Search

Background Racial/ethnic disparities in the utilization of hematopoietic cell transplantation (HCT) have been reported for patients with hematologic malignancies, but population‐based data are lacking for lymphoma patients. The objective of this study was to determine whether racial and ethnic disparities exist in the utilization of autologous HCT for lymphoma in the United States. Method We used Surveillance, Epidemiology, and End Results data linked to Medicare fee‐for‐service claims. We included Medicare beneficiaries aged 66+ years with Hodgkin or Non‐Hodgkin lymphomas diagnosed between 2008 and 2015. The primary outcome was time‐to‐autologous HCT. We used Cox proportional hazards models to estimate racial/ethnic differences in utilization. Missing data were handled using multiple imputation with chained equations. Results We included 40,605 individuals with lymphoma. A total of 452 autologous transplants were performed. In the unadjusted model, Non‐Hispanic Black patients were 51% less likely to receive a transplant than Non‐Hispanic White patients (95% CI, 0.26–0.96; p = 0.04). After adjusting for age at diagnosis and sex, Non‐Hispanic Black patients were 61% less likely to receive a transplant (95% CI, 0.20–0.76; p = 0.01). However, observed differences attenuated and became non‐significant after adjustment for socioeconomic factors (adjusted hazard ratio [aHR], 0.62; 95% CI, 0.32–1.21; p = 0.16) and disease‐specific factors (aHR, 0.58; 95% CI, 0.30–1.12; p = 0.11), separately. In the fully adjusted model, we also did not observe a statistically significant association between Non‐Hispanic Black race/ethnicity and receipt of transplant (aHR, 0.54; 95% CI, 0.28–1.05; p = 0.07). Conclusion In this population‐based cohort study of lymphoma patients, Non‐Hispanic Black patients were less likely to receive autologous HCT compared to Non‐Hispanic White patients, but this difference was partially explained by socioeconomic and disease‐specific factors., Non‐Hispanic Black patients diagnosed with lymphoma between 2008 and 2015 were 51% less likely to receive an autologous transplant compared to Non‐Hispanic White patients. This difference was partially explained by socioeconomic and disease‐specific factors.

The Coronavirus disease 2019 (COVID-19) pandemic forced not only rapid changes in how clinical care and educational programs are delivered but also challenged academic medical centers (AMCs) like never before. The pandemic made clear the need to have coordinated action based on shared data and shared resources to meet the needs of patients, learners, and communities. Family medicine departments across the country have been key partners in AMCs' responses. The Duke Department of Family Medicine and Community Health (FMCH) was involved in many aspects of Duke University's and Health System's responses, including leadership contributions in delivering employee health and student health services. The pandemic also surfaced the biological and social interactions that reveal underlying socioeconomic inequalities, for which family medicine has advocated since its inception. Key to success was the department's ability to integrate "horizontally" with the broader community, thereby accelerating the institution's response to the pandemic.

There is a paucity of data regarding racial disparities in the survival of patients with indolent non-Hodgkin lymphomas (iNHL) in the contemporary time-period. Hence, we sought to determine whether racial disparities exist in the survival of patients with iNHLs in the US. We included 68,059 adult patients with follicular lymphoma (FL, n=41,943), marginal zone lymphoma (MZL, n=22,485), and lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia (LPL/WM, n=3,631) who were diagnosed in the US between 2000-2017. Race was categorized as White, Black, Asian/Pacific Islander, or American Indian/Alaska Native (API/AI). The primary outcome was relative survival (RS), which was estimated using flexible parametric survival models. RS estimates varied according to race and disease histology but were consistently lower for racial minorities, including those diagnosed during the most recent 5-year time-period of 2012-2017. On multivariable analysis for RS, Black patients with FL had a 32% higher excess mortality rate compared to White patients [adjusted excess hazard ratio (aEHR), 1.32; 95% CI, 1.15-1.51; P

Patients with classic Hodgkin lymphoma (cHL) who relapse after autologous hematopoietic cell transplantation (auto-HCT) historically have had poor outcomes. We hypothesized that, post-auto-HCT relapse, overall survival (PR-OS) has improved in recent years as a result of more widespread use of novel therapies and allogeneic HCT (allo-HCT). We conducted a retrospective study in 4 US academic centers, evaluating 215 patients who underwent auto-HCT from 2005 to 2016 and relapsed thereafter. Patients were divided into 2 cohorts based on timing of auto-HCT, 2005 through 2010 (cohort 1; n = 118) and 2011 to 2016 (cohort 2; n = 97), to compare differences in clinical outcomes. The median age and disease status at auto-HCT were similar in cohorts 1 and 2. The proportions of patients who received brentuximab vedotin (Bv; 55% vs 69%; P = .07), checkpoint inhibitors (CPIs; 3% vs 36%; P ≤ .001), and allogeneic-HCT (22% vs 35%, P = .03) were significantly different between cohorts 1 and 2, respectively. At the 5-year follow-up after auto relapse, 32% and 50% of patients were alive in cohorts 1 and 2, respectively (P = .01). In multivariate analysis for PR-OS, cohort 1 vs 2 (hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.14-4.60; P = .01), age at auto-HCT (HR, 1.48; 95% CI, 1.18-1.87; P ≤ .001), and time to relapse from auto-HCT (HR, 0.59; 95% CI, 0.47-74; P ≤ .0001), retained independent prognostic significance for PR-OS. Our study supports the hypothesis that survival of cHL patients after auto-HCT failure has significantly improved in recent years, most likely because of incorporation of novel therapies and more widespread use of allo-HCT.

Outcomes for diffuse large B-cell lymphoma (DLBCL) patients relapsing after autologous hematopoietic cell transplantation (auto-HCT) have been historically poor. We studied outcomes of such patients using data from 4 transplantation centers. Eligibility criteria included adult patients (age ≥18 years) with DLBCL experiencing disease relapse after auto-HCT performed during 2006 to 2015. The time period was stratified into 2 eras (era 1, 2006-2010; era 2, 2011-2015). The primary end point was postrelapse overall survival (PR-OS). Secondary end points were factors prognostic of PR-OS. Of the 700 patients with DLBCL who underwent auto-HCT, 248 (35%) relapsed after auto-HCT. Median PR-OS of all relapsed DLBCL patients after auto-HCT (n = 228) was 9.8 months (95% confidence interval [CI], 7-15). Median PR-OS was significantly better for patients in complete (17.8 months; 95% CI, 7.9-41.6) vs partial remission at auto-HCT (7.1 months; 95% CI, 5.4-11; P = .01), those undergoing auto-HCT >1 year (12.8 months; 95% CI, 7.6-24.9) vs ≤1 year after DLBCL diagnosis (6.3 months; 95% CI, 4.5-9.2; P = .01), and those with late (56.4 months; 95% CI, 23.7-∞) vs early relapse (5.9 months; 95% CI, 4.5-8.8; P < .0001). On multivariate analysis, although late relapse (hazard ratio [HR], 0.21; 95% CI, 0.13-0.34; P < .0001) was associated with significantly lower mortality, the risk of mortality increased with age (HR, 1.25 per decade; 95% CI, 1.06-1.48; P = .009). This is the largest study to date to evaluate outcomes of DLBCL patients relapsing after auto-HCT. Our study provides benchmarking for future trials of chimeric antigen receptor T cells and other promising agents evaluating PR-OS after auto-HCT.

