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Gordon BG, Lowe AE, Kratochvil CJ. Rapid Review of Therapy Protocols for Public Health Emergencies. Ethics Hum Res 2024; 46:16-21. [PMID: 38446100 DOI: 10.1002/eahr.500203] [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] [Indexed: 03/07/2024]
Abstract
How research during a public health emergency is conducted is recognized as essential to the public health response to that emergency. Such research needs to undergo substantive and meaningful ethical review in a timely manner. Rapid ethical review may be accomplished through a number of mechanisms, including use of local rapid-response institutional review boards (IRBs). We describe use of such a model in the setting of the 2014 Ebola virus disease epidemic and the Rapid-Response IRB's subsequent transition to a multisite single IRB model during the current Covid-19 pandemic. The rapid-response review model is characterized by a small IRB with extensive use of alternate members with specific expertise and by close collaboration with the investigator in an iterative process.
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Affiliation(s)
- Bruce G Gordon
- Assistant vice-chancellor for regulatory affairs, and executive chairman of the IRBs at the University of Nebraska Medical Center
| | - Abigail E Lowe
- Assistant professor at the College of Allied Health Professions and a scholar at the Global Center for Health Security at the University of Nebraska Medical Center
| | - Christopher J Kratochvil
- Senior advisor and Distinguished Chair at the Global Center for Health Security, and vice chancellor of external relations at the University of Nebraska Medical Center
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Lowe AE, Kraft C, Kortepeter MG, Hansen KF, Sanger K, Johnson A, Grein JD, Martin J, Rousselle R, Garland JA, Spotts J, Lowe JJ, Sauer LM, Kratochvil CJ, Gordon BG. Developing a Rapid Response Single IRB Model for Conducting Research During a Public Health Emergency. Health Secur 2022; 20:S60-S70. [PMID: 35544310 DOI: 10.1089/hs.2021.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Research is foundational for evidence-based management of patients. Clinical research, however, takes time to plan, conduct, and disseminate-a luxury that is rarely available during a public health emergency. The University of Nebraska Medical Center (UNMC) developed a single institutional review board (IRB), with a vision to establish a rapid review resource for a network focused on clinical research of emerging pathogens in the United States. A core aspect of successful initiation of research during a pandemic or epidemic is the ability to operationalize an approach for rapid ethical review of human subject research and conduct those reviews at multiple sites-without losing any of the substantive aspects of ethics review. This process must be cultivated in anticipation of a public health emergency. US guidance for operationalizing IRB review for multisite research in a public health emergency is not well studied and processes are not well established. UNMC sought to address operational gaps and identify the unique procedural needs of rapid response single IRB (RR-sIRB) review of multisite research by conducting a series of preparedness exercises to develop and test the RR-sIRB model. For decades, emergency responder, healthcare, and public health organizations have conducted emergency preparedness exercises to test requirements for emergency response. In this article, we describe 2 types of simulation exercises conducted by UNMC: workshops and tabletops. This effort represents a unique use of emergency preparedness exercises to develop, refine, and test rapid review functions for an sIRB and to validate readiness of regulatory research processes. Such processes are crucial for conducting rapid, ethical, and sound clinical research in public health emergencies.
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Affiliation(s)
- Abigail E Lowe
- Abigail E. Lowe, MA, is an Assistant Professor, Global Center for Health Security, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE
| | - Colleen Kraft
- Colleen Kraft, MD, MS, is a Professor, Department of Pathology and Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, and Associate Chief Medical Officer, Emory Hospital, Emory University, Atlanta, GA
| | - Mark G Kortepeter
- Mark G. Kortepeter, MD, is Vice President for Research, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Keith F Hansen
- Keith F. Hansen, MBA, is Co-Director, Center for Preparedness Education, College of Public Health; Co-Executive Director, Association of Healthcare Emergency Preparedness Professionals; and an Instructor, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | - Kristine Sanger
- Kristine Sanger is Director of Training and Exercise Programs, Center for Preparedness Education, College of Public Health, and Co-Executive Director, Association of Healthcare Emergency Preparedness Professionals, University of Nebraska Medical Center, Omaha, NE
| | - Ann Johnson
- Ann Johnson, PhD, MPH, CIP, is Director, Institutional Review Board and Human Research Program, University of Utah, Salt Lake City, UT
| | - Jonathan D Grein
- Jonathan D. Grein, MD, is Director, Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Julie Martin
- Julie Martin, RN, MEd, CIP, is Assistant Director, Institutional Review Board, Emory University, Atlanta, GA
| | - Rebecca Rousselle
- Rebecca Rousselle, BA, CIP, is Assistant Vice President, Human Research Protection Program, Emory University, Atlanta, GA
| | - Jennifer A Garland
- Jennifer A. Garland, RN-BC, PhD, CIC, is an Epidemiologist and Special Pathogens Clinical Program Manager, Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jessica Spotts
- Jessica Spotts, CIP, is a Senior IRB Education and Quality Improvement Analyst, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John J Lowe
- John J. Lowe, PhD, is Co-Principal Investigator, National Emerging Special Pathogens Training and Education Center (NETEC), a Professor, Department of Environmental, Agricultural, and Occupational Health, College of Public Health, and Assistant Vice Chancellor for Health Security Training and Education, University of Nebraska Medical Center, Omaha, NE
| | - Lauren M Sauer
- Lauren M. Sauer, MSc, is Director, Special Pathogens Research Network, Global Center for Health Security, and an Associate Professor, Department of Environmental, Agricultural, and Occupational Health, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | - Christopher J Kratochvil
- Christopher J. Kratochvil, MD, Associate Vice Chancellor for Clinical Research, University of Nebraska Medical Center, Omaha, NE
| | - Bruce G Gordon
- Bruce G. Gordon, MD, is Assistant Vice Chancellor for Regulatory Affairs, Executive Chairman of Institutional Review Boards, and Professor in the Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
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Brett-Major DM, Schnaubelt ER, Creager HM, Lowe A, Cieslak TJ, Dahlke JM, Johnson DW, Fey PD, Hansen KF, Hewlett AL, Gordon BG, Kalil AC, Khan AS, Kortepeter MG, Kratochvil CJ, Larson L, Levy DA, Linder J, Medcalf SJ, Rupp ME, Schwedhelm MM, Sullivan J, Vasa AM, Wadman MC, Lookadoo RE, Lowe JMJ, Lawler JV, Broadhurst MJ. Advanced Preparation Makes Research in Emergencies and Isolation Care Possible: The Case of Novel Coronavirus Disease (COVID-19). Am J Trop Med Hyg 2020; 102:926-931. [PMID: 32228780 PMCID: PMC7204595 DOI: 10.4269/ajtmh.20-0205] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022] Open
Abstract
The optimal time to initiate research on emergencies is before they occur. However, timely initiation of high-quality research may launch during an emergency under the right conditions. These include an appropriate context, clarity in scientific aims, preexisting resources, strong operational and research structures that are facile, and good governance. Here, Nebraskan rapid research efforts early during the 2020 coronavirus disease pandemic, while participating in the first use of U.S. federal quarantine in 50 years, are described from these aspects, as the global experience with this severe emerging infection grew apace. The experience has lessons in purpose, structure, function, and performance of research in any emergency, when facing any threat.
