Comparison of intermittent intravenous tacrolimus to continuous tacrolimus in adult allogeneic stem cell transplant recipients.

Introduction: Initial continuous intravenous (CIV) tacrolimus (0.03 mg/kg/day based on ideal body weight [IBW]) has been favored for graft versus host disease (GVHD) prevention in allogeneic stem cell transplant patients due to the consistent, steady-state degree of immunosuppression; however, this method poses many logistical challenges. We implemented intermittent (IIV) tacrolimus at a starting dose of 0.015 mg/kg IBW twice daily over 4 h. To our knowledge this is the first retrospective comparison of CIV to IIV tacrolimus. Objectives: The primary objective was to evaluate the safety of IIV tacrolimus in comparison to CIV with respect to nephrotoxicity and neurotoxicity. The secondary objectives were to compare the incidence of grade II-IV acute GVHD (aGVHD) and chronic GVHD (cGVHD) at day +180, outcomes including relapse and overall survival, cell engraftment, and reactivation of cytomegalovirus and Epstein-Barr virus. Methods: This retrospective, single-center review evaluated adults who received an allogeneic stem cell transplant patients between January 1, 2020, and December 31, 2022. Results: Fifty-one unique patients were eligible for evaluation - 28 in the IIV cohort and 23 in the CIV group. The number of patients who developed nephrotoxicity and neurotoxicity were comparable between groups with no significant differences noted. No severe neurotoxicity was identified in either population. Secondary objectives revealed no significant difference in GVHD incidence or survival outcomes. Conclusion: IIV tacrolimus is comparable to CIV in terms of safety while also maintaining similar outcomes at day +180. IIV is a safe and feasible alternative to CIV in adult allogeneic stem cell transplant recipients.

Evaluation of potential cost savings through chemotherapy and biotherapy dose-rounding at a pediatric institution.

INTRODUCTION: Rapidly increasing costs of medication acquisition can pose a challenge for health-system pharmacy budgets. The impact of dose-rounding in a pediatric oncology population has not previously been well documented and a retrospective review was undertaken to quantify the potential cost benefits. METHODS: A retrospective chart review of patients with an oncologic diagnosis was performed for cytotoxic agents, asparaginase products, and biotherapy administered between January 1, 2014, and December 31, 2017. In the analysis, orders that could be rounded down to the nearest vial size by 5 or 10% were included. Medication pricing information was based on wholesale acquisition cost (WAC) and was provided by the Department of Pharmacy. Cost savings per medication were determined by multiplying the WAC of the medication by the number of vials saved. RESULTS: Over a 4-year span, 347 patients were evaluated and 552 out of a possible 3110 orders (17.7%) met criteria for a theoretical cost savings of approximately $1,126,000 (∼$3200 per patient). Rounding down doses by up to 5% resulted in a potential savings of about $529,000. When rounding was extended to 5-10% of the originally ordered dose, an additional $597,000 of approximate cost savings could have been realized. The medications with the largest impact on cost savings were rituximab, pegaspargase, and erwinia asparaginase. CONCLUSIONS: For pediatric oncology patients, there exists a unique potential cost savings opportunity if doses are rounded down within 5 or 10% of the originally ordered weight-based or body surface area-calculated dose.

Professional partners: Longitudinal interprofessional education events with pharmacy and nursing programs.

BACKGROUND AND PURPOSE: Faculty from a school of pharmacy and a school of nursing developed a series of interprofessional education (IPE) events to create a two-year, longitudinal experience to maximize the time student groups would be able to work together. This paper outlines the activities created and the assessment tool utilized to evaluate the experiences. EDUCATIONAL ACTIVITY AND SETTING: Four activities were planned for 43 pharmacy and 19 nursing students to cover topics encountered by both professions. These included Vitals Techniques, Medication Reconciliation, End of Life Care, and Enteral/Parenteral Nutrition. Each activity was evaluated by students using a modified Interprofessional Collaborative Competency Attainment Survey (ICCAS). FINDINGS: The most challenging part of creating this longitudinal experience was finding dates and keeping the groups the same from activity to activity. Despite this, the activities were well executed and for each event, over 95% of students completing the ICCAS survey agreed that the activities were appropriate and beneficial for IPE. Anecdotally, students enjoyed the experience and appreciated the group consistency over time. SUMMARY: The creation of a series of longitudinal IPE activities was successfully implemented between a school of pharmacy and a school of nursing.

