The transfer of host MHC class I protein protects donor cells from NK cell and macrophage-mediated rejection during hematopoietic stem cell transplantation and engraftment in mice.

Human hematopoietic stem cell engraftment has been studied extensively using xenograft transplant models with immunocompromised mice. It is standard practice to incorporate mouse models, such as the limiting dilution assay, to accurately assess the number of repopulating stem cells in bone marrow or umbilical cord blood collections or to confirm the long-term repopulating ability of cultured hematopoietic stem cells. In a previous study using a standard NOD/SCID mouse model to assess human hematopoietic stem cell engraftment we observed that all human cells had mouse MHC class I protein on their surface, suggesting that this is a mechanism adopted by the cells to evade host immune surveillance. To determine whether this was a xenograft phenomenon we studied host MHC transfer in an intraspecies mouse model and observed similar results. The transfer of MHC class I proteins has implications for antigen presentation and immune modulation. In this report, we used a standard mouse model of bone marrow transplantation to demonstrate that surface protein transfer between cells plays an important role in protecting donor hematopoietic cells from NK cell and macrophage-mediated rejection. The transfer of intact MHC class I antigens from host cells to transplanted donor cells confers a self identity on these otherwise foreign cells. This gives them the ability to evade detection by the host NK cells and macrophages. Once full donor chimerism is established, transplanted cells no longer require host MHC class I protein transfer to survive.

Somatosensory change and pain relief induced by repetitive transcranial magnetic stimulation in patients with central poststroke pain.

OBJECTIVE: To quantify changes in pain and somatosensory function in patients with central poststroke pain (CPSP) syndrome following five sessions of repetitive transcranial magnetic stimulation (rTMS). METHODS: Fourteen CPSP patients underwent MRI-guided TMS mapping to identify the motor hotspot for evoked responses from a muscle corresponding to a painful region (hand, N = 11, or distal leg, N = 3). Targeted rTMS consisting of 2000 stimuli/10 Hz each session was delivered over five sessions. Quantitative somatosensory testing (QST) was performed within the painful area and at the contralateral mirror-image site at baseline and after the rTMS. RESULTS: At baseline there were significant sensory deficits of the affected body side for warm and cold detection and heat/cold pain thresholds. Following rTMS, sensory thresholds showed significant improvements for cold detection threshold (repeated-measures ANOVA, p = 0.04). Subjects' pain reports (numerical rating scale 0-10) showed modest but significant improvements in the first week after rTMS (baseline 7.0 ± 1.5; post-TMS 6.3 ± 1.5; Wilcoxon signed-rank test, p = 0.018), and these were largely maintained for up to four weeks post-rTMS. Improvements in warm detection threshold showed a significant correlation with decrease in pain score (Spearman's rank-order correlation, p = 0.007). CONCLUSIONS: Five sessions of open-label rTMS provided analgesia and improved thermal sensibility. The correlation of reduction of detection threshold for warmth and pain relief suggest that the effect of rTMS may be mediated via circuitries that share the processing of noxious and thermal signals, such as the insula and the somatosensory and anterior cingulate cortices. QST may have a role in the assessment of patients with neuropathic pain for suitability for rTMS treatment and is likely to add to our understanding of how rTMS induces pain relief.

Determining epigenetic memory in kidney proximal tubule cell derived induced pluripotent stem cells using a quadruple transgenic reprogrammable mouse.

