1
|
Aldoss I, Khaled SK, Wang X, Palmer J, Wang Y, Wagner JR, Clark MC, Simpson J, Paul J, Vyas V, Chien SH, Stein A, Pullarkat V, Salhotra A, Al Malki MM, Aribi A, Sandhu K, Thomas SH, Budde LE, Marcucci G, Brown CE, Forman SJ. Favorable Activity and Safety Profile of Memory-Enriched CD19-Targeted Chimeric Antigen Receptor T-Cell Therapy in Adults with High-Risk Relapsed/Refractory ALL. Clin Cancer Res 2023; 29:742-753. [PMID: 36255386 PMCID: PMC10544259 DOI: 10.1158/1078-0432.ccr-22-2038] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/25/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE A phase I/II study evaluating the safety and activity of memory-enriched CD19-directed chimeric antigen receptor (CD19-CAR) T cells in adults with relapsed/refractory B-cell acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS In phase I, we tested sequentially two cell populations for CAR transduction: (i) central memory (Tcm) or (ii) naïve, stem, and central memory (Tn/mem) T cells. The study employed an activity constrained for toxicity design to determine the recommended phase II dose (RP2D), which was tested in phase II. RESULTS The Tcm cohort was closed early due to lack of activity. The 200 ×106 Tn/mem-derived CD19-CAR T-cell dose was found to be safe and active, and was declared the RP2D. At RP2D, 58 participants underwent leukapheresis and 46 received CD19-CAR T cells. Median age for treated participants was 38 years (range, 22-72). Twenty-nine (63%) participants had relapsed post-allogeneic hematopoietic cell transplantation (alloHCT), 18 (39%) had Philadelphia-like (Ph-like) genotype, and 16 (35%) had extramedullary disease (EMD) at lymphodepletion (LD). Three (7%) participants had grade 3 cytokine release syndrome (CRS), and none had grade ≥ 4 CRS. Eight (17%) participants had grade ≥ 3 neurotoxicity, including one fatal cerebral edema. Forty (87%) patients achieved complete remission (CR)/CR with incomplete hematologic recovery, 2 (4%) progressed, and 4 (9%) were unevaluable for response. Among 42 response-evaluable participants, 16/17 with Ph-like ALL and 13/15 with EMD at LD responded. Twenty-one (53%) responders underwent alloHCT consolidation, which was associated with improved relapse-free survival (adjusted HR = 0.16; 95% confidence interval, 0.05-0.48; P = 0.001). CONCLUSIONS Tn/mem-derived CD19-CAR T cells were safe and active, including in Ph-like ALL and EMD. See related commentary by El Marabti and Abdel-Wahab, p. 694.
Collapse
Affiliation(s)
- Ibrahim Aldoss
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Samer K. Khaled
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Xiuli Wang
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| | - Joycelynne Palmer
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Computational and Quantitative Sciences, Division of Biostatistics, Beckman Research Institute, City of Hope, Duarte, California
| | - Yan Wang
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Computational and Quantitative Sciences, Division of Biostatistics, Beckman Research Institute, City of Hope, Duarte, California
| | - Jamie R. Wagner
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| | - Mary C. Clark
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Clinical and Translational Project Development, City of Hope, Duarte, California
| | - Jennifer Simpson
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Jinny Paul
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| | - Vibhuti Vyas
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| | - Sheng-Hsuan Chien
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| | - Anthony Stein
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Vinod Pullarkat
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Amandeep Salhotra
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Monzr M. Al Malki
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ahmed Aribi
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Karamjeet Sandhu
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Sandra H. Thomas
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Clinical and Translational Project Development, City of Hope, Duarte, California
| | - Lihua E. Budde
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| | - Guido Marcucci
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Christine E. Brown
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| | - Stephen J. Forman
- Hematological Malignancies Research Institute, City of Hope, Duarte, California
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- T Cell Therapeutics Research Laboratories, City of Hope, Duarte, California
| |
Collapse
|
2
|
Herrera AF, Palmer J, Adhikarla V, Yamauchi D, Poku EK, Bading J, Yazaki P, Dandapani S, Mei M, Chen R, Cao T, Karras N, McTague P, Nademanee A, Popplewell L, Sahebi F, Shively JE, Simpson J, Smith DL, Song J, Spielberger R, Tsai NC, Thomas SH, Forman SJ, Colcher D, Wu AM, Wong J, Smith E. Anti-CD25 radioimmunotherapy with BEAM autologous hematopoietic cell transplantation conditioning in Hodgkin lymphoma. Blood Adv 2021; 5:5300-5311. [PMID: 34638132 PMCID: PMC9153018 DOI: 10.1182/bloodadvances.2021004981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/31/2021] [Indexed: 11/27/2022] Open
Abstract
High-risk relapsed or refractory (R/R) classical Hodgkin lymphoma (HL) is associated with poor outcomes after conventional salvage therapy and autologous hematopoietic cell transplantation (AHCT). Post-AHCT consolidation with brentuximab vedotin (BV) improves progression-free survival (PFS), but with increasing use of BV early in the treatment course, the utility of consolidation is unclear. CD25 is often expressed on Reed-Sternberg cells and in the tumor microenvironment in HL, and we hypothesized that the addition of 90Y-antiCD25 (aTac) to carmustine, etoposide, cytarabine, melphalan (BEAM) AHCT would be safe and result in a transplantation platform that is agnostic to prior HL-directed therapy. Twenty-five patients with high-risk R/R HL were enrolled in this phase 1 dose-escalation trial of aTac-BEAM. Following an imaging dose of 111In-antiCD25, 2 patients had altered biodistribution, and a third developed an unrelated catheter-associated bacteremia; therefore, 22 patients ultimately received therapeutic 90Y-aTac-BEAM AHCT. No dose-limiting toxicities were observed, and 0.6 mCi/kg was deemed the recommended phase 2 dose, the dose at which the heart wall would not receive >2500 cGy. Toxicities and time to engraftment were similar to those observed with standard AHCT, though 95% of patients developed stomatitis (all grade 1-2 per Bearman toxicity scale). Seven relapses (32%) were observed, most commonly in patients with ≥3 risk factors. The estimated 5-year PFS and overall survival probabilities among 22 evaluable patients were 68% and 95%, respectively, and non-relapse mortality was 0%. aTac-BEAM AHCT was tolerable in patients with high-risk R/R HL, and we are further evaluating the efficacy of this approach in a phase 2 trial. This trial was registered at www.clinicaltrials.gov as #NCT01476839.
Collapse
Affiliation(s)
- Alex F. Herrera
- Department of Hematology and Hematopoietic Cell Transplantation
| | | | | | | | | | | | | | | | - Matthew Mei
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Robert Chen
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Thai Cao
- Department of Hematology and Hematopoietic Cell Transplantation
| | | | | | | | | | - Firoozeh Sahebi
- Department of Hematology and Hematopoietic Cell Transplantation
| | | | | | | | - Joo Song
- Department of Pathology, City of Hope National Medical Center, Duarte, CA
| | | | - Ni-Chun Tsai
- Department of Computational and Quantitative Biology
| | | | | | | | - Anna M. Wu
- Department of Immunology and Theranostics
| | | | - Eileen Smith
- Department of Hematology and Hematopoietic Cell Transplantation
| |
Collapse
|
3
|
Park AK, Fong Y, Kim SI, Yang J, Murad JP, Lu J, Jeang B, Chang WC, Chen NG, Thomas SH, Forman SJ, Priceman SJ. Effective combination immunotherapy using oncolytic viruses to deliver CAR targets to solid tumors. Sci Transl Med 2021; 12:12/559/eaaz1863. [PMID: 32878978 DOI: 10.1126/scitranslmed.aaz1863] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 06/12/2020] [Accepted: 07/29/2020] [Indexed: 12/16/2022]
Abstract
Chimeric antigen receptor (CAR)-engineered T cell therapy for solid tumors is limited by the lack of both tumor-restricted and homogeneously expressed tumor antigens. Therefore, we engineered an oncolytic virus to express a nonsignaling, truncated CD19 (CD19t) protein for tumor-selective delivery, enabling targeting by CD19-CAR T cells. Infecting tumor cells with an oncolytic vaccinia virus coding for CD19t (OV19t) produced de novo CD19 at the cell surface before virus-mediated tumor lysis. Cocultured CD19-CAR T cells secreted cytokines and exhibited potent cytolytic activity against infected tumors. Using several mouse tumor models, delivery of OV19t promoted tumor control after CD19-CAR T cell administration. OV19t induced local immunity characterized by tumor infiltration of endogenous and adoptively transferred T cells. CAR T cell-mediated tumor killing also induced release of virus from dying tumor cells, which propagated tumor expression of CD19t. Our study features a combination immunotherapy approach using oncolytic viruses to promote de novo CAR T cell targeting of solid tumors.
Collapse
Affiliation(s)
- Anthony K Park
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA.,Irell and Manella Graduate School of Biological Sciences, City of Hope, Duarte, CA 91010, USA.,Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Sang-In Kim
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Jason Yang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
| | - John P Murad
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA.,Irell and Manella Graduate School of Biological Sciences, City of Hope, Duarte, CA 91010, USA
| | - Jianming Lu
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Brook Jeang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
| | - Wen-Chung Chang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
| | - Nanhai G Chen
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Sandra H Thomas
- Department of Clinical and Translational Project Development, City of Hope, Duarte, CA 91010, USA
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA.,Department of Immuno-Oncology, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA
| | - Saul J Priceman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA. .,Department of Immuno-Oncology, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA
| |
Collapse
|
4
|
Wang X, Huynh C, Urak R, Weng L, Walter M, Lim L, Vyas V, Chang WC, Aguilar B, Brito A, Sarkissian A, Bandara NA, Yang L, Wang J, Wu X, Zhang J, Priceman SJ, Qin H, Kwak LW, Budde LE, Thomas SH, Clark MC, Popplewell L, Siddiqi T, Brown CE, Forman SJ. The Cerebroventricular Environment Modifies CAR T Cells for Potent Activity against Both Central Nervous System and Systemic Lymphoma. Cancer Immunol Res 2020; 9:75-88. [PMID: 33093217 DOI: 10.1158/2326-6066.cir-20-0236] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/24/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022]
Abstract
Lymphomas with central nervous system (CNS) involvement confer a worse prognosis than those without CNS involvement, and patients currently have limited treatment options. T cells genetically engineered with CD19-targeted chimeric antigen receptors (CAR) are effective against B-cell malignancies and show tremendous potential in the treatment of systemic lymphoma. We aimed to leverage this strategy toward a more effective therapy for patients with lymphoma with CNS disease. NOD-scid IL2Rgammanull (NSG) mice with CNS and/or systemic lymphoma were treated with CD19-CAR T cells via intracerebroventricular (ICV) or intravenous (IV) injection. CAR T cells isolated after treatment were rigorously examined for phenotype, gene expression, and function. We observed that CAR T cells infused ICV, but not IV, completely and durably eradicated both CNS and systemic lymphoma. CAR T cells delivered ICV migrated efficiently to the periphery, homed to systemic tumors, and expanded in vivo, leading to complete elimination of disease and resistance to tumor rechallenge. Mechanistic studies indicated that ICV-delivered CAR T cells are conditioned by exposure to cerebrospinal fluid in the ICV environment for superior antilymphoma activity and memory function compared with IV-delivered CAR T cells. Further analysis suggested that manipulating cellular metabolism or preactivating therapeutic CAR T cells with antigen ex vivo may improve the efficacy of CAR T cells in vivo Our demonstration that ICV-delivered CD19-CAR T cells had activity against CNS and systemic lymphoma could offer a valuable new strategy for treatment of B-cell malignancies with CNS involvement.