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Affiliation(s)
| | - Elizabeth R. Schnaubelt
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
- United States Air Force School of Aerospace Medicine,
Dayton, Ohio
| | - Hannah M. Creager
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Abigail Lowe
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | | | - Jacob M. Dahlke
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Daniel W. Johnson
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Paul D. Fey
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Keith F. Hansen
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Angela L. Hewlett
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Bruce G. Gordon
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Andre C. Kalil
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Ali S. Khan
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Mark G. Kortepeter
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | | | - LuAnn Larson
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Deborah A. Levy
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - James Linder
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Sharon J. Medcalf
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Mark E. Rupp
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | | | - James Sullivan
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Angela M. Vasa
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Michael C. Wadman
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - Rachel E. Lookadoo
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | | | - James V. Lawler
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
| | - M. Jana Broadhurst
- University of Nebraska Medical Center/Nebraska Medicine,
Omaha, Nebraska
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Schonfeld TL, Brown JS, Amoura NJ, Gordon BG. Strength through Structure: Defending a Structured Approach to Contraceptive Mandates in Clinical Research. Ethics Hum Res 2019; 41:33-35. [PMID: 31108572 DOI: 10.1002/eahr.500018] [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: 11/06/2022]
Affiliation(s)
| | - Joseph S Brown
- Professor of psychology at the University of Nebraska Omaha
| | - N Jean Amoura
- Associate professor of obstetrics and gynecology at the University of Nebraska Medical Center
| | - Bruce G Gordon
- Assistant vice chancellor for regulatory affairs at the University of Nebraska Medical Center
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5
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Beck JC, Chen B, Gordon BG. Physician approaches to drug shortages: Results of a national survey of pediatric hematologist/oncologists. World J Clin Oncol 2017; 8:336-342. [PMID: 28848700 PMCID: PMC5554877 DOI: 10.5306/wjco.v8.i4.336] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 05/04/2017] [Accepted: 07/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate personnel involved in scarce drug prioritization and distribution and the criteria used to inform drug distribution during times of shortage among pediatric hematologists/oncologists.
METHODS Using the American Society of Pediatric Hematology/Oncology (ASPHO) membership list, a 20 question survey of pediatric hematologists/oncologists was conducted via email to evaluate personnel involved in scarce drug prioritization and distribution and criteria used to inform scarce drug distribution.
RESULTS Nearly 65% of the 191 study respondents had patients directly affected by drug shortages. Most physicians find out about shortages from the pharmacist (n = 179, 98%) or other doctors (n = 75, 41%). One third of respondents do not know if there is a program or policy for handling drug shortages at their institution. The pharmacist was the most commonly cited decision maker for shortage drug distribution (n = 128, 70%), followed by physicians (n = 109, 60%). One fourth of respondents did not know who makes decisions about shortage drug distribution at their institution. The highest priority criterion among respondents was use of the shortage drug for curative, rather than palliative intent and lowest priority criterion was order of arrival or first-come first-served.
CONCLUSION Despite pediatric hematology/oncology physicians and patients being heavily impacted by drug shortages, institutional processes for handling shortages are lacking. There is significant disparity between how decisions for distribution of shortage drugs are currently made and how study respondents felt those decisions should be made. An institution-based, and more importantly, a societal approach to drug shortages is necessary to reconcile these disparities.
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Beck JC, Smith LD, Gordon BG, Garrett JR. An ethical framework for responding to drug shortages in pediatric oncology. Pediatr Blood Cancer 2015; 62:931-4. [PMID: 25732614 DOI: 10.1002/pbc.25461] [Citation(s) in RCA: 12] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/16/2015] [Indexed: 12/15/2022]
Abstract
The frequency of drug shortages has increased considerably over the last decade. Important ethical issues arise whenever the supply of an effective drug is insufficient to meet demand. Using the ethical principles of beneficence, non-maleficence, and justice, institutions can guide prioritization of drug distribution before a shortage occurs to avoid unfair and unethical distribution of resources. This analysis will give a historical context for drug shortages, identify, and explore the central ethical concerns raised by drug shortages, and propose an ethical framework for addressing them in the context of pediatric oncology.
