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Takahashi T, Watkins B, Bratrude B, Neuberg D, Hebert K, Betz K, Yu A, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Langston A, Kean LS, Qayed M. The Adverse Event Landscape of Stem Cell Transplant: Evidence for aGVHD Driving Early Transplant Associated Toxicities. Transplant Cell Ther 2024:S2666-6367(24)00317-8. [PMID: 38583802 DOI: 10.1016/j.jtct.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024]
Abstract
Although unrelated-donor (URD) hematopoietic cell transplantation (HCT) is associated with many toxicities, a detailed analysis of adverse events, as defined by the Common Terminology Criteria for Adverse Events (CTCAE), has not previously been curated. This represents a major unmet need, especially as it relates to assessing the safety of novel agents. We analyzed a detailed AE database from the "ABA2" randomized, double-blind, placebo-controlled clinical trial of abatacept for acute graft-versus-host disease (aGVHD) prevention, for which the FDA mandated a detailed AE assessment through Day +180, and weekly neutrophil and platelet counts through Day +100. These were analyzed for their relationship to key transplant outcomes, with a major focus on the impact of aGVHD on the development/severity of AEs. A total of 2102 AEs and 1816 neutrophil/platelet counts were analyzed from 142 8/8-HLA-matched URD HCT recipients on ABA2 (placebo cohort, n = 69, abatacept cohort, n = 73). This analysis resulted in 2 major observations. (1) Among graft source, conditioning intensity, age, and Grade 2 to 4 aGVHD, only aGVHD impacted Grade 3 to 5 AE acquisition after the first month post-transplant. (2) The development of Grade 3 to 4 aGVHD was associated with thrombocytopenia. We have created a detailed resource for the transplant community by which to contextualize clinical toxicities after transplant. It has identified aGVHD as a major driver of post-HCT Grade 3 to 5 AEs, and underscored a link between aGVHD and thrombocytopenia. This establishes a critical safety framework upon which the impact of novel post-transplant aGVHD therapeutics should be evaluated. This trial was registered at www.clinicaltrials.gov (#NCT01743131).
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Affiliation(s)
- Takuto Takahashi
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia
| | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donna Neuberg
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kyle Hebert
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, Colorado
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew C Harris
- Memorial Sloan Kettering Cancer Center, New York City, New York
| | - David Jacobsohn
- Children's National Health System, Washington, District of Columbia
| | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, California
| | | | - Michael A Pulsipher
- Spencer Fox Eccles School of Medicine at the University of Utah, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Shalini Shenoy
- Washington University School of Medicine, St Louis, Missouri
| | - Aleksandra Petrovic
- Seattle Children's Hospital and Fred Hutch Cancer Center, Seattle, Washington
| | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amelia Langston
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia
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Schoettler ML, Patel S, Bryson E, Deeb L, Watkins B, Qayed M, Chandrakasan S, Fitch T, Silvis K, Jones J, Chonat S, Williams KM. Compassionate Use Narsoplimab for Severe Refractory Transplantation-Associated Thrombotic Microangiopathy in Children. Transplant Cell Ther 2024; 30:336.e1-336.e8. [PMID: 38145741 DOI: 10.1016/j.jtct.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a common and potentially severe complication of hematopoietic cell transplantation. TA-TMA-directed therapy with eculizumab, a complement C5 inhibitor, has resulted in a survival benefit in some studies. However, children with TA-TMA refractory to C5 inhibition with eculizumab (rTA-TMA) have mortality rates exceeding 80%, and there are no other known therapies. Narsoplimab, an inhibitor of the MASP-2 effector enzyme of the lectin pathway, has been studied in adults with TA-TMA as first-line therapy with a response rate of 61%. Although there are limited data on narsoplimab use as a second-line agent in children, we hypothesized, that complement pathways proximal to C5 are activated in rTA-TMA, and that narsoplimab may ameliorate rTA-TMA in children. In this single-center study, children were enrolled on single-patient, Institutional Review Board-approved compassionate use protocols for narsoplimab treatment. Clinical complement lab tests were obtained at the discretion of the treating physician, although all patients were also offered participation in a companion biomarker study. Research blood samples were obtained at the time of TA-TMA diagnosis, prior to eculizumab treatment, at the time of refractory TA-TMA diagnosis prior to the first narsoplimab dose, and 2 weeks after the first narsoplimab dose. Single ELISA kits were used to measure markers of complement activation according to the manufacture's instructions. Five children with rTA-TMA received narsoplimab; 3 were in multiorgan failure and 2 had worsening multiorgan dysfunction at the time of treatment. Additional comorbidities at the time of treatment included sinusoidal obstructive syndrome (SOS; n = 3), viral infection (n = 3), and steroid-refractory stage 4 lower gut grade IV acute graft-versus-host disease (aGVHD, n = 3). Two infants with concurrent SOS and no aGVHD had resolution of organ dysfunction; 1 also developed transfusion-independence (complete response), and the other's hematologic response was not assessable in the setting of leukemia and chemotherapy (partial response). One additional patient achieved transfusion independence but had no improvement in organ manifestations (partial response), and 2 patients treated late in the course of disease had no response. Narsoplimab was well tolerated without any attributed adverse effects. Three patients consented to provide additional research blood samples. One patient with resolution of organ failure demonstrated evidence of proximal pathway activation prior to narsoplimab treatment with subsequent declines in Ba, Bb, C3a, and C5a and increases in C3 in both clinical and research lab tests. Otherwise, there was no clear pattern of other complement markers, including MASP-2 levels, after therapy. In this cohort of ill children with rTA-TMA and multiple comorbidities, 3 patients benefited from narsoplimab. Notably, the 2 patients with resolution of organ involvement did not have steroid-refractory aGVHD, which is thought to be a critical driver of TA-TMA. Additional studies are needed to determine which patients are most likely to benefit from narsoplimab and which markers may be most helpful for monitoring lectin pathway activation and inhibition.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Seema Patel
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Elyse Bryson
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Laura Deeb
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Taylor Fitch
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Katherine Silvis
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jayre Jones
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
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Schoettler ML, French K, Harris A, Bryson E, Deeb L, Hudson Z, Obordo J, Chandrakasan S, Parikh S, Watkins B, Stenger E, Qayed M, Chonat S, Westbrook A, Switchenko J, Williams KM. D-dimer and sinusoidal obstructive syndrome-novel poor prognostic features of thrombotic microangiopathy in children after hematopoietic cellular therapy in a single institution prospective cohort study. Am J Hematol 2024; 99:370-379. [PMID: 38164997 DOI: 10.1002/ajh.27186] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a common, severe complication of allogeneic hematopoietic cellular therapy (HCT). Even when treated in many studies, morbidity and mortality rates are high. This prospective single-institution cohort study serially enrolled all allogeneic HCT recipients from August 2019-August 2022. Patients were universally screened for TA-TMA and intermediate and high-risk patients were immediately treated with eculizumab. Sub-distribution cox-proportional hazards models were used to identify sub-distribution hazard ratios (sHR) for multi-organ dysfunction (MOD) and non-relapse-related mortality (NRM). Of 136 patients, 36 (26%) were diagnosed with TA-TMA and 21/36 (58%) developed MOD, significantly more than those without TA-TMA, (p < .0001). Of those with TA-TMA, 18 (50%) had high-risk TA-TMA (HR-TA-TMA), 11 (31%) had intermediate-risk TA-TMA (IR-TA-TMA), and 8 (22%) had standard risk (SR-TA-TMA). Twenty-six were treated with eculizumab (1/8 SR, 7/11 IR, and 18/18 HR). Elevated D-dimer predicted the development of MOD (sHR 7.6, 95% confidence interval [CI] 1.8-32.3). Children with concurrent sinusoidal obstructive syndrome (SOS) and TA-TMA had an excess risk of MOD of 34% and data supported a biologic interaction. The adjusted NRM risk was significantly higher in the TA-TMA patients (sHR 10.54, 95% CI 3.8-29.2, p < .0001), despite prompt treatment with eculizumab. Significant RF for NRM in TA-TMA patients included SOS (HR 2.89, 95% 1.07-7.80) and elevated D-dimer (HR 3.82, 95% CI 1.14-12.84). An unrelated donor source and random urine protein to creatine ratio ≥2 mg/mg were significantly associated with no response to eculizumab (odds ratio 15, 95% CI 2.0-113.6 and OR 6.5, 95% CI 1.1-38.6 respectively). TA-TMA was independently associated with NRM despite early diagnosis and treatment with eculizumab in this large pediatric transplant cohort. Prognostic implications of D-dimer in TA-TMA merit further investigation as this is a readily accessible biomarker. Concurrent SOS is an exclusion criterion of many ongoing clinical trials, but these data highlight these patients could benefit from novel therapeutic approaches. Multi-institutional clinical trials are needed to understand the impact of TA-TMA-targeted therapies.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Kaley French
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Anora Harris
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Elyse Bryson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Laura Deeb
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Zuri Hudson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Jeremy Obordo
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Adrianna Westbrook
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | | | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
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Gorfinkel L, Raghunandan S, Watkins B, Hebert K, Neuberg DS, Bratrude B, Betz K, Yu A, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Langston A, Kean LS, Qayed M. Overlap chronic GVHD is associated with adverse survival outcomes compared to classic chronic GVHD. Bone Marrow Transplant 2024:10.1038/s41409-024-02245-y. [PMID: 38383714 DOI: 10.1038/s41409-024-02245-y] [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] [Received: 08/07/2023] [Revised: 12/20/2023] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Chronic graft-versus-host-disease (cGVHD) is divided into two subtypes: classic (absence of acute GVHD features) and overlap cGVHD ('ocGVHD'), in which both chronic and acute GVHD clinical features are present simultaneously. While worse outcomes with ocGVHD have been reported, there are few recent analyses. We performed a secondary analysis of data from the ABA2 trial (N = 185), in which detailed GVHD data were collected prospectively and systematically adjudicated. Analyses included cumulative incidence of classic versus ocGVHD, their specific organ manifestations, global disease severity scores, non-relapse mortality (NRM), disease-free survival (DFS) and overall survival (OS) in these two cGVHD subtypes. Of 92 patients who developed cGVHD, 35 were classified as ocGVHD. The 1-year cumulative incidence, organ involvement, and global severity of classic and ocGVHD were similar between ABA2 patients receiving CNI/MTX+placebo and CNI/MTX+abatacept; thus, cohorts were combined for ocGVHD evaluation. This analysis identified ocGVHD as having significantly higher severity at presentation and at maximum global severity compared to classic cGVHD. OS and DFS were significantly lower for ocGVHD versus classic cGVHD. OcGVHD is associated with increased cGVHD severity scores, and is associated with decreased OS and DFS compared to classic cGVHD, underscoring the high risks with this cGVHD subtype.
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Affiliation(s)
- Lev Gorfinkel
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Kyle Hebert
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna S Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, CO, USA
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Shalini Shenoy
- Washington University School of Medicine, St Louis, MO, USA
| | | | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | - Bruce R Blazar
- University of Minnesota, Department of Pediatrics, Division of Blood and Marrow Transplantation, Minneapolis, MN, USA
| | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Amelia Langston
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA.
