Assessing the Efficacy of Imiquimod Use in Patients With Persistent Locally Advanced Melanoma In Situ

BACKGROUND: The standard of care when treating melanoma in situ (MMIS) is an excision with at least 5 mm surgical margins.1 Some studies have suggested up to 9 mm margins to maximize local recurrence-free survival.2 This retrospective review aims to assess the efficacy of imiquimod as a topical treatment for persistently positive MMIS at the margins of prior excisions or where surgery is not an option. METHODS: Retrospective study conducted at Moffitt Cancer Center between 2019 and 2021 with patients aged > 18 years with MMIS at the margins of excision of an invasive melanoma or MMIS. Included patients were not ideal candidates for primary or additional surgical resection due to non-feasibility of surgery because of comorbidity or cosmetically sensitive location and/or the need for repeated skin grafting, or due to patient's refusal. Patients received imiquimod on protocol for 16 weeks and were monitored for treatment response and side effects. Following completion of the treatment, scouting biopsies were performed to assess histological response, and dermoscopy was used to determine the clinical disease status. RESULTS: Ten patients completed 16 weeks of imiquimod. Seven (75%) had a median of 2 surgical resections, and 3 refused surgery despite discussion that surgery was standard of care. Seven were deemed free of disease on post-imiquimod treatment scouting biopsies, while 2 were found to be clinically free of disease following confocal microscopy, indicating a tumor clearance rate of 90% with imiquimod treatment. One patient was found to have persistent residual disease following 2 rounds of imiquimod and was taken for an additional surgical excision after which they were deemed free of disease. Median follow-up duration from the onset of imiquimod therapy to the last clinic visit was 18 months, without any recurrences to date. CONCLUSION: Imiquimod appears to demonstrate an encouraging tumor clearance among patients with persistent MMIS after surgery where further surgical resection may not be feasible. Although long-term durability has not been demonstrated in this study, a 90% tumor clearance rate is promising. J Drugs Dermatol. 2023;22(5): doi:10.36849/JDD.6987.

Survival Outcomes for Patients with Relapsed/ Refractory Aggressive B Cell Lymphomas Following Receipt of High-Dose Chemotherapy/Autologous Stem Transplantation and/or Chimeric Antigen Receptor-Modified T Cells.

Patients diagnosed with relapsed/refractory (R/R) diffuse large B cell lymphoma (DLBCL) or high-grade B cell lymphoma (HGBL) may achieve prolonged survival following receipt of high-dose chemotherapy/autologous stem cell transplantation (HDC/ASCT) or CD19-directed chimeric antigen receptor modified T cell therapy (CART19). Although early results from randomized clinical trials suggest that assignment to CART19 versus salvage immunochemotherapy as second-line therapy results in improved survival, analysis of a large series of patients who actually received HDC/ASCT or CART19 has yet to be performed. Such an analysis may inform future research efforts to optimize the risk stratification of R/R DLBCL/HGBL patients who are candidates for either therapy. The aim of this study was to evaluate clinicopathologic factors predictive of freedom from treatment failure (FFTF) for R/R DLBCL/HGBL patients following receipt of HDC/ASCT or CART19, and to compare patterns of treatment failure (TF) in R/R DLBCL/HGBL patients receiving HDC/ASCT and those receiving CART19. THE STUDY GROUP COMPRISED: patients age ≤75 years with R/R DLBCL/HGBL who received HDC/ASCT demonstrating partial or complete metabolic response to salvage immunochemotherapy and/or CART19 in the standard of care setting at the University of Pennsylvania between 2013 and 2021. Survival analyses were performed from the time of infusion of either HDC/ASCT or CART19, as well as at landmark time points postinfusion for patients who achieved FFTF. For 100 HDC/ASCT patients with a median follow-up of 62.7 months, the estimated 36-month FFTF and overall survival (OS) rates were 59% and 81%, respectively. For 109 CART19 patients with a median follow-up of 37.6 months, the estimated 36-month FFTF and OS rates were 24% and 48%, respectively. HDC/ASCT patients had significantly higher rates of estimated 36-month FFTF when they achieved actual FFTF at 3, 6, 12 and 24 months. Additionally, the rates of baseline characteristics predictive of TF at 36 months for either HDC/ASCT or CART19 patients were either similar to or significantly lower for CART19 patients compared to HDC/ASCT patients who achieved actual FFTF at 3, 6, 12, and 24 months. Patients with R/R DLBCL/HGBL achieving response to salvage immunochemotherapy who received HDC/ASCT had a high rate of estimated FFTF regardless of whether they harbored features predictive of resistance to salvage immunochemotherapy, which may be more durable than that of R/R DLBCL/HGBL patients receiving CART19. These findings support further investigation of disease characteristics, such as molecular features, that may predict response to salvage immunochemotherapy in patients fit for HDC/ASCT.