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Affiliation(s)
- Jill C Beck
- University of Nebraska Medical Center, Omaha, Nebraska
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Abstract
BACKGROUND There are no data on women's willingness to participate in clinical trials as a function of real or perceived reproductive risk. Further, it is unknown whether the requirement for contraception or the common practice of limiting women's contraceptive choices influences their willingness to participate in research. The uncertainty about women's preferences on these matters remains a barrier for recruiting women to and retaining women as subjects in clinical trials. METHODS We developed a pilot study to determine women's willingness to participate in research with contraceptive requirements by looking at the three most common types of reversible contraceptives: hormonal contraception, barrier contraception, and intrauterine contraception. This study tested the hypotheses that restrictions on contraceptive choice impact women's willingness to participate in research and that the impact of contraceptive choice differs depending on women's perception of risk. RESULTS Women's willingness to participate in the proposed study decreased overall as reproductive risk increased. In addition, requirements for specific contraceptive methods negatively impacted women's reported willingness to participate in the research studies in our survey. CONCLUSIONS Results suggest that requirements for specific contraceptive methods negatively impacted women's reported willingness to participate in research. If confirmed in a larger sample, the negative effect of contraceptive limitations on women's willingness to participate in research would be of importance to clinical investigators and to institutional review boards (IRBs), as most adult biomedical research has as an explicit goal the equitable recruitment of women of childbearing potential.
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Affiliation(s)
- Toby L Schonfeld
- University of Nebraska Medical Center, Omaha, Nebraska 68198-6075, USA.
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8
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Hellbusch LC, Robinson MN, McComb RD, Gordon BG, Meyer RC. Medulloblastoma with extensive nodularity: a report of two cases. Pediatr Neurosurg 2008; 44:430-2. [PMID: 18703894 DOI: 10.1159/000149915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 04/24/2008] [Indexed: 11/19/2022]
Affiliation(s)
- Leslie C Hellbusch
- Department of Surgery, The Nebraska Medical Center, Omaha, NE 68114, USA.
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9
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Brown JS, Schonfeld TL, Gordon BG. "You may have already won..": an examination of the use of lottery payments in research. IRB 2006; 28:12-6. [PMID: 16680874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- Joseph S Brown
- Psychology Department, University of Nebraska, Omaha, NE, USA
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11
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12
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Schonfeld TL, Gordon BG. Contraception in research: a policy suggestion. IRB 2005; 27:15-20. [PMID: 15948327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- Toby L Schonfeld
- Department of Preventive and Societal Medicine, University of Nebraska Medical Center, USA
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Abstract
A discussion of the impact of escalating regulatory requirements is provided, from the point of view of the administration of the institutional review board of an academic institution, and from clinical investigators who conduct studies at that same institution. Current and anticipated future issues are discussed.
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198-7680, USA
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14
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Rubocki RJ, Parsa JR, Hershfield MS, Sanger WG, Pirruccello SJ, Santisteban I, Gordon BG, Strandjord SE, Warkentin PI, Coccia PF. Full hematopoietic engraftment after allogeneic bone marrow transplantation without cytoreduction in a child with severe combined immunodeficiency. Blood 2001; 97:809-11. [PMID: 11157502 DOI: 10.1182/blood.v97.3.809] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bone marrow transplantation (BMT) for severe combined immunodeficiency (SCID) with human leukocyte antigen (HLA)-identical sibling donors but no pretransplantation cytoreduction results in T-lymphocyte engraftment and correction of immune dysfunction but not in full hematopoietic engraftment. A case of a 17-month-old girl with adenosine deaminase (ADA) deficiency SCID in whom full hematopoietic engraftment developed after BMT from her HLA-identical sister is reported. No myeloablative or immunosuppressive therapy or graft-versus-host disease (GVHD) prophylaxis was given. Mild acute and chronic GVHD developed, her B- and T-cell functions became reconstituted, and she is well almost 11 years after BMT. After BMT, repeated studies demonstrated: (1) Loss of a recipient-specific chromosomal marker in peripheral blood leukocytes (PBLs) and bone marrow, (2) conversion of recipient red blood cell antigens to donor type, (3) conversion of recipient T-cell, B-cell, and granulocyte lineages to donor origin by DNA analysis, and (4) increased ADA activity and metabolic correction in red blood cells and PBLs.
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Affiliation(s)
- R J Rubocki
- Departments of Pediatric-Hematology/Oncology and Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
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Baker KS, Gordon BG, Gross TG, Abromowitch MA, Lyden ER, Lynch JC, Vose JM, Armitage JO, Coccia PF, Bierman PJ. Autologous hematopoietic stem-cell transplantation for relapsed or refractory Hodgkin's disease in children and adolescents. J Clin Oncol 1999; 17:825-31. [PMID: 10071273 DOI: 10.1200/jco.1999.17.3.825] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the treatment outcome and clinical factors that are of prognostic significance for children and adolescents with relapsed or refractory Hodgkin's disease (HD) who received treatment with high-dose chemotherapy and autologous hematopoietic stem-cell transplantation (HSCT). PATIENTS AND METHODS Fifty-three consecutive children and adolescents 21 years of age or younger with relapsed or refractory HD underwent HSCT. RESULTS At day 100 after transplantation, 29 patients (55%) were in a complete remission or maintained a continuous complete response, six (11%) had a partial response, and 11 (21%) failed to respond or had progressive disease. The failure-free survival (FFS) at 5 years was 31%, and overall survival was 43%. Twenty-one patients died of progressive HD, and nine died secondary to transplantation-related complications, including two secondary leukemias. Prognostic factors important for FFS were normal pretransplantation lactate dehydrogenase levels (5-year FFS = 42%), compared with patients with elevated LDH levels (5-year FFS = 0%) (P < .001), and disease sensitivity at the time of HSCT with FFS in untreated relapse, sensitive disease, and resistant disease 44%, 35%, and 9%, respectively (P = .06). There was no statistically significant difference in FFS or overall survival between age subgroups that were analyzed (< 13, 13 to 18, 19 to 21) or in comparison with an adult cohort. CONCLUSION HSCT is an effective treatment modality that can result in long-term cures and should be considered for children and adolescents with relapsed HD.
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Affiliation(s)
- K S Baker
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, USA.
