Package Insert Instructions Research Articles

Nasal steroid spray simulations using measured spray characteristics in healthy and rhinitic nasal passages

Intranasal corticosteroid sprays (ICSs) are frequently prescribed for allergic rhinitis (AR), which is the fifth most common chronic disease in the United States. This study aimed to investigate how the intranasal distribution of ICSs is affected by spray characteristics, patient use factors, and anatomical variation. Three-dimensional reconstructions of the nasal cavity were created from computed tomography (CT) scans of one healthy subject and one AR patient. A virtual spray nozzle was positioned in the nasal vestibule according to package insert instructions and subtracted from the nasal airspace. Hybrid tetrahedral-prism meshes were created and spray simulations were conducted in ANSYS Fluent™ with inspiratory airflow present and spray characteristics from in vitro experiments. Changes in regional corticosteroid deposition with variations in spray product, actuation force, inhalation rate, spray cone angle, nozzle insertion depth, nozzle position, and nasal side were assessed. The simulation results demonstrated that, in both models, target site deposition was mostly affected by changes in nozzle position and anatomy (left vs. right nostril). In the healthy subject, target site deposition increased with a higher actuation force, higher inhalation rate, and smaller nozzle depth, but was not significantly affected by changes in the spray cone angle. In the AR patient, target site deposition was not significantly different for changes in actuation force, inhalation rate, nozzle depth, or cone angle. The findings of this numerical study suggest that the intranasal distribution of ICSs is influenced mostly by nozzle position and nasal anatomy.

The Nonirritating Concentrations of Neuromuscular Blocking Agents and Related Compounds

Skin testing (ST) concentrations of neuromuscular blocking agents (NMBAs), NMBA-reversal agents, and the sugammadex-rocuronium inclusion complex (S-R-Cx) vary widely among reports. To determine maximal ST nonirritant concentrations (NICs) of NMBAs (cisatracurium, rocuronium, succinylcholine, and vecuronium), NMBA-reversal agents (neostigmine and sugammadex), and S-R-Cx in NMBA-tolerant and NMBA-naïve participants. A single-center, prospective study between October 2019 and November 2021 of adult participants with or without a planned surgical procedure. The reference standard was tolerance of medication tested during a procedure (NMBA-tolerant group) before ST. Participants received skin prick testing (SPT) and intradermal test (IDT) injections at 5-7 increasing concentrations of 1 or more medications. All medications were reconstituted according to package insert instructions and diluted with 0.9% saline. A concentration was considered irritant when more than 5% of participants had a positive test per ST positivity criteria (wheal ≥3 mm than initial wheal and associated erythema of the same size or greater than wheal). We also compared our results with current guidelines. A total of 187 participants (78% NMBA-tolerant) underwent 7812 skin tests. All undiluted SPT concentrations were nonirritant. We found the following maximal IDT NICs (mg/mL): cisatracurium (0.02), rocuronium (0.05), succinylcholine (0.8), vecuronium (0.01), neostigmine (0.2), sugammadex (50), and S-R-Cx (sugammadex 7.14+ rocuronium 2). Our results suggest that SPT may be performed with undiluted stock concentrations. We confirm maximal IDT NICs for cisatracurium and rocuronium. We also propose that currently recommended maximal IDT NICs of succinylcholine, neostigmine, sugammadex, and S-R-Cx could be increased, whereas the maximal IDT NIC of vecuronium could be decreased compared with current guidelines and prior reports.

Health literacy characteristics of over-the-counter rapid antigen COVID-19 test materials

BackgroundThe United States Food & Drug Administration's emergency authorized use, in December 2020, of over-the-counter (OTC) rapid antigen COVID-19 tests was a pandemic control milestone. ObjectiveTo assess health literacy-related characteristics of OTC rapid antigen COVID-19 test materials. MethodsBetween September–December 2021, we identified eleven (n = 11) OTC rapid antigen COVID-19 tests available for purchase in the US. We assessed readability (Flesch Reading Ease and Fernández-Huerta), formatting and layout features of English- and Spanish-language step-by-step OTC rapid antigen COVID-19 test package insert instructions. Video-based step-by-step OTC rapid antigen COVID-19 test instructions were evaluated for understandability and actionability (Patient Education Materials Assessment Tool for Audiovisual Materials [PEMAT-A/V]), overall quality (Global Quality Scale [GQS]) and cultural diversity and inclusiveness. Descriptive analyses were performed using IBM® Statistical Package for the Social Sciences. ResultsNine (81.8%) OTC rapid antigen COVID-19 tests included English-language (≈8th-9th reading grade level) step-by-step instructions, while 4 included Spanish-language (≈10th-12th reading grade level) instructions. On average, instructions were printed on a tabloid sized piece of paper, with text size ranging from 4 to 12 point and including nearly 20 illustrations. English-language step-by-step OTC rapid antigen COVID-19 test video-based instructions (n = 6) ranged from 1:04 to 5:41 min with PEMAT-A/V scores ranging from 80% to 100%. As indicated by GQS scores, English-language videos were of high quality (5 videos scored 5/5; 1 video scored 4/5). One COVID-19 test product manufacturing website included Spanish-language video-based instructions (time = 4:59 min; PEMAT-A/V = 100%; GQS = 5). ConclusionsOTC COVID-19 test step-by-step instructions—both package inserts and video-based—included features shown to foster patient understanding and facilitate proper use. Moving forward, greater attention needs to be placed on expanding both Spanish-language and video-based OTC COVID-19 test material availability to improve accessibility across diverse populations.

