Initiation of an eligibility screening protocol prior to tissue typing of potential stem cell donors resulted in substantial cost savings

e19047

Background: Human Leukocyte Antigen (HLA) typing is a necessary but expensive process to identify suitable donors for allogeneic hematopoietic cell transplantation (HCT) for the treatment of bone marrow disorders and hematologic malignancies. The likelihood of a patient and sibling being fully HLA matched is 25%. An HLA-identical related donor remains the preferred source among HCT recipients due to superior outcomes when compared to unrelated, mismatched, haploidentical, or cord blood. Because of the high probability of finding an HLA matched donor among siblings, and the benefit of quick access to these donors, it had been standard procedure at our institute to test all siblings to identify potential matches. The estimated costs of HLA typing alone is approximately $300-$1000 and is contingent upon the lab utilized and resolution of typing. The costs of HLA typing, additional testing, and screening are significant to patients and health care systems. Methods: Our institution initiated a protocol to assess potential sibling donors prior to HLA typing as per the donor eligibility guidelines of the National Marrow Donor Program (NMDP). From 2018-2020 each sibling was given a questionnaire prior to HLA typing and screened for suitability. If a sibling was determined to be ineligible for donation based on the NMDP guidelines, HLA typing and work up for that sibling was not pursued. Results: Between 2018 and 2020 we identified 789 potential donors for HCT. All potential donors were sent eligibility questionnaires. Based on this screening, 568 potential donors were found to be eligible for donation whereas 221 were ineligible. HLA typing was pursued in all eligible donors. This resulted in and estimated cost savings of $66,000-$221,000 in HLA typing alone. This translated into a substantial health care cost savings for our institution as compared to our prior policy of typing all siblings. Conclusions: Identification and work up for potential HLA matched siblings is critical for identifying optimal donors for HCT. Our previous policy of universal sibling screening was found to be costly due to typing individuals who later were found to be ineligible to donate. We found that the initiation of a simple donor screening protocol that excluded ineligible sibling donors resulted in significant cost savings compared to our prior policy of HLA typing all potential sibling donors. Cost savings are a relevant consideration in all aspects of healthcare and this screening tool could be a practical component of the best practice guidelines for HLA matching and HCT.

CAMMA 1: A multicenter phase Ib trial evaluating the safety, pharmacokinetics, and activity of cevostamab-containing regimens in patients with relapsed or refractory multiple myeloma

TPS8069

Background: Treatment of relapsed/refractory (R/R) multiple myeloma (MM) is challenging, especially in later lines where drug resistance reduces therapeutic options and remission duration. Prognosis is poor (estimated survival: < 1 year) for patients with MM who have received > 3 prior lines of therapy and are triple refractory to immunomodulatory drugs (IMiDs), proteasome inhibitors (PIs) and anti-CD38 agents (Gandhi et al. 2019). Thus R/R MM constitutes a significant unmet medical need. Fragment crystallizable receptor-like 5 (FcRH5) is expressed on myeloma cells with near 100% prevalence (Li et al. 2017), constituting a novel therapeutic target. Cevostamab is an IgG1-based T-cell-engaging bispecific antibody engineered to target the most membrane-proximal domain of FcRH5 on myeloma cells and cluster of differentiation 3 (CD3) on T-cells, resulting in T-cell killing of myeloma cells. Clinical data from the first-in-human Phase I study (GO39775) suggest that cevostamab monotherapy is highly active in heavily pretreated patients with R/R MM, with an overall response rate of 56.7% at the 132–198mg dose level (Trudel et al. ASH 2021 Oral presentation). Thus, cevostamab’s activity and safety profile support further development. Due to their stimulatory effects on T-cell activity, combination of cevostamab with anti-myeloma agents (pomalidomide [P] or daratumumab [D]) may be synergistic, offering the potential to further improve efficacy. CAMMA 1 (NCT04910568) is an open-label, multicenter Phase Ib trial evaluating the safety, tolerability, pharmacokinetics (PK) and pharmacodynamics of cevostamab-containing combination regimens (Arm B: cevostamab plus P and dexamethasone [d] [Pd]; Arm C: cevostamab plus Dd) in patients with R/R MM. A modified weekly schedule for cevostamab is also under investigation (Arm A: cevostamab monotherapy). Methods: Patients must be aged ≥18 years, have an ECOG performance status of 0 or 1 and a life expectancy of > 12 weeks. Patients in all arms have R/R MM; Arms B and C include patients with prior IMiD and PI exposure. Patients with prior CAR-T therapy may enroll with a washout period of 12 weeks post-CAR-T infusion. Cevostamab is administered by intravenous infusion q1w (C1–2)/q2w (C3–6)/q4w (C7–13) in Arm A, q2w (C1–6)/q4w (C7+) in Arm B, and q3w (C1–8)/q4w (C9+) in Arm C. Each arm consists of a safety run-in and an expansion cohort. Enrolment for Arm A is ongoing, with patients receiving up to 13 treatment cycles. Arms B and C are planned; patients will receive treatment until disease progression or unacceptable toxicity. The primary objective is to evaluate the safety and tolerability of cevostamab plus Pd, cevostamab plus Dd and cevostamab monotherapy. Secondary objectives include assessment of activity, PK, immunogenicity, and pharmacodynamic biomarkers. Clinical trial information: NCT04910568.

