An International Learning Collaborative Phase 2 Trial for Haploidentical Bone Marrow Transplant in Sickle Cell Disease

In the setting of a learning collaborative, we conducted an international multicenter phase 2 clinical trial testing the hypothesis that non-myeloablative related haploidentical BMT with thiotepa and post-transplant cyclophosphamide (PTCy) will result in 2-year event-free survival (no graft failure or death) of at least 80%. A total of 70 participants (median age 19.1 (IQR 14.1 - 25.0) were evaluable based on the conditioning protocol. Graft failure occurred in 11.4% (8/70) and only in participants <18 years (p=0.001); all had autologous reconstitution. After a median follow-up of 2.4 years (IQR 1.5-3.9), the 2-year Kaplan-Meier-based probability of event-free survival was 82.6% (95% CI 71.4%-89.7%). The 2-year overall survival was 94.1% (95% CI 84.9%-97.7%) with no difference between the child and adult participants (p=0.889). After excluding participants with graft failure (n=8), participants with engraftment had median whole blood donor chimerism values at D+180 and D+365 post-transplant of 100.0% (IQR 99.8 - 100.0%; n=59) and 100.0% (IQR 100.0 - 100.0%; n=58), respectively, and 96.6% (57/59) were off immunosuppression at 1-year post-transplant. The 1-year grades III-IV acute graft versus host disease (GvHD) rate was 10.0% (95% CI 4.6 - 18.6%), and the 2-year moderate-severe chronic GvHD rate was 10.0% (95% CI 4.6 - 18.6%). Five participants (7.1%) died from infectious complications. We demonstrate that non-myeloablative haploidentical BMT with thiotepa and PTCy is a readily available curative therapy for most adults, even those with organ damage, instead of the more expensive myeloablative gene therapy and gene editing. Additional strategies are required for children to decrease graft failure rates (ClinicalTrials.gov identifier NCT01850108).

Phase 2 trial of montelukast for prevention of pain in sickle cell disease

Cysteinyl leukotrienes (CysLTs) are lipid mediators of inflammation. In patients with sickle cell disease (SCD), levels of CysLTs are increased compared with controls and associated with a higher rate of hospitalization for pain. We tested the hypothesis that administration of the CysLT receptor antagonist montelukast would improve SCD-related comorbidities, including pain, in adolescents and adults with SCD. In a phase 2 randomized trial, we administered montelukast or placebo for 8 weeks. The primary outcome measure was a >30% reduction in soluble vascular cell adhesion molecule 1 (sVCAM), a marker of vascular injury. Secondary outcome measures were reduction in daily pain, improvement in pulmonary function, and improvement in microvascular blood flow, as measured by laser Doppler velocimetry. Forty-two participants with SCD were randomized to receive montelukast or placebo for 8 weeks. We found no difference between the montelukast and placebo groups with regard to the levels of sVCAM, reported pain, pulmonary function, or microvascular blood flow. Although montelukast is an effective treatment for asthma, we did not find benefit for SCD-related outcomes. This clinical trial was registered at www.clinicaltrials.gov as #NCT01960413.

Designing surveillance for noninfectious outcomes of medical care

We present basic information that a hospital epidemiologist needs when designing a surveillance system for noninfectious adverse outcomes of care. Specific topics reflect key characteristics of such a surveillance system: the purpose, rationale, priorities, definitions, data collection tools, data collection, analysis and reporting, and validation.

Reliability of reporting nosocomial infections in the discharge abstract and implications for receipt of revenues under prospective reimbursement

Proper reporting of discharge diagnoses, including complications of medical care, is essential for maximum recovery of revenues under the prospective reimbursement system. To evaluate the effectiveness of abstracting techniques in identifying nosocomial infections at discharge, discharge abstracts of patients with nosocomial infections were reviewed during September through November of 1984. Patients with nosocomial infections were identified using modified Centers for Disease Control (CDC) definitions and trained surveillance technicians. Records which did not include the diagnosis of nosocomial infections in the discharge abstract were identified, and potential lost revenues were estimated. We identified 631 infections in 498 patients. On average, only 57 per cent of the infections were properly recorded and coded in the discharge abstract. Of the additional monies which might be anticipated by the health care institution to assist in the cost of care of adverse events, approximately one-third would have been lost due to errors in coding in the discharge abstract. Although these lost revenues are substantial, they constitute but a small proportion of the potential costs to the institution when patients acquire nosocomial infections.

Simultaneous determination of penicillin and cephalosporin antibiotics in serum by gradient liquid chromatography

We describe a "high-performance" liquid-chromatographic method for simultaneously measuring various penicillin and cephalosporin antibiotics. After extraction from serum, which in general is quantitative, the drugs are separated by use of a "Bondapak phenyl" column and a gradient mobile phase. For these drugs retention times depend on the pH of the mobile phase; we present retention times under selected pH conditions.

Simultaneous determination of penicillin and cephalosporin antibiotics in serum by gradient liquid chromatography

We describe a "high-performance" liquid-chromatographic method for simultaneously measuring various penicillin and cephalosporin antibiotics. After extraction from serum, which in general is quantitative, the drugs are separated by use of a "Bondapak phenyl" column and a gradient mobile phase. For these drugs retention times depend on the pH of the mobile phase; we present retention times under selected pH conditions.

Gas-chromatographic determination of verapamil and norverapamil, with a nitrogen-selective detector

We present a procedure for the determination of verapamil and its metabolite, norverapamil, in serum. The drugs are extracted under basic conditions into n-heptane/2-butanol (96/4 by vol) and then extracted again into 1 mol/L H2SO4. The acidic solution is made basic with sodium hydroxide, re-extracted with diethyl ether, and the extract evaporated. The residue is redissolved in ethanol and analyzed by gas chromatography with a nitrogen-selective detector. By use of two internal standards, prazepam and D-517 (a verapamil analog), concentration and instrument response are linearly related from 50 micrograms/L to 5 mg/L. Within-run precision (CV) was 3 and 5% for both verapamil and norverapamil at concentrations of 100 and 250 micrograms/L; between-run precision was 11 and 9% at those respective concentrations. Interference studies indicate that most commonly prescribed basic drugs will not interfere with this procedure.

Gas-chromatographic determination of verapamil and norverapamil, with a nitrogen-selective detector

We present a procedure for the determination of verapamil and its metabolite, norverapamil, in serum. The drugs are extracted under basic conditions into n-heptane/2-butanol (96/4 by vol) and then extracted again into 1 mol/L H2SO4. The acidic solution is made basic with sodium hydroxide, re-extracted with diethyl ether, and the extract evaporated. The residue is redissolved in ethanol and analyzed by gas chromatography with a nitrogen-selective detector. By use of two internal standards, prazepam and D-517 (a verapamil analog), concentration and instrument response are linearly related from 50 micrograms/L to 5 mg/L. Within-run precision (CV) was 3 and 5% for both verapamil and norverapamil at concentrations of 100 and 250 micrograms/L; between-run precision was 11 and 9% at those respective concentrations. Interference studies indicate that most commonly prescribed basic drugs will not interfere with this procedure.