To provide evidence-based recommendations on the treatment of multiple myeloma to practicing physicians and others.
ASCO and Cancer Care Ontario convened an Expert Panel of medical oncology, surgery, ...radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and some phase II studies published from 2005 through 2018. Outcomes of interest included survival, progression-free survival, response rate, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.
The literature search identified 124 relevant studies to inform the evidence base for this guideline.
Evidence-based recommendations were developed for patients with multiple myeloma who are transplantation eligible and those who are ineligible and for patients with relapsed or refractory disease.
Biochar has been used to remove heavy metals from aqueous solutions. In this study, a sulfurized wood biochar (SWB) by direct impregnation with elemental sulfur was produced and evaluated along with ...pristine wood biochar (WB) for adsorption characteristics and mechanism of mercury. Mercury adsorption by WB and SWB was well described by Langmuir model and pseudo second order model and the maximum adsorption capacities of WB and SWB were 57.8 and 107.5 mg g−1, respectively. Intraparticle diffusion model showed that mercury adsorption was fast due to boundary layer and slow adsorption due to diffusion into biochar pores. Although, mercury adsorption by both WB and SWB was predominantly influenced by the pH, temperature, salt concentration, and biochar dosage, the SWB showed a relatively stable mercury adsorption compared to WB under different conditions, suggesting the strong affinity of SWB for mercury. The XPS analysis showed different adsorption mechanisms of mercury between WB and SWB. In particular, mercury adsorption in WB was due to Hg-Cπ bond formation and interaction with carboxyl and hydroxyl groups, whereas in SWB it is primarily due to mercury interaction with C-SOx-C and thiophenic groups in addition to Hg-Cπ bond formation and interaction with carboxyl groups. The SEM-EDS mapping also demonstrated that mercury in SWB was related to carbon, oxygen and sulfur. Overall, the sulfurized biochar was effective for removing mercury from aqueous solution, and its direct production through pyrolysis with elemental sulfur impregnation of wood chips could make it an economic option as absorbent for treating mercury-rich wastewater.
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•A sulfurized biochar (SWB) was produced by pyrolysis of wood chip with elemental S.•SWB was an effective adsorbent for removing Hg than pristine biochar (WB).•Hg adsorbed by SWB was more stable and less susceptible to environment changes.•Hg adsorption by WB was dominated by interactions with C=C, COH and COO.•Hg by SWB involved thiophenic and C-SOx-C forms in addition to C=C and COO.
The advent of new, more effective, and less toxic therapies has revolutionized the management of multiple myeloma in the past decade. Despite the availability of new treatments, most patients with ...multiple myeloma will become refractory to the therapies that currently comprise the hematologic standard of care for the malignancy, including proteasome inhibitors, immunomodulatory agents, and monoclonal antibodies. Moreover, in recent years, a new subset of patients with multiple myeloma refractory to all 3 of these agents has emerged. This population, for whom a clear treatment paradigm has remained undefined, has been characterized by poor survival outcomes. The current approaches to the treatment of triple-class refractory disease are limited and include conventional chemotherapy, salvage autologous stem cell transplantation, and recycling previous regimens, each of which have generally had short-lived efficacy. It is anticipated that additional agents will be available for triple-refractory disease in the near future, including selinexor, chimeric antigen receptor T-cell therapy, and next-generation monoclonal antibodies. The development and further refinement of novel treatments for this subset of patients should be considered a key clinical and research priority.