Intra-population variability of ocean acidification impacts on the physiology of Baltic blue mussels (Mytilus edulis): integrating tissue and organism response

Increased maintenance costs at cellular, and consequently organism level, are thought to be involved in shaping the sensitivity of marine calcifiers to ocean acidification (OA). Yet, knowledge of the capacity of marine calcifiers to undergo metabolic adaptation is sparse. In Kiel Fjord, blue mussels thrive despite periodically high seawater PCO₂, making this population interesting for studying metabolic adaptation under OA. Consequently, we conducted a multi-generation experiment and compared physiological responses of F1 mussels from 'tolerant' and 'sensitive' families exposed to OA for 1 year. Family classifications were based on larval survival; tolerant families settled at all PCO₂ levels (700, 1120, 2400 µatm) while sensitive families did not settle at the highest PCO₂ (≥99.8% mortality). We found similar filtration rates between family types at the control and intermediate PCO₂ level. However, at 2400 µatm, filtration and metabolic scope of gill tissue decreased in tolerant families, indicating functional limitations at the tissue level. Routine metabolic rates (RMR) and summed tissue respiration (gill and outer mantle tissue) of tolerant families were increased at intermediate PCO₂, indicating elevated cellular homeostatic costs in various tissues. By contrast, OA did not affect tissue and routine metabolism of sensitive families. However, tolerant mussels were characterised by lower RMR at control PCO₂ than sensitive families, which had variable RMR. This might provide the energetic scope to cover increased energetic demands under OA, highlighting the importance of analysing intra-population variability. The mechanisms shaping such difference in RMR and scope, and thus species' adaptation potential, remain to be identified.

Programmed Death 1 Expression on CD4+ T Cells Predicts Mortality after Allogeneic Stem Cell Transplantation

