scholarly journals Healthcare Utilization and Costs Associated with Different Treatment Protocols for Newly Diagnosed Childhood Acute Lymphoblastic Leukemia: A Population-Based Study

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 46-47
Author(s):  
Sumit Gupta ◽  
Nicole Mittman ◽  
Petros Pechlivanoglou ◽  
Qing Li ◽  
Uma Athale ◽  
...  
Keyword(s):  
Healthcare Utilization ◽  
Pediatric Cancer ◽  
Lymphoblastic Leukemia ◽  
Population Based ◽  
Newly Diagnosed ◽  
Treatment Protocols ◽  
E Coli ◽  
Outpatient Visits ◽  
Ed Visits ◽  
Healthcare Associated

BACKGROUND: Though cooperative trial groups use different treatment protocols for newly diagnosed childhood acute lymphoblastic leukemia (ALL), all achieve high cure rates. The healthcare utilization and costs associated with different treatment strategies have not been rigorously compared. Minimizing utilization and costs may increase quality of life and decrease health system burden. We compared Children's Oncology Group (COG) and Dana-Farber Cancer Institute (DFCI)-based treatment. METHODS: We identified all children diagnosed with ALL in pediatric cancer centers in Ontario, Canada between 2002 and 2012 through the Pediatric Oncology Group of Ontario Networked Information System (POGONIS), a provincial pediatric cancer registry. Detailed data on demographics, disease risk factors (e.g. cytogenetics, minimal residual disease), treatment (e.g. treatment protocol, start and end date of each therapy phase) and events (relapse/progression, death, second cancer) were captured via chart abstraction. Treatment protocols were categorized as either based on COG or DFCI trials. Linkage to population-based health services databases identified all outpatient and emergency department (ED) visits, hospitalizations, and physician billings. Healthcare utilization-associated costs were determined through validated costing algorithms. Chemotherapy-associated costs were calculated separately using local prices. All administered doses of asparaginase (ASNase), including E. Coli, PEG-ASNase, and Erwinia ASNase were recorded. Event-free survival (EFS), overall survival (OS), healthcare utilization rates, and costs were compared between COG and DFCI-treated patients while adjusting for demographics and disease-factors using appropriate regression models. Healthcare-associated costs, ASNase costs, and total chemotherapy costs (2018 Canadian dollars) were compared. RESULTS: The study cohort included 802 patients, 146 (18.2%) of whom were treated on DFCI-based protocols. Median follow-up did not differ between between COG and DFCI patients; nor did EFS or OS. When adjusted for all demographic and disease-related variables, COG patients experienced significantly higher rates of ED visits [rate ratio (RR) 1.3, 95% confidence interval (95CI) 1.1-1.5; p=0.01]. Neither hospitalization rates nor rates of inpatient days differed between the two groups of patients. However, rates of outpatient visits were 60% higher among DFCI patients (RR 1.6, 95CI 1.5-1.7; p<0.0001). The median healthcare-associated cost in the first 5 years following initial diagnosis was $193,700 among COG patients [interquartile range (IQR) 149,200-272,700] compared to $288,000 among DFCI patients (IQR 233,300-407,300; p<0.01), mainly attributable to the cost associated with outpatient visits. In adjusted analyses, DFCI-associated costs were 70% higher (RR 1.7, 95CI 1.5-1.9; p<0.0001). The median ASNase-related cost was similar between COG and DFCI patients [$21,100, IQR 14,800-35,400 vs. $19,900, IQR 15,600-39,900; p=0.91]. The median total chemotherapy cost was higher among COG patients ($29,100, IQR 20,300-50,300 vs. $22,400, IQR 17,300-42,600; p<0.001]. However, ASNase and total chemotherapy costs were highest in DFCI patients treated with PEG-ASNase instead of E. Coli ASNase (N=36), reflecting contemporary practice. Among such patients, median ASNase-related costs were $45,200 (IQR 7,000-68,500) and median total chemotherapy costs were $48,000 (IQR 11,000-73,400) (p=0.004 and p=0.09 vs. COG patients). CONCLUSIONS: Though COG and DFCI protocols are associated with equivalent EFS and OS, patterns of healthcare utilization differ with the former associated with a 30% increase in the rate of ED visits and the latter associated with a 60% increase in the rate of outpatient visits. Overall, healthcare utilization-associated costs were increased in DFCI-treated patients. Though ASNase costs historically did not differ, the shift to PEG-ASNase is associated with higher ASNase and total chemotherapy costs on DFCI protocols. Decreases in PEG-ASNase cost and the ability to administer intravenous or intramuscular chemotherapy at home would decrease overall healthcare utilization and costs, and mitigate differences between COG and DFCI protocols. These results can inform efforts to decrease burden on both families and health systems. Disclosures No relevant conflicts of interest to declare.

