Abu-Sayeef Mirza

A Phase II Study of CLAG Regimen Combined With Imatinib Mesylate for Relapsed or Refractory Acute Myeloid Leukemia

Micro‐Abstract Given the lack of standard salvage chemotherapy regimen for relapsed or refractory (RR) acute myeloid leukemia (AML), a phase 2 clinical study of cladribine, cytarabine, G‐CSF (CLAG) regimen in combination with imatinib mesylate (IM) in patients with RR‐AML was conducted at the Moffitt Cancer Center. Between August 2009 and April 2011, 38 patients were treated and the overall response rate was 37% with a median overall survival of 11.1 month. Among responders, 8/14 patients proceeded to allogeneic hematopoietic cell transplant. Overall, CLAG plus IM was well tolerated, with encouraging signs of activity in patients with poor‐risk AML. Introduction: No standard salvage chemotherapy regimen is available for relapsed or refractory (RR) acute myeloid leukemia (AML). Preclinical data have suggested synergy in vitro between cytarabine and imatinib mesylate (IM) on AML cell growth inhibition. After demonstrating the safety and feasibility in a phase I study, we conducted a phase II clinical study of CLAG (cladribine, cytarabine, granulocyte colony‐stimulating factor) regimen combined with IM for patients with RR‐AML. Patients and Methods: We performed a single‐institution 2‐stage phase II study. The primary endpoint was the remission rate measured using the standard AML response criteria. The secondary endpoints included overall survival (OS) and progression‐free survival (PFS). Results: From August 2009 to April 2011, 38 patients were treated at the Moffitt Cancer Center. Their median age was 62 years (range, 26‐79 years). Of the 38 patients, 7 (18%) had refractory AML, 19 (50%) had early relapse, and 12 (32%) had late relapse. At the original diagnosis, only 2 patients had favorable risk factors, 18 had intermediate risk, and 16 had poor risk; for 2 patients, the karyotype was missing. The overall response rate for all 38 evaluable patients was 37%. The median OS was 11.1 months (95% CI, 4.8‐13.4 months), the median PFS was 4.9 months (95% CI, 1.6‐11.7 months). Among the responders, 8 of 14 patients subsequently underwent allogeneic hematopoietic cell transplantation. Conclusion: CLAG plus IM was well tolerated, with encouraging signs of activity in patients with poor‐risk AML.

Burden of Chronic Conditions among Patients from Free Clinics: A Retrospective Chart Review of 2015

Abstract:Introduction. There is limited research about the poor and uninsured patients who visit free clinics. Methods. We conducted a retrospective chart review of uninsured adult patients in four free clinics seen between January and December 2015. Prevalence of chronic conditions and their association with socioeconomic factors were investigated. Results. In 2015, 3,196 adult patients with chronic conditions were managed in four free clinics. Many of these patients were women (60.8%) and Hispanic (44.7%); the group had a mean age of 47.9 years (SD=14.1) and a median income of

Chronic Disease Burden of the Homeless: A Descriptive Study of Student-Run Free Clinics in Tampa, Florida

14,400. The top five prevalent conditions were hypertension (33.6%), hyperlipidemia (20.7%), diabetes (14%), major depression (11.7%), and arthritis (8.7%). In the multivariable analysis, clinic site, age, marital status, employment status, and household size were significantly associated with the Disease Burden Index. Discussion. Public health prevention programs should focus on uninsured patients of free clinics who are mainly low-income, sicker, and unemployed, and often women and Hispanics.

Corrigendum to ’Cave Diving for a Diagnosis: Disseminated Histoplasmosis in the Immunocompromised’ [IDCases 12 (2018) 92–94]

Variation between homeless populations due to socioeconomic and environmental factors necessitates tailoring medical, health policy, and public health interventions to the unique needs of the homeless population served. Despite the relatively large size of the homeless population in Florida, there is a paucity of research that characterizes the homeless population who frequent homeless clinics within the state. This project describes the demographics, disease prevalence, and other risk factors among homeless individuals in Tampa, Florida. We conducted a retrospective chart review on adult homeless patients seen in 2015 and 2016 at two free clinic sites operated by Tampa Bay Street Medicine, a medical student-run organization from the University of South Florida in Tampa, Florida. Rates of diseases and substance use were recorded and Charlson Comorbidity Index (CCI) was calculated to assess mortality risk. Of the 183 homeless patients in this study, 34.4% reported hypertension, 13.7% reported diabetes, 27.1% reported a respiratory disease, 5.6% reported hyperlipidemia, and 32.8% reported a psychiatric disorder. Tobacco use was reported by 65.6% of patients, 32.2% reported alcohol use, and 17.5% reported illicit drug use. CCI was positively associated with age. Females reported higher rates of anemia, anxiety, chronic obstructive pulmonary disease, and psychiatric disorders. Hypertension, diabetes, certain respiratory diseases, and mental health disorders were more prevalent in the homeless population than in the general population in Tampa, Florida. Homeless women appeared to have higher morbidity than homeless men. Rates of tobacco and illicit drug use were significantly higher whereas alcohol use was lower in the study population than the general population. This study underscores the critical need for mental health initiatives, substance abuse treatment programs, and women’s health programs that are accessible to the homeless in Tampa.

