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Introduction Citrobacter bacteria are gram-negative anaerobic bacilli commonly found in water, soil, food, and the intestinal tracts of animals and humans. Patients at highest risk of these nosocomial infections include neonates and adults who are ≥65 years of age, debilitated, or immunocompromised. Citrobacter braakii ( C. braakii), specifically, has been reported to cause sepsis in immunocompromised patients. Herein, we describe a case of an allogeneic stem cell transplant (SCT) adult patient with C. braakii bloodstream infection. Case Report We report our experience managing a central line-associated bloodstream infection (CLABSI) due to C. braakii in an allogeneic SCT patient. Management and Outcomes: Our patient was initially managed with cefepime. The central venous catheter (CVC) was removed. Blood cultures cleared 24 hours after antibiotic initiation. Therapy was transitioned to oral levofloxacin once susceptibilities resulted. Discussion The course of this patient highlights the important relationship between an unusual pathogen, C. braakii, in an immunocompromised allogeneic SCT patient. In our case, the source of the bacteremia was most likely a CLABSI given the positive catheter tip cultures. Although this report describes the successful utilization of cefepime and levofloxacin in the treatment of C. braakii infection, caution should be exercised when choosing empiric antimicrobial therapy as AmpC resistance. This clinical scenario can aid health care providers in making informed treatment decisions when faced with patients diagnosed with this relatively uncommon pathogen. Further reports should be published to determine C. braakii bacteremia management in hematopoietic stem cell transplant patients.

Introduction Gilteritinib is a multitargeted tyrosine kinase inhibitor (TKI) approved by the Food and Drug Administration (FDA) for acute myeloid leukemia (AML) with a FMS-related tyrosine kinase 3 (FLT3) mutation. The pharmacokinetics of gilteritinib in the setting of severe renal impairment (creatinine clearance [CrCl] 15-29 mL/min utilizing Cockcroft-Gault method) and end-stage renal disease are unknown. Gilteritinib is primarily metabolized by the liver through the CYP3A4 enzyme and is eliminated in both the feces and urine. Its excretion is primarily through the fecal route, accounting for 64.5% of the recovered dose. Only about 16.4% of the recovered dose has been detected in the urine of human subjects. Case Report We describe our patient case documenting the administration of gilteritinib in the setting of end-stage renal disease (ESRD) and hemodialysis (HD). Management and Outcomes: Our patient was initiated on single agent gilteritinib 120 mg by mouth once daily for relapse FLT3-TDK positive AML. Treatment course was complicated by pancytopenia, neutropenic fever, and staphylococcus lugdunensis bacteremia requiring temporary interruption of therapy. Discussion Given that gilteritinib is metabolized by the liver and eliminated primarily in the feces, one does not expect an increase in toxicity related to impaired renal function. Although this report describes the successful utilization of gilteritinib, caution should be exercised when administering in patient populations with end organ disease, and patient comorbidities should be taken into account.

Introduction Acute graft-versus-host disease (aGVHD) is a significant immune-mediated complication of allogeneic hematopoietic stem cell transplant (HSCT). Despite prophylactic immunosuppression, the incidence of grades II–IV aGVHD post-HSCT varies from 20 to 80%. Tumor necrosis factor (TNF) is an important cytokine involved in the pathogenesis of GVHD, and medications such as infliximab (Remicade®) have been utilized as second-line treatment options in patients with steroid-refractory GHVD. Infliximab-dyyb (Inflectra®) and infliximab-qbtx (Ixifi®) are biosimilars approved by the FDA for a variety of autoimmune disorders. This is the first case report documenting the utility of infliximab-dyyb and -qbtx for the management of steroid-refractory aGVHD. Case report We report the post-transplant course of three patients treated with infliximab biosimilars as a part of therapy for management of steroid-refractory aGVHD. Management and outcome Steroid-refractory aGVHD is associated with poor prognosis and its management, as highlighted in our three patient cases, and can be very diverse often requiring different therapeutic modalities which overlap in administration. Discussion In these patients with steroid-refractory aGVHD, we were able to show that infliximab biosimilars could be used in lieu of the reference infliximab product. Although we had important limitations, this case report supports the use of anti-TNF agents in highly mortal steroid-refractory acute GI GVHD and that replacement of infliximab with its biosimilars is feasible.

Midostaurin is a multitargeted tyrosine kinase inhibitor approved by the Food and Drug Administration for FMS-related tyrosine kinase 3-positive acute myeloid leukemia in combination with standard daunorubicin and cytarabine induction and high-dose cytarabine consolidation. The pharmacokinetics of midostaurin in the setting of severe renal impairment (creatinine clearance [CrCl] 15-29 mL/min utilizing Cockcroft-Gault method) and end-stage renal disease are unknown. Midostaurin is primarily metabolized by the liver through the CYP3A4 enzyme with fecal excretion accounting for 95% of the dose (4% recovered as unchanged drug). Only 5% of the parent drug is found in the urine. This is the first case report documenting the administration of midostaurin in two patients with end-stage renal disease on HD. Given the limited excretion of both active and inactive metabolites of midostaurin in the urine, one does not expect an increase in toxicity related to impaired drug excretion. Although this report describes the likely successful utilization of midostaurin, caution should be exercised when administering in patient populations with end organ disease. Medical history, concomitant comorbidities, and goals of therapy should be taken into account.

