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Newman H, Li Y, Huang YV, Elgarten CW, Myers RM, Ruiz J, Zheng DJ, Leahy AB, Aftandilian C, Arnold SD, Bona K, Gramatges MM, Heneghan MB, Maloney KW, Modi AJ, Mody RJ, Morgan E, Rubnitz J, Winick N, Wilkes JJ, Seif AE, Fisher BT, Aplenc R, Getz KD. Household income and health-related quality of life in children receiving treatment for acute myeloid leukemia: Potential impact of selection bias in health equity research. Cancer Med 2024; 13:e6966. [PMID: 38572962 PMCID: PMC10993703 DOI: 10.1002/cam4.6966] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/28/2023] [Accepted: 01/15/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Examine the influence of household income on health-related quality of life (HRQOL) among children with newly diagnosed acute myeloid leukemia (AML). DESIGN Secondary analysis of data prospectively collected from pediatric patients receiving treatment for AML at 14 hospitals across the United States. EXPOSURE Household income was self-reported on a demographic survey. The examined mediators included the acuity of presentation and treatment toxicity. OUTCOME Caregiver proxy reported assessment of patient HRQOL from the Peds QL 4.0 survey. RESULT Children with AML (n = 131) and caregivers were prospectively enrolled to complete PedsQL assessments. HRQOL scores were better for patients in the lowest versus highest income category (mean ± SD: 76.0 ± 14 household income <$25,000 vs. 59.9 ± 17 income ≥$75,000; adjusted mean difference: 11.2, 95% CI: 2.2-20.2). Seven percent of enrolled patients presented with high acuity (ICU-level care in the first 72 h), and 16% had high toxicity (any ICU-level care); there were no identifiable differences by income, refuting mediating roles in the association between income and HRQOL. Enrolled patients were less likely to be Black/African American (9.9% vs. 22.2%), more likely to be privately insured (50.4% vs. 40.7%), and more likely to have been treated on a clinical trial (26.7% vs. 18.5%) compared to eligible unenrolled patients not enrolled. Evaluations of potential selection bias on the association between income and HRQOL suggested differences in HRQOL may be smaller than observed or even in the opposing direction. CONCLUSIONS While primary analyses suggested lower household income was associated with superior HRQOL, differential participation may have biased these results. Future studies should partner with patients/families to identify strategies for equitable participation in clinical research.
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Affiliation(s)
- Haley Newman
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yimei Li
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and InformaticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yuan‐Shung V. Huang
- Department of Biomedical and Health InformaticsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Caitlin W. Elgarten
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Regina M. Myers
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Jenny Ruiz
- Division of Hematology‐Oncology, Department of PediatricsUPMC Children's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Daniel J. Zheng
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Alison Barz Leahy
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Catherine Aftandilian
- Division of Pediatric Hematology‐Oncology, Stem Cell Transplant and Regenerative Medicine, Department of PediatricsStanford UniversityStanfordCaliforniaUSA
| | - Staci D. Arnold
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaEmory University School of MedicineAtlantaGeorgiaUSA
| | - Kira Bona
- Division of Population Sciences, Department of Pediatric OncologyDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - M. Monica Gramatges
- Division of Pediatric Hematology‐Oncology, Department of PediatricsTexas Children's Hospital, Baylor College of MedicineHoustonTexasUSA
| | - Mallorie B. Heneghan
- Division of Pediatric Hematology‐Oncology, Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | - Kelly W. Maloney
- Department of Pediatrics‐Hematology/Oncology and Bone Marrow Transplant, University of Colorado Cancer CenterChildren's Hospital ColoradoAuroraColoradoUSA
| | - Arunkumar J. Modi
- Division of Hematology Oncology, Department of PediatricsUniversity of Arkansas for Medical Sciences, Arkansas Children's HospitalLittle RockArkansasUSA
| | - Rajen J. Mody
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Elaine Morgan
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Jeffrey Rubnitz
- Department of OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Naomi Winick
- Department of Pediatric Hematology OncologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Jennifer J. Wilkes
- Division of Cancer and Blood Disorders, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Alix E. Seif
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Childhood Cancer ResearchChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Brian T. Fisher
- Center for Childhood Cancer ResearchChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Division of Infectious Disease, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Richard Aplenc
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Childhood Cancer ResearchChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Kelly D. Getz
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and InformaticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Brothers AW, Pak DJ, Poole NM, Kronman MP, Bettinger B, Wilkes JJ, Carpenter PA, Englund JA, Weissman SJ. Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital. Clin Infect Dis 2024; 78:15-23. [PMID: 37647637 DOI: 10.1093/cid/ciad518] [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: 06/08/2023] [Revised: 08/15/2023] [Accepted: 08/25/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections. METHODS In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making. RESULTS Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice. CONCLUSIONS Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.
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Affiliation(s)
- Adam W Brothers
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel J Pak
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Nicole M Poole
- Departments of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew P Kronman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Brendan Bettinger
- Department of Clinical Analytics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jennifer J Wilkes
- Department of Pediatrics, Division of Hematology/Oncology, University of Washington, Seattle, Washington, USA
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Paul A Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Janet A Englund
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Scott J Weissman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
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Winestone LE, Getz KD, Li Y, Burrows E, Scheurer ME, Tam V, Gramatges MM, Wilkes JJ, Miller TP, Seif AE, Rabin KR, Fisher BT, Aplenc R. Racial and ethnic disparities in acuity of presentation among children with newly diagnosed acute leukemia. Pediatr Blood Cancer 2024; 71:e30726. [PMID: 37856154 DOI: 10.1002/pbc.30726] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/15/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023]
Abstract
We evaluated disparities in disease burden, organ dysfunction, vital signs, and timing of therapy in children newly presenting with acute leukemia. Among 899 patients with acute leukemia diagnosed at two large children's hospitals, a priori lab-based definitions of high disease burden, infection risk, renal dysfunction, and coagulopathy were applied to electronic health record data. Black patients with acute myeloid leukemia had increased prevalence of elevated white blood cell count and uric acid; Black patients with acute lymphoblastic leukemia demonstrated increased prevalence of coagulopathy. Black patients' presentation more frequently included multiple lab abnormalities consistent with advanced physiologic dysfunction. No differences were found in days to therapy initiation.