The majority of nucleated somatic cells can be reprogrammed to induced pluripotent stem cells (iPSCs). The process of reprogramming involves epigenetic remodelling to turn on pluripotency-associated genes and turn off lineage-specific genes. Some evidence shows that iPSCs retain epigenetic marks of their cell of origin and this "epigenetic memory" influences their differentiation potential, with a preference towards their cell of origin. Here, we reprogrammed proximal tubule cells (PTC) and tail tip fibroblasts (TTF), from a reprogrammable mouse to iPSCs and differentiated the iPSCs to renal progenitors to understand if epigenetic memory plays a role in renal differentiation. This model allowed us to eliminate experimental variability due to donor genetic differences and transfection of the reprogramming factors such as copy number and integration site. In this study we demonstrated that early passage PTC iPSCs and TTF iPSCs expressed low levels of renal progenitor genes and high levels of pluripotency-associated genes, and the transcriptional levels of these genes were not significantly different between PTC iPSCs and TTF iPSCs. We used ChIP-seq of H3K4me3, H3K27me3, H3K36me3 and global DNA methylation profiles of PTC iPSCs and TTF iPSCs to demonstrate that global epigenetic marks were not different between the cells from the two different sets of tissue samples. There were also no epigenetic differences observed when kidney developmental genes and pluripotency-associated genes were closely examined. We did observe that during differentiation to renal progenitor cells the PTC iPSC-derived renal cells expressed higher levels of three renal progenitor genes compared to progenitors derived from TTF iPSCs but the underlying DNA methylation and histone methylation patterns did not suggest an epigenetic memory basis for this.

Decellularization of porcine kidney with submicellar concentrations of SDS results in the retention of ECM proteins required for the adhesion and maintenance of human adult renal epithelial cells.

When decellularizing kidneys, it is important to maintain the integrity of the acellular extracellular matrix (ECM), including associated adhesion proteins and growth factors that allow recellularized cells to adhere and migrate according to ECM specificity. Kidney decellularization requires the ionic detergent sodium dodecyl sulfate (SDS); however, this results in a loss of ECM proteins important for cell adherence, migration, and growth, particularly glycosaminoglycan (GAG)-associated proteins. Here, we demonstrate that using submicellar concentrations of SDS results in a greater retention of structural proteins, GAGs, growth factors, and cytokines. When porcine kidney ECM scaffolds were recellularized using human adult primary renal epithelial cells (RECs), the ECM promoted cell survival and the uniform distribution of cells throughout the ECM. Cells maintained the expression of mature renal epithelial markers but did not organize on the ECM, indicating that mature cells are unable to migrate to specific locations on ECM scaffolds.

Patient-reported outcome measures after mitral valve repair: a comparison between minimally invasive and sternotomy.

OBJECTIVES: To compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair. METHODS: We included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: 'Recovery Time', 'Postoperative Pain' (at day 2 and 1, 3, 6 and 12 weeks) and 'Treatment Satisfaction'. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores. RESULTS: The response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8-62.1) vs MI 61.7 (43.1-73.9), P = 0.03] and Pain [ST 65.7 (40.1-83.1) vs MI 79.1 (65.5-89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5-100) vs MI 100 (95.0-100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7-18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7-14.5, P = 0.03) was MI surgery. CONCLUSIONS: MI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar.

Variation in access to hemophilia A treatments in the United States.

BACKGROUND: US commercial health plans have been found to vary in how they cover specialty drugs indicated for a range of diseases. In this study, we examined patients' access to hemophilia A (HemA) treatments across a set of large commercial health plans. OBJECTIVE: To examine variation in health plans' coverage policies for HemA treatments. METHODS: We reviewed HemA treatment coverage policies (current as of August 2019) issued by 17 commercial health plans primarily using the Tufts Medical Center Specialty Drug Evidence and Coverage Database. We categorized policies as: covered without conditions (coverage consistent with the FDA label); covered with conditions (conditions on coverage beyond the FDA label); broader coverage (coverage for a broader patient population than the FDA label); and mixed (conditions on coverage beyond the FDA label in one way, but coverage was broader than the FDA label in another). RESULTS: We identified 296 coverage policies for 26 HemA treatments, including 15 short half-life factor VIII (FVIII) products, five extended half-life FVIII products, three bypassing agents, two desmopressin products, and emicizumab. We classified 36% of policies as coverage without conditions, 50% as covered with conditions, 7% as broader coverage, and 7% as mixed. Plans applied conditions on coverage with different frequencies: two did not apply conditions in any policies; ten applied conditions in ≥50%; four applied conditions in <40%. One plan did not publish coverage policies for any HemA products. Conditions on coverage most often related to bleeding frequency (36%), although specific requirements varied. Plans applied step therapy protocols in 17% of policies. CONCLUSIONS: How health plans covered HemA treatments varied. Plans added conditions on coverage beyond the FDA label roughly half the time. Conditions most often related to bleeding frequency. Variable coverage affects patients' access to treatment, and potentially has clinical implications on disease management and disease progression.

