By Q. Denpok. University of Minnesota-Morris. 2019.
Day hospital versus inpatient management of uncompli- population of affected individuals relative to the general population discount 100 mg zoloft otc. Future research should assess the potential beneﬁts of the PCMH for Pediatr Blood Cancer zoloft 25mg visa. SCD pain management and determine whether large-scale implemen- 15 buy on line zoloft. Raphael JL, Kamdar A, Beavers MB, Mahoney DH, Mueller tation is warranted. Treatment of uncomplicated vaso-occlusive crises in children with sickle cell disease in a day hospital. This work was supported by the National Institutes of Health (grant 16. Redeﬁning the relationship Conﬂict-of-interest disclosure: The authors declare no competing between primary and specialty care in the patient-centered ﬁnancial interests. Peikes D, Zutshi A, Genevro J, Smith K, Parchman M, Meyers Correspondence D. Early evidence on the patient-centered medical home. Raphael, MD, MPH, Texas Children’s Hospital, 6701 Report (Prepared by Mathematica Policy Research, under Fannin Street, Suite 1540. HHSA290200900019I/HHSA29032002T and 1791; Fax: 832-825-3435; e-mail: raphael@bcm. Rockville, MD: Agency for Healthcare Re- References search and Quality; 2012. Outcomes of implementing patient- survival of children and adolescents with sickle cell disease. Advances in the management of sickle cell Available from: http://www. Health supervision for children with sickle cell disease. Raphael JL, Rattler TL, Kowalkowski MA, Mueller BU, rics. Grosse SD, Schechter MS, Kulkarni R, Lloyd-Puryear MA, with sickle cell disease. Raphael JL, Rattler TL, Kowalkowski MA, Brousseau DC, disorders. Ofﬁce of Minority Health, US Department of Health and home and health care utilization among children with sickle cell Human Services. Stewart EE, Nutting PA, Crabtree BF, Stange KC, Miller WL, Hemoglobin. The observation and description of the national demonstration biopsychosocial approach to chronic pain: scientiﬁc advances project. A review of empirically supported tion on practice outcomes in the National Demonstration psychosocial interventions for pain and adherence outcomes in Project model of the patient-centered medical home. Jacob E, Pavlish C, Duran J, Stinson J, Lewis MA, Zeltzer L. Treatment and prevention of pain due to vaso- disease. Crosby LE, Barach I, McGrady ME, Kalinyak KA, Eastin AR, tional void. Todd KH, Green C, Bonham VL Jr, Haywood C Jr, Ivy E. Future directions of sickle cell disease thies: improving the lives of individuals with hemoglobinopa- research: the NIH perspective. Clinical dashboards: impact on workﬂow, care quality, 30. Lattimer L, Haywood C Jr, Lanzkron S, Ratanawongsa N, and patient safety. Problematic hospital experiences among adult patients with sickle cell disease. Management of Acute and Chronic Pain in Sickle Cell Disease, 32. American Academy of Family Physicians (AAFP), American APS Clinical Practice Guidelines Series, No. Glenview, IL: Academy of Pediatrics (AAP), American College of Physicians American Pain Society; 1999. Crosson JC, Etz RS, Wu S, Straus SG, Eisenman D, Bell DS. Available from: Meaningful use of electronic prescribing in 5 exemplar primary www. Hemoglobinopathy educational module on HIV screening rates and patient knowl- Learning Collaborative: using quality improvement (QI) to edge. Fryer GE Jr, Consoli R, Miyoshi TJ, Dovey SM, Phillips RL Jr, comes for sickle cell disease. Specialist physicians providing primary care ser- 2012;23(3 Suppl):34-48. Hollingsworth JM, Saint S, Hayward RA, Rogers MA, Zhang connections of Medicaid-insured children with sickle cell L, Miller DC. Specialty care and the patient-centered medical disease. Gamaletsou4 1Transplantation-Oncology Infectious Diseases Program, 2Department of Pediatrics, and 3Department of Microbiology & Immunology, Weill Cornell Medical Center of Cornell University, New York, NY; and 4Laikon General Hospital and Medical School, National and Kapodistrian University of Athens, Athens, Greece Invasive fungal infections are important causes of morbidity and attributable mortality in neutropenic patients with hematological malignancies, myelodysplasia, and aplastic anemia. Successful risk-based strategies can be imple- mented for prophylaxis, empirical therapy, and preemptive therapy for the prevention and early treatment of invasive fungal infections in neutropenic hosts. The use of echinocandins for invasive candidiasis and voriconazole for invasive aspergillosis has signiﬁcantly improved outcome. Recent studies demonstrate, however, that resistant fungal pathogens may emerge during the course of these antifungal interventions. Such organisms include echinocandin-resistant Candida glabrata and Candida parapsilosis species complex. The challenges of these emerging pathogens underscore the need for the development of new antifungal agents and strategies. Introduction cytotoxic against predominantly CD4 lymphocytes. Corticosteroids Invasive fungal infections (IFIs) are important causes of morbidity also markedly alter cytokine and chemokine expression, as well as and attributable mortality in neutropenic patients with hematologi- the distribution, trafﬁcking, and functions of lymphocytes, neutro- cal malignancies, myelodysplasia, and aplastic anemia. IFIs in patients with hematological malignancies varies as a function of underlying neoplastic process and degree of immunosup- Corticosteroids also impair oxidative function and hyphal damage pression. Understanding the epidemiology of these mycoses, risks capacity of neutrophils and impair phagocytosis of macrophages. The increased risk of development of IFIs is added to the risk Neutropenia as a key risk factor for development of already conferred by IFIs. IFIs in patients with hematological malignancies In the classic description of the inverse relation between risk of infection and degree of neutropenia, Sipsas et al underscored the Speciﬁc IFIs associated with neutropenia role of profound neutropenia (absolute neutrophil count 100) in Candidiasis leukemia patients for increasing the risk for infection.
