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Jen WY, Konopleva M, Pemmaraju N. Tagraxofusp, a first-in-class CD123-targeted agent: Five-year postapproval comprehensive review of the literature. Cancer 2024. [PMID: 38620053 DOI: 10.1002/cncr.35315] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 04/17/2024]
Abstract
Tagraxofusp is a first-in-class CD123-directed conjugate of an amended diphtheria toxin platform and recombinant interleukin 3. Binding and subsequent internalization of the drug result in cell death via disruption of intracellular protein synthesis. CD123 is a surface marker that is expressed in several hematological malignancies, especially blastic plasmacytoid dendritic cell neoplasm (BPDCN), where its expression is ubiquitous. A pivotal study of tagraxofusp in BPDCN resulted in its approval for the treatment of BPDCN, the first treatment approved for this indication. Since the introduction of tagraxofusp, research has focused on the management of adverse effects, combination therapy to improve outcomes in fit patients, and dosing and combination strategies to mitigate toxicities while preserving efficacy, especially among older patients. The successful targeting of CD123 in BPDCN has also encouraged research into a variety of other CD123-positive hematological neoplasms, including acute myeloid leukemia (AML), and informed the development of other novel agents targeting CD123. This review examines the clinical data leading to the development and approval of tagraxofusp in BPDCN, how it is being used in combination to improve outcomes in BPDCN and AML, and its developing role in other hematological malignancies.
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Affiliation(s)
- Wei-Ying Jen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Konopleva
- Department of Oncology, Montefiore Einstein Comprehensive Cancer Center, Bronx, New York, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Jen WY, Sasaki K, Loghavi S, Wang SA, Qiao W, Borthakur G, Ravandi F, Kadia TM, Issa GC, Short NJ, Yilmaz M, Daver NG, DiNardo CD. Characteristics and outcomes of acute myeloid leukaemia patients with baseline CD7 expression. Br J Haematol 2024. [PMID: 38603594 DOI: 10.1111/bjh.19446] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 04/13/2024]
Abstract
Targeted therapy development for acute myeloid leukaemia (AML) requires an understanding of specific expression profiles. We collected flow cytometry data on 901 AML patients and recorded aberrant CD7 expression on leukaemic blasts. 263 (29.2%) had blasts positive for CD7. CD7+ AML was more likely to be adverse risk (64.6% vs. 55.6%, p = 0.0074) and less likely to be favourable risk (15.2% vs. 24.1%, p = 0.0074) by European LeukemiaNet 2022 criteria. Overall survival was inferior (11.9 [95% CI, 9.7-15.9] vs. 19.0 months [95% CI, 16.1-23.0], p = 0.0174). At relapse, 30.4% lost and 19.0% gained CD7, suggesting moderate instability over time.
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Affiliation(s)
- Wei-Ying Jen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sa A Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Song Y, Lee SY, Chee YL, Jen WY. Hypertensive Emergency with Thrombotic Microangiopathy or TTP? A Case Series and Literature Review. J Clin Med 2024; 13:1880. [PMID: 38610645 PMCID: PMC11012678 DOI: 10.3390/jcm13071880] [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: 02/18/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is associated with both hypertensive emergency and primary thrombocytopenia purpura (TTP). However, their clinical management is vastly different, with the latter necessitating urgent plasma exchange (PEX). We report two cases of hypertension-associated TMA (HTN-TMA) and a literature review of the clinical management of malignant hypertension. We suggest that in patients presenting with hypertensive emergency associated with TMA, a clinical diagnosis of HTN-TMA should be made, with emergent treatment to lower blood pressure started immediately. Although TTP is a differential diagnosis for TMA, PEX should not be started concurrently in the absence of other supporting evidence for TTP.
