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Dunlap TC, Weiner DL, Kemper RM, Kardouh M, DeVane SC, Symonds A, Shaw JR, Armistead PM, Ptachcinski JR, Crona DJ. Utilization of a Population Pharmacokinetic Model to Improve a Busulfan Test-Dose Strategy in Allogeneic Hematopoietic Cell Transplant Recipients. J Clin Pharmacol 2023; 63:1026-1035. [PMID: 37122163 PMCID: PMC10524401 DOI: 10.1002/jcph.2257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/18/2023] [Indexed: 05/02/2023]
Abstract
Busulfan is an alkylating agent used as part of conditioning chemotherapy regimens prior to allogeneic hematopoietic cell transplant (allo-HCT). Pharmacokinetic (PK)-guided test-dose strategies have been shown to improve the number of patients achieving busulfan exposure goals and improve clinical outcomes. However, current practices require extensive PK sampling. In this study, PK data were retrospectively collected from busulfan drug monitoring records from adult allo-HCT recipients who received once-daily intravenous busulfan at the University of North Carolina Medical Center (UNCMC). A population pharmacokinetic (popPK) model was developed to identify sources of interindividual variability and evaluate alternative PK sampling strategies. A 2-compartment model, with covariate effects of actual body weight and sex, best described the data. The typical value of clearance for an 83 kg male was estimated to be 11.21 L/h. Fifty-nine percent of allo-HCT recipients were estimated to have met the UNCMC institutional myeloablative conditioning (MAC) exposure goal based on model post hoc estimates of clearance using all PK samples obtained following MAC dosing. Fifty-seven percent of patients were estimated to have met this goal based on post hoc estimates using a single PK sample. Our results indicate once-daily, intravenous busulfan PK in adult allo-HCT recipients receiving MAC dosing can be reasonably described by a popPK model, and the use of a sparse PK sampling strategy may be feasible for determining target exposure attainment following MAC dosing. Use of a popPK model and sparse PK sampling strategy to carry out busulfan test-dose procedures could reduce health care costs and inconvenience to patients.
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Affiliation(s)
- Tyler C. Dunlap
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Daniel L. Weiner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Ryan M. Kemper
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Miramar Kardouh
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Susanna C. DeVane
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Allison Symonds
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - J. Ryan Shaw
- Bone Marrow Transplant and Cellular Therapy Program, University of North Carolina Medical Center, Chapel Hill, NC
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Paul M. Armistead
- Bone Marrow Transplant and Cellular Therapy Program, University of North Carolina Medical Center, Chapel Hill, NC
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Jonathan R. Ptachcinski
- Bone Marrow Transplant and Cellular Therapy Program, University of North Carolina Medical Center, Chapel Hill, NC
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Daniel J. Crona
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
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Dadkhah A, Wicha SG, Kröger N, Müller A, Pfaffendorf C, Riedner M, Badbaran A, Fehse B, Langebrake C. Population Pharmacokinetics of Busulfan and Its Metabolite Sulfolane in Patients with Myelofibrosis Undergoing Hematopoietic Stem Cell Transplantation. Pharmaceutics 2022; 14:pharmaceutics14061145. [PMID: 35745718 PMCID: PMC9229330 DOI: 10.3390/pharmaceutics14061145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/18/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
For patients with myelofibrosis, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative treatment to date. Busulfan-based conditioning regimens are commonly used, although high inter-individual variability (IIV) in busulfan drug exposure makes individual dose selection challenging. Since data regarding the IIV in patients with myelofibrosis are sparse, this study aimed to develop a population pharmacokinetic (PopPK) model of busulfan and its metabolite sulfolane in patients with myelofibrosis. The influence of patient-specific covariates on the pharmacokinetics of drug and metabolite was assessed using non-linear mixed effects modeling in NONMEM®. We obtained 523 plasma concentrations of busulfan and its metabolite sulfolane from 37 patients with myelofibrosis. The final model showed a population clearance (CL) and volume of distribution (Vd) of 0.217 L/h/kg and 0.82 L/kg for busulfan and 0.021 L/h/kg and 0.65 L/kg for its metabolite. Total body weight (TBW) and a single-nucleotide polymorphism of glutathione-S-transferase A1 (GSTA1 SNP) displayed a significant impact on volume of distribution and metabolite clearance, respectively. This is the first PopPK-model developed to describe busulfan’s pharmacokinetics in patients with myelofibrosis. Incorporating its metabolite sulfolane into the model not only allowed the characterization of the covariate relationship between GSTA1 and the clearance of the metabolite but also improved the understanding of busulfan’s metabolic pathway.