Lifting the Bar: A Relationship-Orienting Intervention Reduces Recidivism Among Children Reentering School From Juvenile Detention.

When children return to school from juvenile detention, they face a severe stigma. We developed a procedure to orient educators and students toward each other as positive relationship partners during this period. In Study 1, through a structured exercise, students reentering school powerfully articulated to an educator of their choosing their prosocial hopes for school as well as challenges they faced. In a preliminary field trial (N = 47), presenting this self-introduction to this educator in a one-page letter via a third-party requesting the educator's help reduced recidivism to juvenile detention through the next semester from 69% to 29%. In Study 2 (preregistered), the letter led experienced teachers (N = 349) to express greater commitment to, anticipate more success for, and feel more love and respect for a student beginning their reentry into school, potentially initiating a better trajectory. The results suggest how relationship-orienting procedures may sideline bias and make school more supportive for students facing stigma.

Evaluation of rejection, infection, and malignancy outcomes in elderly liver transplant recipients receiving a similar level of immunosuppression compared to a younger group.

Elderly liver transplant (LTx) recipients at a lower risk of acute rejection compared to younger recipients due to immunosenescence. As such, they may benefit from reduced immunosuppression (IS) to minimize infectious and malignant complications. We aimed to evaluate outcomes in LTx recipients ≥60 years compared to a younger group of LTx recipients aged 18-59 years maintained on a similar level of IS. This was a single-center retrospective evaluation of adult LTx recipients from 2013 to 2018 who received methylprednisolone induction and were maintained on tacrolimus, mycophenolate mofetil (MMF), and a prednisone taper. A total of 143 LTx recipients were evaluated. Mean age in the older group was 65 ± 3.8 compared to 49 ± 10.4 years in the younger group (p < 0.0001). Mean tacrolimus levels and the duration of MMF and steroids were comparable. Both groups had a similar incidence of first rejection within 1 year (19.2% in the elderly group vs. 23.1% in the younger group, p = 0.57). There were no statistical difference in terms of infection, malignancy, or patient survival. In conclusion, our data suggests that elderly LTx recipients, when treated with a similar level of IS, had similar 1 year incidence of rejection, infection, malignancy, and patient survival as younger LTx recipients.

Tisagenlecleucel Therapy: Nursing Considerations for the Outpatient Setting.

OBJECTIVE: Tisagenlecleucel is a CD19-directed, genetically modified, autologous T-cell immunotherapy indicated for pediatric and young adult patients with relapsed/refractory B-cell precursor acute lymphoblastic leukemia and for adult patients with relapsed/refractory diffuse large B-cell lymphoma. Treatment with any chimeric antigen receptor (CAR)-T cell therapy is a multistep process in which nurses and nurse practitioners are key to managing patient safety. Managing patients receiving CAR-T cell therapy in the outpatient setting (as Penn does with tisagenlecleucel and lisocabtagene maraleucel) requires an even more complex process. The objective of this manuscript is to provide guidance on the role of nurses in the outpatient administration of tisagenlecleucel therapy and postinfusion care in adult patients with diffuse large B-cell lymphoma. Oncology and apheresis nurses discuss institutional processes and perspectives related to the patient experience with tisagenlecleucel therapy at the Hospital of the University of Pennsylvania. DATA SOURCES: Author experience. CONCLUSION: Nurses are vital for the success of the patient management processes involved with tisagenlecleucel therapy. Nurses must be thoroughly educated in tisagenlecleucel therapy and adverse event management and be able to effectively communicate all aspects of therapy among the multidisciplinary team of the hospital, the product manufacturer, and patients and families. Establishment of the nurse cellular therapy coordinator at the Hospital of the University of Pennsylvania was advantageous in facilitating effective communication in all these situations. IMPLICATIONS FOR NURSING: This encompassing approach to patient management is particularly necessary during administration of tisagenlecleucel therapy and other CAR-T cell therapies that are managed in the outpatient setting.