Comparison of the efficacy 100 mg zoloft fast delivery, safety and quality of life provided by fexofenadine hydrochloride 120 mg buy 25 mg zoloft, loratadine 10 mg and placebo administered once daily for the treatment of seasonal allergic rhinitis trusted zoloft 100 mg. Comparison of the efficacy and safety of bilastine 20 mg vs desloratadine 5 mg in seasonal allergic rhinitis patients. Desloratadine for the treatment of cypress pollen-induced allergic rhinitis. Meltzer EO, Jalowayski AA, Vogt K, Iezzoni D, Harris AG. Effect of desloratadine therapy on symptom scores and measures of nasal patency in seasonal allergic rhinitis: results of a single-center, placebo-controlled trial. Desloratadine improves quality of life and symptom severity in patients with allergic rhinitis. Levocetirizine modulates lymphocyte activation in patients with allergic rhinitis. Evaluation of the efficacy and safety of levocetirizine during 8 weeks preceding and following the anticipated onset of the grass pollen season in subjects suffering from seasonal allergic rhinitis associated with pollen-induced asthma [completed]. Bernstein JA, Prenner B, Ferguson BJ, Portnoy J, Wheeler WJ, Sacks HJ. Double-blind, placebo-controlled trial of reformulated azelastine nasal spray in patients with seasonal allergic rhinitis. Efficacy and tolerability of azelastine nasal spray in patients with allergic rhinitis compared to placebo and budesonide. Safety and efficacy of azelastine nasal spray (Astelin NS) for seasonal allergic rhinitis: a 4-week comparative multicenter trial. Efficacy and safety of azelastine nasal spray at a dose of 1 spray per nostril twice daily. A double- blind, controlled trial to assess the safety and efficacy of azelastine nasal spray in seasonal allergic rhinitis. Effectiveness of azelastine nasal solution in seasonal allergic rhinitis. Improved quality of life among seasonal allergic rhinitis patients treated with olopatadine HCl nasal spray 0. Safety and efficacy of olopatadine hydrochloride nasal spray for the treatment of seasonal allergic rhinitis. Safety and efficacy of olopatadine hydrochloride nasal spray for the treatment of seasonal allergic rhinitis to mountain cedar. Martinez-Cocera C, De Molina M, Marti-Guadano E, et al. Rupatadine 10 mg and cetirizine 10 mg seasonal allergic rhinitis: A randomised, double-blind parallel study. Journal of Investigational Allergology and Clinical Immunology. A randomized, double-blind, placebo- controlled study comparing the efficacy and safety of ebastine (20 mg and 10 mg) to loratadine 10 mg once daily in the treatment of seasonal allergic rhinitis. Journal of Investigational Allergology and Clinical Immunology. Montelukast improves symptoms of seasonal allergic rhinitis over a 4-week treatment period. Saint-Martin F, Dumur JP, Perez I, Izquierdo I, French Rupatadine-Rhinitis Study Group. A randomized, double-blind, parallel-group study, comparing the efficacy and safety of rupatadine (20 and 10 mg), a new PAF and H1 receptor-specific histamine antagonist, to loratadine 10 mg in the treatment of seasonal allergic rhinitis. Journal of Investigational Allergology and Clinical Immunology. Safety and efficacy of loratadine (Sch- 29851): a new non-sedating antihistamine in seasonal allergic rhinitis. A study evaluating the efficacy and safety of 5 mg levocetirizine oral tablets, once daily versus 10 mg loratadine oral tablets, once daily for the treatment of perennial allergic rhinitis [completed]. Desloratadine and levocetirizine improve nasal symptoms, airflow, and allergic inflammation in patients with perennial allergic rhinitis: a pilot study. Berlin JM, Golden SJ, Teets S, Lehman EB, Lucas T, Craig TJ. Efficacy of a steroid nasal spray compared with an antihistamine nasal spray in the treatment of perennial allergic rhinitis. Effect of topical nasal azelastine on the symptoms of rhinitis, sleep, and daytime somnolence in perennial allergic rhinitis. Bruttmann G, Charpin D, Germouty J, Horak F, Kunkel G, Wittmann G. Evaluation of the efficacy and safety of loratadine in perennial allergic rhinitis. Comparison of antileukotrienes and antihistamines in the treatment of allergic rhinitis. Amat P, Novella A, Roma J, Valero A, Lluch M, Malet A. Treatment of perennial allergic rhinitis with cetirizine. Antihistamines Page 39 of 72 Final Report Update 2 Drug Effectiveness Review Project 64. Desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis. Kim K, Sussman G, Hebert J, Lumry W, Lutsky B, Gates D. Desloratadine therapy for symptoms associated with perennial allergic rhinitis. Efficacy and safety of desloratadine in the treatment of perennial allergic rhinitis. Efficacy of desloratadine in the treatment of allergic rhinitis: a meta-analysis of randomized, double-blind, controlled trials. Levocetirizine in persistent allergic rhinitis and asthma: effects on symptoms, quality of life and inflammatory parameters. Levocetirizine improves quality of life and reduces costs in long-term management of persistent allergic rhinitis. Levocetirizine improves health-related quality of life and health status in persistent allergic rhinitis. Long-term treatment of persistent allergic rhinitis with levocetirizine - Improvements in activity and sleep items of the Rhinoconjunctivitis quality of life questionnaire (RQLQ).