Differences in health care costs and utilization: BR vs RCHOP in patients with follicular lymphoma.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e19049-e19049
Author(s):  
Jifang Zhou ◽  
Ashutosh K. Pathak ◽  
Danielle M. Brander ◽  
Susan Gabriel
Keyword(s):  
Follicular Lymphoma ◽  
Healthcare Utilization ◽  
Healthcare Costs ◽  
Index Date ◽  
Linear Models ◽  
Newly Diagnosed ◽  
First Line ◽  
Non Hodgkin Lymphoma ◽  
Outpatient Visits ◽  
Pharmacy Claims

e19049 Background: Follicular lymphoma (FL) is the most common subtype of indolent non-Hodgkin lymphoma (iNHL) with an incidence of more than 1500 cases annually and comprising 35% of all iNHL cases in North America. Combination chemotherapy with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) or bendamustine plus rituximab (BR) are both category 1–approved first-line therapies. This analysis examined differences in healthcare costs and utilization between two cohorts of newly diagnosed FL patients undergoing BR or RCHOP therapy. Methods: Newly diagnosed FL patients from 1/1/2006 to 7/31/2016 treated with first-line RCHOP or BR were identified in the Truven Health MarketScan Research Databases. Inclusion criteria were age ≥18 years and continuous enrollment from 3 months before to 1 month after the index date (eg, first prescription for RCHOP/BR). Healthcare utilization and costs were calculated on a per month basis from the index date to 6 months post-index date. Costs included all payments made by insurance providers except for pharmacy claims. Healthcare utilization variables included number of outpatient visits, emergency room (ER) visits (yes/no), and hospitalizations (yes/no). Logistic regression and general linear models were used to test for differences. Results: Of the 6460 FL patients (male = 55%; mean age = 60.46 years, SD = 12.56) identified, 2360 were in the BR cohort and 4100 patients were in the RCHOP cohort. At baseline, the BR cohort was significantly older; had more comorbid conditions, lower costs, and fewer outpatient visits; and was less likely to have an ER visit or hospitalization relative to RCHOP patients. Over the first 6 months of therapy, controlling for baseline differences, the BR group experienced significantly lower costs and fewer outpatient visits. The BR cohort was also significantly less likely to be admitted to the ER or experience a hospitalization. Conclusions: The results of this analysis suggest that, in general, the healthcare costs and utilization of FL patients receiving BR is significantly lower than for RCHOP patients. These results support the emerging prominence of BR as an effective and safe first-line treatment option for FL patients.

Differences in Healthcare Utilization in CLL Patients Treated with BR Versus FCR

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2406-2406 ◽  
Author(s):  
Susan Gabriel ◽  
Erika Szabo ◽  
Francesco Lo-Coco ◽  
Jifang Zhou ◽  
Boxiong Tang ◽  
...  
Keyword(s):  
Healthcare Utilization ◽  
Index Date ◽  
Nonparametric Tests ◽  
Lymphocytic Leukemia ◽  
Western World ◽  
Newly Diagnosed ◽  
First Line ◽  
Outpatient Visits ◽  
The Us ◽  
Equity Ownership

