EFFICACY OF INFLIXIMAB DOSE ESCALATION IN PATIENTS WITH REFRACTORY IMMUNOTHERAPY-RELATED COLITIS: A CASE SERIES

2021 ◽  
Vol 27 (Supplement_1) ◽  
pp. S58-S58
Author(s):  
Jessica Harris ◽  
David Faleck
Keyword(s):  
New York ◽  
Clinical Response ◽  
Dose Escalation ◽  
Fecal Microbiota Transplantation ◽  
Standard Dose ◽  
Care Center ◽  
Tertiary Care ◽  
Case Series ◽  
Fecal Microbiota ◽  
High Dose

Abstract Introduction Immune checkpoint inhibitor (ICI)-related colitis (irColitis) is a frequent complication of ICI use in cancer. Treatment algorithms have been adapted from the treatment of inflammatory bowel disease (IBD), including the use of infliximab (IFX) for patients with irColitis refractory to corticosteroids. The efficacy of IFX dose-escalation in patients not responding to standard dose IFX, a common practice in patients with severe IBD, has not been reported in irColitis. Methods We describe a retrospective study of patients treated with IFX dose escalation (i.e. 10mg/kg dose) after failure of standard dose IFX (5mg/kg) for irColitis at a tertiary care center in New York City between 2016–2020. Clinical response was defined as improvement in diarrhea to CTCAE Grade ≤1. Results Ten patients were treated with high dose IFX for refractory irColitis. High dose IFX was started after a median of 2 (IQR 2-2) doses of standard dose IFX for non-response (n=2) or incomplete response (n=8). Five (50%) patients had a clinical response to high dose IFX after a median of 4 (IQR 3–6) days. Five (50%) patients were refractory to high dose IFX and were treated with Vedolizumab (n= 5) and/or fecal microbiota transplantation (n=2). Patients were followed for a median 457 (IQR 325–567) days from initiation of ICI therapy. No adverse events attributed to IFX were observed in any of the patients. Discussion In this series of patients with irColitis refractory to standard dose IFX, high dose IFX was successful in inducing response in 50% of patients. Prospective studies are needed to further elucidate the role and optimal dosing of IFX in irColitis.

P086 EFFECTIVENESS OF VEDOLIZUMAB IN PATIENTS WITH REFRACTORY IMMUNOTHERAPY-RELATED COLITIS: A CASE SERIES

2020 ◽  
Vol 26 (Supplement_1) ◽  
pp. S73-S73
Author(s):  
Jessica Harris ◽  
David Faleck
Keyword(s):  
Clinical Response ◽  
Fecal Microbiota Transplantation ◽  
Checkpoint Inhibitors ◽  
Tertiary Care ◽  
Case Series ◽  
Fecal Microbiota ◽  
Cancer Center ◽  
Sustained Remission ◽  
Tnf Inhibitor

Abstract Intro Immune checkpoint inhibitors (ICIs) have become a new standard of care in several cancers but often lead to undesirable immune-related adverse effects, including GI toxicity in up to 1/3 of patients. ICI-related colitis (irColitis) is generally treated with immunosuppressive medications such as steroids, but may be refractory in up to 50% of cases and require further treatments such as infliximab. The role of vedolizumab (VDZ), a newer gut-selective agent approved for inflammatory bowel disease (IBD), remains unclear. Methods We describe a retrospective study of all patients treated with VDZ for irColitis at a tertiary care cancer center in New York City between 2018–2019. Clinical response was defined as initial improvement in diarrhea to CTCAE Grade ≤1. Sustained remission was defined as resolution of diarrhea with no further flares within 30 days. Results Eleven patients were treated with VDZ during this time period. Patients were followed for a median of 11.6 months from the time of ICI initiation. Two patients with pre-existing IBD (ulcerative colitis n=1, lymphocytic colitis n=1) with prior severe irColitis were started on VDZ as a steroid-sparing agent (n=1) and prophylaxis during ICI re-challenge (n=1). Both patients’ colitis remained in remission without further flares. Nine patients were treated with VDZ for steroid-refractory irColitis, seven (78%) of whom had already failed at least one TNF inhibitor. VDZ was started a median of 76 (IQR 72–124) days after onset of colitis and patients were treated with a median of 2 (IQR 2–5) doses. The median time to initial clinical response after starting VDZ was 7 (IQR 5–14) days. Six (67%) achieved sustained remission with VDZ after a median of 15 (IQR 5–43) days. Two (22%) of patients were refractory to both infliximab and VDZ therapy and required further salvage with fecal microbiota transplantation and/or surgery. Median total steroid duration was 80 (IQR 52–108) days, and median duration from onset until final resolution of colitis was 126 (IQR 51–133) days. Conclusion In this series of patients with refractory irColitis, VDZ treatment led to successful resolution of colitis in the majority of patients, with sustained remission achieved generally after 1–2 doses. Prospective studies are needed to further elucidate the role of VDZ in the treatment of irColitis. Patient Demographics Immune-Related Colitis Treatment