Results from the INMUNOSUN-SOGUG trial: a prospective phase II study of sunitinib as a second-line therapy in patients with metastatic renal cell carcinoma after immune checkpoint-based combination therapy

BackgroundThe INMUNOSUN trial had the objective of prospectively evaluating the efficacy and safety of sunitinib as a pure second-line treatment in patients with metastatic renal cell carcinoma (mRCC) who have progressed to first-line immune checkpoint inhibitor (ICI)-based therapies.Patients and methodsA multicenter, phase II, single-arm, open-label study was carried out in patients with a histologically confirmed diagnosis of mRCC with a clear-cell component who had progressed to a first-line regimen of ICI-based therapies. All patients received sunitinib 50 mg once daily orally for 4 weeks, followed by a 2-week rest period following package insert instructions. The primary outcome was the objective response rate.ResultsTwenty-one assessable patients were included in the efficacy and safety analyses. Four patients [19.0%, 95% confidence interval (CI) 2.3% to 35.8%] showed an objective response (OR), and all of them had partial responses. Additionally, 14 (67%) patients showed a stable response, leading to clinical benefit in 18 patients (85.7%, 95% CI 70.7% to 100%). Among the four assessable patients who showed an OR, the median duration of the response was 7.1 months (interquartile range 4.2-12.0 months). The median progression-free survival (PFS) was 5.6 months (95% CI 3.1-8.0 months). The median overall survival (OS) was 23.5 months (95% CI 6.3-40.7 months). Patients who had better antitumor response to first-line ICI-based treatment showed a longer PFS and OS with sunitinib. The most frequent treatment-emergent adverse events were diarrhea (n = 11, 52%), dysgeusia (n = 8, 38%), palmar–plantar erythrodysesthesia (n = 8, 38%), and hypertension (n = 8, 38%). There was 1 patient who exhibited grade 5 pancytopenia, and 11 patients experienced grade 3 adverse events. Eight (38%) patients had serious adverse events, four of which were considered to be related to sunitinib.ConclusionAlthough the INMUNOSUN trial did not reach the pre-specified endpoint, it demonstrated that sunitinib is active and can be safely used as a second-line option in patients with mRCC who progress to new standard ICI-based regimens.

Variation in collagenase Clostridium histolyticum practice patterns: a Survey of ISSM Members.

Collagenase clostridium histolyticum (CCH, Xiaflex, Xiapex) is the only FDA-approved medication for treatment of Peyronie's disease. It is unclear how practitioners actually use CCH in their own practices. The objectives of the study were: (1) to identify variability in practice patterns for CCH among practitioners, (2) to assess adherence to the package insert instructions, and (3) to evaluate whether provider satisfaction was associated with adherence to instructions. A 30-question online survey was distributed to 1270 members of the International Society for Sexual Medicine (ISSM) from the EU, USA, Canada and Australia. Of the 30 questions, 10 survey questions had only one response consistent with the CCH package insert recommendations. An "adherence" score was calculated for each survey participant depending on how many of these questions were answered correctly. The average adherence scores of various groups were compared using a student's t-test. A chi-squared test was used to determine association between categorical variables. Of 202 total responses, 132 practitioners reported using CCH out of 1270 ISSM members from countries where CCH is available (10.4% response rate). Practitioners from outside the USA were more likely to be satisfied with CCH (p = 0.006), and more experienced users (>20 uses) were more likely to be satisfied than less experienced users (<10 uses) (p = 0.046). Satisfied users of CCH did not have significantly different adherence scores than non-satisfied users. Even though 67% of practitioners believed they followed the package insert guidelines, only 11% adhered to all the recommendations evaluated by the survey. Treatment adherence to package insert guidelines does not appear to be associated with provider satisfaction. We believe there is utility in seeing a snapshot of these practice patterns so practitioners may feel more comfortable adapting their own practice in light of newer data supporting alternative administration methods.