Collapse
Affiliation(s)
- Xiuli Wang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
| | - Christian Huynh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryan Urak
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Lihong Weng
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Miriam Walter
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Laura Lim
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Vibhuti Vyas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Wen-Chung Chang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Brenda Aguilar
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Alfonso Brito
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Aniee Sarkissian
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - N Achini Bandara
- Clinical and Translational Project Development Core, City of Hope, Duarte, California
| | - Lu Yang
- Department of Molecular and Cellular Biology, Beckman Research Institute, City of Hope, Duarte, California
| | - Jinhui Wang
- Integrative Genomics Core, Beckman Research Institute, City of Hope, Duarte, California
| | - Xiwei Wu
- Integrative Genomics Core, Beckman Research Institute, City of Hope, Duarte, California
| | - Jianying Zhang
- The Department of Computational and Quantitative Medicine, City of Hope, Duarte, California
| | - Saul J Priceman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Hong Qin
- Toni Stephenson Lymphoma Center, Beckman Research Institute, City of Hope, Duarte, California
| | - Larry W Kwak
- Toni Stephenson Lymphoma Center, Beckman Research Institute, City of Hope, Duarte, California
| | - Lihua E Budde
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Sandra H Thomas
- Clinical and Translational Project Development Core, City of Hope, Duarte, California
| | - Mary C Clark
- Clinical and Translational Project Development Core, City of Hope, Duarte, California
| | - Leslie Popplewell
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Tanya Siddiqi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Christine E Brown
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| |
Collapse
|
5
|
Park AK, Fong Y, Kim SI, Yang J, Murad JP, Lu J, Jeang B, Chang WC, Chen NG, Thomas SH, Forman SJ, Priceman SJ. Effective combination immunotherapy using oncolytic viruses to deliver CAR targets to solid tumors. Sci Transl Med 2020. [DOI: 10.1126/scitranslmed.aaz1863
http://stm.sciencemag.org] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An effective combination immunotherapy using oncolytic viruses delivers de novo CD19 to promote CD19-CAR T cell therapy against solid tumors in mice.
Collapse
Affiliation(s)
- Anthony K. Park
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
- Irell and Manella Graduate School of Biological Sciences, City of Hope, Duarte, CA 91010, USA
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Sang-In Kim
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Jason Yang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
| | - John P. Murad
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
- Irell and Manella Graduate School of Biological Sciences, City of Hope, Duarte, CA 91010, USA
| | - Jianming Lu
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Brook Jeang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
| | - Wen-Chung Chang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
| | - Nanhai G. Chen
- Department of Surgery, City of Hope, Duarte, CA 91010, USA
| | - Sandra H. Thomas
- Department of Clinical and Translational Project Development, City of Hope, Duarte, CA 91010, USA
| | - Stephen J. Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
- Department of Immuno-Oncology, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA
| | - Saul J. Priceman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA
- Department of Immuno-Oncology, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA
| |
Collapse
|
6
|
Bhutta ZA, Qureshi I, Shujauddin M, Thomas SA, Masood M, Dsouza LB, Iqbal N, Irfan FB, Pathan SA, Thomas SH. Characterizing Agreement in the Level of Interarm Blood Pressure Readings of Adults in the Emergency Department (CALIBRATE Study). Qatar Med J 2020; 2020:14. [PMID: 32391250 PMCID: PMC7198471 DOI: 10.5339/qmj.2020.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/01/2019] [Indexed: 11/03/2022] Open
Abstract
Background: Increased interarm systolic blood pressure difference (IASBPD) is one of the major predictors of cardiovascular disease. An IASBPD of >10 mmHg is of clinical significance. However, studies have reported a high number of patients visiting the emergency department (ED) with high IASBPD and varying correlation of IASBPD to age, ethnic background, and comorbidities such as hypertension and diabetes. Objective: The CALIBRATE study aimed to measure the IABPDs in the multiethnic patient population presenting to the ED in Qatar and to assess the distribution of IASBPD in this population. Methods: In a sitting position, two consecutive blood pressure (BP) measurements were recorded from the right and left arms for each participant using a calibrated automated machine and appropriate cuff sizes. The data were recorded using predefined data fields, including patient demographics, past medical, and social and family history. The continuous variables were reported as mean or median based on the distribution of data. The data were analyzed using Stata MP 14.0. Results: A total of 1800 patients, with a mean age of 34 (10) years, were prospectively recruited from the ED. The median absolute systolic BP difference (ΔSBP) between the right and left arms was 6 (3-10) mmHg, and it was the same for the first (ΔSBP1) and the second readings (ΔSBP2). The absolute average of ΔSBP1 and ΔSBP2 was 7 (4-10) mmHg. The difference in systolic BP difference (SBP) of < 20 mmHg for interarm blood pressure was seen in the 95th percentile of the population. No meaningful association could be detected between the IABPD and the study variables such as age, demographics, regions of interest, and risk factors. Conclusion: In population presenting to the ED, the IASBPD of at least 20 mmHg reached at the 95th percentile, validating the known significant difference. The utility of SBP difference can be improved further by taking the average of two individual readings.
Collapse
Affiliation(s)
- Z A Bhutta
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Translational Research Institute, Hamad Medical Corporation, Doha, Qatar
| | - I Qureshi
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Translational Research Institute, Hamad Medical Corporation, Doha, Qatar
| | - M Shujauddin
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - S A Thomas
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - M Masood
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - L B Dsouza
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Translational Research Institute, Hamad Medical Corporation, Doha, Qatar
| | - N Iqbal
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Weil Cornell Medical College in Qatar, Doha, Qatar
| | - F B Irfan
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Translational Research Institute, Hamad Medical Corporation, Doha, Qatar
| | - S A Pathan
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Translational Research Institute, Hamad Medical Corporation, Doha, Qatar
| | | |
Collapse
|
7
|
Eisenback JD, Holland LA, Schroeder J, Thomas SH, Beacham JM, Hanson SF, Paes-Takahashi VS, Vieira P. Meloidogyne aegracyperi n. sp. (Nematoda: Meloidogynidae), a root-knot nematode parasitizing yellow and purple nutsedge in New Mexico. J Nematol 2019; 51:e2019-71. [PMID: 34179811 PMCID: PMC6909390 DOI: 10.21307/jofnem-2019-071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Indexed: 11/15/2022] Open
Abstract
Meloidogyne aegracyperi n. sp. is described from roots of purple nutsedge in southern New Mexico, USA. Mature females are small (310–460 µm), pearly white, with their egg masses completely contained inside root galls. The neck is often at a 90 to 130° angle to the protruding posterior end with the perineal pattern. The distance of the dorsal esophageal gland orifice (DGO) to the base of the stylet is relatively long (4.0–6.1 µm), and the excretory pore is level with the base of the stylet. The anterior portion of the rounded lumen lining of the metacorpus contains 3 to 10 small vesicles. The perineal pattern has a rounded dorsal arch with a tail terminal area that is smooth or marked with rope-like striae. Only two males were found. The body twists 90° throughout its length. The DGO to the base of the stylet is long (3.0–3.3) µm. The cephalic framework of the second-stage juvenile is weak, and the stylet is short (10.1–11.8 µm). The DGO to the base of the stylet is long (3–5 µm). The tail is very long (64–89 µm) and the hyaline portion of the tail is very narrow, making the tail finely pointed. Eggs are typical for the genus and vary in length (85.2–99.8 µm) and width (37.1–48.1 µm), having a L/W ratio of (2.1–2.6). Maximum likelihood phylogenetic analyses of the different molecular loci (partial 18S rRNA, D2-D3 of 28S rRNA, internal transcribed spacer (ITS) rRNA, cytochrome oxidase subunit II (COII)-16S rRNA of mitochondrial DNA gene fragments and partial Hsp90 gene) placed this nematode on an independent branch in between M. graminicola and M. naasi and a cluster of species containing M. chitwoodi. M. fallax, and M. minor. Greenhouse tests showed that yellow and purple nutsedge were the best hosts, but perennial ryegrass, wheat, bentgrass, and barley were also hosts.
Collapse
Affiliation(s)
- J D Eisenback
- School of Plant and Environmental Science, Virginia Tech, Blacksburg, VA, 24061
| | - L A Holland
- Department of Plant Pathology, University of California-Davis, Davis, CA, 95616
| | - J Schroeder
- Department of Entomology, Plant Pathology and Weed Science, New Mexico State University, Las Cruces, NM, 88003
| | - S H Thomas
- Department of Entomology, Plant Pathology and Weed Science, New Mexico State University, Las Cruces, NM, 88003
| | - J M Beacham
- Department of Entomology, Plant Pathology and Weed Science, New Mexico State University, Las Cruces, NM, 88003
| | - S F Hanson
- Department of Entomology, Plant Pathology and Weed Science, New Mexico State University, Las Cruces, NM, 88003
| | - V S Paes-Takahashi
- Department of Plant Protection, Universidade Estadual Paulista "Julio Mesquita Filho" (UNESP/FCAV), Jaboticabal, SP, 14884900
| | - P Vieira
- School of Plant and Environmental Science, Virginia Tech, Blacksburg, VA, 24061
| |
Collapse
|
8
|
Wang X, Walter M, Urak R, Weng L, Huynh C, Lim L, Wong CW, Chang WC, Thomas SH, Sanchez JF, Yang L, Brown CE, Pichiorri F, Htut M, Krishnan AY, Forman SJ. Lenalidomide Enhances the Function of CS1 Chimeric Antigen Receptor-Redirected T Cells Against Multiple Myeloma. Clin Cancer Res 2018; 24:106-119. [PMID: 29061640 PMCID: PMC5991104 DOI: 10.1158/1078-0432.ccr-17-0344] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/12/2017] [Accepted: 10/16/2017] [Indexed: 12/11/2022]
Abstract
Purpose: Multiple myeloma remains an incurable malignancy of plasma cells despite considerable advances in treatment. The purpose of the study was to develop novel chimeric antigen receptors (CAR) for the treatment of multiple myeloma and explore combinatorial therapy using CAR T cells and immunomodulatory drugs such as lenalidomide for increasing treatment efficacy.Experimental Design: We redirected central memory T cells to express second-generation CAR-specific for CS1 and adoptively transferred them into multiple myeloma tumor-bearing mice to test their anti-multiple myeloma activity. CS1 CAR T cells were transduced and expanded in the presence of lenalidomide in vitro The phenotype and effector function of CS1 CAR T cells treated with and without lenalidomide were compared. Finally, CS1 CAR T cells and lenalidomide were administered to treat multiple myeloma-bearing mice as combinatorial therapy.Results: CS1 CAR T cells exhibited efficient antitumor activity when adoptively transferred into mice. Mechanistic studies indicated that the addition of lenalidomide during CS1 CAR T-cell expansion in vitro enhanced the immune functions of CS1 CAR T cells, including cytotoxicity, memory maintenance, Th1 cytokine production, and immune synapse formation. Furthermore, lenalidomide enhanced the antitumor activity and persistence of adoptively transferred CS1 CAR T cells in vivoConclusions: The study demonstrates that lenalidomide improves the anti-multiple myeloma properties of CS1-directed CAR T cells and provides a basis for a planned clinical trial using the combination of lenalidomide with engineered T cells against CS1 in relapsed myeloma. Clin Cancer Res; 24(1); 106-19. ©2017 AACR.
