Medical Specialties Commons^™

A Guide To Point Of Care Ultrasound Evaluation Of Pneumonia, Michael Dong, Md, Frances Mae West, Md, Rebecca Davis, Md, Jonathan Foster, Md, Jillian Cooper, Md

The Medicine Forum

A patient presenting with fever, hypoxia, productive cough, and leukocytosis can be diagnosed with pneumonia without any imaging findings. However, we often rely on X-ray and computed tomography (CT) imaging to support the clinical diagnosis. Ultrasound is an effective imaging modality for identifying pneumonia without delay and radiation risks.^1,2 A meta-analysis by Ye et al. in 2015 found that ultrasound diagnosis of pneumonia had a pooled sensitivity of 0.95 and a pooled specificity of 0.9, which is superior to X-ray imaging which had a pooled sensitivity of 0.77 and a similar pooled specificity of 0.9.³ This study used …

A Guide To Point Of Care Ultrasound Lung And Ivc Examination Of A Volume Overloaded Patient, Michael Dong, Md, Frances Mae West, Md, Jonathan Foster, Md, Rebecca Davis, Md, Jillian Cooper, Md

The Medicine Forum

A patient presents with dyspnea, hypoxia, and lower extremity edema. Their history is notable for recent high salt intake and non-compliance with diuretics, and their lungs have rales bilaterally. Clinically, we can diagnose a heart failure exacerbation with pulmonary edema. However, we often rely on X-ray and computed tomography (CT) imaging to support the clinical diagnosis and explore the etiology of the hypoxia and dyspnea to narrow the differential. Ultrasound is an effective modality for identifying pulmonary edema and pleural effusions while at the same time ruling out other etiologies such as pneumonia and pneumothorax. With bedside point of care …

A Guide To Point Of Care Ultrasound Examination Of A Pericardial Effusion, Michael Dong, Md, Frances Mae West, Md, Jillian Cooper, Md, Jonathan Foster, Md, Rebecca Davis, Md

The Medicine Forum

A patient presents with pleuritic chest pain, dyspnea, and a recent viral illness. They have no prior cardiac or pulmonary history. Their X-ray on admission demonstrates no pulmonary findings and an enlarged cardiac silhouette, and their EKG is low voltage with electrical alternans. Ultrasound is an effective modality for identifying pericardial effusion and cardiac tamponade while at the same time evaluating for other causes, such as heart failure. Often patients with symptomatic pericardial ef fusion present with non-specific symptoms. While a “formal” transthoracic echocardiogram remains the gold standard for diagnosis, a bedside point of care ultrasound (POCUS) cardiac evaluation can …

A Guide To Point Of Care Ultrasound Examination Of Acute Decompensated Heart Failure, Michael Dong, Md, Rebecca Davis, Md, Jonathan Foster, Md, Jillian Cooper, Md, Frances Mae West, Md

The Medicine Forum

A patient presents with dyspnea on exertion, orthopnea, and lower extremity edema. They have a prior history of coronary artery disease and reported episodes of chest pain three months ago. They did not seek medical evaluation at the time and have had no chest pain recently. In this setting, there is a high clinical suspicion of heart failure with concern for ischemic heart disease. The gold standard for diagnosis of heart failure is a formal transthoracic echocardiogram. Bedside point of care ultrasound (POCUS) is a tool that can provide essential information without delay in diagnosis.

A Case Of Suspected Lisdexamfetamine (Vyvanse) Drug-Induced Liver Injury, Louis Kishfy, Md, Justin Bilello, Md, Monjur Ahmed, Md, Elizaveta Flerova, Md

The Medicine Forum

Amphetamines are a well-established cause of liver injury though the typical presentation is that of illicit drug abuse rather than liver injury occurring in a prescribed setting.¹ Lisdexamfetamine (Vyvanse) is one of the most commonly prescribed stimulant medications used for the treatment of Attention Deficit Hyperactive Disorder (ADHD). The authors were only able to find a single case of lisdexamfetamine-related drug-induced liver injury (DILI) occurring in the pediatric population in their review of the literature. Here we present a case of suspected lisdexamfetamine DILI in an adult patient.