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Watkins B, Qayed M. Novel approaches to acute graft-versus-host disease prevention. Hematology Am Soc Hematol Educ Program 2023; 2023:155-163. [PMID: 38066861 PMCID: PMC10727007 DOI: 10.1182/hematology.2023000426] [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] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The field of graft-versus-host disease (GvHD) has experienced significant growth, with increased number of clinical trials and the approval of several agents by the US Food and Drug Administration for both acute and chronic GvHD treatment. In addition, the development of prognostic biomarker algorithms has enabled risk stratification in acute GvHD. However, prevention remains the cornerstone of GvHD management. Notable recent changes include the expansion of donor options with the increased use of haploidentical donor and unrelated donor transplantation, the development of ex vivo selective T-cell depletion strategies, recent approval by the Food and Drug Administration of abatacept for GvHD prevention, and the application of posttransplant cyclophosphamide in matched and mismatched donor settings. In this article, we review the results of recent clinical trials in GvHD prophylaxis and discuss the changes in clinical practice and promising emerging strategies driving the field forward.
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Affiliation(s)
- Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
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Patel PA, Teherani MF, Xiang Y, Bernardo V, Chandrakasan S, Goggin KP, Haight A, Horwitz E, Liang WH, Parikh SH, Schoettler ML, Spencer K, Stenger E, Watkins B, Williams KM, Leung K, Jaggi P, Qayed M. Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:778.e1-778.e6. [PMID: 37739225 DOI: 10.1016/j.jtct.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n = 24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.
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Affiliation(s)
- Pratik A Patel
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia; Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Mehgan F Teherani
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Shanmuganathan Chandrakasan
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn P Goggin
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Ann Haight
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Edwin Horwitz
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Wayne H Liang
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Suhag H Parikh
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Michelle L Schoettler
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | | | - Elizabeth Stenger
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn Leung
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Preeti Jaggi
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
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Hughes C, Harris A, Watkins B, Qayed M, Parikh S, Horwitz E, Stenger E, Williams KM, Schoettler ML. Severe refractory hemorrhagic cystitis after hematopoietic cell transplantation responds to recombinant human keratinocyte growth factor-Case report and review of the literature. Pediatr Blood Cancer 2023; 70:e30606. [PMID: 37533091 DOI: 10.1002/pbc.30606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Catherine Hughes
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Anora Harris
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Edwin Horwitz
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
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Takahashi T, Al-Kofahi M, Jaber M, Bratrude B, Betz K, Suessmuth Y, Yu A, Neuberg DS, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Watkins B, Langston A, Qayed M, Kean LS. Higher abatacept exposure after transplant decreases acute GVHD risk without increasing adverse events. Blood 2023; 142:700-710. [PMID: 37319437 PMCID: PMC10797507 DOI: 10.1182/blood.2023020035] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
In the ABA2 study, the T-cell costimulation blockade agent, abatacept, was safe and effective in preventing acute graft-versus-host disease (aGVHD) after unrelated-donor hematopoietic cell transplant (HCT), leading to US Food and Drug Administration approval. Here, we performed a determination of abatacept pharmacokinetics (PK), which enabled an examination of how abatacept exposure-response relationships affected clinical outcomes. We performed a population PK analysis of IV abatacept using nonlinear mixed-effect modeling and assessed the association between abatacept exposure and key transplant outcomes. We tested the association between the trough after dose 1 (Ctrough_1) and grade (GR) 2 or 4 aGVHD (GR2-4 aGVHD) through day +100. An optimal Ctrough_1 threshold was identified via recursive partitioning and classification tree analysis. This demonstrated that abatacept PK was characterized by a 2-compartment model with first-order elimination. The ABA2 dosing regimen was based on previous work targeting a steady-state abatacept trough of 10 μg/mL. However, a higher Ctrough_1 (≥39 μg/mL, attained in ∼60% of patients on ABA2) was associated with a favorable GR2-4 aGVHD risk (hazard ratio, 0.35; 95% confidence interval, 0.19-0.65; P < .001), with a Ctrough_1 <39 μg/mL associated with GR2-4 aGVHD risk indistinguishable from placebo (P = .37). Importantly, no significant association was found between Ctrough_1 and key safety indicators, including relapse, and cytomegalovirus or Epstein-Barr virus viremia. These data demonstrate that a higher abatacept Ctrough_1 (≥39 μg/mL) was associated with a favorable GR2-4 aGVHD risk, without any observed exposure-toxicity relationships. This trial was registered at www.clinicaltrials.gov as #NCT01743131.
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Affiliation(s)
- Takuto Takahashi
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
| | - Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
| | - Mutaz Jaber
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
| | - Brandi Bratrude
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kayla Betz
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Alison Yu
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Donna S. Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Sung W. Choi
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Jeffrey Davis
- BC Children’s Hospital, University of British Columbia, Vancouver, Canada
| | - Christine Duncan
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, CO
| | - Michael Grimley
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew C. Harris
- Pediatric Bone Marrow Transplant and Cellular Therapy Program, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David Jacobsohn
- Division of Blood and Marrow Transplantation, Center for Cancer and Blood Disorders, Children’s National Health System, Washington, DC
| | - Nahal Lalefar
- Division of Pediatric Hematology/Oncology, UCSF Benioff Children’s Hospital Oakland, University of California San Francisco, Oakland, CA
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Michael A. Pulsipher
- Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine, Primary Children’s Hospital, University of Utah, Salt Lake City, UT
| | - Shalini Shenoy
- Division Hematology/Oncology, Washington University School of Medicine, St Louis, MO
| | - Aleksandra Petrovic
- Department of Pediatrics, Seattle Children’s Hospital and Fred Hutch Cancer Center, Seattle, WA
| | - Kirk R. Schultz
- BC Children’s Hospital, University of British Columbia, Vancouver, Canada
| | | | - Bruce R. Blazar
- Division of Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - John T. Horan
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Leslie S. Kean
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
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9
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Raghunandan S, Gorfinkel L, Graiser M, Bratrude B, Suessmuth Y, Gillespie S, Westbrook AL, Williams KM, Schoettler ML, Kean LS, Horan J, Langston AA, Qayed M, Watkins B. Abatacept for the prevention of GVHD in patients receiving mismatched unrelated transplants: a real-world analysis. Blood Adv 2023; 7:4395-4399. [PMID: 37285800 PMCID: PMC10432595 DOI: 10.1182/bloodadvances.2023010225] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/16/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023] Open
Affiliation(s)
- Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Lev Gorfinkel
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | | | - Brandi Bratrude
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | | | | | - Kirsten M. Williams
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Michelle L. Schoettler
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Leslie S. Kean
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | - John Horan
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
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10
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Schoettler ML, Dandoy CE, Harris A, Chan M, Tarquinio KM, Jodele S, Qayed M, Watkins B, Kamat P, Petrillo T, Obordo J, Higham CS, Dvorak CC, Westbrook A, Zinter MS, Williams KM. Diffuse alveolar hemorrhage after hematopoietic cell transplantation- response to treatments and risk factors for mortality. Front Oncol 2023; 13:1232621. [PMID: 37546403 PMCID: PMC10399223 DOI: 10.3389/fonc.2023.1232621] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of hematopoietic cellular therapy (HCT). This study aimed to evaluate the effect of DAH treatments on outcomes using data from consecutive HCT patients clinically diagnosed with DAH from 3 institutions between January 2018-August 2022. Endpoints included sustained complete response (sCR) defined as bleeding cessation without recurrent bleeding, and non-relapse mortality (NRM). Forty children developed DAH at a median of 56.5 days post-HCT (range 1-760). Thirty-five (88%) had at least one concurrent endothelial disorder, including transplant-associated thrombotic microangiopathy (n=30), sinusoidal obstructive syndrome (n=19), or acute graft versus host disease (n=10). Fifty percent had a concurrent pulmonary infection at the time of DAH. Common treatments included steroids (n=17, 25% sCR), inhaled tranexamic acid (INH TXA,n=26, 48% sCR), and inhaled recombinant activated factor VII (INH fVIIa, n=10, 73% sCR). NRM was 56% 100 days after first pulmonary bleed and 70% at 1 year. Steroid treatment was associated with increased risk of NRM (HR 2.25 95% CI 1.07-4.71, p=0.03), while treatment with INH TXA (HR 0.43, 95% CI 0.19- 0.96, p=0.04) and INH fVIIa (HR 0.22, 95% CI 0.07-0.62, p=0.005) were associated with decreased risk of NRM. Prospective studies are warranted to validate these findings.
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Affiliation(s)
- Michelle L. Schoettler
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Christopher E. Dandoy
- Cincinnati Children’s Medical Center, Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Anora Harris
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Marilynn Chan
- Pediatric Pulmonary Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Sonata Jodele
- Cincinnati Children’s Medical Center, Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Muna Qayed
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Benjamin Watkins
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Pradip Kamat
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Toni Petrillo
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Jeremy Obordo
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Christine S. Higham
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher C. Dvorak
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
| | - Adrianna Westbrook
- Department of Pediatrics, Pediatric Biostatistics Core, Emory University, Atlanta, GA, United States
| | - Matt S. Zinter
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
- Pediatric Critical Care, University of California, San Francisco, San Francisco, CA, United States
| | - Kirsten M. Williams
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
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11
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Ayele RH, Yimer YG, Bekuretsion Y, Muhe LM, Patel SA, Cunningham SA, Hailu D, Watkins B. A retrospective review on the histopathological pattern of childhood malignant solid tumors in Ethiopia. Pediatr Blood Cancer 2023:e30424. [PMID: 37194456 DOI: 10.1002/pbc.30424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/18/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023]
Abstract
In low- and middle-income countries (LMICs), malignancies remain underreported due to lack of quality data. This study outlines the histopathological pattern of pediatric solid malignancies in children aged 0-15 years at the largest referral hospital in Ethiopia. A total of 432 solid malignancies were evaluated. The most common malignancies were lymphoma (21.8%), retinoblastoma (19.4%), and Wilms tumor (13.9%). Burkitt lymphoma accounted for 2.1%, despite being the most reported pediatric malignancy in sub-Saharan Africa in published literature. Definitive diagnosis could not be made in 7% of cases, related to the lack of confirmatory testing. The study highlights the need for improvement in diagnostic capabilities in LMICs.
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Affiliation(s)
- Rahell Hailu Ayele
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Yonas Bekuretsion
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lulu M Muhe
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Shivani A Patel
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Daniel Hailu
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Benjamin Watkins
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
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12
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Raghunandan S, Pauly M, Blum WG, Qayed M, Dhodapkar MV, Elkhalifa M, Watkins B, Schoettler M, Horwitz E, Parikh S, Chandrakasan S, Leung K, Bryson E, Deeb L, Kaufman JL, Worthington-White D, Alazraki A, Schecter JM, Madduri D, Jackson CC, Zudaire E, Taraseviciute-Morris A, Babich A, Nesheiwat T, Vogel M, Lendvai N, Pacaud L, Williams KM. BCMA CAR-T induces complete and durable remission in refractory plasmablastic lymphoma. J Immunother Cancer 2023; 11:jitc-2023-006684. [PMID: 37137553 PMCID: PMC10163502 DOI: 10.1136/jitc-2023-006684] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
Plasmablastic lymphoma (PBL) is a rare subtype of aggressive large B-cell lymphoma, with a dismal prognosis despite aggressive therapies. New approaches are needed for those with refractory disease. PBL expresses antigens similar to multiple myeloma (MM), including B-cell maturation antigen (BCMA). Chimeric antigen receptor T-cell (CAR-T) therapy directed against BCMA has shown efficacy for the treatment of heavily pretreated MM with low rates of grades 3 and 4 cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) in a phase Ib/II trial (A Study of JNJ-68284528, a CAR-T Directed Against BCMA in Participants With Relapsed or Refractory Multiple Myeloma (CARTITUDE-1), NCT03548207). However, data for the use of BCMA CAR-T for treating PBL are lacking.We report a challenging case of multiple refractory PBL that emerged from B-cell acute lymphoblastic leukemia in an adolescent who failed to respond to an allogeneic hematopoietic cell transplant. The patient developed rapidly advancing disease despite withdrawal of immunosuppression, treatment with etoposide, ibrutinib, and daratumumab, prompting consideration of BCMA CAR-T (under emergency investigational new drug (eIND)). The patient achieved a complete remission (CR), without recurrent acute graft versus host disease (GVHD), CRS or ICANS after BCMA CAR-T therapy. BCMA CAR-T expansion was detected in vivo, peaking on day 15. The patient remains in CR for more than a year post CAR-T therapy, supporting consideration of immunotherapy for future patients with refractory PBL, a disease with few treatment options.