Neuropsychological functioning of children treated with intensive chemotherapy followed by myeloablative consolidation chemotherapy and autologous hematopoietic cell rescue for newly diagnosed CNS tumors: an analysis of the Head Start II survivors.

BACKGROUND: To evaluate the neuropsychological late effects amongst survivors treated on the Head Start II protocol between 1997 and 2003. PROCEDURES: Forty-nine patients (mean age 2.9 years) diagnosed with a malignant brain tumor underwent baseline neuropsychological assessment prior to autologous hematopoietic cell transplantation (AuHCT). Twenty-six survivors were retested after 3 years of follow-up as 20 patients did not survive. Patients were evaluated for intelligence, academic achievement, receptive language, visual-motor integration (VMI), learning/memory, social-emotional and behavioral functioning based upon age at testing. RESULTS: Overall intelligence and VMI at baseline were low average while verbal and non-verbal intelligence, academic achievement, and receptive vocabulary were in average range. Parents reported social-emotional and behavioral functioning within normal limits. Serial testing revealed Full Scale (FSIQ)/Mental Development Index (MDI), Verbal (VIQ), and Performance (PIQ) Intelligence to be generally stable over 3-year follow-up. Group-average analysis at follow-up demonstrated low average intelligence, academic achievement, receptive language, and VMI. Age at diagnosis was positively correlated with internalizing symptoms and visual immediate memory, while time since diagnosis was inversely correlated with FSIQ, VIQ, PIQ, reading and delayed verbal memory. Craniospinal irradiation (CSI) was avoided in two-thirds of patients. CONCLUSION: Induction, with or without intensification using intravenous methotrexate, followed by myeloablative consolidation chemotherapy with AuHCT, may avoid or delay CSI, with possible stabilization of neuropsychological functioning, including those younger at diagnosis. Continued follow-up is necessary to determine the preservation of neuropsychological, academic, social-emotional and behavioral functioning.

Paralytic ileus precipitating platypnoea-orthodeoxia after right pneumonectomy.

A 78-year-old female underwent a right pneumonectomy for a neuroendocrine tumour. In the early postoperative phase, she developed a paralytic ileus and went on to develop breathlessness and orthostatic desaturation, which characterizes platypnoea-orthodeoxia. She was found to have an intra-atrial shunt on bubble echo, with equal atrial pressures. This was managed by device closure of the atrial connection, following which her condition improved.

Umbilical Cord Tissue as a Source of Young Cells for the Derivation of Induced Pluripotent Stem Cells Using Non-Integrating Episomal Vectors and Feeder-Free Conditions.

The clinical application of induced pluripotent stem cells (iPSC) needs to balance the use of an autologous source that would be a perfect match for the patient against any safety or efficacy issues that might arise with using cells from an older patient or donor. Drs. Takahashi and Yamanaka and the Office of Cellular and Tissue-based Products (PMDA), Japan, have had concerns over the existence of accumulated DNA mutations in the cells of older donors and the possibility of long-term negative effects. To mitigate the risk, they have chosen to partner with the Umbilical Cord (UC) banks in Japan to source allogeneic-matched donor cells. Production of iPSCs from UC blood cells (UCB) has been successful; however, reprogramming blood cells requires cell enrichment with columns or flow cytometry and specialized growth media. These requirements add to the cost of production and increase the manipulation of the cells, which complicates the regulatory approval process. Alternatively, umbilical cord tissue mesenchymal stromal cells (CT-MSCs) have the same advantage as UCB cells of being a source of young donor cells. Crucially, CT-MSCs are easier and less expensive to harvest and grow compared to UCB cells. Here, we demonstrate that CT-MSCs can be easily isolated without expensive enzymatic treatment or columns and reprogramed well using episomal vectors, which allow for the removal of the reprogramming factors after a few passages. Together the data indicates that CT-MSCs are a viable source of donor cells for the production of clinical-grade, patient matched iPSCs.

