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Frame D, Scappaticci GB, Braun TM, Maliarik M, Sisson TH, Pipe SW, Lawrence DA, Richardson PG, Holinstat M, Hyzy RC, Kaul DR, Gregg KS, Lama VN, Yanik GA. Defibrotide Therapy for SARS-CoV-2 ARDS. Chest 2022; 162:346-355. [PMID: 35413279 PMCID: PMC8993696 DOI: 10.1016/j.chest.2022.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND SARS-CoV-2-related ARDS is associated with endothelial dysfunction and profound dysregulation of the thrombotic-fibrinolytic pathway. Defibrotide is a polyanionic compound with fibrinolytic, antithrombotic, and antiinflammatory properties. RESEARCH QUESTION What is the safety and tolerability of defibrotide in patients with severe SARS-CoV-2 infections? STUDY DESIGN AND METHODS We report a prospective, open-label, single-center safety trial of defibrotide for the management of SARS-CoV-2-related ARDS. Eligible participants were 18 years of age or older with clinical and radiographic signs of ARDS, no signs of active bleeding, a serum D-dimer of more than twice upper limit of normal, and positive polymerase chain reaction-based results for SARS-CoV-2. Defibrotide (6.25 mg/kg/dose IV q6h) was administered for a planned 7-day course, with serum D-dimer levels and respiratory function monitored daily during therapy. RESULTS Twelve patients (median age, 63 years) were treated, with 10 patients receiving mechanical ventilation and 6 receiving vasopressor support at study entry. The median D-dimer was 3.25 μg/ml (range, 1.33-12.3) at study entry. The median duration of therapy was 7 days. No hemorrhagic or thrombotic complications occurred during therapy. No other adverse events attributable to defibrotide were noted. Four patients met the day 7 pulmonary response parameter, all four showing a decrease in serum D-dimer levels within the initial 72 h of defibrotide therapy. Three patients died of progressive pulmonary disease 11, 17, and 34 days after study entry. Nine patients (75%) remain alive 64 to 174 days after initiation of defibrotide. Day 30 all-cause mortality was 17% (95% CI, 0%-35%). All patients with a baseline Pao2 to Fio2 ratio of ≥ 125 mm Hg survived, whereas the three patients with a baseline Pao2 to Fio2 ratio of < 125 mm Hg died. INTERPRETATION The use of defibrotide for management of SARS-CoV-2-related ARDS proved safe and tolerable. No hemorrhagic or thrombotic complications were reported during therapy, with promising outcomes in a patient population with a historically high mortality rate. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04530604; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- David Frame
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Department of Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Gianni B. Scappaticci
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Department of Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Thomas M. Braun
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Mary Maliarik
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Thomas H. Sisson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Steven W. Pipe
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
| | - Daniel A. Lawrence
- Department of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Paul G. Richardson
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Michael Holinstat
- Division of Pharmacology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert C. Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Daniel R. Kaul
- Division of Infectious Disease, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Kevin S. Gregg
- Division of Infectious Disease, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Gregory A. Yanik
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Division of Pediatric Hematology-Oncology, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI,CORRESPONDENCE TO: Gregory A. Yanik, MD
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Talagtag M, Patel TS, Scappaticci GB, Perissinotti AJ, Schepers AJ, Petty LA, Pettit KM, Burke PW, Bixby DL, Marini BL. Utility of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening in patients with acute myeloid leukemia (AML). Transpl Infect Dis 2021; 23:e13612. [PMID: 33825279 DOI: 10.1111/tid.13612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/22/2021] [Accepted: 03/28/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Current literature has demonstrated the utility of the MRSA nasal screen as a de-escalation tool to decrease unnecessary anti-MRSA antibiotic therapy. However, data on the applicability of this test in patients with hematologic malignancy is lacking. METHODS This is a single-center, retrospective cohort study of patients with acute myeloid leukemia (AML) with or without a history of hematopoietic cell transplant (HCT), with pneumonia and MRSA nasal screening with respiratory cultures obtained. The primary outcome was to determine the negative predictive value (NPV) of the MRSA nasal screen for MRSA pneumonia. Secondary outcomes included sensitivity, specificity, positive predictive value (PPV) of the MRSA nasal screen and prevalence of MRSA pneumonia. RESULTS Of 98 patients with AML and pneumonia, the prevalence of MRSA pneumonia was 4.1% with confirmed positive MRSA respiratory cultures observed in 4 patient cases. In patients with confirmed MRSA pneumonia, 3 had positive MRSA nasal screens while 1 had a false negative result, possibly due to a long lag time (21 days) between MRSA nasal screen and pneumonia diagnosis. Overall, the MRSA nasal screen demonstrated 75% sensitivity and 100% specificity, with a PPV of 100% and a NPV of 98.9%. CONCLUSIONS Given the low prevalence, empiric use of anti-MRSA therapy in those AML and HCT patients with pneumonia may not be warranted in clinically stable patients. For patients in whom empiric anti-MRSA antibiotics are initiated, nasal screening for MRSA may be utilized to de-escalate anti-MRSA antibiotics in patients with AML with or without HCT.
