Durable benefit of rituximab maintenance post-autograft in patients with relapsed follicular lymphoma: 12-year follow-up of the EBMT lymphoma working party Lym1 trial

We report the 12-year follow-up of the prospective randomized EBMT LYM1 trial to determine whether the benefit of brief duration rituximab maintenance (RM) on progression-free survival (PFS) in patients with relapsed follicular lymphoma (FL) receiving an autologous stem cell transplant (ASCT) is sustained. One hundred and thirty-eight patients received RM with or without purging. The median follow-up after random assignment is 12 years (range 10-13) for the whole series. The 10-year PFS after ASCT is 47% (95% CI 40-54) with only 4 patients relapsing after 7.5 years. RM continues to significantly improve 10-year PFS after ASCT in comparison with NM [P = 0.002; HR 0.548 (95% CI 0.38-0.80)]. Ten-year non-relapse mortality (NRM) was not significantly different between treatment groups (7% overall). 10-year overall survival (OS) after ASCT was 75% (69-81) for the whole series, with no significant differences according to treatment sub-groups. 10-year OS for patients who progressed within 24 months (POD24T) was 60%, in comparison with 85% for patients without progression. Thus the benefit of rituximab maintenance after ASCT on relapse prevention is sustained at 12 years, suggesting that RM adds to ASCT-mediated disease eradication and may enhance the curative potential of ASCT.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Parental and peer supports are associated with an active lifestyle of adolescents: evidence from a population-based survey

OBJECTIVES

Parental and peer support can foster adolescents' activity behaviours; however, little is known about how such support are linked with adolescents' active lifestyle in non-Western settings. The study aimed to explore associations of parental and peer support with an active lifestyle of adolescents in Malaysia.

STUDY DESIGN

This is a cross-sectional study.

METHODS

We used data from the 2012 Malaysian Global School-based Student Health Survey, which covered adolescents aged 11-17 years (51% girls). Adolescents were asked about their physical activity, sitting time, and levels of parental and peer support. Participants with ≥60 min of moderate to vigorous physical activity per day and ≤2 h of sitting time per day were categorised as having an 'active lifestyle'. Binary logistic regression was used to examine the relationships by gender and age group (11-14 and 15-17 years).

RESULTS

Of the participating adolescents (n = 12,081), 15.3% reported to have an active lifestyle (boys: 22.0%; girls: 8.8%). About 31% reported to have higher levels of parental support, whereas 47% reported higher levels of peer support. Higher parental and peer support were significantly associated with an active lifestyle of boys across both age groups. Girls with higher parental support had higher odds of reporting an active lifestyle in both age groups, whereas higher peer support was significantly associated with an active lifestyle among girls aged 11-14 years.

CONCLUSIONS

This study uniquely extends the current evidence by examining the associations of parental and peer support with physical activity and sitting time combined. More research is needed to understand how different types of social support can influence adolescents' active lifestyle.

Physical activity and sedentary behaviour in Bangladesh: a systematic scoping review

OBJECTIVES

Lack of physical activity (PA) contributes to increasing prevalence of non-communicable diseases (NCDs) globally. However, little is known about PA and sedentary behaviour (SB) among populations in low- and middle-income countries (LMICs). This systematic review examined prevalence of PA and SB in Bangladesh.

STUDY DESIGN

Systematic review of the literature.

METHODS

A systematic electronic search in eight databases and a manual search of retrieved articles' references were conducted. Original research conducted in Bangladesh with PA- and/or SB-related outcome(s) were included.

RESULTS

Out of 1,162 retrieved titles, 33 articles (32 cross-sectional and one case-control study) met the inclusion criteria. Twenty-nine studies were with healthy populations: adults (n = 19); children and adolescents (n = 7); and children, adolescents and adults (n = 3). Five studies used nationally representative samples of adults and one of adolescents. Most studies (n = 26) assessed PA only; three only SB, and four both PA and SB. All studies used self-reported measures. Among healthy adults, prevalence of insufficient PA ranged from 5% to 83%. Occupational and transport-related PA contributed the most towards total PA with negligible contribution of recreational PA. Among children and adolescents, the prevalence of insufficient PA ranged between 20% and 67%. Females engaged in less PA compared to males. Limited evidence currently exists about the prevalence of SB, especially among adults.

CONCLUSIONS

PA and SB research has received little attention in Bangladesh. Critical knowledge gaps identified in this review should be taken into account when designing new research and programmes in Bangladesh and other LMICs with similar socio-economic and cultural settings.