Helpful Or Harmful? A Case Report Of Nutritional Supplements Causing Drug-Induced Liver Injury, Amman Bhasin, Md, Phoebe Chun, Md, Justin Bilello, Md, Manju Ambelil, Md, Dina L. Halegoua-Demarzio, Md

The Medicine Forum

Herbal supplement-induced liver injury represents a growing concern in the body of drug-induced liver injury (DILI) literature, with recent studies in mainland China, Iceland, and the United States reporting estimated rates of herb/dietary supplement-induced liver injury (HILI) between 1.16-6.38 per 100,000 (Björnsson et al., 2013; Shen et al., 2019; Vega et al., 2017). Notably, a recent 2020 study demonstrated an increasing prevalence of hepatotoxicity secondary to herbal and dietary supplements in the US and worldwide (Zheng et al., 2020). Recognizing the hepatotoxicity of various supplements is crucial, given the increasing usage of dietary and herbal supplements and the lack of …

End-Stage Chronic Intestinal Pseudo-Obstruction Resulting In Intestinal Pneumatosis, Justin Bilello, Md, Amman Bhasin, Md, Phoebe Chun, Md, Aaron Martin, Md

The Medicine Forum

Chronic intestinal pseudo-obstruction (CIPO) is a rare gastrointestinal motility disorder that presents with symptoms, physical exam, and imaging findings of mechanical bowel obstruction without an anatomical obstruction. Multiple etiologies, including enteric or extrinsic neuropathic dysfunction, myopathic dysfunction, or dysfunction of the interstitial cells of Cajal, cause CIPO’s pathogenesis. The presentation of CIPO may be idiopathic or caused by underlying diseases. The most common presentation is abdominal pain, bloating, and distension. Here, we present a patient with an end-stage case of CIPO who failed medical therapy. Her distension progressed over a decade, requiring emergency surgery due to intestinal pneumatosis.

A Case Presentation Of Pericarditis Associated With Haemophilus Influenzae Bacteremia, Risa Goldberg, Md, Harrison Bell, Md

The Medicine Forum

Acute pericarditis, or inflammation of the pericardial sac, is a clinical condition which can often be attributed to a variety of underlying etiologies, including infection, autoimmune disease, trauma, and malignancy. While viral infections are commonly implicated in the etiology of pericarditis, bacteria known to be associated with pericarditis include staphylococcus species, streptococcal species, tuberculosis, and in children, Haemophilus influenzae.¹ Here we present a rare case of pericarditis in an adult male patient which occurred in association with Haemophilus influenzae bacteremia.

A Case Of Bartonella Endocarditis And Torrential Aortic Regurgitation Leading To Cardiac Arrest, Brandon Pecchia, Md, Ms, Sawyer Kieffer, Md

The Medicine Forum

Infective endocarditis can be difficult to diagnose, especially when blood culture-negative. We describe a case of a patient who presented with signs and symptoms of new, acute decompensated heart failure who was found to have culture-negative endocarditis, a large, mobile aortic valve mass, and torrential aortic regurgitation. Although the patient remained clinically stable during early admission and was planned for surgical correction of the valvular pathology, he suffered abrupt clinical decompensation which resulted in cardiac arrest. Postmortem serologies were found to be positive for Bartonella henselae and Bartonella quintana.