For anxiety disorders the strength of the comparative evidence was fair for some comparisons but poor for most others cheap 50mg zoloft visa. For premenstrual dysphoric disorder purchase 50 mg zoloft free shipping, no comparative evidence could be found and the strength of the evidence was rated poor purchase zoloft 100mg online. Good evidence indicates that second-generation antidepressants have similar adverse events profiles. Fair to good evidence also suggests that differences for some specific adverse events exist among some antidepressants. For example, mirtazapine causes higher rates of weight gain, venlafaxine leads to higher rates of nausea and vomiting, and sertraline has an increased risk of diarrhea than other antidepressants. Except for lower rates of sexual dysfunction for bupropion than for comparator drugs, the evidence on the comparative risks of serious adverse events such as suicidality, seizures, and others was rated poor. Fair evidence indicates that no differences in efficacy for subgroups based on age. For all other subgroups the evidence on the comparative efficacy and harms was rated poor. Limitations As with other types of research, the limitations of this systematic review are important to recognize. These can be divided into 2 groups, those relating to applicability of the results and those relating to methodology within the scope of this review. The applicability of the results are limited by the scope of the key questions and inclusion criteria and by the applicability of the studies included. Most studies included narrowly defined populations of patients who met strict Second-generation antidepressants 111 of 190 Final Update 5 Report Drug Effectiveness Review Project criteria for case definition, had few comorbidities, and used few or no concomitant medications. Minorities, older patients, and the most seriously ill patients were underrepresented. Methodological limitations of the review within the defined scope included the exclusion of studies published in languages other than English and lack of a specific search for unpublished studies. Unfortunately, for many drugs, there are few or no effectiveness studies and many efficacy studies. As a result, clinicians must make decisions about treatment for many patients who would not have been included in controlled trials and for whom the effectiveness and tolerability of the different drugs are uncertain. An evidence report indicates whether or not there is evidence that drugs differ in their effects in various subgroups of patients, but it does not attempt to set a standard for how results of controlled trials should be applied to patients who would not have been eligible for them. With or without an evidence report, these are decisions that must be informed by clinical judgment. In the context of developing recommendations for practice, evidence reports are useful because they define the strengths and limits of the evidence, clarifying whether assertions about the value of the intervention are based on strong evidence from clinical studies. By themselves, they do not tell you what to do: Judgment, reasoning, and applying one’s values under conditions of uncertainty must also play a role in decision making. Users of an evidence report must also keep in mind that not proven does not mean proven not; that is, if the evidence supporting an assertion is insufficient, it does not mean the assertion is not true. The quality of the evidence on effectiveness is a key component, but not the only component, in making decisions about clinical policies. Additional criteria include acceptability to physicians or patients, the potential for unrecognized harms, the applicability of the evidence to practice, and consideration of equity and justice. Applicability A considerable limitation of our conclusions is that they have been derived primarily from efficacy trials. For example, for acute-phase MDD we found only 3 effectiveness studies out of all head-to-head RCTs. Two of these effectiveness studies were conducted in Europe and the applicability to the US health care system might be limited. Although findings from effectiveness studies are generally consistent with those from efficacy trials, the evidence is limited to a few comparisons. Whether, for acute-phase MDD, such findings can be further extrapolated to other second-generation antidepressants remains unclear. Effectiveness studies that would be most applicable to the broad population of depressed patients are generally lacking for most drugs. Effectiveness trials with less stringent eligibility criteria, patient-centered health outcomes, long study durations, and populations representative of patients encountered in primary care would be valuable to determine whether existing differences of second-generation antidepressants are clinically meaningful in “real world” settings. These trials should be powered to be able to assess minimal clinically significant differences. Furthermore, they could provide valuable information on differences in adherence among second-generation antidepressants. Second-generation antidepressants 112 of 190 Final Update 5 Report Drug Effectiveness Review Project Trials in Progress We identified no trials in progress that would meet inclusion criteria for this review and would potentially change conclusions. Summary of principal findings and strength of the evidence Key Question, Disorder, and Strength of Outcome of Interest Evidence Findings Key Question 1. Comparative efficacy and effectiveness of second-generation antidepressants Major depressive disorder Comparative efficacy Fair Results from direct and indirect comparisons indicate that no substantial differences in efficacy exist among second-generation antidepressants. Comparative effectiveness Fair Direct evidence from one good and two fair effectiveness studies and indirect evidence from efficacy trials indicate that no substantial differences in effectiveness exist among second-generation antidepressants. Quality of life Fair Consistent results from 18 mostly fair studies indicate that the efficacy of second-generation antidepressants with respect to quality of life does not differ among drugs. Onset of action Fair Consistent results from seven fair trials suggest that mirtazapine has a significantly faster onset of action than citalopram, fluoxetine, paroxetine, and sertraline. Whether this difference can be extrapolated to other second-generation antidepressants is unclear. Most other trials do not indicate a faster onset of action of one second-generation antidepressant compared with another. Dysthymia Comparative efficacy Poor No head-to head evidence exists. Findings from five placebo-controlled trials were insufficient to draw conclusions about comparative efficacy. Comparative effectiveness Poor One fair effectiveness study provides mixed evidence about paroxetine vs. Subsyndromal depression Comparative efficacy Poor One nonrandomized, open-label trial did not detect any difference between citalopram and sertraline. Findings from two placebo-controlled trials were insufficient to draw conclusions. Comparative effectiveness No evidence Seasonal affective disorder Comparative efficacy Poor No head-to head evidence exists. Findings from placebo-controlled trials were insufficient to draw conclusions about comparative efficacy. Comparative effectiveness No evidence Major depressive disorder in children Comparative efficacy Poor No head-to head evidence exists. Findings from placebo-controlled trials were insufficient to draw conclusions about comparative efficacy. Comparative effectiveness No evidence Generalized anxiety disorder Comparative efficacy Fair to poor Available head-to head evidence is limited to comparisons of fluoxetine with sertraline and paroxetine with escitalopram or venlafaxine.