Dose-Reduced Versus Standard Conditioning Followed by Allogeneic Stem-Cell Transplantation for Patients With Myelodysplastic Syndrome: A Prospective Randomized Phase III Study of the EBMT (RICMAC Trial)

Purpose To compare a reduced-intensity conditioning regimen (RIC) with a myeloablative conditioning regimen (MAC) before allogeneic transplantation in patients with myelodysplastic syndrome (MDS) within a randomized trial. Patients and Methods Within the European Society of Blood and Marrow Transplantation, we conducted a prospective, multicenter, open-label, randomized phase III trial that compared a busulfan-based RIC with MAC in patients with MDS or secondary acute myeloid leukemia. A total of 129 patients were enrolled from 18 centers. Patients were randomly assigned in a 1:1 ratio and were stratified according to donor, age, and blast count. Results Engraftment was comparable between both groups. The CI of acute graft-versus-host disease II to IV was 32.3% after RIC and 37.5% after MAC ( P = .35). The CI of chronic graft-versus-host disease was 61.6% after RIC and 64.7% after MAC ( P = .76). The CI of nonrelapse mortality after 1 year was 17% (95% CI, 8% to 26%) after RIC and 25% (95% CI, 15% to 36%) after MAC ( P = .29). The CI of relapse at 2 years was 17% (95% CI, 8% to 26%) after RIC and 15% (95% CI, 6% to 24%) after MAC ( P = .6), which resulted in a 2-year relapse-free survival and overall survival of 62% (95% CI, 50% to 74%) and 76% (95% CI, 66% to 87%), respectively, after RIC, and 58% (95% CI, 46% to 71%) and 63% (95% CI, 51% to 75%), respectively, after MAC ( P = .58 and P = .08, respectively). Conclusion This prospective, randomized trial of the European Society of Blood and Marrow Transplantation provides evidence that RIC resulted in at least a 2-year relapse-free survival and overall survival similar to MAC in patients with MDS or secondary acute myeloid leukemia.

Rituximab purging and/or maintenance in patients undergoing autologous transplantation for relapsed follicular lymphoma: a prospective randomized trial from the lymphoma working party of the European group for blood and marrow transplantation

PURPOSE

The objective of this randomized trial was to assess the efficacy and safety of rituximab as in vivo purging before transplantation and as maintenance treatment immediately after high-dose chemotherapy and autologous stem-cell transplantation (HDC-ASCT) in patients with relapsed follicular lymphoma (FL).

PATIENTS AND METHODS

Patients with relapsed FL who achieved either complete or very good partial remission with salvage chemotherapy were randomly assigned using a factorial design to rituximab purging (P+; 375 mg/m(2) once per week for 4 weeks) or observation (NP) before HDC-ASCT and to maintenance rituximab (M+; 375 mg/m(2) once every 2 months for four infusions) or observation (NM).

RESULTS

From October 1999 to April 2006, 280 patients were enrolled. The median age was 51 years (range, 26 to 70 years), and baseline characteristics were well balanced between groups. On average, patients were 44 months (range, 3 to 464 months) from diagnosis, with 79% having received two lines and 15% three lines of prior therapy. Median follow-up was 8.3 years. In contrast to purging, 10-year progression-free survival (PFS) was 48% for P+ and 42% for NP groups (hazard ratio [HR], 0.80; 95% CI, 0.58 to 1.11; P = .18); maintenance had a significant effect on PFS (10-year PFS, 54% for M+ and 37% for NM; HR, 0.66; 95% CI, 0.47 to 0.91; P = .012). Overall survival (OS) was not improved by either rituximab purging or maintenance.

CONCLUSION

Rituximab maintenance after HDC-ASCT is safe and significantly prolongs PFS but not OS in patients undergoing transplantation for relapsed FL. Pretransplantation rituximab in vivo purging, even in rituximab-naive patients, failed to improve PFS or OS.