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Affiliation(s)
- Millicynth Talagtag
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Twisha S Patel
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Gianni B Scappaticci
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Allison J Schepers
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Lindsay A Petty
- Department of Internal Medicine, Division of Infectious Diseases, Ann Arbor, MI, USA
| | - Kristen M Pettit
- Department of Internal Medicine, Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Patrick W Burke
- Department of Internal Medicine, Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dale L Bixby
- Department of Internal Medicine, Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Vulaj V, Perissinotti AJ, Uebel JR, Nachar VR, Scappaticci GB, Crouch A, Bixby DL, Burke PW, Maillard I, Talpaz M, Marini BL. The FOSSIL Study: FLAG or standard 7+3 induction therapy in secondary acute myeloid leukemia. Leuk Res 2018; 70:91-96. [PMID: 29908418 DOI: 10.1016/j.leukres.2018.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/23/2018] [Accepted: 05/30/2018] [Indexed: 12/18/2022]
Abstract
Patients with secondary acute myeloid leukemia (sAML) have poor outcomes, with CR/CRi rates of 25-35% with standard 7 + 3 induction chemotherapy, while single center non-comparative analyses suggest promising outcomes with FLAG. We conducted a single-center, retrospective cohort study assessing outcomes in treatment-naïve patients with sAML treated with fludarabine, high-dose cytarabine, and granulocyte colony-stimulating factor (FLAG, n = 40) compared with 7 + 3 (n = 66). Median patient age was 63 years (range: 27-82) in the FLAG group and 60 years (range: 21-76) in the 7 + 3 group (P = 0.968). Patients treated with FLAG achieved higher overall response rates (CR + CRi + MLFS) compared to 7 + 3 (70% vs. 48%, P = 0.043). FLAG was well tolerated, with only one induction death (30-day mortality rate, 3% vs. 8%, P = 0.405) and no cases of cerebellar toxicity. Duration of neutropenia was significantly shorter with FLAG (median 16 vs. 23 days, P < 0.001). Half of the FLAG-treated patients proceeded to consolidative therapy compared with only 27% of those who received 7 + 3 (P = 0.022). Overall survival was comparable between groups (8.5 mos, FLAG vs. 9.1 mos, 7 + 3; P = 0.798). Thus, FLAG may represent a low-cost treatment strategy in sAML that produces higher response rates and promising survival outcomes with minimal treatment-related toxicity. Further studies are required to prospectively compare FLAG to the newly FDA-approved CPX-351 in sAML.