Collapse
MESH Headings
- Angiogenesis Inhibitors/pharmacology
- Animals
- Cell Line, Tumor
- Cytotoxicity, Immunologic/drug effects
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Gene Expression Profiling
- Gene Expression Regulation, Neoplastic
- Humans
- Immunologic Factors/pharmacology
- Immunological Synapses/immunology
- Immunotherapy, Adoptive
- Lenalidomide/pharmacology
- Mice
- Multiple Myeloma/immunology
- Multiple Myeloma/metabolism
- Multiple Myeloma/pathology
- Multiple Myeloma/therapy
- Receptors, Antigen, T-Cell/metabolism
- Receptors, Chimeric Antigen/genetics
- Receptors, Chimeric Antigen/metabolism
- Signaling Lymphocytic Activation Molecule Family/genetics
- Signaling Lymphocytic Activation Molecule Family/immunology
- T-Cell Antigen Receptor Specificity/drug effects
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- Xenograft Model Antitumor Assays
Collapse
Affiliation(s)
- Xiuli Wang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
| | - Miriam Walter
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryan Urak
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Lihong Weng
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Christian Huynh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Laura Lim
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - ChingLam W Wong
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Wen-Chung Chang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - James F Sanchez
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- Judy and Bernard Briskin Center for Multiple Myeloma, City of Hope, Duarte, California
| | - Lu Yang
- Department of Molecular and Cellular Biology, Beckman Research Institute, City of Hope, Duarte, California
| | - Christine E Brown
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Flavia Pichiorri
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- Judy and Bernard Briskin Center for Multiple Myeloma, City of Hope, Duarte, California
| | - Myo Htut
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- Judy and Bernard Briskin Center for Multiple Myeloma, City of Hope, Duarte, California
| | - Amrita Y Krishnan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
- Judy and Bernard Briskin Center for Multiple Myeloma, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| |
Collapse
|
9
|
Stein A, Palmer J, Tsai NC, Al Malki MM, Aldoss I, Ali H, Aribi A, Farol L, Karanes C, Khaled S, Liu A, O'Donnell M, Parker P, Pawlowska A, Pullarkat V, Radany E, Rosenthal J, Sahebi F, Salhotra A, Sanchez JF, Schultheiss T, Spielberger R, Thomas SH, Snyder D, Nakamura R, Marcucci G, Forman SJ, Wong J. Phase I Trial of Total Marrow and Lymphoid Irradiation Transplantation Conditioning in Patients with Relapsed/Refractory Acute Leukemia. Biol Blood Marrow Transplant 2017; 23:618-624. [PMID: 28087456 DOI: 10.1016/j.bbmt.2017.01.067] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/07/2017] [Indexed: 11/27/2022]
Abstract
Current conditioning regimens provide insufficient disease control in relapsed/refractory acute leukemia patients undergoing hematopoietic stem cell transplantation (HSCT) with active disease. Intensification of chemotherapy and/or total body irradiation (TBI) is not feasible because of excessive toxicity. Total marrow and lymphoid irradiation (TMLI) allows for precise delivery and increased intensity treatment via sculpting radiation to sites with high disease burden or high risk for disease involvement, while sparing normal tissue. We conducted a phase I trial in 51 patients (age range, 16 to 57 years) with relapsed/refractory acute leukemia undergoing HSCT (matched related, matched unrelated, or 1-allele mismatched unrelated) with active disease, combining escalating doses of TMLI (range, 1200 to 2000 cGy) with cyclophosphamide (CY) and etoposide (VP16). The maximum tolerated dose was declared at 2000 cGy, as TMLI simulation studies indicated that >2000 cGy might deliver doses toxic for normal organs at or exceeding those delivered by standard TBI. The post-transplantation nonrelapse mortality (NRM) rate was only 3.9% (95% confidence interval [CI], .7 to 12.0) at day +100 and 8.1% (95% CI, 2.5 to 18.0) at 1 year. The cumulative incidence of grades II to IV acute graft-versus-host disease (GVHD) was 43.1% (95% CI, 29.2 to 56.3) and for grade III and IV, it was 13.7% (95% CI, 6.9 to 27.3). The day +30 complete remission rate for all patients was 88% and was 100% for those treated at 2000 cGy. The overall 1-year survival was 55.5% (95% CI, 40.7 to 68.1). The TMLI/CY/VP16 conditioning regimen is well tolerated at TMLI doses up to 2000 cGy with a low 100-day and 1-year NRM rate and no increased risk of GVHD with higher doses of radiation.
Collapse
Affiliation(s)
- Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California.
| | | | - Ni-Chun Tsai
- Department of Biostatistics, City of Hope, Duarte, California
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Ahmed Aribi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Len Farol
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Southern California Kaiser Permanente Bone Marrow Transplant Program, Los Angeles, California
| | - Chatchada Karanes
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Samer Khaled
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - An Liu
- Department of Radiation Oncology, City of Hope, Duarte, California
| | - Margaret O'Donnell
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Pablo Parker
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Anna Pawlowska
- Department of Pediatrics, City of Hope, Duarte, California
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Eric Radany
- Department of Radiation Oncology, City of Hope, Duarte, California
| | | | - Firoozeh Sahebi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Southern California Kaiser Permanente Bone Marrow Transplant Program, Los Angeles, California
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - James F Sanchez
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Tim Schultheiss
- Department of Radiation Oncology, City of Hope, Duarte, California
| | - Ricardo Spielberger
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Southern California Kaiser Permanente Bone Marrow Transplant Program, Los Angeles, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - David Snyder
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope, Duarte, California
| |
Collapse
|
10
|
Khaled SK, Palmer JM, Herzog J, Stiller T, Tsai NC, Senitzer D, Liu X, Thomas SH, Shayani S, Weitzel J, Forman SJ, Nakamura R. Influence of Absorption, Distribution, Metabolism, and Excretion Genomic Variants on Tacrolimus/Sirolimus Blood Levels and Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 22:268-276. [PMID: 26325438 DOI: 10.1016/j.bbmt.2015.08.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/19/2015] [Indexed: 01/23/2023]
Abstract
Allelic variants of genes implicated in drug absorption, distribution, metabolism, and excretion (ADME) determine the pharmacokinetic variability of many medications and are increasingly recognized as important factors determining the success or failure of medical treatments. Both tacrolimus and sirolimus have narrow therapeutic ranges maintained by therapeutic drug monitoring (TDM). Using an ADME panel that covers >99% of the PharmaADME working group core list (188 single nucleotide polymorphism [SNP] and 12 copy number variant [CNV] assays in 36 pharmacogenetically relevant genes), we studied 177 patients who underwent allogeneic hematopoietic cell transplantation (HCT) using tacrolimus/sirolimus-based graft-versus-host disease (GVHD) prophylaxis. We tested for possible associations between ADME variants and tacrolimus/sirolimus drug levels, concentration/dose (C/D) ratio, and clinical endpoints, including acute GVHD. A total of 62 SNP and 6 CNV assays were evaluable after removing the variants, which were homozygous in (nearly) all samples. For sirolimus, rs2032582 (ABCB1) T-carriers versus non-T-carriers were associated with higher blood levels (P = .01), with similar results for C/D ratio. Generalized estimating equation analysis supported these findings. For tacrolimus, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were associated with higher blood levels than CYP3A5*1/*1 (P = .002). By multivariable analysis, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were independently associated with decreased acute GVHD compared with CYP3A5*1/*1, after adjustment for conditioning, donor type, race/ethnicity, and age. We demonstrated association of specific ADME genetic polymorphisms with blood levels of tacrolimus/sirolimus, and incidence of acute GVHD after HCT, in spite of TDM and dose adjustment. A larger ongoing study will determine whether these associations have clinical utility beyond TDM.
Collapse
Affiliation(s)
- Samer K Khaled
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research of the Hematologic Malignancies and Stem Cell Transplantation Institute of the City of Hope, Duarte, CA.
| | | | - Josef Herzog
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Tracey Stiller
- Division of Biostatistics, City of Hope, Duarte, California
| | - Ni-Chun Tsai
- Division of Biostatistics, City of Hope, Duarte, California
| | - David Senitzer
- Division of Histocompatibility (HLA Laboratory), City of Hope, Duarte, California
| | - Xueli Liu
- Division of Biostatistics, City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | | | - Jeffrey Weitzel
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| |
Collapse
|
11
|
Chen R, Palmer JM, Martin P, Tsai N, Kim Y, Chen BT, Popplewell L, Siddiqi T, Thomas SH, Mott M, Sahebi F, Armenian S, Leonard J, Nademanee A, Forman SJ. Results of a Multicenter Phase II Trial of Brentuximab Vedotin as Second-Line Therapy before Autologous Transplantation in Relapsed/Refractory Hodgkin Lymphoma. Biol Blood Marrow Transplant 2015. [PMID: 26211987 DOI: 10.1016/j.bbmt.2015.07.018] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This multicenter prospective phase II study examines the activity and tolerability of brentuximab vedotin as second-line therapy in patients with Hodgkin lymphoma that was relapsed or refractory after induction therapy. Brentuximab vedotin (1.8 mg/kg) was administered i.v. on day 1 of a 21-day cycle for a total of 4 cycles. Patients then proceeded to autologous hematopoietic cell transplantation (AHCT), if eligible, with or without additional salvage therapy, based on remission status after brentuximab vedotin. The primary endpoint was overall response rate (ORR). Secondary endpoints were safety, stem cell mobilization/collection, AHCT outcomes, and association of CD68(+) with outcomes. Of 37 patients, the ORR was 68% (13 complete remission, 12 partial remission). The regimen was well tolerated with few grade 3/4 adverse events, including lymphopenia (1), neutropenia (3), rash (2), and hyperuricemia (1). Thirty-two patients (86%) were able to proceed to AHCT, with 24 patients (65%) in complete remission at time of AHCT. Thirteen patients in complete remission, 4 in partial remission, and 1 with stable disease (49%) received AHCT without salvage combination chemotherapy. CD68 expression did not correlate with response to brentuximab vedotin. The median number of stem cells mobilized was 6.0 × 10(6) (range, 2.6 to 34), and median number of days to obtain minimum collection (2 × 10(6)) was 2 (range, 1 to 6). Brentuximab vedotin as second-line therapy is active, well tolerated, and allows adequate stem cell collection and engraftment. For Hodgkin lymphoma patients with relapsed/refractory disease after induction therapy, second-line brentuximab vedotin, followed by combination chemotherapy for residual disease, can effectively bridge patients to AHCT.
Collapse
Affiliation(s)
- Robert Chen
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
| | - Joycelynne M Palmer
- Department of Information Sciences, Division of Biostatistics, City of Hope, Duarte, California
| | - Peter Martin
- Department of Hematology/Oncology, Weill Cornell Medical College, New York, New York
| | - Nicole Tsai
- Department of Information Sciences, Division of Biostatistics, City of Hope, Duarte, California
| | - Young Kim
- Department Pathology, City of Hope, Duarte, California
| | - Bihong T Chen
- Department Diagnostic Radiology, City of Hope, Duarte, California
| | - Leslie Popplewell
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Tanya Siddiqi
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Michelle Mott
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Firoozeh Sahebi
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, and Kaiser Permanente, Los Angeles, California
| | - Saro Armenian
- Department of Population Sciences, City of Hope, Duarte, California
| | - John Leonard
- Department of Hematology/Oncology, Weill Cornell Medical College, New York, New York
| | - Auayporn Nademanee
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| |
Collapse
|
12
|
Chen R, Hou J, Newman E, Kim Y, Donohue C, Liu X, Thomas SH, Forman SJ, Kane SE. CD30 Downregulation, MMAE Resistance, and MDR1 Upregulation Are All Associated with Resistance to Brentuximab Vedotin. Mol Cancer Ther 2015; 14:1376-84. [PMID: 25840583 DOI: 10.1158/1535-7163.mct-15-0036] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/26/2015] [Indexed: 11/16/2022]
Abstract
Brentuximab vedotin (BV) is an antibody-drug conjugate that specifically delivers the potent cytotoxic drug monomethyl auristatin E (MMAE) to CD30-positive cells. BV is FDA approved for treatment of relapsed/refractory Hodgkin lymphoma and anaplastic large cell lymphoma (ALCL); however, many patients do not achieve complete remission and develop BV-resistant disease. We selected for BV-resistant Hodgkin lymphoma (L428) and ALCL (Karpas-299) cell lines using either constant (ALCL) or pulsatile (Hodgkin lymphoma) exposure to BV. We confirmed drug resistance by MTS assay and analyzed CD30 expression in resistant cells by flow cytometry, qRT-PCR, and Western blotting. We also measured drug exporter expression, MMAE resistance, and intracellular MMAE concentrations in BV-resistant cells. In addition, tissue biopsy samples from 10 Hodgkin lymphoma and 5 ALCL patients who had relapsed or progressed after BV treatment were analyzed by immunohistocytochemistry for CD30 expression. The resistant ALCL cell line, but not the Hodgkin lymphoma cell line, demonstrated downregulated CD30 expression compared with the parental cell line. In contrast, the Hodgkin lymphoma cell line, but not the ALCL cell line, exhibited MMAE resistance and increased expression of the MDR1 drug exporter compared with the parental line. For both Hodgkin lymphoma and ALCL, samples from patients relapsed/resistant on BV persistently expressed CD30 by immunohistocytochemistry. One Hodgkin lymphoma patient sample expressed MDR1 by immunohistocytochemistry. Although loss of CD30 expression is a possible mode of BV resistance in ALCL in vitro models, this has not been confirmed in patients. MMAE resistance and MDR1 expression are possible modes of BV resistance for Hodgkin lymphoma both in vitro and in patients.