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Affiliation(s)
- Yang Song
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
| | - Shi Yan Lee
- Division of Gastroenterology & Hepatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
| | - Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
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Jen WY, Sasaki K, Rausch CR, DiNardo CD, Kadia TM, Yilmaz M, Borthakur G, Alvarado Y, McCue D, McCue D, Kantarjian HM, Ravandi F. Acute kidney injury in acute promyelocytic leukemia: a possible adverse effect of high dose arsenic trioxide in obese patients. Leuk Lymphoma 2024; 65:378-382. [PMID: 38054837 DOI: 10.1080/10428194.2023.2290467] [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: 10/02/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
Arsenic trioxide (ATO)-based regimens are standard in acute promyelocytic leukemia (APL). ATO-related nephrotoxicity has not been reported. We reviewed APL patients treated with ATO to identify cases of acute kidney injury (AKI). Clinically significant cases were characterized. Multivariate analysis was performed to identify predictors of idiopathic, clinically significant AKI. One hundred and eight patients were included. ATO dose was 0.15 mg/kg/day using actual body weight with no dose cap. Thirty-one (28.7%) AKI cases were identified, 10 (32.3%) clinically significant. Six were idiopathic; five required dialysis. The proportion with significant, idiopathic AKI was 15.8% in patients receiving >15mg ATO versus 0% in those receiving ≤15mg (p = 0.001). On multivariate analysis, only ATO dose was a significant predictor of clinically significant AKI (odds ratio of 1.91, 95%CI, 1.19-3.07, p = 0.007). High-dose ATO may be associated with significant nephrotoxicity. We recommend that ATO dose be capped at 15 mg to minimize toxicity for this curable disease.
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Affiliation(s)
- Wei-Ying Jen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caitlin R Rausch
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David McCue
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Deborah McCue
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Tan CJ, Tan MSY, Nagarajan C, Chng WJ, Chee YL, Ooi M, Ng LCK, Chen Y, Yoong JSY, Wong XY, Jen WY. Factors Affecting Patient and Caregiver Preferences for Treatment of Myeloma and Indolent Lymphoma. JCO Oncol Pract 2023; 19:1168-1178. [PMID: 37844267 DOI: 10.1200/op.23.00336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 10/18/2023] Open
Abstract
PURPOSE Treatment options for myeloma and indolent lymphoma are increasing exponentially, with distinct efficacy, side effects, and cost. We aim to determine the factors influencing patient and caregiver treatment preferences. METHODS Patients and caregivers of patients with myeloma and indolent lymphoma were recruited from two cancer centers in Singapore. Preferences were elicited using a discrete choice experiment. Attributes and levels were selected based on a previous qualitative study. The relative preference for levels within each attribute (part worth utility values) and the extent to which an attribute would influence decision making (relative importance) were calculated. Patient and caregiver participation in the treatment plan selection process were assessed using the Control Preference Scale. RESULTS One hundred ninety-nine patients and 169 caregivers were recruited. Patients placed the highest importance on out-of-pocket costs (relative importance = 35%), followed by efficacy (25%), persistent side effects (19%), administration route (8%), treatment duration (7%), and short-term side effects (5%). Caregivers ranked efficacy (27%) as the most important attribute, over out-of-pocket costs (24%). Most patients preferred a collaborative role in the shared decision-making process, while similar proportions of caregivers favored active and collaborative roles. CONCLUSION Our study demonstrates that both patients and caregivers consider cost seriously when making treatment decisions. Furthermore, as patient and caregiver preferences may differ, there are implications for treatment selection and counseling, especially in cultures where caregivers have more prominent roles in treatment planning.
