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Patel SA. The heart of VIALE-A: Cardiac complications of hypomethylating agents and venetoclax in acute myeloid leukaemia. Br J Haematol 2024; 204:1137-1138. [PMID: 38339780 DOI: 10.1111/bjh.19336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
As we commemorate 50 years since the introduction of classical 7 + 3 induction chemotherapy for acute myeloid leukaemia (AML), we also embark upon new territory with the advent of novel targeted therapeutics, including BH3 mimetics. To date, we do not have much large-scale longitudinal data regarding the toxicities of such novel therapies. Johnson et al. perform a comprehensive analysis of cardiac toxicities with hypomethylating agents and venetoclax and offer valuable insight into risk-benefit analysis when considering front-line therapy for AML. Commentary on: Johnson et al. Cardiac events in newly diagnosed acute myeloid leukaemia during treatment with venetoclax + hypomethylating agents. Br J Haematol 2024;204:1232-1237.
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Affiliation(s)
- Shyam A Patel
- Department of Medicine - Division of Hematology/Oncology, Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, Massachusetts, USA
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2
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Patel SA, Gerber WK, Zheng R, Khanna S, Hutchinson L, Abel GA, Cerny J, DaSilva BA, Zhang TY, Ramanathan M, Khedr S, Selove W, Woda B, Miron PM, Higgins AW, Gerber JM. Natural history of clonal haematopoiesis seen in real-world haematology settings. Br J Haematol 2024. [PMID: 38522849 DOI: 10.1111/bjh.19423] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 03/26/2024]
Abstract
Recursive partitioning of healthy consortia led to the development of the Clonal Hematopoiesis Risk Score (CHRS) for clonal haematopoiesis (CH); however, in the practical setting, most cases of CH are diagnosed after patients present with cytopenias or related symptoms. To address this real-world population, we characterize the clinical trajectories of 94 patients with CH and distinguish CH harbouring canonical DNMT3A/TET2/ASXL1 mutations alone ('sole DTA') versus all other groups ('non-sole DTA'). TET2, rather than DNMT3A, was the most prevalent mutation in the real-world setting. Sole DTA patients did not progress to myeloid neoplasm (MN) in the absence of acquisition of other mutations. Contrastingly, 14 (20.1%) of 67 non-sole DTA patients progressed to MN. CHRS assessment showed a higher frequency of high-risk CH in non-sole DTA (vs. sole DTA) patients and in progressors (vs. non-progressors). RUNX1 mutation conferred the strongest risk for progression to MN (odds ratio [OR] 10.27, 95% CI 2.00-52.69, p = 0.0053). The mean variant allele frequency across all genes was higher in progressors than in non-progressors (36.9% ± 4.62% vs. 24.1% ± 1.67%, p = 0.0064). This analysis in the post-CHRS era underscores the natural history of CH, providing insight into patterns of progression to MN.
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Affiliation(s)
- Shyam A Patel
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
- Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - William K Gerber
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Rena Zheng
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Shrinkhala Khanna
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Lloyd Hutchinson
- Department of Pathology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Gregory A Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
- Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Brandon A DaSilva
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Tian Y Zhang
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Muthalagu Ramanathan
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
- Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Salwa Khedr
- Department of Pathology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - William Selove
- Department of Pathology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Bruce Woda
- Department of Pathology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Patricia M Miron
- Department of Pathology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Anne W Higgins
- Department of Pathology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Jonathan M Gerber
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, Massachusetts, USA
- Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, Massachusetts, USA
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Ferrer-Diaz AI, Sinha G, Petryna A, Gonzalez-Bermejo R, Kenfack Y, Adetayo O, Patel SA, Hooda-Nehra A, Rameshwar P. Revealing role of epigenetic modifiers and DNA oxidation in cell-autonomous regulation of Cancer stem cells. Cell Commun Signal 2024; 22:119. [PMID: 38347590 PMCID: PMC10863086 DOI: 10.1186/s12964-024-01512-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/01/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Breast cancer cells (BCCs) can remain undetected for decades in dormancy. These quiescent cells are similar to cancer stem cells (CSCs); hence their ability to initiate tertiary metastasis. Dormancy can be regulated by components of the tissue microenvironment such as bone marrow mesenchymal stem cells (MSCs) that release exosomes to dedifferentiate BCCs into CSCs. The exosomes cargo includes histone 3, lysine 4 (H3K4) methyltransferases - KMT2B and KMT2D. A less studied mechanism of CSC maintenance is the process of cell-autonomous regulation, leading us to examine the roles for KMT2B and KMT2D in sustaining CSCs, and their potential as drug targets. METHODS Use of pharmacological inhibitor of H3K4 (WDR5-0103), knockdown (KD) of KMT2B or KMT2D in BCCs, real time PCR, western blot, response to chemotherapy, RNA-seq, and flow cytometry for circulating markers of CSCs and DNA hydroxylases in BC patients. In vivo studies using a dormancy model studied the effects of KMT2B/D to chemotherapy. RESULTS H3K4 methyltransferases sustain cell autonomous regulation of CSCs, impart chemoresistance, maintain cycling quiescence, and reduce migration and proliferation of BCCs. In vivo studies validated KMT2's role in dormancy and identified these genes as potential drug targets. DNA methylase (DNMT), predicted within a network with KMT2 to regulate CSCs, was determined to sustain circulating CSC-like in the blood of patients. CONCLUSION H3K4 methyltransferases and DNA methylation mediate cell autonomous regulation to sustain CSC. The findings provide crucial insights into epigenetic regulatory mechanisms underlying BC dormancy with KMT2B and KMT2D as potential therapeutic targets, along with standard care. Stem cell and epigenetic markers in circulating BCCs could monitor treatment response and this could be significant for long BC remission to partly address health disparity.
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Affiliation(s)
- Alejandra I Ferrer-Diaz
- Department of Medicine - Division of Hematology/Oncology, Rutgers, New Jersey Medical School, Newark, NJ, 07103, USA
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, NJ, USA
| | - Garima Sinha
- Department of Medicine - Division of Hematology/Oncology, Rutgers, New Jersey Medical School, Newark, NJ, 07103, USA
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, NJ, USA
| | - Andrew Petryna
- Department of Medicine - Division of Hematology/Oncology, Rutgers, New Jersey Medical School, Newark, NJ, 07103, USA
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, NJ, USA
| | | | - Yannick Kenfack
- Department of Medicine - Division of Hematology/Oncology, Rutgers, New Jersey Medical School, Newark, NJ, 07103, USA
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, NJ, USA
| | | | - Shyam A Patel
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA, USA
| | - Anupama Hooda-Nehra
- Department of Medicine - Division of Hematology/Oncology, Rutgers, New Jersey Medical School, Newark, NJ, 07103, USA
- Rutgers Cancer Institute of New Jersey, Newark, NJ, USA
| | - Pranela Rameshwar
- Department of Medicine - Division of Hematology/Oncology, Rutgers, New Jersey Medical School, Newark, NJ, 07103, USA.
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Arun Kumar S, Gao J, Patel SA. The shifting therapeutic paradigm for relapsed/refractory mantle cell lymphoma. Leuk Res 2023; 134:107385. [PMID: 37672954 PMCID: PMC10888497 DOI: 10.1016/j.leukres.2023.107385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 06/26/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023]
Abstract
Mantle cell lymphoma (MCL) is a heterogeneous subtype of non-Hodgkin lymphoma that has been historically associated with poor 5-year overall survival rates, especially for aggressive variants. Traditional cytotoxic chemotherapy had been a mainstay of therapy for relapsed/refractory (R/R) MCL for many years until the advent of molecularly targeted therapies and cell-based approaches. However, a significant concern is the lack of definitive consensus guidelines for management of R/R MCL. The managerial conundrum partly stems from the absence of head-to-head comparisons of novel therapies, with conclusions drawn from cross-trial comparisons. In this evidence-based review, we discuss the current therapeutic options for R/R MCL, including the most recent data from the BRUIN study that led to the approval of the first-in-class non-covalent reversible Bruton's tyrosine kinase (BTK) inhibitor pirtobrutinib in 2023, as well as the recent removal of ibrutinib from the market. We discuss outlooks for targeted therapy and tolerability considerations for novel agents, including unique considerations for the elderly population. We highlight emerging data that support the curative potential of chimeric antigen receptor-T (CAR-T) therapy from ZUMA-2, relative to other promising investigational agents in the pipeline, including glofitamab, epcoritamab, and zilovertamab vedotin. We summarize management recommendations based upon the most rigorous clinical evidence to date.
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Affiliation(s)
- Sumukh Arun Kumar
- Dept. of Internal Medicine, Saint Vincent Hospital, Worcester, MA, USA
| | - Jenny Gao
- RNA Therapeutics Institute, UMass Chan Medical School, Worcester, MA, USA
| | - Shyam A Patel
- Center for Clinical and Translational Science (CCTS), UMass Chan Medical School, Worcester, MA, USA; Dept. of Medicine - Division of Hematology/Oncology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA, USA.
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Patel SA, Cerny J, Gerber WK, Ramanathan M, Ediriwickrema A, Tanenbaum B, Hutchinson L, Meng X, Flahive J, Barton B, Gillis‐Smith AJ, Suzuki S, Khedr S, Selove W, Higgins AW, Miron PM, Simin K, Woda B, Gerber JM. Prognostic heterogeneity and clonal dynamics within distinct subgroups of myelodysplastic syndrome and acute myeloid leukemia with TP53 disruptions. EJHaem 2023; 4:1059-1070. [PMID: 38024632 PMCID: PMC10660125 DOI: 10.1002/jha2.791] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023]
Abstract
TP53 aberrations constitute the highest risk subset of myelodysplastic neoplasms (MDS) and acute myeloid leukemia (AML). The International Consensus Classification questions the blast threshold between MDS and AML. In this study, we assess the distinction between MDS and AML for 76 patients with TP53 aberrations. We observed no significant differences between MDS and AML regarding TP53 genomics. Median overall survival (OS) was 223 days for the entire group, but prognostic discrimination within subgroups showed the most inferior OS (46 days) for AML with multihit allelic state plus TP53 variant allele frequency (VAF) > 50%. In multivariate analysis, unadjusted Cox models revealed the following variables as independent risk factors for mortality: AML (vs. MDS) (hazard ratio [HR]: 2.50, confidence interval [CI]: 1.4-4.4, p = 0.001), complex karyotype (HR: 3.00, CI: 1.4-6.1, p = 0.003), multihit status (HR: 2.30, CI 1.3-4.2, p = 0.005), and absence of hematopoietic cell transplant (HCT) (HR: 3.90, CI: 1.8-8.9, p = 0.0009). Clonal dynamic modeling showed a significant reduction in TP53 VAF with front-line hypomethylating agents. These findings clarify the impact of specific covariates on outcomes of TP53-aberrant myeloid neoplasms, irrespective of the diagnosis of MDS versus AML, and may influence HCT decisions.