Effect of blood contamination on amniotic fluid detection in vitro using immunoassays

Objective: To determine the accuracy of Actim PROM®, Amnisure®, and ROM Plus® tests for detecting amniotic fluid proteins in the setting of blood contamination.Methods: IGFBP-1 and AFP are proteins present in high concentrations in amniotic fluid, and are detected by three commercially-available immunoassays used for diagnosing ruptured membranes: Actim PROM®, Amnisure®, and ROM Plus®. We used whole blood samples and diluted these with amniotic fluid (containing known concentrations of amniotic fluid proteins) to whole blood levels of 50, 20, 10, 5, and 1%. Actim PROM®, Amnisure®, and ROM Plus® tests were performed on each sample in duplicate according to package insert instructions. Results were interpreted independently at 5, 10, 15, and 20 min by two obstetricians who were blinded to the concentrations of blood and amniotic fluid proteins in each sample. Results of each test were determined to be true positive, false negative, false positive, or true negative based on physician interpretation and whether amniotic fluid had been spiked into the samples in detectable concentrations. Overall accuracy, intraobserver concordance, and interobserver concordance, sensitivity, specificity, and predictive values for each test were calculated. Fisher exact test was used to compare test characteristics, with a p-value of <.05 considered significant.Results: Out of 120 tests performed, there were no false positive results for any test. Overall, ROM Plus® had better accuracy (97.9%) than Amnisure® (80.7%) or Actim® PROM (78.3%). Intra- and interobserver concordance were similar for all three tests (98–100%). ROM Plus® had significantly higher sensitivity than Amnisure® and Actim® PROM (p < .0001). There was no significant difference in sensitivity between Amnisure® and Actim® PROM (p = .51).Conclusion: ROM Plus® maintains strong test characteristics for the detection of amniotic fluid proteins in the setting of blood contamination, and performs significantly better than Amnisure® and Actim® PROM tests in the presence of blood.

A phase III study evaluating the efficacy and safety of remimazolam (CNS 7056) compared with placebo and midazolam in patients undergoing colonoscopy

Remimazolam is an ultrashort-acting benzodiazepine. We performed a randomized double-blind comparison of remimazolam to placebo for outpatient colonoscopy. This study design was a requirement of the U.S. Food and Drug Administration. An additional group was randomized to open-label midazolam administered according to its package insert instructions (the randomization ratio for remimazolam:placebo:midazolam was 30:6:10). Study medications were administered under the supervision of the endoscopist, without any involvement of an anesthesia specialist. Patients were given 50 to 75 μg of fentanyl before receiving study medications. Patients who failed to achieve adequate sedation in any arm were rescued with midazolam dosed at the investigator's discretion. The primary endpoint was a composite that required 3 criteria be met: completion of the colonoscopy, no need for rescue medication, and≤5 doses of remimazolam or placebo in any 15-minute interval (≤3 doses of midazolam in any 12-minute interval in the open-label midazolam arm). There were 461 randomized patients in 12 U.S. sites. The primary endpoint was met for remimazolam, placebo, and midazolam in 91.3%, 1.7%, and 25.2% of patients, respectively (P< .0001 for remimazolam vs placebo). Patients administered remimazolam received less fentanyl, had faster recovery of neuropsychiatric function, were ready for discharge earlier, and felt back to normal sooner than patients with both placebo and midazolam. Hypotension was less frequent with remimazolam, and hypoxia occurred in 1% of patients with remimazolam or midazolam. There were no treatment-emergent serious adverse events. Remimazolam can be administered safely under the supervision of endoscopists for outpatient colonoscopy, and it allows faster recovery of neuropsychiatric function compared with placebo (midazolam rescue) and midazolam. (Clinical trial registration number: NCT02290873.).

Measurement of dabigatran: previously demonstrated Hemoclot® Thrombin Inhibitor assay reagent instability on Sysmex CS-2100i is no longer an issue

The Hemoclot® Thrombin Inhibitor (HTI) assay has been recommended for measurement of dabigatran concentrations in specific clinical situations. Traditionally, reagents for biochemical assays are prepared from instructions found in the package insert. For the HTI reagents the manufacturer recommends incubating the reagents much longer than indicated in the package insert. These recommendations are added to the application sheets designed for different analyzers. Many clinicians and laboratory personnel may be unaware of the discrepancy between the two instructions, resulting in incorrect handling of the reagents. The aim of this study was to investigate the effect of the two different preparation methods on reagent stability and test results. For the standard concentration range, reagent stability on Sysmex CS-2100i was only two hours instead of the eight hours indicated by the producer when following package insert instructions (incubation time: 15 min). Stability was increased to five hours when following the application sheet (incubation time: 60 min). Two years later, the study was repeated using samples of patients treated with dabigatran etexilate. This time, reagent stability was at least six hours. Since the reagent composition was unchanged, the increased stability could be due to changed logistics by the supplier, with stock and transfer closer by. Previously demonstrated HTI reagent instability is no longer an issue at our laboratory. The reliability of results of clinical studies in which the assay has been used is potentially compromised.

