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Krishnamurti L, Liang J, He Z, Deng Y, Nallagatla VR, Hamidi R, Flagg A, Shah N. Incidence and risk factors of pain crisis after hematopoietic cell transplantation for sickle cell disease. Blood Adv 2024; 8:1908-1919. [PMID: 38324722 PMCID: PMC11021890 DOI: 10.1182/bloodadvances.2023010749] [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: 05/15/2023] [Revised: 01/09/2024] [Accepted: 01/14/2024] [Indexed: 02/09/2024] Open
Abstract
ABSTRACT Vaso-occlusive episodes (VOC) or pain crises are the most common indications for hematopoietic cell transplantation (HCT) for sickle cell disease (SCD). Elimination of pain crisis after HCT is an important patient-centered outcome and may improve understanding of the natural history of pain syndromes in SCD. We examined deidentified records of 763 patients followed-up for a median of 36.7 months (range, 0.3-168.6 months), with 69.6% patient's age <18 years at HCT, 83.3% patient's Karnofsky-Lansky performance score (KPS) ≥90, overall survival 92.9%, event-free survival 72.4%, graft failure (GF) 22.4%, AGVHD 21.4%, CGVHD 27%, and pain crisis 8.65%. On unadjusted logistic regression, increased risk of pain crisis after HCT was observed in patient's aged >10 years at HCT (range, 11-17 years; OR, 9.43; 95% CI, 3.20-27.79; P < .0001), in age ≥18 years (OR, 16.62; 95% CI, 5.85-47.16; P < .0001), in those with history of pain crisis 2 years before HCT (OR, 13.16; 95% CI, 4.08-42.42; P < .0001), alternate donors (haploidentical [OR, 4.80; 95% CI, 2.48-9.31; P < .0001], unrelated matched [OR, 2.71; 95% CI, 1.23-5.97; P = .0132], and mismatched unrelated [OR, 3.19; 95% CI, 1.44-7.05; P = .0041], and those with GF (n = 41 [5.37%]; OR, 7.15; 95% CI, 4.20-12.18; P < .0001). Pain crisis was less frequent with KPS of ≥90 (OR, 0.31; 95% CI, 0.18-0.55; P < .0001). Multivariable logistic regression models confirmed age at HCT, KPS, graft type, donor type, history of VOC 2 years before HCT, and GF as independent predictors of pain crisis after HCT and generated predictive models and nomograms for pain crisis after HCT for SCD, which can support shared decision making.
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Affiliation(s)
- Lakshmanan Krishnamurti
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
| | - Jingchen Liang
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Zili He
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Vineetha R. Nallagatla
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
| | | | - Aron Flagg
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
| | - Niketa Shah
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
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Shah NC, Flagg A, Hamidi R, Hugo H, Deng Y, Krishnamurti L. The Impact of Current Conditioning Regimen, T Cell Depletion and Graft Versus Host Disease Prophylaxis on the Outcomes of Allogeneic Hematopoietic Stem Cell Transplantation for Sickle Cell Disease. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00448-7] [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: 02/07/2023]
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Hamidi R, He Z, Deng Y, Flagg A, Shah NC, Krishnamurti L. Avascular Necrosis Following Hematopoietic Cell Transplantation for Sickle Cell Disease. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00461-x] [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: 02/07/2023]
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Krishnamurti L, He Z, Deng Y, Hamidi R, Flagg A, Shah NC. Vaso-Occlusive Pain Requiring Hospitalization or Treatment Is Rare Following Successful Hematopoietic Cell Transplantation for Sickle Cell Disease. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00453-0] [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: 02/07/2023]
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Flagg A, Hamidi R, He Z, Deng Y, Shah NC, Krishnamurti L. Endothelial Complications of Hematopoietic Cell Transplantation for Sickle Cell Disease. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00459-1] [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: 02/07/2023]
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Go RS, Jacobsen E, Baiocchi R, Buhtoiarov I, Butler EB, Campbell PK, Coulter DW, Diamond E, Flagg A, Goodman AM, Goyal G, Gratzinger D, Hendrie PC, Higman M, Hogarty MD, Janku F, Karmali R, Morgan D, Raldow AC, Stefanovic A, Tantravahi SK, Walkovich K, Zhang L, Bergman MA, Darlow SD. Histiocytic Neoplasms, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:1277-1303. [PMID: 34781268 DOI: 10.6004/jnccn.2021.0053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Histiocytic neoplasms are rare hematologic disorders accounting for less than 1% of cancers of the soft tissue and lymph nodes. Clinical presentation and prognosis of these disorders can be highly variable, leading to challenges for diagnosis and optimal management of these patients. Treatment often consists of systemic therapy, and recent studies support use of targeted therapies for patients with these disorders. Observation ("watch and wait") may be sufficient for select patients with mild disease. These NCCN Guidelines for Histiocytic Neoplasms include recommendations for diagnosis and treatment of adults with the most common histiocytic disorders: Langerhans cell histiocytosis, Erdheim-Chester disease, and Rosai-Dorfman disease.