RCT Multinational BDP (400) + ML (10) Fair 118 1999 vs buy zoloft 100mg overnight delivery. Systematic Review with meta-analysis 2 trials in children; 25 in adults LTRA plus ICS vs order zoloft 25mg. ICS same dose zoloft 50mg mastercard, ICS same dose Good 226 2004 tapering, or ICS increased dose. RCT Multinational ML (10) + BUD (800) Fair 228, 229 2003 vs. Characteristics of head-to-head studies comparing ICS + LTRA with ICS Study design Country N Study population Comparison Quality Study Duration Setting (total daily dose) rating Age 15 – 75 BUD (1600) COMPACT 16 weeks Multicenter Medium to High dose ICS Fluticasone (FP)+Montelukast (ML) compared with Fluticasone (FP) increased dose Lemanske et al. Symbol use: Drug X > Drug Y = statistically significant difference in outcomes favoring Drug X; Drug X > Drug Y trend = point estimate favors Drug X, but the difference is not statistically significant or tests of statistical significance were NR; No difference = no statistically significant difference or tests of statistical significance were not reported and outcomes are similar. Controller medications for asthma 132 of 369 Final Update 1 Report Drug Effectiveness Review Project 5. Combination products compared with Leukotriene Modifiers Summary of findings 127, 128, 232-234 We found 5 RCTs meeting our inclusion/exclusion criteria for this comparison (Table 22). All 5 compared low dose fluticasone plus salmeterol with montelukast. Two of the 127 RCTs were in adolescents and adults, one enrolled subjects over the age of six (~15% of 128, 234 subjects < 12 years of age), and 2 enrolled children ages 6-14. Overall, our meta-analysis and results from 5 RCTs found the combination of fluticasone plus salmeterol to be more efficacious than montelukast for the treatment of persistent asthma (Appendix I and Appendix H, Table H-14). Detailed Assessment Description of Studies 127, 128, 232-234 We found 5 RCTs meeting our inclusion/exclusion criteria (Table 22). Of the included studies, all compared montelukast with low dose fluticasone plus salmeterol. Study Populations The 5 RCTs included a total of 2,188 patients. Two studies were conducted in adult populations; 127, 128, 234 three studies included children < 12 years of age. Four studies were conducted in the 234 United States and one study was conducted at sites in both Latin America and Turkey. Asthma severity ranged from mild persistent to severe persistent: 2 studies enrolled subjects with mild to moderate persistent asthma; three studies enrolled subjects with any severity of persistent asthma. Methodologic Quality Four trials were rated fair quality; one was rated good quality. Sponsorship Of the 5 RCTs, 3 (60%) were funded by pharmaceutical companies; only one (20%) was funded primarily by sources other than pharmaceutical companies, and one (20%) did not report the source of funding but a significant portion of the study design was dictated by a pharmaceutical 234 company and several authors reported a primary affiliation with the company. Fluticasone (FP)+Salmeterol (SM) compared with Montelukast (ML) The 5 included studies are described below. We conducted meta-analyses for outcomes that were reported with sufficient data in multiple trials (Appendix I). These included symptom-free days, rescue medicine-free days, and exacerbations. We found statistically significant differences favoring those treated with FP/SM for all three outcomes. Those treated with FP/SM had greater improvement in the percentage of symptom-free days SMD -0. Subjects Controller medications for asthma 133 of 369 Final Update 1 Report Drug Effectiveness Review Project with uncontrolled asthma treated with oral or inhaled short-acting beta-agonist age 15 and older were enrolled from 51 different centers in the United States. At endpoint those treated with FP/SM showed a greater improvement in all outcomes compared to ML including a decrease in the combined asthma symptom score (-1 compared with -0. Exacerbations occurred less frequently in the FP/SM group (3% compared with 6%; P = NR). The first fair-rated RCT (N = 423) also compared low dose FP/SM (200 mcg/100mcg 233 daily) (N = 211) compared with ML (10mg/day) (N = 212) for 12 weeks. Subjects with uncontrolled asthma treated with oral or inhaled short-acting beta-agonist age 15 or older were enrolled from multiple centers in the United States. At endpoint, results were similar to those in 232 the good quality RCT described above with significant differences for all outcomes favoring FP/SM over ML: including decrease in symptoms, rescue medicine use, and exacerbations (0%, 5%; P < 0. A third fair-rated RCTs showed mixed results, with some outcomes favoring FP/SM and others finding no difference. The first (N = 500) compared low dose FP (200 mcg/day) (N = 169) compared with low dose FP (100 mcg/day) plus SM (50 mcg/day) (delivered once daily at night) 127 (N = 165) compared with ML (5-10 mg/day) (N = 166) for 16 weeks. Subjects were age six and older, had mild to moderate asthma controlled on ICS, and were enrolled from multiple American Lung Association Asthma Clinical Research Centers in the United States. At endpoint, there were no significant differences between FP plus SM and ML in symptom-free days or rescue medicine use. But, there were significant differences in the percentage of patients with treatment failure (20. The last fair-rated RCT (N = 285), the Pediatric Asthma Controller Trial (PACT), compared low dose FP 200 mcg/day via DPI (N = 96) compared with ML 5 mg/day (N = 95) compared with low dose FP 100 mcg/day plus SM 100 mcg/day via DPI (FP 100 mcg plus SM 50 mcg in the morning plus SM 50 mcg in the evening) 128 (N = 94) for 48 weeks. Of note, the dose of FP/SM used was outside of the product label recommendation. Subjects with mild to moderate asthma age 6 to 14 were enrolled from Childhood Asthma Research and Education Centers in the United States. At endpoint, the trial found no significant difference in the overall percentage of asthma control days (52. There was no significant difference in asthma control as measured by change in ACQ score from baseline (-0. Adherence was similar between groups (86% compared with 90%; P = NR). A final RCT showing mixed results, known as the Pediatric Asthma Control Evaluation (PEACE) study, enrolled children age 6 to 14 with mild to moderate persistent asthma in 234 outpatient centers at 4 sites in Turkey and 23 in Latin America. Using a double-blind, double- dummy design, 281 children treated with FP/SM 100mcg/50mcg twice daily were compared to 267 patients treated with ML 5mg daily. While the results showed significant improvement in Controller medications for asthma 134 of 369 Final Update 1 Report Drug Effectiveness Review Project the percentage of symptom free days (OR 1. The mean exacerbation rate and time was significantly reduced with FP/SM therapy (0. In addition, the percentage of rescue free days increased significantly with FP/SM treatment (OR 3. Quality of life measures, however, demonstrated mixed results. While PACQLQ scores were higher in the FP/SM group (mean treatment difference 0. Adherence was similar between groups (87% compared with 84%; P = NR).
