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Dutra B, Garcia-Rodriguez V, Garcia R, Szafron D, Abraham F, Khurana S, Lockhart J, Amin R, Wang Y, Thomas A. Characteristics and Outcomes of Cancer Patients With Venous Thromboembolic Events After Treatment With Immune Checkpoint Inhibitors. Am J Clin Oncol 2023; 46:94-100. [PMID: 36735530 DOI: 10.1097/coc.0000000000000981] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study aimed to describe the clinical characteristics and outcomes of patients with venous thromboembolism (VTE) after Immune checkpoint inhibitors (ICI), focusing on patients with gastrointestinal (GI) immune-related adverse events (irAE). METHODS In this retrospective, single-center study, we report the clinical outcomes of adult cancer patients who developed a VTE within 2 years of ICI initiation. Patients were excluded if alternate causes of VTE were present apart from malignancy and cancer therapy. The cohort was classified into those with GI-irAE, non-GI-irAE, and no irAE. A control group with ICI exposure without irAE and VTE was selected for comparative analysis. RESULTS Of all ICI-treated patients, 1891 (17.2%) were diagnosed with VTE. In all, 501 (4.6%) had no etiology for VTE aside from malignancy and cancer therapy. Of these, 137 patients were included and classified as: 44 GI-irAE, 42 non-GI-irAE, and 51 no irAE. Chemotherapy within 6 months of ICI therapy was associated with increased VTE risk. There was no difference in the clinical course between those exposed to chemotherapy versus ICI therapy alone, time from ICI initiation to VTE, and VTE type, recurrence, or related hospitalization. While there was no difference in VTE-related mortality, the GI-irAE group was associated with lower all-cause mortality and superior overall survival. CONCLUSION Combined ICI and chemotherapy use increased VTE risk. There is a similar disease course of VTE after ICI exposure, regardless of other irAEs. Co-existing GI-irAE with VTE is associated with superior overall survival. Prospective studies are needed to evaluate the relationship between ICI therapy and VTE and irAE impact on VTE outcomes.
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Affiliation(s)
- Barbara Dutra
- Department of Internal Medicine, The University of Texas Health Science Center
| | | | | | | | - Fiyinfoluwa Abraham
- Department of Internal Medicine, The University of Texas Health Science Center
| | - Shruti Khurana
- Department of Internal Medicine, The University of Texas Health Science Center
| | - Jonathan Lockhart
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
| | - Rajan Amin
- Department of Internal Medicine, The University of Texas Health Science Center
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center
| | - Anusha Thomas
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center
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Affiliation(s)
- Barbara Dutra
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas.
| | - Shaheer Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jamie Everett
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, Texas
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Abu-Sbeih H, Zou F, Dutra B, Altan M, McQuade JL, Thompson JA, Thomas A, Wang Y. Maintenance immunosuppressive therapy with resumption of immune checkpoint inhibitor treatment to reduce recurrence of immune-mediated colitis. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.2642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2642 Background: Immune-mediated colitis (IMC) may limit immune checkpoint inhibitors (ICI) treatment. Current guidelines recommend consideration of resuming ICI when IMC symptoms subside to ≤ grade 1. We aimed to investigate the effect of maintenance immunosuppressive therapy (IST) on the outcome of IMC in patients who resume ICI therapy. Methods: We retrospectively studied patients who resumed ICI therapy after adequate treatment of IMC from March 2015 to June 2020 at MD Anderson Cancer Center. Relevant demographic, oncologic, and ICI data were collected and analyzed. Univariate logistic regression analysis was conducted to assess risk factors of IMC recurrence. Results: We included 102 patients with a median age of 61 years. 