Association of Surgical Margin Distance With Survival in Patients With Resected Head and Neck Squamous Cell Carcinoma: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Clear surgical margins reduce the risk of local recurrence, improve survival, and determine decision-making with regard to adjuvant treatment of squamous cell carcinoma of the head and neck (SCCHN). However, the definitions of clear, close, or positive surgical margins vary in both the literature and in practice. Objective: To examine whether the association between surgical margin distance and survival varies by primary tumor site. Design, Setting, and Participants: This was a secondary analysis of a multi-institutional, multinational randomized clinical trial. The trial enrolled patients from January 22, 2007, to March 29, 2013, with stage II to IVA resected SCCHN with extranodal extension (ENE) or positive margins (<5 mm from invasive tumor to the resected margin). The current analysis included those patients with known ENE and margin status and was conducted from April 29, 2022, to December 19, 2022. Interventions: Patients received adjuvant chemoradiotherapy plus either placebo or lapatinib. Main Outcomes and Measures: Overall survival (OS) was calculated to examine association with surgical margin distance, primary site, and survival, with stratification by ENE status. Results: Among 688 patients enrolled in the trial, 630 patients with known ENE and margin status were included. Exact patient ages were not made available; 523 (83%) patients were male, and 415 (66%) patients were White. Patients with 1 high-risk feature (positive margins or ENE) had significantly better OS vs 2 high-risk features (hazard ratio [HR], 0.65; 95% CI, 0.49-0.87), although most other results were not statistically significant. For example, in the cohort with ENE-negative disease, multivariable adjusted analysis showed nonsignificant improvements with shorter surgical margin distance (1- to 5-mm margins), and no association with OS was found in the cohort with ENE-positive status (either >5 mm margins or 1-5 mm margins). The association between survival and margin distance varied based on primary site, human papillomavirus (HPV) status, and ENE status. For example, HPV-positive status was associated with a significant and clinically meaningful increase in survival (adjusted HR, 0.33; 95% CI, 0.11-0.97). The improvement was greatest, although not significantly so, in patients with ENE- and HPV-negative oropharynx (OP), hypopharynx (HP), and larynx cancer (HR, 0.57; 95% CI, 0.30-1.10). No survival benefit was seen in ENE-negative oral cavity cancer (HR, 0.89; 95% CI, 0.45-1.77), nor was an association observed between margins and OS in HPV-positive OP cancer. Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, the presence of high-risk features (extranodal extension, positive margins, or both) was associated with worse survival; longer survival was observed with greater surgical margin distance among patients with oral cavity tumors and human papillomavirus-negative tumors of the OP, larynx, or HP. No other significant differences were found. These findings support variable interpretation of surgical margin distance based on the primary site and HPV status. Trial Registration: ClinicalTrials.gov Identifier: NCT00424255.

Tolerability and Efficacy of a 1-Bag Pegaspargase Densensitization Protocol in Pediatric Oncology Patients.

Desensitization to pegaspargase has been previously attempted in patients who have a hypersensitivity reaction to pegaspargase when Erwinia asparaginase is not an available alternative because of supply issues. Often, these desensitizations have utilized a 3-bag method to complete the infusion. Retrospective chart review was utilized to evaluate the tolerability and efficacy of a 1-bag method for pegaspargase densensitization at a single center. Pegaspargase was infused over ∼3 hours with increases to the infusion rate every 15 minutes. Fifteen pediatric patients received a total of 28 pegaspargase infusions utilizing a 1-bag method. In total, 23 of the infusions were able to be successfully completed without signs of hypersensitivity reactions. In addition, 9 of the 15 patients were able to both successfully complete all infusions during the study period and have asparaginase levels within the therapeutic range 7 to 14 days after the infusion. Four of the 5 patients that did experience a hypersensitivity reaction were able to complete the infusion, however, none of these patients had acceptable asparaginase levels postinfusion. No patient required intubation or advanced life support measures secondary to anaphylaxis. Overall, the pegaspargase method described here was successful and well tolerated in a majority of patients.

Perioperative thrombelastography serves as an important assessment tool of transfusion requirements during liver transplantation.