Excessive or persistent programmed death 1 (PD-1) expression on virus- or tumor-specific T cells during chronic viral infection or malignancy has been associated with impaired immune control. To assess the role of the PD-1 pathway in allogeneic stem cell transplantation (SCT), we examined PD-1 expression and maturation phenotype on T cells from 42 patients early (day 55 to 85) after cord blood (CB), matched unrelated donor, and matched related donor transplantation. Expression of PD-1 on CD4⁺ T cells was significantly elevated in all transplantation types, with the highest level observed in CB subjects. Elevated PD-1 expression on CD4⁺ T cells early after transplantation was observed in nonsurvivors (median, 40.2%; range, 15.1 to 86.1) compared with survivors (median, 23.6%; range, 8.4 to 55.2; P = .001), indicating its association with increased risk for mortality, especially with CB transplantations, where PD-1 was increased in nonsurvivors (median, 64.6%; range, 36.5 to 86.1) compared with survivors (median, 34.1%; range, 15.9 to 55.2; P = .01). Furthermore, T cell subset analysis revealed that PD-1 expression was further elevated on CD4⁺ T central memory in nonsurvivors (median, 49.8%; range, 15.1 to 83.4) compared with survivors (median, 24.8%; range, 8.9 to 71.3; P = .002) and on T effector memory cells in nonsurvivors (median, 69.1%; range, 24.7 to 92.6) compared with survivors (median, 43.7%; range, 13.9 to 96.5; P = .0003). Our findings suggest that elevation of PD-1 expression on CD4⁺ T cells is associated with mortality in CB and possibly all SCT recipients.

Plasma cell disorders in HIV-infected patients: epidemiology and molecular mechanisms

Highly active antiretroviral therapy (HAART) has significantly improved the outcome and survival of human immunodeficiency virus (HIV)-infected patients. Subsequently, long-term morbidities including cancer have become of major public health and clinical interest for this patient population. Plasma cell disorders occur at higher incidence in HIV-infected patients; however, the molecular mechanisms driving the plasma cell disease process and the optimal management for these patients remain to be defined. This article provides an up-to-date review of the characteristics and management of HIV-infected patients with plasma cell disorders. We first present 3 cases of plasma cell disorders in HIV-infected patients, ranging from polyclonal hypergammaglobulinemia to symptomatic multiple myeloma. We then discuss the epidemiology, clinical presentation, and management of each of these plasma cell disorders, with an emphasis on the molecular events underlying the progression of plasma cell diseases from monoclonal gammopathy to symptomatic multiple myeloma. We propose a three-step hypothesis for the development of multiple myeloma. Finally, we discuss the use of high dose chemotherapy and autologous hematopoietic stem cell transplantation in the treatment of HIV-infected patients with multiple myeloma. Our review includes the care of HIV-infected patients with plasma cell disorders in the current era of HAART and novel agents available for the treatment of multiple myeloma.

Extra-adrenal pheochromocytoma in the organ of Zuckerkandl: diagnosis and treatment strategies

Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare catecholamine-secreting neuroendocrine tumors arising from chromaffin tissue and can occur within the adrenal medulla (PHEO) or extra-adrenal sites (PGL). The most common site for PGL is the organ of Zuckerkandl, extra-adrenal chromaffin tissue near the origin of the inferior mesenteric artery.We here present 2 patients with extra-adrenal PGL in the organ of Zuckerkandl, located by iodine-123-metaiodobenzylguanadine ( (123)I-MIBG) scintigraphy and thereafter treated surgically or with iodine-131-metaiodobenzylguanadine ( (131)I-MIBG). First, in a 15-year-old boy with clinical suspicion of PHEO, the diagnosis was established by biochemical evaluation and confirmed by further imaging studies, including CT and (123)I-MIBG, as PGL in the Zuckerkandl organ. The tumor was completely resected by laparotomy. Second, in a 70-year-old woman presenting with progressive hypertension and palpitations, MR and (123)I-MIBG revealed a singular tumor lesion with abnormal (123)I-MIBG uptake in the Zuckerkandl organ. Due to severe general vascular disease, surgery was not performed and instead the patient underwent (131)I-MIBG therapy. The patient showed a good symptomatic response with improvement of symptoms and no relevant side-effects of therapy.