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16
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Heuermann KG, Romero JR, Abromowitch MA, Gordon BG, Gross TG. Fatal coagulase-negative staphylococci infection after bone marrow transplantation in a patient with persistent adverse reactions to vancomycin. J Pediatr Hematol Oncol 1999; 21:80-1. [PMID: 10029821 DOI: 10.1097/00043426-199901000-00024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Manouilov KK, McGuire TR, Gordon BG, Gwilt PR. Assay for etoposide in human serum using solid-phase extraction and high-performance liquid chromatography with fluorescence detection. J Chromatogr B Biomed Sci Appl 1998; 707:342-6. [PMID: 9613971 DOI: 10.1016/s0378-4347(97)00543-4] [Citation(s) in RCA: 20] [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] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
An HPLC assay for etoposide in human serum was developed. Serum, spiked with podophyllotoxin (internal standard), was treated with sodium dodecyl sulphate prior to solid phase extraction. Analysis was performed on a 300x3.9 mm Bondclone 10 C18 column coupled with a fluorometric detector (lambda(ex) 230 nm, lambda(em) 330 nm). The retention times for etoposide and podophyllotoxin were 14 and 28 min respectively. The range of assay was 0.5 to 20 microg/ml with a detection limit of 0.2 microg/ml. This assay is suitable for use in clinical studies with etoposide.
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Affiliation(s)
- K K Manouilov
- UNMC/Eppley Cancer Center Core Pharmacokinetics Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha 68198-6025, USA
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18
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Gordon BG, Warkentin PI, Strandjord SE, Abromowitch M, Bayever E, Harper JL, Coccia PF. Allogeneic bone marrow transplantation for children with acute leukemia: long-term follow-up of patients prepared with high-dose cytosine arabinoside and fractionated total body irradiation. Bone Marrow Transplant 1997; 20:5-10. [PMID: 9232249 DOI: 10.1038/sj.bmt.1700827] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
High-dose therapy and allogeneic matched sibling bone marrow transplantation (BMT) is considered to be the treatment of choice for children with relapsed acute lymphoblastic leukemia (ALL), or for children with acute myeloid leukemia (AML) in first remission. However, the rate of bone marrow relapse after transplant for either of these diseases remains high. In this study, we assessed the efficacy and toxicity of high-dose cytosine arabinoside and total body irradiation (TBI) followed by allogeneic BMT, for children with acute leukemia or myelodysplastic syndrome (MDS). Sixty-five pediatric patients underwent allogeneic related (n = 57) or unrelated (n = 8) BMT. Twenty-seven were transplanted for ALL in second remission (CR2), and 16 for AML in first remission (CR1). The other 22 were high risk patients: six were transplanted for ALL in third remission (CR3), two for AML in CR2, two for myelodysplastic syndrome (MDS) and 12 for acute leukemia in relapse. Patients were prepared with cytosine arabinoside 3000 mg/m2 per dose twice daily for 6 days followed by 12000 cGy TBI as 200 cGy fractions twice daily for 3 days. Minimum follow-up is 21 months. Five-year event-free survival (EFS) and the actuarial relapse rate is 59 and 14% for patients with ALL in second remission, and 38 and 14+% for patients with AML in first remission. Twelve patients have relapsed (three are alive in remission after testicular or marrow relapse) and 28 have died of other causes. Acute GVHD with or without infection was the cause of death in 11 patients. Ten of the 11 patients who died of acute GVHD were considered at 'high risk' for GVHD (inadequate GVHD prophylaxis, or mismatched family donor or a matched unrelated donor). Toxicities in the immediate post-BMT period included diarrhea, oropharyngeal mucositis and conjunctivitis. Significant late toxicities included short stature, avascular necrosis of bone, and poor school performance (most often in patients who had received prior cranial irradiation). Our conclusions are that high-dose Ara-C and TBI followed by allogeneic bone marrow transplantation is effective therapy for children in second complete remission of their acute leukemia. However, significant late toxicities occur, and it is clear that more effective, less toxic therapies are necessary for these patients.
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-2168, USA
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19
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Prentice ED, Gordon BG, Lin MH. Determining when a clinical activity should be classified as research requiring Institutional Review Board Review. J Extra Corpor Technol 1997; 29:88-91. [PMID: 10168536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The boundary between therapy and research may at times be difficult to distinguish, and it is, therefore, important for health care professionals to recognize when a clinical activity should be properly classified as research. Research may be subject to federal regulations which require advance review and approval by an Institutional Review Board (IRB) in order to protect the rights and welfare of patients who serve as human subjects. This paper will discuss the criteria health care professionals can use to distinguish between therapy, innovative therapy, and therapeutic or clinical research.
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Affiliation(s)
- E D Prentice
- University of Nebraska Medical Center, Omaha 68198-6810, USA
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20
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Weisenburger DD, Gordon BG, Vose JM, Bast MA, Chan WC, Greiner TC, Anderson JR, Sanger WG. Occurrence of the t(2;5)(p23;q35) in non-Hodgkin's lymphoma. Blood 1996; 87:3860-8. [PMID: 8611713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Primary CD30(Ki-1)-positive anaplastic large-cell lymphoma (ALCL) is considered by some to be a distinct clinicopathologic entity associated with the t(2;5) (p23;q35). However, the specificity of t(2;5) for ALCL has not been carefully studied. Therefore, we performed a detailed analysis of all cases of ALCL with abnormal cytogenetics results in the Nebraska Lymphoma Study Group registry, as well as all other cases of non-Hodgkin's lymphoma with t(2;5) in the registry. We found the t(2;5) in only five of 10 cases of ALCL, four of whom were young patients. However, we also found the t(2;5) in 11 other cases of nonanaplastic lymphoma, including eight children with typical peripheral T-cell lymphomas of various types. The t(2;5) was also found in three older adults with B-cell lymphomas of various types. Thus, the t(2;5) was not specific for CD30+ ALCL. However, t(2;5) may define a clinicopathologic entity in children and young adults characterized by variable morphologies with a T-cell or indeterminate phenotype, CD30-positivity, nodal disease with frequent extranodal involvement, advanced stage, and an excellent response to therapy, including bone marrow transplantation for relapsed disease. The clinical relevance of the t(2;5) in older patients requires further study.