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Affiliation(s)
- Shyam A. Patel
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Jan Cerny
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - William K. Gerber
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Asiri Ediriwickrema
- Institute for Stem Cell Biology & Regenerative Medicine; Division of Hematology, Department of MedicineStanford UniversityStanfordCaliforniaUnited States
| | - Benjamin Tanenbaum
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Lloyd Hutchinson
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Xiuling Meng
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Julie Flahive
- Department of Population & Quantitative Health SciencesUMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Bruce Barton
- Department of Population & Quantitative Health SciencesUMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Andrew J. Gillis‐Smith
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Sakiko Suzuki
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Salwa Khedr
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - William Selove
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Anne W. Higgins
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Patricia M. Miron
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Karl Simin
- Dept. of MolecularCell & Cancer BiologyUMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Bruce Woda
- Department of PathologyUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
| | - Jonathan M. Gerber
- Division of Hematology and Oncology, Department of MedicineUMass Memorial Medical Center, UMass Chan Medical SchoolWorcesterMassachusettsUnited States
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Patel SA, Bello E, Wilks A, Gerber JM, Sadagopan N, Cerny J. Harnessing autologous immune effector mechanisms in acute myeloid leukemia: 2023 update of trials and tribulations. Leuk Res 2023; 134:107388. [PMID: 37729719 PMCID: PMC10947503 DOI: 10.1016/j.leukres.2023.107388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/22/2023]
Abstract
Numerous recent advances have been made in therapeutic approaches toward acute myeloid leukemia (AML). Since 2017, we have seen eleven novel Food & Drug Administration (FDA)-approved medications for AML, all of which extend beyond the classical cytarabine-based cytostatic chemotherapy. In the recent two decades, the role of immune surveillance in AML has been intensively investigated. The power of one's own innate and adaptive immunity has been harnessed pharmacologically toward the goal of clearance of AML cells. Specifically, pre-clinical studies have shown great promise for antibodies that disinhibit T cells and macrophages by blocking checkpoint receptors within the immunologic synapse, thereby resulting in the elimination of AML cells. Anti-CD33 CAR-T therapies and anti-CD3/CD123 bispecific antibodies have also exhibited encouraging results in pre-clinical and early clinical studies. However, despite these translational efforts, we currently have no immune-based therapies for AML on the market, with the exception of gemtuzumab ozogamicin. In this focused review, we discuss molecular target validation and the most relevant clinical updates for immune-based experimental therapeutics including anti-CD47 monoclonal antibodies, CAR-T therapies, and bispecific T cell engagers. We highlight barriers to the clinical translation of these therapies in AML, and we propose solutions to optimize the manufacturing and delivery of the most novel immune-based therapies in the pipeline.
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Affiliation(s)
- Shyam A Patel
- Dept. of Medicine - Division of Hematology/Oncology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA, USA; Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, MA, USA
| | - Elisa Bello
- UMass Chan Medical School, Worcester, MA, USA
| | - Andrew Wilks
- Dept. of Medicine - Division of Hematology and Medical Oncology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan M Gerber
- Dept. of Medicine - Division of Hematology/Oncology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA, USA; Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, MA, USA
| | - Narayanan Sadagopan
- MedStar Health - Georgetown/Washington Hospital Center Hematology and Medical Oncology, Washington, DC, USA
| | - Jan Cerny
- Dept. of Medicine - Division of Hematology/Oncology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA, USA; Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, MA, USA.
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Bello E, Liao H, Patel SA. Clinico-Radio-Pathologic Correlation of Leukostasis in Acute Myeloid Leukemia with FLT3 Mutation. Acta Haematol 2023:000531832. [PMID: 37788644 DOI: 10.1159/000531832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Indexed: 10/05/2023]
Abstract
The systemic complications of acute hematologic emergencies account for the high mortality rates seen during inpatient management. Perhaps the most challenging diagnostic entity among all hematologic emergencies is leukostasis. In acute myeloid leukemia, myeloid blasts are often highly adherent to the endothelial vasculature, and high peripheral blood blast count in excess of 100,000 cells per microliter can predispose patients to the pulmonary and neurologic complications, leading to rapid clinical deterioration even before a formal diagnosis of leukostasis is made. The mobilization of the appropriate healthcare personnel in the inpatient setting at inopportune times sometimes poses a major barrier to the successful treatment for patients with leukostasis, and patients often pass away quickly. In this report, we describe clinico-radio-pathologic correlations of leukostasis using pre- and post-mortem analysis in a patient with acute myeloid leukemia (AML) with a FLT3-TKD mutation, and we describe the current literature on best management approaches based on recent evidence.
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Dhere VR, Schuster DM, Goyal S, Schreibmann E, Hershatter B, Patel SA, Shelton JW, Hanasoge S, Patel PR, Sebastian N, Lawal IO, Jani A. Biochemical Relapse-Free Survival in Post-Prostatectomy Patients Receiving 18F-Fluciclovine-Guided Prostate Bed Only Radiation: Post-Hoc Analysis of a Prospective Randomized Trial. Int J Radiat Oncol Biol Phys 2023; 117:e376. [PMID: 37785277 DOI: 10.1016/j.ijrobp.2023.06.2482] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Whole pelvis (WP) radiation therapy (XRT) significantly improved biochemical relapse free survival (bRFS) compared to prostate-bed (PB)-only XRT in RTOG 0534, yet increased toxicity and was performed in an era prior to PET staging (Pollack et al, Lancet, 2022). Separately, 18F-fluciclovine PET/CT (PET)-guided post-prostatectomy XRT demonstrated improved bRFS compared to XRT guided by conventional imaging alone. We hypothesized that patients whose decisions were changed from whole pelvic XRT to PB-only XRT after PET imaging would have bRFS that was (a) not significantly different than patients initially planned for PB-only XRT, and (b) significantly improved over patients planned for WP XRT without PET guidance. MATERIALS/METHODS We conducted a post-hoc analysis of a prospective, randomized, single-institution trial comparing conventional (Arm A) v. PET-guided (Arm B) post-prostatectomy XRT. For patients randomized to Arm B, pre-PET treatment field decisions were recorded, and post-fluciclovine fields were rigidly defined per protocol: pN0 patients with no pelvic or extrapelvic PET uptake received PB-only XRT. Three- and four-year bRFS were compared in patients initially planned for WP with change to PB-only XRT [Arm B (WP→PB)] v Arm B patients initially planned for PB-only with final XRT to PB-only [Arm B(PB→PB)] & Arm A patients treated with whole pelvic XRT [Arm A(WP)] using Z test and log-rank test. Demographics were compared using Chi-square test, Fisher's exact test, or ANOVA as appropriate. RESULTS We identified 10 Arm B (WP→PB), 31 Arm B (PB→PB), and 25 Arm A (WP) patients. Androgen deprivation was used in 50.0% of Arm B (WP→PB) and 3.2% of Arm B (PB→PB) patients, p<0.01. Mean pre-XRT PSA was significantly higher (1.56 v 0.32 ng/mL, respectively, p<0.01) in Arm B (WP→PB) v Arm B (PB→PB) patients, however, there was no significant difference in extracapsular extension (p = 1.00), seminal vesical invasion (p = 1.00), Gleason score ≥8 (p = 0.58) or margin positivity (p = 0.73) between cohorts. Three- and four-year bRFS was 80% in Arm B (WP→PB) & 87.4% in Arm B (PB→PB), p = 0.47, respectively. Arm A (WP) patients had significantly worse three- (35.2%) and four-year (13.2%) bRFS compared to Arm B (WP→PB), p<0.01. CONCLUSION Patients initially planned for WP XRT whose treatment field decisions were changed to PB-only XRT after PET guidance had, in this post-hoc analysis, (a) relapse rates not significantly different than patients initially planned for PB-only XRT and (b) improved relapse rates over patients treated with WP XRT without PET guidance. PET-guided volume de-escalation in selected patients may be one approach to mitigating excess toxicity seen with WP XRT without compromising outcomes and warrants further exploration.
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Affiliation(s)
- V R Dhere
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - D M Schuster
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA
| | - S Goyal
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Atlanta, GA
| | - E Schreibmann
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - B Hershatter
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - S A Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J W Shelton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - S Hanasoge
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - P R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - N Sebastian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, OH
| | | | - A Jani
- Department of Radiation Oncology, Emory University, Atlanta, GA
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Wynne JF, Lei Y, Pan S, Wang T, Roper JR, Patel PR, Patel SA, Godette KD, Jani A, Yang X. Rapid Unpaired CBCT-Based Synthetic CT for CBCT-Guided Adaptive Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:S179. [PMID: 37784444 DOI: 10.1016/j.ijrobp.2023.06.2524] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Quantitative cone beam CT (CBCT) is the foundation for image-guided radiation therapy, improving treatment setup, tumor delineation and dose calculation. However, CBCT images suffer from severe artifacts, limiting clinical utility. Deep learning can overcome these limitations, boosting radiographic and dosimetric quality critical for online adaptive radiotherapy (ART). We hypothesize adapted contrastive unpaired translation (CUT), a recent method for image-to-image translation of photographic images, can improve CBCT quality while reducing compute time, demonstrating utility for ART. MATERIALS/METHODS Same-day CBCT and quality assurance CT (QACT) images acquired from 79 patients receiving proton therapy for prostate cancer between 2019 and 2020 at a single institution were retrospectively collected. QACT images were acquired for quality assurance in accordance with institutional policy. Seventy-nine patients yielded 102 non-contrast CBCT-QACT image sets. Each QACT image was rigidly registered to the corresponding CBCT and resampled to 1 × 1 × 2 mm to establish uniform voxel size and spacing. CBCT images were randomly shuffled prior to input to the CUT model for unsupervised training and QACT-quality synthetic CT images were generated as outputs. We compared mean absolute error (MAE), structural similarity index measure (SSIM), and Fréchet inception distance (FID) against same-day QACT. RESULTS MAE, SSIM, and FID were compared for the CycleGAN and CUT data relative to input QACT and are reported as the mean across five-fold cross-validation ± standard error. CUT achieved superior performance in MAE (19.5 ± 3.9 HU vs. cycleGAN 47.1 ± 25.4) and FID (31.5 ± 6.6 vs cycleGAN 75.9 ± 41.3). MAE indicates pixel-level correspondence to QACT HU intensity values, making the synthetic outputs of CUT useful for dose calculations during ART. FID further demonstrates perceptual visual similarity. SSIM for CycleGAN (0.7 ± 0.2) and CUT (0.8 ± 0.0) were similar, indicating acceptable reproducibility of global structure. CUT was faster and lighter than CycleGAN. CycleGAN contained a total of 28,286,000 parameters; CUT contained 14,703,000, approximately half that of CycleGAN. As a result, CycleGAN computes on a single CT image slice over 0.33s while CUT requires just 0.18s. CONCLUSION The contrastive method investigated here was demonstrated to be faster and more accurate than CycleGAN, requiring fewer networks and parameters to achieve superior performance. We demonstrated anatomic boundary preservation and HU fidelity superior to cycleGAN while significantly reducing compute time. We plan to investigate the use of these synthetic CT images in automated segmentation prior to exploration of CUT in a prospective setting.