Neuroglian regulates Drosophila intestinal stem cell proliferation through enhanced signaling via the epidermal growth factor receptor.

The Drosophila intestine is an excellent system for elucidating mechanisms regulating stem cell behavior. Here we show that the septate junction (SJ) protein Neuroglian (Nrg) is expressed in intestinal stem cells (ISCs) and enteroblasts (EBs) within the fly intestine. SJs are not present between ISCs and EBs, suggesting Nrg plays a different role in this tissue. We reveal that Nrg is required for ISC proliferation in young flies, and depletion of Nrg from ISCs and EBs suppresses increased ISC proliferation in aged flies. Conversely, overexpression of Nrg in ISC and EBs promotes ISC proliferation, leading to an increase in cells expressing ISC/EB markers; in addition, we observe an increase in epidermal growth factor receptor (Egfr) activation. Genetic epistasis experiments reveal that Nrg acts upstream of Egfr to regulate ISC proliferation. As Nrg function is highly conserved in mammalian systems, our work characterizing the role of Nrg in the intestine has implications for the treatment of intestinal disorders that arise due to altered ISC behavior.

Management of hyperkalemia: A focus on kidney transplant recipients.

Hyperkalemia is a frequent complication among kidney transplant recipients that can lead to fatal arrhythmias. The causes of hyperkalemia post kidney transplant are multifactorial and often are drug-induced, and include decreased glomerular filtration rate, tubular dysfunction, and impaired sodium delivery in the distal nephron. This review will discuss pathophysiology and recent updates in the management of both acute and chronic hyperkalemia with a focus on kidney transplant recipients.

Effect of malnutrition-driven nutritional support protocol on clinical outcomes in autologous stem cell transplantation patients.

PURPOSE: Poor nutrition status in patients receiving high-dose chemotherapy and autologous stem cell transplant (ASCT) has been associated with inferior clinical outcomes. We aim to determine whether a malnutrition-driven nutritional support protocol can improve these outcomes. METHODS: In this prospective cohort study, we assessed adults for malnutrition who were consecutively admitted for ASCT between October 2017 and March 2019 (n = 251), and provided enteral or parenteral nutrition (EN/PN) to patients who were malnourished early in the transplantation admission. We compared their clinical outcomes with those of a historical cohort admitted between May 2016 and October 2017 (n = 257) for whom nutrition assessment and initiation of EN/PN were not protocol-driven. RESULTS: Patients receiving ASCT during the intervention period experienced decreased odds of prolonged hospital stay (p = 0.023), central line-associated bloodstream infection (p = 0.015), mucosal barrier injury (p = 0.037), and high weight loss (p = 0.002), in a multivariate analysis as compared with those receiving ASCT during the control period. Outcomes for ICU transfer, deconditioning on discharge, time to platelet engraftment, and unplanned 30-day hospital readmission did not differ significantly between groups. CONCLUSION: A malnutrition-driven nutritional support protocol may improve outcomes for ASCT patients.

TFEB/Mitf links impaired nuclear import to autophagolysosomal dysfunction in C9-ALS.

Disrupted nucleocytoplasmic transport (NCT) has been implicated in neurodegenerative disease pathogenesis; however, the mechanisms by which disrupted NCT causes neurodegeneration remain unclear. In a Drosophila screen, we identified ref(2)P/p62, a key regulator of autophagy, as a potent suppressor of neurodegeneration caused by the GGGGCC hexanucleotide repeat expansion (G4C2 HRE) in C9orf72 that causes amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). We found that p62 is increased and forms ubiquitinated aggregates due to decreased autophagic cargo degradation. Immunofluorescence and electron microscopy of Drosophila tissues demonstrate an accumulation of lysosome-like organelles that precedes neurodegeneration. These phenotypes are partially caused by cytoplasmic mislocalization of Mitf/TFEB, a key transcriptional regulator of autophagolysosomal function. Additionally, TFEB is mislocalized and downregulated in human cells expressing GGGGCC repeats and in C9-ALS patient motor cortex. Our data suggest that the C9orf72-HRE impairs Mitf/TFEB nuclear import, thereby disrupting autophagy and exacerbating proteostasis defects in C9-ALS/FTD.