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Affiliation(s)
- Adrin Dadkhah
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
- Correspondence: ; Tel.: +49-40-7410-58517
| | - Sebastian Georg Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (S.G.W.); (C.P.)
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (N.K.); (A.B.); (B.F.)
| | - Alexander Müller
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Christoph Pfaffendorf
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (S.G.W.); (C.P.)
| | - Maria Riedner
- Technology Platform Mass Spectrometry, University of Hamburg, 20146 Hamburg, Germany;
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (N.K.); (A.B.); (B.F.)
| | - Boris Fehse
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (N.K.); (A.B.); (B.F.)
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (N.K.); (A.B.); (B.F.)
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3
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Dadkhah A, Alihodzic D, Broeker A, Kröger N, Langebrake C, Wicha SG. Evaluation of the Robustness of Therapeutic Drug Monitoring Coupled with Bayesian Forecasting of Busulfan with Regard to Inaccurate Documentation. Pharm Res 2021; 38:1721-1729. [PMID: 34664209 PMCID: PMC8602150 DOI: 10.1007/s11095-021-03115-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/20/2021] [Indexed: 12/13/2022]
Abstract
Background Inaccurate documentation of sampling and infusion times is a potential source of error in personalizing busulfan doses using therapeutic drug monitoring (TDM). Planned times rather than the actual times for sampling and infusion time are often documented. Therefore, this study aimed to evaluate the robustness of a limited sampling TDM of busulfan with regard to inaccurate documentation. Methods A pharmacometric analysis was conducted in NONMEM® 7.4.3 and “R” by performing stochastic simulation and estimation with four, two and one sample(s) per patient on the basis of a one-compartment- (1CMT) and two-compartment (2CMT) population pharmacokinetic model. The dosing regimens consisted of i.v. busulfan (0.8 mg/kg) every 6 h (Q6H) or 3.2 mg/kg every 24 h (Q24H) with a 2 h- and 3 h infusion time, respectively. The relative prediction error (rPE) and relative root-mean-square error (rRmse) were calculated in order to determine the accuracy and precision of the individual AUC estimation. Results A noticeable impact on the estimated AUC based on a 1CMT-model was only observed if uncertain documentation reached ± 30 min (1.60% for Q24H and 2.19% for Q6H). Calculated rPEs and rRmse for Q6H indicate a slightly lower level of accuracy and precision when compared to Q24H. Spread of rPE’s and rRmse for the 2CMT-model were wider and higher compared to estimations based on a 1CMT-model. Conclusions The estimated AUC was not affected substantially by inaccurate documentation of sampling and infusion time. The calculated rPEs and rRmses of estimated AUC indicate robustness and reliability for TDM of busulfan, even in presence of erroneous records. Supplementary Information The online version contains supplementary material available at 10.1007/s11095-021-03115-8.
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Affiliation(s)
- Adrin Dadkhah
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. .,Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.
| | - Dzenefa Alihodzic
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Astrid Broeker
- Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian G Wicha
- Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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Morita K, Ashizawa M, Toda Y, Ikeda T, Kawaguchi SI, Ito S, Ochi SI, Nagayama T, Mashima K, Umino K, Minakata D, Nakano H, Yamasaki R, Yamamoto C, Hatano K, Fujiwara SI, Sato K, Oh I, Ohmine K, Muroi K, Matsumoto K, Kanda Y. Salvage Chemotherapy Followed by Autologous Stem-Cell Transplantation Using Targeted Busulfan for Refractory Diffuse Large B-Cell Lymphoma With Dialysis-Dependent End-Stage Renal Disease. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:e92-e96. [PMID: 31787588 DOI: 10.1016/j.clml.2019.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND A treatment strategy is needed for hemodialysis-dependent patients with end-stage renal disease who have relapsed/refractory diffuse large B-cell lymphoma (DLBCL). We examined the feasibility of salvage chemotherapy followed by autologous stem-cell transplantation (ASCT) and busulfan as a conditioning regimen. PATIENTS AND METHODS We provided a patient with refractory DLBCL who was receiving hemodialysis with modified salvage chemotherapies that were based on the mechanism of drug pharmacokinetics and an evaluation of the pharmacokinetics of busulfan. After chemotherapy, the patient underwent ASCT. RESULTS The regimen was successfully administered without adverse events. CONCLUSION Chemotherapy followed by ASCT using a conditioning regimen of reduced melphalan and pharmacokinetically targeted busulfan is a promising strategy for treating patients with relapsed or refractory DLBCL who also have end-stage renal disease and are receiving hemodialysis.