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Affiliation(s)
- Lena E Winestone
- Division of Allergy, Immunology, and BMT, University of California San Francisco (UCSF) Benioff Children's Hospital, San Francisco, California, USA
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Kelly D Getz
- Departments of Biostatistics, Epidemiology, & Informatics and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yimei Li
- Departments of Biostatistics, Epidemiology, & Informatics and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Evanette Burrows
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael E Scheurer
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Vicky Tam
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - M Monica Gramatges
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jennifer J Wilkes
- Department of Pediatrics, Division of Hematology/Oncology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Tamara P Miller
- Division of Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Alix E Seif
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Karen R Rabin
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Brian T Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Richard Aplenc
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Miller TP, Getz KD, Li Y, Demissei BG, Adamson PC, Alonzo TA, Burrows E, Cao L, Castellino SM, Daves MH, Fisher BT, Gerbing R, Grundmeier RW, Krause EM, Lee J, Lupo PJ, Rabin KR, Ramos M, Scheurer ME, Wilkes JJ, Winestone LE, Hawkins DS, Gramatges MM, Aplenc R. Rates of laboratory adverse events by course in paediatric leukaemia ascertained with automated electronic health record extraction: a retrospective cohort study from the Children's Oncology Group. Lancet Haematol 2022; 9:e678-e688. [PMID: 35870472 PMCID: PMC9444944 DOI: 10.1016/s2352-3026(22)00168-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Adverse events are often misreported in clinical trials, leading to an incomplete understanding of toxicities. We aimed to test automated laboratory adverse event ascertainment and grading (via the ExtractEHR automated package) to assess its scalability and define adverse event rates for children with acute myeloid leukaemia and acute lymphoblastic leukaemia. METHODS For this retrospective cohort study from the Children's Oncology Group (COG), we included patients aged 0-22 years treated for acute myeloid leukaemia or acute lymphoblastic leukaemia at Children's Healthcare of Atlanta (Atlanta, GA, USA) from Jan 1, 2010, to Nov 1, 2018, at the Children's Hospital of Philadelphia (Philadelphia, PA, USA) from Jan 1, 2011, to Dec 31, 2014, and at the Texas Children's Hospital (Houston, TX, USA) from Jan 1, 2011, to Dec 31, 2014. The ExtractEHR automated package acquired, cleaned, and graded laboratory data as per Common Terminology Criteria for Adverse Events (CTCAE) version 5 for 22 commonly evaluated grade 3-4 adverse events (fatal events were not evaluated) with numerically based CTCAE definitions. Descriptive statistics tabulated adverse event frequencies. Adverse events ascertained by ExtractEHR were compared to manually reported adverse events for patients enrolled in two COG trials (AAML1031, NCT01371981; AALL0932, NCT02883049). Analyses were restricted to protocol-defined chemotherapy courses (induction I, induction II, intensification I, intensification II, and intensification III for acute myeloid leukaemia; induction, consolidation, interim maintenance, delayed intensification, and maintenance for acute lymphoblastic leukaemia). FINDINGS Laboratory adverse event data from 1077 patients (583 from Children's Healthcare of Atlanta, 200 from the Children's Hospital of Philadelphia, and 294 from the Texas Children's Hospital) who underwent 4611 courses (549 for acute myeloid leukaemia and 4062 for acute lymphoblastic leukaemia) were extracted, processed, and graded. Of the 166 patients with acute myeloid leukaemia, 86 (52%) were female, 80 (48%) were male, 96 (58%) were White, and 132 (80%) were non-Hispanic. Of the 911 patients with acute lymphoblastic leukaemia, 406 (45%) were female, 505 (55%) were male, 596 (65%) were White, and 641 (70%) were non-Hispanic. Patients with acute myeloid leukaemia had the most adverse events during induction I and intensification II. Hypokalaemia (one [17%] of six to 75 [48%] of 156 courses) and alanine aminotransferase (ALT) increased (13 [10%] of 134 to 27 [17%] of 156 courses) were the most prevalent non-haematological adverse events in patients with acute myeloid leukaemia, as identified by ExtractEHR. Patients with acute lymphoblastic leukaemia had the greatest number of adverse events during induction and maintenance (eight adverse events with prevalence ≥10%; induction and maintenance: anaemia, platelet count decreased, white blood cell count decreased, neutrophil count decreased, lymphocyte count decreased, ALT increased, and hypocalcaemia; induction: hypokalaemia; maintenance: aspartate aminotransferase [AST] increased and blood bilirubin increased), as identified by ExtractEHR. 187 (85%) of 220 total comparisons in 22 adverse events in four AAML1031 and six AALL0923 courses were substantially higher with ExtractEHR than COG-reported adverse event rates for adverse events with a prevalence of at least 2%. INTERPRETATION ExtractEHR is scalable and accurately defines laboratory adverse event rates for paediatric acute leukaemia; moreover, ExtractEHR seems to detect higher rates of laboratory adverse events than those reported in COG trials. These rates can be used for comparisons between therapies and to counsel patients treated on or off trials about the risks of chemotherapy. ExtractEHR-based adverse event ascertainment can improve reporting of laboratory adverse events in clinical trials. FUNDING US National Institutes of Health, St Baldrick's Foundation, and Alex's Lemonade Stand Foundation.
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Affiliation(s)
- Tamara P Miller
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
| | - Kelly D Getz
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Yimei Li
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Biniyam G Demissei
- Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Peter C Adamson
- Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Todd A Alonzo
- Department of Pediatrics, University of Southern California, Los Angeles, CA, USA
| | - Evanette Burrows
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lusha Cao
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sharon M Castellino
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Marla H Daves
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Brian T Fisher
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Robert W Grundmeier
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Edward M Krause
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Judy Lee
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Philip J Lupo
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Karen R Rabin
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Mark Ramos
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael E Scheurer
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer J Wilkes
- Divisions of Hematology and Oncology, Seattle Children's Hospital, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Lena E Winestone
- Division of AIBMT, Department of Pediatrics, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Douglas S Hawkins
- Divisions of Hematology and Oncology, Seattle Children's Hospital, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - M Monica Gramatges
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Richard Aplenc
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Wolfson JA, Bhatia S, Ginsberg JP, Becker L, Bernstein D, Henk HJ, Lyman GH, Nathan PC, Puccetti D, Wilkes JJ, Winestone LE, Kenzik KM. Expenditures in Young Adults with Hodgkin Lymphoma: NCI-designated Comprehensive Cancer Centers vs. Other Sites. Cancer Epidemiol Biomarkers Prev 2021; 31:142-149. [PMID: 34737208 DOI: 10.1158/1055-9965.epi-21-0321] [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: 03/10/2021] [Revised: 06/08/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Outcomes among Hodgkin Lymphoma (HL) patients diagnosed between 22 and 39 years are worse than among those diagnosed <21 years, and have not seen the same improvement over time. Treatment at an NCI-designated Comprehensive Cancer Center (CCC) mitigates outcome disparities, but may be associated with higher expenditures. METHODS We examined cancer-related expenditures among 22-39 year-old HL patients diagnosed between 2001-2016 using de-identified administrative claims data (OptumLabs® Data Warehouse) (CCC: n=1,154; non-CCC: n=643). Adjusting for sociodemographics, clinical characteristics and months enrolled, multivariable general linear models modeled average monthly health-plan paid (HPP) expenditures, and incidence rate ratios compared CCC/non-CCC monthly visit rates. RESULTS In the year following diagnosis, CCC patients had higher HPP-expenditures ($12,869 vs. $10,688, p=0.001), driven by higher monthly rates of CCC non-treatment outpatient hospital visits (p=0.001) and per-visit expenditures for outpatient hospital chemotherapy ($632 vs. $259); higher CCC inpatient expenditures ($1,813 vs. $1,091, p=0.001) were driven by 3.1-times higher rates of chemotherapy admissions (p=0.001). Out-of-pocket expenditures were comparable (p=0.3). CONCLUSIONS Young adults with Hodgkin lymphoma at CCCs saw higher health plan expenditures, but comparable out-of-pocket expenditures. Drivers of CCC expenditures included outpatient hospital utilization (monthly rates of non-therapy visits and per-visit expenditures for chemotherapy). IMPACT Higher HPP-expenditures at CCCs in the year following HL diagnosis likely reflect differences in facility structure and comprehensive care. For young adults, it is plausible to consider incentivizing CCC care to achieve superior outcomes while developing approaches to achieve long-term savings.
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Affiliation(s)
- Julie A Wolfson
- Institute for Cancer Outcomes and Survivorship and Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship and Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham
| | | | | | | | | | - Gary H Lyman
- Public Health Sciences, Fred Hutchinson Cancer Research Center
| | | | - Diane Puccetti
- University of Wisconsin School of Medicine and Public Health
| | - Jennifer J Wilkes
- Pediatric Hematology-Oncology, University of Washington School of Medicine
| | - Lena E Winestone
- Division of Allergy, Immunology & BMT, UCSF Benioff Children's Hospital
| | - Kelly M Kenzik
- Hematology/Oncology, University of Alabama at Birmingham
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6
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Getz KD, Szymczak JE, Li Y, Madding R, Huang YSV, Aftandilian C, Arnold SD, Bona KO, Caywood E, Collier AB, Gramatges MM, Henry M, Lotterman C, Maloney K, Mian A, Mody R, Morgan E, Raetz EA, Rubnitz J, Verma A, Winick N, Wilkes JJ, Yu JC, Fisher BT, Aplenc R. Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia. JAMA Netw Open 2021; 4:e2128385. [PMID: 34709389 PMCID: PMC8554641 DOI: 10.1001/jamanetworkopen.2021.28385] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Pediatric acute myeloid leukemia (AML) requires multiple courses of intensive chemotherapy that result in neutropenia, with significant risk for infectious complications. Supportive care guidelines recommend hospitalization until neutrophil recovery. However, there are little data to support inpatient over outpatient management. OBJECTIVE To evaluate outpatient vs inpatient neutropenia management for pediatric AML. DESIGN, SETTING, AND PARTICIPANTS This cohort study used qualitative and quantitative methods to compare medical outcomes, patient health-related quality of life (HRQOL), and patient and family perceptions between outpatient and inpatient neutropenia management. The study included patients from 17 US pediatric hospitals with frontline chemotherapy start dates ranging from January 2011 to July 2019, although the specific date ranges differed for the individual analyses by design and relative timing. Data were analyzed from August 2019 to February 2020. EXPOSURES Discharge to outpatient vs inpatient neutropenia management. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were course-specific bacteremia incidence, times to next course, and patient HRQOL. Course-specific mortality was a secondary medical outcome. RESULTS Primary quantitative analyses included 554 patients (272 [49.1%] girls and 282 [50.9%] boys; mean [SD] age, 8.2 [6.1] years). Bacteremia incidence was not significantly different during outpatient vs inpatient management (67 courses [23.8%] vs 265 courses [29.0%]; adjusted rate ratio, 0.73; 95% CI, 0.56 to 1.06; P = .08). Outpatient management was not associated with delays to the next course compared with inpatient management (mean [SD] 30.7 [12.2] days vs 32.8 [9.7] days; adjusted mean difference, -2.2; 95% CI, -4.1 to -0.2, P = .03). Mortality during intensification II was higher for patients who received outpatient management compared with those who received inpatient management (3 patients [5.4%] vs 1 patient [0.5%]; P = .03), but comparable with inpatient management at other courses (eg, 0 patients vs 5 patients [1.3%] during induction I; P = .59). Among 97 patients evaluated for HRQOL, outcomes did not differ between outpatient and inpatient management (mean [SD] Pediatric Quality of Life Inventory total score, 70.1 [18.9] vs 68.7 [19.4]; adjusted mean difference, -2.8; 95% CI, -11.2 to 5.6). A total of 86 respondents (20 [23.3%] in outpatient management, 66 [76.7%] in inpatient management) completed qualitative interviews. Independent of management strategy received, 74 respondents (86.0%) expressed satisfaction with their experience. Concerns for hospital-associated infections among caregivers (6 of 7 caregiver respondents [85.7%] who were dissatisfied with inpatient management) and family separation (2 of 2 patient respondents [100%] who were dissatisfied with inpatient management) drove dissatisfaction with inpatient management. Stress of caring for a neutropenic child at home (3 of 3 respondents [100%] who were dissatisfied with outpatient management) drove dissatisfaction with outpatient management. CONCLUSIONS AND RELEVANCE This cohort study found that outpatient neutropenia management was not associated with higher bacteremia incidence, treatment delays, or worse HRQOL compared with inpatient neutropenia management among pediatric patients with AML. While outpatient management may be safe for many patients, course-specific mortality differences suggest that outpatient management in intensification II should be approached with caution. Patient and family experiences varied, suggesting that outpatient management may be preferred by some but may not be feasible for all families. Further studies to refine and standardize safe outpatient management practices are warranted.
