Browsing by Subject "Immunosuppressive Agents"
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Item Culturally Informed Motivational Interviewing to Improve Oral Chemotherapy Adherence for Pediatric Acute Lymphoblastic Leukemia Patients and Their Caregivers: A Feasibility, Acceptability, and Preliminary Efficacy Trial(2019-07-24) El Behadli Gonzalez, Ana Fey; Faith, Melissa A.; Stewart, Sunita M.; Winick, Naomi; Germann, Julie; Acosta, DailynBACKGROUND: Curative therapy for childhood acute lymphoblastic leukemia (ALL) mandates a two-to-three-year maintenance chemotherapy phase wherein patients must take daily oral 6-mercaptopurine (6-MP). 6-MP regimen adherence is challenging and failure to take medication has been associated with an increase in relapse risk. Accordingly, interventions that enhance 6-MP adherence during ALL maintenance chemotherapy may result in decreased morbidity and mortality for pediatric ALL patients. This study investigated the feasibility and acceptability of brief, English- and Spanish-delivered, culturally informed MI sessions during routine outpatient ALL maintenance therapy appointments. Additionally, this study preliminarily explored MI efficacy, compared to an education-only control, for improving caregiver-reported 6-MP adherence, patients' TGN blood serum levels, and caregiver-perceived 6-MP adherence barriers. METHOD: Participants included 121 caregivers (Age M(SD) = 36.66(8.02), 80.7% mothers, 47.1% Hispanic, 23.1% Spanish-speaking) of pediatric ALL patients (Age M(SD) = 7.55(4.80), range = .9-24; 66.1% male; Medicaid = 54.2%; B- and T-ALL risk category: Standard = 50.9%, High/Very High = 49.1%) in maintenance ALL treatment. Eighty caregivers (66.12%) were randomized to receive MI and the remaining 42 caregivers (33.8%) were randomized to the education-only control group. For the purpose of analyses, participants were categorized based on their ethnicity and primary language as a proxy for potential cultural similarities. Cultural categories included: (1) Non-Hispanic, English-speaking caregivers (N=63, 52.07%); (2) Hispanic, English-speaking caregivers (N=30, 24.79%); and (3) Hispanic, Spanish-speaking caregivers (N=28, 23.14%). Participants completed self-report measures assessing demographics, 6-MP adherence, 6-MP knowledge, perceived medication adherence barriers, and intervention acceptability. We obtained biological data (i.e., TGN concentrations) via chart review. MI sessions were audio recorded and rated using the MITI 4.2.1. coding manual to ensure intervention fidelity. Primary analyses included Analysis of Covariance (ANCOVA). We also conducted exploratory post-hoc analyses. RESULTS: Findings confirmed primary MI feasibility and acceptability hypotheses, supporting the possibility of delivering adherence-enhancing MI as part of routine oncological care. Additionally, although methodological limitations hindered adequate assessment of MI efficacy for improving caregiver-reported 6-MP adherence and patients' TGN concentration, post-hoc analyses suggested MI was effective for reducing caregiver-perceived 6-MP adherence barriers. CONCLUSIONS: MI may represent a deliverable, cost-effective, "no-risk" approach to improving adherence and represent an easily incorporated, low cost avenue for enhancing cure. Overall, study findings have the potential to inform a larger, future MI efficacy RCT by establishing the feasibility and acceptability of MI delivery during outpatient oncology clinic visits.Item Cyclosporine-induced hypertension: the search for the billion dollar molecule(1995-11-02) Victor, Ronald G.Item The Effect of Rapamycin Paired with Traumatic Memory Activation on Cognitive Performance in Veterans Diagnosed with PTSD(2012-05-18) Anderson, Elizabeth Hallen; Surís, Alina; North, Carol S.; Powell, Craig M.BACKGROUND: Many individuals with posttraumatic stress disorder (PTSD) experience cognitive impairment in addition to the characteristic psychological symptoms. Animal studies have shown that rapamycin, a protein synthesis inhibitor that targets the protein kinase mTOR, can prevent the reconsolidation of a reactivated fear memory, thereby reducing its emotional strength at a neurochemical level. The aim of the current study was to determine if pairing rapamycin with traumatic memory reactivation in male veterans with combat-related PTSD would lead to an improvement in cognitive performance, based on scores from the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline and 1-month follow-up. SUBJECTS: A sample of 54 male