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Affiliation(s)
- Kaoru Morita
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Masahiro Ashizawa
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Yumiko Toda
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takashi Ikeda
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shin-Ichiro Kawaguchi
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shoko Ito
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shin-Ichi Ochi
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takashi Nagayama
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kiyomi Mashima
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kento Umino
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Daisuke Minakata
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hirofumi Nakano
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryoko Yamasaki
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Chihiro Yamamoto
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kaoru Hatano
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shin-Ichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kazuya Sato
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Iekuni Oh
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ken Ohmine
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kazuo Muroi
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyoto, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan.
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5
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Evaluation of a Test Dose Strategy for Pharmacokinetically-Guided Busulfan Dosing for Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:391-397. [DOI: 10.1016/j.bbmt.2018.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 09/10/2018] [Indexed: 11/17/2022]
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6
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Pharmacokinetics-adapted Busulfan-based myeloablative conditioning before unrelated umbilical cord blood transplantation for myeloid malignancies in children. PLoS One 2018; 13:e0193862. [PMID: 29608607 PMCID: PMC5880335 DOI: 10.1371/journal.pone.0193862] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/20/2018] [Indexed: 11/28/2022] Open
Abstract
Unrelated umbilical cord blood transplantation (UCBT) is an alternative to provide transplants in children with acute leukemia or myelodysplastic syndrome who lack a related donor. Intravenous Busulfan (Bu) combined with therapeutic drug monitoring-guided dosing has been increasingly used, with more predictable bioavailability and better outcomes comparing to oral Bu. There is still an important variation in Bu pharmacokinetic between patients that is associated with an increased risk of toxicity and graft failure. The objective of the study was to analyze the impact of first-dose pharmacokinetic adapted myeloablative conditioning regimen of intravenous Bu on the different outcomes after transplantation. Data of 36 children who underwent allogeneic HSCT with Bu plus a second alkylating agent at Sainte Justine Hospital in Montreal, Canada, between December 2000 and April 2012 were analyzed. For children with high risk myeloid malignancies receiving an UCBT, first dose Bu pharmacokinetic seems to be a significant prognostic factor, influencing neutrophil (100% vs 67.9%) and platelet recovery (95.5% vs 70.5%), non-relapse mortality (0% vs 18.6%), EFS (64% vs 28.6%) and OS (81.3% vs 37.5%) for a first-dose steady-state concentration (Css) <600ng/mL vs >600ng/mL, respectively. These data reinforce the importance of Busulfan therapeutic drug monitoring-guided dosing in pediatric HSCT patients, particularly in the context of UCBT.
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7
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The Impact of Toxicities on First-Year Outcomes after Ex Vivo CD34 +-Selected Allogeneic Hematopoietic Cell Transplantation in Adults with Hematologic Malignancies. Biol Blood Marrow Transplant 2017; 23:2004-2011. [PMID: 28733264 DOI: 10.1016/j.bbmt.2017.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/10/2017] [Indexed: 11/21/2022]
Abstract
Factors that impact first-year morbidity and mortality in adults undergoing myeloablative allogeneic hematopoietic cell transplantation with ex vivo CD34+ selection have not been previously reported. We assessed all toxicities ≥ grade 3 from the start of conditioning to date of death, relapse, or last contact in 200 patients during the first year after transplantation, identifying 1885 individual toxicities among 17 organ-based toxicity groups. The most prevalent toxicities in the first year were of infectious, metabolic, hematologic, oral/gastrointestinal, hepatic, cardiac, and pulmonary etiologies. Renal complications were minimal. Grades II to IV and III and IV acute GVHD at day 100 were 11.5% and 3%, respectively. In separate multivariate models, cardiovascular, hematologic, hepatic, neurologic, pulmonary, and renal toxicities negatively impacted nonrelapse mortality (NRM) and overall survival during the first year. A higher-than-targeted busulfan level, patient cytomegalovirus seropositivity, and an Hematopoietic Cell Transplantation-Specific Comorbidity Index of ≥3 were associated with increased risk of NRM and all-cause death. Ex vivo CD34+ selection had a favorable 1-year OS of 75% and NRM of 17% and a low incidence of sinusoidal obstruction syndrome. These data establish a benchmark to focus efforts in reducing toxicity burden while improving patient outcomes.