66% were males and 97% were Caucasians. 48 patients (47%) received IST maintenance in conjunction with ICI resumption and 54 patients did not. Symptoms of IMC recurred in 28 patients, 8 (17%) in the concurrent IST group and 20 (37%) in the other group. Compared to no concurrent IST group, patients on concurrent IST were more likely to have received combined ICI regimen (60% vs 41%, p = 0.003) and more initial ICI doses (9 vs 5 doses, p = 0.030). Concurrent IST group had significantly longer ICI treatment duration on resumption (72 vs 62 days, p = 0.023), more ICI resumed doses (5 vs 4 doses, p = 0.038), and lower IMC recurrence (17% vs 37%, p = 0.027). Patient who received more IST doses, both therapeutic and prophylactic, had lower rate of IMC recurrence (OR 0.72, p = 0.012; table). IST maintenance treatment (OR 0.34, p = 0.024) was associated with lower IMC recurrence rate after ICI resumption. Vedolizumab was the predominant IST used. Overall survival was comparable among the two groups (p = 0.934). Conclusions: Concurrent IST treatment with ICI resumption after IMC was associated with significantly lower IMC recurrence and more extended ICI treatment while reserving similar overall survival to patients without IST maintenance therapy. Future prospective randomized trial of concurrent IST is still merited for further clarification.[Table: see text]
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Affiliation(s)
| | - Fangwen Zou
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Barbara Dutra
- University of Texas Health Science Center, Houston, TX
| | | | | | | | - Anusha Thomas
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yinghong Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Wagner J, Garcia-Rodriguez V, Yu A, Dutra B, DuPont A, Cash B, Farooq A. Elevated D-Dimer Is Associated with Multiple Clinical Outcomes in Hospitalized Covid-19 Patients: a Retrospective Cohort Study. ACTA ACUST UNITED AC 2020; 2:2561-2567. [PMID: 33195993 PMCID: PMC7648852 DOI: 10.1007/s42399-020-00627-z] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 01/08/2023]
Abstract
D-dimer is a prognostic marker for Covid-19 disease mortality and severity in hospitalized patients; however, little is known about the association between D-dimer and other clinical outcomes. The aim of this paper was to define a threshold of D-dimer to use in hospitalized patients with Covid-19 and to assess its utility in prognosticating in-hospital mortality, development of an acute kidney injury (AKI), and need for hemodialysis, vasopressors, or intubation. This is a single-center, retrospective, cohort review study of 100 predominantly minority patients (94%) hospitalized with Covid-19. The electronic medical record system was used to collect data. Receiver operating characteristics (ROC) and area under the curve (AUC) analysis were used to determine optimal thresholds of peak D-dimer, defined as the highest D-dimer obtained during admission that was clinically meaningful. Odds ratios were then used to assess the relationship between peak D-dimer thresholds and clinical outcomes. D-dimer > 2.1 μg/mL and > 2.48 μg/mL had > 90% sensitivity and > 50% specificity for predicting need for vasopressors (AUC 0.80) or intubation (AUC 0.83) and in-hospital mortality (AUC 0.89), respectively. Additionally, D-dimer > 4.86 μg/mL had a 100% sensitivity and 81% specificity for predicting the need for hemodialysis (AUC 0.92). Furthermore, peak D-dimer > 2.48 μg/mL was associated with in-hospital mortality (p < 0.001), development of an AKI (p = 0.002), and need for intubation (p < 0.001), hemodialysis (p < 0.001), and vasopressors (p < 0.001). Peak D-dimer > 2.48 μg/mL may be a useful threshold that is prognostic of multiple clinical outcomes in hospitalized patients with Covid-19.