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Affiliation(s)
- Vera Vulaj
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - James R Uebel
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Victoria R Nachar
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - Gianni B Scappaticci
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - Ashley Crouch
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Dale L Bixby
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Patrick W Burke
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Ivan Maillard
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Moshe Talpaz
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
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Mackler E, Scappaticci GB, Salgado TM, Petersen L, Davis EJ, Peltier E, Griggs JJ, Sabo RT, Farris KB. Impact of a Statewide Oral Oncolytic Initiative on Five Participating Practices. J Oncol Pract 2018; 14:e304-e309. [PMID: 29641272 DOI: 10.1200/jop.18.00058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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
PURPOSE The shift from infusion to oral oncolytic therapy presents challenges to oncology practitioners. The purpose of this study was to describe how a statewide quality-improvement collaborative can enhance quality of care for patients receiving oral oncolytic therapy. METHODS The Michigan Oncology Quality Consortium hosted a series of learning sessions focused on oral oncolytic quality improvement, providing multiple resources to oncology community practices. The first five participating practices reported which of the evidence-based Michigan Oncology Quality Consortium resources provided were implemented at their site. They also performed prepost self-assessments in October 2013 and April 2015 and another in December 2017 to assess sustainability. Concordance with the ASCO Quality Oncology Practice Initiative oral chemotherapy standards, including documentation (five measures), patient education (seven measures), and follow-up/monitoring (four measures), was compared. RESULTS All practices showed improvement between 2013 and 2015 in documentation (32% to 88%; P = .03), patient education (37% to 100%; P could not be calculated), and monitoring (40% to 80%; P > .2). Overall, a significant improvement in concordance was observed (36% to 91%; P = .03). Use of resources from each practice varied, and practices that used more resources showed greater improvements. There was a slight decrease in overall concordance between 2015 and 2017, which was not found to be significant (91% to 84%; P = .53). CONCLUSION Use of tools from a quality-improvement collaborative improved concordance with national standards of care. Large-scale deployment of this model program may provide a clinically efficient and effective mechanism to enhance widespread change.
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Affiliation(s)
- Emily Mackler
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Gianni B Scappaticci
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Teresa M Salgado
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Laura Petersen
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Emily J Davis
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Emily Peltier
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Jennifer J Griggs
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Roy T Sabo
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
| | - Karen B Farris
- Michigan Oncology Quality Consortium; University of Michigan, Ann Arbor, MI; and Virginia Commonwealth University, Richmond, VA
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Nachar VR, Perissinotti AJ, Scappaticci GB, Bixby DL, Marini BL. Predictors for requiring re-induction chemotherapy in acute myeloid leukemia patients with residual disease on day 14 bone marrow assessment. Leuk Res 2017; 63:56-61. [DOI: 10.1016/j.leukres.2017.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/05/2017] [Accepted: 10/28/2017] [Indexed: 11/30/2022]
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Scappaticci GB, Perissinotti AJ, Nagel JL, Bixby DL, Marini BL. Risk factors and impact of Clostridium difficile recurrence on haematology patients. J Antimicrob Chemother 2017; 72:1488-1495. [DOI: 10.1093/jac/dkx005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/03/2017] [Indexed: 01/25/2023] Open
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Scappaticci GB, Regal RE. Cockcroft-Gault revisited: New de-liver-ance on recommendations for use in cirrhosis. World J Hepatol 2017; 9:131-138. [PMID: 28217249 PMCID: PMC5295146 DOI: 10.4254/wjh.v9.i3.131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/11/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
The Cockcroft-Gault (CG) equation has become perhaps the most popular practical approach for estimating renal function among health care professionals. Despite its widespread use, clinicians often overlook not only the limitations of the original serum creatinine (SCr) based equation, but also may not appreciate the validity of the many variations used to compensate for these limitations. For cirrhotic patients in particular, the underlying pathophysiology of the disease contributes to a falsely low SCr, thereby overestimating renal function with use of the CG equation in this population. We reviewed the original CG trial from 1976 along with data surrounding clinician specific alterations to the CG equation that followed through time. These alterations included different formulas for body weight in obese patients and the “rounding up” approach in patients with low SCr. Additionally, we described the pathophysiology and hemodynamic changes that occur in cirrhosis; and reviewed several studies that attempted to estimate renal function in this population. The evidence we reviewed regarding the most accurate manipulation of the original CG equation to estimate creatinine clearance (CrCl) was inconclusive. Unfortunately, the homogeneity of the patient population in the original CG trial limited its external validity. Elimination of body weight in the CG equation actually produced the estimate closest to the measure CrCl. Furthermore, “rounding up” of SCr values often underestimated CrCl. This approach could lead to suboptimal dosing of drug therapies in patients with low SCr. In cirrhotic patients, utilization of SCr based methods overestimated true renal function by about 50% in the literature we reviewed.
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