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8
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de Castro FA, Simões BP, Godoy ALPC, Bertagnoli Trigo FM, Coelho EB, Lanchote VL. Use of an Oral Busulfan Test Dose in Patients Undergoing Hematopoietic Stem Cell Transplantation Treated With or Without Fludarabine. J Clin Pharmacol 2016; 56:1555-1562. [PMID: 27130252 DOI: 10.1002/jcph.758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 01/28/2023]
Abstract
This study investigated the importance of an oral test dose for busulfan (BU) dose adjustment before a conditioning regimen for hematopoietic stem-cell transplantation (HSCT) and the effect of fludarabine (FLU) on the oral BU pharmacokinetics evaluated after the fifth treatment dose (first BU dose on day 2 of treatment). Twenty-eight patients treated with oral BU (1 mg/kg every 6 hours for 4 days) were divided into 2 groups according to the concomitant administration of FLU (n = 15; 30 mg/m2 for 5 days) or subsequent administration of cyclophosphamide (CY) (n = 13; 60 mg/kg for 2 days). On the day prior to the beginning of the conditioning regimen, blood samples were collected (0-6 hours) after administration of an oral BU test dose of 0.25 mg/kg. Busulfan was quantified in plasma samples by LC-MS/MS, and the pharmacokinetic parameters were calculated using WinNonlin software. Blood samples were collected between the fifth and sixth treatment dose to confirm the mean plasma steady-state concentration (Css ) of BU. The AUC0-6 and apparent clearance of BU did not differ (P < .05) between the groups receiving FLU and CY. In 81% of the patients who received BU doses adjusted based on the test dose (n = 21), the Css was within the target range of 600-900 ng/mL. No association was observed between BU AUC0-6 and clinical outcome in the study group (n = 28). The results suggest that in concomitant administration of FLU and BU during conditioning regimens for HSCT, changes in BU dose should be considered only after the administration of the fifth BU dose.
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Affiliation(s)
- Francine Attié de Castro
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Belinda Pinto Simões
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Ana Leonor Pardo Campos Godoy
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | - Eduardo Barbosa Coelho
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Vera Lucia Lanchote
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
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9
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Damlaj M, Alkhateeb HB, Hefazi M, Partain DK, Hashmi S, Gastineau DA, Al-Kali A, Wolf RC, Gangat N, Litzow MR, Hogan WJ, Patnaik MM. Fludarabine-Busulfan Reduced-Intensity Conditioning in Comparison with Fludarabine-Melphalan Is Associated with Increased Relapse Risk In Spite of Pharmacokinetic Dosing. Biol Blood Marrow Transplant 2016; 22:1431-1439. [PMID: 27164061 DOI: 10.1016/j.bbmt.2016.04.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/30/2016] [Indexed: 11/16/2022]
Abstract
Fludarabine with busulfan (FB) and fludarabine with melphalan (FM) are commonly used reduced-intensity conditioning (RIC) regimens. Pharmacokinetic dosing of busulfan (Bu) is frequently done for myeloablative conditioning, but evidence for its use is limited in RIC transplants. We compared transplant outcomes of FB versus FM using i.v. Bu targeted to the area under the curve (AUC). A total of 134 RIC transplants (47 FB and 87 FM) for acute myelogenous leukemia and myelodysplastic syndrome were identified, and median follow-up of the cohort was 40 months (range, 0 to 63.3). A significantly higher 2-year cumulative incidence of relapse (CIR) was associated with FB versus FM at 35.6% versus 17.3%, respectively (P = .0058). Furthermore, 2-year progression-free survival rates were higher for FM versus FB at 60.5% versus 48.7%, respectively (P = .04). However, 2-year rates of nonrelapse mortality (NRM) and overall survival (OS) were similar. The need for dose adjustment based on AUC did not alter relapse risk or NRM. Patients with Karnofsky performance status ≥ 90 who received FM had a 2-year OS rate of 74.8% versus 48.3% for FB (P = .03). FB use remained prognostic for relapse in multivariable analysis (hazard ratio, 2.75; 95% confidence interval, 1.28 to 5.89; P = .0097). In summary, in spite of AUC-directed dosing, FB compared with FM was associated with a significantly higher CIR.