Concerns with the methodology, analysis and discussion of the Buzzy® and transillumination comparison article.

Concerns with the methodology, analysis and discussion of the Buzzy® and transillumination comparison article.

Solution stability of Captisol-stabilized melphalan (Evomela) versus Propylene glycol-based melphalan hydrochloride injection

Purpose: The objective of this study was to compare the stability of recently approved Captisol-stabilized propylene glycol-free melphalan injection (Evomela™) against currently marketed propylene glycol-based melphalan injection. The products were compared as reconstituted solutions in vials as well as admixture solutions prepared from normal saline in infusion bags.Methods: Evomela and propylene glycol-based melphalan injection were reconstituted in normal saline and organic custom diluent, respectively, according to their package insert instructions. The reconstituted solutions were diluted in normal saline to obtain drug admixture solutions at specific drug concentrations. Stability of the solutions was studied at room temperature by assay of melphalan and determination of melphalan-related impurities.Results: Results show that based on the increase in total impurities in propylene glycol-based melphalan injection at 0.45 mg/mL, Evomela admixture solutions are about 5, 9, 15 and 29 times more stable at concentrations of 0.45, 1.0, 2.0 and 5.0 mg/mL, respectively. Results confirmed that reconstituted Evomela solution can be stored in the vial for up to 1 h at RT or for up to 24 h at refrigerated temperature (2–8 °C) with no significant degradation. After storage in the vial, it remains stable for an additional 3–29 h after preparation of admixture solution in infusion bags at concentrations of 0.25–5.0 mg/mL, respectively. In addition, Evomela solution in saline, at concentration of 5.0 mg/mL melphalan was bacteriostatic through 72 h storage at 2–8 °C.Conclusion: Formulation of melphalan with Captisol technology significantly improved stability compared to melphalan hydrochloride reconstituted with propylene-glycol based diluents.

Acoustic Behavior of a Reactivated, Commercially Available Ultrasound Contrast Agent

Commercially available microbubbles such as Definity contain octafluoropropane encapsulated in a lipid shell. This perfluorocarbon can be compressed into liquid nanodroplets at room temperatures and activated with transthoracic diagnostic ultrasound. The aim of this study was to determine the size range and acoustic characteristics of Definity nanodroplets (DNDs) compared with Definity microbubbles (DMBs). An invitro flow system was used with a diagnostic ultrasound transducer (S5-1, iE33). DMBs were prepared using package insert instructions. DNDs were prepared by cooling DMBs in a -10°C to -15°C isopropyl alcohol bath before hand-pressurizing the solution. The formed DNDs were sized, diluted to 1% solutions, and infused continuously into a phosphate-buffered saline solution running within Silastic tubing. Acoustic intensity (AI) was compared with equivalent dilutions of DMBs at different mechanical indices (MIs) ranging from 0.2 to 1.4 (n=6 comparisons at each MI) using real-time 56-Hz and triggered 2-Hz frame rates (FRs). A 3-cm-thick tissue-mimicking phantom was used to simulate transthoracic attenuation. Invivo transthoracic studies were performed in four normal pigs infused with 10% intravenous infusions of DMBs or DNDs at real-time and triggered end-systolic FRs to compare differences in myocardial and left ventricular cavity AI. DNDs were smaller than DMBs and ranged in size from 50 to 1,000nm. Invitro studies revealed that at an MI of 0.2 and an FR of 56Hz, DMBs had high AI (37±2dB), but AI dropped to 25±2dB at an MI of 1.0 (P<.001, analysis of variance). In comparison, DNDs had virtually no AI at MIs of 0.2 to 0.6 at both triggered and 56-Hz FRs (1±0dB), but AI increased to 34±2dB at an MI of 1.4 using an FR of 56Hz (P<.001 vs MI of 0.2). AI also persisted longer at 56Hz with DNDs when using higher MIs. Invivo studies demonstrated higher myocardial AI for DNDs at higher MIs when using real-time FR, most likely from microvascular nanodroplet activation. These data indicate significant differences in acoustic responses of the commercially available DMBs when administered as an equivalent number of DNDs. The DND formulation may render them more useful for high-MI real-time imaging and other targeted transthoracic diagnostic applications.

The effect of non-compliance of PPI instruction on the stability of reconstituted oral antibiotics

Abstract: The patient package inserts (PPIs) should contain all the required information for the patient. It must be clear and understandable. There are several problems with the PPIs including the wrong information, readability and comprehensibility. Thus the pharmacists have to take an active role in making sure that patient is aware of important instruction including correct storage. Five antibiotics namely Erythromycin ethylsuccinate, Amoxicillin, Cefdinir, Flucloxacillin sodium and Clarithromycin powder for suspensions, were selected for this study, these antibiotic were reconstituted as directed on the label and tested initially and after 7 days when stored at room temperature and in refrigerator. Several chemical and physical pharmacopeial tests were performed. The results showed that two of the antibiotic oral suspensions namely erythromycin ethyl succinate and flucloxacillin sodium failed the accepted shelf life specification limits when stored at room temperature while both passes these limits when stored in refrigerator. Erythromycin ethylsuccinate has failed the tests of taste and odour while the flucloxacillin sodium has failed the assay test. Clarithromycin has failed some tests as viscosity, taste and pouring test when stored in refrigerator while passes all the tests when stored at room temperature. The study showed the vital role of the pharmacist to reiterate the important patient package insert instructions specially those concerned with the storage condition of the drug.