Decellularizing and Recellularizing Adult Mouse Kidneys.

Decellularization is the process by which resident cells are lysed and cellular debris is removed from the tissue, leaving behind the extracellular matrix scaffold. The extracellular matrix scaffold can be used for three-dimensional culturing of cells. Here we describe methods of decellularizing whole and thick sections of mouse kidneys using a 0.1% sodium dodecyl sulfate (SDS) detergent solution and strategies to repopulate whole and thick sections of decellularized mouse kidneys with cells.

Banking Mesenchymal Stromal Cells from Umbilical Cord Tissue: Large Sample Size Analysis Reveals Consistency Between Donors.

Mesenchymal stromal cells (MSCs) have emerged as candidate cells with therapeutic potential to treat different pathologies. The underlying mechanism is paracrine signaling. The cells secrete proteins that can impact inflammation, apoptosis, angiogenesis, and cell proliferation. All are important in wound healing and tissue regeneration. Although the bone marrow has been the most widely used source of MSCs, umbilical cord tissue (CT) presents a source that is just starting to be used in the clinic, yet can be obtained with more ease and easily stored. Here, we characterize CT-MSCs obtained from multiple donors by analyzing cell surface proteins, differentiation capacity, and proteome profile. Analysis of low, medium, and high passage cells indicates that the morphology and proliferation rate stay constant and with the exception of cluster of differentiation (CD) 105 at late passage, there are no changes in the cell surface protein characteristics, indicating the population does not change with passage. TNF-stimulated gene 6 protein was measured in a subset of samples and variable expression was observed, but this did not impact the ability of the cells to enhance skin regeneration. In conclusion, CT-MSC represents a consistent, easily accessible source of cells for cell therapy. Stem Cells Translational Medicine 2019;8:1041-1054.

Topical Application of Culture-Expanded CD34+ Umbilical Cord Blood Cells from Frozen Units Accelerates Healing of Diabetic Skin Wounds in Mice.

Chronic and nonhealing wounds are constant health issues facing patients with type 2 diabetes. As the incidence of type 2 diabetes mellitus (T2DM) increases, the incidence of chronic wounds and amputations will rise. T2DM is associated with peripheral arterial occlusive disease, which leads to the development of nonhealing skin ulcers after minor trauma. Patients develop severe pain limiting their mobility and ability to work and take care of themselves, thus putting a significant burden on the family and society. CD34+ cells from umbilical cord blood (UCB) grown in fibroblast growth factor-4 (FGF-4), stem cell factor, and Flt3-ligand produced a population of cells that have the ability to proliferate and develop properties enabling them to enhance tissue regeneration. The goal of this study was to assess in vitro cultured CD34+ cells in a setting where they would eventually be rejected so we could isolate paracrine signaling mediated therapeutic effect from the therapeutic effect due to engraftment and differentiation. To achieve this, we used db/db mice as a model for diabetic skin ulcers. Here, we report that in vitro cultured UCB CD34+ cells from frozen units can accelerate wound healing and resulted in the regeneration of full thickness skin. This study demonstrates a new indication for banked UCB units in the area of tissue regeneration. Stem Cells Translational Medicine 2018;7:591-601.

Exploring the implementation of patient-reported outcome measures in cancer care: need for more real-world evidence results in the peer reviewed literature.