Collapse
Affiliation(s)
- Robert Chen
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
| | - Jessie Hou
- Department of Cancer Biology, City of Hope, Duarte, California
| | - Edward Newman
- Department of Cancer Biology, City of Hope, Duarte, California
| | - Young Kim
- Department of Pathology, City of Hope, Duarte, California
| | - Cecile Donohue
- Department of Cancer Biology, City of Hope, Duarte, California
| | - Xueli Liu
- Division of Biostatistics, Beckman Research Institute of City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Susan E Kane
- Department of Cancer Biology, City of Hope, Duarte, California
| |
Collapse
|
13
|
Wang X, Wong CW, Urak R, Mardiros A, Budde LE, Chang WC, Thomas SH, Brown CE, La Rosa C, Diamond DJ, Jensen MC, Nakamura R, Zaia JA, Forman SJ. CMVpp65 Vaccine Enhances the Antitumor Efficacy of Adoptively Transferred CD19-Redirected CMV-Specific T Cells. Clin Cancer Res 2015; 21:2993-3002. [PMID: 25838392 DOI: 10.1158/1078-0432.ccr-14-2920] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 03/16/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE T cells engineered with chimeric antigen receptors (CAR) recognizing CD19 can induce complete remission of B-cell malignancies in clinical trials; however, in some disease settings, CAR therapy confers only modest clinical benefit due to attenuated persistence of CAR T cells. The purpose of this study was to enhance persistence and augment the antitumor activity of adoptively transferred CD19CAR T cells by restimulating CAR(+) T cells through an endogenous cytomegalovirus (CMV)-specific T-cell receptor. EXPERIMENTAL DESIGN CMV-specific T cells from CMV seropositive healthy donors were selected after stimulation with pp65 protein and transduced with clinical-grade lentivirus expressing the CD19R:CD28:ζ/EGFRt CAR. The resultant bispecific T cells, targeting CMV and CD19, were expanded via CD19 CAR-mediated signals using CD19-expressing cells. RESULTS The bispecific T cells proliferated vigorously after engagement with either endogenous CMVpp65 T-cell receptors or engineered CD19 CARs, exhibiting specific cytolytic activity and IFNγ secretion. Upon adoptive transfer into immunodeficient mice bearing human lymphomas, the bispecific T cells exhibited proliferative response and enhanced antitumor activity following CMVpp65 peptide vaccine administration. CONCLUSIONS We have redirected CMV-specific T cells to recognize and lyse tumor cells via CD19CARs, while maintaining their ability to proliferate in response to CMV antigen stimulation. These results illustrate the clinical applications of CMV vaccine to augment the antitumor activity of adoptively transferred CD19CAR T cells in patients with B-cell malignancies.
Collapse
Affiliation(s)
- Xiuli Wang
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
| | - ChingLam W Wong
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryan Urak
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Armen Mardiros
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Lihua E Budde
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Wen-Chung Chang
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Sandra H Thomas
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Christine E Brown
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Corinna La Rosa
- Division of Translational Vaccine Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Don J Diamond
- Division of Translational Vaccine Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Michael C Jensen
- Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Ryotaro Nakamura
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - John A Zaia
- Department of Virology, Beckman Research Institute of the City of Hope, Duarte, California
| | - Stephen J Forman
- Departments of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
| |
Collapse
|
14
|
Aldoss I, Stiller T, Cao TM, Palmer JM, Thomas SH, Forman SJ, Pullarkat V. Impact of Additional Cytogenetic Abnormalities in Adults with Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia Undergoing Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 21:1326-9. [PMID: 25842050 DOI: 10.1016/j.bbmt.2015.03.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/24/2015] [Indexed: 11/28/2022]
Abstract
The occurrence of additional cytogenetic abnormalities (ACAs) is common in Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) but is of unknown significance in the tyrosine kinase inhibitor (TKI) era. We retrospectively analyzed data from a consecutive case series of adults with Ph+ ALL who had undergone allogeneic hematopoietic cell transplantation (alloHCT) at City of Hope between 2003 and 2014. Among 130 adults with Ph+ ALL who had TKI therapy before alloHCT, 78 patients had available data on conventional cytogenetics at diagnosis and were eligible for outcomes analysis. ACAs were observed in 41 patients (53%). There were no statistically significant differences in median age, median initial WBC count, post-HCT TKI maintenance, or disease status at the time of transplant between the Ph-only and ACA cohorts; however, the Ph-only cohort had a higher rate of minimal residual disease positivity at the time of HCT. Three-year leukemia-free survival (79.8% versus 39.5%, P = .01) and 3-year overall survival (83% versus 45.6%, P = .02) were superior in the Ph-only cohort compared with the ACA cohort, respectively. Monosomy 7 was the most common additional aberration observed in our ACA cohort (n = 12). Thus, when TKI therapy and alloHCT are used as part of adult Ph+ ALL therapy, the presence of ACAs appears to have a significant deleterious effect on outcomes post-HCT.
Collapse
Affiliation(s)
- Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
| | - Tracey Stiller
- Department of Information Science, City of Hope, Duarte, California
| | - Thai M Cao
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | | | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| |
Collapse
|
15
|
Chen R, Frankel P, Popplewell L, Siddiqi T, Ruel N, Rotter A, Thomas SH, Mott M, Nathwani N, Htut M, Nademanee A, Forman SJ, Kirschbaum M. A phase II study of vorinostat and rituximab for treatment of newly diagnosed and relapsed/refractory indolent non-Hodgkin lymphoma. Haematologica 2015; 100:357-62. [PMID: 25596263 DOI: 10.3324/haematol.2014.117473] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
This study examines the activity and tolerability of a regimen combining vorinostat and rituximab in patients with indolent B-cell non-Hodgkin lymphoma. A total of 28 patients with newly diagnosed or relapsed/refractory follicular, marginal zone, or mantle cell lymphoma, with 4 or less prior therapies were eligible for this open-label phase II study. Oral vorinostat 200 mg was administered twice daily on days 1-14 along with 375 mg/m(2) of intravenous rituximab on day 1 of a 21-day cycle, continuing until disease progression or unacceptable toxicity. Primary end point was objective response rate, with secondary end points of progression-free survival, time to progression, duration of response, safety, and tolerability. Median follow up was 25.6 months and median number of vorinostat cycles was 11.5. Overall response rate was 46% for all patients, 67% for previously untreated, and 41% for relapsed/refractory patients. Median progression-free survival was 29.2 months for all patients, 18.8 months for previously treated patients, and not reached for untreated patients. The regimen was well tolerated over long treatment periods with the most common grade 3/4 adverse events being asymptomatic thrombosis, neutropenia, thrombocytopenia, lymphopenia, and fatigue. The vorinostat/rituximab combination exhibits activity in indolent B-cell non-Hodgkin lymphoma with an acceptable safety profile and durable responses. Re-treatment was effective in 2 of 3 relapsing responders. This phase II clinical trial was registered at clinicaltrials.gov identifier: 00720876.
Collapse
Affiliation(s)
- Robert Chen
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Paul Frankel
- Department of Biostatistics, City of Hope, Duarte, CA, USA
| | - Leslie Popplewell
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Tanya Siddiqi
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Nora Ruel
- Department of Biostatistics, City of Hope, Duarte, CA, USA
| | - Arnold Rotter
- Department of Radiology, City of Hope, Duarte, CA, USA
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Michelle Mott
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Nitya Nathwani
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Myo Htut
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Auayporn Nademanee
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| | - Mark Kirschbaum
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, CA, USA
| |
Collapse
|
16
|
Abstract
Brentuximab vedotin (BV) is an antibody-drug conjugate that targets CD30-positive malignancies via an anti-CD30 monoclonal antibody linked to monomethyl auristatin E, a microtubule-disrupting agent, by a protease-cleavable linker. BV has received accelerated approval from the US Food and Drug Administration for the treatment of classical Hodgkin lymphoma that has relapsed either after autologous stem cell transplantation (ASCT) or after two lines of combination chemotherapy in patients ineligible for ASCT, and in systemic anaplastic large cell lymphoma after failure of at least one line of multiagent chemotherapy. Phase I studies in CD30-positive lymphomas have determined the maximum tolerated dose to be 1.8 mg/kg intravenously every 21 days. In relapsed/refractory Hodgkin lymphoma, a pivotal Phase II study of single-agent BV showed an overall response rate of 75%, with 34% complete responses and a median remission duration of 20 months for complete responders. BV has a modest toxicity profile, with peripheral neuropathy as one of the most clinically significant side effects, and this is largely reversible. Therefore, BV is the treatment of choice for patients with relapsed/refractory Hodgkin lymphoma after ASCT or two standard regimens. Ongoing trials are evaluating the role of BV as salvage therapy prior to ASCT and for maintenance after ASCT for patients with relapsed/refractory disease.
Collapse
Affiliation(s)
- Tanya Siddiqi
- City of Hope, Department of Hematology and Hematopoietic Cell Transplantation, Duarte, CA, USA
| | - Sandra H Thomas
- City of Hope, Department of Hematology and Hematopoietic Cell Transplantation, Duarte, CA, USA
| | - Robert Chen
- City of Hope, Department of Hematology and Hematopoietic Cell Transplantation, Duarte, CA, USA
| |
Collapse
|
17
|
Levine M, Froberg B, Ruha AM, Burns-Ewald M, Yen M, Claudius IA, Arthur AO, Tormoehlen L, Thomas SH. Assessing the toxicity and associated costs among pediatric patients admitted with unintentional poisonings of attention-deficit/hyperactivity disorder drugs in the United States. Clin Toxicol (Phila) 2013; 51:147-50. [PMID: 23473458 DOI: 10.3109/15563650.2013.772623] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is widespread, with a national (United States) prevalence of nearly 10%. The 2011 changes in the diagnostic criteria will likely further increase the prevalence of this disorder. Little is known about the incidence of toxicity from unintentional poisonings of ADHD medications. This study attempted to determine the incidence of these ingestions and the corresponding financial impact in the United States. METHODS Four geographically different centers were chosen. Subjects with unintentional poisonings due to ADHD medications were included if the admission dates were between 2000 and 2002 (cohort A) or between 2009 and 2010 (cohort B). Using data from the participating hospitals and the number of monitored beds in each corresponding county, data were extrapolated on a national (United States) level. RESULTS Sixty-three subjects were admitted at four hospitals (18, cohort A and 45, cohort B). The crude incidence rate ratio increased in the later time frame as compared to that in the earlier time frame (incidence rate ratio, 3.13; 95% CI, 1.80-5.68; p < 0.0001). The median (IQR) charges per patient, adjusted for inflation, were $4780 ($3,895-$8,287) and $5912 ($3,432-$9,433) for cohorts A and B, respectively (p = 0.57). If the subjects in the participating counties were only admitted to the participating hospitals, the annual charges, extrapolated throughout the United States for the two periods, would be $2,419,016 and $8,129,538, respectively. If the subjects were evenly distributed across all pediatric monitored beds in a given county, the annual charges extrapolated throughout the United States for the two periods would be $5,694,232 and $24,126,640, respectively. CONCLUSION The incidence of unintentional poisonings from ADHD drugs is increasing and is associated with a significant cost.