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Affiliation(s)
- Chia Jie Tan
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Melinda Si Yun Tan
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | | | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Yunxin Chen
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Joanne Su Yin Yoong
- Research for Impact, Singapore, Singapore
- Behavioral and Implementation Science Interventions, National University of Singapore, Singapore, Singapore
- Center for Economic and Social Research, University of Southern California, Los Angeles, CA
- Sim Kee Boon Institute for Financial Economics, Singapore Management University, Singapore, Singapore
| | - Xin Yi Wong
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, National University of Singapore, Singapore, Singapore
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Jen WY, Chan ZY, Lee YM, Ng N, Tan B, Teo C, Wong YP, Chee CE, Chee YL. Reducing Chemotherapy Waiting Times in the Ambulatory Setting of a Tertiary Cancer Centre Using a Design Thinking Approach. Cancers (Basel) 2023; 15:4625. [PMID: 37760594 PMCID: PMC10526492 DOI: 10.3390/cancers15184625] [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: 08/19/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Chemotherapy is complex. We hypothesized that a design thinking approach could redesign preparatory processes and reduce wait times. METHODS A multidisciplinary process mapping exercise was undertaken to understand the current processes, followed by proposing and testing solutions. Proposals were selected based on desirability and feasibility. These focused on starting the morning treatments on time and scheduling pre-made regimens in these slots. The primary outcome measure was the time from the appointment to starting treatment. Treatments in the post-intervention study group were compared against a historical control group. RESULTS The median time to start morning treatment decreased by 46%, from 83 min (with an interquartile range 50-127) in the control group to 45 min (with an interquartile range of 24-81 min) in the study group (p < 0.001). This translated into an overall improvement for the day, with the median time to start treatment decreasing from 77 min (with an interquartile range of 40-120 min) to 47 min (with an interquartile range of 20-79 min) (p < 0.001). Pre-makes increased by 258%, from 908 (28.5%) to 2340 (71.7%) regimens (p < 0.001). The number of patients starting treatment within an hour of their appointment increased from 1688 (32.8%) to 3355 (62.3%, p < 0.001). CONCLUSION We have shown that a data-driven, design thinking approach can improve waiting times. This can be adapted to improve other processes in an empathetic, sustainable manner.
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Affiliation(s)
- Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute Singapore, Singapore 119074, Singapore
| | - Zhi Yao Chan
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore
| | - Yee Mei Lee
- Division of Oncology Nursing, National University Cancer Institute Singapore, Singapore 119074, Singapore (B.T.)
| | - Noel Ng
- Operations and Administration, National University Cancer Institute Singapore, Singapore 119074, Singapore
| | - Belinda Tan
- Division of Oncology Nursing, National University Cancer Institute Singapore, Singapore 119074, Singapore (B.T.)
| | - Constance Teo
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore
| | - Yuet Peng Wong
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore
| | - Cheng Ean Chee
- Department of Haematology-Oncology, National University Cancer Institute Singapore, Singapore 119074, Singapore
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute Singapore, Singapore 119074, Singapore
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Thong EWS, Tan SS, Sethi SK, Chee YL, Jen WY. Falsely elevated serum vitamin B12 levels in a case of pernicious anemia. Ann Hematol 2021; 101:889-892. [PMID: 34505941 DOI: 10.1007/s00277-021-04612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/10/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Edwin W S Thong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, 5 Lower Kent Ridge Rd, 119074, Singapore, Singapore.
| | - Shaun S Tan
- Department of Laboratory Medicine, National University Hospital, National University Health System, 5 Lower Kent Ridge Rd, 119074, Singapore, Singapore
| | - Sunil K Sethi
- Department of Laboratory Medicine, National University Hospital, National University Health System, 5 Lower Kent Ridge Rd, 119074, Singapore, Singapore
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, 5 Lower Kent Ridge Rd, 119074, Singapore, Singapore
| | - Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, 5 Lower Kent Ridge Rd, 119074, Singapore, Singapore
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Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
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Affiliation(s)
- Ada Pei Yu Ng
- Department of Internal Medicine, National University Health System, Singapore
| | - Yen-Lin Chee
- Department of Haematology, National University Cancer Institute Singapore, National University Health System, Singapore
| | - Sb Justin Wong
- Department of Pathology, National University Health System, Singapore
| | - Wei-Ying Jen
- Department of Haematology, National University Cancer Institute Singapore, National University Health System, Singapore
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Abstract
OBJECTIVES The COVID-19 outbreak in Singapore has largely centred around migrant worker dormitories, comprising over 90% of all cases in the country. Dormitories are home to a culturally and linguistically distinct, low-income population, without on-site healthcare after-hours. The primary objective of this study was to assess the engagement and utilisation of a simple, low-cost, accessible, mobile health solution for remote self-reporting of vital parameters in dormitory residents with COVID-19. DESIGN Retrospective review of medical care. SETTING Two large migrant worker dormitories with a combined population of 31 546. PARTICIPANTS All COVID-19-affected residents housed in dormitories during the study period. INTERVENTION All residents were taught to use a chat assistant to self-report their temperature, heart rate and oxygen saturations. Results flowed into a dashboard, which alerted clinicians of abnormal results. OUTCOMES The primary outcome measure was engagement rate. This was derived from the total number of residents who registered on the platform over the total number of COVID-19-affected residents in the dormitories during the study period. Secondary outcome measures included outcomes of the alerts and subsequent escalations of care. RESULTS 800 of the 931 COVID-19-affected residents (85.9%) engaged with the platform to log a total of 12 511 discrete episodes of vital signs. Among 372 abnormal readings, 96 teleconsultations were initiated, of which 7 (1.8%) were escalated to emergency services and 18 (4.9%) were triaged to earlier physical medical review on-site. CONCLUSIONS A chat-assistant-based self-reporting platform is an effective and safe community-based intervention to monitor marginalised populations with distinct cultural and linguistic backgrounds, living communally and affected by COVID-19. Lessons learnt from this approach may be applied to develop safe and cost-effective telemedicine solutions across similar settings.