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Affiliation(s)
- D D Weisenburger
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha 68198-3135, USA
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21
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Patton DF, Harper JL, Wooldridge TN, Gordon BG, Coccia P, Haire WD. Treatment of veno-occlusive disease of the liver with bolus tissue plasminogen activator and continuous infusion antithrombin III concentrate. Bone Marrow Transplant 1996; 17:443-7. [PMID: 8704704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Veno-occlusive disease (VOD) of the liver is a common complication of BMT and is accompanied by reduced levels of natural anticoagulants and by multi-organ dysfunction. We describe two cases of clinical VOD developing after autologous BMT and accompanied by ultrasonographic features of reversed portal venous flow. In both cases the patients had decreased levels of antithrombin (AT). Once the diagnosis of VOD was made, these patients were treated with tissue plasminogen activator (tPA) and continuous infusion AT. Each patient had radiographic and clinical resolution of VOD with the therapy. This novel treatment appears to have reversed the course of VOD without the increased risk of bleeding seen in the use of heparin therapy.
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Affiliation(s)
- D F Patton
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-3330, USA
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22
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Haire WD, Ruby EI, Gordon BG, Patil KD, Stephens LC, Kotulak GD, Reed EC, Vose JM, Bierman PJ, Kessinger A. Multiple organ dysfunction syndrome in bone marrow transplantation. JAMA 1995; 274:1289-95. [PMID: 7563534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To define the frequency and outcome of organ dysfunction in bone marrow transplantation (BMT) and to determine if patients with organ dysfunction have lower levels of protein C (PC) and/or antithrombin III (ATIII) than those without organ dysfunction. DESIGN Inception cohort of patients undergoing BMT, followed for 28 days, until hospital dismissal, or until death. SETTING Bone marrow transplant department of a university hospital. PATIENTS A total of 199 consecutive patients admitted for BMT. INTERVENTIONS Standard supportive care was given to all patients. MAIN OUTCOME MEASURES Definitions of organ dysfunction were arrived at prior to beginning the study. They include pulmonary, central nervous system (CNS), hepatic, and renal dysfunction. Protein C and ATIII levels were measured prior to beginning the preparative regimen and weekly thereafter. RESULTS Single organ dysfunction, manifesting as pulmonary, CNS, or hepatic dysfunction, occurred in 93 (48.5%) of the 199 patients and was a strong predictor of multiple organ dysfunction syndrome (MODS) and death. Death occurred in 14 (7.0%) of the patients. Cause of death was precisely identified in only four patients. Low levels of either PC or ATIII were associated with death and pulmonary, CNS, and hepatic dysfunction. Multivariate analysis showed ATIII and PC levels were associated with single organ dysfunction independent of the type of transplant, the type of preparative regimen, and the presence of bacteremia. CONCLUSIONS Single organ dysfunction during BMT is a marker for a systemic abnormality that has a high likelihood of progressing to MODS, similar to that seen in other critically ill patient populations. MODS is the leading cause of death in series of BMT patients. Low levels of ATIII and PC are markers of and may be involved in the pathogenesis of MODS in BMT.
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Affiliation(s)
- W D Haire
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-3330, USA
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23
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Haire WD, Stephens LC, Kotulak GD, Ruby EI, Gordon BG. Pharmacokinetics of antithrombin concentrate during autologous hematopoietic stem cell transplantation. Bone Marrow Transplant 1995; 15:505-7. [PMID: 7655373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Antithrombin is a naturally-occurring anticoagulant protein. Congenital deficiency of this protein predisposes to thrombotic complications. Acquired deficiency of antithrombin occurs in a variety of clinical circumstances, including hematopoietic stem cell transplantation (HSCT), and is associated with multiorgan failure and death in these situations. Normalization of antithrombin levels by infusion of concentrates of this protein has been found to be beneficial in many of these situations, but has not been routinely used in HSCT. Before antithrombin concentrates can be widely recommended in HSCT, its pharmacokinetics at various phases of the transplant process must be defined to allow estimation of the proper dose and dosing interval. To this end, the recovery and half-life of antithrombin concentrate was determined prior to and 7, 14 and 28 days after beginning the preparative regimen in nine patients with lymphoma undergoing HSCT. The recovery of the infused material was constant during the transplant hospitalization, averaging 2.0% per unit/kg. The half-life, however, dropped significantly during the latter half of the transplant procedure. The half-lives pre-chemotherapy and on day 7 were similar and averaged 20.4 h. On days 14 and 21 the the half-lives were significantly lower at 12.2 and 15.5 h, respectively. The drop in half-life during the transplant process will require antithrombin concentrate to be given more frequently during this time to maintain constant antithrombin levels.
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Affiliation(s)
- W D Haire
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-3330, USA
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24
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Brissette MD, Duval-Arnould BJ, Gordon BG, Cotelingam JD. Acute megakaryoblastic leukemia following transient myeloproliferative disorder in a patient without Down syndrome. Am J Hematol 1994; 47:316-9. [PMID: 7977305 DOI: 10.1002/ajh.2830470413] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [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: 01/28/2023]
Abstract
Transient myeloproliferative disorder (TMD) and subsequent acute myeloid leukemia (AML) occur with increased frequency in infants and children with Down syndrome. TMD can also occur in phenotypically normal newborns. We describe the second case of a non-Down syndrome child with TMD who subsequently developed AML. Trisomy 21 karyotypic was restricted to hematopoietic cells in the blood and bone marrow. No other karyotypic abnormalities were found. Leukemic blasts showed megakaryoblastic features with immunophenotyping. This case shows that TMD in a child without Down syndrome may not be entirely benign. Close follow-up is warranted.