On university campuses and in similar congregate environments, surveillance testing of asymptomatic persons is a critical strategy (1,2) for preventing transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). All students at Duke University, a private research university in Durham, North Carolina, signed the Duke Compact (3), agreeing to observe mandatory masking, social distancing, and participation in entry and surveillance testing. The university implemented a five-to-one pooled testing program for SARS-CoV-2 using a quantitative, in-house, laboratory-developed, real-time reverse transcription-polymerase chain reaction (RT-PCR) test (4,5). Pooling of specimens to enable large-scale testing while minimizing use of reagents was pioneered during the human immunodeficiency virus pandemic (6). A similar methodology was adapted for Duke University's asymptomatic testing program. The baseline SARS-CoV-2 testing plan was to distribute tests geospatially and temporally across on- and off-campus student populations. By September 20, 2020, asymptomatic testing was scaled up to testing targets, which include testing for residential undergraduates twice weekly, off-campus undergraduates one to two times per week, and graduate students approximately once weekly. In addition, in response to newly identified positive test results, testing was focused in locations or within cohorts where data suggested an increased risk for transmission. Scale-up over 4 weeks entailed redeploying staff members to prepare 15 campus testing sites for specimen collection, developing information management tools, and repurposing laboratory automation to establish an asymptomatic surveillance system. During August 2-October 11, 68,913 specimens from 10,265 graduate and undergraduate students were tested. Eighty-four specimens were positive for SARS-CoV-2, and 51% were among persons with no symptoms. Testing as a result of contact tracing identified 27.4% of infections. A combination of risk-reduction strategies and frequent surveillance testing likely contributed to a prolonged period of low transmission on campus. These findings highlight the importance of combined testing and contact tracing strategies beyond symptomatic testing, in association with other preventive measures. Pooled testing balances resource availability with supply-chain disruptions, high throughput with high sensitivity, and rapid turnaround with an acceptable workload.

PURPOSESARS-CoV-2 (COVID-19) is a systemic infection. Patients with cancer are immunocompromised and may be vulnerable to COVID-related morbidity and mortality. The objectives of this study were to determine if patients with cancer have worse outcomes compared with patients without cancer and to identify demographic and clinical predictors of morbidity and mortality among patients with cancer.METHODSWe used data from adult patients who tested positive for COVID-19 and were admitted to two New York–Presbyterian hospitals between March 3 and May 15, 2020. Patients with cancer were matched 1:4 to controls without cancer in terms of age, sex, and number of comorbidities. Using Kaplan-Meier curves and the log-rank test, we compared morbidity (intensive care unit admission and intubation) and mortality outcomes between patients with cancer and controls. Among those with cancer, we identified demographic and clinical predictors of worse outcomes using Cox proportional hazard models.RESULTSWe included 585 patients who were COVID-19 positive, of whom 117 had active malignancy, defined as those receiving cancer-directed therapy or under active surveillance within 6 months of admission. Presenting symptoms and in-hospital complications were similar between the cancer and noncancer groups. Nearly one half of patients with cancer were receiving therapy, and 45% of patients received cytotoxic or immunosuppressive treatment within 90 days of admission. There were no statistically significant differences in morbidity or mortality ( P = .894) between patients with and without cancer.CONCLUSIONWe observed that patients with COVID-19 and cancer had similar outcomes compared with matched patients without cancer. This finding suggests that a diagnosis of active cancer alone and recent anticancer therapy do not predict worse COVID-19 outcomes and therefore, recommendations to limit cancer-directed therapy must be considered carefully in relation to cancer-specific outcomes and death.

Increasing evidence suggests that asymptomatic carriers are an important source of healthcare-associated Clostridium difficile infection. However, it is not known which test for the detection of C. difficile colonization is most sensitive in patients with haematological malignancies. We performed a prospective cohort study of 101 patients with haematological malignancies who had been admitted to the hospital for scheduled chemotherapy or haematopoietic cell transplantation. Each patient provided a formed stool sample. We compared the performance of five different commercially available assays, using toxigenic culture as the reference method. The prevalence of toxigenic C. difficile colonization as determined by toxigenic culture was 14/101 (14 %). The Cepheid Xpert PCR C. difficile/Epi was the most sensitive test for the detection of toxigenic C. difficile colonization, with 93 % sensitivity and 99 % negative predictive value. Our findings suggest that the Xpert PCR C. difficile/Epi could be used to rule out toxigenic C. difficile colonization in this population.

A series of synthetic F,Cl apatites with low hydroxyl content was investigated using 31P, 19F, and 35Cl solid-state magic angle spinning (MAS) NMR spectroscopic methods. 31P single-pulse (SP) NMR spectra show that for each composition the phosphate 31P chemical shift depends on occupancy of the nearest anion site for each composition. Overall the average chemical shift deviates from linear across the F/Cl series. For intermediate compositions 19F SP NMR spectra reveal complex, broadened spectral profiles that are not correlated to composition. 19F{35Cl} TRAPDOR results indicate that the spectral profiles do not reflect occupancy of F and Cl in adjacent column anion sites. We propose that the complex 19F lineshapes are principally due to broad distributions of 19F–Ca distances arising from displacement of F along the anion channel. Approximate fluorine atomic positions are estimated based on 19F chemical shifts of alkaline earth fluoride salts, and the results are in good accord with those proposed for int...