Abstract Introduction: Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in the Western world. In the US, there was an estimated 14,620 new cases of CLL and 4650 deaths due to CLL in 2015; the incidence is 4.5 per 100,000 based on 2008-2012 data. CLL is a disease of the elderly; the median age at diagnosis in the US is 71 years, whereas only 11% of patients are younger than 55 years. Median survival ranges from 2 to over 10 years depending on a patient's medical conditions and disease characteristics. Combination chemotherapy with fludarabine, cyclophosphamide, and rituximab (FCR) is the standard of care first-line therapy for CLL without comorbidities. Bendamustine plus rituximab (BR) is recommended in patients not eligible for FCR. The purpose of the current analysis is to examine differences in healthcare utilization between two cohorts of newly diagnosed CLL patients undergoing BR or FCR therapy. Moreover, we analyzed differences between the cohorts across age groups. Methods: Newly diagnosed CLL patients between 1/1/2005-10/31/2015 treated with first-line BR or FCR were identified from the Truven Health MarketScan® Research Databases. Inclusion criteria were: age ≥18 years, continuous enrollment from 6 months prior to 1 month after index date (e.g., first prescription for BR/FCR), and no other CLL prescription prior to the index date. Healthcare utilization variables included number of outpatient visits, emergency room (ER) visits (yes/no), and hospitalizations (yes/no), and were calculated on a per-month basis from the index date through end of available data as well as every 6 months up to 218 months. Nonparametric tests, logistic regression, and general linear models were used to test for differences while controlling for baseline variables. Analysis examined main effects of cohort and age as well as the interaction between the two. Results: Of 1795 CLL patients (male = 68%; mean age = 63.33 years, SD = 10.32) identified, 946 were in the BR cohort and 849 patients were in the FCR cohort. Baseline differences are presented in Table 1. The BR cohort was significantly older, comprised more females, and had more frequent comorbid conditions relative to FCR patients. As shown in Table 2, the BR cohort also experienced significantly fewer outpatient visits over the course of enrollment during the first 6 months of therapy and during months 12-18. The BR cohort was consistently less likely to experience an ER visit or hospitalization than the FCR cohort across all follow-up periods (Table 3). Differences between the cohorts were particularly salient for the FCR patients who were 70 years or older, who experienced, on average, more outpatient visits as well as had a greater likelihood of an ER visit or hospitalization stay. Conclusion: The results of this analysis suggest that, in general, the healthcare utilization of CLL patients that remain on BR is significantly lower than patients who remain on FCR. Patients aged ≥70 receiving FCR experienced significantly more days of hospitalization, outpatient visits, and ER visits than patients of the same age treated with BR. These results support the emerging saliency of BR as an effective and safe treatment option for elderly CLL patients. Disclosures Gabriel: Teva Pharmaceuticals, Inc.: Employment. Szabo:Eli Lilly & Company; Zoetis: Equity Ownership; Patient Centered Outcomes Research (PCORI): Consultancy; Teva Pharmaceuticals, Inc.: Employment. Lo-Coco:Teva, Lundbeck: Honoraria, Speakers Bureau; Teva, Novartis, Baxalta, Pfizer: Consultancy. Tang:Teva Pharmaceuticals, Inc.: Employment. Pathak:Teva Pharmaceuticals: Employment, Equity Ownership.

scholarly journals Associations of Healthcare Utilization and Costs with Increasing Pain and Treatment Intensity Levels in Osteoarthritis Patients: an 18-Year Retrospective Study

2021 ◽  
Author(s):  
Jove Graham ◽  
Tonia Novosat ◽  
Haiyan Sun ◽  
Brian J. Piper ◽  
Joseph A. Boscarino ◽  
...  
Keyword(s):  
Healthcare Utilization ◽  
Complex Disease ◽  
Emergency Department Visits ◽  
Treatment Intensity ◽  
Linear Regression Models ◽  
Rating Score ◽  
Pain Scores ◽  
Outpatient Visits ◽  
Numerical Rating ◽  
Ed Visits