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Affiliation(s)
| | - Eric Jacobsen
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | - Robert Baiocchi
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Ilia Buhtoiarov
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute Cleveland Clinic Children's Hospital
| | | | - Patrick K Campbell
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | - Aron Flagg
- Yale Cancer Center/Smilow Cancer Hospital
| | | | | | | | - Paul C Hendrie
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Filip Janku
- The University of Texas MD Anderson Cancer Center
| | - Reem Karmali
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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Bhunia N, Ondrejka S, Flagg A, Buhtoiarov IN. Classical Hodgkin Lymphoma of cystic thymus in a patient with infectious mononucleosis: Diagnostic challenges and practical considerations. Pediatric Hematology Oncology Journal 2021. [DOI: 10.1016/j.phoj.2021.03.002] [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: 10/21/2022] Open
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Pruitt J, Flagg A, Hanna R, Rotz SJ. Brachial plexus chloroma as a presenting feature of relapse in a child with KMT2A-rearranged acute lymphoblastic leukemia, a case report. Pediatr Hematol Oncol 2021; 38:179-183. [PMID: 33150840 PMCID: PMC7987733 DOI: 10.1080/08880018.2020.1826071] [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: 10/23/2022]
Abstract
Approximately 30–40% of relapses in pediatric acute lymphoblastic leukemia (ALL) are extra-medullary. KMT2A gene rearrangements are common in patients with infantile ALL. Chloromas are rare tumors composed of collections of acute leukemic cells that typically involve the bone or skin. Exceptionally uncommon, chloromas invade the peripheral nervous system, a phenomenon termed “neuroleukemiosis.” We describe A 6-year-old girl with a history of pre-B ALL with CNS involvement and KMT2A rearrangement diagnosed initially at 4 months of age. During continuation therapy she developed a scalp mass that was confirmed to be a leukemic relapse. She underwent re-induction chemotherapy followed by blinatumomab with subsequent remission and proceeded to allogeneic hematopoietic cell transplant (HCT). Three years following HCT, she presented with brachial plexus palsy and was found to have a lymphoblastic chloroma invading the brachial plexus. Review of existing literature shows relapse in pediatric ALL patients presenting as brachial plexus chloroma has only been documented once before. It has long been suggested that KMT2A gene rearrangements play a role in development of chloromas in patients with AML, however it is still unclear what role KMT2A has in ALL. Here we report a rare case of ALL relapse that presented as a left arm palsy secondary to a leukemic chloroma invading the brachial plexus and aim to explore the potential role of KMT2A in the formation of ALL chloromas.
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Affiliation(s)
- Jamie Pruitt
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Aron Flagg
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rabi Hanna
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Seth J. Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
Megaloblastic anemia causes macrocytic anemia from ineffective red blood cell production and intramedullary hemolysis. The most common causes are folate (vitamin B9) deficiency and cobalamin (vitamin B12) deficiency. Megaloblastic anemia can be diagnosed based on characteristic morphologic and laboratory findings. However, other benign and neoplastic diseases need to be considered, particularly in severe cases. Therapy involves treating the underlying cause-eg, with vitamin supplementation in cases of deficiency, or with discontinuation of a suspected medication.