(1,3)-β-d-glucan in cerebrospinal fluid for diagnosis of fungal meningitis associated with contaminated methylprednisolone injections.

Prompt diagnosis and treatment of fungal meningitis are critical, but culture is insensitive. (1,3)-β-d-Glucan (BDG) testing is FDA approved for serological diagnosis of invasive fungal disease; however, BDG testing is not approved for cerebrospinal fluid (CSF), and the appropriate cutoff value is unknown. We aimed to validate the diagnostic accuracy of CSF BDG measurements for fungal meningitis among patients exposed to contaminated methylprednisolone acetate (MPA). A retrospective observational study was conducted at St. Joseph Mercy Hospital and Vanderbilt University from November 2013 to February 2014. Patients were included if they had received a contaminated MPA injection. Cases were classified as probable or proven meningitis according to Centers for Disease Control and Prevention guidelines. CSF BDG testing was performed according to the package insert instructions for serum samples, and results were validated using Clinical and Laboratory Standards Institute procedures (MiraVista Diagnostics). Of 233 patients, 45 had meningitis (28 proven cases), 53 had spinal/paraspinal infections (19 proven cases), and 135 did not develop disease. Using the manufacturer's cutoff value (≥80 pg/ml), the sensitivity and specificity were 96% and 95%, respectively, for proven meningitis and 84% and 95% for probable or proven meningitis. Receiver operating characteristic analysis identified the optimal cutoff value for proven meningitis to be 66 pg/ml (sensitivity, 100%; specificity, 94%) and that for probable or proven meningitis to be 66 pg/ml (sensitivity, 91%; specificity, 92%). Our results suggest that CSF BDG measurements are highly sensitive and specific for the diagnosis of fungal meningitis associated with contaminated MPA injections. Further study on the utility of CSF BDG testing for other types of fungal meningitis is needed.

Genotype impact on HCV RNA levels determined with the VERSANT HCV RNA 1.0 Assay (kPCR)

BackgroundAccurate quantitation of hepatitis C virus (HCV) RNA is mandatory for the management of anti-HCV therapy. ObjectivesThe genotype-dependent performance of the new commercially available VERSANT HCV RNA 1.0 Assay (kPCR) and the COBAS AmpliPrep/COBAS TaqMan HCV Quantitative Test, version 2.0 was investigated. Study designThe molecular assays for quantitation of HCV RNA were performed according to the manufacturer's package insert instructions. HCV genotypes/subtypes/isolates, and mutations in the 5′NCR were detected by direct sequencing. ResultsWhen members of a worldwide HCV performance panel including HCV subtypes 1a, 1b, 2a, 3b, and 4a were tested with the Siemens assay and the results were compared with those obtained by the Roche assay, the mean log10 unit differences for members containing HCV subtypes 1a, 1b, 3b, and 4a were found to be within ±0.5 log10 units. For the panel member containing HCV subtype 2a, the HCV RNA concentration was found to be >0.5 log10 units lower with the Siemens assay. When clinical samples were tested, the HCV RNA concentration of all samples containing HCV subtype 2a were found to be >0.5 log10 units lower with the Siemens assay while that of certain HCV subtype 3a and 4a isolates were found to be >1.0 log10 units lower. ConclusionThe VERSANT HCV RNA 1.0 Assay substantially underestimates HCV RNA concentrations in HCV subtype 2a samples and in HCV subtype 3a and 4a samples containing certain isolates. This may be caused by mismatches with the target sequences due to the primer and/or probe design.

The Development of Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) in a Patient with Hepatitis C Virus Cirrhosis on Telaprevir

