSC density had no effect on the recoveries of CD34+ cells or committed progenitors and once again CAMPATH-1H gave similar recoveries to those obtained using CAMPATH-1M.

DISCUSSION

Although CAMPATH-1M resulted in greater ex vivo T-cell depletion of BM than CAMPATH-1H, in all other respects, the humanised CAMPATH-1H was just as effective as CAMPATH-1M and -1G.

In vivo CAMPATH-1H prevents GvHD following nonmyeloablative stem-cell transplantation

BACKGROUND

We have investigated a novel nonmyeloablative conditioning regimen in 44 patients with hematological malignancies. The median patient age was 41 years. Many of the patients had high-risk features, including 19 patients with a previous failed transplant.

METHODS

Recipient conditioning consisted of CAMPATH-1H 20 mg/day on Days -8 to -4, fludarabine 30 mg/m(2) on Days -7 to -3 and melphalan 140 mg/m(2) on Day -2. Thirty-six recipients received unmanipulated G-CSF mobilized PBSC from HLA identical siblings and eight received unmanipulated BM from MUD. GvHD prophylaxis was with CYA alone for 38 patients and CYA plus MTX for six sibling recipients.

RESULTS

Forty-two of the 43 evaluable patients had sustained engraftment. Results of chimerism analysis using microsatellite PCR indicate that 18 of 31 patients studied were full donor chimeras, while the other patients were mixed chimeras in one or more lineages. At a median follow-up of 9 months (range, 3-29 months) 33 patients remain alive in CR, or with no evidence of disease progression. Seven patients relapsed or progressed post-transplant and four of them subsequently died. Four patients died from regimen-related complications. There were no cases of Grades III-IV acute GvHD. Only two patients developed Grade II acute GvHD and only one had chronic GvHD. The estimated probability of non-relapse mortality at 1 year was 11%.Results: Although longer follow-up is needed to establish the long-term remission rates, this study demonstrates that this nonmyeloablative preparative regimen is associated with durable engraftment, minimal toxicity and low incidence of GvHD.

CAMPATH-1 antibodies in stem-cell transplantation

BACKGROUND

CAMPATH-1 (CD52) Abs have been used in stem-cell transplants for the prevention of GvHD and graft rejection. These complications can effectively be prevented by depletion of T lymphocytes from both donor and recipient. However, donor lymphocytes might contribute an anti-leukemia effect and lymphocyte depletion may exacerbate problems with immune reconstitution. There is a fine balance between the risks of GvHD and host-versus-graft reactions, relapse and infection.

METHODS

Clinical outcomes for 4264 patients were reported to a central registry and analyzed by univariate and multivariate methods to determine the superior protocols. Various protocols of lymphocyte depletion were tested, using either CAMPATH-1M (IgM) plus complement or CAMPATH-1G (IgG2b) to treat the donor BM ex vivo and CAMPATH-1G in vivo to treat the recipient. The humanized antibody CAMPATH-1H has recently replaced CAMPATH-1G. A meeting of the clinical collaborators was convened to discuss the results and to review the experiences of individual centers.

RESULTS

Interest focused on the use of mobilized PBSC for transplantation and on the use of reduced-intensity conditioning regimens ('mini' or 'non-Correspondence myeloablative' transplants). These approaches are likely to become increasingly important in the future and will allow transplant procedures to be used for relatively older patients. The use of CAMPATH-1G or CAMPATH-1H was associated with a low incidence of GvHD or rejection, though there were some differences that might be related to the longer half-life of the humanized antibody. An unexpected and apparently paradoxical effect of post-transplant CYA was observed - it appeared to reduce the risk of dying from infection after 6 months. Although part of the benefit could be explained by a reduction in GvHD, the effect was still evident when patients with GvHD or graft rejection were excluded from analysis.

DISCUSSION

CAMPATH-1H appears to have a useful role in the prevention of graft rejection and GvHD, particularly in patients who are at high risk of these complications. It can equally well be used by admixture with the infused stem cells, or by administration to the patient prior to the transplant. Future studies will seek to understand the mechanism of the CYA effect and to improve the quality of immune reconstitution.