Histiocytic sarcoma is a rare histiocytic neoplasm of unknown etiology that constitutes less than 1% of hematologic malignancies. A few cases of histiocytic sarcoma harboring the BRAF V600E mutation have been reported, but this finding has not been confirmed in all studies. We report the case of a 63-year-old white woman with a history of splenic marginal zone lymphoma who presented with 2 weeks of right-sided neck swelling. Positron emission tomography revealed an intensely hypermetabolic and destructive soft tissue mass in her right skull base. A bone marrow biopsy was performed, which revealed an infiltrate of malignant cells characterized as large pleomorphic cells with frequent folded/irregular nuclei, variably prominent nucleoli, fine chromatin, and abundant amounts of eosinophilic cytoplasm. The malignant cells were positive for CD163, CD68 (granular), lysozyme (granular), CD4, and CD45 (partial). Based on the biopsy findings, she was diagnosed as having histiocytic sarcoma. The malignant cells tested positive for the BRAFV600E protein using immunohistochemistry. Before treatment of her histiocytic sarcoma could be initiated, she developed disseminated intravascular coagulation and acute hypoxemic respiratory failure secondary to non-cardiogenic pulmonary edema. She decided to pursue comfort care and died in our hospital 2 weeks following admission. Our case illustrates the aggressive nature of histiocytic sarcoma, and provides rare evidence that histiocytic sarcoma associated with indolent lymphomas may harbor the BRAF V600E mutation. Further research is needed to clarify the role of targeted therapies such as vemurafenib in the treatment of patients with this disorder.

Background Population‐based studies previously showed an improvement in overall survival (OS) for patients with diffuse large B‐cell lymphoma (DLBCL) who received chemoimmunotherapy with rituximab. However, there is limited data (especially at the population level) that show a similar trend in OS improvement, in the most recent time period. We hypothesized that survival for DLBCL patients diagnosed in the United States has continued to improve in recent years and intended to measure outcome improvements. Methods Using the SEER‐18 registries, we compared the incidence and relative survival rates (RSRs) of DLBCL patients between 2002‐2007 and 2008‐2013 (availability of novel agents, broader use of autologous hematopoietic cell transplantation and improvement in supportive care). Multivariable Cox regression models were used to assess associations between the year of diagnosis and OS while controlling for age, gender, stage, and ethnicity. Results There were a total of 53 439 patients with DLBCL who were diagnosed between 2002 and 2013. Of these, 25 810 were diagnosed during time period‐1 and 27 629 diagnosed during time period‐2. There was a slight decline in incidence of DLBCL (time period‐1 vs time period‐2), 7.75 (95% CI = 7.66‐7.84) vs 7.43 (95% CI = 7.34‐7.52) cases per 100 000 persons, respectively (P, There is a paucity of data at the population level on the overall survival trend in DLBCL patients in the contemporaneous time period. We show that although there has been a continuous improvement in the outcomes of DLBCL patients over the past decade, the magnitude of improvement is small, reflecting the modest progress made beyond rituximab in the treatment of DLBCL.

The reversible methanolysis of an azomethine C[double bond, length as m-dash]N in a series of copper(ii) Schiff base complexes has been investigated through combined spectroscopic, structural, and kinetic studies. Pentadentate copper(ii) complexes [L1-Cu(X)]Y (L1 = 1,2-bis[(1-methyl-2-imidazolyl)methyleneamino]ethane; X = Y = ClO4- (1); X = Y = TfO- (2); X = Y = BF4- (3); X = H2O, Y = (ClO4-)2 (4) spontaneously add methanol in a ligand centered reaction to yield stable, isolable hemiaminal ether product complexes 5-8. In methanol free solution, 5-8 spontaneously release alcohol to regenerate 1-4. The methanol addition reaction is first-order in methanol and first-order in complex with second-order rate constants varying from 1.1 × 10-4 to 187 × 10-4 M-1 s-1 dependent on the donor ability of the axial ligand. Rate constants for methanol elimination vary from 0.67 to 3.7 × 10-4 s-1 with dependence on the counterion and water content of the solvent. Equilibrium constants for methanolysis range from 1.5 to 51 M-1. Structural comparisons of the Schiff base complexes 1-4 and the hemiaminal ether complexes 5-8 suggest methanol addition is favored by the release of ligand strain associated with three planar five-membered chelates in 1-4.

Acute leukemia is a family of clonal hematopoietic disorders characterized by genetic and epigenetic alterations leading to a block in differentiation and accumulation of leukemic blasts in blood a...

Introduction: Splenic marginal zone lymphoma (SMZL) is an indolent B-cell non-Hodgkin lymphoma that usually presents in elderly patients with splenomegaly, lymphocytosis, and cytopenias (either due to hypersplenism or autoimmune phenomena). Treatment of SMZL has advanced over the past decade including identification of better tolerable chemotherapy regimens (such as rituximab and bendamustine) and the advent of novel agents (such as ibrutinib and lenalidomide). We sought to determine whether advances in treatment and supportive care over the past decade have translated to decreased lymphoma-specific mortality among patients with SMZL. Method: We used the population-based Surveillance, Epidemiology, and End Results (SEER)-18 database. We included adult patients with SMZL diagnosed between 2000-2017 who were 18-84 years old at the time of diagnosis. We excluded patients with a history of malignancy prior to SMZL, those with missing survival times and those with central nervous system involvement. Patients were divided into two cohorts based on period of diagnosis (era-1: 2000-2008, and era-2: 2009-2017). Five-year relative survival (RS) was estimated using the Pohar-Perme method. Differences between RS distributions was tested with a log-rank-type test. The risk of SMZL-specific death was estimated by calculating the cumulative incidence function (CIF). The difference between CIF distributions was tested with the Pepe-Mori test. The competing risks of SMZL-specific death and death from other causes were modeled using Fine and Gray regression. All tests of differences were performed at a two-sided alpha of 0.05. Results: We included 1,548 patients with SMZL. Table 1 shows the baseline characteristics. The median age at diagnosis was 66 years (IQR = 57-74) years. Most patients were non-Hispanic White (81%) with advanced stage at diagnosis (stage III-IV, 70%). Five-year RS was 84% (95% CI = 80-87%) during era-1 and 89% (95% CI = 85-92%) during era-2 (p = 0.21. The CIF distributions for SMZL-specific death and death from other causes are shown in Figure 1A and Figure 1B, respectively (Pepe-Mori p = 0.02). In our multivariable competing risks model, the period of diagnosis, age, and stage at diagnosis were significant predictors of SMZL-specific death (Table 2). Patients in era-2 had significantly lower risk of SMZL-specific death [subhazard ratio (SHR) = 0.30, 95% CI = 0.22-0.41), while the cumulative incidence of mortality significantly increased with age (SHR = 1.39 per decade, 95% CI = 1.24-1.56) and advanced stage (SHR = 1.55, 95% CI= 1.04-2.13). Conclusion: There has been a significant reduction in the risk of SMZL-specific death for patients with SMZL in the most recent era possibly due to advances in therapy. This reduction in mortality persists even after accounting for competing risks of mortality from other causes. Disclosures Olszewski: Spectrum Pharmaceuticals: Research Funding; Adaptive Biotechnologies: Research Funding; TG Therapeutics: Research Funding; Genentech, Inc.: Research Funding. Epperla:Verastem Oncology: Speakers Bureau; Pharmacyclics: Honoraria.