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Affiliation(s)
- Kelly D. Getz
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yimei Li
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel Madding
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yuan-Shung V. Huang
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine Aftandilian
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Stanford University, Palo Alto, California
| | - Staci D. Arnold
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Kira O. Bona
- Pediatric Hematology/Oncology, Children’s Hospital Boston, Boston, Massachusetts
| | - Emi Caywood
- A.I. Dupont Hospital for Children, Nemours, Wilmington, Delaware
| | | | | | | | | | - Kelly Maloney
- Children’s Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Amir Mian
- Arkansas Children’s Hospital, Little Rock
| | | | - Elaine Morgan
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Elizabeth A. Raetz
- Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, New York, New York
| | - Jeffrey Rubnitz
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Anupam Verma
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, Salt Lake City
| | - Naomi Winick
- Department of Pediatric Hematology Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Jennifer J. Wilkes
- Department of Pediatrics, University of Washington, Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle
| | - Jennifer C. Yu
- Division of Pediatric Hematology Oncology, Rady Children’s Hospital San Diego, San Diego, California
| | - Brian T. Fisher
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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7
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Cahen VC, Li Y, Getz KD, Elgarten CW, DiNofia AM, Wilkes JJ, Winestone LE, Huang YSV, Miller TP, Gramatges MM, Rabin KR, Fisher BT, Aplenc R, Seif AE. Identifying relapses and stem cell transplants in pediatric acute lymphoblastic leukemia using administrative data: Capturing national outcomes irrespective of trial enrollment. Pediatr Blood Cancer 2021; 68:e28315. [PMID: 32391940 DOI: 10.1002/pbc.28315] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Our objectives were to design and validate methods to identify relapse and hematopoietic stem cell transplantation (HSCT) in children with acute lymphoblastic leukemia (ALL) using administrative data representing hospitalizations at US pediatric institutions. METHODS We developed daily billing and ICD-9 code definitions to identify relapses and HSCTs within a cohort of children with newly diagnosed ALL between January 1, 2004, and December 31, 2013, previously assembled from the Pediatric Health Information System (PHIS) database. Chart review for children with ALL at the Children's Hospital of Philadelphia (CHOP) and Texas Children's Hospital (TCH) was performed to establish relapse and HSCT gold standards for sensitivity and positive predictive value (PPV) calculations. We estimated incidences of relapse and HSCT in the PHIS ALL cohort. RESULTS We identified 362 CHOP and 314 TCH ALL patients in PHIS and established true positives by chart review. Sensitivity and PPV for identifying both relapse and HSCT in PHIS were > 90% at both hospitals. Five-year relapse incidence in the 10 150-patient PHIS cohort was 10.3% (95% CI 9.8%-10.9%) with 7.1% (6.6%-7.6%) of children underwent HSCTs. Patients in higher-risk demographic groups had higher relapse and HSCT rates. Our analysis also identified differences in incidences of relapse and HSCT by race, ethnicity, and insurance status. CONCLUSIONS Administrative data can be used to identify relapse and HSCT accurately in children with ALL whether they occur on- or off-therapy, in contrast with published approaches. This method has wide potential applicability for estimating these incidences in pediatric ALL, including patients not enrolled on clinical trials.
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Affiliation(s)
- Viviane C Cahen
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yimei Li
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kelly D Getz
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Caitlin W Elgarten
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amanda M DiNofia
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer J Wilkes
- Division of Hematology/Oncology, Seattle Children's Hospital and the Department of Pediatrics, University of Washington, Seattle, Washington
| | - Lena E Winestone
- Division of Blood and Marrow Transplantation, UCSF Benioff Children's Hospital, University of California - San Francisco, San Francisco, California
| | - Yuan-Shung V Huang
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tamara P Miller
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University, Atlanta, Georgia
| | - M Monica Gramatges
- Division of Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Karen R Rabin
- Division of Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Brian T Fisher
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alix E Seif
- Center for Childhood Cancer Research, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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8
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Scoville NM, Feng S, Taylor MR, Herlihy E, Wilkes JJ, Chisholm KM, Tarczy-Hornoch K. Bilateral Pseudo-hypopyon as Presenting Symptom of Acute Monocytic Leukemia in an 8-Month-Old Infant. J Pediatr Ophthalmol Strabismus 2021; 58:e30-e33. [PMID: 34592122 DOI: 10.3928/01913913-20210708-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A previously healthy 8-month-old female infant presenting with lethargy and bilateral eye redness and cloudiness had bilateral hypopyon uveitis, which persisted despite topical steroids. Cytology of the anterior chamber and cerebrospinal fluid and flow cytometry of cerebrospinal fluid revealed malignant cells consistent with acute monocytic leukemia. Bone marrow aspirates and biopsies showed no evidence of disease. She was treated with systemic and intrathecal chemotherapy, with subsequent remission and resolution of pseudo-hypopyon. Anterior chamber involvement is a rare presentation of acute myeloid leukemia and may indicate concurrent central nervous system involvement. This has important therapeutic implications, because additional treatment modalities such as intrathecal chemotherapy, local chemotherapy, and ocular radiation may be required to overcome the "pharmacologic sanctuary" created by the blood-ocular barrier. [J Pediatr Ophthalmol Strabismus. 2021;58(5):e30-e33.].