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Affiliation(s)
- Daniel S Socha
- Department of Laboratory Medicine, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic
| | - Sherwin I DeSouza
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic
| | - Aron Flagg
- Department of Pediatric Hematology and Oncology, Yale School of Medicine, New Haven, CT
| | - Mikkael Sekeres
- Department of Hematology and Medical Oncology and Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic.,Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve, Cleveland, OH
| | - Heesun J Rogers
- Department of Laboratory Medicine, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic .,Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Dandoy CE, Kim S, Chen M, Ahn KW, Ardura MI, Brown V, Chhabra S, Diaz MA, Dvorak C, Farhadfar N, Flagg A, Ganguly S, Hale GA, Hashmi SK, Hematti P, Martino R, Nishihori T, Nusrat R, Olsson RF, Rotz SJ, Sung AD, Perales MA, Lindemans CA, Komanduri KV, Riches ML. Incidence, Risk Factors, and Outcomes of Patients Who Develop Mucosal Barrier Injury-Laboratory Confirmed Bloodstream Infections in the First 100 Days After Allogeneic Hematopoietic Stem Cell Transplant. JAMA Netw Open 2020; 3:e1918668. [PMID: 31913492 PMCID: PMC6991246 DOI: 10.1001/jamanetworkopen.2019.18668] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Patients undergoing hematopoietic stem cell transplant (HSCT) are at risk for bloodstream infection (BSI) secondary to translocation of bacteria through the injured mucosa, termed mucosal barrier injury-laboratory confirmed bloodstream infection (MBI-LCBI), in addition to BSI secondary to indwelling catheters and infection at other sites (BSI-other). OBJECTIVE To determine the incidence, timing, risk factors, and outcomes of patients who develop MBI-LCBI in the first 100 days after HSCT. DESIGN, SETTING, AND PARTICIPANTS A case-cohort retrospective analysis was performed using data from the Center for International Blood and Marrow Transplant Research database on 16 875 consecutive pediatric and adult patients receiving a first allogeneic HSCT from January 1, 2009, to December 31, 2016. Patients were classified into 4 categories: MBI-LCBI (1481 [8.8%]), MBI-LCBI and BSI-other (698 [4.1%]), BSI-other only (2928 [17.4%]), and controls with no BSI (11 768 [69.7%]). Statistical analysis was performed from April 5 to July 17, 2018. MAIN OUTCOMES AND MEASURES Demographic characteristics and outcomes, including overall survival, chronic graft-vs-host disease, and transplant-related mortality (only for patients with malignant disease), were compared among groups. RESULTS Of the 16 875 patients in the study (9737 [57.7%] male; median [range] age, 47 [0.04-82] years) 13 686 (81.1%) underwent HSCT for a malignant neoplasm, and 3189 (18.9%) underwent HSCT for a nonmalignant condition. The cumulative incidence of MBI-LCBI was 13% (99% CI, 12%-13%) by day 100, and the cumulative incidence of BSI-other was 21% (99% CI, 21%-22%) by day 100. Median (range) time from transplant to first MBI-LCBI was 8 (<1 to 98) days vs 29 (<1 to 100) days for BSI-other. Multivariable analysis revealed an increased risk of MBI-LCBI with poor Karnofsky/Lansky performance status (hazard ratio [HR], 1.21 [99% CI, 1.04-1.41]), cord blood grafts (HR, 2.89 [99% CI, 1.97-4.24]), myeloablative conditioning (HR, 1.46 [99% CI, 1.19-1.78]), and posttransplant cyclophosphamide graft-vs-host disease prophylaxis (HR, 1.85 [99% CI, 1.38-2.48]). One-year mortality was significantly higher for patients with MBI-LCBI (HR, 1.81 [99% CI, 1.56-2.12]), BSI-other (HR, 1.81 [99% CI, 1.60-2.06]), and MBI-LCBI plus BSI-other (HR, 2.65 [99% CI, 2.17-3.24]) compared with controls. Infection was more commonly reported as a cause of death for patients with MBI-LCBI (139 of 740 [18.8%]), BSI (251 of 1537 [16.3%]), and MBI-LCBI plus BSI (94 of 435 [21.6%]) than for controls (566 of 4740 [11.9%]). CONCLUSIONS AND RELEVANCE In this cohort study, MBI-LCBI, in addition to any BSIs, were associated with significant morbidity and mortality after HSCT. Further investigation into risk reduction should be a clinical and scientific priority in this patient population.