Abstract BackgroundOsteoarthritis (OA) is a complex disease, and prior studies have documented the health and economic burdens of patients with OA compared to those without OA. Our goal was to use two strategies to further stratify OA patients based on both pain and treatment intensity to examine healthcare utilization and costs using electronic records from 2001-2018 at a large integrated health system. Methods Adult patients with ≥1 pain numerical rating score (NRS) and diagnosis of OA were included. Pain episodes of ≥90 days were defined as mild (0-3), moderate (4-6) or severe (7-10) based on initial NRS. Patients were initially classified as mild and moved to moderate-severe OA if any of eight treatment-based criteria were met. Outpatient visits (OP), emergency department visits (ED), inpatient days, and healthcare costs (both all-cause and OA-specific) were compared among pain levels and OA severity levels as frequencies and per-member-per-year rates, using generalized linear regression models adjusting for age, sex and body mass index, with contrasts of p<0.05 considered significant. ResultsWe identified 127,656 patients, 92,576 with pain scores. Moderate and severe pain were associated with significantly higher rates of OA-related utilization and costs, and all-cause ED visits and pharmacy costs. Moderate-severe OA patients had significantly higher OA-related utilization and costs, and all-cause OP, ED and pharmacy costs. ConclusionsPain and treatment intensity were both strongly associated with OA-related resource utilization but not consistently with all-cause utilization. With better understanding of how OA patients intensify services, thus increasing costs, we can deploy targeted preventative strategies aimed at halting progression into more costly phases of the disease.

scholarly journals Newly Diagnosed Acute Lymphoblastic Leukemia in a Child with COVID-19 Complicated By MIS-C: A Case Report from Kuwait

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 24-25
Author(s):  
Fatemah Al-Haddad ◽  
Abdullah Ali ◽  
Danah Al-Sharrah ◽  
Suha Atyani ◽  
Hadeel Saleh ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
Cancer Patients ◽  
Pediatric Cancer ◽  
Lymphoblastic Leukemia ◽  
Hypovolemic Shock ◽  
Cancer Center ◽  
Newly Diagnosed ◽  
Blood Products ◽  
Data Reporting ◽  
Pediatric Cancer Patients

Introduction: Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a major challenge worldwide. Data reporting manifestations of COVID-19 in pediatric cancer patients are limited. This report describes the presentation and initial management challenges of a newly diagnosed child with acute lymphoblastic leukemia (ALL) with positive (+) SARS-CoV-2 complicated by multisystem inflammatory syndrome in children (MIS-C). Case Description: A previously healthy 9-year-old female had (+)SARS-CoV-2 following a 4-day history of fatigability. This was followed by a day of severe gastroenteritis (GE) necessitating a visit to Jaber Al-Ahamed Hospital (JAH), the designated COVID-19 pandemic center. Examination revealed hypovolemic shock, hepatosplenomegaly (HSM) and cervical lymphadenopathy. Patient also had significant pancytopenia and high inflammatory markers (Table).Bone marrow aspiration (BMA) - done 7 days from diagnosis of SARS-CoV-2 - was consistent with B-ALL. Transfer to National Bank of Kuwait Children's Hospital (NBKCH) - the pediatric cancer center - was delayed for 11 days given her (+)SARS-CoV-2, but once tested negative, transfer was complete. Due to logistical issues, lumbar puncture and repeat BM were delayed. She then developed new fever, abdominal pain and vomiting. Her febrile neutropenia (FN) was managed according to local protocol including antifungal therapy for prolonged FN. Five days into her FN, she developed hematemesis and septic shock. In addition to pancytopenia, she also had disseminated intravascular coagulation with further raise in CRP (Table). She also had a new maculopapular rash (Image). Infectious work-up was negative except for (+)SARS-CoV-2 (after 10 days of negativity), fulfilling criteria of MIS-C. Patient was transferred back to JAH according to local pandemic protocol. Induction chemotherapy as perUK-MRC-ALL 2011 regimen Afor standard risk ALL - with modifications given her MIS-C - was started after 22 days (Figure). On day 5 of chemotherapy, patient was clinically stable with negative SARS-CoV-2, therefore transferred back to NBKCH for continuation of leukemia management. Discussion: Although children tend to have a milder course of COVID-19, this case described a fulminant presentation initially with GE, hypovolemic shock and complicated by MIS-C, lacking any respiratory symptoms throughout her course. Until more data reporting manifestations of SARS-CoV-2 in pediatric cancer patients are available, physicians should keep high index of suspicion for leukemia in presence of pancytopenia and HSM in spite of (+)SARS-CoV-2. Prompt diagnosis of ALL is fundamental to avoid delays in treatment and consequent effects on prognosis. Logistical issues such as lack of optimum COVID-19 isolation measures in our cancer center and paucity of blood products have led to delayed initiation of chemotherapy. These cancer-related challenges have been well described. Another interesting aspect of our case is the seroconversion to (+)SARS-CoV-2 after proved negativity. It is possible that protective antibodies were not well developed as she is immunocompromised, making such patients prone to recurrent SARS-CoV-2 infection. The re-emergence of SARS-CoV-2 has led to the diagnosis of MIS-C after fulfilling other criteria. This phenomenon of negative to (+)SARS-CoV-2 seroconversion has been reported in 20-40% of MIS-C cases. Increased risk of venous thromboembolism (VTE) is linked to the hyperinflammatory state of COVID-19. Chemotherapy is also identified as an independent risk factor for VTE in malignancy. To avoid the collateral effects of these factors, modifications of the planned chemotherapy were implemented in our case to minimize the VTE risk. The high steroid dose with chemotherapy was also planned as a treatment for MIS-C, which is consistent with different modalities of MIS-C treatment offered in literature. Conclusion: Children with B-ALL may suffer from fulminant clinical course when diagnosed with COVID-19 and could be prone to recurrent SARS-CoV-2 infection. Our experience highlights the importance of optimizing isolation measures and raising awareness for need of blood products to avoid treatment delay. Further research can aid in forming recommendations to prevent management pitfalls especially with the anticipation of a second wave of this pandemic. Disclosures No relevant conflicts of interest to declare.