BACKGROUND: To explore the existing evidence of the real-world implementation of patient-reported outcomes (PROs) in oncology clinical practice and address two aims: (1) summarize available evidence of PRO use in clinical practice using a framework based on the International Society for Quality of Life Research (ISOQOL) PRO Implementation Guide; and (2) describe reports of real-world, standardized PRO administration in oncology conducted outside of scope of a research study. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was developed to guide the systematic literature review (SLR) that was conducted in MEDLINE and Embase databases. A two step search strategy was implemented including two searches based on previously completed reviews. Studies published from 2006 to 2017 were synthesized using a framework based on the ISOQOL PRO Implementation Guide. RESULTS: After screening 4427 abstracts, 36 studies met the eligibility criteria. Most elements of the ISOQOL PRO Implementation Guide were followed. Two notable exceptions were found: 1) providing PRO score interpretation guidelines (39% of studies); and 2) providing patient-management guidance for addressing issues identified by PROs (25% of studies). Of the 22 studies with an intervention component, 19 (86%) reported intervention effects on study outcomes. The European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (EORTC QLQ-C30) was the most commonly used PRO (n = 10, 28%); use of 38 other PRO measures was also reported. Only three studies (8%) reported real-world PRO implementation. CONCLUSION: Reports of real-world PRO implementation are limited. Reports from studies conducted in clinical settings suggest gaps in information on PRO score interpretation and the use of PRO results to inform patient management. Before the promise of practice-based PRO assessment in oncology can be truly realized, investigators need to advance the state-of-the-art of real-time PRO score interpretation as well as developing guidance on how to use PRO insights to drive clinically-meaningful patient-management strategies.

Acellular Mouse Kidney ECM can be Used as a Three-Dimensional Substrate to Test the Differentiation Potential of Embryonic Stem Cell Derived Renal Progenitors.

The development of strategies for tissue regeneration and bio-artificial organ development is based on our understanding of embryogenesis. Differentiation protocols attempt to recapitulate the signaling modalities of gastrulation and organogenesis, coupled with cell selection regimens to isolate the cells of choice. This strategy is impeded by the lack of optimal in vitro culture systems since traditional culture systems do not allow for the three-dimensional interaction between cells and the extracellular matrix. While artificial three-dimensional scaffolds are available, using the natural extracellular matrix scaffold is advantageous because it has a distinct architecture that is difficult to replicate. The adult extracellular matrix is predicted to mediate signaling related to tissue repair not embryogenesis but existing similarities between the two argues that the extracellular matrix will influence the differentiation of stem and progenitor cells. Previous studies using undifferentiated embryonic stem cells grown directly on acellular kidney ECM demonstrated that the acellular kidney supported cell growth but limited differentiation occurred. Using mouse kidney extracellular matrix and mouse embryonic stem cells we report that the extracellular matrix can support the development of kidney structures if the stem cells are first differentiated to kidney progenitor cells before being applied to the acellular organ.

The burden of atopic dermatitis in US adults: results from the 2013 National Health and Wellness Survey.

OBJECTIVES: To characterize comorbidities, health-related quality-of-life (HRQoL), productivity, and healthcare resource use in adults with atopic dermatitis (AD) relative to those without AD, and to evaluate the impact of patient-reported AD severity on these outcomes. METHODS: Data were from the 2013 National Health and Wellness Survey (NHWS), which collected self-reported information on demographics, comorbidities, HRQoL (SF-36v2 Health Survey), productivity (Work Productivity and Impairment questionnaire [WPAI]), and healthcare utilization, which were weighted to the US general population. The AD cohort consisted of subjects who reported that they experienced AD within the past 12 months (n = 428), and the non-AD cohort included all subjects who did not report experiencing AD (n = 74,572); 366 AD subjects self-reported mild (n = 182) or moderate/severe (n = 184) disease. Univariable and multivariable analyses compared characteristics and outcomes between cohorts and between AD severity levels. RESULTS: The AD cohort was younger than non-AD cohort (44.3 vs. 46.6 years; P = 0.0033), and had a higher proportion of females (64.4% vs. 51.8%; P < 0.0001). Relative to the non-AD cohort, the AD cohort had a significantly higher prevalence of atopic conditions including nasal allergies (46.4% vs. 19.8%) and asthma (22.4% vs. 7.9%), and neuropsychiatric conditions such as anxiety (42.5% vs. 21.3%) and depression (37.2% vs. 20.9%) (all P < 0.0001). Units of resource use (healthcare practitioner visits, emergency room, hospitalizations) were higher (all P < 0.05) and HRQoL was poorer (P < 0.0001) with AD. On the WPAI, AD employees reported almost twice as much lost work productivity as non-AD employees (30.0% vs. 16.3%; P < 0.0001). No clear differences in outcomes were observed among patient-reported AD severity categories, except greater impairment of work productivity and daily activities in those with moderate/severe AD relative to mild. CONCLUSIONS: The significant burden associated with AD relative to those without AD suggests an unmet need for more effective management strategies. There also appears to be a need for further characterization of disease severity and its impact on HRQoL.