Purpose: A 56-year-old Caucasian male with a past medical history of hypothyroidism, hepatitis C virus (HCV) cirrhosis, genotype 1a diagnosed twenty years ago previously treated two times with interferon (IFN) alone then with pegylated interferon alfa-2a (peg-IFN) and ribavirin (RBV) presents with drug rash with eosinophilia and systemic symptoms (DRESS) while on a third treatment regimen with the new protease inhibitor telaprevir (TVR), RBV and peg-IFN. As a prior relapser, with well compensated cirrhosis he underwent a liver biopsy before initiating treatment which showed stage four cirrhosis. The patient had extended rapid virological response (eRVR) defined as undetectable HCV RNA at week 4 and 12 with a dose reduction of peg-IFN to 135 mcg injected subcutaneously once weekly secondary to rectal bleeding without changes in RBV or TVR dosing. His hospital course was complicated with gram positive bacteremia treated with antibiotics and IV steroid induced psychosis while being treated for DRESS syndrome. His rash, bacteremia and psychosis were treated successfully and he was discharged on IV antibiotics. His skin biopsy, “definite” diagnosis according to the RegiSCAR's scoring system and response to treatment highlights the importance of recognition and treatment of DRESS associated with telaprevir use. This is the first reported case of the use of IV steroids for DRESS linked to TVR. Although dermatologists may use it for other cases of DRESS, TVR package insert does not recommend use of systemic steroids. Cases like this, which are prone to life-threatening situations, should be reported and might also prompt for a change of the package insert instructions to include the use of systemic steroids in such high risk cases. Along with the development of DRESS, our patient is unique. He relapsed despite continuation of peg-IFN and RBV after a brief interruption of therapy.

Efficacy of Ofatumumab and High-Dose Methylprednisolone for the Treatment of Relapsed or Refractory Chronic Lymphocytic Leukemia (CLL)

Abstract 4619 Background:Ofatumumab is a fully-humanized anti-CD20 monoclonal antibody approved in refractory CLL. The combination of high-dose methylprednisolone (HDMP) and anti-CD20 monoclonal antibody rituximab has previously shown positive results in high-risk refractory CLL. Herein we report our institutional experience with the combination of ofatumumab and HDMP for the treatment of patients with relapsed or refractory CLL. Methods:Between October 2009 and June 2011, 10 consecutive patients with relapsed or refractory CLL received HDMP and ofatumumab at Moffitt Cancer Center. HDMP was dosed at 1 g/m2 IV weekly for 3 weeks every 28 days for two cycles, then monthly for 3 cycles. Ofatumumab was administered according to package insert instructions along with prophylactic antimicrobials. The primary endpoint was to evaluate response as defined by the updated National Cancer Institute Working Group Guidelines (NCIWG 2008). Secondary objectives were to assess treatment tolerance and toxicity. Descriptive statistics were used for baseline characteristics and response rates. Results:Eight of ten patients were male, with a median age of 60 years (range 43–81). All patients were previously treated with rituximab, and were intolerant to or failed fludarabine and/or alemtuzumab. The median number of prior treatments was 3.5 (range 1–5). Seven patients had high-risk prognostic markers including unfavorable cytogenetics or unmutated IgVH. Six patients had 17p deletion, 2 patients had 11q deletion, and 3 patients had an unmutated IgVH (6 patients had two prognostic markers). Eight patients were able to complete all planned treatments. One patient discontinued treatment due to worsening performance status and 1 patient discontinued treatment due to progressive disease. HDMP and ofatumumab were used as a bridge to allogeneic hematopoietic stem cell transplant in 4 patients. Based on NCIWG 2008 criteria, 2 patients had a partial response (PR), 1 patient had progressive disease (PD), and 6 patients had stable disease (SD). Five patients with stable disease had a clinical decrease of lymph nodes or a decrease in lymphocyte counts.Despite the use of prophylactic antimicrobials severe infectious complications occurred in 40% of patients. Infections included 1 patient with norovirus, 1 patient with cytomegalovirus viremia and a fusarium infection of the neck, 1 patient with aspergillus pneumonia, Pseudomonas aeruginosa bacteremia, and an Escherichia coli bacteremia, and 1 patient with a necrotizing pneumonia. Conclusion:This data demonstrates the benefit of HDMP and ofatumumab combination in patients with heavily pretreated CLL. The combination of ofatumumab and HDMP has a role as salvage therapy and as a bridge to allogeneic stem cell transplant. The incidence of infection was high despite the use of prophylactic antibiotics. Aggressive antibiotic prophylaxis is warranted including coverage for mould infections. Disclosures:Off Label Use: Ofatumumab in combination with high dose methylprednisolone for the treatment of relapsed/ refractory CLL. Pinilla-Ibarz:GSK: Speakers Bureau.