Collapse
Affiliation(s)
- M Levine
- Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, CA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Krishnan AY, Wang S, Palmer JM, Tsai NC, Thomas SH, Htut M, Farol L, Forman SJ. A phase I study of intravenous plerixafor following cyclophosphamide mobilization in patients with multiple myeloma. Leuk Lymphoma 2013; 55:201-3. [PMID: 23573824 DOI: 10.3109/10428194.2013.794268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
19
|
Sahebi F, Shen Y, Thomas SH, Rincon A, Murata-Collins J, Palmer J, Krishnan AY, Karanes C, Htut M, Somlo G, Forman SJ. Late relapses following reduced intensity allogeneic transplantation in patients with multiple myeloma: a long-term follow-up study. Br J Haematol 2012; 160:199-206. [PMID: 23151215 DOI: 10.1111/bjh.12123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 09/20/2012] [Indexed: 12/22/2022]
Abstract
We analysed the long-term outcomes of 60 multiple myeloma patients who underwent reduced intensity allogeneic stem cell transplantation between August 2000 and March 2008. Regimens included fludarabine and melphalan conditioning (flu-mel regimen) for allogeneic haematopoietic cell transplant (HCT) or a planned tandem regimen consisting of high-dose melphalan conditioning for autograft followed by low-dose total body irradiation conditioning for allogeneic HCT (auto-allo regimen). Donors included human-leucocyte-antigen-matched siblings (n = 55) or matched unrelated donors (n = 5). With a median follow-up of 9·8 years, 7-year overall survival (OS) and progression-free survival (PFS) were 60% and 31%, respectively. By multivariate Cox regression analysis, disease status of complete response (CR) or partial response (PR) at transplant and the presence of chronic graft-versus-host disease were significantly associated with improved OS. Only disease status was significantly associated with improved PFS. We noted a surprising number of very late relapses, with six patients (10%) relapsing between 6 and 12 years post-transplant. Among the six late relapse patients, all were transplanted within 14 months of diagnosis, five had normal karyotypes, and five were in CR/PR. Our data provide additional evidence that, while survival may be extended by reduced intensity allogeneic transplant, ultimately, it may not offer a cure.
Collapse
Affiliation(s)
- Firoozeh Sahebi
- Department of Hematology, City of Hope National Medical Center, Duarte, CA 91010, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Shayani S, Palmer J, Stiller T, Liu X, Thomas SH, Khuu T, Parker PM, Khaled SK, Forman SJ, Nakamura R. Thrombotic microangiopathy associated with sirolimus level after allogeneic hematopoietic cell transplantation with tacrolimus/sirolimus-based graft-versus-host disease prophylaxis. Biol Blood Marrow Transplant 2012; 19:298-304. [PMID: 23078784 DOI: 10.1016/j.bbmt.2012.10.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 10/10/2012] [Indexed: 11/12/2022]
Abstract
Posttransplantation thrombotic microangiopathy (TMA) is a multifactorial complication of allogeneic hematopoietic cell transplantation (allo-HCT) whose incidence is increased with the use of a sirolimus plus tacrolimus (SIR/TAC) regimen for acute graft-versus-host disease (aGVHD) prophylaxis. We evaluated the incidence and possible risk factors for TMA in a case series of 177 patients who received allo-HCT using SIR/TAC-based GVHD prophylaxis. The patients received either a sibling donor graft (n = 82) or a matched unrelated donor graft (n = 95). Within the first 100 days post-HCT, 30 patients (17%) were diagnosed with TMA, and an additional 9 patients (5%) were classified as probable TMA cases. The median time to onset of TMA was 4.6 weeks (range, 1.6-10.6 weeks). Thirty-four patients developed both TMA and aGVHD, with the majority (81%) developing aGVHD first. Multivariate analysis identified the following factors as associated with increased risk of TMA: day 14 serum sirolimus level ≥9.9 ng/mL (hazard ratio [HR], 2.19; 95% confidence interval [CI], 1.13-4.27; P = .02), presence of previous aGVHD grade II-IV (HR, 3.04; 95% CI, 1.38-6.71; P < .01), and fully myeloablative conditioning (HR, 3.47; 95% CI, 1.60-7.53; P < .01). These risk factors for TMA suggest that when using a SIR/TAC regimen for GVHD prophylaxis, careful monitoring and adjustment of the sirolimus dosage is critical, particularly in patients with active aGVHD.
Collapse
Affiliation(s)
- Sepideh Shayani
- Pharmacy Department, City of Hope, Duarte, California 91010, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Krishnan AY, Mei M, Sun CL, Thomas SH, Teh JB, Kang T, Htut M, Somlo G, Sahebi F, Forman SJ, Bhatia S. Second primary malignancies after autologous hematopoietic cell transplantation for multiple myeloma. Biol Blood Marrow Transplant 2012; 19:260-5. [PMID: 23073267 DOI: 10.1016/j.bbmt.2012.09.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 09/27/2012] [Indexed: 12/22/2022]
Abstract
Recent studies demonstrate an increased risk of second primary malignancies (SPMs) in patients with multiple myeloma (MM) receiving maintenance lenalidomide after autologous stem cell transplantation (ASCT). We explored the possibility of other risk factors driving post-ASCT SPMs in patients with MM through analysis of our large transplantation database in conjunction with our Long-Term Follow-Up Program. We conducted a retrospective cohort study of 841 consecutive patients with MM who underwent ASCT at City of Hope between 1989 and 2009, as well as a nested case-control analysis evaluating the role of all therapeutic exposures before, during, and after ASCT. Median duration of follow-up for the entire cohort was 3.4 years (range, 0.3-19.9 years). Sixty cases with a total of 70 SPMs were identified. The overall cumulative incidence of SPMs was 7.4% at 5 years and 15.9% at 10 years when nonmelanoma skin cancers (NMSCs) were included and 5.3% at 5 years and 11.2% at 10 years when NMSCs were excluded. Multivariate analysis of the entire cohort revealed associations of both older age (≥55 years; relative risk, 2.3; P < .004) and race (non-Hispanic white; relative risk, 2.4; P = .01) with an increased risk of SPM. Furthermore, thalidomide exposure demonstrated a trend toward increased risk (odds ratio, 3.5; P = .15); however, an insufficient number of patients were treated with lenalidomide to allow us to accurately assess the risk of this agent. Exclusion of NMSCs retained the association with these variables but was accompanied by loss of statistical significance. This large single-institution analysis identified associations between race and older age and increased risk of developing SPM. The trend toward increased risk with thalidomide exposure suggests a class effect from immunomodulatory drugs that might not be restricted to lenalidomide.
Collapse
Affiliation(s)
- Amrita Y Krishnan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California 91010, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Kogut N, Tsai NC, Thomas SH, Palmer J, Paris T, Murata-Collins J, Forman SJ. Extramedullary relapse following reduced intensity allogeneic hematopoietic cell transplant for adult acute myelogenous leukemia. Leuk Lymphoma 2012; 54:665-8. [PMID: 22906206 DOI: 10.3109/10428194.2012.720375] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
23
|
Nakamura R, Palmer JM, O'Donnell MR, Stiller T, Thomas SH, Chao J, Alvarnas J, Parker PM, Pullarkat V, Maegawa R, Stein AS, Snyder DS, Bhatia R, Chang K, Wang S, Cai JL, Senitzer D, Forman SJ. Reduced intensity allogeneic hematopoietic stem cell transplantation for MDS using tacrolimus/sirolimus-based GVHD prophylaxis. Leuk Res 2012; 36:1152-6. [PMID: 22677229 DOI: 10.1016/j.leukres.2012.04.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 04/17/2012] [Accepted: 04/22/2012] [Indexed: 11/17/2022]
Abstract
We report a consecutive series of 59 patients with MDS who underwent reduced-intensity hematopoietic stem cell transplantation (RI-HSCT) with fludarabine/melphalan conditioning and tacrolimus/sirolimus-based GVHD prophylaxis. Two-year OS, EFS, and relapse incidences were 75.1%, 65.2%, and 20.9%, respectively. The cumulative incidence of non-relapse mortality at 100 days, 1 year, and 2 years was 3.4%, 8.5%, and 10.5%, respectively. The incidence of grade II-IV acute GVHD was 35.4%; grade III-IV was 18.6%. Forty of 55 evaluable patients developed chronic GVHD; of these 35 were extensive grade. This RI-HSCT protocol produces encouraging outcomes in MDS patients, and tacrolimus/sirolimus-based GVHD prophylaxis may contribute to that promising result.
Collapse
Affiliation(s)
- Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Nathwani N, Krishnan AY, Huang Q, Kim Y, Karanes C, Smith EP, Forman SJ, Sievers E, Thomas SH, Chen RW. Persistence of CD30 expression in Hodgkin lymphoma following brentuximab vedotin (SGN-35) treatment failure. Leuk Lymphoma 2012; 53:2051-3. [PMID: 22369501 DOI: 10.3109/10428194.2012.666543] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
25
|
Abstract
PURPOSE OF REVIEW Acute lymphoblastic leukemia (ALL) is a heterogeneous disease, for which treatment guidelines are still evolving. Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative therapeutic modality for ALL, and this review describes the recent studies and current practice patterns concerning the who, when, and how of allo-HCT in the management of ALL. RECENT FINDINGS Allogeneic stem cell transplantation is the treatment of choice for patients with ALL after first relapse and is also recommended for high-risk patients in first complete remission (CR1). Minimal residual disease evaluation and monitoring is developing as an important prognostic factor and could guide physicians in determining which patients, especially those with standard risk, might require transplant. Tyrosine kinase inhibitor (TKI) therapy allows a much higher proportion of Philadelphia-chromosome-positive ALL patients to attain remission and proceed to transplant with improved results; posttransplant TKI maintenance therapy may also provide survival benefit. Reduced-intensity conditioning regimens are a reasonable alternative for patients who would otherwise be ineligible for transplant because of age or comorbidity. SUMMARY For patients with high-risk features, there is general agreement that allo-HCT in CR1 is a potentially curative option; however, there is no consensus on early transplant for standard-risk patients.
Collapse
Affiliation(s)
- Samer K Khaled
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | | | | |
Collapse
|
26
|
Sahebi F, Frankel PH, Farol L, Krishnan AY, Cai JL, Somlo G, Thomas SH, Reburiano E, Popplewell LL, Parker PM, Spielberger RT, Kogut NM, Karanes C, Htut M, Ruel C, Duarte L, Murata-Collins JL, Forman SJ. Sequential bortezomib, dexamethasone, and thalidomide maintenance therapy after single autologous peripheral stem cell transplantation in patients with multiple myeloma. Biol Blood Marrow Transplant 2011; 18:486-92. [PMID: 22198542 DOI: 10.1016/j.bbmt.2011.12.580] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 12/17/2011] [Indexed: 11/29/2022]
Abstract
We report feasibility and response results of a phase II study investigating prolonged weekly bortezomib and dexamethasone followed by thalidomide and dexamethasone as maintenance therapy after single autologous stem cell transplantation (ASCT) in patients with multiple myeloma. Within 4 to 8 weeks of ASCT, patients received weekly bortezomib and dexamethasone for six cycles, followed by thalidomide and dexamethasone for six more cycles. Thalidomide alone was continued until disease progression. Forty-five patients underwent ASCT. Forty patients started maintenance therapy; of these, 36 patients received four cycles, and 32 completed six cycles of maintenance bortezomib. Of these 40 patients, nine (22%) were in complete response (CR) before ASCT, 13 (32%) achieved CR after ASCT but before bortezomib maintenance therapy, and 21 (53%) achieved CR after bortezomib maintenance therapy. Nine patients not previously in CR (33%) upgraded their response to CR with bortezomib maintenance. At 1 year post-ASCT, 20 patients achieved CR, and two achieved very good partial response. Twenty-seven patients experienced peripheral neuropathy during bortezomib therapy, all grade 1 or 2. Our findings indicate that prolonged sequential weekly bortezomib, dexamethasone, and thalidomide maintenance therapy after single ASCT is feasible and well tolerated. Bortezomib maintenance treatment upgraded post-ASCT CR responses with no severe grade 3/4 peripheral neuropathy.
Collapse
Affiliation(s)
- Firoozeh Sahebi
- Department of Hematology and HCT, City of Hope, Duarte, California 91010, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Krishnan A, Palmer JM, Tsai NC, Simpson JR, Nademanee A, Raubitschek A, Thomas SH, Forman SJ. Matched-cohort analysis of autologous hematopoietic cell transplantation with radioimmunotherapy versus total body irradiation-based conditioning for poor-risk diffuse large cell lymphoma. Biol Blood Marrow Transplant 2011; 18:441-50. [PMID: 21801706 DOI: 10.1016/j.bbmt.2011.07.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 07/20/2011] [Indexed: 11/12/2022]
Abstract
We conducted a matched-cohort analysis of autologous transplant conditioning regimens for diffuse large cell lymphoma in 92 patients treated with either radioimmunotherapy (RIT) or total body irradiation (TBI)-based conditioning regimens. The RIT regimen consisted of 0.4 mCi/kg of (90)Y-ibritumomab tiuxetan plus BEAM (BCNU, etoposide, cytarabine, melphalan). The TBI-based regimen combined fractionated TBI at 1200 cGy, with etoposide and cyclophosphamide. Five factors were matched between 46 patient pairs: age at transplant ±5 years, disease status at salvage, number of prior regimens, year of diagnosis ±5 years, and year of transplantation ±5 years. Patients in the TBI group had higher rates of cardiac toxicity and mucositis, whereas Z-BEAM patients had a higher incidence of pulmonary toxicity. Overall survival at 4 years was 81.0% for the Z-BEAM and 52.7% for the TBI group (P = .01). The 4-year cumulative incidence of relapse/progression was 40.4% and 42.1% for Z-BEAM and TBI, respectively (P = .63). Nonrelapse mortality was superior in the Z-BEAM group: 0% compared with 15.8% for TBI at 4 years (P < .01). Our data demonstrate that RIT-based conditioning had a similar relapse incidence to TBI, with lower toxicity, resulting in improved overall survival, particularly in patients with ≥2 prior regimens.