Nonsteroidal Anti-Inflammatory Drugs: Updates on Dosage Formulations and Adverse Effects.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used medications due to their prescription and nonprescription availability, various dosage formulations, and therapeutic efficacy. Although NSAIDs have many known benefits, their effects on gastrointestinal, cardiovascular, bone, and renal physiology limit their widespread and long-term use. This article provides an update on dosage formulations, product availability, and pertinent adverse effects and warnings regarding the use of NSAIDs, with an emphasis on nonaspirin NSAIDs.

Description of a transitions of care and telemedicine simulation lab activity.

BACKGROUND AND PURPOSE: Transitions of Care (ToC) is an important clinical practice area requiring trained health care professionals, but there is limited literature describing ToC in the didactic curriculum. The purpose of this study was to describe and evaluate a ToC telemedicine simulation activity in a doctor of pharmacy curriculum. EDUCATIONAL ACTIVITY AND SETTING: A one-hour lecture and simulation activity was incorporated into a second-year course. Student teams participated in discharge and telemedicine encounters with standardized patients (SPs). Six medication-related problems (MRPs) were incorporated into the activity. Activity documents were collected to identify student competency. FINDINGS: Fifty-nine student pharmacists in 16 teams participated. All teams accurately identified five of the six MRPs. Fourteen teams (87.5%) accurately identified the sixth MRP after completion of the telemedicine encounter. Six teams (62.5%) completed the discharge medication list accurately and completely. All teams provided medication education, and 93.8% (n = 15) of teams identified follow-up was needed. Ten teams utilized effective interview sequence and structure during both encounters. Activity challenges included resources, financial support and SP training. SUMMARY: Case-based learning and the use of simulation has good evidence supporting its use in education. Utilizing these techniques to reinforce concepts may be a beneficial way for students to be trained effectively to deliver impactful ToC services.

Corticosteroids.

Corticosteroids are commonly prescribed for a variety of indications due to the wide range of effects on the human body. Although they exhibit many therapeutic uses, corticosteroids are unfortunately known for their many dose- and duration-dependent toxicities. The purpose of this review is to explore indications for corticosteroid use, differences among formulations, and adverse effects and their management.

Stress Granule Assembly Disrupts Nucleocytoplasmic Transport.

Defects in nucleocytoplasmic transport have been identified as a key pathogenic event in amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) mediated by a GGGGCC hexanucleotide repeat expansion in C9ORF72, the most common genetic cause of ALS/FTD. Furthermore, nucleocytoplasmic transport disruption has also been implicated in other neurodegenerative diseases with protein aggregation, suggesting a shared mechanism by which protein stress disrupts nucleocytoplasmic transport. Here, we show that cellular stress disrupts nucleocytoplasmic transport by localizing critical nucleocytoplasmic transport factors into stress granules, RNA/protein complexes that play a crucial role in ALS pathogenesis. Importantly, inhibiting stress granule assembly, such as by knocking down Ataxin-2, suppresses nucleocytoplasmic transport defects as well as neurodegeneration in C9ORF72-mediated ALS/FTD. Our findings identify a link between stress granule assembly and nucleocytoplasmic transport, two fundamental cellular processes implicated in the pathogenesis of C9ORF72-mediated ALS/FTD and other neurodegenerative diseases.

Mutant Huntingtin Disrupts the Nuclear Pore Complex.

Huntington's disease (HD) is caused by an expanded CAG repeat in the Huntingtin (HTT) gene. The mechanism(s) by which mutant HTT (mHTT) causes disease is unclear. Nucleocytoplasmic transport, the trafficking of macromolecules between the nucleus and cytoplasm, is tightly regulated by nuclear pore complexes (NPCs) made up of nucleoporins (NUPs). Previous studies offered clues that mHTT may disrupt nucleocytoplasmic transport and a mutation of an NUP can cause HD-like pathology. Therefore, we evaluated the NPC and nucleocytoplasmic transport in multiple models of HD, including mouse and fly models, neurons transfected with mHTT, HD iPSC-derived neurons, and human HD brain regions. These studies revealed severe mislocalization and aggregation of NUPs and defective nucleocytoplasmic transport. HD repeat-associated non-ATG (RAN) translation proteins also disrupted nucleocytoplasmic transport. Additionally, overexpression of NUPs and treatment with drugs that prevent aberrant NUP biology also mitigated this transport defect and neurotoxicity, providing future novel therapy targets.