The proteasome inhibitor bortezomib induced apoptosis in primary effusion lymphoma through (PS-341) inhibits growth and induces apoptosis in primary azidothymidine-mediated inhibition of NF-kappa B buy 50 mg zoloft with visa. The eradication of H pylori using antibiotics is successful in 60% to 80% of affected patients cheap zoloft 25 mg with visa. In contrast to the previous paradigm buy zoloft with amex, we and other investigators have shown that a certain proportion of patients with H pylori–positive early-stage diffuse large B-cell lymphoma (DLBCL) of the stomach with histological evidence of MALT lymphoma, including high-grade transformed gastric MALT lymphoma and gastric DLBCL(MALT), achieved long-term complete pathological remission (pCR) after ﬁrst-line H pylori eradication therapy, indicating that the loss of H pylori dependence and high-grade transformation are separate events in the progression of gastric lymphoma. In addition, patients with H pylori–positive gastric DLBCL without histological evidence of MALT (gastric pure DLBCL) may also respond to H pylori eradication therapy. A long-term follow-up study showed that patients who achieved pCR remained lymphoma free. Gastric MALT lymphoma is indirectly inﬂuenced by H pylori infection through T-cell stimulation, and recent studies have shown that H pylori–triggering chemokines and their receptors, H pylori–associated epigenetic changes, H pylori–regulated miRNA expression, and tumor inﬁltration by CD4 CD25 regulatory T cells contribute to lymphomagenesis of gastric MALT lymphoma. Recent studies have also demonstrated that the translocation of CagA into B lymphocytes inhibits apoptosis through p53 accumulation, BAD phosphorylation, and the up-regulation of Bcl-2 and Bcl-XL expression. In gastric MALT lymphoma, CagA may stimulate lymphomagenesis directly, through the regulation of signal transduction, and intracellular CagA is associated with H pylori dependence. These ﬁndings represent a substantial paradigm shift compared with the classical theory of H pylori–reactive T cells contributing indirectly to the development of MALT lymphoma. In conclusion, a wide range of H pylori–related gastric lymphomas have been identiﬁed. The use of antibiotics as the sole ﬁrst-line therapy for early-stage gastric pure DLBCL requires validation in a prospective study. The clinical and biological signiﬁcance of the CagA oncoprotein in the lymphomagenesis of gastric MALT lymphoma warrants further study. Introduction follicles morphologically similar to healthy MALT developed in With a relatively high incidence and unique clinicopathological H pylori–infected patients. In 1983, Isaacson and Wright described a group acquisition of gastric MALT in H pylori infection facilitates the of extranodal low-grade B-cell lymphomas derived from Peyer development of gastric MALT lymphoma. In tial follow-up endoscopic examinations to monitor disease progres- some studies, tumors that had resolved to Wotherspoon grade 2 sion or to verify pCR. Successful eradication of H pylori was (chronic active gastritis with ﬂorid lymphoid follicle formation) or achieved in 96. The median time to pCR after completion of HPE as tumors with no remaining lymphoma cells and an “empty” tunica was 4. The histological scoring system proposed by Groupe d’Etude des In our previous study of the relationship between the depth of tumor Lymphomes de l’Adult (GELA) is currently recommended to inﬁltration and the tumor response, the pCR rate of tumors limited to improve the consistency between the ﬁndings of different studies. Complete clinical remission is deﬁned 1215 MALT lymphoma and 56 DLBCL(MALT) patients showed as no macroscopic ﬁndings of lymphoma and negative histological that the tumor regression rate after successful HPE was higher in ﬁndings equivalent to pCR or the presence of small lymphoid MALT lymphoma patients than in DLBCL(MALT) patients (78. Delayed pCR has been reported in some gastric MALT lymphoma patients,11 whereas reports of relapse after pCR are extremely rare. H pylori–positive gastric pure DLBCL is dependent on Zulio et al reported a relapse rate of 7. However, epidemiological and case-control studies have demonstrated an association between H pylori infection and gastric In contrast to gastric MALT lymphoma, gastric diffuse large B-cell DLBCL,8,23,24 with prevalence rates of H pylori infection in gastric lymphoma (DLBCL) is a heterogeneous disease that has been DLBCL patients of 85% to 89%. In our study, gastric DLBCL(MALT), is DLBCL with features of MALT lym- patients received their ﬁrst upper-gastrointestinal endoscopic fol- phoma and should not be classiﬁed strictly as MALT lymphoma. Eleven patients achieved pCR after HPE and were free of H pylori–positive early-stage gastric DLBCL(MALT) patients lymphoma at a median follow-up of 3. Our previous study revealed that gastric DLBCL without histologi- Our results are consistent with those of a recent multicenter phase 2 cal evidence of MALT (gastric pure DLBCL) can also be cured by study showing an efﬁcacy rate of 50% for ﬁrst-line antibiotic HPE,21 which represents a revolutionary ﬁnding in the treatment of treatment for high-grade gastric lymphoma in 5 DLBCL(MALT) gastric lymphoma. Most importantly, the spectrum of H pylori– and 11 pure DLBCL patients (Table 1). We discuss new insights into the with a median interval to pCR of 3 months (Table 1), and all patients molecular mechanisms of H pylori–induced gastric MALT lym- who achieved pCR had tumor invasion of the mucosa or shallow phoma focusing on indirect H pylori antigen-driven lymphomagen- lesions of the submucosa. Potential molecular and biologic markers that predict the H pylori–dependent status of early-stage gastric MALT lymphoma patients with ﬁrst-line antibiotic treatment Response to HP eradication Markers Methods Reference(s) HP dependence Costimulatory molecules CD86 (B7. The H pylori protein CagA might function as a bacterium-derived oncoprotein in the carcinogenesis of gastric MALT lymphoma. Intracellular CagA coimmunoprecipitates with SHP-2, suggesting the involvement of CagA in the regulation of intracellular signaling pathways. Our preliminary results showed that polymor- Treg involvement in the immunomodulation