Cave diving for a diagnosis: Disseminated histoplasmosis in the immunocompromised

[This corrects the article DOI: 10.1016/j.idcr.2018.03.020.].

Transformation of T-Cell Acute Lymphoblastic Lymphoma to Peripheral T-Cell Lymphoma: A Report of Two Cases

Highlights • Tumor necrosis factor (TNF) inhibitors are associated with risks of invasive infections.• Disseminated histoplasmosis can be easily mistaken for a pneumonia.• Confounding comorbidities and travel-associated risk factors may delay diagnoses.• Liposomal amphotericin b, may or may not have altered the course of this patient’s illness.

Thrombotic Microangiopathy With Granulomatosis Interstitial Nephritis in an Allogenic Bone Marrow Transplant Patient: A Case Report and Review of the Literature

Nonhepatosplenic/noncutaneous γδ peripheral T-cell lymphoma (NHNCγδ PTCL) represents a miscellaneous group of unrelated T-cell lymphomas of which only isolated cases have been reported. We describe two cases of transformation from T-lymphoblastic leukemia/lymphoma to NHNCγδ PTCL. Transformation into more aggressive disease is a rare event in T-cell lineage-derived hematologic malignancies compared to B-cell neoplasms. Nevertheless, both of our cases involved relapse as PTCL manifested with skin involvement and an overt shift from blastic morphology to large granular leukemia-like mature T cells. Among other notable molecular characteristics, expression of immature markers such as TdT was lost in both cases. Based on cytogenetics, phenotype, and morphology, both patients represent a novel phenomenon of clonal transformation from T-ALL to PTCL which has rarely been reported in the literature. Such transformation may carry important diagnostic and biological implications.

A single-institution study of renal outcomes in patients receiving checkpoint inhibitors.

Transplant-associated thrombotic microangiopathy (TA-TMA) is a rare complication of hematopoietic stem cell transplantation (HSCT) with variable presentations. TA-TMA has often been described as a diagnosis of exclusion but a renal biopsy is rarely pursued to confirm the diagnosis, an essential step for our patient with renally limited TMA. We report a case report from the onconephrology clinic and review the literature associated with TA-TMA as it relates to diagnosis and treatment. A 45-year-old woman with acute myeloid leukemia and stage 3 chronic kidney disease underwent a matched unrelated donor allogenic HSCT. Postoperatively, she developed gastrointestinal graft versus host disease (GvHD) and was treated with tacrolimus, sirolimus, budesonide, and beclomethasone. Following discharge, she developed uncontrolled hypertension and required losartan, amlodipine, carvedilol, clonidine patch, and hydralazine as needed. On day 180 post-transplant, she developed lower extremity edema and acute kidney injury (AKI) with creatinine increasing to 2 mg/dL. On day 480 post-transplant, she developed worsening thrombocytopenia, anemia, new hematuria, left flank pain, and worsening renal function with creatinine peaking to 6 mg/dL. Peripheral smear revealed no schistocytes, lactate dehydrogenase of 265 mg/dL, and urinalysis with 100 mg/dL protein. ADAMTS 13 activity was normal (92%) and no inhibitor was detected. She became anuric and was started on hemodialysis. Renal biopsy revealed glomerular changes consistent with TA-TMA. During HSCT, systemic vascular endothelial injury triggers microangiopathic hemolytic anemia, platelet consumption, injury of glomerular endothelial cells and fibrin occluded renal capillaries. Thus, TA-TMA should be considered in HSCT patients with elevated LDH, proteinuria, hypertension, and AKI. However, a diagnosis is difficult to confirm without a renal biopsy. Treatment involves discontinuing potentially toxic agents such as calcineurin inhibitors and sirolimus, prescribing adequate antimicrobial treatment, and using renal replacement therapy if needed. A renal biopsy early in the course of disease not only confirms the diagnosis, but may limit the extent of disease.