Comparison of a-Si1-xCx:H Layers Based on Methane, Di-, Tri- and Tetrasilylmethane as Feedstocks

Using standard rf glow discharge deposition, we compare the properties of a-Si1-xCx:H films prepared with different carbon sources, namely methane and di-, tri- and tetrasilylme-thane (DSM, TSM and TetraSM). The optical bandgap EG was varied between 1.8 eV and 2.4 eV. All oua-Si1-xCx:H films exhibit low Urbach energies (EQ < 60 meV for EG< 2.0 eV) and low defect absorption, both determined by PDS. Using the silylmetha-nes as feedstocks, we do not find significant differences relative to our methane-based material. Independently of the carbon source material, the energy gap dependences of the film properties (photoconductivity, activation energy of the dark conductivity, Urbach energy and subbandgap defect absorption) show a distinct change around EG = 2.1 eV, which is interpreted as a consequence of structural changes with increasing carbon content.

["Ultrasound tonsillectomy" in comparison with conventional tonsillectomy]

BACKGROUND AND OBJECTIVE

The postoperative convalescence after tonsillectomy is difficult because of a high rate of secondary hemorrhages and severe pain. The Ultracision Harmonic Scalpel cuts in the longitudinal direction and coagulates simultaneously by means of a 55.500 Hz vibrating blade. A randomized prospective simple blind study was conceived to compare the advantages and disadvantages of the "Ultrasound Tonsillectomy" with the conventional method.

PATIENTS

Between 8/1999 and 3/2000 25 tonsillectomies were performed with the Ultracision (TEuc-group) and 25 with conventional methods (TEkonv-group). The age of the patients was between 18 and 65 years.

RESULTS

The median intraoperative blood loss in the TEuc-group was significantly lower than the TEkonv-group (19.0 g/176.0 g), the pain symptoms were comparatively less. On the other hand postoperative blood losses of the TEuc-group were clearly higher (7/25 vs. 3/25), wounds healed more slowly, the development of the wound covering and the swelling of the uvula were significantly larger.

CONCLUSIONS

Based on the results of the study the ultrasound technique is not superior to the conventional tonsillectomy.

Separation of human pancreatic carboxypeptidase A isoenzymes by high performance liquid chromatography

Human pancreatic carboxypeptidase A, which was isolated from a pool of necrobiotic pancreae, crystallized spontaneously and appeared homogenous in sodium dodecylsulphate polyacrylamide gel electrophoresis. Reversed phase high performance liquid chromatography of the dissolved crystals, however, revealed the presence of two distinct isoenzymes, which were shown by aminoterminal sequence analysis to be only 61% homologous in their 31 amino terminal amino acids. On the other hand, amino terminal sequences of the isoenzymes were found to be 79% and 87% homologous with CAP1 and CPA2 of the rat, respectively. Thus, the presence of two distinct pancreatic carboxypeptidase A isoenzymes could be clearly demonstrated for the first time in human tissue.

[Inpatient, day clinic and ambulatory care of children and adolescents with chronic kidney disease]

Based on personal experience in caring for about 2,500 children with various kidney disorders, the role of individual factors such as age, diagnosis, and origin of patients for the type of medical care is discussed. Most patients can be cared for in an outpatient or day-clinic setting. Major interventions such as renal biopsy requiring hospital admission are exceptions. For a successful therapy a constant flow of information between medical practitioners or non specialised hospital services and the pediatric nephrology centre is needed. Daytime care in a clinical setting today is feasible in a number of situations, e.g. for performing renal function tests and for introducing parents into certain diagnostic or therapeutic procedures such as measurement of blood pressure, manual bladder expression and dietary manipulations. Training for home dialysis as well as centre dialysis are preferably performed under outpatient conditions. The recent introduction of continuous ambulatory peritoneal dialysis for outpatients has allowed to reduce the number of patients requiring hospital dialysis which is more expensive.

[Special hormone-determined constitutional types in women from the anthropological viewpoint]

The question is examined, whether in females hormonal determined constitution types are present which would require a different dosage of the estrogen respectively gestagen portion in the compound of ovulation inhibitors. Various aspects of constitution biology as well as of hormone physiology connected with this question are discussed in detail. Provided that a coherence between the hormonal balance and the constitutional type would be present, ovulation inhibitors could be dosed for the estrogen respectively gestagen portion. However, until now such a coherence could not be proved convincingly.