of gastric MALT phism of IL-22 plays an important role in the development of lymphoma and evaluated Treg-mediated inﬂuences on treatment MALT lymphoma and that IL-22 expression is associated with response. In addition to ratio than H pylori–independent tumors. Direct effects of H pylori on B-cell proliferation in gastric H pylori–regulated epigenetic changes and miRNA MALT lymphoma expression are associated with gastric MALT We recently reported that the H pylori protein CagA is translocated lymphoma tumorigenesis into human B lymphocytes. Intracellular CagA coimmunoprecipi- Because most H pylori–positive gastric MALT lymphomas are tated with SHP-2, suggesting that it stimulates the proliferation of sensitive to HPE, epigenetics and other regulatory processes, rather B cells by regulating intracellular signaling pathways, such as the than genetics, may drive the progression of the early stages of activation of ERK and p38 MAP kinase and the up-regulation of MALT lymphoma. Studies have reported that the methylation of the expression of Bcl-2 and Bcl-X. Involvement of CagA-derived signals, T-cell–derived signals, and tumor microenvironment-related mediators in H pylori–induced lymphomagenesis of gastric MALT lymphoma. H pylori infection stimulates T lymphocytes in the gastric mucosa and indirectly induces the formation of MALT, from which B lymphocytes migrate and inﬁltrate the site of H pylori infection in the stomach. H pylori infection can stimulate CD4 CD25 Tregs expressing FOXP3. Recent studies have reported that certain genes, such as p16, MGMT, and MINT31, was associated BCR signaling inhibitors such as ibrutinib (a Bruton tyrosine kinase with H pylori infection. Our study showed that the expression of E2A, a 67 H pylori–independent gastric MALT lymphoma are warranted. In the showed that the expression of miR-203 and its target ABL1 was future, validation of the efﬁcacy of HPE for gastric pure DLBCL is dysregulated in MALT lymphoma biopsy samples. We have gastric MALT lymphomas and the surrounding nontumor mucosae also witnessed a paradigm shift in the study of carcinogenesis in revealed that miR-142 and miR-155 were expressed at much higher H pylori–related gastric lymphomas. In addition to the classical levels in the MALT lymphoma lesions and that the expression levels “H pylori 3 T-cell 3 marginal-zone B cell” pathway of lym- of miR-142-5p and miR-155 were signiﬁcantly higher in H pylori– phoma carcinogenesis, H pylori may also have direct effects on independent tumors than in H pylori–dependent tumors. It is equally important to explore the cellular origins of H pylori–related New treatment strategies for localized gastric MALT lymphomas. In addition to the classical “marginal-zone B lymphoma that does not respond to HPE cell 3 MALT lymphoma 3 DLBCL(MALT) 3 pure DLBCL” Previous studies have shown that conventional therapeutic modali- pathway of carcinogenesis, the possibility that H pylori may contrib- ties such as chemotherapy using chlorambucil, ﬂudarabine, or ute to the development of lymphoma by transforming B cells other cyclophosphamide; radiotherapy; and immunotherapy (anti-CD20 than those in the marginal zone warrants further study. J Natl Cancer Research, National Health Research Institutes, Tainan, Taiwan; the Inst. Department of Internal Medicine, Kaoshiung Medical University 14. Classiﬁcation of Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; and lymphoid neoplasms: the microscope as a tool for disease the Department of Internal Medicine, National Cheng Kung Univer- discovery. Prospective study of script, for providing detailed information regarding his unpublished Helicobacter pylori eradication therapy in stage I(E) high-grade data, and for helpful discussions.
Although side effects such as abnormal liver functions order zoloft with a mastercard, virilization in females 50 mg zoloft fast delivery, and peliosis hepatitis were not reported order zoloft 100 mg on line, this The key features of haploidentical related HSCT are that a graft is could be due to the short treatment phase. However, the presence of HLA antibodies in the Supportive care in refractory SAA recipient that are directed against a haploidentical family member What is the current best supportive care and why is it will likely preclude the use of that donor. Historically, haploidentical HSCT was invari- disease. The quality of supportive care at initial presentation of SAA ably unsuccessful, with high rates of graft rejection and GVHD. A is vital and will determine the survival when patients are frequently recent review by the EBMT SAAWP on 73 patients receiving at high risk of bleeding and infection. Best supportive care transplantations between 1976 and 2011 and mostly using nonmy- 31 continues through initial therapies, whether with HSCT or ATG. Disappoint- Because response to ATG is delayed until 3 months, best ingly, there was no improvement in OS with procedures performed supportive care is critical during this time to help ensure optimal even after 1999, highlighting the need for a new approach to outcome. A novel approach is nonmy- eloablative conditioning with high-dose CY given on days 3 and Patients who respond to ﬁrst-line IST have signiﬁcantly better 4 after transplantation to prevent GVHD by depleting dividing survival than nonresponders. However, the OS of refractory patients donor-alloreactive T cells but sparing quiescent, nonalloreactive has also improved signiﬁcantly over time (23% vs 35% vs 57% T cells. High-dose CY is not toxic to the infused HSCs due to their during time periods 1989-1996 vs 1996-2002 vs 2002-2008, high content of aldehyde dehydrogenase, which confers resistance 38 respectively) ; there was a signiﬁcant reduction in deaths from to CY. Such an approach has been reported anecdotally in PNH and 32 infection including invasive fungal infections, emphasizing the warrants further exploration in SAA. As for CBT, patients must be importance of improvements in supportive care in refractory screened for HLA antibodies directed against the donor cells and, if patients (Figure 2). Alloimmunization after transfusion RBC and platelet transfusions should be administered to maintain Other agents: eltrombopag and androgens. Eltrombopag