External quality assessment on the use of malaria rapid diagnostic tests in a non-endemic setting

BackgroundMalaria rapid diagnostic tests (RDTs) are increasingly used as a tool for the diagnosis of malaria, both in endemic and in non-endemic settings. The present study reports the results of an external quality assessment (EQA) session on RDTs in a non-endemic setting.MethodsAfter validation of antigen stability during shipment at room temperature, three clinical samples and a questionnaire were sent to clinical laboratories in Belgium and the Grand Duchy of Luxembourg using malaria RDTs. Participants were asked to report the results of the RDTs as observations (visibility of the RDT control and test lines) and interpretations (report as formulated to the clinician). In addition, participants were invited to fill in a questionnaire on the place of RDTs in the diagnostic strategy of malaria.ResultsA total of 128/133 (96.2%) of clinical laboratories using RDTs participated. Six three-band and one four-band RDT brands were used. Analytical errors were rare and included (i) not recognizing invalid RDT results (1.6%) and (ii) missing the diagnosis of Plasmodium falciparum (0.8%). Minor errors were related to RDT test result interpretation and included (i) reporting "RDT positive" without species identification in the case of P. falciparum and non-falciparum species (16.9% and 6.5% respectively) and (ii) adding incorrect comments to the report (3.2%). Some of these errors were related to incorrect RDT package insert instructions such as (i) not reporting the possibility of mixed species infection in the case of P. falciparum and Plasmodium vivax (35.5% and 18.5% respectively) and (ii) the interpretation of P. vivax instead of non-falciparum species at the presence of a pan-species antigen line (4.0%). According to the questionnaire, 48.8% of participants processed ≤20 requests for malaria diagnosis in 2009. During opening hours, 93.6% of 125 participants used RDTs as an adjunct to microscopy but outside opening hours, nearly one third of 113 participants relied on RDTs as the primary (4.4%) or the single tool (25.7%) for malaria diagnosis.ConclusionIn this non-endemic setting, errors in RDT performance were mainly related to RDT test line interpretations, partly due to incorrect package insert instructions. The reliance on RDTs as the primary or the single tool for the diagnosis of malaria outside opening hours is of concern and should be avoided.

Ofatumumab and High-Dose Methylprednisolone Is An Effective Salvage Treatment for Heavily Pretreated, Unfit or Refractory Patients with Chronic Lymphocytic Leukemia: Single Institution Experience

AbstractAbstract 4638High-dose methylprednisolone (HDMP) and the fully human monoclonal anti-CD 20 Ofatumumab each can produce partial responses in CLL, even though complete remissions are not often observed following treatment with either agent alone.Previously we have reported that the combination of Rituximab and HDMP is an effective non-myelosuppressive treatment combination for previously untreated CLL patients as well as in patients that are fludarabine refractory. We report here our single institution experience of treatment using the combination of HDMP and Ofatumumab in CLL patients that were not considered to be good candidates for chemotherapy treatment due to comorbidities, poor performance status, profound cytopenias or because refractory status to fludarabine and/or alemtuzumab.Eight patients with progressive, symptomatic CLL were treated with HDMP 1 g/m2 IV daily × 3 every 28 days for three consecutive cycles, and ofatumumab administered based on package insert instructions (300 mg dose # 1 followed by 11 doses of 2,000 mg over a 6 month period) along with prophylactic antimicrobial therapy. The main objectives were to determine the safety, toxicity and clinical efficacy of this regimen.All of the patients were males with a median age of 69 years (range 49–78). The median of prior treatments was 4.5 including 4 patients that have received previously HDMP and rituximab and two patients that underwent matched unrelated donor stem cell transplant. All patients have been previously treated with rituximab, 75% of the patients failed or were intolerant to fludarabine and/or aletuzumab and 88% had high-risk disease by the modified Rai classification. Most of the patients had bulky disease with median lymph node product of 42 cms2 and median splenomegaly of 6. 5 cm (range 0–17) below the left costal margin. The median lymphocyte count was 28,000 cells/mm3. 75% of the patients had high-risk prognostic markers including unfavorable cytogenetics, unmutated IgVH region genes or high expression levels of ZAP-70.All patients completed the planned therapy with no major side effects or toxicities. There was no evidence of marrow suppression and even patients with pancytopenia improved their peripheral blood counts with this salvage regimen. During treatment patients experience significant decrease in peripheral white blood cell counts, increase in hemoglobin, elevation of platelets and a dramatic reduction in lymphadenopathy and splenomegaly. Response assessment based on the IW-CLL 2008 criteria showed that the overall response rate was 50% (4 partial remissions), 25% of patients had stable disease and the remainder showed progressive disease.Overall, these data suggest that the combination of HDMP and Ofatumumab is a safe and effective salvage regimen for high-risk CLL patients that otherwise were not candidates for additional treatment. The response rates observed for the combination of HDMP and Ofatumumab in this group of patients appear to be favorable with the majority of patients achieving a response to therapy or experiencing disease stabilization. Moreover, HDMP and Ofatumumab treatment was not associated with bone marrow suppression, which is a major limiting factor for treatment administration, making this regimen a potential valid alternative for high-risk CLL patients. Additional clinical studies of this combination are warranted. Disclosures:No relevant conflicts of interest to declare.