Health-related quality of life during bosutinib (SKI-606) therapy in patients with advanced chronic myeloid leukemia after imatinib failure.

OBJECTIVES: The tyrosine kinase inhibitor (TKI) bosutinib has demonstrated activity in patients with advanced phase chronic myeloid leukemia (CML), but effects on health-related quality of life (HRQoL) remain unexplored. This study evaluated HRQoL in advanced CML patients receiving bosutinib in an ongoing phase 2 study following resistance or intolerance to prior imatinib therapy. METHODS: This analysis included data from 76 accelerated-phase (AP) and 64 blast-phase (BP) patients resistant/intolerant to prior imatinib with or without prior exposure to other TKIs. Patient-reported HRQoL assessments completed at baseline; weeks 4, 8, and 12; every 12 weeks thereafter; and at treatment completion included the Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu); general health status was assessed using the 5-item EuroQol (EQ-5D) instrument and a visual analog scale (VAS). RESULTS: HRQoL at baseline was somewhat worse in BP versus AP CML patients. There was a significant improvement in the mean FACT-Leu Total scale at weeks 24, 36, and 48 in AP CML patients and at weeks 4, 8, 12, 24, 36, 48, and 96 in BP CML patients compared with baseline. EQ-5D Utility scores were stable throughout treatment in AP CML patients but significantly improved versus baseline in BP CML patients at weeks 4, 8, 12, and 36. Mean VAS scores were significantly improved at weeks 8, 36, and 48 in AP CML patients and at weeks 4, 8, 12, 24, 36, and 96 in BP CML patients. The lack of a comparison group limits attribution of improvements in HRQoL specifically to bosutinib treatment; potential bias due to non-ignorable dropout may limit the ability to generalize these findings to situations where durations of therapy exceed the 96-week follow-up duration of the present study. CONCLUSION: These findings suggest that bosutinib therapy is associated with improved HRQoL in advanced phase CML patients. CLINICAL TRIAL REGISTRATION: NCT00261846.

Real-world analysis of tyrosine kinase inhibitor treatment patterns among patients with chronic myeloid leukemia in the United States.

PURPOSE: The treatment of chronic myeloid leukemia (CML) has improved considerably since the introduction of the tyrosine kinase inhibitor (TKI) imatinib in 2001 and the approval of second-generation TKIs (dasatinib and nilotinib) beginning in 2006.The objective of this study was to explore treatment patterns of TKI therapy (adherence, duration, and switching) among patients with CML in the United States, following the availability of second-generation TKIs. METHODS: This study used US health plan claims data from January 1, 2007, through December 31, 2011. Patients were required to be aged ≥18 years, have a prescription fill for a TKI, and a diagnosis of CML. Duration of TKI use was determined based on a gap in TKI coverage of ≥180 consecutive days after TKI initiation or switch to another TKI within the 180-day window. To account for censoring due to disenrollment from the health plan or end of the study period, median treatment duration was projected by using the Kaplan-Meier estimator. FINDINGS: We identified 695 patients who started TKI treatment and had a CML diagnosis during the study time frame. The mean age of patients was 55 years, and 58% of patients were male. The most common first-line TKI was imatinib (82%), with dasatinib and nilotinib use equally distributed (9%). Among the 148 (21.3%) patients who initiated a second-line TKI, the majority had switched from imatinib to dasatinib or nilotinib (86%). The median duration of first-line TKI use was 39.8 months and second-line TKI use was 22.4 months. Median duration of treatment for first-line (P = 0.4342) and second-line (P = 0.1792) treatment did not differ significantly according to TKI. Mean adherence (ie, proportion of days covered) during the first line of therapy was 0.90. IMPLICATIONS: For the US patients studied, we found that imatinib was used more frequently than other TKIs in the first-line setting, but there was an increased use of second-generation TKIs in the first-line setting over time (9% in 2008 vs 43% in 2011 were nilotinib or dasatinib users). Only about one fifth of patients switched to a second-line TKI during the period of data collection.