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Affiliation(s)
- M D Brissette
- Department of Pathology, Madigan Army Medical Center, Tacoma, Washington
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25
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Gordon BG, Weisenburger DD, Sanger WG, Armitage JO, Coccia PF. Peripheral T-cell lymphoma in children and adolescents: role of bone marrow transplantation. Leuk Lymphoma 1994; 14:1-10. [PMID: 7920214 DOI: 10.3109/10428199409049645] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [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: 01/27/2023]
Abstract
Although PTCL in children, as in adults, has a spectrum of clinical, morphologic, cytogenetic and immunologic features, there are several significant differences in these features between children and adults. Our data show that CD30 expression is much more common in pediatric PTCL than is reported in adult PTCL. Furthermore, the majority of children with CD30-positive PTCL do not have tumors with anaplastic large cell histology. Our data also suggest that the t(2;5) is not a specific marker of anaplastic large cell lymphoma in childhood. The likelihood of cure for children with PTCL is unclear, predominantly because of the lack of large numbers of pediatric patients with this less common entity. As with other NHL, we expect that treatment with conventional dose chemotherapy following relapse will be unsuccessful in most cases. Although the data are preliminary, it appears that high dose chemoradiotherapy followed by hematopoietic stem cell transplantation is an effective therapy in these patients. We have been particularly successful with a regimen based on thioTEPA, VP-16 and total body irradiation, but other regimens may also be efficacious. Further studies of this interesting group of tumors are clearly needed.
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MESH Headings
- Adolescent
- Adult
- Age Factors
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor
- Bone Marrow Transplantation
- Child
- Child, Preschool
- Combined Modality Therapy
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Immunophenotyping
- Infant
- Ki-1 Antigen/analysis
- Lymphoma, T-Cell, Peripheral/drug therapy
- Lymphoma, T-Cell, Peripheral/mortality
- Lymphoma, T-Cell, Peripheral/pathology
- Lymphoma, T-Cell, Peripheral/radiotherapy
- Lymphoma, T-Cell, Peripheral/therapy
- Male
- Neoplasm Staging
- Neoplastic Stem Cells/chemistry
- Remission Induction
- Retrospective Studies
- Salvage Therapy
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-2168
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26
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Gordon BG, Haire WD, Stephens LC, Kotulak GD, Kessinger A. Protein C deficiency following hematopoietic stem cell transplantation: optimization of intravenous vitamin K dose. Bone Marrow Transplant 1993; 12:73-6. [PMID: 8104071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Patients undergoing hematopoietic stem cell transplantation (HSCT) are dependent on i.v. vitamin K supplementation to prevent deficiency. Vitamin K deficiency may contribute to the development of a hypercoagulable state by limiting hepatic synthesis of fully functional carboxylated anticoagulant protein C (PC). The ratio of PC antigen (CAg) to PC measured in a clot-based functional assay (CFx) reflects the degree to which PC is carboxylated. The 133 patients undergoing HSCT received vitamin K 10 mg per week (low dose, 101 patients) or 5 mg per day (high dose, 32 patients) i.v. as their sole exogenous source of vitamin K. CAg and CFx were assayed before HSCT preparative regimen and again 14 days later. CAg and CFx fell significantly in both groups from day 0 to day 14 but there were no differences between the low-dose and high-dose vitamin K groups. For both groups, CAg correlated strongly with CFx at day 14 (p = 0.0001). At day 14, the CAg/CFx ratio for the low-dose group was significantly greater than for the high-dose group (1.26 +/- 0.4 vs 1.09 +/- 0.1, p < 0.0002), suggesting that low-dose patients had a higher proportion of incompletely carboxylated PC. The CAg/CFx ratio at day 14 correlated with serum albumin for the high-dose group (p = 0.05), but not the low-dose group (p = 0.09), suggesting that the change in ratio in the low-dose group was not simply due to a lack of protein synthesis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-2168
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27
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Gordon BG, Weisenburger DD, Warkentin PI, Anderson J, Sanger WG, Bast M, Gnarra D, Vose JM, Bierman PJ, Armitage JO. Peripheral T-cell lymphoma in childhood and adolescence. A clinicopathologic study of 22 patients. Cancer 1993; 71:257-63. [PMID: 8380117 DOI: 10.1002/1097-0142(19930101)71:1<257::aid-cncr2820710139>3.0.co;2-b] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.3] [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: 01/30/2023]
Abstract
BACKGROUND Peripheral T-cell lymphoma (PTCL), although the most common T-cell lymphoma in adults, is relatively rare in childhood, and only small series have been reported. METHODS/RESULTS Twenty-two cases of PTCL were studied that occurred in patients 18 months to 20 years of age. Nine were seen when the condition was diagnosed, and the other 13 were referred after they had relapses. The stage at diagnosis was I or II (45%), III (41%), and IV (14%). Patients with Stage IV disease were younger than those with Stage I or II disease (2.5 versus 14.8 years, P = 0.04). Twelve patients had extranodal disease when the diagnosis was made; the skin was the most common site. Ten tumors were classified as diffuse large cell type; five, as diffuse anaplastic large cell type; and seven, as diffuse mixed cell type. Twenty of the 21 tumors tested were CD30 (Ki-1 or Ber-H2) antigen positive. Of the nine patients seen when the diagnosis was made and treated by the authors, three had a relapse (median, 12 months), a 2-year relapse-free survival (RFS) rate of 61%. For the total group, the RFS was longer for patients older than 12 years of age compared with those who were younger (20 versus 12 months, P = 0.05). Overall, six patients remained in their first complete remission. Sixteen patients had a relapse, and 13 of these underwent bone marrow transplantation (BMT). Six of these remained in complete remission (median, 18 months after BMT). Overall, only 6 of 22 patients died (median survival, > 60 months). CONCLUSION It was concluded that aggressive therapy, including BMT for relapses, can provide prolonged disease control in most children with PTCL.