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Affiliation(s)
- Sharmila Raghunandan
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Melinda Pauly
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - William G Blum
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Madhav V Dhodapkar
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Mohamed Elkhalifa
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Michelle Schoettler
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Edwin Horwitz
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Suhag Parikh
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Shanmuganathan Chandrakasan
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kathryn Leung
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Elyse Bryson
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Laura Deeb
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Diana Worthington-White
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Adina Alazraki
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Deepu Madduri
- Janssen Research and Development LLC, Raritan, New Jersey, USA
| | | | | | | | | | | | - Martin Vogel
- Janssen Global Services LLC, Raritan, New Jersey, USA
| | | | - Lida Pacaud
- Legend Biotech USA Inc, Piscataway, New Jersey, USA
| | - Kirsten M Williams
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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13
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Schoettler ML, Saldana BD, Berkenkamp L, Chonat S, Watkins B, Rotz SJ, Simons D, Graf E, Rossi C, Cheng J, Hammers YA, Rytting H, Williams KM. Pulmonary Manifestations and Vascular Changes in Pediatric Transplantation-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2023; 29:45.e1-45.e8. [PMID: 36202334 PMCID: PMC11003462 DOI: 10.1016/j.jtct.2022.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 11/08/2022]
Abstract
Although transplant-associated thrombotic microangiopathy (TA-TMA) commonly complicates pediatric hematopoietic cellular therapy (HCT), pulmonary manifestations and histology of TA-TMA (pTA-TMA) are rarely reported, with scant data available on timing, risk factors, pathogenesis, and outcomes. Pulmonary hypertension (PH) and diffuse alveolar hemorrhage (DAH) are recognized manifestations of pTA-TMA. The objective of this study was to characterize the pathologic findings, outcomes, and coincident diagnoses preceding biopsy-proven pTA-TMA. In Institutional Review Board- approved retrospective studies, available lung tissue was reviewed at 2 institutions between January 2016 and August 2021 to include those with pulmonary vascular pathology. Histologic features of pTA-TMA were present in 10 children with prior respiratory decline after an allogeneic HCT (allo-HCT; n = 9) or autologous HCT (n = 1). Pathologic lesions included muscular medialization, microthrombi, and red cell fragments, in addition to perivasculitis and intimal arteritis. Parenchymal findings included diffuse alveolar damage, organizing pneumonia, and plasmocytic infiltrates. Six children were clinically diagnosed with TA-TMA, and all were treated with eculizumab, at a median of 2.5 days after clinical diagnosis (range, 0 to 11 days). Four were identified postmortem. Coincident pulmonary infection was confirmed in 8 of the 10 patients. Five allo-HCT recipients (56%) experienced graft-versus-host disease (GVHD; 4 acute, 1 chronic) prior to the onset of respiratory symptoms. Two patients (20%) had clinically recognized DAH, although 9 (90%) had evidence of DAH on histology. Although all 10 patients underwent echocardiography at the time of symptom onset and 9 had serial echocardiograms, only 2 patients had PH detected. Treatments varied and included sildenafil (n = 3), steroids (n = 1), and eculizumab (n = 6). One patient was alive at the time of this report; the remaining 9 died, at a median of 52 days after onset of respiratory symptoms (range 4 to 440 days) and a median of 126 days post-HCT (range, 13 to 947 days). pTA-TMA is a heterogeneous histologic disease characterized by arteriolar inflammation, microthrombi, and often DAH. pTA-TMA presented with respiratory decline with systemic TA-TMA in all patients. Clinicians should maintain a high degree of suspicion for DAH in patients with TA-TMA and pulmonary symptoms. Coincident rates of GVHD and pulmonary infections were high, whereas the rate of PH identified by echocardiography was 20%. Outcomes were poor despite early use of eculizumab and other therapies. Our data merit consideration of pTA-TMA in patients with acute respiratory decline in the setting of systemic TA-TMA, GVHD, and infection. Investigation of additional therapies for pTA-TMA is needed as well. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Blachy D Saldana
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC
| | - Lisa Berkenkamp
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Dawn Simons
- Children's Healthcare of Atlanta, Emory University, Pediatric Pulmonology, Atlanta, Georgia
| | - Emily Graf
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC
| | | | - Jinjun Cheng
- Division of Pathology, Children's National Hospital, Washington, DC
| | - Yuki A Hammers
- Children's Healthcare of Atlanta, Department of Pathology, Atlanta, Georgia
| | - Heather Rytting
- Children's Healthcare of Atlanta, Department of Pathology, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
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14
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Watkins B, Williams KM. Controversies and expectations for the prevention of GVHD: A biological and clinical perspective. Front Immunol 2022; 13:1057694. [PMID: 36505500 PMCID: PMC9726707 DOI: 10.3389/fimmu.2022.1057694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022] Open
Abstract
Severe acute and chronic graft versus host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation. Historically, cord blood and matched sibling transplantation has been associated with the lowest rates of GVHD. Newer methods have modified the lymphocyte components to minimize alloimmunity, including: anti-thymocyte globulin, post-transplant cyclophosphamide, alpha/beta T cell depletion, and abatacept. These agents have shown promise in reducing severe GVHD, however, can be associated with increased risks of relapse, graft failure, infections, and delayed immune reconstitution. Nonetheless, these GVHD prophylaxis strategies have permitted expansion of donor sources, especially critical for those of non-Caucasian decent who previously lacked transplant options. This review will focus on the biologic mechanisms driving GVHD, the method by which each agent impacts these activated pathways, and the clinical consequences of these modern prophylaxis approaches. In addition, emerging novel targeted strategies will be described. These GVHD prophylaxis approaches have revolutionized our ability to increase access to transplant and have provided important insights into the biology of GVHD and immune reconstitution.
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15
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Lyvannak S, Sreynich K, Heng S, Thyl M, Chandna A, Chanpheaktra N, Pises N, Farrilend P, Jarzembowski J, Leventaki V, Davick J, Neunert C, Keller F, Kean LS, Camitta B, Tarlock K, Watkins B. Case Report: The First Case Report of Visceral Leishmaniasis in Cambodia. Am J Trop Med Hyg 2022; 107:336-338. [PMID: 35895585 PMCID: PMC9393436 DOI: 10.4269/ajtmh.22-0085] [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: 01/28/2022] [Accepted: 03/31/2022] [Indexed: 08/03/2023] Open
Abstract
Leishmaniasis is considered a neglected tropical disease that is commonly found in Asia, Africa, South America, and Mediterranean countries. Visceral leishmaniasis (VL) is the most severe form of the disease and is almost universally fatal if left untreated. The symptoms of VL overlap with many infectious diseases, malignancies, and other blood disorders. The most common findings include fever, cytopenias, and splenomegaly. Given the nonspecific symptoms, the diagnosis requires detailed laboratory investigations, including bone marrow examination, that can be challenging in low- and middle-income countries. Diagnostic limitations likely lead to the underdiagnosis or delay in diagnosis of VL. We describe, to our knowledge, the first case report of VL in Cambodia in a child presenting with fever, anemia, and thrombocytopenia. The diagnosis required a liver biopsy and multiple bone marrow biopsies to visualize intracellular Leishmania spp. Our case illustrates the diagnostic challenges and the importance of timely diagnosis. This case also highlights the need for heightened awareness of the diagnostic findings of VL and improved reporting of tropical diseases.
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Affiliation(s)
- Sam Lyvannak
- Angkor Hospital for Children, Siem Reap, Cambodia
| | | | - Sing Heng
- Angkor Hospital for Children, Siem Reap, Cambodia
| | - Miliya Thyl
- Angkor Hospital for Children, Siem Reap, Cambodia
| | - Arjun Chandna
- Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Ngeth Pises
- Angkor Hospital for Children, Siem Reap, Cambodia
| | | | | | | | | | | | - Frank Keller
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Leslie S. Kean
- Boston Children’s Hospital, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
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16
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Tkachev V, Kaminski J, Potter EL, Furlan SN, Yu A, Hunt DJ, McGuckin C, Zheng H, Colonna L, Gerdemann U, Carlson J, Hoffman M, Olvera J, English C, Baldessari A, Panoskaltsis-Mortari A, Watkins B, Qayed M, Suessmuth Y, Betz K, Bratrude B, Langston A, Horan JT, Ordovas-Montanes J, Shalek AK, Blazar BR, Roederer M, Kean LS. Spatiotemporal single-cell profiling reveals that invasive and tissue-resident memory donor CD8 + T cells drive gastrointestinal acute graft-versus-host disease. Sci Transl Med 2021; 13:13/576/eabc0227. [PMID: 33441422 DOI: 10.1126/scitranslmed.abc0227] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/11/2020] [Indexed: 12/11/2022]
Abstract
Organ infiltration by donor T cells is critical to the development of acute graft-versus-host disease (aGVHD) in recipients after allogeneic hematopoietic stem cell transplant (allo-HCT). However, deconvoluting the transcriptional programs of newly recruited donor T cells from those of tissue-resident T cells in aGVHD target organs remains a challenge. Here, we combined the serial intravascular staining technique with single-cell RNA sequencing to dissect the tightly connected processes by which donor T cells initially infiltrate tissues and then establish a pathogenic tissue residency program in a rhesus macaque allo-HCT model that develops aGVHD. Our results enabled creation of a spatiotemporal map of the transcriptional programs controlling donor CD8+ T cell infiltration into the primary aGVHD target organ, the gastrointestinal (GI) tract. We identified the large and small intestines as the only two sites demonstrating allo-specific, rather than lymphodepletion-driven, T cell infiltration. GI-infiltrating donor CD8+ T cells demonstrated a highly activated, cytotoxic phenotype while simultaneously developing a canonical tissue-resident memory T cell (TRM) transcriptional signature driven by interleukin-15 (IL-15)/IL-21 signaling. We found expression of a cluster of genes directly associated with tissue invasiveness, including those encoding adhesion molecules (ITGB2), specific chemokines (CCL3 and CCL4L1) and chemokine receptors (CD74), as well as multiple cytoskeletal proteins. This tissue invasion transcriptional signature was validated by its ability to discriminate the CD8+ T cell transcriptome of patients with GI aGVHD from those of GVHD-free patients. These results provide insights into the mechanisms controlling tissue occupancy of target organs by pathogenic donor CD8+ TRM cells during aGVHD in primate transplant recipients.