an safe blood counts, but they should not be given unnecessarily. Most oral thrombopoietin mimetic licensed in chronic immune thrombo- centers administer prophylactic platelets at a count of 10 109/L cytopenic purpura that induces platelet maturation and release by or 20 109/L if fever or bleeding is present, rather than Hematology 2013 91 Figure 2. Improvement in survival of refractory AA patients over time. The data indicate the outcomes for 174 patients with SAA who were unresponsive to initial IST at 6 months. Three patient groups were identiﬁed, group 1 (n 43); December 1989-October 1996; group 2 (n 51, November 1996-October 2002); and group 3 (n 80, November 2002-April 2008). The ﬁrst column indicates survival curves censored for HSCT and the second graph is not censored for HSCT. A signiﬁcantly improved 5-year OS for nonresponders to IST was seen in group 3 compared with other groups. Adapted and modiﬁed with permission from Valdez et al. RBC and platelet When should iron chelation be started and what is the transfusions should not be avoided for fear of either alloimmuniza- best drug to use? There is no evidence base to establish when to start iron chelation therapy in multi-transfused AA patients and recommendations are Despite leukodepletion of blood products, HLA alloimmuniza- extrapolated from other disorders such as MDS. Currently, ferritin tion in AA remains a problem and may occur through indirect or of 1000 g/L is the proposed threshold to initiate chelation for direct allorecognition. The consequences of alloimmunization potential transplantation candidates because iron overload contrib- are platelet transfusion refractoriness most often due to HLA utes to transplantation-related mortality. For other patients, the need antibodies (less often HPA antibodies) and graft rejection after for iron chelation is made on an individual basis. The use of HLA-identical HSCT due to minor HC antigens or HLA subcutaneous/IV desferrioxamine or oral deferasirox varies be- antibodies in the setting of mismatched HSCT. Desferrioxamine is an effective iron riness is usually managed with HLA-matched platelets. AA chelator, although data in AA are lacking and compliance is often a patients with multispeciﬁc HLA antibodies are especially prob- big issue. Deferasirox is an oral iron chelator and is effective in AA, lematic because it may be difﬁcult to obtain suitably matched but may be dose limited by nephrotoxicity when used with CSA, platelet donors. In this situation, platelet units can be selected and other side effects such as rash and gastrointestinal upset have that are negative for the antigens recognized by the HLA occurred. Infection is the major cause of death in SAA: what is best treatment and prophylaxis? Should irradiated blood products be given to all AA Infection is the major cause of death in SAA, in which neutropenia patients? Invasive fungal infection is a major cause of death, most products in AA is to reduce the risk of transfusion-associated often due to Aspergillus species; but the Zygomycetes (Mucor, GVHD after ATG or alemtuzumab and possible allosensitization to Rhizopus), Candida, Fusarium, and other fungi with a predilection HLA and non-HLA antigens, based on canine experiments. A for the lungs, nasal sinuses, and brain may also be responsible. Some centers have a universal policy for nas, E coli, and Klebsiella species. Febrile neutropenia requires all AA patients regardless of type of treatment or if untreated or for broad spectrum IV antibiotics, with early administration of systemic all myeloid patients in general. Diagnostic criteria to distinguish hypocel- dexamethasone, granulocyte transfusions may be potentially lifesav- lular acute myeloid leukemia from hypocellular myelodysplas- ing in severe sepsis such as invasive fungal disease, particularly for tic syndromes and aplastic anemia: recommendations for a patients due to proceed to HSCT. Recent insights into inherited bone candidates should be retested after granulocyte transfusions to marrow failure syndromes. Scheinberg P, Cooper JN, Sloand EM, Wu CO, Calado RT, Young NS. Association of telomere length of peripheral blood leukocytes with hematopoietic relapse, malignant transforma- What is the best prophylaxis for SAA? A third course of prophylactic antibiotics and antifungals in SAA to help prevent anti-thymocyte globulin in aplastic anaemia is only beneﬁcial gram-negative infections and invasive fungal infections, but other in previous responders. Predicting commence systemic antifungals early with febrile neutropenic response to immunosuppressive therapy and survival in severe episodes. Antiviral prophylaxis with acyclovir or valacyclovir aplastic anaemia. Fludarabine, cyclophos- subclinical reactivation of CMV and EBV is common but self- phamide, antithymocyte globulin, with or without low dose limiting, and therefore does not require antiviral treatment. EBV total body irradiation, for alternative donor transplants, in posttransplantation lymphoproliferative disorder has only very acquired severe aplastic anemia: a retrospective study from the rarely been reported after ATG, most often after rabbit ATG. Alemtuzumab with ﬂudara- Nebulized pentamidine is an appropriate drug for prophylaxis bine and cyclophosphamide reduces chronic graft-versus-host because cotrimoxazole is myelosuppressive. Evaluation of HLA There is no role for corticosteroids in the treatment of AA because matching in unrelated hematopoietic stem cell transplantation they increase the risk of fungal and bacterial colonization. Prospective multicenter The use of G-CSF for initial treatment of AA is not encouraged trial comparing repeated immunosuppressive therapy with because it is not effective in treating AA and merely delays the onset stem-cell transplantation from an alternative donor as second- of appropriate speciﬁc treatment, during which time the patient may line treatment for children with severe and very severe aplastic have become infected and/or alloimmunized. Allogeneic BM transplantation for the treatment of Disclosures aplastic anemia: current results and expanding donor possibili- Conﬂict-of-interest disclosure: A. Rabbit antithymocyte and oxymetholone as treatment for AA.