District cooling companies enforce a large penalty based on peak demands, which current cooling methods do not address properly. Building developers are exploring alternatives methods to reduce the said peak demands. The use of Ice Thermal Storage is an nontraditional method within the Scandinavian countries, but has shown to be a method to peak shave as well as load shifting in other regions of the worlds. The goal of the thesis was to "investigate the potential of ice thermal storage for cooling demand and peak shaving for Beridarebanan 4, 11, 77". The energy simulation was accomplished using the building performance simulator software IES VE. As inputs to the simulation, building data from the renovation project and corresponding weather data were used. The resulting simulation model was validated against renovated data with differences of 3,3% and 41,9% for the heating and cooling loads, respectively. The large discrepancy within cooling was determined to be weighted heavily by cooling strategy implemented within the building. When similar cooling strategies were implemented results were consistent with one another. This validation was investigated on a building, zone, and room level to look for consistency. The resulting simulated heating and cooling demands from IES VE were input into a then created ice thermal storage controller within MS Excel. In all, with the stable electrical and district cooling prices, a payback of 12 years was calculated for a 4,5 MWh, 6 hour storage ITS system. Results also show that for a 6 hour storage capacity,the controller exceeded the 1 000 kW price tier 4 hours out of the entire year, making it an ideal storage size. Current Swedish Electrical Market incentivize peak shaving rather than energy saving, accounting for nearly 80% of the yearly savings. The margin for earning more for the energy savings has negative consequences for potentially exceeding the 1 000 kW cooling threshold.

This study arises from the will to know the aspects related to births in Albania, focusing mainly on three stages: pregnancy, birth and postpartum. The random sample of this pilot study consisted of 50 women. Among the most important results of the study we can identify: the use of folic acid begins mainly during the early pregnancy process; the number of ultrasounds scans remains high for women of any age or level of education; natural births are more common to any group of age or level of education and monitoring of breastfeeding is generally adequate. Exception is for the group of women with middle class degree which demonstrated lower results to this variable.

T-cell acute lymphoblastic leukemia (ALL) is a very challenging disease to attain durable remission once relapses. We treated a 40 year-old female with T-cell ALL, normal cytogenetic who relapsed twice after her matched related donor allogeneic stem cell transplantation (allo-SCT) with Nelarabine achieving third complete remission prior to second allo-SCT. She was initially treated with HyperCVAD x 5 cycles with IT chemo (negative cytopathology). After achieving complete remission (CR), she received PK-directed IV Busulfan and Fludarabine myeloablative conditioning followed by 12/12 HLA-MRD allo-SCT with 11.06 x 106 CD34+cells/kg. GVHD prophylaxis was Tacrolimus and mini-Methotrexate (5 mg/m2/dose). She engrafted on time. She never had GVHD. On day+ 100, bone marrow biopsy revealed relapsed disease involving 60% of marrow space. Patient was treated with one cycle augmented HyperCVAD resulted in second CR. She developed elevated transaminases, liver biopsy was consistent with NASH and drug-induced liver injury, negative for GVHD. She was given alpha interferon 3 million units MWF in attempt to induce GVHD/GVL while pending insurance approval for donor lymphocyte infusion. She developed full donor chimerism as well as extensive chronic GVHD involving skin, liver, skin, lung, eyes, vagina, and mouth after interferon. She was treated only with topical steroid therapies and remained in CR until day+266. On Day+266, she was again found to have relapse of her disease with significant leukocytosis and circulating blasts. CT scan showed recurrent large anterior mediastinal mass. She was treated with Cytoxan (500 mg/m2) and Etoposide (100 mg/m2 x 5 days), complicated with neutropenic fevers before receiving outpatient Nelarabine. She recovered with progressive leukemia, which was treated with a single dose of Cytoxan 600mg/m2. She developed diffuse alveolar hemorrhage, treated in the MICU with high dose steroids and antimicrobials. She was discharged to outpatient clinic and given Nelarabine at 1500 mg/m2 on days +1, +3, +5, every 3 weeks for 2 cycles. Her clinical condition and peripheral counts improved with disappearing peripheral blasts after the initial cycle of Nelarabine. She received second cycle and subsequent restaging studies showed remission marrow (CR-3) with complete resolution of mediastinal mass on CT scan. She developed mild neuropathy after Nelarabine. She is currently inpatient receiving her for second MRD allo-SCT. This case is noteworthy and clearly illustrates lack of GVL effect in T-cell ALL and an efficacy of two cycles of Nelarabine even in the setting of refractory T-cell ALL relapsing twice after allogeneic SCT. Disclosures No relevant conflicts of interest to declare.