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Affiliation(s)
- Victor Tkachev
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.
| | - James Kaminski
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.,Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - E Lake Potter
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20858, USA
| | - Scott N Furlan
- Fred Hutchinson Cancer Research Center, Department of Pediatrics, University of Washington, Seattle, WA 98109, USA
| | - Alison Yu
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel J Hunt
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Connor McGuckin
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Hengqi Zheng
- University of Washington, Seattle, WA 98195, USA
| | - Lucrezia Colonna
- Fred Hutchinson Cancer Research Center, Department of Pediatrics, University of Washington, Seattle, WA 98109, USA
| | - Ulrike Gerdemann
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | | | - Michelle Hoffman
- Fred Hutchinson Cancer Research Center, Department of Pediatrics, University of Washington, Seattle, WA 98109, USA
| | - Joe Olvera
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Chris English
- Washington National Primate Research Center, Seattle, WA 98195, USA
| | | | - Angela Panoskaltsis-Mortari
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55454, USA
| | | | - Muna Qayed
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | - Kayla Betz
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Brandi Bratrude
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | | | - John T Horan
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jose Ordovas-Montanes
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA.,Division of Gastroenterology, Boston Children's Hospital and Program in Immunology, Harvard Medical School, Boston, MA 02115, USA.,Harvard Stem Cell Institute, Cambridge, MA 02138, USA
| | - Alex K Shalek
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA.,Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, MIT, Cambridge, MA 02142, USA.,Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55454, USA
| | - Mario Roederer
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20858, USA
| | - Leslie S Kean
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.
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17
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Qayed M, Watkins B, Gillespie S, Bratrude B, Betz K, Suessmuth Y, Yu A, Furlan SN, Zhang C, Mccracken C, Cribbin K, Choi S, Davis JH, Duncan C, Giller RH, Grimley MS, Harris AC, Jacobsohn DA, Yanik GA, Rogatko A, Tighiouart M, Bresee C, Kim S, Lalefar NR, Rhodes J, Norkin M, Farhadfar N, Shenoy S, Petrovic A, Schultz KR, Pulsipher MA, Waller EK, Blazar BR, Langston AA, Kean LS, Horan J. Comparable Outcomes for Matched and Mismatched Unrelated Donor (URD) Transplantation with the Addition of Abatacept to Standard Graft Versus Host Disease Prophylaxis. Transplant Cell Ther 2021. [DOI: 10.1016/s2666-6367(21)00059-2] [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: 11/26/2022]
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18
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Stenger EO, Watkins B, Suessmuth Y, Chiang KY, Haight AE, Qayed M, Kean LS, Horan J. Immune Reconstitution Following Unrelated Donor Hematopoietic Cell Transplantation for Pediatric Non-Malignant Diseases Using Abatacept Graft-Versus-Host Disease Prophylaxis. Transplant Cell Ther 2021. [DOI: 10.1016/s2666-6367(21)00352-3] [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: 10/22/2022]
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19
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Watkins B, Qayed M, McCracken C, Bratrude B, Betz K, Suessmuth Y, Yu A, Sinclair S, Furlan S, Bosinger S, Tkachev V, Rhodes J, Tumlin AG, Narayan A, Cribbin K, Gillespie S, Gooley TA, Pasquini MC, Hebert K, Kapoor U, Rogatko A, Tighiouart M, Kim S, Bresee C, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Norkin M, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Waller EK, Levine JE, Ferrara JL, Blazar BR, Langston A, Horan JT, Kean LS. Phase II Trial of Costimulation Blockade With Abatacept for Prevention of Acute GVHD. J Clin Oncol 2021; 39:1865-1877. [PMID: 33449816 DOI: 10.1200/jco.20.01086] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Severe (grade 3-4) acute graft-versus-host disease (AGVHD) is a major cause of death after unrelated-donor (URD) hematopoietic cell transplant (HCT), resulting in particularly high mortality after HLA-mismatched transplantation. There are no approved agents for AGVHD prevention, underscoring the critical unmet need for novel therapeutics. ABA2 was a phase II trial to rigorously assess safety, efficacy, and immunologic effects of adding T-cell costimulation blockade with abatacept to calcineurin inhibitor (CNI)/methotrexate (MTX)-based GVHD prophylaxis, to test whether abatacept could decrease AGVHD. METHODS ABA2 enrolled adults and children with hematologic malignancies under two strata: a randomized, double-blind, placebo-controlled stratum (8/8-HLA-matched URD), comparing CNI/MTX plus abatacept with CNI/MTX plus placebo, and a single-arm stratum (7/8-HLA-mismatched URD) comparing CNI/MTX plus abatacept versus CNI/MTX CIBMTR controls. The primary end point was day +100 grade 3-4 AGVHD, with day +180 severe-AGVHD-free-survival (SGFS) a key secondary end point. Sample sizes were calculated using a higher type-1 error (0.2) as recommended for phase II trials, and were based on predicting that abatacept would reduce grade 3-4 AGVHD from 20% to 10% (8/8s) and 30% to 10% (7/8s). ABA2 enrolled 142 recipients (8/8s, median follow-up = 716 days) and 43 recipients (7/8s, median follow-up = 708 days). RESULTS In 8/8s, grade 3-4 AGVHD was 6.8% (abatacept) versus 14.8% (placebo) (P = .13, hazard ratio = 0.45). SGFS was 93.2% (CNI/MTX plus abatacept) versus 82% (CNI/MTX plus placebo, P = .05). In the smaller 7/8 cohort, grade 3-4 AGVHD was 2.3% (CNI/MTX plus abatacept, intention-to-treat population), which compared favorably with a nonrandomized matched cohort of CNI/MTX (30.2%, P < .001), and the SGFS was better (97.7% v 58.7%, P < .001). Immunologic analysis revealed control of T-cell activation in abatacept-treated patients. CONCLUSION Adding abatacept to URD HCT was safe, reduced AGVHD, and improved SGFS. These results suggest that abatacept may substantially improve AGVHD-related transplant outcomes, with a particularly beneficial impact on HLA-mismatched HCT.
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Affiliation(s)
- Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
| | | | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | | | - Scott Furlan
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Steven Bosinger
- Emory University, Yerkes National Primate Research Center, Atlanta, GA
| | - Victor Tkachev
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | - James Rhodes
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Audrey Grizzle Tumlin
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | | | | | | | - Ted A Gooley
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Marcelo C Pasquini
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
| | - Kyle Hebert
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | - Sungjin Kim
- Cedars Sinai Medical Center, Los Angeles, CA
| | | | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, CO
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew C Harris
- University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | | | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Maxim Norkin
- Baptist Medical Center Jacksonville, Jacksonville, FL
| | - Nosha Farhadfar
- University of Florida, UF Health Shands Hospital, Gainesville, FL
| | - Michael A Pulsipher
- Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA
| | | | | | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | | | | | | | | | - Bruce R Blazar
- University of Minnesota, Department of Pediatrics, Division of Blood and Marrow Transplantation, Minneapolis, MN
| | | | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
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20
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Suessmuth Y, Betz K, Yu A, Bratrude B, Watkins B, Qayed M, Horan J, Kean LS, Langston A. Potent interaction between CMV reactivation and GVHD: Immunologic evidence for the blunting of CMV-driven immune reconstitution in the setting of GVHD in transplant patients. The Journal of Immunology 2020. [DOI: 10.4049/jimmunol.204.supp.87.12] [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: 01/03/2023]
Abstract
Abstract
Allogeneic hematopoietic cell transplantation (HCT) may be curative for patients with marrow and immune disorders, but acute graft-vs-host-disease (aGVHD) and infections cause significant morbidity and non-relapse mortality. We conducted a multicenter, double blind, placebo-controlled phase II trial of costimulation blockade with abatacept (Aba) combined with standard GVHD prophylaxis with a calcineurin inhibitor and methotrexate (CNI + MTX) following HLA matched unrelated donor transplant (n=140).
In order to assess whether Aba produces clinically relevant compromise of immune reconstitution, and whether this reconstitution is influenced during CMV reactivation, we longitudinally evaluated post-transplant whole blood samples with multiparameter flow cytometry using markers for CD3, CD4, CD8, CD197 and CD45RA to measure reconstitution of CD4 and CD8 T cell populations and their respective memory subsets over time.
We show here that post-transplant CMV reactivation induces a marked expansion of CD8 effector memory (EM) cells, which is similar in Aba vs placebo pts. We found that development of moderate (gr 2–4) or severe (gr 3–4) GVHD does not cause more CMV reactivation in patients, but patients with moderate GVHD show a blunted expansion of CD8 EM cells compared to those without GVHD. Remarkably, CD8 EM expansion was essentially absent among CMV reactivating patients with severe aGVHD.
Our results suggest that adding abatacept to CNI/MTX does not materially affect reconstitution of T cell immunity in the presence or absence of CMV reactivation, but aGVHD remains a major driver of compromised immune recovery after HCT.
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Affiliation(s)
| | - Kayla Betz
- 2Boston Children’s Hospital/Harvard Medical School
| | - Alison Yu
- 2Boston Children’s Hospital/Harvard Medical School
| | | | | | | | | | - Leslie S Kean
- 4Boston Children’s Hospital and the Dana-Farber Cancer Institute, Boston, MA, 02115, USA
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21
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Qayed M, Cash T, Tighiouart M, MacDonald TJ, Goldsmith KC, Tanos R, Kean L, Watkins B, Suessmuth Y, Wetmore C, Katzenstein HM. A phase I study of sirolimus in combination with metronomic therapy (CHOAnome) in children with recurrent or refractory solid and brain tumors. Pediatr Blood Cancer 2020; 67:e28134. [PMID: 31876107 DOI: 10.1002/pbc.28134] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 09/02/2019] [Revised: 11/22/2019] [Accepted: 11/24/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND/PURPOSE To determine the maximum tolerated dose, toxicities, and response of sirolimus combined with oral metronomic therapy in pediatric patients with recurrent and refractory solid and brain tumors. PROCEDURE Patients younger than 30 years of age with recurrent, refractory, or high-risk solid and brain tumors were eligible. Patients received six-week cycles of sirolimus with twice daily celecoxib, and alternating etoposide and cyclophosphamide every three weeks, with Bayesian dose escalation over four dose levels (NCT01331135). RESULTS Eighteen patients were enrolled: four on dose level (DL) 1, four on DL2, eight on DL3, and two on DL4. Diagnoses included solid tumors (Ewing sarcoma, osteosarcoma, malignant peripheral nerve sheath tumor, rhabdoid tumor, retinoblastoma) and brain tumors (glioblastoma multiforme [GBM], diffuse intrinsic pontine glioma, high-grade glioma [HGG], medulloblastoma, ependymoma, anaplastic astrocytoma, low-grade infiltrative astrocytoma, primitive neuroectodermal tumor, nongerminomatous germ cell tumor]. One dose-limiting toxicity (DLT; grade 4 neutropenia) was observed on DL2, two DLTs (grade 3 abdominal pain and grade 3 mucositis) on DL3, and two DLTs (grade 3 dehydration and grade 3 mucositis) on DL4. The recommended phase II dose of sirolimus was 2 mg/m2 (DL3). Best response was stable disease (SD) in eight patients, and partial response (PR) in one patient with GBM. A patient with HGG was removed from the study with SD and developed PR without further therapy. Western blot analysis showed inhibition of phospho-S6 kinase in all patients during the first cycle of therapy. CONCLUSION The combination of sirolimus with metronomic chemotherapy is well tolerated in children. A phase II trial of this combination is ongoing.