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Affiliation(s)
- Christopher E. Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Soyoung Kim
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
| | - Min Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
| | - Monica I. Ardura
- Division of Infectious Disease, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Valerie Brown
- Division of Pediatric Oncology/Hematology, Department of Pediatrics, Penn State Hershey Children’s Hospital and College of Medicine, Hershey, Pennsylvania
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Divsion of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Nino Jesus, Madrid, Spain
| | - Christopher Dvorak
- Divsion of Pediatric Allergy, Immunology & Bone Marrow Transplantation, Benioff Children’s Hospital, University of California, San Francisco
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville
| | - Aron Flagg
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Yale New Haven Hospital, New Haven, Connecticut
| | - Siddartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City
| | - Gregory A. Hale
- Department of Hematology/Oncology, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Shahrukh K. Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin, Madison
| | - Rodrigo Martino
- Division of Clinical Hematology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Roomi Nusrat
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Richard F. Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Seth J. Rotz
- Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children’s Hospital, Cleveland, Ohio
| | - Anthony D. Sung
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Caroline A. Lindemans
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht University, Netherlands
- Division of Pediatric Stem Cell Transplantation, Department of Pediatrics, Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Marcie L. Riches
- Division of Hematology/Oncology, The University of North Carolina at Chapel Hill
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Mahat U, Dermawan JKT, Herman R, Mamoun I, Flagg A. Ovarian Torsion in an Adolescent with Beckwith-Wiedemann Syndrome and Unilateral Tubo-ovarian Hyperplasia. J Pediatr Adolesc Gynecol 2019; 32:446-449. [PMID: 30981832 DOI: 10.1016/j.jpag.2019.04.008] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 04/02/2019] [Accepted: 04/06/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Beckwith-Wiedemann syndrome (BWS) is the most common pediatric overgrowth syndrome. BWS has a broad phenotypic presentation along with an increased propensity to develop various embryonal tumors. There are very few reported cases of gonadal hyperplasia in BWS patients in the existing literature. CASE We describe a 13-year-old girl with BWS who presented with an episode of abdominal pain and was found to have torsion and necrosis of a markedly hyperplastic right ovary and fallopian tube. We present a brief literature review on ovarian hyperplasia in BWS patients for which we used an online search of the databases PubMed, Embase, Ovid Medline, and Cochrane. RESULTS AND CONCLUSION Through an extensive literature search, we only found 3 previous reports of ovarian hyperplasia in BWS patients, all in postmortem specimens. Our case highlights a potentially important aspect of visceral organ hyperplasia in patients with BWS that could remain indolent until adolescence and might present as an abrupt-onset abdominopelvic catastrophe.
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Affiliation(s)
- Upendra Mahat
- Department of Pediatric Hematology Oncology and BMT, Cleveland Clinic Children's, Cleveland, Ohio.
| | | | - Richard Herman
- Department of Pediatric Surgery, Cleveland Clinic Children's, Cleveland, Ohio
| | - Ihsan Mamoun
- Department of Pediatric Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Aron Flagg
- Department of Pediatric Hematology Oncology and BMT, Cleveland Clinic Children's, Cleveland, Ohio
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Mathanda R, Hamilton BK, Rybicki L, Advani AS, Bolwell B, Flagg A, Hanna R, Kalaycio ME, Sobecks RM, Majhail NS, Rotz SJ. Time to Transplantation (TTT) for Acute Myeloid Leukemia (AML) in First Complete Remission (CR1) Is Comparable Among Adolescent and Young Adults (AYAs) and Older Adults. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.409] [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: 12/01/2022]
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13
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Le J, Zembillas A, Stanton M, Dahl E, Hanna R, Flagg A, Rivard K, Gonzalez B. Letermovir for Secondary Cytomegalovirus (CMV) Prophylaxis in a Pediatric Stem Cell Transplant Patient. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Arepalli S, Flagg A, Venkat A, Singh AD. Sporadic Burkitt Lymphoma with Orbital Extramedullary Infiltration. Ocul Oncol Pathol 2019; 5:46-49. [PMID: 30675476 DOI: 10.1159/000488710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 02/15/2018] [Revised: 03/23/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND/AIMS Sporadic Burkitt lymphoma is rarely associated with orbital involvement. METHODS We present a case of sporadic Burkitt lymphoma with extramedullary subperiosteal leukemic infiltrates of the orbit and facial bones. RESULTS Follow-up examination after chemotherapy and disease remission reveals resolution of the subperiosteal infiltrates. CONCLUSION Despite an aggressive presentation, cure is common with appropriate, intensive treatment. To our knowledge, this report is the first to photographically depict the resolution of extramedullary orbital subperiosteal leukemic infiltrates after appropriate chemotherapy.