scholarly journals Trends in healthcare use in children aged less than 15 years: a population-based cohort study in England from 2007 to 2017

BMJ Open ◽  
2020 ◽  
Vol 10 (5) ◽  
pp. e033761 ◽  
Author(s):  
Judith Ruzangi ◽  
Mitch Blair ◽  
Elizabeth Cecil ◽  
Geva Greenfield ◽  
Alex Bottle ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Hospital Admissions ◽  
Population Based ◽  
Urgent Care ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Emergency Hospital ◽  
Outpatient Visits ◽  
Ed Visits

ObjectiveTo describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade following major primary care reforms from 2007 to 2017DesignPopulation-based retrospective cohort study.MethodsWe used linked data from the Clinical Practice Research Datalink to study children’s primary care consultations and use of hospital care including emergency department (ED) visits, emergency and elective admissions to hospital and outpatient visits to specialists.ResultsBetween 1 April 2007 and 31 March 2017, there were 7 604 024 general practitioner (GP) consultations, 981 684 ED visits, 287 719 emergency hospital admissions, 2 253 533 outpatient visits and 194 034 elective admissions among 1 484 455 children aged less than 15 years. Age-standardised GP consultation rates fell (−1.0%/year) to 1864 per 1000 child-years in 2017 in all age bands except infants rising by 1%/year to 6722 per 1000/child-years in 2017. ED visit rates increased by 1.6%/year to 369 per 1000 child-years in 2017, with steeper rises of 3.9%/year in infants (780 per 1000 child-years in 2017). Emergency hospital admission rates rose steadily by 3%/year to 86 per 1000 child-years and outpatient visit rates rose to 724 per 1000 child-years in 2017.ConclusionsOver the past decade since National Health Service primary care reforms, GP consultation rates have fallen for all children, except for infants. Children’s use of hospital urgent and outpatient care has risen in all ages, especially infants. These changes signify the need for better access and provision of specialist and community-based support for families with young children.

QoL of pediatric-inspired compared to hyper-CVAD regimens for newly diagnosed AYA patients with Ph-ALL: A modeling analysis.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e22002-e22002 ◽  
Author(s):  
Ellen Hooper ◽  
Xingdi Hu ◽  
Peggy L Lin ◽  
Daniel J. DeAngelo
Keyword(s):  
Complete Remission ◽  
Lymphoblastic Leukemia ◽  
Progression Free Survival ◽  
Weibull Function ◽  
Newly Diagnosed ◽  
Health States ◽  
Lifetime Horizon ◽  
Treatment Protocols ◽  
Life Years ◽  
First Complete Remission