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9
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Wolfson JA, Bhatia S, Ginsberg J, Becker LK, Bernstein D, Henk HJ, Lyman GH, Nathan PC, Puccetti D, Wilkes JJ, Winestone LE, Kenzik KM. Expenditures among young adults with acute lymphoblastic leukemia by site of care. Cancer 2021; 127:1901-1911. [PMID: 33465248 DOI: 10.1002/cncr.33413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 11/11/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Individuals diagnosed with acute lymphoblastic leukemia (ALL) between the ages of 22 and 39 years experience worse outcomes than those diagnosed when they are 21 years old or younger. Treatment at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) mitigates these disparities but may be associated with higher expenditures. METHODS Using deidentified administrative claims data (OptumLabs Data Warehouse), the cancer-related expenditures were examined among patients with ALL diagnosed between 2001 and 2014. Multivariable generalized linear model with log-link modeled average monthly health-plan-paid (HPP) expenditures and amount owed by the patient (out-of-pocket [OOP]). Cost ratios were used to calculate excess expenditures (CCC vs non-CCC). Incidence rate ratios (IRRs) compared CCC and non-CCC monthly visit rates. Models adjusted for sociodemographics, comorbidities, adverse events, and months enrolled. RESULTS Clinical and sociodemographic characteristics were comparable between CCC (n = 160) and non-CCC (n = 139) patients. Higher monthly outpatient expenditures in CCC patients ($15,792 vs $6404; P < .001) were driven by outpatient hospital HPP expenditures. Monthly visit rates and per visit expenditures for nonchemotherapy visits (IRR = 1.6; P = .001; CCC = $8247, non-CCC = $1191) drove higher outpatient hospital expenditures among CCCs. Monthly OOP expenditures were higher at CCCs for outpatient care (P = .02). Inpatient HPP expenditures were significantly higher at CCCs ($25,918 vs $13,881; ꞵ = 0.9; P < .001) before accounting for adverse events but were no longer significant after adjusting for adverse events (ꞵ = 0.4; P = .1). Hospitalizations and length of stay were comparable. CONCLUSIONS Young adults with ALL at CCCs have higher expenditures, likely reflecting differences in facility structure, billing practices, and comprehensive patient care. It would be reasonable to consider CCCs comparable to the oncology care model and incentivize the framework to achieve superior outcomes and long-term cost savings. LAY SUMMARY Health care expenditures in young adults (aged 22-39 years) with acute lymphoblastic leukemia (ALL) are higher among patients at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) than those at non-CCCs. The CCC/non-CCC differences are significant among outpatient expenditures, which are driven by higher rates of outpatient hospital visits and outpatient hospital expenditures per visit at CCCs. Higher expenditures and visit rates of outpatient hospital visits among CCCs may also reflect how facility structure and billing patterns influence spending or comprehensive care. Young adults at CCCs face higher inpatient HPP expenditures; these are driven by serious adverse events.
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Affiliation(s)
- Julie A Wolfson
- Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jill Ginsberg
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Gary H Lyman
- Divisions of Public Health Sciences and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Paul C Nathan
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Diane Puccetti
- Division of Pediatric Hematology-Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jennifer J Wilkes
- Department of Pediatrics, Division of Cancer and Blood Disorders, University of Washington School of Medicine, Seattle, Washington
| | - Lena E Winestone
- Division of Allergy, Immunology, and Bone Marrow Transplant, Department of Pediatrics, UCSF Benioff Children's Hospitals, San Francisco, California
| | - Kelly M Kenzik
- Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
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10
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Chow EJ, Doody DR, Wilkes JJ, Becker LK, Chennupati S, Morin PE, Winestone LE, Henk HJ, Lyman GH. Adverse events among chronic myelogenous leukemia patients treated with tyrosine kinase inhibitors: a real-world analysis of health plan enrollees. Leuk Lymphoma 2020; 62:1203-1210. [PMID: 33283555 DOI: 10.1080/10428194.2020.1855340] [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] [Indexed: 12/31/2022]
Abstract
With tyrosine kinase inhibitor (TKI) therapy, chronic myelogenous leukemia (CML) is now a chronic disease. CML patients treated with TKIs (n = 1200) were identified from the OptumLabs® Data Warehouse (de-identified claims and electronic health records) between 2000 and 2016 and compared with a non-cancer cohort (n = 7635). The 5-year cumulative incidence of all organ system outcomes was significantly greater for the TKI versus non-cancer group. In the first year, compared with imatinib, later generation TKIs were associated with primary infections (hazard ratios [HR] 1.43, 95% CI 1.02-2.00), circulatory events (HR 1.15, 95% CI 1.01-1.31), and skin issues (HR 1.43, 95% CI 1.13-1.80); musculoskeletal and nervous system/sensory issues were less common (HRs 0.83-0.84, p < 0.05). Increased risk of infections, cardiopulmonary and skin issues associated with later generation TKIs persisted in subsequent years. In this real-world population, TKI therapy was associated with a high burden of adverse events. Later generation TKIs may have greater toxicity than imatinib.
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Affiliation(s)
- Eric J Chow
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, USA.,OptumLabs Visiting Fellow, Cambridge, MA, USA
| | - David R Doody
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jennifer J Wilkes
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Shasank Chennupati
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Lena E Winestone
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | | | - Gary H Lyman
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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11
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Wilkes JJ, Lyman GH, Doody DR, Chennupati S, Becker LK, Morin PE, Winestone LE, Henk HJ, Chow EJ. Health Care Cost Associated With Contemporary Chronic Myelogenous Leukemia Therapy Compared With That of Other Hematologic Malignancies. JCO Oncol Pract 2020; 17:e406-e415. [PMID: 32822255 DOI: 10.1200/op.20.00143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Given the widespread introduction of tyrosine kinase inhibitors (TKIs), we evaluated the cost associated with chronic myelogenous leukemia (CML) care compared with the cost of care for patients with hematologic malignancies (HEM) and for patients without cancer (GEN), to aid with resource allocation and clinical decision making. METHODS A retrospective cohort was constructed from the OptumLabs Data Warehouse using claims from 2000 to 2016. Eligible patients had ≥ 2 CML claims and were enrolled continuously for ≥ 6 months before diagnosis and ≥ 1 year afterward (n = 1,909). Patients with CML were frequency matched 4:1 with HEM and GEN cohorts and were observed through October 2017. We used generalized linear models to assess the variation in total mean annualized health care costs in the 3 cohorts and to examine the influence of factors associated with costs. RESULTS Mean annualized costs for CML were $82,054 (ie, $25,471 [95% CI, $20,808 to $30,133] more than those for HEM and $74,993 [95% CI, $70,818 to $79,167] more than those for GEN); these differences were driven by pharmacy costs in the CML group. The cost of CML care exceeded that for HEM and GEN for all index years in this study and increased over each diagnostic interval until 2015, peaking at $91,990. The mean annual cost of all TKIs increased. Imatinib's mean annualized cost was $41,546 in the period 2000-2004 but increased to $105,069 in the period 2015-2017. In multivariable analysis, percent days on TKIs had the greatest influence on cost: ≥ 75% of the time versus none showed a difference in cost of $108,716 (95% CI, $99,193 to $118,239). CONCLUSION Contemporary CML costs exceeded the cost of treatment of other hematologic malignancies. Cost was primarily driven by TKIs, whose cost continued to increase over time.
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Affiliation(s)
- Jennifer J Wilkes
- Center for Clinical and Translational Research, Seattle, WA.,Department of Pediatrics, University of Washington, Seattle, WA.,OptumLabs, Eden Prairie, MN
| | - Gary H Lyman
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA.,Department of Medicine, University of Washington, Seattle, WA
| | - David R Doody
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Shasank Chennupati
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | - Lena E Winestone
- University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - Eric J Chow
- Center for Clinical and Translational Research, Seattle, WA.,Department of Pediatrics, University of Washington, Seattle, WA.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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12
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Wolfson JA, Bhatia S, Ginsberg JP, Becker L, Bernstein D, Henk HJ, Lyman GH, Nathan PC, Puccetti D, Wilkes JJ, Winestone L, Kenzik K. Health plan expenditures young adults with newly-diagnosed Hodgkin lymphoma (HL) by care at NCI-designated comprehensive cancer centers (CCC) vs. other treatment sites (non-CCC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7081 Background: Patients diagnosed with HL between 22-39y have worse outcomes than younger patients (≤21y); we previously reported that treatment at a CCC mitigates these disparities [Wolfson, Leukemia 2017]. While there is general consensus that CCC care is expensive, expenditures for managing young adults with HL in CCC vs. non-CCC are not known. Methods: Cancer-related expenditures were examined in HL patients diagnosed between 2001-2014 at age 22-39y and treated at CCC and non-CCC sites using commercial insurance claims data (OptumLabs Data Warehouse). Multivariable generalized linear models with log link modeled average monthly health plan paid expenditures, adjusting for sociodemographics, stage, adverse events, pre-existing comorbidities, and diagnostic era. Results: Of the 1501 HL patients, 33% (n = 489) were treated at a CCC. Patients treated at CCC vs. non-CCC did not differ with respect to race, sex, income, diagnostic era or comorbidities (p≥0.3). Mean duration of enrollment was longer in CCC than non-CCC (25 vs. 23 mos; p < 0.001) patients. During the first year after HL diagnosis, total average monthly expenditures were higher in CCC ($9,111) than non-CCC ($7,834, p = 0.001), including those related to inpatient (CCC: $1,790 vs. non-CCC: $1,011; p = 0.001) and outpatient (CCC: $6,971 vs. non-CCC: $6,487; p = 0.001) expenditures. The higher CCC expenditures were associated with higher monthly rates of inpatient admissions (IRR = 1.3, p = 0.001) and outpatient visits (IRR = 1.1, p = 0.02) at CCC. Rates of chemotherapy-related inpatient admissions were higher (IRR = 2.3, p = 0.001) in CCC than non-CCC patients, while outpatient chemotherapy visit rates were lower (IRR = 0.9, p = 0.001) in CCC. During Years 2-3, total average monthly expenditures were higher in CCC ($19,259) than non-CCC ($4,145, p = 0.002) patients. Outpatient expenditures were higher in CCC ($10,164) vs. non-CCC ($2,901, p = 0.001), with higher monthly outpatient visit rates (IRR = 1.7, p = 0.001) at CCC. Conclusions: Inpatient and outpatient cancer-related expenditures in young adults with HL were higher at CCC than non-CCCs. Higher outpatient expenditures at CCC were associated with only higher monthly visit rates. Higher inpatient expenditures were in the setting of higher admission rates, including those related to chemotherapy. Additional work is necessary to understand whether these higher expenditures at CCC are related to supportive care and/or differences in facility structure and billing practices.