This phase 1b dose-escalation study evaluated isatuximab plus pomalidomide/dexamethasone in patients with relapsed/refractory multiple myeloma (RRMM). Patients who had received ≥2 prior MM therapies, ...including lenalidomide and a proteasome inhibitor (PI), were enrolled and received isatuximab at 5, 10, or 20 mg/kg (weekly for 4 weeks, followed by every 2 weeks), pomalidomide 4 mg (days 1-21), and dexamethasone 40 mg (weekly) in 28-day cycles until progression/intolerable toxicity. The primary objective was to determine the safety and recommended dose of isatuximab with this combination. Secondary objectives included evaluation of pharmacokinetics, immunogenicity, and efficacy. Forty-five patients received isatuximab (5 n = 8, 10 n = 31, or 20 n = 6 mg/kg). Patients received a median of 3 (range, 1-10) prior lines; most were refractory to their last regimen (91%), with 82% lenalidomide-refractory and 84% PI-refractory. Median treatment duration was 9.6 months; 19 patients (42%) remain on treatment. Most common adverse events included fatigue (62%), and upper respiratory tract infection (42%), infusion reactions (42%), and dyspnea (40%). The most common grade ≥3 treatment-emergent adverse event was pneumonia, which occurred in 8 patients (17.8%). Hematologic laboratory abnormalities were common (lymphopenia, leukopenia, anemia, 98% each; neutropenia, 93%; and thrombocytopenia, 84%). Overall response rate was 62%; median duration of response was 18.7 months; median progression-free survival was 17.6 months. These results demonstrate potential meaningful clinical activity and a manageable safety profile of isatuximab plus pomalidomide/dexamethasone in heavily pretreated patients with RRMM. The 10 mg/kg weekly/every 2 weeks isatuximab dose was selected for future studies. This trial was registered at www.clinicaltrials.gov as #NCT02283775.
•Isatuximab combined with pomalidomide/dexamethasone has a manageable safety profile with promising clinical activity.•Isatuximab 10 mg/kg (4 weekly doses followed by dosing every 2 weeks thereafter) has been selected for future combination studies.
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Cyclophosphamide, bortezomib, and dexamethasone (CyBorD) is highly effective in multiple myeloma. We treated patients with light chain amyloidosis (AL) before stem cell transplantation (ASCT), ...instead of ASCT in ineligible patients or as salvage. Treatment was a combination of bortezomib (1.5 mg/m2 weekly), cyclophosphamide (300 mg/m2 orally weekly), and dexamethasone (40 mg weekly). Seventeen patients received 2 to 6 cycles of CyBorD. Ten (58%) had symptomatic cardiac involvement, and 14 (82%) had 2 or more organs involved. Response occurred in 16 (94%), with 71% achieving complete hematologic response and 24% a partial response. Time to response was 2 months. Three patients originally not eligible for ASCT became eligible. CyBorD produces rapid and complete hematologic responses in the majority of patients with AL regardless of previous treatment or ASCT candidacy. It is well tolerated with few side effects. CyBorD warrants continued investigation as treatment for AL.
Background: Disruptions due to the COVID-19 pandemic have forced medical schools around the world to adapt. Major changes in curriculum delivery during the pandemic have impacted medical students’ ...professional development. We assess undergraduate medical students’ adaptations and Professional Identity Formation (PIF) by exploring their written reflections.
Methods: This phenomenology study analyzes undergraduate medical students’ written reflections. We perform a thematic analysis to identify emerging themes.
Results: We purposively selected 80 written reflections, considering the students’ year of study, gender, GPA, and education stage (preclinical or clinical). Three themes emerged: students’ adaptation processes and coping strategies in facing the pandemic; their adaptation processes for learning; and their perceived roles as medical students during the pandemic.
Conclusions: Adaptive coping mechanisms were implemented by the medical students in this study. The socialization processes that promote professional identity formation may change due to the tremendous disruption wrought by the pandemic; this has prompted our investigation of students’ roles and various ways of interacting with role models. We highlight the importance of the medical school supporting students’ adaptations and professional identity formation during this pandemic.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Treatment of multiple myeloma (MM) is complex; however, with equal access to care, clinical outcomes for Black patients match those in other patient groups. To reveal and begin to address clinical ...practice barriers to equitable, patient-centered MM care, this quality improvement (QI) initiative assessed patient electronic medical records (EMRs) and surveyed patients and providers at two large hospital systems and four community-based practices. For the educational intervention, providers participated in feedback-focused grand rounds sessions to reflect on system barriers and develop action plans to improve MM care. EMR reviews revealed infrequent documentation of cytogenetics and disease staging at community-based practices compared to large hospital systems. In surveys, providers from each care setting reported different challenges in MM care. Notably, the goals of treatment for patients and providers aligned at community clinics while providers and patients from large hospital systems had discordant perspectives. However, providers in community settings underreported race-associated barriers to care and identified different factors impacting treatment decision-making than Black patients. Relative to pre-session responses, providers were more likely to report high confidence after the educational sessions in aligning treatment decisions with guidelines and clinical evidence and shared decision-making (SDM). This QI study identified discordant perceptions among providers at large hospital systems and community-based practices in providing quality MM care. Provider education yielded increased confidence in and commitment to patient-centered care.
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