Collapse
Affiliation(s)
- Amrita Krishnan
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, California 91010, USA.
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Rosenthal J, Pawlowska A, Bolotin E, Cervantes C, Maroongroge S, Thomas SH, Forman SJ. Transplant-associated thrombotic microangiopathy in pediatric patients treated with sirolimus and tacrolimus. Pediatr Blood Cancer 2011; 57:142-6. [PMID: 21557459 PMCID: PMC3307590 DOI: 10.1002/pbc.22861] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 09/13/2010] [Indexed: 11/12/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TMA) syndromes are reported to occur with increased frequency in transplant patients treated with siroliumus combined with a calcineurin inhibitor. We performed a retrospective study of all pediatric transplant patients at City of Hope who were administered combined tacrolimus/sirolimus (TAC/SIR) to determine the occurrence of TMA. PROCEDURE This analysis includes 41 consecutive patients between the ages of 2 and 20 (median age 9.1) who received an allogeneic hematopoietic stem cell transplant from any source and also received TAC/SIR for prevention or treatment of GVHD. Of those 41 patients, 20 received TAC/SIR as GVHD prohpylaxis and were designated the preventative group (PG), while 21 received TAC/SIR as treatment for GVHD and were designated the therapy group (TG). TMA occurrence in both groups was documented from day -1 of transplant to day 60 for the PG, and until 30 days after last dose for the TG. TMA was defined according to 2005 consensus criteria. RESULTS Five of twenty patients in the PG, and five of twenty one in the TG, experienced TMA, with an overall rate of 23.8% for the population. All ten patients with TMA showed elevated levels of TAC, SIR or both and nine of ten suffered from organ injury due to regimen-related toxicity or GVHD. CONCLUSION Physicians should exercise caution in the use of TAC/SIR in pediatric patients due to a high rate of TMA. It is not recommended for heavily pre-treated patients and peak levels of TAC/SIR must be very carefully controlled.
Collapse
Affiliation(s)
| | - Anna Pawlowska
- Department of Pediatrics, City of Hope, Duarte, CA 91010,Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
| | - Ellen Bolotin
- Department of Pediatrics, City of Hope, Duarte, CA 91010,Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
| | | | | | - Sandra H. Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
| | - Stephen J. Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
| |
Collapse
|
29
|
Rosenthal J, Woolfrey AE, Pawlowska A, Thomas SH, Appelbaum F, Forman S. Hematopoietic cell transplantation with autologous cord blood in patients with severe aplastic anemia: an opportunity to revisit the controversy regarding cord blood banking for private use. Pediatr Blood Cancer 2011; 56:1009-12. [PMID: 21370429 DOI: 10.1002/pbc.22970] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 11/16/2010] [Indexed: 11/12/2022]
Abstract
The controversy surrounding private banking of umbilical cord blood units (CBU), as a safeguard against future malignancy or other life-threatening conditions, raises many questions in pediatric clinical practice. Recent favorable experiences with autologous transplantation for severe aplastic anemia using privately stored CBU, suggested a possible utility. While private banking is difficult to justify statistically or empirically, there may exist rare cases where autologous transplant of stored umbilical CBU could be beneficial. The reality of privately banked CBU and the possibility for future discovery of additional indications for autologous cord blood transplant, motivated us to re-examine our attitudes towards private cord blood banking.
Collapse
Affiliation(s)
- Joseph Rosenthal
- Department of Pediatrics, City of Hope, Duarte, California, USA.
| | | | | | | | | | | |
Collapse
|
30
|
Abstract
Primary T-cell anaplastic large-cell lymphoma (ALCL) of the breast is a rare entity, which has been reported in association with breast implants. In a retrospective analysis of the City of Hope pathology database, we uncovered nine such patients, eight of whom had breast implants proximal to primary ALCL. The diagnosis of ALCL in the implant capsule occurred at a median of 7 years (range 5-30) following implant surgery, and median patient age was 45.5 years (range 32-62). Malignancy was effusion-associated in two cases and tissue-associated in six. Seven patients were negative for anaplastic large-cell kinase (ALK) and one patient was positive. Treatment and follow-up data were available for four patients, all tissue-associated cases: two patients were lost to follow-up after failing to mobilize stem cells and two patients were in remission, 6 years and 7.5 years post-autologous transplant. These cases represent 24% of reported primary ALCL cases associated with breast implants. Our review of these cases and the literature suggest that (1) there is a strong skew in primary breast lymphomas associated with implant capsules toward T-cell, ALCL ALK-, and (2) the disease course for tissue-associated cases is not always indolent, with four patients requiring multiple treatment regimens.
Collapse
Affiliation(s)
- Leslie Popplewell
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91030, USA
| | | | | | | | | |
Collapse
|
31
|
Delioukina ML, Palmer JM, Thomas SH, Krishnan A, Stiller T, Forman SJ. Allogeneic hematopoietic cell transplant with fludarabine-based reduced-intensity conditioning as treatment for advanced chronic lymphocytic leukemia. Leuk Lymphoma 2011; 52:719-23. [PMID: 21281228 DOI: 10.3109/10428194.2010.541311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
MESH Headings
- Adult
- Aged
- Antineoplastic Agents/therapeutic use
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Male
- Middle Aged
- Neoplasm Staging
- Survival Analysis
- Transplantation, Homologous
- Treatment Outcome
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
Collapse
|
32
|
Stein AS, Palmer JM, O'Donnell MR, Kogut NM, Spielberger RT, Slovak ML, Tsai NC, Senitzer D, Snyder DS, Thomas SH, Forman SJ. Reduced-intensity conditioning followed by peripheral blood stem cell transplantation for adult patients with high-risk acute lymphoblastic leukemia. Biol Blood Marrow Transplant 2009; 15:1407-14. [PMID: 19822300 DOI: 10.1016/j.bbmt.2009.07.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 07/03/2009] [Indexed: 10/20/2022]
Abstract
Acute lymphoblastic leukemia (ALL) with high-risk features has a poor prognosis in adults despite aggressive chemotherapy. Reduced-intensity conditioning (RIC) is a lower toxicity alternative for high-risk patients requiring hematopoietic cell transplantation (HCT); however, it has not been widely used for ALL. We conducted a retrospective study of 24 high-risk adult ALL patients who received an RIC regimen of fludarabine (Flu)/melphalan (Mel) prior to allogeneic peripheral blood stem cell transplantation (PBSCT) between 6/14/02 and 6/15/07 at the City of Hope. Indications for the RIC regimen were: (1) aged 50 years or older (42%), (2) compromised organ function (54%), or (3) recipient of a previous HCT (37.5%). Patients had a median age of 47.5 years and the median follow-up was 28.5 months for living patients. Both overall survival (OS) and disease-free survival (DFS) at 2 years was 61.5%. Relapse incidence was 21.1% and nonrelapse mortality (NRM) was 21.5% at 2 years. Chronic graft-versus-host (cGVHD) developed in 86% of evaluable patients. In this series, no significant correlations were made between outcomes and patient age, presence of Philadelphia chromosome, relatedness of donor source, or prior HCT. These high survival rates for high-risk ALL patients following RIC HCT may offer a promising option for patients not eligible for a standard myeloablative transplant.
Collapse
Affiliation(s)
- Anthony S Stein
- Department of Hematology/Hematopoietic Cell Transplantation City of Hope National Medical Center, Duarte, California 91010-3000, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Thomas SH, Smith SW, Slater NG, Pearson TC, Treacher DF. The haemodynamic responses to venesection and the effects of cardiovascular disease. Clin Lab Haematol 2008; 14:201-8. [PMID: 1451400 DOI: 10.1111/j.1365-2257.1992.tb00366.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The haemodynamic effects of the venesection of one unit (450 ml) of blood over 9 min were measured using non-invasive techniques, in 14 healthy controls and 18 patients with coronary heart disease or hypertension. Venesection was associated with significant reductions in supine and standing systolic and diastolic blood pressure, stroke volume index and cardiac index, and increases in standing heart rate, in both patient groups. No significant differences were observed between the responses of subjects with and without cardiovascular disease. The authors conclude that, in contrast to established teaching, blood loss can be detected in its early stages by careful haemodynamic monitoring and that venesection can be performed safely without volume replacement in patients with stable cardiovascular disease.
Collapse
Affiliation(s)
- S H Thomas
- Division of Clinical Pharmacology and Toxicology, United Medical and Dental School, London
| | | | | | | | | |
Collapse
|
34
|
Abstract
We report here our retrospective observations on the use of recombinant human hyaluronidase (rHuPH20) for the facilitation of subcutaneous hydration and drug infusion. Thirty-two patients were treated with rHuPH20 in a hospice setting over a 6-month period. Of these, 26 received this agent to enhance hypodermoclysis with standard hydration fluids for symptom control of delirium, myoclonus and mild to moderate dehydration. Flow rates up to 500 mL/hr were attained without difficulty. Electrolyte replacement in hydration fluid was achieved without incident in 5 patients receiving potassium and in 1 patient receiving both potassium and magnesium. In addition to use for hydration, 6 patients received recombinant human hyaluronidase to enhance subcutaneous infusion of 9 medications, primarily because the medication dosage required subcutaneous flow rates greater than the standard 3 mL/hr. There were no significant adverse events. Induration at the infusion site occurred in 1 patient receiving hydration and higher than expected serum lidocaine concentration was observed in another patient. Based on our positive initial experience with recombinant human hyaluronidase, there is interest in expanding its use in our facility in both the inpatient and outpatient settings.
Collapse
Affiliation(s)
- Rosene D Pirrello
- San Diego Hospice & Palliative Care, San Diego, California 92103, USA.
| | | | | |
Collapse
|
35
|
Abstract
The use of appetite suppressants, a putative inverse marker of prescribing quality, was analysed in the former Northern Regional Health Authority (RHA) and in England using National Health Service prescribing data and sales and patient-linked prescribing data supplied by Intercontinental Medical Statistics (IMS). The number (in thousands) of National Health Service prescriptions for appetite suppressants dispensed fell from 393 in 1991 to 235 in 1994. Per capita prescribing frequency varied threefold between different RHA and between individual Family Health Service Authorities (FHSA) within the former Northern RHA (NRHA). Prescribing frequency was higher in the spring and summer quarters and reduced in the winter quarter. Of 532 general practices in the NRHA, 82 (15%) prescribed no appetite suppressants between April 1993 and March 1994, while 70 (13%) prescribed more than 500 defined daily doses (DDDs) per 1000 patients, accounting for 47% of all prescribing. Only 53% of pharmacy purchases of appetite suppressants were accounted for by NHS prescribing and as little as 21% for phentermine, indicating substantial prescribing outwith the NHS. In 1991, 73,759 DDDs were supplied to pharmacies each day, the majority being diethylpropion (31,226) and phentermine (24,349). The fall in NHS prescribing is welcome as these drugs are of dubious clinical value and may be associated with serious adverse effects. Because of substantial non-NHS prescribing, routinely available prescribing data does not accurately quantify total prescribing of these agents.