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Affiliation(s)
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Diane Puccetti
- Department of Pediatrics and Carbone Cancer Center University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Lena Winestone
- UCSF Benioff Children's Hospital and Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Kelly Kenzik
- University of Alabama at Birmingham, Birmingham, AL
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13
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Phillips CA, Razzaghi H, Aglio T, McNeil MJ, Salvesen-Quinn M, Sopfe J, Wilkes JJ, Forrest CB, Bailey LC. Development and evaluation of a computable phenotype to identify pediatric patients with leukemia and lymphoma treated with chemotherapy using electronic health record data. Pediatr Blood Cancer 2019; 66:e27876. [PMID: 31207054 PMCID: PMC7135896 DOI: 10.1002/pbc.27876] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 01/07/2019] [Revised: 04/30/2019] [Accepted: 05/25/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Widespread implementation of electronic health records (EHR) has created new opportunities for pediatric oncology observational research. Little attention has been given to using EHR data to identify patients with pediatric hematologic malignancies. METHODS This study used EHR-derived data in a pediatric clinical data research network, PEDSnet, to develop and evaluate a computable phenotype algorithm to identify pediatric patients with leukemia and lymphoma who received treatment with chemotherapy. To guide early development, multiple computable phenotype-defined cohorts were compared to one institution's tumor registry. The most promising algorithm was chosen for formal evaluation and consisted of at least two leukemia/lymphoma diagnoses (Systematized Nomenclature of Medicine codes) within a 90-day period, two chemotherapy exposures, and three hematology-oncology provider encounters. During evaluation, the computable phenotype was executed against EHR data from 2011 to 2016 at three large institutions. Classification accuracy was assessed by masked medical record review with phenotype-identified patients compared to a control group with at least three hematology-oncology encounters. RESULTS The computable phenotype had sensitivity of 100% (confidence interval [CI] 99%, 100%), specificity of 99% (CI 99%, 100%), positive predictive value (PPV) and negative predictive value (NPV) of 100%, and C-statistic of 1 at the development institution. The computable phenotype performance was similar at the two test institutions with sensitivity of 100% (CI 99%, 100%), specificity of 99% (CI 99%, 100%), PPV of 96%, NPV of 100%, and C-statistic of 0.99. CONCLUSION The EHR-based computable phenotype is an accurate cohort identification tool for pediatric patients with leukemia and lymphoma who have been treated with chemotherapy and is ready for use in clinical studies.
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Affiliation(s)
- Charles A Phillips
- Division of Oncology and Center for Childhood Cancer Research, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Hanieh Razzaghi
- Division of Oncology and Center for Childhood Cancer Research, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Taylor Aglio
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael J McNeil
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | | | - Jenna Sopfe
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado, Denver, CO
| | - Jennifer J Wilkes
- Division of Hematology and Oncology and Center for Clinical and Translational Research, Department of Pediatrics, Seattle Children’s Hospital and the University of Washington, Seattle, WA
| | - Christopher B Forrest
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - L Charles Bailey
- Division of Oncology and Center for Childhood Cancer Research, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA
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14
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Henk HJ, Winestone LE, Wilkes JJ, Becker L, Morin P, Lyman GH, Chow EJ. HSR19-090: Changes in Adherence to Tyrosine Kinase Inhibitor Treatment Patterns Among Patients With Chronic Myeloid Leukemia and the Impact on Costs: 2001–2017. J Natl Compr Canc Netw 2019. [DOI: 10.6004/jnccn.2018.7191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Chronic myeloid leukemia (CML) treatment improved considerably after introduction of oral tyrosine kinase inhibitors (TKI). As a result, the number of patients living with CML may reach 250,000 by 2040. We track changes in TKI treatment adherence since 2001 and provide an early assessment of treatment costs following the availability of second-generation TKIs and generic imatinib. Methods: A retrospective cohort from the OptumLabs Data Warehouse, which includes claims data for privately insured and Medicare Advantage (MA) enrollees in a large private U.S. health plan with medical and pharmacy benefits, was used. Patients with CML initiated TKI treatment between May 2001 and October 2016 and were continuously enrolled in the health plan 6 months prior through 12 months following TKI start. Adherence was defined by medication possession ratio (MPR1=total days’ supply of imatinib in 1st year divided by 365, 1=perfect adherence). Total health care costs include medical and prescription medication benefits. MPR1 was modeled using ordinary least squares regression. The association between MPR1 and healthcare costs was estimated using a generalized linear model specified with a gamma error distribution and a log link. Results: We identified 1,793 eligible patients. First-line TKI has changed over time (dasatinib and nilotinib represent 45% of all 2016 starts; imatinib 55%). From 2001 to 2016, adherence increased (Table 1). MPR1 was higher in men and increased with age until age ∼62 after which it declined. MPR1 was lower for patients with more comorbid conditions prior to treatment. Overall, MPR1 was inversely associated with total health care costs (medical and pharmacy) among privately insured (P<.001) but not MA enrollees. The net impact of MPR1 on total healthcare costs diminished over time (P<.001) where a 10% point decrease in MPR1 was associated with 12% and 4% lower total costs, prior to and following availability of 2nd generation TKIs, respectively. When examining medical costs only, MPR1 was inversely associated with medical costs for both privately insured (P<.001) and MA enrollees (P=.016). Conclusions: We found that adherence to TKI treatment increased over time. While imatinib is still used more frequently than other TKIs as first-line therapy, second-generation TKIs are becoming increasingly used as first-line agents. Possible cost-offsets are decreasing over time but it may be too early to formally evaluate the impact of generic imatinib.
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Affiliation(s)
| | - Lena E. Winestone
- bUniversity of California, San Francisco (UCSF) Benioff Children's Hospital, San Francisco, CA
| | | | | | | | - Gary H. Lyman
- dFred Hutchinson Cancer Research Center, Seattle, WA
| | - Eric J. Chow
- dFred Hutchinson Cancer Research Center, Seattle, WA
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15
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Esbenshade AJ, Zhao Z, Aftandilian C, Saab R, Wattier RL, Beauchemin M, Miller TP, Wilkes JJ, Kelly MJ, Fernbach A, Jeng M, Schwartz CL, Dvorak CC, Shyr Y, Moons KGM, Sulis ML, Friedman DL. Multisite external validation of a risk prediction model for the diagnosis of blood stream infections in febrile pediatric oncology patients without severe neutropenia. Cancer 2017; 123:3781-3790. [PMID: 28542918 DOI: 10.1002/cncr.30792] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 01/30/2017] [Revised: 03/24/2017] [Accepted: 04/24/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pediatric oncology patients are at an increased risk of invasive bacterial infection due to immunosuppression. The risk of such infection in the absence of severe neutropenia (absolute neutrophil count ≥ 500/μL) is not well established and a validated prediction model for blood stream infection (BSI) risk offers clinical usefulness. METHODS A 6-site retrospective external validation was conducted using a previously published risk prediction model for BSI in febrile pediatric oncology patients without severe neutropenia: the Esbenshade/Vanderbilt (EsVan) model. A reduced model (EsVan2) excluding 2 less clinically reliable variables also was created using the initial EsVan model derivative cohort, and was validated using all 5 external validation cohorts. One data set was used only in sensitivity analyses due to missing some variables. RESULTS From the 5 primary data sets, there were a total of 1197 febrile episodes and 76 episodes of bacteremia. The overall C statistic for predicting bacteremia was 0.695, with a calibration slope of 0.50 for the original model and a calibration slope of 1.0 when recalibration was applied to the model. The model performed better in predicting high-risk bacteremia (gram-negative or Staphylococcus aureus infection) versus BSI alone, with a C statistic of 0.801 and a calibration slope of 0.65. The EsVan2 model outperformed the EsVan model across data sets with a C statistic of 0.733 for predicting BSI and a C statistic of 0.841 for high-risk BSI. CONCLUSIONS The results of this external validation demonstrated that the EsVan and EsVan2 models are able to predict BSI across multiple performance sites and, once validated and implemented prospectively, could assist in decision making in clinical practice. Cancer 2017;123:3781-3790. © 2017 American Cancer Society.