However buy zoloft 100 mg with visa, an individual who is groups before initiating immunosuppressive therapy and to start seropositive only for anti-HBs with a history of vaccination against antiviral treatment immediately before hepatitis onset after HBV hepatitis B should be excluded from the risk group for HBV reactivation buy 25mg zoloft with amex. The identiﬁcation of these risk groups for HBV reactivation is strongly recommended before initiating immunosuppressive therapy order 25 mg zoloft free shipping, Strategy to prevent HBV reactivation in HBsAg-positive because this may decrease titers of serum HBV antibodies and make patients it difﬁcult to evaluate the risk of HBV reactivation. Antiviral prophylaxis should also be given to patients who are HBsAg-negative but who Management of HBV reactivation after anti-B-cell have detectable HBV DNA (Risk Group 2), who are potentially at a therapy higher risk for HBV reactivation (Figure 2). Yeo et al conducted a containing chemotherapy without antiviral prophylaxis has been Hematology 2014 579 reported to be 59%–80%. Of the HBsAg-positive patients, most HBV reactivation occurs during and after chemotherapy, but patients with high HBV DNA levels at baseline potentially suffer HBV reactivation at an early stage of chemotherapy. Which drug is recommended in an antiviral prophylaxis setting to prevent HBV reactivation? Lamivudine is a ﬁrst-generation nucleo- side analog that can suppress HBV replication and improve hepatitis B. Some prospective studies have demonstrated the efﬁcacy and safety of lamivudine for preventing HBV reactivation in HBsAg- positive patients who received immunosuppressive therapy. Lamivudine resistance was reported as 24% at 1 year and 50% at 5 years in patients with chronic hepatitis B. Kim et al recently reported that no HBV reactiva- tion was observed in 31 HBsAg-positive patients who received entecavir, whereas 30 of 96 (31%) who received lamivudine developed HBV reactivation after R-CHOP-like regimens. There is no consensus regarding the optimal duration of antiviral prophylaxis for HBsAg-positive patients. To establish when to discontinue the antiviral prophylaxis safely, we propose the following criteria as being essential: (1) planned immunosuppres- sive therapy completed, (2) undetectable HBV DNA levels by real-time PCR assay, and (3) both conditions 1 and 2 maintained at least for 1 year. More importantly, regular monitoring of HBV DNA for at least 6 months after discontinuation of antiviral prophylaxis is desirable to prevent HBV reactivation because reemergence of HBV was observed within 6 months after withdrawal of antiviral prophylaxis according to data collected by the Zenyaku Kogyo Company and the Chugai Pharmaceutical Company. Strategy to prevent HBV reactivation in patients with resolved HBV infection (anti-HBc-positive and/or anti-HBs-positive in HBsAg-negative patients, Risk Group 3) Although there is no consensus on a strategy to prevent HBV reactivation in patients with resolved HBV infection, regular HBV DNA-monitoring-guided preemptive antiviral therapy is a reason- 580 American Society of Hematology Table 2. Comparison of large-scale prospective studies on HBV DNA-monitoring-guided preemptive antiviral therapy in lymphoma patients with resolved HBV infection after rituximab-containing chemotherapy (preliminary results) ID no. NCT00931229 UMIN000001299 Locations Taiwan Japan Study design Prospective Prospective observational HBV DNA-monitoring-guided preemptive HBV DNA-monitoring-guided preemptive antiviral therapy antiviral therapy No. Conversely, although antiviral prophylaxis is an 2 study designs: preemptive antiviral therapy and antiviral alternative approach to preventing HBV reactivation in patients prophylaxis. We hypothesized that by measuring serum HBV markers including HBsAg, anti-HBc, and monthly HBV DNA-monitoring-guided preemptive antiviral therapy anti-HBs to identify groups at risk of HBV reactivation. To prevent can prevent hepatitis due to HBV reactivation7 and conducted a hepatitis due to HBV reactivation after anti-B-cell therapy, antiviral multicenter prospective study in Japan (Study UMIN000001299, prophylaxis is recommended for HBsAg-positive patients and/or Table 1). These studies demonstrated that Acknowledgments monthly monitoring of HBV DNA could prevent HBV-related 38,39 Financial Support was partly provided by the Ministry of Health, death. However, in the Taiwanese study, 10 of 150 (7%) Labour and Welfare of Japan (Grant-in-Aid H24-kanen-004-MM). HBV-resolved patients who received R-CHOP developed hepatitis due to HBV reactivation and 7 of 150 (5%) developed severe This study was also supported in part by the National Cancer Center hepatitis deﬁned as alanine aminotransferase 10-fold the upper Research and Development Fund (Grant 26-S-4). Patients with HBV reactivation were more likely to Yasuhito Tanaka (Department of Virology and Liver Unit, Nagoya have a poorer prognosis. Ryuzo Ueda (Department of Tumor Immunology, Aichi tive HBV clones such as precore mutants. Chugai Pharmaceutical Company for providing clinical data on 211 These 2 studies also showed that most HBV reactivation was patients developing serious hepatitis B after rituximab-containing observed within 1 year after completion of rituximab-containing chemotherapy. Frequency of hepatitis B virus Conﬂict-of-interest disclosures: K. Mortality secondary to Kensei Tobinai, MD, PhD, Department of Hematology, National fulminant hepatic failure in patients with prior resolution of hepatitis B Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, virus infection in Japan. Phone: 81-3-3542-2511; Fax: 81-3-3542-3815; e-mail: 20. Lok AS, Liang RH, Chiu EK, Wong KL, Chan TK, Todd D. Reactivation of hepatitis B virus replication in patients receiving 21. Reverse seroconversion of preemptive lamivudine therapy for hepatitis B patients undergoing hepatitis B after allogeneic bone marrow transplantation: a retrospective chemotherapy. Hepatitis B virus reactivation in B-cell N Engl J Med. Hepatitis B virus reactivation in immunosuppressive therapy: evaluation of both HBsAg-positive and lymphoma patients with prior resolved hepatitis B undergoing antican- HBsAg-negative cohorts. B virus following systemic chemotherapy for malignant lymphoma. Rituximab-associated hepatitis hepatitis B virus infection. B virus (HBV) reactivation in lymphoproliferative diseases: meta- 28. Prevention of hepatitis B virus analysis and examination of FDA safety reports. FDA: Increased HBV reactivation risk with ofatumumab or 29. Management of patients with hepatitis B who rituximab. EASL clinical practice targeted therapy with rituximab in patients with rheumatoid arthritis. A revisit of prophylactic lamivudine for granulomatosis with polyangiitis (Wegener’s granulomatosis): compari- chemotherapy-associated hepatitis B reactivation in non-Hodgkin’s son of efﬁcacy in granulomatous versus vasculitic manifestations. Clinical and virological mide for ANCA-associated vasculitis. A comparison of entecavir and CD20 immunotherapy in ﬂudarabine-refractory chronic lymphocytic lamivudine for HBeAg-positive chronic hepatitis B. Tenofovir disoproxil fumarate patients with CLL and coexisting conditions. Efﬁcacy of entecavir treatment virus persists for decades after patients’ recovery from acute viral for lamivudine-resistant hepatitis B over 3 years: histological improve- hepatitis despite active maintenance of a cytotoxic T-lymphocyte ment or entecavir resistance? Retrospective and prospective therapy: results of interim analysis [abstract]. Blood (ASH Annual studies of hepatitis B virus reactivation in malignant lymphoma with Meeting Abstracts). Chemotherapy-induced hepatitis B entecavir prophylaxis for rituximab-associated hepatitis B virus reactiva- reactivation in lymphoma patients with resolved HBV infection: a tion in patients with lymphoma and resolved hepatitis B.