An Educational Case For Applying The Alveolar- Arterial Gradient In Hypoxemia: An Underutilized And Underappreciated Clinical Tool, Chioma Nwonu, Do, Michael Dong, Md, Daniel Kramer, Md

The Medicine Forum

The Alveolar-arterial gradient, commonly known as the A-a gradient, measures the difference in the oxygen concentration in the alveoli and the arteries across the capillary membrane in the lung. In an ideal system, the A-a gradient would be zero because there would be perfect equilibrium as oxygen diffuses and equalizes across the alveolar and arterial sides of the capillary membrane. However, there is a physiologic A-a gradient because of the differences in perfusion and ventilation in the apical and basilar regions of the lungs. Because this relationship exists, the changes in the A-a gradient have clinical utility in guiding the …

Achenbach Syndrome: A Classic Presentation Of A Not-So-Common Condition, Brandon Pecchia, Md, Ms

The Medicine Forum

Also called “acute idiopathic blue finger” or “paroxysmal finger hematoma,” Achenbach syndrome is a benign collection of findings that is often mistaken for more serious conditions. Characteristically presenting with discrete unexplained bruising or discoloration of the volar aspect of one or two fingers, it is a diagnosis that physicians should include on their differential given its innocuous course and excellent outcomes, without need for invasive testing or intervention. The purpose of this case report therefore is to increase awareness of this rare condition, especially among emergency department physicians and internists, in order to minimize the incidence of unnecessary testing, procedures, …

From The Chief Residents, Tina Boortalary, Md, Justin Robbins, Md, Svenja Schneider, Md

The Medicine Forum

As your Chief Residents, we would like to take a moment to express our heartfelt congratulations to each and every one of you on your incredible scholarly achievements over the past year. We have been impressed by the quality and diversity of your scholarly work. From interdisciplinary clinical research projects that have been submitted to journals across numerous subspecialties, to contributions to the Health Equity and Quality Improvement Summit, you have all demonstrated a passion for excellence and a commitment to advancing the field of medicine. We are grateful for the opportunity to have worked alongside you and to have …

From The Editors, Harrison Bell, Md, Akash Patel, Do, Benjamin Tasevac, Md

The Medicine Forum

We are honored to present the 24th Annual edition of The Medicine Forum to the Jefferson community. Over the years, it has been remarkable to see the quality and diversity of projects submitted to this forum, and this year is no exception. The Medicine Forum aims to celebrate the scholarly activity among physicians in training at our institution. We hope that this year's edition will continue to honor this long standing tradition. Despite the uncertainties and stressors that are inherent to working in a hospital, our authors have found the time to produce scholarly work that will diversify and further …

From The Desk Of The Residency Program Director, Christopher Henry, Md, Facp

The Medicine Forum

It is my pleasure to introduce myself to you for the first time as Program Director, as I also introduce to you our latest edition of The Medicine Forum. Having done my residency training at Jefferson, I am so proud that the tradition of this journal has continued throughout the years despite new residents, new leadership, and new challenges both locally and globally. Our residents’ commitment to not only patient care, but also to scholarship and inquiry remains outstanding and impactful.

Tradition, coming from the Latin word “tradere”, means to transmit, to hand over, or to give for safekeeping; …

Table Of Contents: The Medicine Forum Volume 24, 2022-2023

The Medicine Forum

Table of Contents: The Medicine Forum Volume 24, 2022-2023

The Medicine Forum: Volume 24

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 24, 2022-2023

TABLE OF CONTENTS

• Case Reports
• Ultrasound Education

Sindrom Respons Inflamasi Sistemik, Yefta Moenadjat

Department of Surgery Teaching Materials and Monographs

Materi perkuliahan memuat uraian respons inflamasi pascatrauma yang berkembang menjadi sindrom respons inflamasi sistemik, berakhir dengan kegagalan organ multipel ditinjau dari aspek biomolekuler.

Buku ini merupakan bagian pertama dari seri inflamasi yang disusun dalam bentuk digital dan dipublikasi menurut konsep lisensi Commons Attribution-NonCommercial 4.0 International License untuk tujuan diseminasi.

Arthroscopic Treatment Of Shoulder Stiffness With Rotator Cuff Repair Yields Similar Outcomes To Isolated Rotator Cuff Repair, Parker L. Brush, Adrian Santana, Ruchir Nanavati, Gregory R. Toci, Tariq Z. Issa, Daniel J. Fletcher, Joshua Hornstein

Rothman Institute Papers

Purpose To compare patient-reported and surgical outcome measures in patients with and without secondary shoulder stiffness (SSS) undergoing rotator cuff repair (RCR).