Single-Dose Basiliximab Induction in Low-Risk Renal Transplant Recipients.

OBJECTIVES: To compare the efficacy of a single dose of basiliximab with two doses in preventing acute rejection in selected low-risk renal transplant recipients. METHODS: This observational study of 760 kidney transplant recipients considered to be at low immunologic risk (peak panel reactive antibody less than 10%) compared patient and graft outcomes following a single-dose versus a two-dose regimen of basiliximab. MAIN RESULTS: No differences were found in patient survival (92% vs 92%, p=0.6), graft survival (86% vs 83%, p=0.2), acute rejection (cellular [4% vs 7%, p=0.2], antibody-mediated rejection [19% vs 19%, p=0.9]), or opportunistic infections (34% vs 30%, p=0.3) between the single versus two-dose regimens, respectively. In multivariate analyses, the number of doses of basiliximab was not associated with acute rejection or patient/graft survival despite adjustment with Cox regression and propensity scores. However, delayed graft function (DGF), donor age older than 65 years, and human leukocyte antigen mismatch of 3 or higher were associated with acute rejection (hazard ratio [HR] 2.64, 1.91, and 1.57, respectively, p≤0.04), and DGF and diabetes were associated with death/graft loss (HR 2.56 and 1.63, respectively, p≤0.009). PRINCIPAL CONCLUSIONS: A single dose of basiliximab is safe and effective for induction in low-risk kidney transplant recipients.

FIG4 regulates lysosome membrane homeostasis independent of phosphatase function.

FIG4 is a phosphoinositide phosphatase that is mutated in several diseases including Charcot-Marie-Tooth Disease 4J (CMT4J) and Yunis-Varon syndrome (YVS). To investigate the mechanism of disease pathogenesis, we generated Drosophila models of FIG4-related diseases. Fig4 null mutant animals are viable but exhibit marked enlargement of the lysosomal compartment in muscle cells and neurons, accompanied by an age-related decline in flight ability. Transgenic animals expressing Drosophila Fig4 missense mutations corresponding to human pathogenic mutations can partially rescue lysosomal expansion phenotypes, consistent with these mutations causing decreased FIG4 function. Interestingly, Fig4 mutations predicted to inactivate FIG4 phosphatase activity rescue lysosome expansion phenotypes, and mutations in the phosphoinositide (3) phosphate kinase Fab1 that performs the reverse enzymatic reaction also causes a lysosome expansion phenotype. Since FIG4 and FAB1 are present together in the same biochemical complex, these data are consistent with a model in which FIG4 serves a phosphatase-independent biosynthetic function that is essential for lysosomal membrane homeostasis. Lysosomal phenotypes are suppressed by genetic inhibition of Rab7 or the HOPS complex, demonstrating that FIG4 functions after endosome-to-lysosome fusion. Furthermore, disruption of the retromer complex, implicated in recycling from the lysosome to Golgi, does not lead to similar phenotypes as Fig4, suggesting that the lysosomal defects are not due to compromised retromer-mediated recycling of endolysosomal membranes. These data show that FIG4 plays a critical noncatalytic function in maintaining lysosomal membrane homeostasis, and that this function is disrupted by mutations that cause CMT4J and YVS.

The C9orf72 repeat expansion disrupts nucleocytoplasmic transport.