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Affiliation(s)
- Jason Wagner
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX USA
| | - Victor Garcia-Rodriguez
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX USA
| | - Abraham Yu
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX USA
| | - Barbara Dutra
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX USA
| | - Andrew DuPont
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX USA
| | - Brooks Cash
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX USA
| | - Ahmad Farooq
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX USA.,Department of Medicine, Division of Gastroenterology and Hepatology, Duke University, Durham, NC USA
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Dutra B, Lissauer M, Rashid H. Nutrition Education on the Wards: A Self-Study Module for Improving Medical Student Knowledge of Nutrition Assessment and Interventions. MedEdPORTAL 2020; 16:10968. [PMID: 33094154 PMCID: PMC7566223 DOI: 10.15766/mep_2374-8265.10968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 03/09/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Nutrition plays a key role in the prevention and treatment of disease. Hospitalized patients are often malnourished, which is a major contributor to medical complications, decreased quality of life, lengthened medical stay, increased health care costs, and mortality. However, medical students continue to have inadequate education in nutrition and report feeling poorly trained in nutrition. We proposed an online module that could be used by medical students as a self-study activity to learn about key signs for the diagnosis of malnutrition and the nutrition interventions available in the hospital setting. METHODS Third- and fourth-year medical students at Rutgers Robert Wood Johnson Medical School in medicine, surgery, and critical care clerkships were given access to an online nutrition education module discussing the signs of malnutrition in hospitalized patients and the interventions available in the inpatient setting. A premodule and postmodule survey was given via email at the beginning and at the end of the clerkship. A one-sample t test was used to assess the relationship between the mean scores of the pre- and postmodule surveys. RESULTS One hundred nine out of 255 students responded to the premodule survey. Thirty-two students completed the module and postmodule survey. There was a significant difference in mean scores between students who completed the module and postmodule survey compared to the overall student population prior to having access to the module. DISCUSSION Medical students have limited training in nutrition education, and our findings show that a self-study online module can improve students' knowledge.
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Affiliation(s)
- Barbara Dutra
- Resident, Department of Internal Medicine, University of Texas Health Science Center at Houston
| | - Matthew Lissauer
- Associate Professor of Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School
| | - Hanin Rashid
- Associate Director, Office for Advancing Learning, Teaching, and Assessment, Rutgers Robert Wood Johnson Medical School; Assistant Professor, Department of Psychiatry, Rutgers Robert Wood Johnson Medical School
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Wagner J, Garcia-Rodriguez V, Yu A, Dutra B, Bhatt A, Larson S, Farooq A. The Model for End-Stage Liver Disease-Sodium Score at Admission Is Prognostic of Covid-19 Disease Severity. ACTA ACUST UNITED AC 2020; 2:1978-1982. [PMID: 33015551 PMCID: PMC7521764 DOI: 10.1007/s42399-020-00534-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 01/08/2023]
Abstract
Covid-19 is a systemic viral respiratory illness that can cause gastrointestinal manifestations. There is evidence that Covid-19 can infect liver tissue and may cause transaminemia. A prognostic model is needed to aid clinicians in determining disease severity. The Model for End-Stage Liver Disease-Sodium (MELD-Na) score is a mortality assessment tool in liver transplant patients that has been found to be prognostic in other clinical situations. This study aimed to determine if the MELD-Na score was associated with disease severity in patients with Covid-19, as assessed by multiple clinical outcomes including death within 30 days of discharge and development of an acute kidney injury (AKI). This is a retrospective cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19. The 30-day MELD-Na score was found to be significantly higher in those who died (14.38 ± 6.92) relative to those who survived (9.68 ± 5.69; p = 0.03). Additionally, patients with a MELD-Na score greater than 10 were found to have higher risk of developing an AKI (odds ratio (OR) 3.31 (1.08, 10.17); p = 0.03), need for hemodialysis (OR 9.69 (1.74, 53.96); p = 0.007), require vasopressors (OR 4.55 (1.22, 16.99); p = 0.02), and have a longer hospital stay (OR 4.17 (1.05, 16.47); p = 0.03). The MELD-Na score may serve as a useful clinical scoring system for prognosis in patients admitted to the hospital with Covid-19.
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Affiliation(s)
- Jason Wagner
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030 USA
| | - Victor Garcia-Rodriguez
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030 USA
| | - Abraham Yu
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030 USA
| | - Barbara Dutra
- Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030 USA
| | - Asmeen Bhatt
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030 USA
| | - Scott Larson
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030 USA
| | - Ahmad Farooq
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030 USA.,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Duke University, Durham, NC USA
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Tostoes R, Dutra B, Lee K, Saloio J, Jurkiewicz C, Leslie S, Lipkens B. Volume reduction, cell washing and affinity cell selection using multi-dimensonal standing wave acoustic technology. Cytotherapy 2018. [DOI: 10.1016/j.jcyt.2018.03.015] [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: 11/17/2022]
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