Methods Patients undergoing rotator cuff repair from 2014 to 2020 with complete patient-reported outcome measures (PROMs) by the short-form 12 survey (SF-12) were retrospectively reviewed to identify if operative intervention for SSS was performed alongside the RCR. Those patients with operative intervention for SSS were propensity matched to a group without prior intervention for stiffness by age, sex, laterality, body mass index, diabetes mellitus status, and the presence of a thyroid disorder. The groups were compared by rotator …

Impact Of Type Of Induction Therapy On Outcomes In Older Adults With Aml After Allogeneic Stem Cell Transplantation, Nicholas J Short, Faustine Ong, Farhad Ravandi, Graciela Nogueras-Gonzalez, Tapan M Kadia, Naval Daver, Courtney D Dinardo, Marina Konopleva, Gautam Borthakur, Betul Oran, Gheath Al-Atrash, Rohtesh Mehta, Elias J Jabbour, Musa Yilmaz, Ghayas C Issa, Abhishek Maiti, Richard E Champlin, Hagop Kantarjian, Elizabeth J Shpall, Uday Popat

Faculty, Staff and Student Publications

Although venetoclax-based lower-intensity regimens have greatly improved outcomes for older adults with acute myeloid leukemia (AML) who are unfit for intensive chemotherapy, the optimal induction for older patients with newly diagnosed AML who are suitable candidates for hematopoietic stem cell transplant (HSCT) is controversial. We retrospectively analyzed the post HSCT outcomes of 127 patients ≥60 years of age who received induction therapy at our institution with intensive chemotherapy (IC; n = 44), lower-intensity therapy (LIT) without venetoclax (n = 29), or LIT with venetoclax (n = 54) and who underwent allogeneic HSCT in the first remission. The 2-year relapse-free survival …

Agrp Neurons Are Not Indispensable For Body Weight Maintenance In Adult Mice, Jing Cai, Jing Chen, Joshua Ortiz-Guzman, Jessica Huang, Benjamin R Arenkiel, Yuchen Wang, Yan Zhang, Yuyan Shi, Qingchun Tong, Cheng Zhan

Faculty, Staff and Student Publications

In addition to their role in promoting feeding and obesity development, hypothalamic arcuate agouti-related protein/neuropeptide Y (AgRP/NPY) neurons are widely perceived to be indispensable for maintaining normal feeding and body weight in adults, and consistently, acute inhibition of AgRP neurons is known to reduce short-term food intake. Here, we adopted complementary methods to achieve nearly complete ablation of arcuate AgRP/NPY neurons in adult mice and report that lesioning arcuate AgRP/NPY neurons in adult mice causes no apparent alterations in ad libitum feeding or body weight. Consistent with previous studies, loss of AgRP/NPY neurons blunts fasting refeeding. Thus, our studies show …

Gene Signature Reveals Decreased Sox10-Dependent Transcripts In Malignant Cells From Immune Checkpoint Inhibitor-Resistant Cutaneous Melanomas, Timothy J. Purwin, Signe Caksa, Ahmet Sacan, Claudia Capparelli, Andrew E. Aplin

Department of Pharmacology, Physiology, and Cancer Biology Faculty Papers

Evidence is mounting for cross-resistance between immune checkpoint and targeted kinase inhibitor therapies in cutaneous melanoma patients. Since the loss of the transcription factor, SOX10, causes tolerance to MAPK pathway inhibitors, we used bioinformatic techniques to determine if reduced SOX10 expression/activity is associated with immune checkpoint inhibitor resistance. We integrated SOX10 ChIP-seq, knockout RNA-seq, and knockdown ATAC-seq data from melanoma cell models to develop a robust SOX10 gene signature. We used computational methods to validate this signature as a measure of SOX10-dependent activity in independent single-cell and bulk RNA-seq SOX10 knockdown, cell line panel, and MAPK inhibitor drug-resistant datasets. Evaluation …