e22002 Background: The treatment of acute lymphoblastic leukemia (ALL) requires 2+ years of intensive multi-agent chemotherapy, with significant impact on quality of life (QoL). While treatment protocols exist for adolescent / young adult (AYA) patients, there is limited evidence on the QoL impact for patients treated with pediatric-inspired protocols, which include asparaginase, versus regimens such as Hyper-CVAD. Objective: To compare the QoL impact of pediatric-inspired vs Hyper-CVAD regimens in the 1st-line treatment of AYA patients with Ph- ALL using disease simulation. Methods: A 6-state Markov model was developed to simulate total life-years and quality-adjusted life-years (QALYs) for AYA ALL patients receiving 1st line pediatric-inspired or Hyper-CVAD regimens. Modeled health states were: no first complete remission (no treatment/non-response to 1st line), first complete remission, first relapse, second complete remission, second relapse, and death. Model inputs for CR, EFS, OS, AEs, and health utility were obtained from literature. Weibull function was fitted to extrapolate survival and QALY over time. Results: Compared with Hyper-CVAD, the pediatric-inspired protocol resulted in increased life-years and QALYs at years 5, 10 and through a lifetime horizon. Benefits were mainly driven by more favorable progression-free survival and OS of patients in pediatric-inspired protocols compared to hyper-CVAD. Conclusions: This disease simulation model suggests that pediatric-inspired protocols for newly diagnosed AYA patients with Ph- ALL may increase QoL, as measured by QALYs, compared to Hyper-CVAD. Future long-term follow-up studies are needed to confirm these findings. [Table: see text]

Cerebrospinal Fluid Asparagine Concentrations After Escherichia coli Asparaginase in Children With Acute Lymphoblastic Leukemia

1999 ◽  
Vol 17 (5) ◽  
pp. 1568-1568 ◽  
Author(s):  
Michael H. Woo ◽  
Lawrence J. Hak ◽  
Michael C. Storm ◽  
Amar J. Gajjar ◽  
John T. Sandlund ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Cerebrospinal Fluid ◽  
Acute Lymphoblastic Leukemia ◽  
Induction Chemotherapy ◽  
Time Course ◽  
Lymphoblastic Leukemia ◽  
Childhood Acute Lymphoblastic Leukemia ◽  
Newly Diagnosed ◽  
E Coli

PURPOSE: The CNS is an important sanctuary site in childhood acute lymphoblastic leukemia (ALL). CSF asparagine concentration reflects asparaginase systemic pharmacodynamics. We evaluated the time course of CSF asparagine depletion in children with ALL during and after a course of Escherichia coli asparaginase. PATIENTS AND METHODS: Thirty-one children (24 newly diagnosed and seven at relapse) received E coli asparaginase 10,000 IU/m2 intramuscularly three times weekly for six and nine doses, respectively, as part of multiagent induction chemotherapy. CSF asparagine levels were measured before, during, and after asparaginase dosing. RESULTS: The percentage of patients with undetectable (< 0.04 μmol/L) CSF asparagine was 3.2% (one of 31 patients) at baseline, 73.9% (17 of 23) during asparaginase therapy, and 56.3% (nine of 16) 1 to 5 days, 43.8% (seven of 16) 6 to 10 days, 20.0% (two of 10) 11 to 30 days and 0% (zero of 21) more than 30 days after asparaginase therapy. The proportion of patients with depleted CSF asparagine was higher during asparaginase therapy than at baseline (P < .001), 11 to 30 days (P = .003), and more than 30 days after asparaginase therapy (P < .001). Median CSF asparagine concentrations were 4.42 μmol/L before, less than 0.04 μmol/L during, and less than 0.04 μmol/L at 1 to 5 days, 1.63 μmol/L at 6 to 10 days, 1.70 μmol/L at 11 to 30 days, and 5.70 μmol/L at more than 30 days after asparaginase therapy, respectively. CSF depletion was more common in patients with low baseline CSF asparagine concentrations (P = .003). CONCLUSION: CSF asparagine concentrations are depleted by conventional doses of E coli asparaginase in the majority of patients, but they rebound once asparaginase therapy is completed.

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