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Affiliation(s)
- Sruthi Arepalli
- Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Aron Flagg
- Department of Pediatric Hematology/Oncology and Blood and Marrow Transplant, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arthi Venkat
- Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Arun D Singh
- Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Patterson AR, Endale M, Lampe K, Flagg A, Woodgett J, Bleesing J, Hoebe K. Gimap5-dependent inactivation of GSK3β is required for CD4+ T cell homeostasis and prevention of immune pathology. The Journal of Immunology 2018. [DOI: 10.4049/jimmunol.200.supp.116.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
GTPase of immunity-associated protein 5 (Gimap5) has been linked with lymphocyte survival, autoimmunity and colitis, but its mechanisms of action are unclear. Here we show that Gimap5 is essential for inactivation of glycogen synthase kinase-3β (GSK3β) following T cell activation. In the absence of Gimap5, constitutive GSK3β activity constrains c-Myc induction as well as NFATc1 nuclear import, thereby reducing the frequency of CD4+ T cells that complete cell cycle. Additionally, Gimap5 facilitates phosphorylation of GSK3β at Ser389 and its nuclear translocation. Impairment in the latter steps of GSK3β regulation by Gimap5 is associated with increased DNA damage and reduced survival of activated CD4+ T cells. Importantly, pharmacological targeting and genetic deletion of GSK3β in mice can override Gimap5-deficiency in CD4+ T cells, limiting DNA damage and enhancing T cell proliferation and survival. Additionally, this ameliorates immune-mediated pathology in vivo caused by loss of Gimap5. Finally, we show that a human patient with a GIMAP5 loss-of-function mutation has lymphopenia and impaired T cell proliferation. T cells from this patient exhibit impaired proliferation, but can be rescued in vitro with GSK3 inhibitors. Given the restricted expression of Gimap5 in lymphocytes, we propose that its control of GSK3b activity is an important checkpoint in lymphocyte proliferation and function.
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Affiliation(s)
| | | | | | | | - James Woodgett
- 4The Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Canada
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Flagg A, Money L, Bielek K, Majhail NS, Kalaycio ME, Dean RM, Gerds AT, Hill BT, Liu H, Hamilton BK, Jagadeesh D, Sobecks RM, Hanna R. Resolution of Secondary Thrombocytopenia with Thrombopoietin Receptor Agonists in Two Allogeneic Hematopoietic Cell Transplant Recipients Treated at a Pediatric Center. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.542] [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: 10/18/2022]
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Patel SS, Rybicki L, Yurch M, Thomas D, Jagadeesh D, Dean RM, Liu H, Flagg A, Gerds AT, Hill BT, Hanna R, Hamilton BK, Pohlman B, Kalaycio ME, Bolwell B, Zhang A, Majhail NS, Askar M, Sobecks RM. Impact of MHC Class I Chain-Related Gene a (MICA) Mismatch on Haploidentical Hematopoietic Cell Transplantation Outcomes. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.428] [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: 11/30/2022]
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18
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Patel SS, Rybicki L, Corrigan D, Jagadeesh D, Dean RM, Liu H, Flagg A, Gerds AT, Hill BT, Hanna R, Bolwell B, Pohlman B, Kalaycio ME, Sobecks RM, Majhail NS, Hamilton BK. Propensity Matched Analysis of Autologous Hematopoietic Stem Cell Transplantation Outcomes in Solid Organ Transplant Recipients. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.255] [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: 11/25/2022]
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Patel SS, Rybicki L, Yurch M, Thomas D, Jagadeesh D, Dean RM, Liu H, Flagg A, Cober E, Mossad SB, Gerds AT, Hill BT, Hanna R, Hamilton BK, Pohlman B, Kalaycio ME, Bolwell B, Zhang A, Majhail NS, Askar M, Sobecks RM. Impact of MHC Class I Chain-Related Gene a (MICA) Mismatch on Umbilical Cord Blood Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.300] [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: 10/18/2022]
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20
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Ramgopal A, Hanna R, Flagg A, Buhtoiarov I, Majhail NS, Dean RM, Hamilton BK, Gerds AT, Money L, Bielek K. Safety of Allogeneic HCT in Beta Thalassemia Patients with Chronic Hepatitis C Virus Infections Treated at a Pediatric Center. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.479] [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: 11/25/2022]
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21
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Patterson AR, Endale M, Lampe K, Aksoylar HI, Flagg A, Woodgett JR, Hildeman D, Jordan MB, Singh H, Kucuk Z, Bleesing J, Hoebe K. Gimap5-dependent inactivation of GSK3β is required for CD4 + T cell homeostasis and prevention of immune pathology. Nat Commun 2018; 9:430. [PMID: 29382851 PMCID: PMC5789891 DOI: 10.1038/s41467-018-02897-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 01/08/2018] [Indexed: 12/16/2022] Open
Abstract
GTPase of immunity-associated protein 5 (Gimap5) is linked with lymphocyte survival, autoimmunity, and colitis, but its mechanisms of action are unclear. Here, we show that Gimap5 is essential for the inactivation of glycogen synthase kinase-3β (GSK3β) following T cell activation. In the absence of Gimap5, constitutive GSK3β activity constrains c-Myc induction and NFATc1 nuclear import, thereby limiting productive CD4+ T cell proliferation. Additionally, Gimap5 facilitates Ser389 phosphorylation and nuclear translocation of GSK3β, thereby limiting DNA damage in CD4+ T cells. Importantly, pharmacological inhibition and genetic targeting of GSK3β can override Gimap5 deficiency in CD4+ T cells and ameliorates immunopathology in mice. Finally, we show that a human patient with a GIMAP5 loss-of-function mutation has lymphopenia and impaired T cell proliferation in vitro that can be rescued with GSK3 inhibitors. Given that the expression of Gimap5 is lymphocyte-restricted, we propose that its control of GSK3β is an important checkpoint in lymphocyte proliferation. Loss of function GIMAP5 mutation is associated with lymphopenia, but how it mediates T cell homeostasis is unclear. Here the authors study Gimap5−/− mice and a patient with GIMAP5 deficiency to show how this GTPAse negatively regulates GSK3β activity to prevent DNA damage and cell death.