Pseudohypercreatininemia After Surgery For Aortic Dissection: A Case Report, Ayako Tasaki, Makoto Fukuda, Yuki Ikeda, Masatora Yamasaki, Ikko Yamaguchi, Shinichi Aishima, Motoaki Miyazono

Children’s Nutrition Research Center Staff Publications

Background: Elevated creatinine concentrations often indicate acute renal injury and renal biopsies are considered in this situation. However,pseudohypercreatininemia is potential cause of elevated creatinine concentrations, and invasive interventions should be avoided.

Case presentation: A 54-year-old woman underwent surgery for descending aortic dissection.Nine days postoperatively, her creatinine concentration increased from 1 mg/dl to 5.78 mg/dl (normal range, 0.47-0.7 mg/dl). Azotemia and hyperkalemia were absent and physical examination findings were unremarkable. Cystatin C concentration was 1.56 mg/l (normal range, 0.56-0.8 mg/l) and pseudohypercreatininemia was suspected. Testing with different reagents showed a creatinine concentration of 0.84 mg/dl. Immunoglobulin (Ig)G was markedly elevated, and …

Dual Targeting Of Cdk4/6 And Bcl-2 Exhibits A Potent Antitumor Effect On Mantle Cell Lymphoma, Yuxuan Che, Yang Liu, Yijing Li, Joseph M Mcintosh, Alexa Jordan, Fangfang Yan, Wei Wang, Lei Nie, Heng-Huan Lee, Jingling Jin, Yixin Yao, Zhongming Zhao, Vivian Changying Jiang, Michael Wang

Faculty, Staff and Student Publications

No abstract provided.

The Mastery Lifestyle Intervention To Reduce Biopsychosocial Risks For Pregnant Latinas And African Americans And Their Infants: Protocol For A Randomized Controlled Trial, Berta H Ganizada, Koen D Reesink, Shaiv Parikh, Mitch J F G Ramaekers, Asim C Akbulut, Pepijn J M H Saraber, Gijs P Debeij, Mumc-Taa Student Team, Armand M Jaminon, Ehsan Natour, Roberto Lorusso, Joachim E Wildberger, Barend Mees, Geert Willem Schurink, Michael J Jacobs, Jack Cleutjens, Ingrid Krapels, Alexander Gombert, Jos G Maessen, Ryan Accord, Tammo Delhaas, Simon Schalla, Leon J Schurgers, Elham Bidar

Faculty, Staff and Student Publications

Current management guidelines for ascending thoracic aortic aneurysms (aTAA) recommend intervention once ascending or sinus diameter reaches 5-5.5 cm or shows a growth rate of >0.5 cm/year estimated from echo/CT/MRI. However, many aTAA dissections (aTAAD) occur in vessels with diameters below the surgical intervention threshold ofMoreover, during aTAA repair surgeons observe and experience considerable variations in tissue strength, thickness, and stiffness that appear not fully explained by patient risk factors. To improve the understanding of aTAA pathophysiology, we established a multi-disciplinary research infrastructure: The Maastricht acquisition platform for studying mechanisms of tissue-cell crosstalk (MAPEX). The explicit scientific focus of the …

Deep Learning-Based Tem Image Analysis For Fully Automated Detection Of Gold Nanoparticles Internalized Within Tumor Cell, Amrit Kaphle, Sandun Jayarathna, Hem Moktan, Maureen Aliru, Subhiksha Raghuram, Sunil Krishnan, Sang Hyun Cho

Faculty, Staff and Student Publications

Transmission electron microscopy (TEM) imaging can be used for detection/localization of gold nanoparticles (GNPs) within tumor cells. However, quantitative analysis of GNP-containing cellular TEM images typically relies on conventional/thresholding-based methods, which are manual, time-consuming, and prone to human errors. In this study, therefore, deep learning (DL)-based methods were developed for fully automated detection of GNPs from cellular TEM images. Several models of "you only look once (YOLO)" v5 were implemented, with a few adjustments to enhance the model's performance by applying the transfer learning approach, adjusting the size of the input image, and choosing the best optimization algorithm. Seventy-eight original …