Introduction: Racial and ethnic disparities have been described for patients with aggressive non-Hodgkin lymphomas (NHLs), but few studies have investigated racial disparities in patients with indolent NHLs. Indolent NHLs are a large group of lymphoid neoplasms that include follicular lymphoma (FL), marginal zone lymphoma (MZL), mantle cell lymphoma (MCL), and Waldenstrom macroglobulinemia (WM). Differences in biologic factors (e.g., metabolism of drugs), health disparities (e.g., enrollment in clinical trials), individual factors (e.g., comorbid conditions), and structural barriers (e.g., access to novel therapies) may lead to racial and ethnic disparities in these patients. We aimed to determine whether racial and ethnic disparities exist in the survival of patients with indolent NHLs in the United States. Method: We used the population-based Surveillance, Epidemiology, and End Results (SEER)-18 database. We included adult patients with FL, MZL, MCL, and WM diagnosed between 2000-2017 who were 18-84 years old at the time of diagnosis. We excluded patients with a history of prior malignancies, missing survival times, central nervous system involvement, and unknown race/ethnicity. Race/ethnicity were categorized as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native. Marginal relative survival (RS) was estimated using the Pohar-Perme method, which estimates net survival within a relative survival framework. Expected survival was determined by matching patients to individuals in the general population by age, sex, race/ethnicity, and year. RS was modeled using Poisson regression where the effect of follow-up time was included as restricted cubic spline with 5 knots. The primary exposure variable in our model was race/ethnicity. Interactions between the main effect and significant covariates were examined (in particular disease histology). All tests of differences were performed at a two-sided alpha of 0.05. Results: There were a total of 63,855 patients included in our study. Among these patients, 35,466 had FL, 18,188 had MZL, 7,005 had MCL, and 3,196 had WM. Table 1 shows the baseline characteristics stratified based on the race/ethnicity. The median age for all patients was 63 years (IQR = 54-72 years). The majority of patients were NHW (75%). Median length of follow-up was 5.4 years (IQR = 2.2-9.7 years). As shown in Figure 1, RS (unadjusted) for patients with indolent NHL varied according to race and ethnicity. American Indians/Alaska Natives had the lowest survival at 10 years. Estimated 10-year RS (95% CI) was 78% (77-79%) for NHW, 76% (73-79%) for NHB, 79% (77-81%) for Hispanics, 79% (76-81%) for Asians/Pacific Islanders, and 69% (59-76%) for American Indians/Alaska Natives. On multivariable Poisson regression after adjusting for differences in age, sex, stage, median household income, and disease histology, racial/ethnic minorities had significantly increased hazard for excess mortality (NHB=1.37, Hispanic=1.14, Asians/Pacific Islanders=1.20, American Indians/Alaska Natives=1.75) compared to NHW patients (Table 2). There was no significant interaction between race and disease histology (likelihood ratio test p=0.21). Conclusion: In this large population-based analysis of patients with indolent NHL in the US, we found that racial and ethnic minorities had inferior survival over the past two decades after adjusting for other confounding variables. American Indians and Alaska Natives had the highest mortality followed by NHB, Asians/Pacific Islanders, and Hispanics. One of the plausible explanations for this trend could be related to decreased access to healthcare. Our study emphasizes the need for additional research into racial/ethnic disparities for lymphoma patients. Disclosures Epperla: Verastem Oncology: Speakers Bureau; Pharmacyclics: Honoraria.

Introduction: Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (EMZL) is the most common subtype of MZL. EMZL can affect multiple organs throughout the body, and the management depends on the primary site of involvement and extent of disease. The most common primary site is the stomach, but other sites can be involved including the breasts, eyes, lungs, salivary glands, and skin. The last population-based survival analysis of EZML included follow-up through 2009 (Olszewski and Castillo, 2013). Given the paucity of population-based analyses of EMZL in the contemporary time-period, we sought to provide an updated analysis of disease-specific mortality and site-associated mortality using the Surveillance, Epidemiology, and End Results (SEER)-18 database. Method: We included adult patients with EMZL diagnosed between 2000-2017 who were 18-84 years old at the time of diagnosis. We excluded patients with a history of malignancy prior to EMZL, those with missing survival times and those with central nervous system involvement. Patients were divided into two cohorts based on period of diagnosis (era-1: 2000-2008, and era-2: 2009-2017). Five-year relative survival (RS) was estimated using the Pohar-Perme method. The risk of EMZL-specific death was estimated by calculating the cumulative incidence function (CIF). The difference between CIF distributions was tested with the Pepe-Mori test. The competing risks of EMZL-specific death and death from other causes were modeled using Fine and Gray regression. All tests of differences were performed at a two-sided alpha of 0.05. Results: We included a total of 11,597 patients with EMZL. Table 1 shows the baseline characteristics. Among the entire cohort, the median age at diagnosis was 63 years (IQR = 53-72). There was a slight female predominance (55%), and most patients were Non-Hispanic White (65%). Five-year RS was 95% (95% CI = 94-96%) during era-1 and 96% (95-97%) during era-2. There was a significant reduction in the cumulative incidence of EMZL-specific death between era-1 and era-2 (p < 0.001, Figure 1A) but not death from other causes (p = 0.35, Figure 1B). The cumulative incidence of EMZL-specific death varied according to EMZL subtype (Figure 2). In our multivariable competing risks model after adjusting for confounders (Table 2), EZMLs arising from the genitourinary (GU) tract had the worst prognosis [subhazard ratio (SHR) = 2.06, 95% CI=1.30-3.27, p=0.002], whereas EZMLs arising from the skin and connective tissue had the best prognosis [SHR = 0.66, 95% CI = 0.48 - 0.91, p = 0.01]. Conclusion: In this updated population-based analysis of EZML that includes patients treated in the contemporaneous time-period, we found that patients diagnosed with EZML in the most recent era had a significantly better prognosis. Additionally, we noted that the outcomes varied depending on primary site of involvement. Patients with EZMLs involving the GU tract had the worst prognosis, whereas patients with primary sites in the skin and connective tissue had the best prognosis. It is important to study the biology of EMZL involving the GU tract to design better therapeutic options to improve the outcomes. Disclosures Epperla: Pharmacyclics: Honoraria; Verastem Oncology: Speakers Bureau.