Treatment patterns and prognostic indicators of response to therapy among patients with chronic myeloid leukemia in Australia, Canada, and South Korea.

OBJECTIVE: Given the multiple options for treatment of chronic-phase chronic myeloid leukemia (CML) with tyrosine kinase inhibitors, our objective was to understand treatment patterns in routine practice and prognostic indicators of response. RESEARCH DESIGN AND METHODS: We conducted a retrospective medical record review of 681 patients with CML in Australia, Canada, and South Korea. Eligible patients had a diagnosis of chronic-phase CML, were Philadelphia chromosome and/or BCR-ABL positive, were aged 18 years or older, and had been treated with first-line imatinib therapy between January 2005 and September 2010. Data on patient demographics, medical history (e.g., comorbidities, Sokal score), and treatment characteristics (e.g., time to initiation, therapy duration) were abstracted. Descriptive analyses were stratified by country and therapy line. Prognostic indicators of response to imatinib were evaluated using multivariable logistic regression, adjusting for country, patient demographics, medical history, treatment characteristics, and side effects. MAIN OUTCOME MEASURES: Hematologic, cytogenetic, and molecular responses at 3, 6, 12, and 18 months following initiation of each therapy line. RESULTS: Patients' average age was 57 years, and 59% were male. Overall, imatinib was initiated approximately 4 months following CML diagnosis. Complete or major molecular response (C/MMR) at 6 months following imatinib initiation was 54% in Australia, 22% in Canada, and 38% in South Korea. At 18 months, over 60% of patients achieved C/MMR. Approximately 30% of patients discontinued imatinib primarily due to intolerance and lack of response. Among patients who received second-line treatment, dasatinib was used more frequently than nilotinib. Multivariable regression results indicated Sokal score was identified as a prognostic indicator of response to imatinib therapy at several time points. LIMITATIONS: There are several limitations to this study. First, we selected a convenience sample of patients and physicians and therefore results may not be representative of the true population of patients with chronic-phase CML. Second, data were entered by the selected physician and could be subject to data entry errors or inaccuracies. Third, limited information was collected from the patient records, and it is possible that we did not capture additional prognostic or confounding factors related to the measured outcomes. Next, because this was an analysis of previously documented data (i.e., retrospective), we were unable to provide a priori definitions of response. Finally, multivariable analyses were limited to imatinib-related outcomes. CONCLUSIONS: Treatment patterns and prognostic indicators differed by country. Health care providers, payers, and patients can utilize these results to inform treatment and policies aimed at improving the effectiveness of care for patients with chronic-phase CML.

Pyrexia in patients with uncontrolled systemic hypertension: could they have an aortic dissection?

Aortic dissection can present in a variety of ways and one of the most documented risk factors includes systemic hypertension. Occasionally aortic dissection can be diagnosed late due to an insidious presentation. Fever has been described in people with aortic dissection but rarely as the main presenting feature. We present the cases of two patients with type B aortic dissections who shared three pertinent features which could have alerted the clinicians of the potential diagnosis; systemic hypertension, small left sided pleural effusion and a fever of unknown origin.