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Affiliation(s)
- J F Wynne
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Y Lei
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - S Pan
- Emory University School of Medicine Department of Radiation Oncology, Atlanta, GA
| | - T Wang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J R Roper
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - P R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - S A Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - K D Godette
- Winship Cancer Institute, Department of Radiation Oncology, Emory University, Atlanta, GA
| | - A Jani
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - X Yang
- Department of Radiation Oncology, Emory University, Atlanta, GA
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10
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Sebastian N, Goyal S, Liu Y, Patel PR, Hanasoge S, Dhere VR, Shelton JW, Godette KD, Jani A, Hershatter B, Fischer-Valuck B, Patel SA. Association of Radiation Facility Volume with Overall Survival in Patients with Very High-Risk Prostate Cancer Treated with Radiation and Androgen Deprivation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e434-e435. [PMID: 37785414 DOI: 10.1016/j.ijrobp.2023.06.1604] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Studies suggest an association of treatment at high volume facilities with improved survival in cancer patients receiving surgery or radiation therapy. This association has not been studied in patients with very high-risk prostate cancer, who are treated using a multimodality approach that often requires specialized care with advanced diagnostic imaging, complex radiotherapeutic planning, and multidrug antiandrogen regimens. We used the National Cancer Database (NCDB) to study the association of radiation treatment facility volume (FV) with overall survival (OS). MATERIALS/METHODS We selected for patients with very high risk, localized prostate cancer by NCCN criteria (cT3b-T4, primary Gleason pattern 5, >4 cores with grade group 4-5, and/or 2-3 high risk features). We included patients who received hormone therapy with either external beam radiation to a dose of ≥60 Gy or external beam radiation to a dose of ≥45 Gy combined with brachytherapy. Association of FV with OS was evaluated through a bias-adjusted log-rank test to identify the optimal cut point of FV for dichotomization. Kaplan-Meier curves were used to study the association of binary FV with overall survival (OS) with and without IPTW (inverse probability treatment weighting) balancing the following confounders: age, race, median income, education, insurance, academic treatment facility, Charlson comorbidity score, T stage, PSA, Gleason score, total radiation dose, year of diagnosis, and patient distance from treatment facility. Cox proportional hazards model was built using backward variable selection strategy (α of 0.05 for removal). RESULTS We identified 25,219 very high-risk prostate cancer patients by NCCN criteria (median follow up 57.36 months; 95% CI 56.67 - 58.09) diagnosed between 2004 and 2015. High FV (n = 6,438) was associated with better OS on univariable analysis (hazard ratio [HR] = 0.81; 95% confidence interval [CI] 0.77 - 0.86; p < 0.001) and multivariable analysis (HR = 0.89; 95% CI 0.84 - 0.95; p < 0.001). Other factors associated with improved OS on multivariable analysis included younger age, non-white/black race, higher income, private insurance, academic/research treatment facility, lower comorbidity, lower T-stage, lower PSA, and lower Gleason score. After IPTW adjustment, high FV remained associated with better OS (HR = 0.90; 95% CI 0.85 - 0.95; p < 0.001). CONCLUSION Patients with NCCN very high-risk prostate cancer treated at a radiation facility with high case volume had better OS than patients treated at a facility with low volume, after adjustment for confounders. This may suggest that for very high-risk patients, outcomes may be improved by the expertise and optimal multidisciplinary care that typically accompany high facility treatment volume.
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Affiliation(s)
- N Sebastian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, OH
| | - S Goyal
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Atlanta, GA
| | - Y Liu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - P R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - S Hanasoge
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - V R Dhere
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J W Shelton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - K D Godette
- Winship Cancer Institute, Department of Radiation Oncology, Emory University, Atlanta, GA
| | - A Jani
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - B Hershatter
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | | | - S A Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
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11
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Corriher TJ, Janopaul-Naylor J, Liu Y, Dhere VR, Sebastian N, Weiss A, Hershatter B, Filson CP, Patel SA. Utilization of Radical Prostatectomy vs. Radiation Therapy for Gleason Grade Group 5 Prostate Cancer before and after USPSTF Grade D Recommendation against Prostate-Specific Antigen Screening in 2012. Int J Radiat Oncol Biol Phys 2023; 117:e374. [PMID: 37785273 DOI: 10.1016/j.ijrobp.2023.06.2478] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The 2012 United States Preventive Services Task Force (USPSTF) Grade D recommendation against prostate-specific antigen (PSA) screening has resulted in a shift to higher-stage prostate cancer (PC) at diagnosis. While incidence of low-risk prostate cancer has declined, more men are diagnosed with high-risk disease, and multimodal treatment is often required. The impact of this epidemiologic shift on practice patterns, specifically radical prostatectomy (RP) versus definitive radiation therapy (RT), for men with localized PC at high risk of recurrence is unknown. Herein, we evaluate the utilization of RP versus RT in the United States for Gleason grade group 5 (GG5) prostate cancer before and after 2012. MATERIALS/METHODS We identified 34,011 men with localized GG5 PC treated with (1) RP or (2) RT plus androgen deprivation therapy (ADT) between 2004 and 2017 in the National Cancer Database. We excluded those who were clinically node-positive, had metastatic disease, or received chemotherapy or palliative-intent treatment. Chi-square was used to compare the relative use of RP and RT before versus after January 1, 2012, corresponding to the year of USPSTF recommendation against PSA screening. Annual use of RP versus RT from 2004 to 2017 was compared in academic and non-academic centers using Cochran-Armitage test for trend. Joinpoint regression assessed if 2012 was significant for inflection of crude rates of RP. Finally, we modeled the effect of treatment year (i.e., 2012-2017 versus 2004-2011) on use of RP using multivariable logistic regression. Sensitivity analysis tested an interaction term for facility type (i.e., academic versus community). Tests were two-sided with a 0.05 level of significance. RESULTS Of the eligible men, 10,745 (31.6%) had T3-T4 disease. Between 2004 and 2011, 36.5% (n = 5,483) underwent RP; between 2012 and 2017, 42.3% (n = 8,034) underwent RP (p = .02). Across all centers, use of RP increased from 31% to 41% (p for trend <.001). In academic centers, use of RP increased from 32% to 44% (p for trend <.001); in community centers, use of RP increased from 30% to 39% (p for trend <.001). 2012 was associated with significant inflection for increase in RP use in all centers. On multivariable analysis, there was an increased odds of receiving RP after 2012 (adjusted OR 1.34, 95% CI 1.28-1.40, p<.001). No differential effect by facility type was observed (p = .15). CONCLUSION Utilization of RP for GG5 PC has significantly increased in the United States over the past decade, particularly after the USPSTF Grade D recommendation against PSA screening in 2012. It remains unknown whether oncologic or functional outcomes may be compromised in this group of high-risk men, many of whom require post-prostatectomy RT and/or ADT. While historically rare, prospective comparison of RP versus RT+ADT for GG5 PC may be helpful given the evolving epidemiology of localized PC.
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Affiliation(s)
- T J Corriher
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J Janopaul-Naylor
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Y Liu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - V R Dhere
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - N Sebastian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - A Weiss
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - B Hershatter
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - C P Filson
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - S A Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
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Janopaul-Naylor J, Corriher TJ, Switchenko J, Hanasoge S, Esdaille A, Mahal BA, Filson CP, Patel SA. Disparities in Time to Prostate Cancer Treatment Initiation before and after the Affordable Care Act. Int J Radiat Oncol Biol Phys 2023; 117:e28. [PMID: 37785048 DOI: 10.1016/j.ijrobp.2023.06.709] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for men with PCa is unknown. MATERIALS/METHODS Men with intermediate- and high-risk PCa diagnosed 2010-2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis to start of surgery, radiotherapy, or hormonal therapy. Cochran-Armitage test measured annual trends in delays, and join point regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays. RESULTS Of 422,506 eligible men, 18,720 (4.4%) experienced >180-day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72-1.87, p<.001) and Hispanic (OR 1.37, 95% CI 1.28-1.48, p<.001) patients had higher odds of delay. These disparities persisted when analyzing only patients treated after 2014 or for patients who had Medicare or Private insurance. Compared to uninsured patients, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84-1.06, p = .31), while those with private insurance (OR 0.57, 95% CI 0.52-0.63, p<.001) or Medicare (OR 0.64, 95% CI 0.58-0.70, p<.001) had lower odds of delay. These disparities persisted when analyzing only patients treated after 2014. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p<.001); 2014 was associated with a significant inflection for increase in rates of major delays. CONCLUSION The impact of race and insurance status were independently associated with longer delays to PCa treatment in the US. These disparities were unaffected by implementation of the ACA. In fact, implementation of ACA was associated with increased delays in treatment initiation for all men, regardless of race. As the epidemiology of newly diagnosed prostate cancer in the United States continues to shift due to tempered screening and the COVID pandemic, further work will be needed to increase equity in prostate cancer care.
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Affiliation(s)
- J Janopaul-Naylor
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - T J Corriher
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | | | - S Hanasoge
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - A Esdaille
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - B A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - C P Filson
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - S A Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
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Gao J, Dahiya S, Patel SA. Challenges and solutions to superior chimeric antigen receptor-T design and deployment for B-cell lymphomas. Br J Haematol 2023; 203:161-168. [PMID: 37488074 PMCID: PMC10913150 DOI: 10.1111/bjh.19001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 07/26/2023]
Abstract
Chimeric antigen receptor-T (CAR-T) therapies represent a major breakthrough in cancer medicine, given the ex vivo-based technology that harnesses the power of one's own immune system. These therapeutics have demonstrated remarkable success for relapsed/refractory B-cell lymphomas. Although more than a decade has passed since the initial introduction of CAR-T therapeutics for patients with leukaemia and lymphoma, there is still significant debate as to where CAR-T therapeutics fit into the management paradigm, as consensus guidelines are limited. Competing interventions deployed in subsequent lines of therapy for aggressive lymphoma include novel targeted agents, bispecific antibodies, and time-honoured stem cell transplant. In this focused review, we discuss the major obstacles to advancing the therapeutic reach for CAR-T products in early lines of therapy. Such barriers include antigen escape, "cold" tumour microenvironments, host inflammation and CAR-T cell exhaustion. We highlight solutions including point-of-care CAR-T manufacturing and early T lymphopheresis. We review the evidence basis for early CAR-T deployment for B-cell lymphomas in light of the recent Food and Drug Administration (FDA) approval of three first-in-class anti-CD3/CD20 bispecific antibodies-mosunetuzumab, epcoritamab and glofitamab. We propose practical recommendations for 2024.
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Affiliation(s)
- Jenny Gao
- RNA Therapeutics Institute, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Saurabh Dahiya
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University School of Medicine, Stanford, California, USA
| | - Shyam A. Patel
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Center for Clinical and Translational Science, UMass Chan Medical School, Worcester, Massachusetts, USA
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14
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Patel SA. Precision and strategic targeting of novel mutation-specific vulnerabilities in acute myeloid leukemia: the semi-centennial of 7 + 3. Leuk Lymphoma 2023; 64:1503-1513. [PMID: 37328939 PMCID: PMC10913147 DOI: 10.1080/10428194.2023.2224473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/18/2023]
Abstract
The year 2023 marks the semi-centennial of the introduction of classic '7 + 3' chemotherapy for acute myeloid leukemia (AML) in 1973. It also marks the decennial of the first comprehensive sequencing efforts from The Cancer Genome Atlas (TCGA), which revealed that dozens of unique genes are recurrently mutated in AML genomes. Although more than 30 distinct genes have been implicated in AML pathogenesis, the current therapeutic armamentarium that is commercially available only targets FLT3 and IDH1/2 mutations, with olutasidenib as the most recent addition. This focused review spotlights management approaches that exploit the exquisite molecular dependencies of specific subsets of AML, with an emphasis on emerging therapies in the pipeline, including agents targeting TP53-mutant cells. We summarize precision and strategic targeting of AML based on leveraging functional dependencies and explore how mechanisms involving critical gene products can inform rational therapeutic design in 2024.