BACKGROUND: Thrombelastography has become increasingly used in liver transplantation. The implications of thrombelastography at various stages of liver transplantation, however, remain poorly understood. Our goal was to examine thrombelastography-based coagulopathy profiles in liver transplantation and determine whether preoperative thrombelastography is predictive of transfusion requirements perioperatively. METHODS: A retrospective review of 364 liver transplantations from January 2013 to May 2017 at a single institution was performed. Patients were categorized as hypocoagulable or nonhypocoagulable based on their preoperative thrombelastography profile. The primary outcome was intraoperative transfusion requirements. RESULTS: Of patients undergoing liver transplantation, 47% (n = 170) were hypocoagulable and 53% (n = 194) were nonhypocoagulable preoperatively. Hypocoagulable patients had higher transfusion requirements compared to nonhypocoagulable patients, requiring more units of packed red blood cells (7 vs 4, P < .01), fresh frozen plasma (14 vs 8, P < .01), cryoprecipitate (2 vs 1, P < .01), platelets (3 vs 2, P < .01), and cell saver (3 vs 2 L, P < .01). Additionally, these patients were more likely to receive platelets and cryoprecipitate in the first 24 hours following liver transplantation (both P < .05). No differences were found between rates of intensive care unit length of stay, 30-day readmission, or mortality. CONCLUSION: Coagulation abnormalities are common among liver transplantation patients and can be identified using thrombelastography. Identification of a patient's coagulation state preoperatively aids in guiding transfusion during liver transplantation. This work serves to better direct clinicians during major surgery to improve perioperative resource utilization. Future prospective work should aim to identify specific thrombelastography values that may predict transfusion requirements.

Pilot Study to Assess the Use of Ultrasound in Evaluating the Abnormal Pediatric Airway.

In this study, we sought to explore the feasibility of using ultrasonography to evaluate airway anomalies in awake children with previous airway reconstruction. For the month of December 2018, we reviewed the medical records of patients aged <18 years old with prior airway reconstruction who had an outpatient appointment and a microlaryngoscopy and bronchoscopy within 24 hours of each other. Four patients met inclusion criteria and were enrolled. Sonographic airway images and measurements were obtained during the outpatient appointment and compared with those obtained during endoscopy. Ultrasound identified extraluminal stents and glottic, subglottic, and tracheal pathology. Subglottic measurements obtained sonographically were within 0.1 to 0.5 mm of the outer diameter of the appropriate endotracheal tubes. Ultrasound did not visualize tracheotomy tubes or posterolateral pathology. Our findings lay the foundation for expanding the role of ultrasound in pediatric airway assessment, keeping in mind its apparent inability to visualize posterolateral airway pathology.

Benefit of social media on patient engagement and satisfaction: Results of a 9-month, qualitative pilot study using Facebook.

BACKGROUND: Despite the potential benefits of social media, health care providers are often hesitant to engage patients through these sites. Our aim was to explore how implementation of social media may affect patient engagement and satisfaction. METHODS: In September 2016 a Facebook support group was created for liver transplant patients to use as a virtual community forum. Data including user demographics and group activity were reviewed. A survey was conducted evaluating users' perceptions regarding participation in the group. RESULTS: Over 9 months, 350 unique users (50% liver transplant patients, 36% caregivers/friends, 14% health care providers) contributed 339 posts, 2,338 comments, and 6,274 reactions to the group; 98% of posts were reacted to or commented on by other group members. Patients were the most active users compared with health care providers and caregivers. A total of 95% of survey respondents reported that joining the group had a positive impact on their care; and 97% reported that their main motivation for joining was to provide or receive support from other patients. CONCLUSION: This pilot study indicates that the integration of social media into clinical practice can empower surgeons to synthesize effectively a patient support community that augments patient engagement and satisfaction.

Transient neonatal myasthenia gravis in a baby born to a mother with new-onset anti-MuSK-mediated myasthenia gravis.

We describe a 30-year-old pregnant woman with undiagnosed weakness who delivered a severely weak neonate. Subsequent workup of the mother revealed myasthenia gravis with muscle-specific kinase antibodies. The infant responded to intravenous immunoglobulin and symptoms normalized. He was presumed to have an anti-muscle-specific kinase-mediated transient neonatal myasthenia gravis.