In 2012, Richard E. Wainerdi retired as president and chief executive officer of the Texas Medical Center after almost three decades at the helm. During his tenure, Wainerdi oversaw the expansion of ...the center into the world’s largest medical complex, hosting more than fifty separate institutions. “I wasn’t playing any of the instruments, but it’s been a privilege being the conductor,” he once said to a newspaper reporter. William Henry Kellar traces Wainerdi’s remarkable life story from a bookish childhood in the Bronx to a bold move west to study petroleum engineering at the University of Oklahoma. Wainerdi went on to earn a master’s degree and a PhD from Penn State University where he immersed himself in nuclear engineering. By the late 1950s, Texas A&M University recruited Wainerdi to found the Nuclear Science Center, where he also served as professor and later associate vice president for academic affairs. In the 1980s, Wainerdi took charge of the Texas Medical Center, embarking on a “second career” that ultimately expanded the center from thirty-one institutions to fifty-three and increased its size threefold. Wainerdi pushed for and ensured a culture of collaboration and cooperation. In doing this, he developed a new nonprofit administrative model that emphasized building consensus, providing vital support services, and connecting member institutions with resources that enabled them to focus on their unique areas of expertise. At a time when Houston was widely known as the “energy capital of the world,” the city also became home to the largest medical complex in the world. Wainerdi’s success was to enable each member of the Texas Medical Center to be an integral part of something bigger and something very special in the development of modern medicine.
Patients with non-Hodgkin's lymphoma (NHL) who fail conventional chemotherapy have a dismal outcome. Reports from single institutions utilizing high-dose chemoradiotherapy plus Autologous Bone Marrow ...Transplantation (ABMT) in this setting suggest three-year disease-free survival between 15-60 per cent. From 1985 to 1989 the Southwest Oncology Group performed a prospective multi-institutional study involving ABMT in relapsed/refractory NHL. Forty-five patients, ages 6-60 (median 38), with relapsed NHL were treated with high-dose cyclophosphamide (60 mg/kg/d x 2), total body irradiation (200 cGy/d x 6), and autologous unpurged bone marrow. Histologic subtypes included high grade lymphoma (10), intermediate grade lymphoma (33), and low grade lymphoma (2). Disease status pre-ABMT was sensitive relapse (16), resistant relapse (13), and untreated relapse (16). The actuarial three-year event-free survival and overall survival for all patients were 27 per cent and 38 per cent respectively. Causes of failure included regimen-related deaths (4), lack of response (10), or tumour progression (20) which occurred at a median of 5 months (1-22) post-ABMT and usually at previous sites of involvement. Response to salvage therapy pre-ABMT, a reflection of a tumour's biological behaviour, was the most important predictor of good outcome post-ABMT. This study confirms that a significant number of patients with recurrent NHL can achieve prolonged disease-free survival after ABMT.
Over the past four decades, allogeneic hematopoietic cell transplantation (alloHCT) has evolved as a curative modality for patients with hematologic diseases. This study describes changes in use, ...technique, and survival in a population-based cohort.
The study included 38,060 patients with hematologic malignancies or disorders who underwent first alloHCT in a US or Canadian center from 1994 to 2005 and were reported to the Center for International Blood and Marrow Transplant Research.
AlloHCT as treatment for acute lymphoblastic (ALL) and myeloid leukemias (AML), myelodysplastic syndrome (MDS), and Hodgkin and non-Hodgkin lymphomas increased by 45%, from 2,520 to 3,668 patients annually. From 1994 to 2005, use of both peripheral (7% to 63%) corrected and cord blood increased (2% to 10%), whereas use of marrow decreased (90% to 27%). Despite a median age increase from 33 to 40 years and 165% corrected increase in unrelated donors for alloHCT, overall survival (OS) at day 100 significantly improved for patients with AML in first complete remission after myeloablative sibling alloHCT (85% to 94%; P < .001) and unrelated alloHCT (63% to 86%; P < .001); 1-year OS improved among those undergoing unrelated alloHCT (48% to 63%; P = .003) but not among those undergoing sibling alloHCT. Similar results were seen for ALL and MDS. Day-100 OS after cord blood alloHCT improved significantly from 60% to 78% (P < .001) for AML, ALL, MDS, and chronic myeloid leukemia. Use of reduced-intensity regimens increased, yielding OS rates similar to those of myeloablative regimens.