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Affiliation(s)
- Moussab Damlaj
- Division of Hematology & HSCT, Department of Oncology, King AbdulAziz Medical City, Riyadh, Saudi Arabia; Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Hassan B Alkhateeb
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mehrdad Hefazi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Daniel K Partain
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shahrukh Hashmi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Gastineau
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aref Al-Kali
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert C Wolf
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - William J Hogan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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10
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de Castro FA, Piana C, Simões BP, Lanchote VL, Della Pasqua O. Busulfan dosing algorithm and sampling strategy in stem cell transplantation patients. Br J Clin Pharmacol 2015; 80:618-29. [PMID: 25819742 DOI: 10.1111/bcp.12648] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/25/2015] [Accepted: 03/24/2015] [Indexed: 01/22/2023] Open
Abstract
AIM The aim of this investigation was to develop a model-based dosing algorithm for busulfan and identify an optimal sampling scheme for use in routine clinical practice. METHODS Clinical data from an ongoing study (n = 29) in stem cell transplantation patients were used for the purposes our analysis. A one compartment model was selected as basis for sampling optimization and subsequent evaluation of a suitable dosing algorithm. Internal and external model validation procedures were performed prior to the optimization steps using ED-optimality criteria. Using systemic exposure as parameter of interest, dosing algorithms were considered for individual patients with the scope of minimizing the deviation from target range as determined by AUC(0,6 h). RESULTS Busulfan exposure after oral administration was best predicted after the inclusion of adjusted ideal body weight and alanine transferase as covariates on clearance. Population parameter estimates were 3.98 h(-1), 48.8 l and 12.3 l h(-1) for the absorption rate constant, volume of distribution and oral clearance, respectively. Inter-occasion variability was used to describe the differences between test dose and treatment. Based on simulation scenarios, a dosing algorithm was identified, which ensures target exposure values are attained after a test dose. Moreover, our findings show that a sparse sampling scheme with five samples per patient is sufficient to characterize the pharmacokinetics of busulfan in individual patients. CONCLUSION The use of the proposed dosing algorithm in conjunction with a sparse sampling scheme may contribute to considerable improvement in the safety and efficacy profile of patients undergoing treatment for stem cell transplantation.
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Affiliation(s)
- Francine A de Castro
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Chiara Piana
- Leiden Academic Centre for Drug Research, Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - Belinda P Simões
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Vera L Lanchote
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - O Della Pasqua
- Leiden Academic Centre for Drug Research, Division of Pharmacology, Leiden University, Leiden, The Netherlands.,Clinical Pharmacology & Therapeutics, University College London, London, UK
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Once-daily i.v. BU-based conditioning regimen before allogeneic hematopoietic SCT: a study of influence of GST gene polymorphisms on BU pharmacokinetics and clinical outcomes in Chinese patients. Bone Marrow Transplant 2015; 50:696-705. [PMID: 25730183 DOI: 10.1038/bmt.2015.14] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 01/05/2015] [Accepted: 01/05/2015] [Indexed: 02/05/2023]
Abstract