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Affiliation(s)
- Shyam A Patel
- Department of Medicine, Division of Hematology/Oncology, UMass Memorial Medical Center, Center for Clinical & Translational Science, UMass Chan Medical School, Worcester, MA, USA
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15
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Balaji G, Yadav G, Patel SA, Ramesh A, Nema S, Ramalingam T. Accuracy of Femoral Tunnel Placement between Anteromedial and Anterolateral Visualisation Portals in Anterior Cruciate Ligament Reconstruction - Outcomes of a CT based Cross-Sectional Study. Malays Orthop J 2023; 17:7-12. [PMID: 37583529 PMCID: PMC10424999 DOI: 10.5704/moj.2307.002] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/18/2022] [Indexed: 08/17/2023] Open
Abstract
Introduction Anatomical femoral tunnel placement is critical for anterior cruciate ligament reconstruction (ACLR). Tunnel placement may vary with different surgical techniques. The aim of this study was to compare the accuracy of femoral tunnel placement between the Anteromedial (AM) and Anterolateral (AL) visualisation portals on post-operative CT scans among a cohort of ACLR patients. Materials and methods This cross-sectional study was conducted from January 2018 to March 2020 after obtaining ethics clearance. Patients who went for arthroscopic ACLR in our institute were divided into an AM (group 1) and an AL (group 2) based on the visualisation portal for creating the femoral tunnel and a 3D CT scan was done. The femoral tunnel position was calculated in deep to shallow and high to low direction using the Bernard Hertel grid. Femoral tunnel angle was measured in the 2D coronal image. Statistical analysis was done with the data collected. Results Fifty patients with an average age of 26.36 (18-55) years ±7.216 SD were enrolled in the study. In this study, the AM technique was significantly more accurate (p<0.01) than the AL technique in terms of femoral tunnel angle. Furthermore, the deep to the shallow position was significantly (p= 0.018) closer to normative values, as determined by the chi-square test. The chances of error in tunnel angle in femoral condyle are 2.6 times greater in the AL technique (minimal clinical difference). Conclusion To conclude, in ACLR the anteromedial visualisation portal can facilitate accurate femoral tunnel placement compared to the anterolateral visualisation portal.
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Affiliation(s)
- G Balaji
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - G Yadav
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - S A Patel
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - A Ramesh
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - S Nema
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - T Ramalingam
- Department of Orthopaedics, Sarvajanik College of Physiotherapy Rampura, Surat, India
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16
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Bohannon D, Janopaul-Naylor J, Rudra S, Yang X, Chang CW, Wang Y, Ma C, Patel SA, McDonald MW, Zhou J. Prediction of plan adaptation in head and neck cancer proton therapy using clinical, radiographic, and dosimetric features. Acta Oncol 2023:1-8. [PMID: 37335043 DOI: 10.1080/0284186x.2023.2224050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Because proton head and neck (HN) treatments are sensitive to anatomical changes, plan adaptation (re-plan) during the treatment course is needed for a significant portion of patients. We aim to predict re-plan at plan review stage for HN proton therapy with a neural network (NN) model trained with patients' dosimetric and clinical features. The model can serve as a valuable tool for planners to assess the probability of needing to revise the current plan. METHODS AND MATERIALS Mean beam dose heterogeneity index (BHI), defined as the ratio of the maximum beam dose to the prescription dose, plan robustness features (clinical target volume (CTV), V100 changes, and V100 > 95% passing rates in 21 robust evaluation scenarios), as well as clinical features (e.g., age, tumor site, and surgery/chemotherapy status) were gathered from 171 patients treated at our proton center in 2020, with a median age of 64 and stages from I-IVc across 13 HN sites. Statistical analyses of dosimetric parameters and clinical features were conducted between re-plan and no-replan groups. A NN was trained and tested using these features. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performance of the prediction model. A sensitivity analysis was done to determine feature importance. RESULTS Mean BHI in the re-plan group was significantly higher than the no-replan group (p < .01). Tumor site (p < .01), chemotherapy status (p < .01), and surgery status (p < .01) were significantly correlated to re-plan. The model had sensitivities/specificities of 75.0%/77.4%, respectively, and an area under the ROC curve of .855. CONCLUSION There are several dosimetric and clinical features that correlate to re-plans, and NNs trained with these features can be used to predict HN re-plans, which can be used to reduce re-plan rate by improving plan quality.
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Affiliation(s)
- D Bohannon
- Department of Nuclear and Radiological Engineering, Georgia institute of Technology, Atlanta, GA, USA
| | - J Janopaul-Naylor
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - S Rudra
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - X Yang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - C W Chang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Y Wang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - C Ma
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - S A Patel
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - M W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - J Zhou
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
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17
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Yang DS, McDonald CL, DiSilvestro KJ, Patel SA, Li NY, Cohen EM, Daniels AH. Risk of Dislocation and Revision Following Primary Total Hip Arthroplasty in Patients With Prior Lumbar Fusion With Spinopelvic Fixation. J Arthroplasty 2023; 38:700-705.e1. [PMID: 35337945 DOI: 10.1016/j.arth.2022.03.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The effect of spinopelvic fixation in addition to lumbar spinal fusion (LSF) on dislocation/instability and revision in patients undergoing primary total hip arthroplasty (THA) has not been reported previously. METHODS The PearlDiver Research Program was used to identify patients aged 30 and above undergoing primary THA who received (1) THA only, (2) THA with prior single-level LSF, (3) THA with prior 2-5 level LSF, or (4) THA with prior LSF with spinopelvic fixation. The incidence of THA revision and dislocation/instability was compared through logistic regression and Chi-squared analysis. All regressions were controlled for age, gender, and Elixhauser Comorbidity Index (ECI). RESULTS Between 2010 and 2018, 465,558 patients without history of LSF undergoing THA were examined and compared to 180 THA patients with prior spinopelvic fixation, 5,299 with prior single-level LSF, and 1,465 with prior 2-5 level LSF. At 2 years, 7.8% of THA patients with prior spinopelvic fixation, 4.7% of THA patients with prior 2-5 level LSF, 4.2% of THA patients with prior single-level LSF, and 2.2% of THA patients undergoing only THA had a dislocation event or instability (P < .0001). After controlling for length of fusion, pelvic fixation itself was associated with higher independent risk of revision (at 2 years: 2-5 level LSF + spinopelvic fixation: aHR = 3.15, 95% CI 1.77-5.61, P < .0001 vs 2-5 level LSF with no spinopelvic fixation: aOR = 1.39, 95% CI 1.10-1.76, P < .0001). CONCLUSION At 2 years, spinopelvic fixation in THA patients were associated with a greater than 3.5-fold increase in hip dislocation risk compared to those without LSF, and an over 2-fold increase in THA revision risk compared to those with LSF without spinopelvic fixation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Daniel S Yang
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christopher L McDonald
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kevin J DiSilvestro
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Shyam A Patel
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Neill Y Li
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Eric M Cohen
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
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Abstract
From a historic lens, treatment for patients with relapsed/refractory multiple myeloma (R/R MM) has advanced significantly since the advent of immunomodulatory agents (IMiDs) in the 1990s, proteasome inhibitors in the 2000s, monoclonal antibodies in the 2010s, and CAR-T treatments in the 2020s. However, the availability of multiple new therapies has also created significant ambiguity regarding therapy selection and sequencing, as consensus guidelines are limited, and cross-trial comparisons of the novel agents are challenging. In this focused review, we discuss the novel Food & Drug Administration (FDA)-approved medications for R/R MM, including the recently approved first-in-class BCMA-directed bispecific antibody teclistamab. We highlight the seminal clinical trials data and discuss optimal sequencing considerations based on the goal of treatment, with an emphasis on the two novel CAR-T cell products. We consider the limited tolerability of certain agents, prospects for our aging population, and financial aspects of these therapies. Finally, we spotlight ongoing trials involving promising agents making their way through the pharmacologic pipeline including the BCMA-directed bispecific antibody elranatamab and the GPRC5D-directed bispecific antibody talquetamab. We summarize our recommendations based on the best available evidence as we enter 2023.
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Affiliation(s)
- Benjamin Tanenbaum
- Department of Medicine, UMass Chan Medical School, UMass Memorial Medical Center, 55 Lake Ave. North, Worcester, MA, 01655, USA
| | - Timothy Miett
- Department of Medicine, UMass Chan Medical School, UMass Memorial Medical Center, 55 Lake Ave. North, Worcester, MA, 01655, USA
| | - Shyam A Patel
- Department of Medicine - Division of Hematology/Oncology, UMass Chan Medical School, UMass Memorial Medical Center, 55 Lake Ave. North, Worcester, MA, 01655, USA.
- Center for Clinical and Translational Science (CCTS), UMass Chan Medical School, 55 Lake Ave. North, Worcester, MA, 01655, USA.
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Glasser JL, Patel SA, Li NY, Patel RA, Daniels AH, Antoci V. Understanding Health Economics in Joint Replacement Surgery. Orthopedics 2022; 45:e174-e182. [PMID: 35394379 DOI: 10.3928/01477447-20220401-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The number of arthroplasty procedures has been rising at a significant rate, contributing to a notable portion of the nation's health care spending. This growth has contributed to an increase in the number of health care economic studies in the field of adult reconstruction surgery. Although these articles are filled with important information, they can be difficult to understand without a background in business or economics. The goal of this review is to define the common terminology used in health care economic studies, assess their value and benefit in the context of total joint arthroplasty, and highlight shortcomings in the current literature. [Orthopedics. 2022;45(4):e174-e182.].
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20
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Nuvvula S, Dahiya S, Patel SA. The Novel Therapeutic Landscape for Relapsed/Refractory Diffuse Large B Cell Lymphoma. Clin Lymphoma Myeloma Leuk 2022; 22:362-372. [PMID: 34922844 DOI: 10.1016/j.clml.2021.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/12/2022]
Abstract
Diffuse large B cell lymphoma (DLBCL) is an aggressive malignancy that has been traditionally treated with anthracycline-based chemotherapy, but approximately one-third of patients relapse after first-line therapy or have primary refractoriness. In this focused review, we discuss the 7 novel Food & Drug Administration (FDA)-approved medications for relapsed/refractory (R/R) DLBCL. We describe 5 CD19-targeted therapies, 3 of which are chimeric antigen receptor (CAR)-T cell therapies. We also highlight novel non-cell-based targeted therapies and discuss optimal sequencing considerations based on the goal of treatment, with an emphasis on CAR-T cell therapy as curative intent. We consider the limited tolerability of certain novel agents, prospects for elderly patients, and financial aspects of these approaches. We discuss advantages and limitations of these targeted therapies based on seminal clinical trials. Finally, we summarize ongoing trials involving promising agents making their way into the pharmacologic pipeline. These therapies include allogeneic CAR-T treatments and multi-antigen targeting therapies such as the CD19/CD22 CAR-T and the CD3/CD20 bispecific antibodies mosunetuzumab and odronextamab. We summarize our approach based on the best available evidence as we enter 2022.