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MESH Headings
- Adolescent
- Adult
- Age Factors
- Antigens, CD/analysis
- Antigens, Neoplasm/analysis
- Bone Marrow Transplantation
- Child
- Child, Preschool
- Chromosomes, Human, Pair 2
- Chromosomes, Human, Pair 5
- Female
- Humans
- Infant
- Ki-1 Antigen
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/immunology
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Non-Hodgkin/genetics
- Lymphoma, Non-Hodgkin/immunology
- Lymphoma, Non-Hodgkin/mortality
- Lymphoma, Non-Hodgkin/pathology
- Lymphoma, T-Cell, Peripheral/genetics
- Lymphoma, T-Cell, Peripheral/immunology
- Lymphoma, T-Cell, Peripheral/mortality
- Lymphoma, T-Cell, Peripheral/pathology
- Male
- Neoplasm Staging
- Recurrence
- Translocation, Genetic
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-2165
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28
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Gordon BG, Haire WD, Patton DF, Manno PJ, Reed EC. Thrombotic complications of BMT: association with protein C deficiency. Bone Marrow Transplant 1993; 11:61-5. [PMID: 8431711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A decrease in levels of circulating anticoagulant protein C has been shown to occur following autologous BMT, and this deficiency may contribute to a hypercoagulable state placing patients at risk for thromboembolic events. We report four patients who suffered a variety of thrombotic complications following BMT (non-bacterial thrombotic endocarditis, superior vena cava thrombosis, thrombotic stroke, purpura fulminans, small bowel infarction secondary to diffuse microvascular thrombosis), which were preceded by or temporally related to decreased levels of protein C. Treatment with fresh frozen plasma (FFP) led to slight, temporary increases in protein C levels but infusions of FFP did not prevent either death or extension of the thrombus in these four cases, suggesting the need for higher protein C doses and/or concomitant anticoagulation. Though no direct causal relationship between these thrombotic complications and the protein C deficiency can be proved, a generalized hypercoagulable state caused by protein C deficiency may have contributed to the development, severity or progression of these complications.
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-2168
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29
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Gordon BG, Warkentin PI, Weisenburger DD, Vose JM, Sanger WG, Strandjord SE, Anderson JR, Verdirame JD, Bierman PJ, Armitage JO. Bone marrow transplantation for peripheral T-cell lymphoma in children and adolescents. Blood 1992; 80:2938-42. [PMID: 1450419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We report nine children with relapsed (n = 8) or high-risk (n = 1) peripheral T-cell lymphoma (PTCL) who underwent autologous (n = 6) or allogeneic (n = 3) bone marrow transplantation (BMT). These children received transplants as part of a prospective phase I/II study of thioTEPA (TT) and total body irradiation (TBI) with escalating doses of VP-16. The median age of these patients at time of BMT was 6.5 years (range 2.5 years to 14 years). Three were transplanted with active disease after failing salvage chemotherapy. Of the other six, one was transplanted in first complete remission (CR) and five in second or subsequent CR. Of these nine patients, eight are free of disease a median of 25 months after BMT (range, 6 to 48 months), with an estimated 2-year relapse-free survival (RFS) of 89%. Six of these eight patients have been followed for 12 or more months after BMT, and in each their current remission exceeds their longest previous remission duration. The toxicity of the TT/TBI +/- VP-16 regimens was significant but manageable, predominantly consisting of severe mucositis. For a comparison, we reviewed retrospective data on the six additional children and adolescents with PTCL who underwent BMT during the 3-year period preceding this phase I/II study. The median age at BMT of these six patients was 19 years (range 15.5 years to 20 years). These patients were prepared for BMT with a variety of other regimens. One had no response to BMT and the other five relapsed at 1.5 to 5 months after BMT (median, 3 months) with an RFS of 0%. Our data suggest that thioTEPA plus TBI, with or without VP-16, is an effective preparative regimen for BMT for young patients with relapsed or high-stage PTCL and leads to prolonged RFS.
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-2165
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30
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Vaughan WP, Dennison JD, Reed EC, Klassen L, McGuire TR, Sanger WG, Kumar PP, Warkentin PI, Gordon BG, Bierman PJ. Improved results of allogeneic bone marrow transplantation for advanced hematologic malignancy using busulfan, cyclophosphamide and etoposide as cytoreductive and immunosuppressive therapy. Bone Marrow Transplant 1991; 8:489-95. [PMID: 1790429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Twenty-four patients between the ages of 8 and 48 years (median 27.5) with high-risk for relapse hematologic malignancy received a marrow transplant from an HLA and MLC compatible sibling donor after chemotherapy with busulfan, 4 mg/kg/day for 4 days by mouth, cyclophosphamide 60 mg/kg/day i.v. for 2 days, and etoposide 60 mg/kg i.v. over 4 h on the first day of cyclophosphamide treatment (BU/CY/VP). Toxicity consisted of mucositis, skin rash, and nausea and vomiting in all patients, transient fever thought to be due to etoposide administration in 16/24 (67%) patients, and clinical veno-occlusive disease (VOD) of the liver in 4/24 (17%). There were nine deaths from causes other than recurrent disease in the first 100 days after transplant and two deaths after day 100, a total transplant mortality of 11/24 (46%). Three patients relapsed, but 10/24 (40%) remain alive and disease free 26-182 weeks (median 60 weeks) from transplant. These results compare favorably with results in a group of 12 similar risk patients treated with total body irradiation (TBI) containing regimens during an overlapping time period. Six of the TBI patients have had persistent or recurrent disease and only two (17%) are currently alive and disease free. The probability of disease persistence or relapse is 67% in the TBI group and 20% in the BU/CY/VP group (p less than 0.02).