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Affiliation(s)
- Stephanie Q Ko
- Division of Advanced Internal Medicine, University Medicine Cluster, National University Hospital, Singapore
| | - Benjamin M Y Hooi
- Division of Advanced Internal Medicine, University Medicine Cluster, National University Hospital, Singapore
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore
| | - Daniel W P Chor
- Department of Emergency Medicine, National University Hospital, Singapore
| | - Zheng Jye Ling
- Department of Medical Informatics, National University Health System, Singapore
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
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Jen WY, Yoong J, Liu X, Tan MSY, Chng WJ, Chee YL. Qualitative Study of Factors Affecting Patient, Caregiver and Physician Preferences for Treatment of Myeloma and Indolent Lymphoma. Patient Prefer Adherence 2020; 14:301-308. [PMID: 32109996 PMCID: PMC7034971 DOI: 10.2147/ppa.s241340] [Citation(s) in RCA: 5] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The number of treatment options for myeloma and indolent lymphoma are expanding at an exponential rate, with few direct head-to-head comparisons on which to base efficacy measures. We sought to understand how patients, their caregivers and physicians weigh treatment characteristics in order to come to a decision on which treatment option to pursue. METHODS Patients, their caregivers and physicians were recruited and interviewed until data saturation was reached. A qualitative, thematic analysis was done to identify themes important to each stakeholder. RESULTS We found that, while all three groups valued efficacy the most, the consideration of other secondary characteristics of the treatment, such as cost, toxicity and logistical issues all differed subtly between the different groups. Patients valued minimising cost and toxicity, even at small trade-offs in efficacy. Caregivers and physicians valued efficacy foremost. CONCLUSION Acknowledging and managing these differences is paramount because they influence shared decision-making and may affect patient outcomes in the short term, as well as their more general well-being in the long term.
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Affiliation(s)
- Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
- Correspondence: Wei-Ying Jen Department of Haematology-Oncology, National University Cancer Institute, 1E Kent Ridge Road, NUHS Tower Block Level 7, 119228, SingaporeTel +65 6772 5286Fax +65 6772 2998 Email
| | - Joanne Yoong
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Xin Liu
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | | | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
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Jen WY, Kristanto W, Teo L, Phua J, Yip HS, MacLaren G, Teoh K, Sim TB, Loh J, Ong CC, Chee YL, Kojodjojo P. Assessing the Impact of a Pulmonary Embolism Response Team and Treatment Protocol on Patients Presenting With Acute Pulmonary Embolism. Heart Lung Circ 2019; 29:345-353. [PMID: 30910512 DOI: 10.1016/j.hlc.2019.02.190] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 09/11/2018] [Revised: 01/14/2019] [Accepted: 02/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) care has traditionally been fragmented. The newly introduced Pulmonary Embolism Response Team (PERT) model provides streamlined care based on expedient, multi-disciplinary decision-making. This study aimed to quantify the impact of PERT, as part of a hospital-wide PE treatment protocol, on clinical outcomes. METHODS Consecutive adult patients with acute PE diagnosed via computed tomography pulmonary angiogram (CTPA) were included. The PERT and treatment protocol were introduced in January 2015. Patient characteristics, therapies, quality measures of CTPA reporting, and clinical outcomes of PE patients treated for 2 years before and after implementation of these changes were evaluated. Primary endpoints were median length of stay in intensive care (ICU) and survival to discharge. RESULTS A total of 321 consecutive PE patients were enrolled, of which 154 (treated in 2013-2014) and 167 (2015-2016) patients formed the historical control and study groups, respectively. Implementation of the algorithm was associated with less variance in anticoagulation and improved reporting of right heart strain parameters on CTPA. The ICU stay was reduced from a median of 5 to 2 days (p < 0.01). Eligible massive PE patients receiving reperfusion increased from 30% to 92% (p = 0.01), with mean delay from diagnosis to reperfusion decreasing from 763 to 181 minutes (p < 0.01). Bleeding complications were not increased, but overall survival to discharge remained unchanged. CONCLUSIONS Introducing a PERT and treatment protocol reduced ICU stay, enhanced quality measures, and improved access of massive PE patients to reperfusion therapies, without increasing bleeding complications or health care costs.