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Affiliation(s)
- Sri Nuvvula
- Department of Medicine - Division of Hematology/Oncology, University of Massachusetts Chan Medical School, UMass Memorial Medical Center, Worcester, MA
| | - Saurabh Dahiya
- Department of Medicine - Division of Hematology/Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Shyam A Patel
- Department of Medicine - Division of Hematology/Oncology, University of Massachusetts Chan Medical School, UMass Memorial Medical Center, Worcester, MA.
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21
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Patel SA, Glasser J, Berns EM, Barrett CC, Jenkins D, Antoci V, Cohen E, Froehlich J. Applicant Ranking Criteria in Adult Reconstruction Fellowship: Your Interview Counts When Applying for Fellowship. Cureus 2021; 13:e20636. [PMID: 35103200 PMCID: PMC8783569 DOI: 10.7759/cureus.20636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/20/2022] Open
Abstract
Background The criteria for successful ranking in the fellowship match remains unclear. Although some data are available regarding the qualities sought after in medical students for the residency match, little information is available regarding the fellowship match. In this study, for arthroplasty applications to our institution, the interview was hypothesized to be the most important factor for ranking, with little impact from other commonly assessed variables. Methodology All 40 applicants who applied for fellowship were selected to interview for the 2017 Brown University Comprehensive Adult Reconstruction Fellowship and were evaluated on the interview, United States Medical Licensing Examination (USMLE) scores, letters of recommendation, personal statement, extracurricular activities, research, and caliber of undergraduate institution, medical school, and residency program. The interview score was based on a combined score of individual components of personality, program fit, and research. Results Of the 40 applicants who were interviewed, eight did not match. The interview score was the only statistically significant variable and had the highest correlation with ranking (r = 0.92). Moreover, extracurricular activities correlated with a higher ranking whereas USMLE Step 1/Step 2 scores had a relatively low correlation (r = 0.32 and 0.29, respectively). Recommendation letters and caliber of medical school, undergraduate education, and residency demonstrated low correlations. The personal statement and research components had the lowest correlations. Conclusions The combined interview score, in particular the personality and program fit components, was the most important determinant of successful ranking at our institution. Because all 40 applicants who applied for an arthroplasty fellowship at our institution were selected for an interview, there was no pre-interview selection bias that would confound these results. However, the ranking does not correlate with an applicant’s success in fellowship, and further research is required to determine the qualifications of a successful surgeon.
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22
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Hassan M, Awadalla M, Tan TC, Scherrer-Crosbie M, Zhang L, Zlotoff DA, Bany Bakar R, Hickey SB, Patel SA, Januzzi JL, Passeri JJ, Keane F, Jimenez R, MacDonald SM, Neilan TG. Serial measurement of global longitudinal strain among women with breast cancer treated with proton radiation therapy. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2850] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Conventional photon radiotherapy (RT) for breast cancer is associated with reduction in global longitudinal strain (GLS), an increase in both troponin and N-terminal pro-B type natriuretic peptide (NT-proBNP), and incident heart failure. The cardiac radiation exposure with proton-RT is reduced and, thus may be associated with less cardiotoxicity.
Objectives
To test the effect of proton-RT on GLS, troponin and NT-proBNP.
Methods
A prospective observational single center study of 69 women being treated with proton-RT for breast cancer. Serial measurements of GLS, high-sensitivity cardiac troponin-I (hs-cTnI), and NT-proBNP were performed at pre-specified intervals (pre proton-RT, 4 weeks after completion of proton-RT and again at 2 months post proton-RT).
Results
The mean age was 46±11 years, BMI was 25.6±5.2 kg/m2, 32% had hypertension and mean radiation dose to the heart and left ventricle (LV) were 0.44 Gy and 0.12 Gy respectively. There was no change in LV ejection fraction (pre proton-RT vs. 4-weeks post proton-RT vs. 2 months post proton-RT, 65±5 vs. 66±5 vs. 64±4%, p=0.15), global GLS (−21.7±2.7 vs. −22.7±2.3 vs. −22.8±2.1%, p=0.24) or segmental GLS from pre-to post proton-RT. Similarly, there was no change in hs-cTnI or NT-proBNP with proton-RT. However, post proton-RT, we found that patients with a history of hypertension had lower GLS when compared to women without hypertension (−21.3±3.5 vs. −24.0±2.4%, p=0.006).
Conclusion
Proton-RT did not impact LV function, or associate with an increase in biomarkers. These data support the potential cardiac benefits of proton-RT compared to conventional RT.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- M Hassan
- Massachusetts General Hospital - Harvard Medical School, Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Boston, United States of America
| | - M Awadalla
- Massachusetts General Hospital - Harvard Medical School, Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Boston, United States of America
| | - T C Tan
- Westmead and Blacktown Hospitals, University of Western Sydney and School of Medical Sciences, Division of Cardiology, Blacktown, Australia
| | - M Scherrer-Crosbie
- Hospital of the University of Pennsylvania, Cardiovascular Medicine Division, Philadelphia, United States of America
| | - L Zhang
- Massachusetts General Hospital - Harvard Medical School, Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Boston, United States of America
| | - D A Zlotoff
- Massachusetts General Hospital - Harvard Medical School, Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Boston, United States of America
| | - R Bany Bakar
- Massachusetts General Hospital - Harvard Medical School, Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Boston, United States of America
| | - S B Hickey
- Massachusetts General Hospital - Harvard Medical School, Radiation Oncology Department, Boston, United States of America
| | - S A Patel
- Massachusetts General Hospital - Harvard Medical School, Radiation Oncology Department, Boston, United States of America
| | - J L Januzzi
- Massachusetts General Hospital - Harvard Medical School, Division of Cardiology, Boston, United States of America
| | - J J Passeri
- Massachusetts General Hospital - Harvard Medical School, Division of Cardiology, Boston, United States of America
| | - F Keane
- Massachusetts General Hospital - Harvard Medical School, Radiation Oncology Department, Boston, United States of America
| | - R Jimenez
- Massachusetts General Hospital - Harvard Medical School, Radiation Oncology Department, Boston, United States of America
| | - S M MacDonald
- Massachusetts General Hospital - Harvard Medical School, Radiation Oncology Department, Boston, United States of America
| | - T G Neilan
- Massachusetts General Hospital - Harvard Medical School, Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Boston, United States of America
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23
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Patel SA, Lloyd MR, Cerny J, Shi Q, Simin K, Ediriwickrema A, Hutchinson L, Miron PM, Higgins AW, Ramanathan M, Gerber JM. Clinico-genomic profiling and clonal dynamic modeling of TP53-aberrant myelodysplastic syndrome and acute myeloid leukemia. Leuk Lymphoma 2021; 62:3348-3360. [PMID: 34496723 DOI: 10.1080/10428194.2021.1957869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
TP53-aberrant myelodysplastic syndrome and acute myeloid leukemia have dismal outcomes. Here, we define the clinico-genomic landscape of TP53 disruptions in 40 patients and employ clonal dynamic modeling to map the mutational hierarchy against clinical outcomes. Most TP53 mutations (45.2%) localized to the L3 loop or LSH motif of the DNA-binding domain. TP53 disruptions had high co-occurrence with mutations in epigenetic regulators, spliceosome machinery, and cohesin complex and low co-occurrence with mutations in proliferative signaling genes. Ancestral and descendant TP53 mutations constituted measurable residual disease and fueled relapse. High mutant TP53 gene dosage predicted low durability of remission. The median overall survival (OS) was 280 days. Hypomethylating agent-based therapy served as an effective bridge to transplant, leading to improved median OS compared to patients who did not receive a transplant (14.7 vs. 5.1 months). OS was independent of the genomic location of TP53 disruption, which has implications for rational therapeutic design.
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Affiliation(s)
- Shyam A Patel
- Department of Medicine-Hematology & Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Maxwell R Lloyd
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jan Cerny
- Department of Medicine-Hematology & Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Qiming Shi
- Department of Medicine-Hematology & Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Population & Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Karl Simin
- Department of Molecular, Cell & Cancer Biology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Asiri Ediriwickrema
- Division of Hematology, Department of Medicine, Institute for Stem Cell Biology & Regenerative Medicine, Stanford University, Stanford, CA, USA
| | - Lloyd Hutchinson
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Patricia M Miron
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Anne W Higgins
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Muthalagu Ramanathan
- Department of Medicine-Hematology & Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jonathan M Gerber
- Department of Medicine-Hematology & Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
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24
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Patel SA, Bledsoe JR, Higgins AW, Hutchinson L, Gerber JM. Rapid and Deep Remission Induced by Blinatumomab for CD19-Positive Chronic Myeloid Leukemia in Lymphoid Blast Phase. JCO Precis Oncol 2021; 5:PO.21.00039. [PMID: 34409243 PMCID: PMC8367045 DOI: 10.1200/po.21.00039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/10/2021] [Accepted: 06/03/2021] [Indexed: 01/13/2023] Open
Affiliation(s)
- Shyam A Patel
- Department of Medicine-Hematology/Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA
| | - Jacob R Bledsoe
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA
| | - Anne W Higgins
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA
| | - Lloyd Hutchinson
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA
| | - Jonathan M Gerber
- Department of Medicine-Hematology/Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA
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25
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Patel SA, Dalela D, Fan AC, Lloyd MR, Zhang TY. Niche-directed therapy in acute myeloid leukemia: optimization of stem cell competition for niche occupancy. Leuk Lymphoma 2021; 63:10-18. [PMID: 34407733 DOI: 10.1080/10428194.2021.1966779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute myeloid leukemia (AML) is an aggressive malignancy of stem cell origin that contributes to significant morbidity and mortality. The long-term prognosis remains dismal given the high likelihood for primary refractory or relapsed disease. An essential component of relapse is resurgence from the bone marrow. To date, the murine hematopoietic stem cell (HSC) niche has been clearly defined, but the human HSC niche is less well understood. The design of niche-based targeted therapies for AML must account for which cellular subsets compete for stem cell occupancy within respective bone marrow microenvironments. In this review, we highlight the principles of stem cell niche biology and discuss translational insights into the AML microenvironment as of 2021. Optimization of competition for niche occupancy is important for the elimination of measurable residual disease (MRD). Some of these novel therapeutics are in the pharmacologic pipeline for AML and may be especially useful in the setting of MRD.