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Affiliation(s)
- Adam J Esbenshade
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.,Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.,Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Zhiguo Zhao
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University, Nashville, Tennessee.,Center for Quantitative Science, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Catherine Aftandilian
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Raya Saab
- Department of Pediatrics, Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rachel L Wattier
- Department of Pediatrics, University of California at San Francisco, San Francisco, California
| | - Melissa Beauchemin
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, New York
| | - Tamara P Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer J Wilkes
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Kelly
- Division of Pediatric Hematology/Oncology, The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
| | - Alison Fernbach
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, New York
| | - Michael Jeng
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Cindy L Schwartz
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher C Dvorak
- Department of Pediatrics, University of California at San Francisco, San Francisco, California
| | - Yu Shyr
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University, Nashville, Tennessee.,Center for Quantitative Science, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karl G M Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maria-Luisa Sulis
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, New York
| | - Debra L Friedman
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.,Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.,Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
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16
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Winestone LE, Getz KD, Miller TP, Wilkes JJ, Sack L, Li Y, Huang YS, Seif AE, Bagatell R, Fisher BT, Epstein AJ, Aplenc R. The role of acuity of illness at presentation in early mortality in black children with acute myeloid leukemia. Am J Hematol 2017; 92:141-148. [PMID: 27862214 DOI: 10.1002/ajh.24605] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/04/2016] [Accepted: 11/08/2016] [Indexed: 01/20/2023]
Abstract
Black patients with acute myeloid leukemia (AML) experience higher mortality than White patients. We compared induction mortality, acuity of illness prior to chemotherapy, and insurance type between Black and White patients to assess whether acuity of presentation mediates the disparity. Within a retrospective cohort of 1,122 children with AML treated with two courses of standard induction chemotherapy between 2004 and 2014 in the Pediatric Health Information System (PHIS) database, the association between race (Black versus White) and inpatient mortality during induction was examined. Intensive Care Unit (ICU)-level resource utilization during the first 72 hours following admission for initial AML chemotherapy was evaluated as a potential mediator. The total effect of race on mortality during Induction I revealed a strong association (unadjusted HR 2.75, CI: 1.18, 6.41). Black patients had a significantly higher unadjusted risk of requiring ICU-level resources within the first 72 hours after initial presentation (17% versus 11%; RR 1.52, CI: 1.04, 2.24). Mediation analyses revealed the indirect effect of race through acuity accounted for 61% of the relative excess mortality during Induction I. Publicly insured patients experienced greater induction mortality than privately insured patients regardless of race. Black patients with AML have significantly greater risk of induction mortality and are at increased risk for requiring ICU-level resources soon after presentation. Higher acuity amongst Black patients accounts for a substantial portion of the relative excess mortality during Induction I. Targeting factors affecting acuity of illness at presentation may lessen racial disparities in AML induction mortality.
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Affiliation(s)
- Lena E. Winestone
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia; Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania; Pennsylvania
| | - Kelly D. Getz
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia; Pennsylvania
| | - Tamara P. Miller
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia; Pennsylvania
| | - Jennifer J. Wilkes
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia; Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania; Pennsylvania
| | - Leah Sack
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
| | - Yimei Li
- Department of Biostatistics and Epidemiology; Perelman School of Medicine, University of Pennsylvania; Pennsylvania
| | - Yuan-Shung Huang
- Healthcare Analytics Unit; The Children's Hospital of Philadelphia; Pennsylvania
| | - Alix E. Seif
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
- Department of Pediatrics; Perelman School of Medicine, University of Pennsylvania; Pennsylvania
| | - Rochelle Bagatell
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
- Department of Pediatrics; Perelman School of Medicine, University of Pennsylvania; Pennsylvania
| | - Brian T. Fisher
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia; Pennsylvania
- Division of Infectious Diseases; The Children's Hospital of Philadelphia; Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania; Pennsylvania
| | - Andrew J. Epstein
- Leonard Davis Institute of Health Economics, University of Pennsylvania; Pennsylvania
- Division of General Internal Medicine; Perelman School of Medicine, University of Pennsylvania; Pennsylvania
- Department of Veterans Affairs' Center for Health Equity Research and Promotion; Philadelphia Veterans Affairs Medical Center; Pennsylvania
| | - Richard Aplenc
- Division of Oncology; The Children's Hospital of Philadelphia; Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia; Pennsylvania
- Department of Pediatrics; Perelman School of Medicine, University of Pennsylvania; Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania; Pennsylvania
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17
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Sun W, Orgel E, Malvar J, Sposto R, Wilkes JJ, Gardner R, Tolbert VP, Smith A, Hur M, Hoffman J, Rheingold SR, Burke MJ, Wayne AS. Treatment-related adverse events associated with a modified UK ALLR3 induction chemotherapy backbone for childhood relapsed/refractory acute lymphoblastic leukemia. Pediatr Blood Cancer 2016; 63:1943-8. [PMID: 27437864 PMCID: PMC7451261 DOI: 10.1002/pbc.26129] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 03/11/2016] [Revised: 05/25/2016] [Accepted: 06/08/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND The UK ALLR3 (R3) regimen has been adopted to treat pediatric relapsed acute lymphoblastic leukemia (ALL) by many centers in the United States and has become a preferred therapeutic backbone for testing novel agents in clinical trials. A detailed toxicity profile of this platform has not previously been reported. The toxicity and response rates for its use beyond first relapse are unknown. PROCEDURES We performed a multi-institutional, retrospective study including children with relapsed ALL treated with the R3 reinduction chemotherapy backbone block 1 across five pediatric centers. Data were extracted from medical records and analyzed. RESULTS Fifty-nine patients were included in the study, including 16 patients with ≥2nd relapse. Ninety-seven percent of patients experienced at least one Grade ≥3 nonhematologic adverse event (AE). Grade 3 or higher infection was reported in 90% of patients. Other nonhematologic Grade ≥3 AEs included electrolyte abnormalities, elevation in hepatic enzymes, and pain. Eighty-five percent of patients achieved a complete remission (CR). There were no significant differences in the incidence of AEs, CR rate, and rate of minimal residual disease negativity between patients with 1st or ≥2nd relapse. CONCLUSION Our study confirmed that R3 block 1 is a highly active reinduction regimen in childhood relapsed ALL. However, it was associated with a high incidence of severe toxicities, particularly infection. The toxicity profiled in our report should be used to inform optimal supportive care and future clinical trial design with the R3 backbone, particularly when new agents are combined with this regimen.
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Affiliation(s)
- Weili Sun
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, California. .,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California.
| | - Etan Orgel
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Jemily Malvar
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California
| | - Richard Sposto
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Jennifer J. Wilkes
- Department of Pediatrics, Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca Gardner
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Vanessa P. Tolbert
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Alison Smith
- Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Minjun Hur
- School of Medicine, St. Louis University, St. Louis, Missouri
| | - Jill Hoffman
- Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California,Infectious Disease, Children’s Hospital Los Angeles, California
| | - Susan R. Rheingold
- Department of Pediatrics, Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J. Burke
- Pediatric Leukemia and Lymphoma, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alan S. Wayne
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
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18
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Rao P, Li Y, Getz KD, Miller TP, Huang YS, Wilkes JJ, Seif AE, Bagatell R, Fisher BT, Gracia C, Aplenc R. Low rates of pregnancy screening in adolescents before teratogenic exposures in a national sample of children's hospitals. Cancer 2016; 122:3394-3400. [PMID: 27618636 DOI: 10.1002/cncr.30225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 02/09/2016] [Revised: 04/27/2016] [Accepted: 06/06/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Adolescents with cancer engage in sexual behaviors and are exposed to teratogenic chemotherapy. There are no data regarding pregnancy screening patterns for adolescents before chemotherapy exposure. METHODS A cross-sectional study of leukemia and emergency room (ER) admissions in the Pediatric Health Information System from 1999 to 2011 was conducted. Females who were 10 to 18 years old and 1) had newly diagnosed acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML) or 2) had ER visits with computed tomography (CT) of the abdomen/pelvis were included. The exposure was a hospital visit with either chemotherapy or an abdominal/pelvic CT scan. The main outcome was a pregnancy test billed on the same day or before the teratogenic exposure within the same index admission. Log-binomial regressions were used to compute prevalence ratios and 95% confidence intervals comparing pregnancy screening in the leukemia and ER cohorts. RESULTS A total of 35,650 admissions were identified. The proportion of visits with an appropriately timed pregnancy test was 35%, 64%, and 58% in the ALL (n = 889), AML (n = 127), and ER cohorts (n = 34,634), respectively. Patients with ALL were significantly less likely to have a pregnancy test than the ER cohort (adjusted prevalence ratio, 0.71; 95% confidence interval, 0.65-0.78), but there was no significant difference between the AML and ER cohorts (adjusted prevalence ratio, 1.12; 95% confidence interval, 0.99-1.27). There was substantial hospital-level variation in pregnancy screening patterns. CONCLUSIONS Adolescents with acute leukemia and ER visits have low rates of pregnancy screening before teratogenic exposures. Standardized practice guidelines for pregnancy screening among adolescents may improve screening rates. Cancer 2016;122:3394-3400. © 2016 American Cancer Society.