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Affiliation(s)
- Andrew R Patterson
- Division of Immunobiology, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,Immunology Graduate Program, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, 231 Albert Sabin Way # E251n, Cincinnati, OH, 45267, USA
| | - Mehari Endale
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Kristin Lampe
- Division of Immunobiology, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Halil I Aksoylar
- Department of Genetics and Complex Diseases, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Aron Flagg
- Pediatric Hematology/Oncology and Blood & Marrow Transplant, Cleveland Clinic Children's, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Jim R Woodgett
- The Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - David Hildeman
- Division of Immunobiology, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,Immunology Graduate Program, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, 231 Albert Sabin Way # E251n, Cincinnati, OH, 45267, USA
| | - Michael B Jordan
- Division of Immunobiology, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,Immunology Graduate Program, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, 231 Albert Sabin Way # E251n, Cincinnati, OH, 45267, USA
| | - Harinder Singh
- Division of Immunobiology, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,Immunology Graduate Program, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, 231 Albert Sabin Way # E251n, Cincinnati, OH, 45267, USA
| | - Zeynep Kucuk
- Division of Bone Marrow Transplantation & Immune Deficiency, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Jack Bleesing
- Division of Bone Marrow Transplantation & Immune Deficiency, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Kasper Hoebe
- Division of Immunobiology, Cincinnati Children's Hospital Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,Immunology Graduate Program, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, 231 Albert Sabin Way # E251n, Cincinnati, OH, 45267, USA. .,Department of Pediatrics, University of Cincinnati, College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA.
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22
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Coelho R, Hanna R, Flagg A, Stempak LM, Ondrejka S, Procop GW, Harrington S, Zembillas A, Kusick K, Gonzalez BE. Mycobacterium genavense-induced spindle cell pseudotumor in a pediatric hematopoietic stem cell transplant recipient: Case report and review of the literature. Transpl Infect Dis 2017; 19. [PMID: 28039955 DOI: 10.1111/tid.12656] [Citation(s) in RCA: 7] [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] [Received: 06/28/2016] [Revised: 09/16/2016] [Accepted: 09/25/2016] [Indexed: 11/30/2022]
Abstract
We describe the first reported pediatric patient to our knowledge with a spindle cell pseudotumor caused by Mycobacterium genavense in a hematopoietic stem cell transplant recipient, and review the literature of such an entity in the transplant population.