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Affiliation(s)
- Shyam A Patel
- Department of Medicine - Division of Hematology & Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Disha Dalela
- Department of Medicine - Division of Hematology & Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Amy C Fan
- Immunology Graduate Program, Stanford University School of Medicine, Stanford, CA, USA
| | - Maxwell R Lloyd
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tian Y Zhang
- Department of Medicine, Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
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26
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Patel SA, Litzow MR, Cerny J. Targeted and cytotoxic therapies as maintenance treatment for non-transplant eligible patients with acute myeloid leukemia. Blood Rev 2021; 50:100863. [PMID: 34210571 DOI: 10.1016/j.blre.2021.100863] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
In the recent years, there have been multiple approvals by the Food and Drug Administration (FDA) for therapeutics for acute myeloid leukemia (AML). The role of maintenance therapy in AML has been rather unrealized mostly due to lack of efficacy and increased toxicity of classical chemotherapy agents. Many clinical trials have demonstrated a disease-free survival benefit for various therapeutics in the maintenance setting for patients with AML who are ineligible for stem cell transplant. Notably, oral hypomethylating agent therapy has recently shown an overall survival and disease-free survival benefit in the maintenance setting for AML. In this review, we summarize the relevant data on maintenance therapy with a specific focus on cytotoxic antimetabolite chemotherapeutics, hypomethylating agents, targeted agents, and immunotherapeutics. We discuss our approach to maintenance therapy in AML in 2021 and propose a measurable residual disease (MRD)-adapted, personalized approach based on the best available evidence.
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Affiliation(s)
- Shyam A Patel
- Deparment of Medicine, Division of Hematology/Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mark R Litzow
- Division of Hematology and Transplant Center, Mayo Clinic, Rochester, MN, USA
| | - Jan Cerny
- Deparment of Medicine, Division of Hematology/Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA.
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27
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Wang X, Patel SA, Haddadin M, Cerny J. Post-allogeneic hematopoietic stem cell transplantation viral reactivations and viremias: a focused review on human herpesvirus-6, BK virus and adenovirus. Ther Adv Infect Dis 2021; 8:20499361211018027. [PMID: 34104434 PMCID: PMC8155777 DOI: 10.1177/20499361211018027] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/27/2021] [Indexed: 12/30/2022] Open
Abstract
Human cytomegalovirus and Epstein-Barr virus have been recognized as potential drivers of morbidity and mortality of patients undergoing allogeneic stem cell transplantation for years. Specific protocols for monitoring, prophylaxis and pre-emptive therapy are in place in many transplant settings. In this review, we focus on the next three most frequent viruses, human herpesvirus-6, BK virus and adenovirus, causing reactivation and/or viremia after allogeneic transplant, which are increasingly detected in patients in the post-transplant period owing to emerging techniques of molecular biology, recipients' characteristics, treatment modalities used for conditioning and factors related donors or stem cell source. Given the less frequent detection of an illness related to these viruses, there are often no specific protocols in place for the management of affected patients. While some patients develop significant morbidity (generally older), others may not need therapy at all (generally younger or children). Furthermore, some of the antiviral therapies used are potentially toxic. With the addition of increased risk of secondary infections, risk of graft failure or increased risk of graft-versus-host disease as well as the relationship with other post-transplant complications, the outcomes of patients with these viremias remain unsatisfactory and even long-term survivors experience increased morbidity.
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Affiliation(s)
- Xin Wang
- Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Shyam A Patel
- Division of Hematology-Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Michael Haddadin
- Division of Hematology-Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Jan Cerny
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA, 01655, USA
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28
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Abstract
» The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. » Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. » Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. » Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. » Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.
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Affiliation(s)
| | | | - Neill Y Li
- Rhode Island Hospital, Providence, Rhode Island
| | | | | | - Jeffrey A Rihn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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29
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Sandiford OA, Donnelly RJ, El-Far MH, Burgmeyer LM, Sinha G, Pamarthi SH, Sherman LS, Ferrer AI, DeVore DE, Patel SA, Naaldijk Y, Alonso S, Barak P, Bryan M, Ponzio NM, Narayanan R, Etchegaray JP, Kumar R, Rameshwar P. Mesenchymal Stem Cell-Secreted Extracellular Vesicles Instruct Stepwise Dedifferentiation of Breast Cancer Cells into Dormancy at the Bone Marrow Perivascular Region. Cancer Res 2021; 81:1567-1582. [PMID: 33500249 DOI: 10.1158/0008-5472.can-20-2434] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/16/2020] [Accepted: 01/19/2021] [Indexed: 11/16/2022]
Abstract
In the bone marrow (BM), breast cancer cells (BCC) can survive in dormancy for decades as cancer stem cells (CSC), resurging as tertiary metastasis. The endosteal region where BCCs exist as CSCs poses a challenge to target them, mostly due to the coexistence of endogenous hematopoietic stem cells. This study addresses the early period of dormancy when BCCs enter BM at the perivascular region to begin the transition into CSCs, which we propose as the final step in dormancy. A two-step process comprises the Wnt-β-catenin pathway mediating BCC dedifferentiation into CSCs at the BM perivascular niche. At this site, BCCs responded to two types of mesenchymal stem cell (MSC)-released extracellular vesicles (EV) that may include exosomes. Early released EVs began the transition into cycling quiescence, DNA repair, and reorganization into distinct BCC subsets. After contact with breast cancer, the content of EVs changed (primed) to complete dedifferentiation into a more homogeneous population with CSC properties. BCC progenitors (Oct4alo), which are distant from CSCs in a hierarchical stratification, were sensitive to MSC EVs. Despite CSC function, Oct4alo BCCs expressed multipotent pathways similar to CSCs. Oct4alo BCCs dedifferentiated and colocalized with MSCs (murine and human BM) in vivo. Overall, these findings elucidate a mechanism of early dormancy at the BM perivascular region and provide evidence of epigenome reorganization as a potential new therapy for breast cancer. SIGNIFICANCE: These findings describe how the initial process of dormancy and dedifferentiation of breast cancer cells at the bone marrow perivascular niche requires mesenchymal stem cell-derived exosomes, indicating a potential target for therapeutic intervention.
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Affiliation(s)
- Oleta A Sandiford
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey.,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Robert J Donnelly
- Deptartment of Pathology, Immunology and Laboratory Medicine, New Jersey Medical School, Newark, New Jersey
| | - Markos H El-Far
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey.,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Lisa M Burgmeyer
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey.,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Garima Sinha
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey.,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sri Harika Pamarthi
- Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Lauren S Sherman
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey.,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alejandra I Ferrer
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey.,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Dariana E DeVore
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey
| | - Shyam A Patel
- Deptartment of Medicine-Hematology/Oncology, University of Massachusetts Medical School, University of Massachusetts Memorial Center, Worcester, Massachusetts
| | - Yahaira Naaldijk
- Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sara Alonso
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey.,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Margarette Bryan
- Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Nicholas M Ponzio
- Deptartment of Pathology, Immunology and Laboratory Medicine, New Jersey Medical School, Newark, New Jersey
| | | | | | - Rakesh Kumar
- Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey.,Cancer Biology Program, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Pranela Rameshwar
- Rutgers School of Graduate Studies at New Jersey Medical School, Newark, New Jersey. .,Deptartment of Medicine-Hematology/Oncology, Rutgers New Jersey Medical School, Newark, New Jersey
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30
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Azizi A, Ediriwickrema A, Dutta R, Patel SA, Shomali W, Medeiros B, Iberri D, Gotlib J, Mannis G, Greenberg P, Majeti R, Zhang T. Venetoclax and hypomethylating agent therapy in high risk myelodysplastic syndromes: a retrospective evaluation of a real-world experience. Leuk Lymphoma 2020; 61:2700-2707. [PMID: 32543932 DOI: 10.1080/10428194.2020.1775214] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Treatment with hypomethylating agents (HMAs) azacitidine or decitabine is the current standard of care for high risk myelodysplastic syndromes (MDSs) but is associated with low rates of response. The limited number of treatment options for patients with high risk MDS highlights a need for new therapeutic options. Venetoclax is an inhibitor of the BCL-2 protein which, when combined with an HMA, has shown high response rates in unfit and previously untreated acute myeloid leukemia. We performed a retrospective study of high risk MDS patients receiving combination HMA plus venetoclax in order to determine their effectiveness in this context. We show that in our cohort, the combination results in high response rates but is associated with a high frequency of myelosuppression. These data highlight the efficacy of combination HMA plus venetoclax in high risk MDS, warranting further prospective evaluation in clinical trials.
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Affiliation(s)
- Armon Azizi
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Asiri Ediriwickrema
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Ritika Dutta
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Shyam A Patel
- Department of Medicine, Division of Hematology-Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - William Shomali
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Bruno Medeiros
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - David Iberri
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Jason Gotlib
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Gabriel Mannis
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Peter Greenberg
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Ravindra Majeti
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
| | - Tian Zhang
- Department of Medicine, Division of Hematology, Cancer Institute, Stanford University, Stanford, CA, USA
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Shah MK, Kondal D, Patel SA, Singh K, Devarajan R, Shivashankar R, Ajay VS, Menon VU, Varthakavi PK, Viswanathan V, Dharmalingam M, Bantwal G, Sahay RK, Masood MQ, Khadgawat R, Desai A, Prabhakaran D, Narayan KMV, Tandon N, Ali MK. Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial. Diabet Med 2020; 37:1825-1831. [PMID: 31479537 PMCID: PMC7051882 DOI: 10.1111/dme.14124] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2019] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care. METHODS Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol. RESULTS Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively]. CONCLUSIONS The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.
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Affiliation(s)
- M K Shah
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - D Kondal
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - S A Patel
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - K Singh
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - R Devarajan
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - R Shivashankar
- Centre for Chronic Disease Control India, Public Health Foundation of India, Gurgaon, India
| | - V S Ajay
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - V U Menon
- Department of Endocrinology and Diabetes, Amrita Institute of Medical Sciences, Kerala, India
| | - P K Varthakavi
- Department of Endocrinology, TNM College and BYL Nair Charity Hospital, Mumbai, India
| | - V Viswanathan
- MV Hospital for Diabetes & Diabetes Research Centre, Chennai, India
| | - M Dharmalingam
- Bangalore Endocrinology and Diabetes Research Centre, Karnataka, India
| | - G Bantwal
- Department of Endocrinology, St John's Medical College and Hospital, Karnataka, India
| | - R K Sahay
- Department of Endocrinology, Osmania General Hospital, Hyderabad, India
| | - M Q Masood
- Department of Medicine, Section of Endocrinology and Diabetes, Aga Khan University, Karachi, Pakistan
| | - R Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - A Desai
- Department of Medicine Endocrine Unit, Goa Medical College, Goa, India
| | - D Prabhakaran
- Department of Medicine Endocrine Unit, Goa Medical College, Goa, India
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - K M V Narayan
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N Tandon
- Department of Medicine, Section of Endocrinology and Diabetes, Aga Khan University, Karachi, Pakistan
| | - M K Ali
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Yang DS, Patel SA, DiSilvestro KJ, Li NY, Daniels AH. Postoperative complication rates and hazards-model survival analysis of revision surgery following occipitocervical and atlanto-axial fusion. North American Spine Society Journal (NASSJ) 2020; 3:100017. [PMID: 35141587 PMCID: PMC8820023 DOI: 10.1016/j.xnsj.2020.100017] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/01/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022]
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Daniel S. Yang
- Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Shyam A. Patel
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Kevin J. DiSilvestro
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Neill Y. Li
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
- Corresponding author at: Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Avenue, East Providence, RI 02914, United States.