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Affiliation(s)
- Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Thomas Cash
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Mourad Tighiouart
- Samuel Oschkin Comprehensive Cancer Institute, Los Angeles, California
| | - Tobey J MacDonald
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Kelly C Goldsmith
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Rachel Tanos
- Emory University School of Medicine, Atlanta, Georgia
| | - Leslie Kean
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | | | - Cynthia Wetmore
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona
| | - Howard M Katzenstein
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Nemours Children's Specialty Care and Wolfson Children's Hospital, Jacksonville, Florida
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22
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Tkachev V, Furlan SN, Watkins B, Hunt DJ, Zheng HB, Panoskaltsis-Mortari A, Betz K, Brown M, Schell JB, Zeleski K, Yu A, Kirby I, Cooley S, Miller JS, Blazar BR, Casson D, Bland-Ward P, Kean LS. Combined OX40L and mTOR blockade controls effector T cell activation while preserving T reg reconstitution after transplant. Sci Transl Med 2018; 9:9/408/eaan3085. [PMID: 28931653 DOI: 10.1126/scitranslmed.aan3085] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/27/2017] [Indexed: 12/14/2022]
Abstract
A critical question facing the field of transplantation is how to control effector T cell (Teff) activation while preserving regulatory T cell (Treg) function. Standard calcineurin inhibitor-based strategies can partially control Teffs, but breakthrough activation still occurs, and these agents are antagonistic to Treg function. Conversely, mechanistic target of rapamycin (mTOR) inhibition with sirolimus is more Treg-compatible but is inadequate to fully control Teff activation. In contrast, blockade of OX40L signaling has the capacity to partially control Teff activation despite maintaining Treg function. We used the nonhuman primate graft-versus-host disease (GVHD) model to probe the efficacy of combinatorial immunomodulation with sirolimus and the OX40L-blocking antibody KY1005. Our results demonstrate significant biologic activity of KY1005 alone (prolonging median GVHD-free survival from 8 to 19.5 days), as well as marked, synergistic control of GVHD with KY1005 + sirolimus (median survival time, >100 days; P < 0.01 compared to all other regimens), which was associated with potent control of both TH/TC1 (T helper cell 1/cytotoxic T cell 1) and TH/TC17 activation. Combined administration also maintained Treg reconstitution [resulting in an enhanced Treg/Teff ratio (40% over baseline) in the KY1005/sirolimus cohort compared to a 2.9-fold decrease in the unprophylaxed GVHD cohort]. This unique immunologic signature resulted in transplant recipients that were able to control GVHD for the length of analysis and to down-regulate donor/recipient alloreactivity despite maintaining anti-third-party responses. These data indicate that combined OX40L blockade and sirolimus represents a promising strategy to induce immune balance after transplant and is an important candidate regimen for clinical translation.
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Affiliation(s)
- Victor Tkachev
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA.
| | - Scott N Furlan
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA.,Department of Pediatrics, University of Washington, Seattle, WA 98195, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Benjamin Watkins
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA.,Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Daniel J Hunt
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Hengqi Betty Zheng
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Angela Panoskaltsis-Mortari
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Kayla Betz
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Melanie Brown
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - John B Schell
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Katie Zeleski
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Alison Yu
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | | | - Sarah Cooley
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Jeffrey S Miller
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | | | | | - Leslie S Kean
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA. .,Department of Pediatrics, University of Washington, Seattle, WA 98195, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
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23
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Sano H, Hilinski JA, Qayed M, Applegate K, Newton JG, Watkins B, Chiang KY, Horan J. Early blood stream infection following allogeneic hematopoietic stem cell transplantation is a risk factor for acute grade III-IV GVHD in children and adolescents. Pediatr Blood Cancer 2018; 65. [PMID: 28921804 DOI: 10.1002/pbc.26821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) remains a major cause of mortality and morbidity in allogeneic hematopoietic stem cell transplantation (HSCT). In adults, early blood stream infection (BSI) and acute GVHD (AGVHD) have been reported to be related. The impact of BSI on risk for AGVHD, however, has not been assessed in pediatric patients. PROCEDURE We conducted a retrospective analysis to test the hypothesis that early BSI (before day +30) predisposes allogeneic pediatric transplant patients to severe AGVHD. We analyzed 293 allogeneic HSCT performed at Children's Healthcare of Atlanta between 2005 and 2014 that met eligibility criteria. RESULTS The cumulative incidence of acute grade III-IV GVHD at 100 days after HSCT was 17.1%. In multivariate analysis, risk for acute grade III-IV GVHD was associated with HLA-mismatched donor (hazard ratio [HR] = 4.870, P < 0.001), and BSI between day 0 and +30 prior to AGVHD (HR = 3.010, P = 0.001). CONCLUSIONS These results indicate that early BSI appears to be a risk factor for acute grade III-IV GVHD. Further research is needed to determine if the link is causal.
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Affiliation(s)
- Hirozumi Sano
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Joseph A Hilinski
- Division of Pediatric Infectious Diseases, St. Luke's Children's Hospital, Boise, Idaho
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kristy Applegate
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Joanna G Newton
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kuang-Yueh Chiang
- Department of Pediatrics, Haematology/Oncology, the Hospital for Sick Children, Toronto, Canada
| | - John Horan
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
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Zheng H(B, Watkins B, Tkachev V, Yu S, Tran D, Furlan S, Zeleski K, Singh K, Hamby K, Hotchkiss C, Lane J, Gumber S, Adams A, Cendales L, Kirk AD, Kaur A, Blazar BR, Larsen CP, Kean LS. The Knife's Edge of Tolerance: Inducing Stable Multilineage Mixed Chimerism but With a Significant Risk of CMV Reactivation and Disease in Rhesus Macaques. Am J Transplant 2017; 17:657-670. [PMID: 27500470 PMCID: PMC5338742 DOI: 10.1111/ajt.14006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 08/04/2016] [Indexed: 01/25/2023]
Abstract
Although stable mixed-hematopoietic chimerism induces robust immune tolerance to solid organ allografts in mice, the translation of this strategy to large animal models and to patients has been challenging. We have previously shown that in MHC-matched nonhuman primates (NHPs), a busulfan plus combined belatacept and anti-CD154-based regimen could induce long-lived myeloid chimerism, but without T cell chimerism. In that setting, donor chimerism was eventually rejected, and tolerance to skin allografts was not achieved. Here, we describe an adaptation of this strategy, with the addition of low-dose total body irradiation to our conditioning regimen. This strategy has successfully induced multilineage hematopoietic chimerism in MHC-matched transplants that was stable for as long as 24 months posttransplant, the entire length of analysis. High-level T cell chimerism was achieved and associated with significant donor-specific prolongation of skin graft acceptance. However, we also observed significant infectious toxicities, prominently including cytomegalovirus (CMV) reactivation and end-organ disease in the setting of functional defects in anti-CMV T cell immunity. These results underscore the significant benefits that multilineage chimerism-induction approaches may represent to transplant patients as well as the inherent risks, and they emphasize the precision with which a clinically successful regimen will need to be formulated and then validated in NHP models.
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Affiliation(s)
- Hengqi (Betty) Zheng
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle WA
| | | | - Victor Tkachev
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle WA
| | - Shan Yu
- Tulane National Primate Research Center, New Orleans, LA
| | - Dollnovan Tran
- Tulane National Primate Research Center, New Orleans, LA
| | - Scott Furlan
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle WA
| | - Katie Zeleski
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle WA
| | | | - Kelly Hamby
- Emory University School of Medicine, Atlanta GA
| | - Charlotte Hotchkiss
- Washington National Primate Research Center, University of Washington, Seattle WA
| | - Jennifer Lane
- Washington National Primate Research Center, University of Washington, Seattle WA
| | - Sanjeev Gumber
- Emory University School of Medicine, Atlanta GA,Division of Pathology, Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
| | | | | | | | - Amitinder Kaur
- Tulane National Primate Research Center, New Orleans, LA
| | - Bruce R. Blazar
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | - Leslie S. Kean
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle WA,Department of Pediatrics, University of Washington School of Medicine, Seattle WA,Fred Hutchinson Cancer Research Center, Seattle WA,Corresponding Author: Address: 1100 Olive Way Suite 100, Seattle WA 98101, Phone: 206-884-4079
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Furlan SN, Watkins B, Tkachev V, Flynn R, Cooley S, Ramakrishnan S, Singh K, Giver C, Hamby K, Stempora L, Garrett A, Chen J, Betz KM, Ziegler CGK, Tharp GK, Bosinger SE, Promislow DEL, Miller JS, Waller EK, Blazar BR, Kean LS. Transcriptome analysis of GVHD reveals aurora kinase A as a targetable pathway for disease prevention. Sci Transl Med 2016; 7:315ra191. [PMID: 26606970 DOI: 10.1126/scitranslmed.aad3231] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Graft-versus-host disease (GVHD) is the most common complication of hematopoietic stem cell transplant (HCT). However, our understanding of the molecular pathways that cause this disease remains incomplete, leading to inadequate treatment strategies. To address this, we measured the gene expression profile of nonhuman primate (NHP) T cells during acute GVHD. Utilizing microarray technology, we measured the expression profiles of CD3(+) T cells from five cohorts: allogeneic transplant recipients receiving (i) no immunoprophylaxis (No Rx), (ii) sirolimus monotherapy (Siro), (iii) tacrolimus-methotrexate (Tac-Mtx), as well as (iv) autologous transplant recipients (Auto) and (v) healthy controls (HC). This comparison allowed us to identify transcriptomic signatures specific for alloreactive T cells and determine the impact of both mTOR (mechanistic target of rapamycin) and calcineurin inhibition on GVHD. We found that the transcriptional profile of unprophylaxed GVHD was characterized by significant perturbation of pathways regulating T cell proliferation, effector function, and cytokine synthesis. Within these pathways, we discovered potentially druggable targets not previously implicated in GVHD, prominently including aurora kinase A (AURKA). Utilizing a murine GVHD model, we demonstrated that pharmacologic inhibition of AURKA could improve survival. Moreover, we found enrichment of AURKA transcripts both in allo-proliferating T cells and in sorted T cells from patients with clinical GVHD. These data provide a comprehensive elucidation of the T cell transcriptome in primate acute GVHD and suggest that AURKA should be considered a target for preventing GVHD, which, given the many available AURKA inhibitors in clinical development, could be quickly deployed for the prevention of GVHD.
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Affiliation(s)
- Scott N Furlan
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | | | - Victor Tkachev
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | - Ryan Flynn
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Sarah Cooley
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | | | - Karnail Singh
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Cindy Giver
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Kelly Hamby
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Linda Stempora
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | - Jingyang Chen
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | - Kayla M Betz
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | | | - Gregory K Tharp
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA
| | - Steven E Bosinger
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA
| | - Daniel E L Promislow
- Department of Pathology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Jeffrey S Miller
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | | | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Leslie S Kean
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA.