Introduction Racial disparities have been documented in hematopoietic cell transplantation (HCT), a complex and expensive therapeutic modality for hematologic malignancies. Prior work suggests that racial minorities in the US have lower rates of utilization of HCT compared to White patients. However, the available literature on racial disparities in HCT is limited, particularly with regard to lymphoma patients. Objectives The objective of this study was to determine if racial differences exist in utilization of HCT for lymphoma by comparing transplant activity to disease incidence rates between 2013-2016. Methods This was a retrospective cohort study using publicly available data from the Center for International Blood and Marrow Transplant Research; Surveillance, Epidemiology, End Results program; and US Census Bureau. All patients in the US who underwent HCT for Hodgkin lymphoma (HL) and Non-Hodgkin lymphoma (NHL) between 2013-2016 were included. Patients with unknown race or multiple races were excluded. We assessed transplant utilization by calculating the transplant utilization rate (TUR) for each disease, separately. Rates were operationalized as the number of transplants performed per 100 new cases of the disease diagnosed in the US during the same time period. Results There were a total of 18,569 transplants for HL and NHL included. Table 1 shows patient characteristics by transplant type. During the same time period, age-adjusted incidence rates [95% confidence interval (CI)] for HL for Whites, Blacks, Asians/Pacific Islanders (API), and American Indians/Alaska Natives (AI) were 2.65 (2.59-2.71), 2.61 (2.46-2.77), 1.24 (1.14-1.36), and 1.00 (0.73-1.34) cases/100,000 persons at risk, respectively. Incidence rates were higher for NHL for the same racial groups at 20.22 (20.05-20.38), 14.44 (14.06-14.82), 13.53 (13.16-13.90), and 8.75 (7.82-9.75), respectively. Transplant and incidence data were consistent from 2013-2016. There were no significant differences in TURs for HL between racial groups. However, Whites with NHL had a higher TUR than Blacks [7.02 (95% CI 6.90-7.13) vs 4.75 (95% CI 4.49-5.02), p Conclusion Autologous HCT for NHL is underutilized for Black patients compared to White patients in the US. Additional research is needed to understand the reasons for this difference.

Only a minority of patients with high risk lymphoma will be cured with autologous transplant, so maintenance with vorinostat, an oral agent with activity in relapsed lymphoma, was studied starting day + 60 for 21 consecutive days followed by a week off for up to 11 cycles. Twenty-three patients with lymphoma were treated. Ten patients completed the full 11-cycle treatment plan per protocol, four patients were removed due to progressive disease and seven withdrew or were removed from the study due to toxicities. Despite Prevnar vaccine administration every 2 months for three injections, the mean antibody concentration never reached protective levels (0.35 μg/mL). Fatigue and functional well-being measured by Brief Fatigue Inventory and Functional Assessment of Cancer Therapy-General improved significantly from cycle 1 to cycle 7, but depression scores from the Center for Epidemiologic Studies Depression scale did not change. Given the toxicities observed, this broad-spectrum deacetylase inhibitor at this schedule is not optimal for prolonged maintenance therapy.

Introduction: The majority of patients with classical Hodgkin lymphoma (cHL) will be cured with anthracycline-containing chemotherapy regimens. However, 10-20% of patients with early-stage disease and 30-40% of patients with advanced-stage cHL will relapse. The standard treatment for patients with relapsed cHL is salvage chemoimmunotherapy followed by high-dose chemotherapy (HDT) and autologous hematopoietic cell transplantation (auto-HCT) in chemotherapy-sensitive patients. Patients with primary treatment failure (PTF), i.e. patients who have progressive disease while on therapy or who fail to achieve complete remission (CR) at the end of initial therapy, or experience early relapse after CR1 are expected to have a worse prognosis than patients with late relapse. Since 2011 newer treatments, namely Brentuximab vedotin and PD1/PDL1 blockers have been introduced for the treatment of relapsed and refractory cHL. It is unknown whether changes in disease monitoring and management, including the availability of new agents, impacted survival of patients with cHL and PTF. Methods: Fifteen US academic medical centers contributed cases to the ECLIPSE study (Evaluation of Classical Hodgkin Lymphoma patients wIth Primary treatment failure and analySis of outcomEs). ECLIPSE retrospectively captured patient, disease and treatment characteristics and treatment response as assessed by treating physicians. Eligible patients were ≥ 15 years diagnosed with cHL on or after 2005, who received treatment with curative intent with anthracycline-containing chemotherapy regimens, and developed one of the 3 patterns of PTF: detection of progressive disease during or within 6 weeks of completion of chemotherapy (PP cohort, primary progression), partial response (PR) or stable disease (SD) by functional imaging at completion of chemotherapy (PR/SD cohort), or disease progression detected within 12 months of completion of chemotherapy after prior documentation of CR (ER cohort, early relapse). Patients were divided into two "eras" based on year of diagnosis, 2005-2010 (era1) and 2011-2018 (era2), with the latter expected to reflect changes in salvage therapy for cHL. Results: Patient characteristics for the 553 cases are summarized in Table. Median follow up of survivors was 58.7 and 31.2 months for patients diagnosed in era1 and era2, respectively. ABVD was the upfront treatment for 97.6% of cases. Nearly all patients (98.5%) received salvage therapy after PTF and 60.9% underwent auto-HCT. Patients who relapsed or progressed post auto-HCT received a median of 1 (range 0 to 3) salvage regimens. Five-year overall survival (OS) from time of PTF was 70.3% (95% CI=63.4-77.2%) for patients diagnosed in era1, and 77.6% (95% CI=70.3-84.8%, p = 0.018) for patients diagnosed in era2 (Figure A). While there was no difference in OS among the PP, PR/SD and ER cohorts in the era1 (Figure B), the PR/SD and ER cohorts had better OS than PP cohort in era2 (Figure C). On comparing the OS for each of the 3 cohorts between era1 and era2, there was an improvement in OS in the PR/SD (Figure E) and ER cohorts (Figure F) but no improvement among the PP cohort (D). Multivariable analysis of patients in era 2 identified only age (HR 1.05, 95% CI=1.03-1.07, P Conclusions: Though there has been an improvement in survival among cHL cases with PTF treated in the most recent years, the outcome of patients with PP did not change significantly across eras. Patients with PP disease should be prioritized for clinical trials incorporating newer agents and innovative cellular therapy to current available effective treatments. Disclosures Epperla: Pharmacyclics: Honoraria; Verastem Oncology: Speakers Bureau. Costa:Abbvie: Consultancy; Karyopharm: Consultancy; Fujimoto Pharmaceutical Corporation Japan: Other: Advisor; Sanofi: Consultancy, Honoraria, Speakers Bureau; GSK: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Janssen: Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding. Cashen:Novartis: Other: Speaker's Bureau; Seattle Genetics: Other: Speaker's Bureau; Celgene: Other: Speaker's Bureau. Hamadani:Otsuka: Research Funding; Takeda: Research Funding; Pharmacyclics: Consultancy; ADC Therapeutics: Consultancy, Research Funding; Merck: Research Funding; Sanofi Genzyme: Research Funding, Speakers Bureau; Celgene: Consultancy; Janssen: Consultancy; Medimmune: Consultancy, Research Funding. Barta:Mundipharma: Honoraria; Celgene: Research Funding; Takeda: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Honoraria, Research Funding; Bayer: Consultancy, Research Funding; Mundipharma: Honoraria; Merck: Research Funding; Celgene: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees. Reddy:Celgene: Consultancy; BMS: Consultancy, Research Funding; Genentech: Research Funding; Abbvie: Consultancy; KITE Pharma: Consultancy. Karmali:Gilead/Kite; Juno/Celgene: Consultancy, Speakers Bureau; Takeda, BMS: Other: Research Funding to Institution; Astrazeneca: Speakers Bureau. Bello:Celgene: Speakers Bureau. Chavez:Novartis: Membership on an entity's Board of Directors or advisory committees; Kite: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bayer: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Genentech: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Svoboda:AstraZeneca: Consultancy; Celgene: Research Funding; Incyte: Research Funding; Pharmacyclics: Consultancy, Research Funding; Kyowa: Consultancy; Merck: Research Funding; BMS: Consultancy, Research Funding; Seattle Genetics: Consultancy, Research Funding. Glenn:BMS: Research Funding; Merck: Research Funding; Genentech: Research Funding. Cohen:Lymphoma Research Foundation: Research Funding; Seattle Genetics, Inc.: Consultancy, Research Funding; ASH: Research Funding; Takeda Pharmaceuticals North America, Inc.: Research Funding; Gilead/Kite: Consultancy; Bristol-Meyers Squibb Company: Research Funding; Genentech, Inc.: Consultancy, Research Funding; Janssen Pharmaceuticals: Consultancy; LAM Therapeutics: Research Funding; UNUM: Research Funding; Hutchison: Research Funding; Astra Zeneca: Research Funding.