Can the cognitively impaired safely use patient-controlled analgesia?

2018 ◽  
Vol 5 (5) ◽  
pp. 307 ◽  
Author(s):  
Eugene Licht, MD ◽  
Eugenia L. Siegler, MD ◽  
M. Carrington Reid, MD, PhD
Keyword(s):  
Older Adults ◽  
New York ◽  
Pain Management ◽  
Care Center ◽  
Tertiary Care ◽  
Case Series ◽  
Screening Tools ◽  
Cognitively Impaired ◽  
Patient Controlled Analgesia ◽  
Device Use

Although patient-controlled analgesia (PCA) is considered the standard in postoperative pain control, research examining PCA use among cognitively impaired older adults is lacking. The authors reviewed a case series of 10 adults aged 65 years and older admitted to the geriatrics or orthopedic services of an urban tertiary care center in New York City with acute pain and cognitive impairment or dementia who were administered PCA. Four patients from this cohort are presented in detail, demonstrating the challenges of PCA use in this population. A series of clinical pearls follows each case, outlining strategies for improving pain management. The authors’ findings suggest that cognitive evaluations limited to alertness and orientation and failure to perform functional assessments may hinder the identification of patients who are poor candidates for PCA. Once PCA has been initiated, clinicians must regularly review device use and document cognitive function and pain score patterns to identify PCA underuse or misuse. Finally, rapid fluctuations in cognitive or functional status may require adoption of a more flexible pain management strategy. Despite these challenges, a subset of cognitively impaired older adults can successfully understand and operate PCA devices. Additional research is needed to (1) develop screening tools for identifying and monitoring older adults who may benefit from PCA and (2) create innovative approaches for improving pain management in the cognitively impaired.

Autoimmune Encephalitis in Children: A Case Series at a Tertiary Care Center

2020 ◽  
Vol 35 (9) ◽  
pp. 591-599 ◽  
Author(s):  
Alice Rutatangwa ◽  
Nikita Mittal ◽  
Carla Francisco ◽  
Kendall Nash ◽  
Emmanuelle Waubant
Keyword(s):  
San Francisco ◽  
Care Center ◽  
Tertiary Care ◽  
Case Series ◽  
Autoimmune Encephalitis ◽  
Complete Recovery ◽  
Response To Treatment ◽  
High Dose ◽  
Presenting Symptoms ◽  
Nmdar Encephalitis

Autoimmune encephalitis is the third most common cause of encephalitis in children. We provide a detailed account of presenting symptoms, diagnosis, and response to treatment in pediatric autoimmune encephalitis patients evaluated at University of California San Francisco within a 2.5-year period. Eleven were identified: anti– N-methyl-d-aspartate receptor (NMDAR) encephalitis (n = 4), antibody-negative autoimmune encephalitis (n = 4), steroid-responsive encephalopathy associated with thyroiditis (SREAT) (n = 2), and glial fibrillary acidic protein (GFAP)–associated encephalitis (n = 1). Most common presenting symptoms included seizures and behavior changes (54%). More than 90% of patients showed improvement following first-line immunotherapy (high-dose corticosteroids, intravenous immunoglobulin, and/or plasma exchange). A total of 64% received second-line treatment with rituximab, cyclophosphamide, or mycophenolate mofetil. One patient with NMDAR encephalitis died despite escalating immunotherapy. None of the patients showed complete recovery after median follow-up of 9 months (range 0.5-66). Children with autoimmune encephalitis have a diverse clinical presentation and may lack an identifiable autoantibody. Majority of patients show a good response to immunotherapy; however, recovery can be delayed.