Collapse
Affiliation(s)
- S H Thomas
- Department of Pharmacological Sciences, University of Newcastle upon Tyne, Newcaastle, UK
| | | |
Collapse
|
36
|
Thomas SH, Schroeder J, Murray LW. Cyperus Tubers Protect Meloidogyne incognita from 1,3-Dichloropropene. J Nematol 2004; 36:131-136. [PMID: 19262797 PMCID: PMC2620761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Meloidogyne incognita-infected and noninfected tubers of yellow nutsedge (Cyperus esculentus) and purple nutsedge (Cyperus rotundus) were treated with 56 L/ha 1,3-dichloropropene (1,3-D) in microplots and subsequently examined for tuber and nematode viability in the greenhouse using a chile pepper (Capsicum annuum) bioassay system. The study was conducted three times. Nutsedge tuber viability and M. incognita harbored in both yellow and purple nutsedge tubers were unaffected by 1,3-D treatment. Nematode reproduction on nutsedges and associated chile pepper plants varied among years, possibly due to differing levels of tuber infection or soil temperature, but was not affected by fumigation. The presence of M. incognita resulted in greater yellow nutsedge tuber germination and reproduction. The efficacy of 1,3-D for management of M. incognita in chile pepper production is likely to be reduced when nutsedges are present in high numbers, reinforcing the importance of managing these weeds and nematodes simultaneously.
Collapse
|
37
|
Abstract
BACKGROUND The question of whether it is safe to provide analgesia for patients with undifferentiated acute abdominal pain is marked by longstanding controversy over the possible masking of physical findings. The goal of this review is to assess the pertinent studies. METHOD A Medline search was performed in April 2002, using the terms 'analgesia', 'abdominal pain', 'acute abdomen' and 'morphine'. Other articles were identified using the bibliographies of papers found through Medline. All articles reporting clinical trials of analgesia and its effects on diagnosis or physical examination were reviewed. RESULTS A total of eight trials (one reported only as an abstract) were identified. Because of significant disparity in trial design, no formal analysis such as meta-analysis was performed. However, detailed review of the trials revealed a striking consistency in results. In no study was there an association between analgesia and diagnostic impairment or dangerous masking of the findings of physical examination. CONCLUSION The literature addressing early pain relief for abdominal pain is characterized by weaknesses, but there is a common theme suggesting that analgesia is safe. Pending further research, which should address some of the shortcomings of extant studies, a practice of judicious provision of analgesia appears safe, reasonable and in the best interests of patients in pain.
Collapse
Affiliation(s)
- S H Thomas
- Department of Surgery, Harvard medical School, Massachusetts General Hospital, Boston, Massachusetts 02114-2696, USA.
| | | |
Collapse
|
38
|
Abstract
In July 2000, tree decline was observed in a commercial pecan (Carya illinoensis (Wang.) K. Koch) orchard in Crisp County, GA. Most affected trees exhibited dead branches in the upper canopy, stunted growth, and feeder roots with small galls and associated egg masses typical of root-knot nematode infection. All declining trees that were examined had root systems infected with a Meloidogyne sp. Efforts to culture the nematode on tomato (Lycopersicon esculentum Mill. 'Rutgers') were unsuccessful. Identification of the nematode was determined by two laboratory procedures in March 2001. Female nematodes were teased from fresh pecan root galls of declining trees in Georgia, and identified by determining the esterase phenotype from replicate samples of single females compared with standard root-knot nematode species, including a population of M. partityla (3). Galled roots also were sent to New Mexico State University in Las Cruces, where mitochondrial DNA from specimens was extracted and compared with that from standard root-knot nematode species and known populations of M. partityla (2). Specimens had esterase phenotypes and DNA patterns consistent with M. partityla. Esterase phentoypes were inconsistent with M. incognita and M. arenaria, and DNA patterns were inconsistent with M. incognita, M. javanica, and M. hapla. Specimens at both locations were identified as M. partityla Kleynhans (1). To our knowledge, this is the first report of M. partityla from Georgia and the third report of this nematode outside of South Africa. The first and second report of M. partityla from pecan in the United States occurred in Texas and New Mexico in 1996 and 2001, respectively (3,4). Our inability to culture the M. partityla-GA isolate on tomato substantiates previous experience with this nematode in the United States (3) and is not surprising, since this species has a host range limited to the Juglandaceae. Furthermore, M. partityla may be endemic to North America and not South Africa. It is believed this nematode entered South Africa on pecan seedling roots imported from the United States between 1912 and 1940 (1). The unusually narrow host range may explain why M. partityla has gone unrecognized for so long in the United States compared with the more common Meloidogyne spp. (i.e., M. incognita and M. arenaria) with wider host ranges found in pecan orchards. Determining the distribution of M. partityla within the major pecan-growing regions of Georgia and throughout North America is warranted. References: (1) K. P. N. Kleynhans. Phytophylactica 18:103, 1986. (2) T. O. Powers and T. S. Harris. J. Nematol. 25:1, 1993. (3) J. L. Starr et al. J. Nematol. 28:565, 1996. (4) S. H. Thomas et al. Plant Dis. 85:1030, 2001.
Collapse
Affiliation(s)
- A P Nyczepir
- U.S. Department of Agriculture, ARS, Southeastern Fruit and Tree Nut Research Laboratory, Byron, GA 31008
| | - C C Reilly
- U.S. Department of Agriculture, ARS, Southeastern Fruit and Tree Nut Research Laboratory, Byron, GA 31008
| | - B W Wood
- U.S. Department of Agriculture, ARS, Southeastern Fruit and Tree Nut Research Laboratory, Byron, GA 31008
| | - S H Thomas
- Department of Entomology, Plant Pathology, and Weed Science, New Mexico State University, Las Cruces 88003
| |
Collapse
|
39
|
Abstract
For several years, decline was observed in mature pecan (Carya illinoensis (F.A. Wangenheim) K. Koch) trees in an orchard in Dona Ana County, New Mexico despite normal fertilization and irrigation practices. Affected trees were growing in sandy soil in two widely separated irrigation terraces and exhibited chlorosis of foliage and substantial die-back of branches in the upper canopy. Examination of feeder roots revealed the presence of numerous small galls and egg masses, with root-knot nematode females often visibly protruding from root tissue. Attempts to culture the nematode on tomato (Lycopersicon esculentum Mill. 'Rutgers') were unsuccessful. Females and egg masses were collected from fresh pecan roots and sent to the USDA Nematology Laboratory in Beltsville, MD, in October 2000, where specimens were identified as Meloidogyne partityla Kleynhans (1) based on morphological examination. This is the first report of M. partityla from New Mexico, and the second report of this nematode outside South Africa. Starr et al. (2) first reported M. partityla from pecan in the United States in 1996, after recovering the nematode from five orchards in Texas. In their study, the host range of M. partityla was limited to members of the Juglandaceae, which may explain the inability of the New Mexico population to reproduce on tomato. Additional information is needed regarding distribution of this nematode within pecan-growing regions throughout North America. References: (1) K. P. N. Kleynhans. Phytophylactica 18:103, 1986. (2) J. L. Starr et al. J. Nematol. 28:565, 1996.
Collapse
Affiliation(s)
- S H Thomas
- Department of Entomology, Plant Pathology, and Weed Science, New Mexico State University, Las Cruces 88003
| | - J M Fuchs
- Department of Entomology, Plant Pathology, and Weed Science, New Mexico State University, Las Cruces 88003
| | - Z A Handoo
- USDA-ARS Nematology Laboratory, Beltsville, MD 20705
| |
Collapse
|
40
|
Thomas SH, Sanderson SA, Handoo ZA. First Report of Columbia Root-Knot Nematode (Meloidogyne chitwoodi) in Potato in New Mexico. Plant Dis 2001; 85:924. [PMID: 30823080 DOI: 10.1094/pdis.2001.85.8.924c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Following a report of Columbia root-knot nematode in potatoes (Solanum tuberosum L.) imported by Mexico from the United States in spring 2000, six fields in San Juan County, NM, were surveyed in August 2000. Soil samples from two fields in which the exported potatoes had been produced contained second-stage juveniles that were tentatively identified as Columbia root-knot nematode. During the 2000 potato harvest, state inspectors detected tubers from four additional fields that exhibited symptoms of Columbia root-knot nematode, including warty exteriors and discrete small brown lesions that were apparent to a depth of 1 cm below the tuber surface. Meloidogyne chitwoodi Golden et al. (1) was confirmed from a subsample of tubers sent to the USDA Nematology Laboratory in Beltsville, MD, in October 2000. Identification was based on morphological examination of the nematodes recovered from tubers. To our knowledge, this is the first report of M. chitwoodi from New Mexico. No Columbia root-knot nematodes were recovered from soil samples collected at 26 locations throughout San Juan County in 1988 and 1989, nor had symptomatic tubers or plants been observed in this area previously. Columbia root-knot nematode most likely represents a recent introduction into northwestern New Mexico. Additional information regarding distribution of this nematode within the region is needed. References: (1) A. M. Golden et al. J. Nematol. 12:319-327, 1980.
Collapse
Affiliation(s)
- S H Thomas
- Department of Entomology, Plant Pathology, and Weed Science, New Mexico State University, Las Cruces 88003
| | - S A Sanderson
- Entomology and Nursery Industries Bureau, New Mexico Department of Agriculture, Las Cruces 88003
| | - Z A Handoo
- USDA-ARS Nematology Laboratory, Beltsville, MD 20705
| |
Collapse
|
41
|
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory, autoimmune disease with a prevalence of approximately 1% and an annual incidence of 0.04%. Up to 50% of patients with RA are unable to work 10 years after diagnosis. The disease is associated with significant morbidity and mortality with associated medical costs to the UK of between £240 m and £600 m per year. Non steroidal anti-inflammatory drugs (NSAIDs) have little effect on the underlying course of RA, but they have some anti-inflammatory and analgesic properties. Disease modifying antirheumatic drugs (DMARDs) have been shown to slow progression of RA and are currently recommended early in the course of treatment of RA which is when disease progression is most rapid. Etanercept and infliximab belong to a new group of parentally administered antitumour necrosis factor (TNF) drugs. Etanercept is licensed in the UK for the treatment of active rheumatoid arthritis in patients who have not responded to other DMARDs and in children with polyarticular-course juvenile arthritis who have not responded to or are intolerant of methotrexate. In adults it produces significant improvements in all measures of rheumatic disease activity compared to placebo. In patients whose disease remains active despite methotrexate treatment, further improvement in control is obtained with the addition of etanercept without an increase in toxicity. In one small trial, etanercept was found to be more effective than placebo in a selected group of children. Infliximab is a monoclonal antibody which is currently licensed in the UK for Crohn's disease and, in combination with methotrexate for the treatment of rheumatoid arthritis in patients with active disease when the response to disease-modifying drugs, including methotrexate, has been inadequate. In clinical trials infliximab produced significant improvements in all measures of rheumatic disease activity compared with placebo. Infliximab in combination with methotrexate was shown to be superior to methotrexate or infliximab alone. There are currently no predictors of a good response to anti-TNF drugs and a percentage of patients fail to respond to treatment (25% to 38% of etanercept patients; 21% to 42% of infliximab patients). Infliximab monotherapy induces the production of anti-infliximab antibodies, which may reduce its effectiveness. Adding methotrexate to infliximab therapy may prevent this response. Anti-TNF drugs may affect host defences against infection and malignancy; whether these agents affect the development and course of malignancies and chronic infections is unknown and safety and efficacy in patients with immunosuppression or chronic infections has not been investigated. With infliximab, upper respiratory tract infections, general infections and those requiring antimicrobial treatment were more common in patients than placebo. Likewise, upper respiratory tract infections were more common in patients treated with etanercept than with placebo. Injection site reactions occur with both infliximab (16%–20%) and etanercept (37%). There are approximately 600 000 patients with RA in the UK, and of these between 2% and 3.5% may have severe disease which has failed to respond to conventional treatment and who might be eligible for anti-TNF therapy. If between 50% and 70% of patients treated with anti-TNF drugs respond and continue on long-term treatment then the recurrent annual cost to the NHS could be between £48 m and £129 m .
