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The ED FNP is a significant quality initiative with sustainable interventions, and was able to demonstrate value by decreasing TTA compared to both historical and DA controls in cancer patients presenting to the ED.

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Febrile neutropenia (FN) can occur at any time during the course of a malignancy, especially hematologic malignancies, from diagnosis to end-stage disease. The majority of FN episodes are typically confined to the period of initial diagnosis and active treatment. Because of suppressed inflammatory responses, fever is often the sole sign of infection. As FN is a true medical emergency, prompt identification of and intervention in FN can prolong survival and improve quality of life. This article reviews FN in the setting of hematologic malignancies, specifically myelodysplastic syndromes and acute leukemias, providing an overview of the definition of fever and neutropenia, diagnostic approach, categories of risk/risk assessment, management in patients at low and high risk, and prophylaxis of infections.

Most drugs used in standard regimens for acute lymphoblastic leukemia (ALL) were developed more than 30 years ago. Since that time, several new drugs have been developed and incorporated into ALL treatment. In spite of this, novel therapeutic approaches are still needed to improve outcomes for high-risk or relapsed ALL. This manuscript discusses newer treatment strategies, including purine nucleoside analogs, monoclonal antibodies, antibody drug conjugates, mammalian target of rapamycin (mTOR) inhibitors, proteasome inhibitors, histone deacetylase (HDAC) inhibitors, hypomethylating agents, spleen tyrosine kinase inhibitors, Bruton's tyrosine kinase (BTK) inhibitors, Janus kinase-signal transducer and activator of transcription (JAK-STAT) inhibitors, anti-programmed cell death protein (anti-PD-1) antibodies, mitogen-activated protein kinase (MEK) inhibitors, CXCR4 antagonists, poly (ADP-ribose) polymerase (PARP) inhibitors, and FMS-like tyrosine kinase 3 (FLT3) inhibitors. Additionally, this manuscript discusses the impact of diagnostic approaches on management of ALL. Specifically, minimal residual disease is increasingly felt to be important and will likely dramatically impact the care of ALL patients in the near future.

Purpose: Constitutive signal transducer and activator of transcription 3 (STAT3) activity, observed in f50% of acute myelogenous leukemia cases and associated with adverse treatment outcome, is down-regulated by arsenic trioxide (ATO). Heat shock protein (HSP) 90 is a molecular chaperone involved in signal transduction pathways. We hypothesized that HSP90 inhibitors will potentiate ATO effect on constitutive STAT3 activity and cell killing. One concern was that the effect of ATO and HSP90 inhibitors will result in up-regulation of HSP70, a protein known to inhibit apoptosis. Experimental Design: We have used a semimechanistic pharmacodynamic model to characterize concentration-effect relationships of ATO and HSP90 inhibitors on constitutive STAT3 activity, HSP70 expression, and cell death in a cell line model. Results: Pharmacodynamic interaction of ATO and three HSP90 inhibitors showed synergistic interactions in inhibiting constitutive STAT3 activity and inducing cell death, in spite of a concurrent synergistic up-regulation of HSP70. Conclusions: These preliminary results provide a basis for studying the combined role of ATO with HSP90 inhibitors in acute myelogenous leukemia with constitutive STAT3 activity.Constitutive signal transducer and activator of transcription 3 (STAT3) activity has been shown to be present in leukemia cells in 50% of acute myelogenous leukemia (AML) cases and to correlate with adverse treatment outcome (1). We have shown that arsenic trioxide (ATO) down-regulates constitutive STAT3 activity in AML cells within 6 h, without affecting cell survival until 48 h (2). Heat shock protein (HSP) 90 is implicated in maintaining the conformation, stability, and function of key proteins involved in signal transduction pathways (3), and we therefore hypothesized that HSP90 inhibitors [geldanamycin,, and 17-(dimethylaminoethylamino)-17-demethoxygeldanamycin (NSC 707545, 17-DMAG)] would potentiate the effect of ATO on constitutive STAT3 activity in AML cells. One concern was that up-regulation of HSP70, a protein known to inhibit apoptosis (4, 5), by exposure to either ATO (6 -8) or HSP90 inhibitors (9, 10), might abrogate their effect on constitutive STAT3 activity and survival.Identifying the type and extent of drug-drug interactions has been a challenge since the early 1900s. When the mechanisms of action of two pharmacologic agents are not known, empirical drug-drug interaction models such as Loewe additivity (11), Bliss independence (12), or the Chou and Talalay method (13, 14) can be applied. When the true behavior is well appreciated, mechanistic models offer insight into the physiologic processes influencing the degree of interaction (15 -17). The HSP90 inhibitors act by binding HSP90 and preventing the stabilization of ''client'' protein complexes, involving cancer targets such as mutated p53, Raf-1, ErbB2, and other proteins associated with signal transduction. On the other hand, the mechanism of ATO action toward DNA fragmentation and cell death is not completely understood. It...

This study aimed to identify the rate and impact of vancomycin-resistant enterococcal (VRE) bacteremia in patients with acute myeloid leukemia (AML) receiving induction chemotherapy (IC). Thirty-seven (10.6%) of 350 patients had VRE bacteremia during IC, with increasing rates of VRE bacteremia over the course of the study period. The overall complete remission (CR) rate for the cohort was 73%, and there was no difference in CR rate between the VRE bacteremia and non-VRE bacteremia cohorts (70% vs. 73%, p = 0.70). Unadjusted median overall survival (OS) was 12.8 months, and differed significantly between those with and without VRE bacteremia (7.1 months vs. 13.1 months, respectively; p = 0.03). The presence of VRE bacteremia during IC for AML was independently associated with increased all-cause mortality (hazard ratio 1.72, 95% confidence interval 1.13-2.63, p = 0.01).

Relapsed/refractory (R/R) acute lymphoblastic leukemia (ALL) is associated with a poor prognosis in both children and adults. Traditionally, there were limited options for salvage therapy, which consisted mostly of conventional chemotherapy. However, in the past 5 years, novel agents have changed our treatment strategies in this population. Blinatumomab, a bispecific CD19 directed CD3 T-cell engager, has shown to be effective in both minimal residual disease and R/R B-cell ALL. In R/R B-cell ALL, blinatumomab was associated with an improved median overall survival of 7.7 months vs 4.0 months with traditional chemotherapy (HR for death, 0.71; 95% CI, 0.55–0.93; P=0.01). It has distinctive side effects as compared to chemotherapy, specifically cytokine release syndrome and neurological toxicities. When compared to standard of care chemotherapy, patients have higher quality of life scores and less financial burden. Using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, blinatumomab-treated patients fared better and had a longer time to deterioration or death (global health status/quality of life subscale: HR 0.66; 95% CI 0.48–0.92; P=0.009) compared to conventional chemotherapy. Using an incremental cost effective ratio threshold of US$150,000 per quality adjusted life year, blinatumomab was determined to be more cost effective compared to chemotherapy with a probability of 73.7%. This review summarizes the current and future data with blinatumomab in R/R B-cell ALL in the adult and pediatric population.