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Affiliation(s)
- Pooja Rao
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Yimei Li
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly D Getz
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tamara P Miller
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yuan-Shung Huang
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer J Wilkes
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Leonard Davis Institute of Healthcare Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alix E Seif
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rochelle Bagatell
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian T Fisher
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Clarisa Gracia
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Wilkes JJ, Hennessy S, Xiao R, Rheingold S, Seif AE, Huang YS, Vendetti N, Li Y, Bagatell R, Aplenc R, Fisher BT. Volume-Outcome Relationships in Pediatric Acute Lymphoblastic Leukemia: Association Between Hospital Pediatric and Pediatric Oncology Volume With Mortality and Intensive Care Resources During Initial Therapy. Clin Lymphoma Myeloma Leuk 2016; 16:404-410.e1. [PMID: 27246140 DOI: 10.1016/j.clml.2016.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/30/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND There are few contemporary studies of volume-outcome relationships in pediatric oncology. Children with acute lymphoblastic leukemia (ALL) are treated at a wide variety of hospitals. We investigated if inpatient hospital volume influences outcomes. The objective of this study was to evaluate the relationship between inpatient pediatric and pediatric oncology volume and mortality and intensive care resources (ICU care). We hypothesized an inverse relationship between volume and these outcomes. PATIENTS AND METHODS This was a retrospective cohort study. Patients 0 to 18 years of age in the Pediatric Health Information System or Perspective Premier Database from 2009 to 2011 with ALL were included. Exposures were considered as the average inpatient pediatric and pediatric oncology volume. The primary outcome was inpatient mortality; secondary outcome was need for ICU care. RESULTS The included population comprised 3350 patients from 75 hospitals. The inpatient mortality rate was 0.86% (95% confidence interval, 0.58%-1.2%). In the unadjusted analysis, mortality increased as pediatric oncology volume increased from low (0%) to high volume (1.3%) (P = .009). The small number of deaths precluded multivariable analysis of this outcome. Pediatric and pediatric oncology volume was not associated with ICU care when we controlled for potential confounders. CONCLUSION Induction mortality was low. We did not observe an inverse relationship between volume and mortality or ICU care. This suggests that in a modern treatment era, treatment at a low-volume center might not be associated with increased mortality or ICU care in the first portion of therapy. This relationship should be evaluated in other oncology populations with higher mortality rates and with longer-term outcomes.
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Affiliation(s)
- Jennifer J Wilkes
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Sean Hennessy
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rui Xiao
- The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Susan Rheingold
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alix E Seif
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yuan-Shung Huang
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Neika Vendetti
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yimei Li
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rochelle Bagatell
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Richard Aplenc
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian T Fisher
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA
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20
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Wilkes JJ, Xiao R, Seif AE, Huang YS, Vendetti ND, Rheingold SR, Aplenc R, Hennessy S, Fisher B. Variation in antibiotic use in pediatric acute lymphoblastic leukemia (ALL) by hospital pediatric volume. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e17703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Rui Xiao
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alix Eden Seif
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | - Richard Aplenc
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Brian Fisher
- The Children's Hospital of Philadelphia, Philadelphia, PA
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21
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de Blank P, Cole K, Kersun L, Green A, Wilkes JJ, Belasco J, Bagatell R, Bailey LC, Fisher MJ. fdg-pet in two cases of neurofibromatosis type 1 and atypical malignancies. ACTA ACUST UNITED AC 2014; 21:e345-8. [PMID: 24764718 DOI: 10.3747/co.21.1803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with neurofibromatosis type 1 (nf1) are at increased risk for both benign and malignant tumours, and distinguishing the malignant potential of an individual tumour is a common clinical problem in these patients. Here, we review two cases of uncommon malignancies (Hodgkin lymphoma and mediastinal germ-cell tumour) in patients with nf1. Although (18)F-fluorodeoxyglucose positron-emission tomography (fdg-pet) has been used to differentiate benign neurofibromas from malignant peripheral nerve sheath tumours, fdg-pet characteristics for more rare tumours have been poorly described in children with nf1. Here, we report the role of pet imaging in clinical decision-making in each case. In nf1, fdg-pet might be useful in the clinical management of unusual tumour presentations and might help to provide information about the malignant potential of uncommon tumours.
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Affiliation(s)
- P de Blank
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Rainbow Babies and Children's Hospital, Cleveland, OH, U.S.A
| | - K Cole
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - L Kersun
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - A Green
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J J Wilkes
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J Belasco
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Bagatell
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - L C Bailey
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M J Fisher
- Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A. ; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
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22
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Wilkes JJ, Zaoutis TE, Keren R, Desai B, Leckerman KH, Hodinka RL, Metjian TA, Coffin SE. Treatment with oseltamivir in children hospitalized with community-acquired, laboratory-confirmed influenza: review of five seasons and evaluation of an electronic reminder. J Hosp Med 2009; 4:171-8. [PMID: 19301375 DOI: 10.1002/jhm.431] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND When initiated within 48 hours of the onset of symptoms, oseltamivir has been shown to reduce severity and length of influenza illness. Few studies have evaluated the use of oseltamivir in patients hospitalized with influenza. OBJECTIVE To describe the prescribing practices for oseltamivir in children hospitalized with influenza and to evaluate a mechanism to improve the rate of appropriate prescription. DESIGN, SETTING, PATIENTS Retrospective cohort study of 929 patients aged 21 years or younger hospitalized with community-acquired laboratory-confirmed influenza (CA-LCI) during 5 consecutive seasons (2000-2005). We examined oseltamivir eligibility, which included patients 1 year of age or older with an influenza test result available within 48 hours of symptom onset. During the 2005-2006 season, an observational trial of an electronic reminder was conducted to improve the frequency of oseltamivir prescription. MEASUREMENTS Oseltamivir prescription. RESULTS Of 305 patients (32.8%) eligible for treatment with oseltamivir, 49 (16.1% of those eligible) were prescribed oseltamivir during hospitalization. Prescription rates for indications consistent with the US Food and Drug Administration (FDA) approval ("on label") increased from 0% to 37.2% over 5 seasons (P < 0.0001). Prescriptions outside this recommendation ("off label") also increased over 5 seasons (P < 0.0001). Twenty-nine (5%) of 624 patients were treated with oseltamivir off label; 11 were less than 1 year of age. Initiation of a reminder had no impact on prescription (P > 0.05). CONCLUSIONS Oseltamivir was used infrequently for children hospitalized with influenza. In addition, use inconsistent with the FDA label of oseltamivir occurs. Mechanisms are needed to improve appropriate prescription of oseltamivir.
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Affiliation(s)
- Jennifer J Wilkes
- Division of Infectious Diseases, The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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23
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Wilkes JJ, Leckerman KH, Coffin SE, Keren R, Metjian TA, Hodinka RL, Zaoutis TE. Use of antibiotics in children hospitalized with community-acquired, laboratory-confirmed influenza. J Pediatr 2009; 154:447-9. [PMID: 19874761 DOI: 10.1016/j.jpeds.2008.09.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [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: 03/20/2008] [Revised: 08/04/2008] [Accepted: 09/12/2008] [Indexed: 11/28/2022]
Abstract
Many children with influenza are treated with antibiotics. In this report, we describe the rate and indications for antibacterial use in children hospitalized with influenza. A total of 333 of 729 (46%) patients received >2 days of treatment with antibacterial medications, of whom 36% did not have an apparent indication for therapy.