scholarly journals Vitamin C Deficiency in Inflammatory Bowel Disease: The Forgotten Micronutrient

2021 ◽  
Author(s):  
Katie A Dunleavy ◽  
Ryan C Ungaro ◽  
Laura Manning ◽  
Stephanie Gold ◽  
Joshua Novak ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Vitamin C ◽  
Bowel Disease ◽  
Fruits And Vegetables ◽  
Nutritional Assessment ◽  
Care Center ◽  
Tertiary Care ◽  
Case Series ◽  
Vitamin C Deficiency ◽  
Inflammatory Bowel

Abstract Background Micronutrient deficiencies are common in patients with inflammatory bowel disease (IBD). To date, the literature has focused on vitamin D, vitamin B12, and iron deficiencies. Methods We report a case series of 20 patients with IBD and vitamin C deficiency treated at a single tertiary care center. Results Sixteen (80%) patients had symptoms of clinical scurvy, including arthralgia, dry brittle hair, pigmented rash, gingivitis, easy bruising and/or brittle nails. Eighteen patients underwent a nutritional assessment, 10 (56%) patients reported complete avoidance of fruits and vegetables, and 3 (17%) reported reduced intake of fruits and vegetables. Conclusions Vitamin C deficiency should be considered in IBD patients, particularly those with reduced fruit/vegetable intake, as it can lead to significant signs and symptoms.

scholarly journals Response of an Obstetric Unit during the Coronavirus Disease of 2019 (COVID-19) Pandemic: Experiences from a Tertiary Care Center

2020 ◽  
Vol 10 (03) ◽  
pp. e281-e287
Author(s):  
Sangeeta Kumaraswami ◽  
Tana S. Pradhan ◽  
Sorana Vrabie-Wolf ◽  
Sadaf Lodhi ◽  
Geetha P. Rajendran ◽  
...  
Keyword(s):  
New York ◽  
Care Center ◽  
Tertiary Care ◽  
New York State ◽  
York State Department ◽  
Obstetrical Care ◽  
Expert Opinions ◽  
Department Of Health ◽  
Delivery Unit ◽  
Westchester County

Abstract Objective To describe our experiences in preparing our obstetric unit in Westchester County, New York, during the COVID-19 (coronavirus disease of 2019) pandemic. We focus on describing our timeline, continuously evolving actions, observations, and challenges. Methods With guidance from the New York State Department of Health (NYSDOH), our institutional epidemiologist, and key multidisciplinary faculty members, we evaluated emerging national data as well as expert opinions to identify issues and challenges to create action plans. Results We created and modified policies for our patients presenting for obstetrical care on the labor and delivery unit to accommodate their unique needs during this pandemic. Conclusion The COVID-19 pandemic has posed many unique challenges. Balancing communication, risks of infection to providers, patient autonomy and rights, and resources for testing and personal protective equipment were among the valuable lessons learnt. We have shared our experiences and described our observations and challenges in Westchester County, New York.

High-Dose Intravenous Immune Globulin in the Management of Severe Guillain-Barre Syndrome

1992 ◽  
Vol 26 (1) ◽  
pp. 32-33 ◽  
Author(s):  
Miguel Urtasun ◽  
Adolfo López de Murrain ◽  
Nieves Carrera ◽  
José F. Martí-Massó ◽  
Gonzalo López de Dicastillo ◽  
...  
Keyword(s):  
Ad Hoc ◽  
Care Center ◽  
Tertiary Care ◽  
Final Analysis ◽  
Multicenter Trial ◽  
Guillain Barre Syndrome ◽  
High Dose ◽  
The North ◽  
Guillain Barré Syndrome ◽  
Guillain Barré