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Affiliation(s)
- Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - William Kristanto
- Department of Cardiology, National University Heart Centre, Singapore
| | - Lynette Teo
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Jason Phua
- Division of Respiratory & Critical Care Medicine, National University Hospital, Singapore
| | - Hwee Seng Yip
- Division of Respiratory & Critical Care Medicine, National University Hospital, Singapore
| | - Graeme MacLaren
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Kristine Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Tiong Beng Sim
- Department of Emergency Medicine, National University Hospital, Singapore
| | - Joshua Loh
- Department of Cardiology, National University Heart Centre, Singapore
| | - Ching Ching Ong
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Yen Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore.
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Jen WY, Jeon YS, Kojodjojo P, Lee EHE, Lee YH, Ren YP, Tan TJS, Song Y, Zhang T, Teo L, Feng M, Chee YL. A New Model for Risk Stratification of Patients With Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2018; 24:277S-284S. [PMID: 30370786 PMCID: PMC6714854 DOI: 10.1177/1076029618808922] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Pulmonary embolism (PE) is associated with mortality. There are many clinical
prediction tools to predict early mortality in acute PE but little consensus on
which is best. Our study aims to validate existing prediction tools and derive a
predictive model that can be applied to all patients with acute PE in both
inpatient and outpatient settings. This is a retrospective cohort study of
patients with acute PE. For each patient, the Pulmonary Embolism Severity Index
(PESI), simplified PESI (sPESI), European Society of Cardiology (ESC), and
Angriman scores were calculated. Scores were assessed by the area under the
receive-operating curve (AUC) for 30-day, all-cause mortality. To develop a new
prognostic model, elastic logistic regression was used on the derivation cohort
to estimate β-coefficients of 8 different variables; these were normalized to
weigh them. A total of 321 patients (mean age 60±17 years) were included.
Overall 30-day mortality was 10.3%. None of the scores performed well; the AUCs
for the PESI, sPESI, ESC, and Angriman scores were 0.67 (95% confidence interval
[CI], 0.57-0.77), 0.58 (0.48-0.69), 0.65 (0.55-0.75), and 0.67 (0.57-0.76),
respectively. Our new prediction model outperformed PESI, with an AUC of 0.82
(95% CI, 0.76-0.88). At a cutoff score of 100, 195 (60.1%) patients were
classified as low risk. Thirty-day mortality was 2.1% (95% CI, 0.8%-5.2%) and
23.0% (16.5%-31.1%) for low- and high-risk groups, respectively
(P < .001). In conclusion, we have developed a new model
that outperforms existing prediction tools in all comers with PE. However,
further validation on external cohorts is required before application.
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Affiliation(s)
- Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Young Seok Jeon
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore
| | - Eleen Hui Er Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ya Hui Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yi Ping Ren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Teng Jie Shawn Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yang Song
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tianjiao Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lynette Teo
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Mengling Feng
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
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Jen WY, Chee YL, Khor LK, Nga ME, Poon L, De Mel S. Diffuse Intrasinusoidal Hepatic Metastasis From Occult Breast Carcinoma Presenting as Thrombotic Microangiopathy: A Case Report and Literature Review. J Hematol 2015. [DOI: 10.14740/jh230w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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