I.v. BU has been proven to have better bioavailability, reliable systemic drug exposure with more predictable blood levels and lower toxicity than oral BU when used as part of conditioning regimens before hematopoietic SCT (HSCT). Some studies have shown that once-daily i.v. BU had the same clinical efficacy as i.v. BU administered four times daily. To observe the clinical efficacy and pharmacokinetics (PK) of once-daily i.v. BU and to evaluate the influence of glutathione S-transferase (GST) gene polymorphisms on once-daily i.v. BU PK in adult Chinese patients with allogeneic HSCT, we analyzed 25 patients receiving related or unrelated donor transplant conditioned with i.v. BU-based regimens. With a median follow-up of 32.7 months, the 2-year OS and EFS were 64 and 63.8% for all the patients, respectively, and the 2-year cumulative incidence of relapse for all patients was 18.3%. On the basis of HPLC analysis, the mean clearance and mean daily area under the curve (AUC) of i.v. BU were calculated as 4.02 mL/min per kg and 3380.77 μM/min, respectively. The estimated Cmax was 1.031±0.0325 μg/mL. The estimated t1/2 and Vd values were 3.618±0.1932 h and 1.212±0.0352 L/kg. The once-daily i.v. BU-based conditioning regimen was very well tolerated with minor toxicity in patients, most likely because of dose assurance with predictable PK. There was no GSTA1 *B/*B homozygous patient in our Chinese patients. A significant association between BU metabolism and GSTA1 polymorphism was observed. The GSTA1 *A/*B genotype group showed a significantly higher AUC (P<0.0001), higher Cmax (P=0.0003) and lower clearance (P=0.0007) than the GSTA1 *A/*A genotype group. AUC was lower in GSTP1 *A/*A genotypes compared with*A/*G (P=0.0283) and *G/*G genotypes (P=0.0111). The BU clearance in GSTP1 *A/*A genotype was shown to be higher than *A/*G (P=0.0255) and *G/*G genotypes (P=0.0111). In addition, the differences of PK in BU among different ethnic groups existed because of the different distribution frequencies of GST gene polymorphism in Chinese patients and Caucasian patients.
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Ayala E, Figueroa J, Perkins J, Kim J, Yue B, Riches M, Nishihori T, Locke F, Anasetti C, Kharfan-Dabaja MA. Myeloablative intravenous pharmacokinetically targeted busulfan plus fludarabine as conditioning for allogeneic hematopoietic cell transplantation in patients with non-Hodgkin lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:335-40. [PMID: 25659459 DOI: 10.1016/j.clml.2014.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/29/2014] [Accepted: 12/30/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mortality associated with allogeneic hematopoietic cell transplantation (allo-HCT) has limited its broader application in patients with non-Hodgkin lymphoma (NHL). Pharmacokinetic treatment with targeted intravenous busulfan combined with fludarabine (BuFlu) was developed as a preparative regimen for acute leukemia and myelodysplasia. Data from this regimen in lymphoid malignancies are limited. PATIENTS AND METHODS We assessed outcomes in 60 consecutive patients with various subtypes of NHL and a median age of 54 years (range, 27-68 years) who received allo-HCT with targeted intravenous BuFlu between December 2004 and August 2010. The median number of previous therapies was 3 (range, 1-8) and median time from diagnosis to HCT was 32 months (range, 4.5-177.5 months). RESULTS At conditioning, 28 (47%) patients had a complete response (CR). Graft versus host disease (GVHD) prophylaxis consisted of tacrolimus plus methotrexate in 65% of cases. Donors were matched/related (n = 32 [53%]), matched/unrelated (n = 21 [35%]), or mismatched/unrelated (n = 7 [12%]). All patients underwent grafting. The cumulative incidence of grade II/IV acute GVHD was 74% (grade III/IV was 20%). The 2-year cumulative incidence of moderate to severe chronic GVHD was 62%. Nonrelapse mortality (NRM) at 100 days and 3 years was 10% and 25%, respectively. The cumulative incidence of relapse was 27%. Three-year progression-free and overall survival for all patients was 47.8% and 55%, respectively. CONCLUSION Targeted intravenous BuFlu is a relatively well tolerated regimen and offers an alternative option when myeloablation is deemed necessary in patients with NHL.
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Affiliation(s)
- Ernesto Ayala
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, FL.