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Affiliation(s)
- Jennifer J Wilkes
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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24
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Abstract
During development of the central nervous system, oligodendrocyte progenitor cells differentiate into mature myelinating cells. The molecular signals that promote this process, however, are not well defined. One molecule that has been implicated in oligodendrocyte differentiation is the Src family kinase Fyn. In order to probe the function of Fyn in this system, a yeast two hybrid screen was performed. Using Fyn as bait, p190 RhoGAP was isolated in the screen of an oligodendrocyte cDNA library. Coimmunoprecipitation and in vitro binding assays verified that p190 RhoGAP bound to the Fyn SH2 domain. Phosphorylation of p190 required active Fyn tyrosine kinase and was increased threefold upon differentiation of primary oligodendrocytes. Moreover, complex formation between p190 and p120 RasGAP occurred in differentiated oligodendrocytes. p190 RhoGAP activity is known to regulate the RhoGDP:RhoGTP ratio. Indeed, expression of dominant negative Rho in primary oligodendrocytes caused a hyperextension of processes. Conversely, constitutively activated Rho caused reduced process formation. These findings define a pathway in which Fyn activity regulates the phosphorylation of p190, leading to an increase in RhoGAP activity with a subsequent increase in RhoGDP, which in turn, regulates the morphological changes that accompany oligodendrocyte differentiation.
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Affiliation(s)
- R M Wolf
- Cell Biology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10021, USA
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25
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Abstract
Insulin signaling was examined in muscle made insulin resistant by short-term (24-h) denervation. Insulin-stimulated glucose transport in vitro was reduced by 28% (P < 0.05) in denervated muscle (DEN). In control muscle (SHAM), insulin increased levels of surface-detectable GLUT-4 (i.e., translocated GLUT-4) 1.8-fold (P < 0.05), whereas DEN surface GLUT-4 was not increased by insulin (P > 0.05). Insulin treatment in vivo induced a rapid appearance of phospho[Ser(473)]Akt-alpha in SHAM 3 min after insulin injection. In DEN, phospho[Ser(473)]Akt-alpha also appeared at 3 min, but Ser(473)-phosphorylated Akt-alpha was 36% lower than in SHAM (P < 0. 05). In addition, total Akt-alpha protein in DEN was 37% lower than in SHAM (P < 0.05). Akt-alpha kinase activity was lower in DEN at two insulin levels tested: 0.1 U insulin/rat (-22%, P < 0.05) and 1 U insulin/rat (-26%, P < 0.01). These data indicate that short-term (24-h) denervation, which lowers insulin-stimulated glucose transport, is associated with decreased Akt-alpha activation and impaired insulin-stimulated GLUT-4 appearance at the muscle surface.
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Affiliation(s)
- J J Wilkes
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, N2L 3G1 Canada
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26
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Abstract
We hypothesized that variation in dietary fatty acid composition in rats fed a high-fat diet had tissue-specific effects on glucose uptake sufficient to maintain normal glucose tolerance. Rats were fed one of three diets for 3 wk. The isocaloric high-fat-mixed oil (HF-mixed) diet and the high-fat-safflower oil (HF-saff) diet both provided 60% kcal fat, but fat composition differed [HF-mixed = saturated, polyunsaturated (n-3 and n-6), and monounsaturated fatty acids; HF-saff = polyunsaturated fatty acids (mainly n-6)]. The control diet was high carbohydrate (HCHO, 10% kcal fat). Insulin-stimulated 3-O-methylglucose uptake into perfused hindlimb muscles was reduced in rats fed HF-saff and HF-mixed diets compared with those fed HCHO diet (P < 0.02). Basal uptake increased in HF-saff- and HF-mixed-fed rats vs. HCHO-fed rats (P < 0.04). In adipocytes, HF-saff feeding decreased 2-deoxyglucose uptake vs. HF-mixed feeding and HCHO feeding (P < 0.05), but 2-deoxyglucose uptake in HF-mixed-fed rats did not differ from that in HCHO-fed rats (P > 0.05). Glucose tolerance was significantly reduced in HF-saff-fed rats but was unaffected by the HF-mixed diet. Therefore, in skeletal muscle of rats, 1) feeding a diet high in fat induces a reduction in insulin-stimulated glucose uptake but 2) provides an increase in basal glucose uptake. In contrast, 3) in adipocytes, insulin-stimulated glucose transport is reduced only when the high-fat diet is high in n-6 polyunsaturated fatty acids but not when fat comes from these mixed sources. Glucose intolerance becomes evident when insulin resistance is seen in multiple tissues.
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Affiliation(s)
- J J Wilkes
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1
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27
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Wilkes JJ, DeForrest LL, Nagy LE. Chronic ethanol feeding in a high-fat diet decreases insulin-stimulated glucose transport in rat adipocytes. Am J Physiol 1996; 271:E477-84. [PMID: 8843741 DOI: 10.1152/ajpendo.1996.271.3.e477] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ethanol consumption has been associated with glucose intolerance and insulin resistance and is suggested to be an independent risk factor in the development of non-insulin-dependent diabetes mellitus. We have investigated the long-term effects of ethanol consumption on insulin-regulated glucose transport in rat adipocytes. Male Wistar rats were fed a high-fat liquid diet containing 35% ethanol (ethanol fed) or a control diet that isocalorically substituted maltose dextrin for ethanol (ad libitum). A third group was pair fed the control diet. Basal rates of 2-deoxyglucose uptake were similar in adipocytes from all three groups. Treatment with insulin increased 2-deoxyglucose uptake in ad libitum- and pair-fed rats but did not stimulate uptake in ethanol-fed rats. Similarly, although okadaic acid increased 2-deoxyglucose uptake in pair-fed rats, it had no effect in ethanol-fed rats. GLUT-1 quantity was greater in pair-fed and ethanol-fed rats compared with ad libitum controls. GLUT-4 was decreased in ethanol-fed compared with pair-fed rats but was not different from ad libitum controls. In ad libitum- and pair-fed rats, insulin increased the translocation of GLUT-4 to the cell surface by 2.0-fold. In contrast, translocation of GLUT-4 was not observed after insulin stimulation of ethanol-fed rats, paralleling the loss of insulin-stimulated glucose uptake. In ethanol-fed rats, GLUT-4 protein quantity was negatively associated with increased Gs alpha protein and isoproterenol-stimulated adenosine 3',5'-cyclic monophosphate production. These data suggest that loss of insulin-stimulated glucose uptake in rat adipocytes after chronic ethanol feeding is at least partially due to decreased movement of GLUT-4 to the cell surface after insulin stimulation.
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Affiliation(s)
- J J Wilkes
- Department of Human Biology and Nutritional Sciences, University of Guelph, Ontario, Canada
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28
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Wilkes JJ, Nagy LE. Chronic ethanol feeding impairs glucose tolerance but does not produce skeletal muscle insulin resistance in rat epitrochlearis muscle. Alcohol Clin Exp Res 1996; 20:1016-22. [PMID: 8892521 DOI: 10.1111/j.1530-0277.1996.tb01940.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [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: 02/02/2023]
Abstract
Herein, we have investigated whether male Wistar rats develop impaired glucose tolerance after ethanol feeding. Rats were fed a liquid diet providing 35% calories from ethanol (EF) or a control diet that isocalorically replaced ethanol with maltose-dextrins for 4 weeks. Intravenous glucose tolerance was impaired in EF rats compared with pair-fed (PF), but not ad libitum (AL) controls. Areas under the intravenous glucose tolerance test curve were 5476 +/- 516 mm2, 3056 +/- 421 mm2, and 4199 +/- 613 mm2 (p < 0.05) for AL, PF, and EF rats, respectively. Initial plasma insulin concentrations in EF rats were comparable with PF rats; however, 15 min after a dextrose challenge, plasma insulin levels in EF rats were 39% lower than PF rats. Because skeletal muscle is the primary sink for insulin-mediated glucose disposal, the development of skeletal muscle insulin resistance after ethanol feeding could contribute to impaired glucose tolerance. Total GLUT1 was not affected by diet in either red or white muscle. No difference in the total quantity of insulin-responsive glucose transporter, GLUT4, was observed in red muscle. In contrast, GLUT4 was 20% lower in white muscle from EF rats, compared with PF and AL rats. However, insulin-stimulated glucose transport into the epitrochlearis, a white muscle group, was not impaired with ethanol feeding. These data demonstrate that chronic ethanol feeding impairs glucose tolerance; impaired glucose tolerance was associated with an inability to maintain plasma insulin levels, rather than the development of skeletal muscle insulin resistance.
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Affiliation(s)
- J J Wilkes
- Department of Human Biology and Nutritional Sciences, University of Guelph, Ontario, Canada
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