Survival for those undergoing alloHCT has significantly improved over time. However, new approaches are needed to further improve 1-year OS.
Allogeneic hematopoietic cell transplantation (alloHCT) is a highly specialized procedure. We surveyed adult transplant centers in the United States (US) and then used data reported to the Center for ...International Blood and Marrow Transplant Research (CIBMTR) (2008-2010) to evaluate associations of center volume, infrastructure, and care delivery models with survival post alloHCT. Based on their 2010 alloHCT volume, centers were categorized as low-volume (≤40 alloHCTs; N = 42 centers, 1900 recipients) or high-volume (>40 alloHCTs; N = 41 centers, 9637 recipients). 100-day survival was 86% (95% CI, 85-87%) in high-volume compared with 83% (95% CI, 81-85%) in low-volume centers (difference 3%; P < 0.001). One-year survival was 62% (95% CI, 61-63%) and 56% (95% CI, 54-58%), respectively (difference 6%; P < 0.001). Logistic regression analyses adjusted for patient and center characteristics; alloHCT at high-volume centers (odds ratio OR 1.32; P < 0.001) and presence of a survivorship program dedicated to HCT recipients (OR 1.23; P = 0.009) were associated with favorable 1-year survival compared to low-volume centers. Similar findings were observed in a CIBMTR validation cohort (2012-2014); high-volume centers had better 1-year survival (OR 1.24, P < 0.001). Among US adult transplant centers, alloHCT at high-volume centers and at centers with survivorship programs is associated with higher 1-year survival.
BACKGROUNDEvidence supporting convalescent plasma (CP), one of the first investigational treatments for coronavirus disease 2019 (COVID-19), has been inconclusive, leading to conflicting ...recommendations. The primary objective was to perform a comparative effectiveness study of CP for all-cause, in-hospital mortality in patients with COVID-19.METHODSThe multicenter, electronic health records-based, retrospective study included 44,770 patients hospitalized with COVID-19 in one of 176 HCA Healthcare-affiliated community hospitals. Coarsened exact matching (1:k) was employed, resulting in a sample of 3774 CP and 10,687 comparison patients.RESULTSExamination of mortality using a shared frailty model, controlling for concomitant medications, date of admission, and days from admission to transfusion, demonstrated a significant association of CP with lower mortality risk relative to the comparison group (adjusted hazard ratio aHR = 0.71; 95% CI, 0.59-0.86; P < 0.001). Examination of patient risk trajectories, represented by 400 clinico-demographic features from our real-time risk model (RTRM), indicated that patients who received CP recovered more quickly. The stratification of days to transfusion revealed that CP within 3 days after admission, but not within 4 to 7 days, was associated with a significantly lower mortality risk (aHR = 0.53; 95% CI, 0.47-0.60; P < 0.001). CP serology level was inversely associated with mortality when controlling for its interaction with days to transfusion (HR = 0.998; 95% CI, 0.997-0.999; P = 0.013), yet it did not reach univariable significance.CONCLUSIONSThis large, diverse, multicenter cohort study demonstrated that CP, compared with matched controls, is significantly associated with reduced risk of in-hospital mortality. These observations highlight the utility of real-world evidence and suggest the need for further evaluation prior to abandoning CP as a viable therapy for COVID-19.FUNDINGThis research was supported in whole by HCA Healthcare and/or an HCA Healthcare-affiliated entity, including Sarah Cannon and Genospace.