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Affiliation(s)
- Ritika Coelho
- Center for Pediatric Infectious Diseases, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Rabi Hanna
- Centers for Hematology - Oncology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Aron Flagg
- Centers for Hematology - Oncology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Lisa M Stempak
- Departments of Pathology and Laboratory Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.,Department of Pharmacy, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Sarah Ondrejka
- Departments of Pathology and Laboratory Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Gary W Procop
- Departments of Pathology and Laboratory Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Susan Harrington
- Departments of Pathology and Laboratory Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Anthony Zembillas
- Department of Pharmacy, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Karissa Kusick
- Department of Pharmacy, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Blanca E Gonzalez
- Center for Pediatric Infectious Diseases, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
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23
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Dhir A, Hanna R, Rybicki L, Abounader D, Flagg A, Hamilton BK, Hill B, Jagadeesh D, Liu H, Gerds A, Kalaycio ME, Bolwell B, Majhail NS. Incidence and Risk Factors for Central Nervous System Relapse after Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acute Leukemia. Biol Blood Marrow Transplant 2016. [DOI: 10.1016/j.bbmt.2015.11.592] [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: 11/29/2022]
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24
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Nakashima MO, Shetty S, Chicka M, Flagg A, Eng C, Cotta CV. Transient abnormal myelopoiesis of a newborn not associated with chromosome 21 abnormalities or GATA1 mutations. Pediatr Blood Cancer 2015; 62:353-355. [PMID: 25175265 DOI: 10.1002/pbc.25226] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/25/2014] [Indexed: 11/06/2022]
Abstract
Transient abnormal myelopoiesis (TAM) is a disorder of Down syndrome newborns characterized by megakaryocytic blasts indistinguishable from acute myeloid leukemia (AML), which undergoes spontaneous remission. Acquired GATA1 mutations are present in blasts of both TAM and the subsequent AML which sometimes develops. We present a unique case of a newborn with leukemic megakaryoblasts indistinguishable from those of TAM who had neither extra material from chromosome 21 in the germline or blasts, nor evidence of GATA1 mutations. These findings suggest there are other genetic abnormalities that can lead to TAM besides GATA1 mutation in the setting of trisomy 21. Pediatr Blood Cancer 2015;62:353-355. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Megan O Nakashima
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, 44195, Ohio
| | - Shashirekha Shetty
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, 44195, Ohio
| | | | - Aron Flagg
- Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charis Eng
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Claudiu V Cotta
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, 44195, Ohio
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25
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Tran CN, Collie AM, Flagg A, Rhee A. Testicular Myeloid Sarcoma: A Rare Manifestation of Acute Myeloid Leukemia in an Infant. Urology 2014; 84:925-7. [DOI: 10.1016/j.urology.2014.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/27/2014] [Accepted: 07/01/2014] [Indexed: 11/26/2022]
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26
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Flagg A, Hanna R, Mossad SB, Rybicki L, Hamilton BK, Gerds A, Sobecks R, Duong H, Andresen S, Bolwell B, Majhail NS, Kalaycio ME. Risk Factors for Infections in Recipients of Hematopoietic Cell Transplantation in Relation to Donor Source. Biol Blood Marrow Transplant 2014. [DOI: 10.1016/j.bbmt.2013.12.320] [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: 11/29/2022]
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27
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Stokken J, Manz RM, Flagg A, Kate Gowans L, Anne S. Synchronous occurrence of nasopharyngeal carcinoma and Hodgkin lymphoma. Int J Pediatr Otorhinolaryngol 2014; 78:154-6. [PMID: 24290306 DOI: 10.1016/j.ijporl.2013.10.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 07/11/2013] [Revised: 10/16/2013] [Accepted: 10/19/2013] [Indexed: 11/17/2022]
Abstract
Latent Epstein-Barr virus infection is associated with several lymphoid and epithelial malignancies. This is the first reported case of a patient presenting with synchronous nasopharyngeal carcinoma and Hodgkin lymphoma associated with Epstein-Barr virus. A 17-year-old previously healthy African-American male presented with anterior mediastinal mass and a nasopharyngeal mass. Histology from biopsy of both lesions revealed evidence of Epstein-Barr virus. The patient successfully completed sequential therapies with chemo radiation with no evidence of active disease. Simultaneous occurrence of the two malignancies is undoubtedly a rare event, and their coexistence raises the question of a common etiologic factor.
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Affiliation(s)
- Janalee Stokken
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA
| | - Ryan M Manz
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA
| | - Aron Flagg
- Cleveland Clinic, Department of Pediatric Hematology and Oncology, Cleveland, OH, USA
| | - L Kate Gowans
- Cleveland Clinic, Department of Pediatric Hematology and Oncology, Cleveland, OH, USA
| | - Samantha Anne
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA.