Introduction The outcomes for DLBCL patients who relapse following auto-HCT have been historically poor. Using data from four transplant centers, we studied the outcomes of DLBCL patients who relapsed following auto-HCT and evaluated whether survival improved in the most recent time period with the advent of novel agents. Methods Eligibility criteria included adult (≥18 years) patients with DLBCL experiencing disease relapse following auto-HCT performed during 2006-2015. The time-period was stratified into two eras (era-1: 2006-2010 and era-2: 2011-2015). The primary endpoint was to determine post-relapse overall survival (PR-OS). Secondary endpoints included a comparison of PR-OS based on the timing of relapse post auto-HCT (early [≤1 year] vs late [>1 year]) and era of transplant (era-1 vs era-2). PR-OS was measured from the date of relapse following auto-HCT to date of death or last follow-up. Results Of the total 700 patients with DLBCL undergoing auto-HCT, 250 patients (36%) (n=113 from era-1 and n=137 from era-2) relapsed following auto-HCT between 2006 and 2015. Patient characteristics are shown in Table with a breakdown between the two eras. The median age was 59 years with male predominance. 92% were chemosensitive (n=230) at the time of auto-HCT. The median time to relapse post auto-HCT was 5.6 months (range: 0.8–96.6 months). Median lines of therapy for post auto-HCT relapse were 1 (range: 0-9), with the most common treatments being allogeneic HCT (21%), lenalidomide (18%) and on clinical trials (17%). Median follow-up of survivors post auto-HCT relapse was 39 months (range: 1-116 months). At 5-year post auto-HCT relapse, the PR-OS for the entire population was 25%, with a median PR-OS of 8.5 months (95% CI=6.3-11.5). Median PR-OS (in months) was significantly better for patients who had late relapse vs early relapse (56.4 [95% CI=23.7-∞] vs 5.5 [95% CI=4.1-7.2], respectively, p Conclusion In DLBCL patients who relapse following auto-HCT, there has been no significant improvement in PR-OS despite the advent of novel agents in the most recent era. More importantly, the outcomes are dismal for patients who relapse within 1 year of auto-HCT representing an urgent unmet need.

The reversible methanolysis of an azomethine C[double bond, length as m-dash]N in a series of copper(ii) Schiff base complexes has been investigated through combined spectroscopic, structural, and kinetic studies. Pentadentate copper(ii) complexes [L

Background Classical Hodgkin Lymphoma (cHL) is a highly curable disease; however, 10% of patients (pts) with limited stage and 20%-30% with advanced stage disease still fail first line-treatment. Autologous hemopoietic cell transplantation (auto-HCT) is the standard of care in pts who fail to achieve remission with first-line therapy, or who relapse after induction chemotherapy. However, approximately 50% of cHL pts will ultimately relapse post auto-HCT. These pts historically have had poor outcomes, with median survival in the 1.5 year range. In recent years, highly active new therapies such as brentuximab vedotin (BV), checkpoints inhibitors (i.e. nivolumab and pembrolizumab), and increased accessibility to allogeneic HCT (including utilization of haploidentical donors) have become more widely available. We hypothesized that, in recent years, survival has improved in cHL patients who relapse after auto-HCT since the introduction of these novel therapies into more widespread clinical practice. Methods We conducted a multi-center retrospective study from 3 academic institutions in the U.S. (Medical College of Wisconsin, Ohio State University, and Washington University in St. Louis) to evaluate survival of cHL pts after the failure of an auto-HCT. We reviewed 341 pts who received auto-HCT from 2006-2015. Among them, 126 (37%) pts relapsed post auto-HCT and were evaluated in more detail. For the purpose of analysis, pts were divided into 2 cohorts based on timing of auto-HCT; 2006-2010 (Cohort 1, n=57) and 2011-2015 (Cohort 2, n=69) to compare outcomes. Results The median age at auto-HCT, time from diagnosis to transplant, time from transplant to relapse were similar in Cohort 1 & 2 (see Table 1). The proportion of pts who achieved complete remission (CR) at the time of auto-HCT were 22.8% in Cohort 1 and 40.6% in Cohort 2. Whereas, 68.4% of pts in Cohort 1 and 52.2% of pts in Cohort 2 had partial remission (PR) at the time of auto-HCT. The median number of lines of therapy after relapse from auto-HCT were 2 each in Cohort 1 (range, 0-13) and Cohort 2 (range, 0-7), respectively (p= 0.74). Twenty-five (45%) pts in Cohort 1 and 49 (73%) pts in Cohort 2 received BV as a salvage therapy post auto-HCT (p= 0.002). Similarly, 3 (5.5%) pts in Cohort 1 versus (vs.) 21 (32%) pts in Cohort 2 received check point inhibitors as salvage therapy post auto-HCT relapse (p= Conclusion Our analysis supports that survival of cHL pts post auto-HCT failure has significantly improved in recent years (2011-2015), most likely due to incorporation of novel therapies including BV, checkpoint inhibitors, and more widespread use of allogeneic HCT. Disclosures Shah: Miltenyi: Other: Travel funding, Research Funding; Juno Pharmaceuticals: Honoraria; Exelexis: Equity Ownership; Oncosec: Equity Ownership; Geron: Equity Ownership; Lentigen Technology: Research Funding. Hamadani:Celgene Corporation: Consultancy; Janssen: Consultancy; MedImmune: Consultancy, Research Funding; ADC Therapeutics: Research Funding; Takeda: Research Funding; Cellerant: Consultancy; Ostuka: Research Funding; Sanofi Genzyme: Research Funding, Speakers Bureau; Merck: Research Funding.