The hexanucleotide repeat expansion (HRE) GGGGCC (G4C2) in C9orf72 is the most common cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Recent studies support an HRE RNA gain-of-function mechanism of neurotoxicity, and we previously identified protein interactors for the G4C2 RNA including RanGAP1. A candidate-based genetic screen in Drosophila expressing 30 G4C2 repeats identified RanGAP (Drosophila orthologue of human RanGAP1), a key regulator of nucleocytoplasmic transport, as a potent suppressor of neurodegeneration. Enhancing nuclear import or suppressing nuclear export of proteins also suppresses neurodegeneration. RanGAP physically interacts with HRE RNA and is mislocalized in HRE-expressing flies, neurons from C9orf72 ALS patient-derived induced pluripotent stem cells (iPSC-derived neurons), and in C9orf72 ALS patient brain tissue. Nuclear import is impaired as a result of HRE expression in the fly model and in C9orf72 iPSC-derived neurons, and these deficits are rescued by small molecules and antisense oligonucleotides targeting the HRE G-quadruplexes. Nucleocytoplasmic transport defects may be a fundamental pathway for ALS and FTD that is amenable to pharmacotherapeutic intervention.

Dual intraventricular plus systemic antibiotic therapy for the treatment of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae ventriculitis.

OBJECTIVE: To report a case of Klebsiella pneumoniae carbapenemase (KPC)-producing K pneumoniae ventriculitis successfully treated with dual intraventricular plus systemic antibiotic therapy. CASE SUMMARY: A 43-year-old woman with a ventriculoperitoneal shunt was transferred from a nursing home with fever, altered mental status, and leukocytosis. She was found to have KPC-producing K pneumoniae ventriculitis. Combination intraventricular antibiotic therapy with colistin and gentamicin plus systemic colistin and amikacin led to the resolution of infection. DISCUSSION: Utilization of intraventricular or intrathecal antibiotics has been described in the literature for multidrug resistant (MDR) Gram-negative central nervous system (CNS) infections; however, none of the cases were caused by a KPC-producing organism. Given the pathogenicity and limited treatment options for this resistant organism, we utilized intraventricular colistin 10 mg and intraventricular gentamicin 10 mg in combination with systemic colistin and amikacin. An extensive literature search revealed several case reports and case series of documented MDR Acinetobacter baumanii CNS infections successfully treated with intraventricular colistin or aminoglycoside therapy with good tolerability. Additionally, recent pharmacokinetic analyses suggest improved cerebrospinal fluid (CSF) concentrations with direct CNS antimicrobial administration in combination with systemic therapy. Although our patient's cerebral spinal fluid cultures were cleared with dual intraventricular plus systemic therapy, she continued to deteriorate clinically because of her comorbid conditions and required hospice admission. CONCLUSIONS: This describes the first reported case of KPC-producing K pneumoniae ventriculitis microbiologically cured based on negative blood and CSF cultures with a combination of intraventricular and systemic therapy.

Plerixafor mobilization leads to a lower ratio of CD34+ cells to total nucleated cells which results in greater storage costs.

BACKGROUND: Plerixafor (Mozobil, AMD3100) with granulocyte-colony stimulating factor (G-CSF) mobilizes more CD34+ cells/kg compared to G-CSF alone. Given that plerixafor enhances mobilization of multiple white blood cell lineages, we determined if more storage space is required for products collected from patients mobilized with plerixafor. METHODS: A review of the medical records of 15 patients mobilized with chemotherapy and G-CSF (control) and 14 patients mobilized with plerixafor plus G-CSF (plerixafor) was performed. Data on demographics, baseline characteristics, CD34+ cells/kg, total nucleated cells, total mononuclear cells, total apheresis sessions, and total bags for storage were collected. Mean values were determined and compared using Student's t-test. RESULTS: We found that the proportion of CD34+ cells among total nucleated cells was less in the plerixafor group compared to the control group (P = 0.0427). More nucleated cells (10.7 x 10(10) vs. 7.1 x 10(10), P =0.0452) and mononuclear cells (9.7 x 10(10) vs. 5.9 x 10(10), P = 0.0059) were mobilized with plerixafor plus G-CSF. However, there was no significant difference in CD34+ cells/kg, total CD34+ cells or the proportion of mononuclear cells among total nucleated cells between the two groups. More storage bags were required for the plerixafor group compared to the control group (15 vs. 9, P = 0.0299). CONCLUSION: Mobilization with plerixafor plus G-CSF resulted in a smaller proportion of CD34+ cells collected and a greater number of storage bags. An increase in the number of bags required for stem cell storage may be logistically problematic and will also lead to increased costs for storage of stem cells.