Collapse
Affiliation(s)
- H E Seymour
- Regional Drug and Therapeutics Centre, Wolfson Unit, Claremont Place, Newcastle upon Tyne, NE2 4HH, UK.
| | | | | | | |
Collapse
|
42
|
Abstract
The objective was to compare rates of successful endotracheal intubation (ETI) and requirement for multiple ETI attempts in patients receiving etomidate (ETOM) versus succinylcholine (SUX). This retrospective study analyzed adults in whom oral ETI was attempted by a helicopter EMS (HEMS) service between July 1997 to July 1999. Data were from records of the HEMS service, which uses a RN/EMTP crew; analysis was with chi-square and logistic regression (P = .05). ETI was successful in 269 (97.8%) of 275 patients, with multiple attempts occurring in 54 (20.1%) of 269. Success rates for SUX (209 of 213, 98.1%) and ETOM (60 of 62, 96.8%) were similar (P = .62). However, of 60 ETOM patients successfully intubated, 7 (11.7%) required rescue succinylcholine. When these patients are tallied as ETOM failures and SUX successes, resultant success rates for ETOM (86.9%) and SUX (98.2%) are different (P = .001). ETOM patients were more likely (P = .004) than SUX patients to require multiple attempts (33.3% versus 16.3%). ETI success rates were high in patients receiving SUX or ETOM as primary adjuncts for airway control, but initial success was more likely with SUX, and ETOM patients were more likely to require multiple attempts.
Collapse
Affiliation(s)
- C Kociszewski
- Boston Medflight Critical Care Transport Service, MA, USA
| | | | | | | |
Collapse
|
43
|
Orf J, Thomas SH, Ahmed W, Wiebe L, Chamberlin P, Wedel SK, Houck C. Appropriateness of endotracheal tube size and insertion depth in children undergoing air medical transport. Pediatr Emerg Care 2000; 16:321-7. [PMID: 11063359 DOI: 10.1097/00006565-200010000-00004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Guidelines for pediatric endotracheal tube (ETT) size and insertion depth are important in the helicopter EMS (HEMS) setting, where intubated patients are frequently transported by a non-physician flight crew providing protocol-based care in an environment noted for limitations in clinical airway assessment. The objectives of this study were to characterize, in a HEMS pediatric population, the frequency of compliance with guideline-recommended ETT size and insertion depth, and to test for association between guideline noncompliance and subsequent receiving hospital adjustment of ETT size or insertion depth. DESIGN This retrospective review analyzed 216 consecutive pediatric (age <14) scene and interfacility HEMS transports, of patients intubated before or during HEMS transport, by an urban two-helicopter HEMS service providing protocol-based care with a nurse/paramedic crew configuration. Patients were transported to one of three receiving academic pediatric referral centers. Pediatric Advanced Life Support (PALS) criteria for ETT size and insertion depth were used to assess guideline-appropriateness of pediatric ETTs. Receiving hospital records were reviewed to determine if post-transport ETT size or lipline adjustment were associated with guideline-appropriateness of size and lipline during HEMS transport. Univariate (chi-square and Fisher's exact) and multivariate (logistic regression) statistics were used to assess and control for the following covariates: intubator group (physician, flight crew, ground EMS), transport year, sex, age, transport type (scene versus interfacility), and receiving hospital. For all analyses, statistical significance was set at the 0.05 level. RESULTS The initial ETT size was within 0.5 mm of guideline-recommended sizes in 178 (83.6%) of the 213 patients for whom this data were available. Inappropriate sized ETTs were nearly always (32 of 35, 91.4%) too small. Compared to initial ETTs placed by ground EMS personnel, initial ETTs placed by flight crew or physicians were more likely to be appropriate as defined by guidelines (P = .008 and .032, respectively). Receiving hospitals changed the ETT size in 18 (8.3% of 216) cases. Receiving hospital ETT size change was more likely with later transport year (P = .018) and less likely in patients over 2 years of age (P = .03); there was no significant association between receiving hospital ETT size change and intubator group (P > .22) or guideline-appropriateness of ETT size (P = 0.94). The initial ETT insertion depth was within 1 cm of the guideline-recommended lipline in 86 (43.2%) of the 199 patients for whom this data were available. Inappropriate liplines were almost always (109 of 113, 96.5%) too deep. Compared to initial ETT liplines determined by ground EMS personnel, initial liplines determined by flight crew (P = .007), but not physician (P = .47) were more likely to be appropriate as defined by guidelines. Receiving hospitals changed the ETT insertion depth in 72 (33.3% of 216) cases. Receiving hospital lipline change was more likely (P = .03) in patients older than 2 years of age, but was not associated with intubator group (P = .75) or lipline guideline-appropriateness (P = .35). CONCLUSIONS As judged by frequently used guidelines, pediatric ETTs are often too small and commonly inserted too deep. However, this retrospective study, limited by lack of clinical correlation for ETT size and insertion depth, failed to find an association between lack of ETT size or lipline guideline compliance and subsequent ETT adjustment at receiving pediatric centers. This study's findings, which should be confirmed with prospective investigation, cast doubt upon the utility of pediatric ETT size/lipline guidelines as strict clinical or quality assurance tools for use in pediatric airway management.
Collapse
Affiliation(s)
- J Orf
- Boston MedFlight Critical Care Transport Service, Massachusetts, USA
| | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
Rotor-wing aircraft have previously proven utility in disaster operations, but recent expert reviewers have identified areas of potential improvement in integration of helicopter emergency medical services (HEMS) resources into disaster planning and management. This paper discusses salient points regarding helicopter operations in disaster management, using prior reports regarding rotor-wing aircraft utilization as a basis upon which to provide a concise review of HEMS operations in disasters.
Collapse
Affiliation(s)
- S H Thomas
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston 02114-2696, USA.
| | | | | | | |
Collapse
|
45
|
Abstract
We report substantial reductions in the frequency of severe paracetamol hepatotoxicity locally and nationally after legislative limitations on its sale. These reductions were not explained by changes in referral patterns or use of N-acetylcysteine.
Collapse
|
46
|
Abstract
BACKGROUND Sudden unexplained death in psychiatric patients may be due to drug-induced arrhythmia, of which lengthening of the rate-corrected QT interval (QTc) on the electrocardiogram is a predictive marker. We estimated the point prevalence of QTc lengthening in psychiatric patients and the effects of various psychotropic drugs. METHODS Electrocardiograms were obtained from 101 healthy reference individuals and 495 psychiatric patients in various inpatient and community settings and were analysed with a previously validated digitiser technique. Patients with and without QTc lengthening, QTc dispersion, and T-wave abnormality were compared by logistic regression to calculate odds ratios for predictive variables. FINDINGS Abnormal QTc was defined from the healthy reference group as more than 456 ms and was present in 8% (40 of 495) of patients. Age over 65 years (odds ratio 3.0 [95% CI 1.1-8.3]), use of tricyclic antidepressants (4.4 [1.6-12.1]), thioridazine (5.4 [2.0-13.7]), and droperidol (6.7 [1.8-24.8]) were robust predictors of QTc lengthening, as was antipsychotic dose (high dose 5.3 [1.2-24.4]; very high dose 8.2 [1.5-43.6]). Abnormal QT dispersion or T-wave abnormalities were not significantly associated with antipsychotic treatment, but were associated with lithium therapy. INTERPRETATION Antipsychotic drugs cause QTc lengthening in a dose-related manner. Risks are substantially higher for thioridazine and droperidol. These drugs may therefore confer an increased risk of drug-induced arrhythmia.
Collapse
Affiliation(s)
- J G Reilly
- Academic Department of Psychiatry, University of Newcastle Upon Tyne, UK
| | | | | | | | | |
Collapse
|
47
|
Thomas SH, Orf J, Peterson C, Wedel SK. Frequency and costs of laboratory and radiograph repetition in trauma patients undergoing interfacility transfer. Am J Emerg Med 2000; 18:156-8. [PMID: 10750920 DOI: 10.1016/s0735-6757(00)90008-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Receiving trauma centers often duplicate laboratory and radiograph testing performed by referring institutions. Our objective was to quantify frequency and costs of this practice. In this prospective study of 104 consecutive interfacility-transported adult trauma patients flown by an emergency medical service to an urban level I center, flight crew noted which labs and radiographs were done at referring hospitals, which tests were sent with patients, and which were repeated on trauma center arrival. Overall, results from 246 of 283 (86.9%) laboratory tests and 241 of 249 (96.8%) radiographs done at referring hospitals were sent with patients. Repetition of laboratory tests at the receiving hospital was frequent regardless of whether initial results were sent (P = .6 by chi2), and radiograph repetition was unrelated to whether sent films were originals or copies (P = .2 by chi2). For these 104 patients, the receiving hospital charged $66,463 for repetition of work-up done at referring facilities.
Collapse
Affiliation(s)
- S H Thomas
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston 02114, USA
| | | | | | | |
Collapse
|
48
|
Abstract
AIMS Oral activated charcoal is used to treat drug overdose and is effective at reducing drug absorption when administered within 1 h of drug ingestion. There are fewer data on efficacy when the delay is longer, as is the case in most drug overdoses. This study investigated the efficacy of activated charcoal at preventing paracetamol (acetaminophen) absorption after simulated overdose when administration was delayed between 1 and 4 h. METHODS An open randomized-order four-way crossover study was performed in healthy volunteers comparing the effect of activated charcoal 50 g on the absorption of 3 g paracetamol tablets when administered after an interval of 1, 2 or 4 h or not at all. Plasma paracetamol concentrations were measured over 9 h after paracetamol ingestion using h.p.l.c. and areas under the curve between 4 and 9 h (AUC(4,9 h)) calculated as a measure of paracetamol absorption. RESULTS Activated charcoal significantly reduced paracetamol AUC(4,9 h) when administered after 1 h (mean reduction 56%; 95% Confidence intervals 34, 78; P<0.002) or 2 h (22%; 6, 39; P<0.03) but not after 4 h (8%; -8, 24). When administered after 1 h activated charcoal reduced individual plasma paracetamol concentrations significantly at all times between 4 and 9 h after paracetamol administration. Administration at 2 or 4 h had no significant effect. CONCLUSIONS These results in healthy volunteers cannot be extrapolated directly to poisoned patients. However, they provide no evidence of efficacy for activated charcoal when administered after an interval of more than 2 h.
Collapse
Affiliation(s)
- P J Yeates
- Wolfson Unit of Clinical Pharmacology, University of Newcastle upon Tyne, Newcastle, UK
| | | |
Collapse
|
49
|
Abstract
Prospective follow-up of 136 babies exposed to ecstasy in utero indicated that the drug may be associated with a significantly increased risk of congenital defects (15.4% [95% CI 8.2-25.4]). Cardiovascular anomalies (26 per 1000 livebirths [3.0-90.0]) and musculoskeletal anomalies (38 per 1000 [8.0-109.0]) were predominant.
Collapse
|
50
|
Abstract
OBJECTIVE To analyze flight crew airway management in four different settings (in flight, at trauma scenes, in ambulance, and in referring hospitals) and in two different aircraft used by the same helicopter EMS (HEMS) service. The null hypothesis was that there was no association between practice setting, or aircraft, and airway practices or success rate. METHODS This retrospective study analyzed all patients in whom advanced airway management was attempted by the HEMS service during the study period October 1991 through October 1997. Data used were from flight records of Boston MedFlight Critical Care Transport Service, which uses a nurse/paramedic crew and had a paralytic-assisted intubation protocol in place. Data were analyzed with chi-square and Fisher's exact testing, risk ratio analysis, and logistic regression. RESULTS Advanced airway management was attempted in 722 patients, with an airway placed in 705 (97.8%). Intubation success was unrelated to site of airway management (p = 0.14), but patients were more likely to have intubation attempted prior to flight (as opposed to in flight) if the crew were in the AS365N2 Dauphin as compared with the BK-117 (p<0.0001). In addition, patients were 0.77 times as likely (95% confidence interval, 0.68-0.88) to receive paralytic-facilitated intubation if airway management occurred in the hospital setting as compared with other sites. CONCLUSIONS While HEMS crew airway management success rates are equally high in all practice settings, airway management decision making and practice appear to be significantly influenced by practice setting and aircraft type. These data support contentions that nonphysician HEMS crews can effectively manage airways in a variety of circumstances.
Collapse
Affiliation(s)
- S H Thomas
- Boston MedFlight Critical Care Transport Service, Massachusetts General Hospital and Harvard Medical School, 02114-2696, USA.
| | | | | |
Collapse
|