veterans with combat-related PTSD receiving healthcare at a large southwestern VA medical center participated in the study. METHODS: In a double-blind, placebo-controlled study, male veterans with combatrelated PTSD were administered either a single dose of rapamycin or placebo, followed by a script-driven memory reactivation task. Measures included the RBANS, Clinician Administered PTSD Scale (CAPS), and the Quick Inventory of Depressive Symptomatology (QIDS). RESULTS: A repeated measures ANOVA was conducted to assess the impact of two different interventions (rapamycin, placebo) on participants' scores on the RBANS, across two time periods (baseline, one-month follow-up). The main effect comparing the two type of interventions revealed no significant differences in the effectiveness of the two interventions in the entire sample; F (1,48) = .01, p = .921, partial eta squared < .001. When the sample was limited to participants who demonstrated a clinically significant reduction (≥ 20 points) in their CAPS score, a repeated measures ANOVA revealed a significant interaction between time and treatment intervention; Wilks Lambda = .44, F (1, 13) = 16.74, p = .001, partial eta squared = .563. Pairwise comparisons showed a significant improvement between baseline and one-month follow-up on the RBANS for participants in the placebo group, mean difference = 10.00, p = .002. DISCUSSION: Based on these results, a single rapamycin treatment does not appear to be detrimental or beneficial to cognitive performance. Furthermore, a clinically significant reduction in PTSD symptoms due to rapamycin is not associated with an improvement in cognitive performance.Item Kidney transplantation(1966-01-27) Stastny, PeterItem Live Donor Renal Transplantation in India: Outcome and Comparison of Different Induction Therapies with a Focus on Gender Bias in Live Donor Renal Transplantation(2018-03-23) Khan, Maryam Idrees; Nwariaku, Fiemu; Rajora , Nilum; Tanriover , BekirBACKGROUND: As of 2014, an estimated 9% of the global population aged 18+ years was affected by diabetes. The World Health Organization (WHO) also estimated around 2.5% of deaths were attributed to diabetes in 2012 and more than 80% of those deaths occurred in low-middle income countries. It is apparent that diabetes and its complications are becoming a global issue as an increasing common, preventable, non-communicable disease. Along with cardiovascular disease, blindness, and neuropathy, end stage renal disease (ESRD) is one of the serious complications that can develop as a result of diabetes. Diabetes is the leading cause of ESRD in both developed countries like the United States and developing countries like India. India is a particularly interesting country to observe given their vast population base, rapid growing economy, genetic predisposition to diabetes and increased insulin resistance. It is estimated that 100,000 patients develop ESRD each year in India with diabetes as the main underlying cause (44% of all ESRD cases). Once a patient develops ESR, renal replacement therapy (RRT) is required to sustain life. RRT consists of three options: 1) hemodialysis (HD), 2) peritoneal dialysis (PD), or 3) renal transplant (RT). Of the three options, renal transplant is considered the best in terms of quality of life and cost effectiveness, but only about 5% of Indian patients with ESRD end up receiving RT. Most RT in India come from living donors rather than cadaveric donors like in the United States. Induction therapy with interleukin-2 receptor alpha chain (IL2-RA) is recommended as a first line agent in LRT however comparative outcomes of induction therapy remains controversial in Indian LRT population. OBJECTIVE: To evaluate patient survival and allograft function in LRT with a specific focus on the Indian population between 2010 and 2014 and to access the impact of different induction therapies on the outcomes of Indian LRT patients. METHODS: A single center (Medanta Medicity, Gurgaon, India) dataset was retrospectively studies for patients receiving LRT from 2010 to 2014 (N=901) to compare effectiveness of IL2-RA to other induction options (no-induction and rabbit anti-thymocyte globulin [r-ATG]). IL2-RA and no induction were chosen for immunologically low risk patients. R-ATG was primarily given to the recipient with PRA>20% and HLA mismatch >5 antigen out of 6. Patient paper charts were analyzed for dates not included in the Medanta database which included follow-up dates with corresponding creatinine levels (at 3 months, 