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Affiliation(s)
- W P Vaughan
- Department of Internal Medicine, College of Pharmacy, University of Nebraska Medical Center, Omaha
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31
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Gordon BG, Saving KL, McCallister JA, Warkentin PI, McConnell JR, Roberts WM, Coccia PF, Haire WD. Cerebral infarction associated with protein C deficiency following allogeneic bone marrow transplantation. Bone Marrow Transplant 1991; 8:323-5. [PMID: 1756332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hypercoagulable states associated with deficiencies in circulating anticoagulant protein C occur after chemotherapy for a variety of malignant diseases. Protein C deficiency also occurs following bone marrow transplantation (BMT) and may be responsible for a variety of transplantation-associated complications. We report the case of a child who suffered a stroke associated with low protein C antigen and activity occurring 11 months after allogeneic BMT. Protein C levels recovered spontaneously by 18 months after BMT. We speculate that the protein C deficiency and and resultant hypercoagulable state led to the stroke, and the deficiency of this anticoagulant was a sequela of the transplant.
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Affiliation(s)
- B G Gordon
- Section of Pediatric Hematology/Oncology and Bone Marrow Transplantation, University of Nebraska Medical Center, Omaha 68195-2165
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32
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Gordon BG, DeBoer JM, Wooldridge LD, Sharp JG. Effect of 6-hydroxydopamine on murine hematopoietic stem cells: enhanced cytotoxicity on megakaryocyte colony forming units. Life Sci 1991; 49:121-7. [PMID: 1905771 DOI: 10.1016/0024-3205(91)90025-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We examined the effect of catecholaminergic neurotoxin 6-hydroxydopamine (6-OHDA) on murine committed megakaryocyte progenitor cells, the megakaryocyte-colony forming unit (CFU-Meg). More mature cells of the megakaryocyte series have the capacity for active uptake of catecholamines, and we speculated that the CFU-Meg would also take up 6-OHDA and be selectively killed. CFU-Meg were much more sensitive to the effects of this agent than were granulocyte-macrophage colony forming units (CFU-GM) or spleen-colony forming units. Co-incubation with catalase, which would destroy hydrogen peroxide generated extracellularly by the autoxidation of 6-OHDA, ablated 6-OHDA toxicity towards CFU-GM, but also significantly reduced the effect on CFU-Meg. Mazindol, a selective dopamine uptake inhibitor did not alter 6-OHDA effect on either CFU-Meg or CFU-GM. Finally, CFU-Meg were no more sensitive to incubation with hydrogen peroxide than were CFU-GM. These data suggest that CFU-Meg, unlike their more mature progeny, do not actively concentrate 6-OHDA, and the excess toxicity of this agent towards CFU-Meg is probably due to increased sensitivity to autoxidation products of 6-OHDA, other than hydrogen peroxide, generated extracellularly.
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Affiliation(s)
- B G Gordon
- Section of Pediatric Hematology/Oncology and Bone Marrow Transplantation, University of Nebraska Medical Center, Omaha
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33
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Gordon BG, Kiwanuka J, Kadushin J. Autoimmune neutropenia and Hodgkin's disease: successful treatment with intravenous gammaglobulin. Am J Pediatr Hematol Oncol 1991; 13:164-7. [PMID: 2069225 DOI: 10.1097/00043426-199122000-00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We describe a child with Hodgkin's disease (HD) who presented with profound neutropenia, secondary to an antineutrophil antibody. The patient responded to intravenous immunoglobulin (IVIG), with prompt and sustained improvement in total white blood cell count (WBC) and absolute neutrophil count (ANC). The literature pertaining to autoimmune cytopenias complicating HD is reviewed, as well as the role of IVIG in management of these disorders.
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Affiliation(s)
- B G Gordon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-2185
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34
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Gordon BG, Strandjord SE, Warkentin PI, Kadushin J, Coccia PF. Successful treatment of severe aplastic anemia by bone marrow transplantation from HLA nonidentical family members: preliminary results utilizing cyclophosphamide and 600 cGY fractionated total body irradiation. Am J Pediatr Hematol Oncol 1991; 13:29-33. [PMID: 2029074 DOI: 10.1097/00043426-199121000-00007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We have performed bone marrow transplants on four children with severe aplastic anemia who lacked an human leukocyte antigen (HLA)-identical sibling donor. Patients were prepared with cyclophosphamide and 600 cGy fractionated total body irradiation, and then received marrow from a parent donor mismatched for one (two patients), two (one patient), or three (one patient) HLA antigens. All four patients engrafted. One died early of acute graft-versus-host disease. The three others showed sustained complete hematopoietic reconstitution. Two are alive and hematologically normal 43-87 months after transplant. Both have had acute and chronic graft-versus-host disease (CGVHD), and one of the two remains on immunosuppressive drugs. The fourth died at 48 months after transplant of CGVHD. The previous experience with HLA-incompatible marrow transplants is reviewed, and the rationale for this preparative regimen is discussed. Cyclophosphamide and 600 cGy fractionated total body irradiation is an effective preparative regimen for children with severe aplastic anemia receiving transplants from HLA-nonidentical parental donors, allowing engraftment and full hematologic reconstitution.
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Affiliation(s)
- B G Gordon
- Section of Pediatric Hematology/Oncology, University Nebraska Medical Center, Omaha
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Abstract
Acute lymphoblastic leukemias with phenotypic characteristics of natural killer cell derived lineage are extremely uncommon. We identified an ALL with a phenotype consistent with an NK-cell of origin. The blasts underwent a proliferative response to r-IL2 in culture but showed no spontaneous or r-IL2 or gamma-INF induced cytotoxicity. With r-IL2 stimulation however, the tumor cells demonstrated a dramatic acquisition of low density CD8 surface positivity and a loss of CD11b expression after short term culture. By comparison to ALL of B or T lineage, NK ALL likely represents an early stage of bone marrow derived NK-cell precursor.
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Affiliation(s)
- S J Pirruccello
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha 68105-1065
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