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Patel SA, Li NY, Yang DS, Reid DBC, Disilvestro KJ, Babu JM, Kuris EO, Barrett T, Daniels AH. Patients Who Undergo Primary Lumbar Spine Fusion After Recent but Not Remote Total Hip Arthroplasty Are at Increased Risk for Complications, Revision Surgery, and Prolonged Opioid Use. World Neurosurg 2020; 144:e523-e532. [PMID: 32891851 DOI: 10.1016/j.wneu.2020.08.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease. METHODS A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA> 2 years previously, and 3) patients with a history of LSF after having recent THA <2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use. RESULTS Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P < 0.0001; hazard ratio, 1.69; P < 0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120). CONCLUSIONS Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (<2 years).
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Affiliation(s)
- Shyam A Patel
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA.
| | - Neill Y Li
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Daniel S Yang
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Daniel B C Reid
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kevin J Disilvestro
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jacob M Babu
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Eren O Kuris
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Tom Barrett
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
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Johnson JR, Babu JM, Durand WM, Eltorai AEM, Patel SA, Daniels AH. Recognition and Management of Emergent Spinal Pathology Among First-Line Providers. Orthopedics 2020; 43:e244-e250. [PMID: 32271932 DOI: 10.3928/01477447-20200404-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/15/2019] [Indexed: 02/03/2023]
Abstract
Spinal emergencies require prompt identification, management, and surgical referral (if needed) from first-line providers. Diagnostic delays from a failure to recognize emergency conditions can lead to adverse patient outcomes. The objective of this study was to understand the proficiency with which first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This was a cross-sectional analysis of 143 internal medicine, family medicine, emergency care, and neurology questionnaires collected at a single-site academic center. Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Only 35.0% (n=50) of respondents felt "very prepared" to handle spinal emergencies. Bivariate analyses revealed interdepartmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (P<.0001), epidural abscess (P=.0002), and cervical myelopathy (P<.0001). Following pairwise comparisons of interdepartmental differences, emergency medicine statistically outperformed internal medicine (P=.0007) and neurology (P<.0001) on initial management of lumbar radiculopathy, while also having markedly higher success in identifying and managing epidural abscess with respect to family medicine (P<.0001). The likelihood of appropriate initial treatment of cervical myelopathy was significantly higher for neurology than for emergency medicine (P<.0001). A minority of first-line providers reported being very prepared to handle spinal emergencies. Disparities exist between first-line provider specialties regarding clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. Because appropriate handling of emergent spinal pathologies is essential to patient outcomes and optimal resource use, measures should be taken to further educate first-line providers regarding the spinal conditions they will be treating. [Orthopedics. 2020;43(4):e244-e250.].
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Nehser M, Dark J, Schweitzer D, Campbell M, Zwicker J, Hitt DM, Little H, Diaz-Correa A, Holley DC, Patel SA, Thompson CM, Bridges RJ. System X c- Antiporter Inhibitors: Azo-Linked Amino-Naphthyl-Sulfonate Analogues of Sulfasalazine. Neurochem Res 2020; 45:1375-1386. [PMID: 31754956 PMCID: PMC10688270 DOI: 10.1007/s11064-019-02901-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 09/17/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/18/2023]
Abstract
The cystine/glutamate antiporter system Xc- (SXc-) mediates the exchange of intracellular L-glutamate (L-Glu) with extracellular L-cystine (L-Cys2). Both the import of L-Cys2 and the export of L-Glu take on added significance in CNS cells, especially astrocytes. When the relative activity of SXc- overwhelms the regulatory capacity of the EAATs, the efflux of L-Glu through the antiporter can be significant enough to trigger excitotoxic pathology, as is thought to occur in glioblastoma. This has prompted considerable interest in the pharmacological specificity of SXc- and the development of inhibitors. The present study explores a series of analogues that are structurally related to sulfasalazine, a widely employed inhibitor of SXc-. We identify a number of novel aryl-substituted amino-naphthylsulfonate analogues that inhibit SXc- more potently than sulfasalazine. Interestingly, the inhibitors switch from a competitive to noncompetitive mechanism with increased length and lipophilic substitutions, a structure-activity relationship that was previously observed with aryl-substituted isoxazole. These results suggest that the two classes of inhibitors may interact with some of the same domains on the antiporter protein and that the substrate and inhibitor binding sites may be in close proximity to one another. Molecular modeling is used to explore this possibility.
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Affiliation(s)
- M Nehser
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - J Dark
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - D Schweitzer
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - M Campbell
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - J Zwicker
- Deciphera Pharmaceuticals, Lawrence, KA, 66044, USA
| | - D M Hitt
- Chemistry Department, Carroll College, Helena, MT, 56925, USA
| | - H Little
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - A Diaz-Correa
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - D C Holley
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - S A Patel
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - C M Thompson
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA
| | - R J Bridges
- Department of Biomedical and Pharmaceutical Science, Center for Structural and Functional Neuroscience, Skaggs School of Pharmacy, University of Montana, Missoula, MT, 59812, USA.
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Abstract
Adult spinal deformity (ASD) is a challenging problem for spine surgeons given the high risk of complications, both medical and surgical.
Surgeons should have a high index of suspicion for medical complications, including cardiac, pulmonary, thromboembolic, genitourinary and gastrointestinal, renal, cognitive and psychiatric, and skin conditions, in the perioperative period and have a low threshold for involving specialists.
Surgical complications, including neurologic injuries, vascular injuries, proximal junctional kyphosis, durotomy, and pseudarthrosis and rod fracture, can be devastating for the patient and costly to the health-care system. Mortality rates have been reported to be between 1.0% and 3.5% following ASD surgery. With the increasing rate of ASD surgery, surgeons should properly counsel patients about these risks and have a high index of suspicion for complications in the perioperative period.
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Patel SA, Gerber JM. A User's Guide to Novel Therapies for Acute Myeloid Leukemia. Clin Lymphoma Myeloma Leuk 2020; 20:277-288. [PMID: 32113891 DOI: 10.1016/j.clml.2020.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 01/01/2023]
Abstract
Few diseases have been marked by a 40-year period of stagnation with regard to therapeutic advances and United States Food and Drug Administration (FDA) approvals, as has been the case for acute myeloid leukemia (AML). Cytarabine and anthracyclines were introduced for the treatment of AML in the 1970s, and in the ensuing 4 decades, the pharmacologic pipeline has experienced a standstill. The absence of FDA approvals in AML is not a reflection of the lack of understanding of the disease biology. The field has seen major advances from the standpoint of stem cell biology and clonal evolution, and the field has also seen some therapeutic advances, but these therapeutic advances have arisen from optimization of the same traditional cytotoxic chemotherapeutics rather than the development of novel therapies. The year 2017 marked a turning point with regard to FDA approvals. This review summarizes the salient clinical trials that led to the approval of 8 novel agents in AML in the past 2 years. For these agents, the clinical activity is often defined by specific molecular aberrations or metabolic features of AML cells. We also emphasize the principles of management of AML in the current era of genomic medicine, with a focus on considerations for targeting mutation-specific vulnerabilities in select patients. This review also highlights unique challenges to the use of novel agents in 2020, including considerations of curative potential with regards to bridging to allogeneic stem cell transplant, tolerability, financial toxicities, and microenvironmental hurdles. Finally, we discuss prospects on future immunotherapeutic investigational agents in the pharmacologic pipeline.
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Affiliation(s)
- Shyam A Patel
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA
| | - Jonathan M Gerber
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA.
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Reid DBC, Patel SA, Shah KN, Shapiro BH, Ruddell JH, Akelman E, Palumbo MA, Daniels AH. Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion. Spine J 2020; 20:69-77. [PMID: 31487559 DOI: 10.1016/j.spinee.2019.08.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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: 06/08/2019] [Revised: 08/14/2019] [Accepted: 08/23/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Since 2016, 35 of 50 US states have passed opioid-limiting laws. The impact on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) remains unknown. PURPOSE To evaluate the effect of opioid-limiting regulations on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions, and reoperations following elective ACDF. STUDY DESIGN/SETTING Retrospective review of prospectively-collected data. PATIENT SAMPLE Two hundred and eleven patients (101 pre-law, 110 post-law) undergoing primary elective 1-3 level ACDF during specified pre-law (December 1st, 2015-June 30th, 2016) and post-law (June 1st, 2017-December 31st, 2017) study periods were evaluated. METHODS Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) filled was compared at 30-day postoperative intervals, before and after stratification by preoperative opioid-tolerance. Thirty- and 90-day ED visit, readmission, and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated. RESULTS Demographic, medical, and surgical factors were similar pre-law versus post-law (all p>.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 vs. 62.08 pills, p<.001; 202.23 vs. 549.18 MMEs, p<.001) and in their first 30 postoperative days (cumulative 30-day MMEs 444.14 vs. 877.87, p<.001). Furthermore, post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 vs. 632.20 MMEs, p<.001) and opioid-tolerant (730.08 vs. 1,122.90 MMEs, p=.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period, preoperative opioid exposure, preoperative benzodiazepine exposure, and number of levels fused (all p<.05). Chronic (>90 day) opioid requirements were associated with preoperative opioid exposure (odds ratio 4.42, p<.001) but not with pre/post-law status (p>.05). Pre- and post-law patients were similar in terms of 30- or 90-day ED visits, unplanned readmissions, and reoperations (all p>.05). CONCLUSIONS Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain.
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Affiliation(s)
- Daniel B C Reid
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA.
| | - Shyam A Patel
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA
| | - Kalpit N Shah
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA
| | - Benjamin H Shapiro
- Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA
| | - Jack H Ruddell
- Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA
| | - Edward Akelman
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA
| | - Mark A Palumbo
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA
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Li NY, Patel SA, Durand WM, Ready LV, Owens BD, Daniels AH. Increased Risk of Chronic Opioid Use and Revision After Anterior Cervical Diskectomy and Fusion in Patients with Prior Shoulder Arthroscopy. World Neurosurg 2019; 135:e202-e208. [PMID: 31786377 DOI: 10.1016/j.wneu.2019.11.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to compare differences in the outcomes of patients who undergo anterior cervical diskectomy and fusion (ACDF) with and without a history of shoulder arthroscopy. METHODS The PearlDiver Patient Records Database (www.peardiverinc.com) from 2007 to 2017 was used to query patients by Current Procedural Terminology, isolating those who underwent ACDF with and without prior shoulder arthroscopy. Postoperative complications within 30 days of the index procedure, opioid use, and revision procedures were assessed for each cohort using ICD-9/10 and Current Procedural Terminology coding. RESULTS A total of 39,969 ACDF patients were queried, of which 38,859 (97.2%) underwent ACDF alone and 1110 (2.8%) underwent ACDF with prior shoulder arthroscopy. ACDF revision rates were significantly greater in patients with prior shoulder arthroscopy compared with ACDF alone (5.8% vs. 3.6%, aOR = 1.64, P = 0.0002). Patients with prior shoulder arthroscopy were also significantly more likely to fill opioid prescriptions at 3 months (aOR 1.19, P = 0.02), 6 months (aOR 1.22, P = 0.01), and 12 months (aOR 1.18, P = 0.04). CONCLUSIONS Patients who undergo ACDF with a prior shoulder arthroscopy have significantly greater revision rates, respiratory complications, and prolonged opioid use compared with patients without prior shoulder arthroscopy. With efforts to limit narcotic use and the importance of maximizing patient satisfaction, this analysis improves on the surgeon's ability to set expectations and postoperative plans for patients undergoing ACDF who have a history of shoulder arthroscopy.