6 months, 1 year, and last follow up), date and type of rejection if applicable, graft loss and death. Patients included in the data set had their last follow up at Medanta within the last 6 months from the time data was collected. The patient data was used to calculate rejection rate, graft failure, and hazard ratio (HR) for overall graft failure. The main outcomes were the risk of acute rejection at one-year and overall allograft failure (graft failure or death) post-transplantation through the end of follow-up. RESULTS: Similar Kaplan Meier curves for overall graft survivals were observed among induction categories. Rejection rate was higher in no-induction and IL2-RA groups (~25%) compared to r-ATG induction. On univariate Cox analysis, compared to no-induction therapy, overall allograft failure was similar among induction categories. Most of the rejections were borderline or Banff Type I acute cellular rejections. CONCLUSION: Compared to no-induction therapy, IL2-RA induction was not associated with better outcomes in Indian LRT recipients. R-ATG appears to be an acceptable and possibly preferred induction alternative for IL2-RA in high rejection risk Indian patients.Item New advances in immunosuppressive therapy for renal transplantation(1997-04-17) Vazquez, Miguel A.Item New immunosuppressive therapies in renal transplantation(1992-04-16) Lu, Christopher Y.Item [News](1987-12-07) Rutherford, SusanItem Optimizing Immunosupression in Patients Following Heart Transplantation(2008-06-13) Mitchell, Joshua D.; DiMaio, J. MichaelBACKGROUND: Effective immunosuppression is necessary for long-term survival following heart transplantation, but it is also associated with a multitude of adverse effects. Protocols have emerged to attempt to optimize the risk-to-benefit ratio of immunosuppression. We reviewed our center's experience with two such protocols: tapering corticosteroids following heart transplantation and administering basiliximab as an induction agent. METHODS: We reviewed the records of all cardiac transplant recipients at our center between 1988 and August 2004. Patients treated with traditional triple therapy immunosuppression (cyclosporine, azathioprine, and prednisone; CAP) were compared to a similar group of patients treated with a goal of rapid (within 6 months) steroid taper and discontinuation (CAPT). Patients who received basiliximab as an induction agent were compared to a historical control group of patients who received a similar immunosuppressive protocol without basiliximab induction. RESULTS: Fifty-seven percent of the patients in the CAPT group were successfully withdrawn from steroids at six months post-transplantation. This group had a decreased freedom from acute rejection (p<0.01) and increased frequency of acute rejection (p<0.01) when compared to the CAP group. There was, however, no difference in freedom from transplant coronary artery disease (p=0.53). The CAPT group enjoyed an increased freedom from malignancy (p=0.01) and trended towards a decreased frequency of infection (p=0.10) and improved survival (p=0.06) when compared to the CAP group.One hundred forty-five patients were included in the comparison between basiliximab and control. At one and two-years post-transplantation, no difference was found between groups in the rise of serum creatinine (p=0.29). Basiliximab induction decreased the frequency of acute rejection (p=0.02) and improved the freedom from first acute rejection episode (p<0.01) during the first two years after transplantation. It had no statistically significant effect on freedom from infection, malignancy, or overall survival in our cardiac transplant population (p=0.52, p=0.85,p=0.27 respectively). CONCLUSIONS: Steroid withdrawal was possible in 57% of patients at six months posttransplantation.The institution of an early steroid taper protocol improves the overall freedom from malignancies and may decrease the frequency of infection and prolong overall survival. Basiliximab induction does not affect renal function at mid-term follow-up; however, it decreases the frequency of acute rejection and increases the freedom from first acute rejection episode. It accomplishes this without decreasing the freedom from infection, malignancy, and transplant vasculopathy. Novel medications and treatment protocols provide an opportunity for transplant teams to continue to optimize immunosuppression while simultaneously minimizing side-effects.Item The rationale and approach to immunosuppresive therapy(1970-02-26) Frenkel, Eugene P.