A Rapid Radiochemical Purity Testing Method for 99mTc-Tetrofosmin

The standard radiochemical purity (RCP) testing method for (99m)Tc-tetrofosmin as described in the package insert requires extensive time (20-30 min) and considerable skill to achieve accurate results. Additionally, the instant thin-layer chromatography strip impregnated with silica gel (2x20 cm) used in the standard method will not be commercially available in the future. The purpose of this study was to evaluate whether a method developed by our laboratory for RCP testing of (99m)Tc-sestamibi could also be used as an alternative method for the RCP assay of (99m)Tc-tetrofosmin. The alternative RCP testing system consisted of a precut paper strip (1x8.5 cm) from solvent saturation pads (Pall Corp.) as the stationary phase, with 1:1 chloroform:tetrahydrofuran used as the mobile phase. To validate the reliability of the alternative method, RCP values from 17 kit preparations were compared with the 2 methods. Kits were reconstituted according to the package insert instructions, and 4 additions of (99m)Tc-sodium pertechnetate were purposely added to create trials with RCP values below the accepted limit of 90% purity. Two hundred four trials (100 of which were replicated) were run from the 17 kit preparations. Sixty-four (31%) of the 204 trials were below 90% purity based on the standard method. The overall agreement between the standard and alternative methods was 94% (192/204). The sensitivity of the alternative method for unacceptable RCP limits was 86% (55/64), and the specificity for acceptable RCP values was 98% (137/140). The agreement between the replicated trials of the alternative method was 99% (99/100), and for the standard method it was 92% (92/100). The standard method proved to be a much slower method and requires much more precision and attention. The alternative method is much faster, is easier, requires less attention to the solvent-development process, and can be used for RCP testing of both (99m)Tc-tetrofosmin and (99m)Tc-sestamibi. Furthermore, the stationary phase is much more readily available, is not moisture-sensitive, and is less susceptible to operator technique. Our method is accurate in determining the RCP value of (99m)Tc-tetrofosmin and is a better RCP testing method for (99m)Tc-tetrofosmin.

Evaluating the Role of a New Dilute Prothrombin Time Assay ACTICLOT dPT in Lupus Anticoagulant Testing.

The current ISTH recommendations for Lupus Anticoagulant (LA) testing include screening with two or more sensitive assays with different assay principles. Many laboratories utilize a single Global assay such as the Hexagonal Phase Neutralization (STACLOT-LA) to satisfy the diagnostic criteria of a prolonged screen, inhibitor on mixing study, and demonstration of phospholipid dependence. Recent data presented at the SSC meeting of the ISTH suggests that laboratories may be relying too heavily on global assay to make the determination of LA. The aim of this study was to evaluate LA positivity in a pre-selected cohort of LA positive plasmas in which the diagnosis was based only upon a single positive result from a hexagonal phase global assay using a new dilute Prothrombin time test ACTICLOT dPT™Methods: 100 LA positive plasmas characterized as STACLOT-LA positive and dRVVT negative were collected. A STACLOT-LA delta > 8 sec was considered positive. The sample mean delta was 13.3 (SD +/− 5.5). ACTICLOT dPT screen and confirm was performed according to package insert instructions on a Beckman Coulter ACL automated coagulation analyzer. Additionally, 1:1 immediate and 1 hour incubated mixing studies were performed. The samples were also characterized for antiphospholipid antibodies using IMUCLONE aCL-HS and IMUCLONE anti-B2GPI IgM and IgG ELISAs. Thirty dRVVT Positive LA controls were also tested using the same ELISAs. Results are tabulated below. In graphs that will be presented, the STACLOT-LA Positive/dRVVT Negative samples have a stronger association with IgM antiphospholipid antibodies, whereas the dRVVT positive control cases demonstrate a stronger association with IgG antiphospholipid antibodies.Conclusions: The hexagonal phase positive/dRVVT negative samples examined in this study (n=100) were characterized as “weak” positive LA by hexagonal phase assay and contained mostly low titer IgM antiphospholipid antibodies by ELISA. These results suggest that many of the LA plasmas pre-selected in this cohort by hexagonal phase alone are likely to be transient LA positives. About 25% of the samples were considered LA positive using the ACTICLOT dPT screening, confirmatory and mixing protocols. The diagnosis of LA in the remaining samples may still be equivocal based upon the hexagonal phase results alone. Adding the dPT test which functions through the extrinsic pathway may improve current LA screening panels comprised of dRVVT and hexagonal phase assays. The third LA test may also identify certain LA samples that are not picked up by the dRVVT or hexagonal phase assays. Additional studies (in progress) of other LA cohorts such as STACLOT-LA Negative/dRVVT positive and prospective evaluations will help determine if single global assays overestimate LA positivity.dPT Screen, Mix, and Confirm Results (n=100)Prolonged screenProlonged screenProlonged screenProlonged screenInhibitor pattern on 1:1 mixCorrection pattern on mixing studyInhibitor pattern on mixing studyCorrection pattern on mixing studyPositive confirmNegative confirmNegative confirmPositive confirm23 %21%5 %1 %