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Mavigner M, Watkins B, Lawson B, Lee ST, Chahroudi A, Kean L, Silvestri G. Persistence of virus reservoirs in ART-treated SHIV-infected rhesus macaques after autologous hematopoietic stem cell transplant. PLoS Pathog 2014; 10:e1004406. [PMID: 25254512 PMCID: PMC4177994 DOI: 10.1371/journal.ppat.1004406] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/18/2014] [Indexed: 11/24/2022] Open
Abstract
Despite many advances in AIDS research, a cure for HIV infection remains elusive. Here, we performed autologous hematopoietic stem cell transplantation (HSCT) in three Simian/Human Immunodeficiency Virus (SHIV)-infected, antiretroviral therapy (ART)-treated rhesus macaques (RMs) using HSCs collected prior to infection and compared them to three SHIV-infected, ART-treated, untransplanted control animals to assess the effect of conditioning and autologous HSCT on viral persistence. As expected, ART drastically reduced virus replication, below 100 SHIV-RNA copies per ml of plasma in all animals. After several weeks on ART, experimental RMs received myeloablative total body irradiation (1080 cGy), which resulted in the depletion of 94–99% of circulating CD4+ T-cells, and low to undetectable SHIV-DNA levels in peripheral blood mononuclear cells. Following HSC infusion and successful engraftment, ART was interrupted (40–75 days post-transplant). Despite the observed dramatic reduction of the peripheral blood viral reservoir, rapid rebound of plasma viremia was observed in two out of three transplanted RMs. In the third transplanted animal, plasma SHIV-RNA and SHIV DNA in bulk PBMCs remained undetectable at week two post-ART interruption. No further time-points could be assessed as this animal was euthanized for clinical reasons; however, SHIV-DNA could be detected in this animal at necropsy in sorted circulating CD4+ T-cells, spleen and lymph nodes but not in the gastro-intestinal tract or tonsils. Furthermore, SIV DNA levels post-ART interruption were equivalent in several tissues in transplanted and control animals. While persistence of virus reservoir was observed despite myeloablation and HSCT in the setting of short term ART, this experiment demonstrates that autologous HSCT can be successfully performed in SIV-infected ART-treated RMs offering a new experimental in vivo platform to test innovative interventions aimed at curing HIV infection in humans. While antiretroviral therapy (ART) can reduce HIV replication, it does not eradicate the virus from an infected individual. Replication-competent viruses persist on ART and our incomplete understanding of these viral reservoirs greatly complicates the generation of a cure for HIV. In this study we performed, for the first time, hematopoietic stem cell transplant (HSCT) in the established model of SIV infection of rhesus macaques (RM). The HSC originating from the bone marrow were collected before SIV infection. After SIV infection, RM were treated with ART for several weeks to reduce viral replication before performing a total body irradiation and a transplant with their own, pre-infection, stem cells. The irradiation eliminated 94–99% of the circulating CD4+ T-cells, the main cell target of HIV/SIV infection. A successful engraftment of the HSC was observed and blood viral reservoirs were drastically reduced. However, when ART was interrupted, a rapid rebound of plasma viremia was observed in two out of three transplanted RM indicating that the massive reset of the hematopoietic compartment was not sufficient to eliminate the total-body virus reservoir in the setting of short term ART. This model of HSCT in SIV-infected RM provides a new platform to investigate HIV eradication strategies.
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Affiliation(s)
- Maud Mavigner
- Emory Vaccine Center and Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Benton Lawson
- Emory Vaccine Center and Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
| | - S. Thera Lee
- Emory Vaccine Center and Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
| | - Ann Chahroudi
- Emory Vaccine Center and Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
- Center for Immunology and Vaccines, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Leslie Kean
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, United States of America
- Center for Immunology and Vaccines, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Guido Silvestri
- Emory Vaccine Center and Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
- Center for Immunology and Vaccines, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
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Saylors RL, Watkins B, Saccente S, Tang X. Comparison of automated red cell exchange transfusion and simple transfusion for the treatment of children with sickle cell disease acute chest syndrome. Pediatr Blood Cancer 2013; 60:1952-6. [PMID: 24000077 DOI: 10.1002/pbc.24744] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [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: 02/18/2013] [Accepted: 07/26/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Both simple transfusion (ST) of packed red blood cells and automated red cell exchange (RCE) are used in the treatment of acute chest syndrome (ACS). We report our experience using each of these modalities for the treatment of ACS. METHODS Retrospective chart review of patients with ACS treated with ST only (51 episodes, ST group) or RCE performed either at diagnosis (U-RCE group, 15 episodes) or after ST (ST + RCE group, 15 episodes). RESULTS The mean clinical respiratory score (CRS) at diagnosis was significantly higher in the U-RCE group than in the ST group, but there were no significant differences among the other groups. The CRS and WBC each decreased significantly after simple transfusion in the ST group and after RCE in the U-RCE group, but both the CRS and WBC increased significantly, and the mean platelet count fell significantly, after simple transfusion in the ST + RCE group. Only patients in the ST + RCE group required mechanical ventilation. There were no significant differences in length of stay (LOS) or total hospital charges among any of the groups, probably due to the small sample size. CONCLUSIONS We conclude that the CRS identifies the patients who are most severely affected with ACS, and that upfront RCE is a safe and effective treatment for these patients. Additional work is needed to develop a method to predict which of the apparently less severely affected patients will fail to improve after simple transfusion and should receive upfront RCE.
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Affiliation(s)
- Robert L Saylors
- Division of Pediatric Hematology and Oncology, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Sergeev E, Grach S, Shindin A, Mishin E, Bernhardt P, Briczinski S, Isham B, Broughton M, LaBelle J, Watkins B. Artificial ionospheric layers during pump frequency stepping near the 4th gyroharmonic at HAARP. Phys Rev Lett 2013; 110:065002. [PMID: 23432261 DOI: 10.1103/physrevlett.110.065002] [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] [Received: 09/14/2012] [Indexed: 06/01/2023]
Abstract
We report on artificial descending plasma layers created in the ionosphere F region by high-power high-frequency (HF) radio waves from High-frequency Active Auroral Research Program at frequencies f(0) near the fourth electron gyroharmonic 4f(ce). The data come from concurrent measurements of the secondary escaping radiation from the HF-pumped ionosphere, also known as stimulated electromagnetic emission, reflected probing signals at f(0), and plasma line radar echoes. The artificial layers appeared only for injections along the magnetic field and f(0)>4f(ce) at the nominal HF interaction altitude in the background ionosphere. Their average downward speed ~0.5 km/s holds until the terminal altitude where the local fourth gyroharmonic matches f(0). The total descent increases with the nominal offset f(0)-4f(ce).
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Affiliation(s)
- E Sergeev
- Radiophysical Research Institute, 25a/12 Bolshaya Pecherskaya Street, Nizhny Novgorod 603950, Russia
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Kozyr N, Ramakrishnan S, Polnett A, Hamby K, Tiwari D, Watkins B, Deane T, Stempora L, Elder E, Esiashvili N, Jenkins J, Strobert E, Garcia A, Sharma P, Courtney C, Giver C, Waller EK, Mortari A, Blazar BR, Kean LS. Synergistic Control of Acute GvHD: Effectively Down-Regulating T Cell Proliferation and Cytotoxicity with Combined mTOR Inhibition and CD28:CD80/86 Costimulation Blockade. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.079] [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: 10/27/2022]
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Pollard TCB, Batra RN, Judge A, Watkins B, McNally EG, Gill HS, Thomas GER, Glyn-Jones S, Arden NK, Carr AJ. The hereditary predisposition to hip osteoarthritis and its association with abnormal joint morphology. Osteoarthritis Cartilage 2013; 21:314-21. [PMID: 23123686 DOI: 10.1016/j.joca.2012.10.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 10/07/2012] [Accepted: 10/26/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Genetic factors and abnormalities of joint morphology are important in the aetiology of hip osteoarthritis (OA). The extent to which genetic influences are manifest through joint morphology has undergone limited investigation. Using a cohort with an hereditary predisposition to end-stage hip OA and a control group with no inherited risk, we aimed to identify associations with abnormal joint morphology and clinical features. DESIGN One hundred and twenty-three individuals (mean age 52 years) with a family history of total hip arthroplasty (THA) (termed 'sibkids') were compared with 80 spouse controls. Morphology was assessed using standardised radiographs and cam, dysplasia, and pincer deformities defined. Regression modelling described the association of cohort with abnormal joint morphology, adjusting for confounders [age, gender, body mass index (BMI), OA, and osteophyte]. RESULTS Sibkids had an odds ratio of 2.1 [95%confidence interval (CI) 1.3-3.5] for cam deformity. There were no differences in the prevalence of dysplasia or pincer deformities. In both groups, hips with cam deformities or dysplasia were more likely to have clinical features than normal hips [odds ratio (OR) 4.46 (1.8-11.3), and 4.40 (1.4-14.3) respectively]. Pincer deformity was associated with positive signs in the sibkids but not in the controls (OR 3.0; 1.1-8.2). DISCUSSION After adjustment for confounders that cause secondary morphological change, individuals with an hereditary predisposition to end-stage hip OA had a higher prevalence of morphological abnormalities associated with hip OA. Sibkids were more likely to demonstrate clinical features in the presence of pincer deformity, suggesting that the genes are acting not only through abnormal morphology but also through other factors that influence the prevalence of pain.
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Affiliation(s)
- T C B Pollard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre NHS Trust, Headington, Oxford, United Kingdom.
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Beck PA, Anders M, Watkins B, Gunter SA, Hubbell D, Gadberry MS. 2011 and 2012 Early Careers Achievement Awards: improving the production, environmental, and economic efficiency of the stocker cattle industry in the southeastern United States. J Anim Sci 2012; 91:2456-66. [PMID: 23243161 DOI: 10.2527/jas.2012-5873] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Grazing forages on small-grain fields can be a profitable "second crop" for grain producers and an opportunity for cow-calf producers to retain ownership of weaned calves. The increasing costs of conventional tillage and movement of soil nutrients into surface water creates a need for more sustainable production practices to be incorporated by producers into wheat pasture production systems. Research at the Livestock and Forestry Research Station near Batesville, AR, and the Southwest Research and Extension Center near Hope, AR, has been conducted over a 9-yr span to characterize the impacts of pasture systems on forage production, animal performance, soil quality, water runoff, and the economics associated with the stocker cattle enterprises. Gains of growing cattle grazing nontoxic endophyte-infected tall fescue and small-grain forages can be increased by 80 and 150%, respectively, compared with grazing Bermuda grass or toxic endophyte-infected tall fescue. Producers grazing spring-calving cowherds can use these improved forages to accelerate stocker performance when retaining calves in the fall and improve net returns by 99% with winter annual or nontoxic tall fescue production systems compared with Bermuda grass or toxic tall fescue. Rainfall simulation of small grain pastures indicates that runoff volume and nutrient load does not differ between conventionally tilled fields and no-till fields in the spring before tillage when soil surface cover is similar. In the fall after tillage, however, conventionally tilled fields had 4 times greater runoff; hence, there was 1.9 times greater N runoff and 3.2 times greater P runoff in conventionally tilled fields compared with no-till. Total natural rainfall runoff from conventionally tilled wheat fields were 2 times greater than from no-till fields with 25 mm rainfall events yet were 4 times greater with 62-mm rainfall events. Soil analysis shows that soil aggregate content was greater in no-till compared with conventional till, indicating greater soil porosity, improved water infiltration rate, and reduced erositivity of soil. Carbon concentration in no-till soils was 50% greater than conventional tillage after 9 yr. These experiments show that production systems can be designed that maintain livestock production, increase soil quality, reduce nutrient discharge, and promote improved economic returns.
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Affiliation(s)
- P A Beck
- University of Arkansas Division of Agriculture, Southwest Research and Extension Center, Hope 71801, USA.
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Pollard TCB, Batra RN, Judge A, Watkins B, McNally EG, Gill HS, Arden NK, Carr AJ. Genetic predisposition to the presence and 5-year clinical progression of hip osteoarthritis. Osteoarthritis Cartilage 2012; 20:368-375. [PMID: 22343497 DOI: 10.1016/j.joca.2012.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [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] [Received: 09/12/2011] [Revised: 01/31/2012] [Accepted: 02/07/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Genetic factors are important in the aetiology of hip osteoarthritis (OA), but studies are limited by cross-sectional design and poor association with clinically important disease. Identifying cohorts with progressive OA will facilitate development of OA biomarkers. Using a middle-aged cohort with genetic predisposition to hip OA and a control group, we compared the prevalence of clinical and radiographic hip OA and incidence of progression over 5 years. DESIGN 123 individuals (mean age 52 years) with a family history of total hip arthroplasty (THA) ('sibkids') were compared with 80 (mean age 54 years) controls. The prevalence of radiographic OA [scored according to Kellgren & Lawrence (K&L)], clinical features, and incidence of clinical progression over a 5-year period were compared. A multivariate logistic regression model was used to adjust for confounders. RESULTS Sibkids had odds ratios (ORs) of 2.7 [95% confidence interval (CI) 1.1-6.3, P = 0.02] for hip OA (K&L grade ≥2), 3.4 (1.4-8.4, P = 0.008) for clinical signs, and 2.1 (0.8-5.8, P = 0.14) for signs and symptoms. Over 5 years, sibkids had ORs of 4.7 (1.7-13.2, P = 0.003) for the development of signs, and 3.2 (1.0-10.3, P = 0.047) for the development of signs and symptoms. DISCUSSION Compared to a control group and after adjustment for confounders, individuals with genetic predisposition to end-stage hip OA have higher prevalence of OA, clinical features, and progression. In addition to structural degeneration, the inherited risk may include predisposition to pain. Genetically-loaded cohorts are useful to develop hip OA biomarkers, as they develop progressive disease at a young age.