Background: Haploidentical hematopoietic cell transplantation (haplo-HCT) is an advancing and potentially curative therapy for patients with hematologic malignancies when the availability of HLA-matched donors are limited. The common source for haplo-HCT is donor bone marrow, but peripheral blood (PB) haplo-HCT is an emerging and less invasive option with similar survival outcomes. However, multiple series showed an increased incidence of culture negative fever early after haplo-HCT, which has been attributed to cytokine release syndrome (CRS) and more commonly observed with PB haplo-HCT. In this study, we investigated the incidence and impact of CRS on clinical outcomes and financial toxicity in PB haplo-HCT patients treated at a single center. Methods: A total of 40 patients who underwent PB haplo-HCT in the Ohio State University between Jan 2015 - Dec 2017 were included. CRS was defined and graded based on the criteria proposed by Lee, et al (Blood, 2014). Symptoms occurring before day +14 were included, patients with a documented infection (e.g. positive culture data) and clinical suspicion of sepsis were excluded. Overall survival (OS) was defined as the time from transplantation until death. Transplant-related mortality (TRM) was defined as death before day +28 from any cause and patients who died after day +28 with no evidence of disease. Results:. The median age at HCT was 53 years (range, 19 to 74), 63% were male. The most common diagnosis was acute myeloid leukemia (47.5%), followed by lymphoma (22.5%), acute lymphoblastic leukemia (7.5%) and myelodysplastic syndrome (7.5%). Two patients had undergone previous autologous HCT. At the time of haplo-HCT, 62% of patients were in complete remission, 38% had relapsed/refractory disease. Donor was the child in 58%, sibling in 24% and parent in 18% with an antigen match ratio of 5/10 in 50%, 6/10 in 30%, 7/10 in 12.5%, 8/10 in 7.5%. Mismatch for sex and ABO blood group were seen in 50% and 45%, respectively. Twenty percent of patients received myeloablative conditioning with fludarabine/busulfan/thiotepa, while 80% received reduced-intensity regimen with fludarabine/cyclophosphamide/total body irradiation. The incidence of CRS was 85%, including grade 1-2 CRS in 77.5% and grade 3-4 CRS in 7.5%. Time to the onset of CRS was Conclusions: CRS is commonly observed after PB haplo-HCT and usually manifests with fever within 48 hours of cell infusion. We observed favorable survival outcomes in patients who experienced mild CRS, which may suggest an association between mild CRS and graft-versus-leukemia effect. A minority of patients developed severe CRS requiring intensive care unit support, which was associated with poor OS, high TRM, prolonged hospital stay and increased financial toxicity. Further studies investigating biomarkers that can predict the development of severe CRS might enable the incorporation of CRS prophylaxis (e.g. with tocilizumab) into standard conditioning regimens for PB haplo-HCT. Disclosures Vasu: Boehringer Ingelheim Inc: Membership on an entity's Board of Directors or advisory committees. Mims:Novartis: Consultancy; Abbvie Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Agios Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees. Devine:Kiadis Pharma: Consultancy. Jaglowski:Novartis Pharmaceuticals Corporation: Consultancy, Research Funding; Kite Pharma: Consultancy, Research Funding; Juno: Consultancy.

This paper briefly describes the structure of the national higher education association community, discusses the role of coalitions in collective advocacy, and reviews collaborations between the Association of American Universities (AAU) and the Association of Research Libraries (ARL) carried out during the tenure of ARL Executive Director Duane Webster. The AAU/ARL collaborations benefitted both associations and their members and were part of a larger set of partnerships and collaborations developed by Duane that expanded the reach and impact of ARL in both national and institutional policy development and implementation.

Purpose Heavy episodic (i.e., "binge") drinking (i.e., ≥five drinks/occasion) is highly prevalent among young adults; those who binge do so four times per month on average, consuming nine drinks on average on each occasion. Although it is well established that chronic heavy drinking (≥two alcoholic beverages per day) increases the risk of hypertension, the relationship between binge drinking and blood pressure is not well described. Our aim was to describe the relationship between frequency of binge drinking, both current (at age 24 years) and past (at age 20 years), and systolic blood pressure (SBP) at age 24 years. Methods Participants (n = 756) from the longitudinal Nicotine Dependence in Teens study reported alcohol consumption at ages 20 and 24 years and had SBP measured at age 24 years. We examined the association between binge drinking and SBP using multiple linear regression, controlling for sex, race/ethnicity, education, monthly drinking in high school, cigarette smoking, and body mass index. Results Compared to nonbinge drinkers, SBP at age 24 years was 2.61 [.41, 4.82] mm Hg higher among current monthly bingers and 4.03 [1.35, 6.70] mm Hg higher among current weekly bingers. SBP at age 24 years was 2.90 [.54, 5.25] mm Hg higher among monthly bingers at age 20 years and 3.64 [.93, 6.35] mm Hg higher among weekly bingers at age 20 years, compared to nonbinge drinkers. Conclusions Frequent binge drinking at ages 20 and 24 years is associated with higher SBP at age 24 years and may be implicated in the development of hypertension.