| | - Javier Figueroa
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL
| | - Janelle Perkins
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL
| | - Jongphil Kim
- Department of Biostatistics, Moffitt Cancer Center, Tampa, FL
| | - Binglin Yue
- Department of Biostatistics, Moffitt Cancer Center, Tampa, FL
| | - Marcie Riches
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, FL
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, FL
| | - Frederick Locke
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, FL
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, FL
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, FL
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Song G, Valdez BC, Li Y, Dominguez JR, Corn P, Champlin RE, Andersson BS. The histone deacetylase inhibitor SAHA sensitizes acute myeloid leukemia cells to a combination of nucleoside analogs and the DNA-alkylating agent busulfan. Leuk Lymphoma 2014; 55:1625-34. [PMID: 24144307 DOI: 10.3109/10428194.2013.856007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Fludarabine (Flu), clofarabine (Clo) and busulfan (Bu) are used in allogeneic hematopoietic stem cell transplant (allo-HSCT). We reported that combining [Flu + Clo + Bu] had a synergistic cytotoxicity in AML cells. We hypothesized that combining [Flu + Clo + Bu] with the histone deacetylase inhibitor SAHA will further enhance cytotoxicity. We exposed the acute myeloid leukemia (AML) cell lines KBM3/Bu250(6) and OCI-AML3 to Flu, Clo, Bu and SAHA alone and in various combinations. [Flu + Clo + Bu + SAHA] resulted in synergistic cytotoxicity, which can be attributed to (1) activated DNA-damage response and cell cycle checkpoint activation through the ATM-CHK2-P53 (or P73) pathway or ATM-CHK2-cdc25-cdc2 pathway, (2) histone modifications and (3) activated apoptosis pathway. The [Flu + Clo + Bu + SAHA] combination causes mitochondrial outer membrane permeabilization, leakage of cytochrome c and Smac/Diablo into the cytosol with caspase activation, and release of apoptosis-inducing factor (AIF) into the nucleus resulting in nuclear fragmentation and cell death. These results provide a mechanistic basis for using SAHA in future clinical trials with double nucleoside analog-busulfan combinations in pretransplant conditioning therapy.
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Affiliation(s)
- Guiyun Song
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M. D. Anderson Cancer Center , Houston, TX , USA
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14
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Kunter G, Perkins JB, Pidala J, Nishihori T, Kharfan-Dabaja MA, Field T, Fernandez H, Perez L, Locke F, Ayala E, Tomblyn M, Ochoa-Bayona JL, Betts B, Nieder M, Anasetti C. Pharmacokinetically-targeted BU and fludarabine as conditioning before allogeneic hematopoietic cell transplantation for adults with ALL in first remission. Bone Marrow Transplant 2013; 49:11-6. [PMID: 23995098 DOI: 10.1038/bmt.2013.121] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 06/03/2013] [Accepted: 06/28/2013] [Indexed: 01/22/2023]
Abstract
Allogeneic hematopoietic cell transplantation offers improved survival in patients with ALL, but with regimens containing TBI, the nonrelapse mortality is 20-40%. Efforts to lessen transplant toxicities by reducing conditioning regimen intensity have led to increased relapse risk. Therefore, there is a need for less toxic regimens that maintain an anti-leukemia effect. We report here a retrospective review of 65 patients with ALL in first remission receiving grafts from allogeneic donors after fludarabine 40 mg/m(2)/day for 4 days and i.v. BU targeted to a median daily area under the concentration-time curve below 6000 μmoles min/L. At 2 years after transplantation, OS was 65% (95% confidence interval (CI): 52-77%), relapse-free survival was 61% (95% CI: 48-73%), cumulative incidence of relapse was 26% (95% CI: 17-39%) and cumulative incidence of nonrelapse mortality was 14% (95% CI: 8-26%). Age over 35 years, Ph chromosome positivity and minimal residual disease at transplant did not adversely affect outcomes. Pharmacokinetically targeted BU and fludarabine can provide intensive pre-transplant conditioning for adults with ALL in first remission, with promising relapse-free and OS rates.
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Affiliation(s)
- G Kunter
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - J B Perkins
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - J Pidala
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - T Nishihori
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - M A Kharfan-Dabaja
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - T Field
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - H Fernandez
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - L Perez
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - F Locke
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - E Ayala
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - M Tomblyn
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - J L Ochoa-Bayona
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - B Betts
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - M Nieder
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - C Anasetti
- 1] Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA [2] Oncologic Sciences, University of South Florida, Tampa, FL, USA
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Perkins JB, Kim J, Anasetti C, Fernandez HF, Perez LE, Ayala E, Kharfan-Dabaja MA, Tomblyn MR, Sullivan DM, Pidala JA, Field TL. Maximally Tolerated Busulfan Systemic Exposure in Combination with Fludarabine as Conditioning before Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2012; 18:1099-107. [DOI: 10.1016/j.bbmt.2011.12.584] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/21/2011] [Indexed: 11/12/2022]
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