Pithedulosides A-G, oleanane glycosides from Pithecellobium dulce

Seven saponins named pithedulosides A-G were isolated from the seeds of Pithecellobium dulce. Their structures were established through spectral analyses as echinocystic acid 3-O-alpha-L-arabinopyranosyl-(1-->6)-beta-D-glucopyranoside, echinocystic acid and oleanolic acid 3-O-alpha-L-arabinopyranosyl- (1-->2)-alpha-L-arabinopyranosyl-(1-->6)-beta-D-glucopyranosides and 3-O-beta-D-xylopyranosyl-(1-->2)-alpha-L-arabinopyranosyl -(1-->6)-beta-D-glucopyranosides, oleanolic acid 3-O-alpha-L-arabinopyranosy-(1-->2)-alpha-L- arabinopyranosyl-(1-->6)-[beta-D-glucopyranosyl-(1-->2)]-beta- D-glucopyranoside, and 3-O-beta-D-xylopyranosyl-(1-->2)-alpha-L-arabinopyranosyl-(1-->6) -[beta-D-glucopyranosyl-(1-->2)]--beta-D-glucopyranoside.

Quality of drinking water in the Aligarh Muslim University Campus, Aligarh, U.P. (India) with respect to heavy metals

The physico-chemical characteristics of the drinking water in nine residential halls of the Aligarh Muslim University, Aligarh, U.P. (India), were studied. Nine samples each of running and standing water were taken four times over a period of one month at weekly intervals from all of the residential halls and were analysed for physico-chemical characteristics and heavy metal contents. The temperature, pH and electrical conductivity of water samples ranged between 20.0-26.0°C; 7.00-8.00 and 116.00-199.04 micromhos cm(-1) respectively whereas the values of total alkalinity, total hardness, Cl(-), SO 4 (-) , F(-), NH3-N, NO2-N; NO3-N were found between 261.00-396.00; 128.00-200.00; 8.00-69.00; 12.00-46.00; 0.90-1.35; 0.20-0.44; ND; 1.60-6.50 mg l(-1) respectively. The ranges of heavy metal concentrations in the running water samples were as follows: Cd (0.70-3.75); Cr (ND-5.00); Co (9.50-18.75); Cu (0.75-15.00); Fe (ND-13.50); Mn (3.50-51.00); Ni (7.00-17.50); Pb (0.50-2.50) and Zn (10.00-176.50) μg l(-1). The heavy metal concentrations in standing water samples were found to be: Cd (1.20-4.90); Cr (ND-10.00); Co (10.25-19.00); Cu (1.75-20.00); Fe (ND-18.00); Mn (5.00-66.50); Ni (8.75-19.75); Pb (0.75-5.50) and Zn (28.60-364.00) μg l(-1). The concentrations of heavy metals in drinking water supplies of the Aligarh Muslim University campus were well below the guidelines for drinking water quality as prescribed by World Health Organisation (1984). It is evident from the results that the drinking water may not cause any significant health hazard to water consumers due to heavy metals but these may be hazardous if they get accumulated in the body due to continuous consumption of water.

Studies on heavy metals in the ground waters of the city of Aligarh U.P. (India)

A study was conducted to determine the levels of heavy metals Cd, Cr, Cu, Fe, Mn, Ni, Pb, and Zn along with physico-chemical parameters in ground waters of Aligarh city, U.P. (India). Twenty seven samples of hand pump water and twenty three samples of municipal water supply were collected from different localities of the Aligarh city, five times during the period of two months at intervals of 12 days. The samples were analysed for physico-chemical characteristics (pH, electrical conductivity, chlorides, sulphates, total hardness, total alkalinity, nitrate-nitrogen, fluoride, calcium and magnesium) and heavy metal contents. The concentrations of heavy metals in the hand pump water samples were found in the ranges of Cd (ND-5.00); Cr (ND-30.00); Cu (ND-82.50); Fe (16.80-460.00); Mn (ND-425.00); Ni (ND-25.00); Pb (ND-25.00) and Zn (28.60-775.00) μg l(-1). The heavy metal concentrations in the municipal water supply samples were found to be Cd (ND-5.00); Cr (ND-25.00); Cu (ND-37.50); Fe (8.00-37.50); Mn (ND-320.00); Ni (ND-25.00); Pb (ND-25.00) and Zn (2.00-271.87) μg l(-1).It appears from the results of these studies the concentrations of Cd, Cr, Cu, Ni, Pb, and Zn in the ground waters of the Aligarh City were found to be lower than the prescribed limits of World Health Organisation (1984), whereas the values of Fe and Mn were found above the prescribed limits in some localities. The chloride total hardness and nitrate-nitrogen were comparatively higher in the hand pump water than the municipal supply water. The reason of higher values of these parameters may be ascribed to the surface disposal of sewage wastes, wastes from metal processing industries and other house hold refuses.