Phenomenon: Medical students commonly participate in patient care in a variety of different settings. However, a systematic review of patients' attitudes toward medical student participation across specialties has not been performed.The authors searched 7 databases (CINAHL, Cochrane Library, ERIC, MEDLINE, PsycINFO, Scopus, and Web of Science) between January 1, 1999, and August 5, 2014. Two authors independently screened the results and selected articles that were written in English, were published in a peer-reviewed journal, and used a structured or semistructured survey or interview to determine patients' attitudes toward medical student participation in their care. Study quality was assessed using the Medical Education Research Study Quality Instrument.Fifty-nine studies were included. Average study quality was low. Sixty-one unique evaluation instruments were used, and 34 instruments (56%) lacked validity data. Patient satisfaction was not significantly affected by medical student participation. However, patients' acceptance of medical student participation varied widely between studies and depended on the type of participation. The most common reason for acceptance was a desire to contribute to the education of others, and the most common reason for refusal was concerns about privacy. Minorities were more likely to refuse medical student participation. Patients preferred to be informed before medical students participated in their care. Insights: Patient satisfaction is not significantly affected by medical student participation. However, patient satisfaction may be a poor surrogate marker of patients' acceptance of medical students. Future research should employ validated evaluation instruments to further explore patients' attitudes toward medical student participation.

Sulindac is a long-acting nonsteroidal anti-inflammatory drug (NSAID) widely used for the management of osteoarthritis, rheumatoid arthritis, ankylosing sponydlitis, and acute gouty arthritis. Reports of sulindac toxicity in the literature are rare. We report the case of a 22-year old male with a history of bipolar disorder who was brought to the emergency department after ingesting approximately 15 g of sulindac in a suicide attempt. He was found to have acute kidney injury and hyperbilirubinemia. Despite aggressive fluid resuscitation, his renal function progressively worsened requiring the initiation of hemodialysis. Ten days following ingestion of sulindac, he began to develop ischemic skin changes with a gangrenous appearance in his hands and feet. He continued to receive supportive treatment, and his acute kidney injury, hyperbillirubinemia, and ischemic skin necrosis eventually resolved. Clinicians should be aware of this long-acting NSAID and its ability to cause prolonged multisystem organ dysfunction.

Background: The Quick Sepsis-related Organ Failure Assessment (qSOFA) was recently introduced with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) as a way to quickly identify patients at risk of suffering adverse outcomes from infection. qSOFA is a bedside scoring tool that assigns one point each for altered mentation, respiratory rate of 22/min or greater, and systolic blood pressure of 100 mmHg or less. Scores of 2 or greater are associated with increased rates of ICU admission and in-hospital mortality. Although it has been validated in general emergency department and hospital ward patients, its performance in cancer patients remains unknown. The aim of this study was to evaluate the performance of qSOFA in predicting adverse outcomes in patients with acute leukemia receiving induction chemotherapy. Methods: We reviewed the electronic health records of all patients with acute leukemia who were admitted for induction chemotherapy between October of 2011 and December of 2015 at our institution. Clinical variables included demographic information, type of leukemia, type of chemotherapy, vital signs, and assessment of mental status by the Richmond Agitation-Sedation Scale. The primary endpoints were shock and in-hospital mortality. The qSOFA score was calculated for each patient for each day of their hospitalization using the worst physiologic parameters for each day. The maximum score for each patient from 48 hours prior to the development of clinical infection to 24 hours post development was then included in subsequent analysis. Clinical infection was defined as a positive culture from any source, and shock was defined as a vasopressor requirement to maintain a mean arterial pressure of ≥ 65 mmHg. Results: 572 patients with acute leukemia were admitted for induction chemotherapy between October of 2011 and December of 2015. Three hundred ninety patients (68%) had acute myeloid leukemia, 114 (20%) had acute lymphoblastic leukemia, 55 (10%) had acute promyelocytic leukemia, and 13 (2%) had mixed phenotypes. Among those patients admitted for induction chemotherapy, 212 (42%) developed clinical infection during their hospitalization. Further analysis revealed that 32 (15%) clinically infected patients developed shock and 14 (7%) died in the hospital. Using the existing cut-off score of 2, sensitivity was 88% (95% Confidence Interval [CI]: [71%, 97%]) and specificity was 64% (95% CI: [57%, 71%]) for detecting shock. For mortality, sensitivity was 79% (95% CI: [49%, 95%]) and specificity was 59% (95% CI: [52%, 66%]). Considering scores continuously, the area under the receiver operating characteristic curve for shock was 0.84 (95% CI: [0.77, 0.91]) and was 0.76 (95% CI: [0.63, 0.88]) for mortality. Conclusion: qSOFA is a bedside scoring tool that may help clinicians predict adverse outcomes in acute leukemia patients receiving induction chemotherapy who are suspected of having infection. However, it is limited by relatively low specificity in this subset of patients, which may be due the confounding effect that intensive chemotherapy has on vital signs and mental status. Future studies should focus on developing scoring systems with less false positives in this population. Disclosures Walker: Gilead Sciences: Research Funding.

There are few events as shocking and scary as a mass murder. The volatility of such an event makes us ponder, what could we do to reduce the chances of it happening again? According to the FBI, mas...

On July 8, 2004, the Garrett Lee Smith Memorial Act was introduced to the 108th Congress of the United States by Senator Christopher Dodd (D-CT). The bill amended the Public Health Service Act to, ...

Vaccine-preventable diseases contribute significantly to the morbidity and mortality of U.S. adults. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention updates its recommended adult immunization schedule annually. The most recent updates include the permissive but not routine use of the quadrivalent human papillomavirus vaccine to prevent genital warts in males; a single dose of herpes zoster vaccine for adults 60 years and older, regardless of their history; replacing a single dose of tetanus and diphtheria toxoids (Td) vaccine with tetanus, diphtheria, and acellular pertussis (Tdap) vaccine in adults 19 years and older who have not previously received Tdap; expanding the indications for pneumococcal polyvalent-23 vaccine to include all adults with asthma and all smokers; annual seasonal influenza vaccination for all adults; and booster doses of meningococcal vaccine for adults with high-risk conditions. It is vital for family physicians to implement a systematic approach to adult immunization that is patient-, staff-, and physician-focused.

The authors describe 2 cases of Chiari type I malformation (CM-I) in students presenting to a college health center within a 6-month period. A review of CM-I, including epidemiology, typical presentation, evaluation, and management, is followed by a discussion of the clinical and functional implications of the disorder in an emerging adult population.