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Affiliation(s)
- T C B Pollard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom.
| | - R N Batra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom
| | - A Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom
| | - B Watkins
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom
| | - E G McNally
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom
| | - H S Gill
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom
| | - N K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom
| | - A J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the NIHR Biomedical Research Unit, University of Oxford, United Kingdom
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Watkins B, Pouliot K, Fey E, Tuthill C, Sonis S. Attenuation of radiation- and chemoradiation-induced mucositis using gamma-D-glutamyl-L-tryptophan (SCV-07). Oral Dis 2010; 16:655-60. [PMID: 20412446 DOI: 10.1111/j.1601-0825.2010.01671.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the efficacy of a novel immunomodulating peptide (SCV-07) in attenuating the course of radiation-induced mucositis in an established animal model of oral mucositis (OM). MATERIAL AND METHODS In three separate experiments, golden Syrian hamsters received either an acute radiation challenge to the buccal mucosa of eight fractionated doses of 7.5 Gy of radiation over a 2-week-period, or a combination of acute radiation and cisplatin. In each experiment, animals were treated with varying doses or schedules of SCV-07 or placebo. OM was scored in a blinded fashion using digital images obtained during the experimental period. RESULTS We found that SCV-07 reduced the severity and duration of both acute and fractionated radiation-induced OM. Similarly, when radiation and chemotherapy were used to induce OM, treatment with SCV-07 significantly reduced the duration of ulcerative OM. The therapeutic benefit was dependent on both dose and schedule of administration. CONCLUSION Taken together, we found SCV-07 was able to modify the duration and severity of oral mucositis and was dependent on schedule and dose.
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Affiliation(s)
- B Watkins
- Biomodels, L.L.C. Watertown, MA, USA
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Panoutsopoulou K, Southam L, Elliott KS, Wrayner N, Zhai G, Beazley C, Thorleifsson G, Arden NK, Carr A, Chapman K, Deloukas P, Doherty M, McCaskie A, Ollier WER, Ralston SH, Spector TD, Valdes AM, Wallis GA, Wilkinson JM, Arden E, Battley K, Blackburn H, Blanco FJ, Bumpstead S, Cupples LA, Day-Williams AG, Dixon K, Doherty SA, Esko T, Evangelou E, Felson D, Gomez-Reino JJ, Gonzalez A, Gordon A, Gwilliam R, Halldorsson BV, Hauksson VB, Hofman A, Hunt SE, Ioannidis JPA, Ingvarsson T, Jonsdottir I, Jonsson H, Keen R, Kerkhof HJM, Kloppenburg MG, Koller N, Lakenberg N, Lane NE, Lee AT, Metspalu A, Meulenbelt I, Nevitt MC, O'Neill F, Parimi N, Potter SC, Rego-Perez I, Riancho JA, Sherburn K, Slagboom PE, Stefansson K, Styrkarsdottir U, Sumillera M, Swift D, Thorsteinsdottir U, Tsezou A, Uitterlinden AG, van Meurs JBJ, Watkins B, Wheeler M, Mitchell S, Zhu Y, Zmuda JM, Zeggini E, Loughlin J. Insights into the genetic architecture of osteoarthritis from stage 1 of the arcOGEN study. Ann Rheum Dis 2010; 70:864-7. [PMID: 21177295 PMCID: PMC3070286 DOI: 10.1136/ard.2010.141473] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [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] [Indexed: 12/21/2022]
Abstract
Objectives The genetic aetiology of osteoarthritis has not yet been elucidated. To enable a well-powered genome-wide association study (GWAS) for osteoarthritis, the authors have formed the arcOGEN Consortium, a UK-wide collaborative effort aiming to scan genome-wide over 7500 osteoarthritis cases in a two-stage genome-wide association scan. Here the authors report the findings of the stage 1 interim analysis. Methods The authors have performed a genome-wide association scan for knee and hip osteoarthritis in 3177 cases and 4894 population-based controls from the UK. Replication of promising signals was carried out in silico in five further scans (44 449 individuals), and de novo in 14 534 independent samples, all of European descent. Results None of the association signals the authors identified reach genome-wide levels of statistical significance, therefore stressing the need for corroboration in sample sets of a larger size. Application of analytical approaches to examine the allelic architecture of disease to the stage 1 genome-wide association scan data suggests that osteoarthritis is a highly polygenic disease with multiple risk variants conferring small effects. Conclusions Identifying loci conferring susceptibility to osteoarthritis will require large-scale sample sizes and well-defined phenotypes to minimise heterogeneity.
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Frampton I, Watkins B, Gordon I, Lask B. Do abnormalities in regional cerebral blood flow in anorexia nervosa resolve after weight restoration? Eur Eat Disorders Rev 2010; 19:55-8. [DOI: 10.1002/erv.1047] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Gwilym SE, Watkins B, Cooper CD, Harvie P, Auplish S, Pollard TCB, Rees JL, Carr AJ. Genetic influences in the progression of tears of the rotator cuff. ACTA ACUST UNITED AC 2009; 91:915-7. [PMID: 19567856 DOI: 10.1302/0301-620x.91b7.22353] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to investigate genetic influences on the development and progression of tears of the rotator cuff. From a group of siblings of patients with a tear of the rotator cuff and of controls studied five years earlier, we determined the prevalence of tears of the rotator cuff with and without associated symptoms using ultrasound and the Oxford Shoulder Score. In the five years since the previous assessment, three of 62 (4.8%) of the sibling group and one of the 68 (1.5%) controls had undergone shoulder surgery. These subjects were excluded from the follow-up. Full-thickness tears were found in 39 of 62 (62.9%) siblings and in 15 of 68 (22.1%) controls (p = 0.0001). The relative risk of full-thickness tears in siblings as opposed to controls was 2.85 (95% confidence interval (CI) 1.75 to 4.64), compared to 2.42 (95% CI 1.77 to 3.31) five years earlier. Full-thickness tears associated with pain were found in 30 of 39 (76.9%) tears in the siblings and in eight of 15 (53.3%) tears in the controls (p = 0.045). The relative risk of pain associated with a full-thickness tear in the siblings as opposed to the controls was 1.44 (95% CI 2.04 to 8.28) (p = 0.045). In the siblings group ten of 62 (16.1%) had progressed in terms of tear size or development compared to one of 68 (1.5%) in the control group which had increased in size. Full-thickness rotator cuff tears in siblings are significantly more likely to progress over a period of five years than in a control population. This implies that genetic factors have a role, not only in the development but also in the progression of full-thickness tears of the rotator cuff.
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Affiliation(s)
- S E Gwilym
- NDORMS, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK
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Rottiers P, Caluwaerts S, Steidler L, Vandenbroucke K, Watkins B, Sonis S, Coulie B. Effect of a mouth rinse formulation with human trefoil factor 1-secreting Lactococcus lactis in experimental oral mucositis in hamsters. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e14570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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
e14570 Background: Oral mucositis (OM) is a painful and dose-limiting toxicity of cancer chemotherapy and irradiation, characterized by breakdown of the oral mucosa. Trefoil factors (TFFs) are involved in protecting and healing mucosal tissue, and might thus represent a pharmacological tool for treatment of OM. Local delivery of recombinant TFFs at the oral mucosa by living, genetically modified Lactococcus (L.) lactis bacteria (ActoBiotics) seems a promising, safe and cost-effective clinical approach for the prevention and attenuation of oral mucositis. Methods: An environmentally contained Lactococcus lactis strain (AG013), engineered to express human (h)TFF1, was formulated for topical administration in the form of a mouth rinse. Efficacy of AG013 was assessed in a clinically relevant hamster model of acute, radiation-induced OM. The dosing regimen was 1.3 x 109 CFU/dose, once (qd) or three rinses (tid) daily, from day 0 (=day of radiation) to day 18. OM was scored from day 6 to day 28 using the WHO grading scale, and compared to the score of placebo-treated hamsters. The viability and survival of live L. lactis and the pharmacokinetics of the hTFF1 secreted were studied in healthy and OM hamsters. Results: Topical application of AG013 to the oral mucosa significantly reduced the severity and course of radiation-induced OM. In the AG013-treated groups, the number of animals days with ulcerative mucositis (grade 3 or higher) was significantly reduced to 27.5% and 30.8% (qd and tid respectively; P < 0.001), compared to 45.8 % in the placebo-treated group. Based on the observed survival and weight changes, AG013 appeared to be well-tolerated. Pharmacokinetic studies demonstrated that both living L. lactis and the hTFF1 secreted could be recovered from the administration site, for maximum 24 hours post-dosing, without systemic exposure. Conclusions: Oral administration of AG013 is safe and effective in reducing the severity and the course of OM in the hamster model, and therefore supports proof-of-concept for a mouth rinse formulation of AG013 to treat OM patients. [Table: see text]
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Affiliation(s)
- P. Rottiers
- ActoGeniX, Zwijnaarde, Belgium; Biomodels, Watertown, MA; Brigham and Women's Hospital, Boston, MA
| | - S. Caluwaerts
- ActoGeniX, Zwijnaarde, Belgium; Biomodels, Watertown, MA; Brigham and Women's Hospital, Boston, MA
| | - L. Steidler
- ActoGeniX, Zwijnaarde, Belgium; Biomodels, Watertown, MA; Brigham and Women's Hospital, Boston, MA
| | - K. Vandenbroucke
- ActoGeniX, Zwijnaarde, Belgium; Biomodels, Watertown, MA; Brigham and Women's Hospital, Boston, MA
| | - B. Watkins
- ActoGeniX, Zwijnaarde, Belgium; Biomodels, Watertown, MA; Brigham and Women's Hospital, Boston, MA
| | - S. Sonis
- ActoGeniX, Zwijnaarde, Belgium; Biomodels, Watertown, MA; Brigham and Women's Hospital, Boston, MA
| | - B. Coulie
- ActoGeniX, Zwijnaarde, Belgium; Biomodels, Watertown, MA; Brigham and Women's Hospital, Boston, MA
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Murray L, Kramer M, Watkins B, Fey E, Hesson D, Sonis S. Serum Amyloid P Inhibits Radiation-induced Mucositis. Int J Radiat Oncol Biol Phys 2008. [DOI: 10.1016/j.ijrobp.2008.06.601] [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: 11/16/2022]
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Meyer C, Yore M, Ferguson D, Watkins B, Fey E, Sporn M, Huff J, Sonis S. 536 POSTER RTA 402 suppresses tumor and treatment induced inflammation, sensitizing tumors to and protecting normal tissue from radiation. EJC Suppl 2006. [DOI: 10.1016/s1359-6349(06)70541-9] [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: 10/23/2022] Open
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Sonis S, Haddad R, Posner M, Watkins B, Fey E, Morgan TV, Mookanamparambil L, Ramoni M. Gene expression changes in peripheral blood cells provide insight into the biological mechanisms associated with regimen-related toxicities in patients being treated for head and neck cancers. Oral Oncol 2006; 43:289-300. [PMID: 16920386 DOI: 10.1016/j.oraloncology.2006.03.014] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [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: 03/02/2006] [Revised: 03/21/2006] [Accepted: 03/24/2006] [Indexed: 11/17/2022]
Abstract
UNLABELLED Patients treated with radiotherapy are prone to a constellation of local and systemic toxicities including mucositis, xerostomia, fatigue and anorexia. The biological complexities and similarities underlying the development of toxicities have recently been realized. Mucosal barrier injury is one of the best studied, and gene expression patterns, based on animal tissue samples, have added to its understanding. While investigations gene expression based on tissue samples was valuable, its use precludes more generalizable conclusions relative to common pathogenic mechanisms. Additionally, attempting to define the kinetics of changes in gene expression by sequential sampling is pragmatically unrealistic. Our objectives were: 1. to determine if changes in gene expression could be detected during toxicity development using PBM from patients receiving chemoradiation; 2. to characterize the relationship of expressed genes using graph theory and pathway analysis; and 3. to evaluate potential relationships between the expression of particular genes, canonical pathways, and functional networks in explaining the pathogenesis of regimen-related toxicities. DESIGN Microarray analysis was performed using PBM-derived cRNA obtained before and 2 weeks after the initiation of chemoradiation in five patients with head and neck cancer who developed documented regimen-related toxicities. We created a database of those genes newly expressed at 2 weeks and evaluated their potential significance relative to toxicity, by canonical pathway analysis, compilation of regional networks around focus genes, and development of a model globalizing the individual functional networks. There was strong concordance between known pathogenic mechanisms of toxicity and the genes, pathways, and networks developed by our data. A role was elicited for unsuspected genes in toxicity development. Our results support the concept that radiation induced toxicities have common underlying mechanisms and demonstrate the utility of PBM as an RNA source for genetic studies. This methodology could be broadly applicable to the study of regimen-related toxicities.