OBJECTIVE: To evaluate the efficacy of high-dose intravenous gammaglobulin (IGIV) versus plasmapheresis in patients with severe Guillain-Barré syndrome (GBS) and compare the costs of both treatments. DESIGN: Retrospective review of all severely disabled GBS patients admitted between January 1 and December 31, 1990. SETTING: Neurologic unit of a tertiary-care center. PATIENTS: Six patients fulfilling the criteria for the diagnosis of GBS agreed upon by the ad hoc National Institute of Neurological and Communicative Disorders and Stroke committee. INTERVENTION: Four patients treated with plasmapheresis underwent three to six sessions of plasma exchange. Two patients received IGIV 0.4 g/kg/d administered over a five-day period. MAIN OUTCOME MEASURES: Recovery time, functional assessment (performed according to the grading scale used in the North American trial) at 30, 60, and 90 days after treatment. Cost of plasmapheresis, IGIV, and bed/day were compared. RESULTS: Clinical recovery appeared to be faster and more complete in the IGIV group than in the plasmapheresis group. No adverse reactions related to IGIV treatment appeared. The total cost was greater in the plasmapheresis group. CONCLUSIONS: These preliminary results suggest that IGIV may be more beneficial and less expensive than plasmapheresis in treatment of GBS. Definitive conclusions regarding the efficacy of IGIV in GBS will need to await the final analysis of the Ducht randomized multicenter trial comparing IGIV with plasmapheresis.

76 FECAL MICROBIOTA TRANSPLANTATION (FMT) FOR THE TREATMENT OF IMMUNE-MEDIATED DIARRHEA AND COLITIS: A CASE SERIES

2021 ◽  
Vol 160 (6) ◽  
pp. S-17
Author(s):  
Arielle Elkrief ◽  
Jonathan U. Peled ◽  
Matthew D. Hellmann ◽  
Jamie E. Chaft ◽  
Juliana Eng ◽  
...  
Keyword(s):  
Fecal Microbiota Transplantation ◽  
Case Series ◽  
Fecal Microbiota ◽  
Immune Mediated

Potential for Single High-Dose Influenza Immunization in Unprimed Children

PEDIATRICS ◽  
1982 ◽  
Vol 70 (6) ◽  
pp. 982-986 ◽  
Author(s):  
Peter A. Gross ◽  
Gerald V. Quinnan ◽  
Pureza F. Gaerlan ◽  
Carolyn R. Denning ◽  
Anne Davis ◽  
...  
Keyword(s):  
New York ◽  
Influenza A ◽  
Standard Dose ◽  
Geometric Mean ◽  
High Dose ◽  
York Metropolitan Area ◽  
Reaction Index ◽  
Number Of Patients ◽  
Sibling Control ◽  
High Concentrations

High concentrations of split-product vaccine (SPV) are more immunogenic than lower concentrations. These studies were verified with another influenza strain, B/Singapore/22/79. Two ether-treated SPVs were compared in 80 children and young adults. The vaccine strains were influenza A/Bangkok/79, A/Brazil/78, and B/Singapore /79; 44 patients received a high-dose SPV containing 7, 7, and 60 µg each of the respective hemagglutinins (HA) and 36 received a standard dose SPV containing 7, 7, and 7 µg of HA, respectively. Among persons initially seronegative by hemagglutination inhibition (HAI) tests, the geometric mean titer (GMT) in 15 recipients of one high dose was 97 vs GMT of 37 in 18 recipients of one standard dose (P < .05). Furthermore, 87% of high-dose recipients had HAI titer ≥ 40 vs 44% of standard dose recipients. In initially seropositive persons, GMT in 29 recipients of one high dose was 170 vs GMT of 84 in 18 recipients of one standard dose (P < .05). Immune response to the other two virus strains was comparable for the two vaccines. The reaction index for the high dose vaccine was 0.70 vs 0.45 for the standard dose (P = NS). An A/Bangkok epidemic struck the New York metropolitan area. The attack rate in unvaccinated matched sibling control subjects was 35% (15/43). There were no vaccine failures. In conclusion, in the small number of patients studied, a 60-µg HA dose of B/Singapore/79 was significantly more immunogenic than a standard 7-µg HA dose without an increase in reactogenicity.

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