The American Society for Transplantation and Cellular Therapy (ASTCT) published its first white paper on indications for autologous and allogeneic hematopoietic cell transplantation (HCT) in 2015. It ...was identified at the time that periodic updates of indications would be required to stay abreast with state of the art and emerging indications and therapy. In recent years the field has not only seen an improvement in transplantation technology, thus widening the therapeutic scope of HCT, but additionally a whole new treatment strategy using modified immune effector cells, including chimeric antigen receptor T cells and engineered T-cell receptors, has emerged. The guidelines review committee of the ASTCT deemed it optimal to update the ASTCT recommendations for indications for HCT to include new data and to incorporate indications for immune effector cell therapy (IECT) where appropriate. The guidelines committee established a multiple stakeholder task force consisting of transplant experts, payer representatives, and a patient advocate to provide guidance on indications for HCT and IECT. This article presents the updated recommendations from the ASTCT on indications for HCT and IECT. Indications for HCT/IECT were categorized as (1) Standard of care, where indication is well defined and supported by evidence; (2) Standard of care, clinical evidence available, where large clinical trials and observational studies are not available but have been shown to be effective therapy; (3) Standard of care, rare indication, for rare diseases where demonstrated effectiveness exists but large clinical trials and observational studies are not feasible; (4) Developmental, for diseases where preclinical and/or early-phase clinical studies show HCT/IECT to be a promising treatment option; and (5) Not generally recommended, where available evidence does not support the routine use of HCT/IECT. The ASTCT will continue to periodically review these guidelines and update them as new evidence becomes available.
Abstract Approximately 20,000 hematopoietic cell transplantation (HCT) procedures are performed in the United States annually. With advances in transplantation technology and supportive care ...practices, HCT has become safer, and patient survival continues to improve over time. Indications for HCT continue to evolve as research refines the role for HCT in established indications and identifies emerging indications where HCT may be beneficial. The American Society for Blood and Marrow Transplantation (ASBMT) established a multiple-stakeholder task force consisting of transplant experts, payer representatives, and a patient advocate to provide guidance on “routine” indications for HCT. This white paper presents the recommendations from the task force. Indications for HCT were categorized as follows: (1) Standard of care, where indication for HCT is well defined and supported by evidence; (2) Standard of care, clinical evidence available, where large clinical trials and observational studies are not available but HCT has been shown to be effective therapy; (3) Standard of care, rare indication, for rare diseases where HCT has demonstrated effectiveness but large clinical trials and observational studies are not feasible; (4) Developmental, for diseases where preclinical and/or early phase clinical studies show HCT to be a promising treatment option; and (5) Not generally recommended, where available evidence does not support the routine use of HCT. The ASBMT will periodically review these guidelines and will update them as new evidence becomes available.
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Background: Sarah Cannon Blood Cancer Network (SCBCN) is a network of seven markets dedicated to provide high quality and safe care to patients with complex blood cancers. Continuous ...quality management (QM) and improving patient safety are critical components to the mission of SCBCN. Methods: Four SCBCN disease-specific working groups have developed evidence-based pathways for complex blood cancers. However, there are currently no SCBCN clinical quality of care metrics to monitor value-based care. To address this unmet need, the SCBCN leadership endorsed a team-based approach to measure QM for complex blood cancers, using basic clinical performance metrics proposed by the American Society of Hematology, the American Medical Association-convened Physician Consortium for Performance Improvement, the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality National Quality Measures Clearinghouse, and Centers for Medicare & Medicaid Services. Results: Between 2012 and September 2015, 1221 new adult cases of Acute Myeloid Leukemia (AML) and 253 new adult cases of Myelodysplastic Syndrome (MDS), respectively, were reported within the SCBCN. Based on the volume of cases and to measure QM in AML and MDS, quality indicators were selected based on meaningfulness to program goals and feasibility of data capture, leading to development of quality metrics dashboard for AML and MDS in SCBCN. Also, keeping in mind the changing paradigm of personalized care using new and emerging therapies in AML and MDS, exploratory quality metrics are also proposed to evaluate access to new trials as QM of AML and MDS in SCBCN. Conclusions: SCBCN is a wide network of community hospitals with expertise in managing complex blood cancers. As proof of concept study, the AML and MDS dashboard was developed and chosen as a model for continuous QM for complex blood cancers. This dashboard will initially be tested to evaluate QM at two SCBCN sites to facilitate the overarching programmatic goal of continuous QM for all AML/MDS and other blood cancers presenting within the SCBCN.
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