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28
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Marcotty A, Flagg A, Nasman C, Brubaker J, Boyle G. 587 Long-Term Outcomes in Pediatric Heart Transplant Recipients Treated for Neoplasia: A Single-Institution Experience. J Heart Lung Transplant 2011. [DOI: 10.1016/j.healun.2011.01.599] [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: 10/18/2022] Open
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29
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Abstract
Ventricular fibrillation (VF) is a leading cause of sudden death. Electrical defibrillation is the primary modality of treatment, but evidence is accumulating that its use in the late stage of VF prior to providing ventilation, chest compressions and the administration of appropriate medication is detrimental. In VF of <5 min duration a 'shock first' strategy is effective. In VF of 5> min duration a 'perfuse first' approach is more effective. Because of the difficulty in determining the duration of VF in the clinical setting we have sought to develop method which analyze 5 s intervals of VF waveform and quickly provide an estimate of duration. Such methods would be useful in directing clinical interventions. Using methods of nonlinear dynamics and fractal geometry we have previously derived a quantitative measure of VF duration, namely the scaling exponent (ScE). In this study we report on a novel method also based on nonlinear dynamics, the angular velocity (AV). By constructing a flat, circular disk-shaped structure in a three-dimensional phase space and measuring the velocity of rotation of the position vector over time, a statistic is developed which rises from 58 rad/s at 1 min to 79 rad/s at 4 min and then decreases in a linear manner to 32 rad/s at 12.5 min. Using ScE and AV probability density estimated, VF of <5 min duration can be identified with 90% sensitivity on the basis of a single 5 s recording of the waveform. The combination of ScE and AV can be used in developing strategies for the treatment of VF during the different clinical phases of VF.
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Affiliation(s)
- Lawrence D Sherman
- Department of Emergency Medicine, University of Pittsburg School of Medicine, Pittsburgh, PA 15213, USA.
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30
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Gillespie DL, Patel A, Fileta B, Chang A, Barnes S, Flagg A, Kidwell M, Villavicencio JL, Rich NM. Varicose veins possess greater quantities of MMP-1 than normal veins and demonstrate regional variation in MMP-1 and MMP-13. J Surg Res 2002; 106:233-8. [PMID: 12175972 DOI: 10.1006/jsre.2002.6455] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Studies have reported that structural proteins such as elastin and collagen are decreased in varicose veins compared to normal controls. We hypothesized that the changes observed in varicose vein wall composition may be related to alterations in extracellular matrix remodeling proteins, such as the matrix metalloproteases and serine proteases. In addition we hypothesized that there may be regional variation in the expression of these enzymes within the leg. PATIENTS AND MATERIALS One-centimeter segments of the proximal and distal greater saphenous vein (GSV) were obtained from patients undergoing ligation and stripping for venous insufficiency (vv) (n = 15) or GSV harvest in conjunction with coronary artery bypass grafting (CABG) (n = 7). All vv patients had incompetence of the GSV by color flow duplex. Vein specimens were examined for MMP-1, 3, and 13, tryptase, and GAPDH mRNA using semiquantitative RT-PCR analysis. Quantification of MMP-1 and 13 (active/latent forms) and tryptase was performed using Western blot analysis. Western blots were analyzed using scanning densitometry and standardized to normal controls and values expressed as the median densitometric index (D.I.). Nonparametric statistical methods (Wilcoxan signed rank test and Mann-Whitney U test) were used for analysis. RESULTS We were able to amplify MMP-1, MMP-13, and tryptase mRNA from both proximal and distal segments of all greater saphenous veins studied. MMP-3 mRNA, however, was not found in either segment of any of the veins examined. A semiquantitative analysis of RT-PCR products comparing the ratio of MMP-1, MMP-13, or tryptase mRNA to GAPDH mRNA showed no difference between cases and controls nor proximal vs distal vein segments. Western blot analysis revealed larger quantities of MMP-1 in varicose veins than in nondiseased veins from CABG patients (48.0 +/- 36.7 D.I. vs 12.5 +/- 6.8 D.I., P = 0.036). Investigation into the regional variation of proteases revealed lower amounts of MMP-1 in distal than in proximal vein segments (37.9 +/- 35.0 D.I. vs 44.1 +/- 41.6 D.I., P = 0.01). Similarly, we found significantly less MMP-13 in distal segments of varicose veins than in proximal segments (152.8 +/- 130.0 D.I. vs 206.7 +/- 173.3 D.I., P = 0.006). CONCLUSIONS This study found that MMP-1 protein is increased in varicose veins when compared to controls despite no differences in mRNA expression. In addition we found that there is regional variation of MMP-1 and MMP-13 in diseased varicose veins. Lower leg veins have significantly reduced amounts of these proteolytic enzymes when compared to veins of the upper thigh. These data suggest that posttranscriptional regulatory controls could be responsible for the observed differences.
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Affiliation(s)
- D L Gillespie
- Department of Surgery, Uniformed Services University, Bethesda, Maryland 20854, USA
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