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Affiliation(s)
- S Sonis
- Division of Oral Medicine and Head and Neck Cancer, Dana-Farber Cancer Institute, Boston, MA, USA.
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Maclachlan T, Narayanan B, Gerlach VL, Smithson G, Gerwien RW, Folkerts O, Fey EG, Watkins B, Seed T, Alvarez E. Human fibroblast growth factor 20 (FGF-20; CG53135-05): a novel cytoprotectant with radioprotective potential. Int J Radiat Biol 2005; 81:567-79. [PMID: 16298938 DOI: 10.1080/09553000500211091] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [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
The aim was to evaluate the radioprotective properties of recombinant human fibroblast growth factor 20 (FGF-20; CG53135-05) in vitro and in vivo and to examine its effects on known cellular pathways of radioprotection. Relative transcript levels of the cyclooxygenase 2 (COX2), Mn-super oxide dismutase (SOD), CuZn-SOD, extracellular (EC)-SOD, nuclear respiratory factor 2 (Nrf2), glutathione peroxidase 1 (GPX1) and intestinal trefoil factor 3 (ITF3) genes, which are involved in radiation response pathways, were assessed by reverse transcriptase-polymerase chain reaction (RT-PCR) in NIH/3T3, IEC18, CCD-18Co, CCD-1070sk and human umbilical vein endothelial cells (HUVEC) cells exposed to FGF-20. Activation of the radioprotective signal transduction pathways initiating with the serine/threonine Akt kinase and the extracellular regulated kinase (ERK) were analysed. Levels of intracellular hydrogen peroxide and cytosolic redox potential were also measured in irradiated and unirradiated cells in the presence or absence of FGF-20. The effects of FGF-20 on cell survival in vitro following ionizing radiation were evaluated using clonogenic assays. To test the potential activity of FGF-20 as a radioprotectant in vivo, mice were administered a single dose of FGF-20 (4 mg kg(-1), intraperitoneally (i.p.) 1 day before lethal total-body irradiation and evaluated for survival. In vitro exposure to FGF-20 increased expression of the Nrf2 transcription factor and oxygen radical scavenging enzymes such as MnSOD, activated signal transduction pathways (ERK and Akt) and resulted in increased survival of irradiated cells in vitro. FGF-20 treatment also resulted in a concomitant reduction in intracellular levels of injurious reactive oxygen species (ROS) following acute ionizing irradiation. Finally, prophylactic administration of FGF-20 to mice before potentially lethal, whole-body X-irradiation led to significant increases in overall survival. FGF-20 reduced the lethal effects of acute ionizing radiation exposure in cells by up-regulating important signalling and free radical scavenging pathways. Survival-sparing effects of FGF-20 prophylaxis in acutely irradiated mice presumably are elicited by comparable mechanisms. These results indicate that FGF-20, has significant radioprotective attributes with potential applications in clinical and non-clinical exposure settings.
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Affiliation(s)
- S. T. Sonis
- Brigham & Women’s Hosp, Boston, MA; Biomodels, LLC, Cambridge, MA; McNeil Consumer and Specialty Pharmaceuticals, Fort Washington, PA
| | - B. Watkins
- Brigham & Women’s Hosp, Boston, MA; Biomodels, LLC, Cambridge, MA; McNeil Consumer and Specialty Pharmaceuticals, Fort Washington, PA
| | - E. Fey
- Brigham & Women’s Hosp, Boston, MA; Biomodels, LLC, Cambridge, MA; McNeil Consumer and Specialty Pharmaceuticals, Fort Washington, PA
| | - M. Yuschak
- Brigham & Women’s Hosp, Boston, MA; Biomodels, LLC, Cambridge, MA; McNeil Consumer and Specialty Pharmaceuticals, Fort Washington, PA
| | - D. Parenti
- Brigham & Women’s Hosp, Boston, MA; Biomodels, LLC, Cambridge, MA; McNeil Consumer and Specialty Pharmaceuticals, Fort Washington, PA
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Abstract
This study investigates the correlation between early-onset eating disorders and past history of physical illness. Subjects for this study were children and adolescents aged between 7 and 19 years, and were divided into two groups: those with anorexia nervosa (n=62) and those with "other eating disorders" (n=28). Data on medical history were obtained retrospectively from the patient's files and coded by a consultant psychiatrist. There was no significant difference between the two groups in relation to a history of prior physical illness. However, those with anorexia nervosa were significantly more likely to have suffered more than one serious physical illness prior to the onset of their eating disorder, and both groups were significantly more likely to have had a prior physical illness than an adult control group [Patton, G. C., Wood, K., & Johnson-Sabine. Br. J. Psychiatry 149 (1986) 756.]. Thus, it appears that a past history of physical illness is a significant risk factor for early-onset eating disorders in general, and for anorexia nervosa in particular when there has been more than one physical illness.
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Affiliation(s)
- B Watkins
- Child and Adolescent Eating Disorders Research Team, St George's Hospital Medical School, University of London, UK.
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Abstract
BACKGROUND Although cases of early onset anorexia nervosa have been described, there has been no systematic comparison of early onset cases with classic cases of later onset, or with other forms of early onset eating disturbance. METHOD A consecutive series of patients referred to two specialist child and adolescent eating disorder services with a clinical diagnosis of eating disorder (N = 126) was systematically assessed using a child version of the Eating Disorder Examination (EDE) and the K-SADS interview. RESULTS Of 86 patients with a diagnosis of eating disorder of early onset, 38 received a clinical diagnosis of anorexia nervosa (AN). The remainder were mainly diagnosed as having food avoidance emotional disorder (25 patients) and selective eating (17 patients). Six received other diagnoses (bulimia nervosa, or functional dysphasia). These 48 patients were combined to form a group of early onset non-AN eating disturbance. In terms of specific eating disorder psychopathology and general psychopathology, the early onset AN group was very similar to the late onset AN sample. When the two early onset groups were compared, there was a marked difference between them in terms of eating disorder psychopathology. A discriminant function analysis using the EDE information produced a clear discrimination, with the EDE restraint and shape concern subscales doing most of the discrimination work. CONCLUSIONS The specific psychopathology of AN of early onset is very similar to that of classic adolescent onset AN. Other forms of early onset eating disorder do not evidence this specific psychopathology.
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Affiliation(s)
- P J Cooper
- Department of Psychology, University of Reading, Whiteknights
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Affiliation(s)
- A R Vaccaro
- Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, Philadelphia, PA 19107, USA
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Abstract
On-line carcass inspection of chickens in the United States is currently done using visual (organoleptic) methods. Inspectors from the USDA Food Safety and Inspection Service (FSIS) inspect the viscera and carcass and, for older birds, the heads using a sequence of observations and palpations at a postmortem inspection station. The streamlined inspection system (SIS) and the new line speed inspection system (NELS) are the most prevalent visual inspection methods. The former has a line speed of 70 birds/min with two inspectors per line, and the latter has a line speed of 91 birds/min requiring three inspectors per line. Both inspection methods are labor intensive and prone to human error. In addition, the speed of the slaughter line is dictated by the number of birds per minute that can be inspected by FSIS inspectors. Ninety-one birds/min is currently the maximum visual inspection line speed allowed under current Federal regulations. This study evaluates the economic benefits of using automated inspection in place of visual inspection from the perspective of both the slaughter plant and FSIS. The results indicate that FSIS and slaughter plants would gain economic benefits by using automated inspection in place of visual inspection. The economic benefits to FSIS would accrue from labor savings, whereas the economic benefits to slaughter plants would accrue primarily from increased throughput from faster inspection line speeds.
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Affiliation(s)
- B Watkins
- USDA, Agricultural Research Service, Remote Sensing and Modeling Laboratory, Beltsville, Maryland, USA.
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Abstract
Pneumothorax was noted after an arthroscopic procedure during which a small guidewire overpenetrated the glenoid from a posterior-superior direction. This anatomic study was undertaken to determine the structures at risk from pins overpenetrating from the posterior-superior aspect and to determine whether scapulothoracic position altered the risk. The glenoid was intentionally overpenetrated with wooden dowels from the posterior-superior aspect of the glenoid in seven fresh cadaveric shoulders. The dowels were placed arthroscopically using the Suretac instrumentation (Acufex Microsurgical, Mansfield, MA). The specimens were planed, and the relationship of these wooden pins to vital structures was evaluated. In all specimens, the dowels entered the thoracic cavity between the first and second ribs, regardless of scapular position. The pins consistently passed posterior to the neurovascular bundle but were precariously close, with an average distance to the closest neurovascular structure of 7.4 mm (range, 1 to 19 mm). Scapular position did not seem to affect this relationship.
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Affiliation(s)
- S C Slattery
- 1st Medical Group Hospital, Langley Air Force Base, Virginia, USA
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Hoffman FO, Thiessen KM, Watkins B. Opportunities for the testing of environmental transport models using data obtained following the Chernobyl accident. Health Phys 1996; 70:5-7. [PMID: 7499152 DOI: 10.1097/00004032-199601000-00001] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The aftermath of the Chernobyl accident has provided a unique opportunity to collect data sets specifically for the purpose of model testing, and with these data to create scenarios against which environmental transport models may be tested in a format constituting a blind test. This article serves as an introduction to three test scenarios designed for testing models at the process level: (1) surface water contamination with radionuclides initially deposited onto soils; (2) contamination of different aquatic media and biota due to fallout of radionuclides into a body of water; and (3) atmospheric resuspension of radionuclides from contaminated land surfaces. These scenarios are the first such tests to use data sets collected in the former Soviet Union. Interested modelers are invited to participate in the test exercises by making calculations for any of these test scenarios. Information on participation is included.
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Affiliation(s)
- F O Hoffman
- SENES Oak Ridge, Inc., Center for Risk Analysis, TN 37830, USA
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