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Affiliation(s)
- Neill Y Li
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Shyam A Patel
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Wesley M Durand
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lauren V Ready
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Affiliation(s)
- Shyam A Patel
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
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Gao B, Dwivedi S, Patel SA, Nwizu C, Cruz AI. Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures in Pediatric and Adolescent Patients: A Systematic Review and Meta-Analysis. J Orthop Trauma 2019; 33:e439-e446. [PMID: 31633645 DOI: 10.1097/bot.0000000000001580] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to systematically review and quantitatively analyze outcomes in operative versus nonoperative management of displaced midshaft clavicle fractures in pediatric and adolescent patients. DATA SOURCES Using the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, systematic searches of PubMed and EMBASE were conducted to identify English-language studies reporting outcomes in displaced pediatric midshaft clavicle fractures from 1997 to 2018. STUDY SELECTION Studies that reported on outcomes of operative and/or nonoperative treatment of displaced midshaft clavicle fractures in patients younger than 19 years were included. DATA EXTRACTION Patient and treatment characteristics, union rates, time to union, time to return to activity, patient-reported outcome measures, and complications were extracted. DATA SYNTHESIS All extracted data were recorded and qualitatively compared. QuickDASH (Quick Disabilities of the Arm, Shoulder, and Hand) scores and Constant scores were pooled using random-effects modeling and compared among studies, which adequately reported data for hypothesis testing. CONCLUSIONS Three thousand eight hundred ten articles were identified, and 12 met inclusion criteria. These studies encompassed 497 patients with an average age of 14.1 years (8-18 years, range). Both operative and nonoperative management of displaced midshaft clavicle fractures in this population provide excellent rates of union and patient-reported outcome measures. Compared with nonoperative management, operative management yielded faster return to activity, superior Constant scores, and equal QuickDASH scores. Operative management had higher complication rates and complications that required secondary operative treatment (mostly related to implant prominence). LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Burke Gao
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Shashank Dwivedi
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Shyam A Patel
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Chibuikem Nwizu
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
- Department of Orthopaedic Surgery, Hasbro Children's Hospital, Providence, RI
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Daniels AH, Patel SA, Reid DBC, Gao B, Kuris EO, Babu JM, Depasse JM. Proximal junctional failure prevention in adult spinal deformity surgery utilizing interlaminar fixation constructs. Orthop Rev (Pavia) 2019; 11:8068. [PMID: 31210915 PMCID: PMC6551454 DOI: 10.4081/or.2019.8068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/09/2019] [Indexed: 11/23/2022] Open
Abstract
Proximal junctional kyphosis (PJK) is a common complication following fusion for Adult Spinal Deformity. PJK and proximal junctional failure (PJF) may lead to pain, neurological injury, reoperation, and increased healthcare costs. Efforts to prevent PJK and PJF have aimed to preserve or reconstruct the posterior spinal tension band and/or modifying instrumentation to allow for more gradual transitions in stiffness at the cranial end of long spinal constructs. We describe placement of an interlaminar fixation construct at the upper instrumented vertebra which may decrease PJK/PJF severity, and is placed with little additional operative time and minimal posterior soft tissue trauma.
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Affiliation(s)
- Alan H Daniels
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Shyam A Patel
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Daniel B C Reid
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Burke Gao
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Eren O Kuris
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Jacob M Babu
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - J Mason Depasse
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
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Eltorai AEM, Martin TJ, Patel SA, Tran M, Eltorai AS, Daniels AH, Baird GL. Visual Obstruction of Flow Indicator Increases Inspiratory Volumes in Incentive Spirometry. Respir Care 2019; 64:590-594. [DOI: 10.4187/respcare.06331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Permanent neurologic sequela and even death can result if delays in appropriate treatment occur. A focused, critical review of 34 peer-reviewed articles was performed to identify current data about accurate diagnosis of spinal emergencies. This review highlights the key features of these 3 pathological entities with an emphasis on appropriate diagnostic strategy to intervene efficiently and minimize morbidity.
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Affiliation(s)
- Jacob M Babu
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI.
| | - Shyam A Patel
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Mark A Palumbo
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Alan H Daniels
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
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Martin TJ, Patel SA, Tran M, Eltorai AS, Daniels AH, Eltorai AEM. Patient Factors Associated with Successful Incentive Spirometry. R I Med J (2013) 2018; 101:14-18. [PMID: 30384513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Incentive spirometers (IS) are commonly prescribed after various surgical procedures with the intended effect of reducing postoperative pulmonary complications. Factors associated with correct use of IS by postoperative patients has not previously been studied. METHODS A cross-sectional analysis of postoperative patients was completed to assess whether patients knew how to correctly inhale on their IS. For each patient, the following variables were collected: whether the device was within arm's reach of the patient, if the patient reported having used their IS, if they considered the IS to be helpful, and if they felt more confident using IS after a brief educational intervention was performed by study investigators. RESULTS A total of 26.2% (11/42) of patients failed to use their IS correctly, and 38.1% (16/42) denied ever using the device in their postoperative care. Device location, perceived benefit, and previous use were identified as statistically significant determinants of successful use. Following a brief educational intervention by a physician, 73.8% (31/42) of patients were more confident in their ability to use IS during the remainder of their care. DISCUSSION A substantial portion of postoperative patients failed to correctly utilize their IS. Device proximity to the patient, patient perspectives on potential benefits of IS, and previous use of the device may affect correct use. Patient education and optimization of device placement should be considered to increase compliance during IS implementation.
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Affiliation(s)
- Thomas J Martin
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Shyam A Patel
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Megan Tran
- Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Alan H Daniels
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Adam E M Eltorai
- Warren Alpert Medical School of Brown University, Providence, RI
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Eltorai AEM, Baird GL, Pangborn J, Eltorai AS, Antoci V, Paquette K, Connors K, Barbaria J, Smeals KJ, Riley B, Patel SA, Agarwal S, Healey TT, Ventetuolo CE, Sellke FW, Daniels AH. Financial Impact of Incentive Spirometry. Inquiry 2018; 55:46958018794993. [PMID: 30175643 PMCID: PMC6122234 DOI: 10.1177/0046958018794993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite largely unproven clinical effectiveness, incentive spirometry (IS) is widely used in an effort to reduce postoperative pulmonary complications. The objective of the study is to evaluate the financial impact of implementing IS. The amount of time nurses and RTs spend each day doing IS-related activities was assessed utilizing an online survey distributed to the relevant national nursing and respiratory therapists (RT) societies along with questionnaire that was prospectively collected every day for 4 weeks at a single 10-bed cardiothoracic surgery step-down unit. Cost of RT time to teach IS use to patients and cost of nurse time spent reeducating and reminding patients to use IS were used to calculate IS implementation cost estimates per patient. Per-patient cost of IS implementation ranged from $65.30 to $240.96 for a mean 9-day step-down stay. For the 566 patients who stayed in the 10-bed step-down in 2016, the total estimated cost of implementing IS ranged from $36 959.80 to $136 383.36. Using national survey workload data, per-patient cost of IS implementation costed $107.36 (95% confidence interval [CI], $97.88-$116.98) for a hospital stay of 4.5 days. For the 9.7 million inpatient surgeries performed annually in the United States, the total annual cost of implementing postoperative IS is estimated to be $1.04 billion (95% CI, $949.4 million-$1.13 billion). The cost of implementing IS is substantial. Further efficacy studies are necessary to determine whether the cost is justifiable.
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Affiliation(s)
- Adam E M Eltorai
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Grayson L Baird
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA.,2 Rhode Island Hospital, Providence, USA
| | - Joshua Pangborn
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Valentin Antoci
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | | | | | | | - Shyam A Patel
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Saurabh Agarwal
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Terrance T Healey
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey E Ventetuolo
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA.,2 Rhode Island Hospital, Providence, USA
| | - Frank W Sellke
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Patel SA, Longacre TA, Ladabaum U, Lebensohn A, Lin AY, Haraldsdottir S. Tumor Molecular Testing Guides Anti-PD-1 Therapy and Provides Evidence for Pathogenicity of Mismatch Repair Variants. Oncologist 2018; 23:1395-1400. [PMID: 30072391 DOI: 10.1634/theoncologist.2018-0108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/07/2018] [Accepted: 05/15/2018] [Indexed: 12/27/2022] Open
Abstract
Lynch syndrome is characterized by germline abnormalities in mismatch repair (MMR) genes, leading to predisposition to multiple cancers [1]. A second hit to the unaffected allele is required for tumorigenesis. MMR proteins repair incorrectly paired nucleotides and prevent generation of insertions and deletions at microsatellites [2]. Aberrancies in these MMR proteins can be a result of germline mutations or somatic alterations. Defective MMR results in microsatellite instability (MSI) and a high mutational burden [3].The clinical implications of MSI are becoming readily apparent, as presence of MSI leads to the generation of neoantigens, stimulating tumor-associated lymphocytes [4], [5]. This has led to the use of programmed cell death protein 1 blockade for MMR-deficient tumors [6]. The U.S. Food and Drug Administration recently approved pembrolizumab for any advanced solid tumor demonstrating MSI and nivolumab for metastatic MSI colorectal cancer. However, the clinical significance of numerous MMR gene variants remains uncertain. The International Society for Gastrointestinal Hereditary Tumors classification system categorizes 2,360 MMR variants, which can be used to gauge pathogenicity [7]. There are many variants of uncertain significance (VUS; or class 3) for which clinicians are unable to provide recommendations. In this study, we employed the combination of germline testing and tumor mutational assessment to help discern the clinical relevance of VUS and guide immunotherapeutic decisions. KEY POINTS: A clinical dilemma arises when genomic testing yields variants of uncertain significance (VUS).Germline VUS were identified in two patients with gastrointestinal malignancies, but only one patient had a second-hit mutation in a mismatch repair gene leading to mismatch repair deficiency that conferred response to immunotherapy.The combination of germline testing along with tumor mutational assessment can help discern the clinical relevance of VUS and can help guide therapeutic decision-making toward individualized patient care.
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Affiliation(s)
- Shyam A Patel
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, California, USA
| | - Teri A Longacre
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology & Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Alexandra Lebensohn
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, California, USA
| | - Albert Y Lin
- Division of Oncology, Department of Internal Medicine, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Sigurdis Haraldsdottir
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, California, USA
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Affiliation(s)
- Shyam A. Patel
- Department of Medicine, Divisions of Hematology and Oncology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
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Patel SA, Mahmood SS, Nguyen T, Yeap BY, Jimenez RB, Taghian AG, Meyersohn NM, Neilan TG, MacDonald SM. Abstract P2-11-04: Not presented. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p2-11-04] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
This abstract was not presented at the symposium.
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Affiliation(s)
- SA Patel
- Massachusetts General Hospital, Boston, MA
| | - SS Mahmood
- Massachusetts General Hospital, Boston, MA
| | - T Nguyen
- Massachusetts General Hospital, Boston, MA
| | - BY Yeap
- Massachusetts General Hospital, Boston, MA
| | - RB Jimenez
- Massachusetts General Hospital, Boston, MA
| | - AG Taghian
- Massachusetts General Hospital, Boston, MA
| | | | - TG Neilan
- Massachusetts General Hospital, Boston, MA
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