Abatacept, Cenicriviroc, Or Infliximab For Treatment Of Adults Hospitalized With Covid-19 Pneumonia: A Randomized Clinical Trial, Jane A O'Halloran, Emily R Ko, Kevin J Anstrom, Eyal Kedar, Matthew W Mccarthy, Reynold A Panettieri, Martin Maillo, Patricia Segura Nunez, Anne M Lachiewicz, Cynthia Gonzalez, P Brian Smith, Sabina Mendivil-Tuchia De Tai, Akram Khan, Alfredo J Mena Lora, Matthias Salathe, Gerardo Capo, Daniel Rodríguez Gonzalez, Thomas F Patterson, Christopher Palma, Horacio Ariza, Maria Patelli Lima, John Blamoun, Esteban C Nannini, Eduardo Sprinz, Analia Mykietiuk, Radica Alicic, Adriana M Rauseo, Cameron R Wolfe, Britta Witting, Jennifer P Wang, Luis Parra-Rodriguez, Tatyana Der, Kate Willsey, Jun Wen, Adam Silverstein, Sean M O'Brien, Hussein R Al-Khalidi, Michael A Maldonado, Richard Melsheimer, William G Ferguson, Steven E Mcnulty, Pearl Zakroysky, Susan Halabi, Daniel K Benjamin, Sandra Butler, Jane C Atkinson, Stacey J Adam, Soju Chang, Lisa Lavange, Michael Proschan, Samuel A Bozzette, William G Powderly, Activ-1 Im Study Group Members

Faculty, Staff and Student Publications

IMPORTANCE: Immune dysregulation contributes to poorer outcomes in COVID-19.

OBJECTIVE: To investigate whether abatacept, cenicriviroc, or infliximab provides benefit when added to standard care for COVID-19 pneumonia.

DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-masked, placebo-controlled clinical trial using a master protocol to investigate immunomodulators added to standard care for treatment of participants hospitalized with COVID-19 pneumonia. The results of 3 substudies are reported from 95 hospitals at 85 clinical research sites in the US and Latin America. Hospitalized patients 18 years or older with confirmed SARS-CoV-2 infection within 14 days and evidence of pulmonary involvement underwent randomization between October 2020 and …

Editorial: Targeting Dna Damage Response To Enhance Antitumor Innate Immunity In Radiotherapy, Victoria Valvo, Emanuele Vitale, Marco Tigano, Rachel Evans, Meredith A. Morgan, Qiang Zhang

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

No abstract provided.

Nanoparticle-Based Treatment Approaches For Skin Cancer: A Systematic Review., Michael Joseph Diaz, Nicole Natarelli, Shaliz Aflatooni, Sarah J. Aleman

School of Medicine Faculty Publications

Nanoparticles have shown marked promise as both antineoplastic agents and drug carriers. Despite strides made in immunomodulation, low success rates and toxicity remain limitations within the clinical oncology setting. In the present review, we assess advances in drug delivery nanoparticles, for systemic and topical use, in skin cancer treatment. A systematic review of controlled trials, meta-analyses, and Cochrane review articles was conducted. Eligibility criteria included: (1) a primary focus on nanoparticle utility for skin cancer; (2) available metrics on prevention and treatment outcomes; (3) detailed subject population; (4) English language; (5) archived as full-text journal articles. A total of 43 …

Coronary Ostial Acquired Occlusion Or Congenital Atresia: An Ongoing Discussion, Divyansh Sharma, Abhisheik Prashar

The Texas Heart Institute Journal

Coronary ostial atresia is a developmental abnormality that typically causes asymptomatic anomalies in the coronary blood supply. This case report, which presents 2 symptomatic patients with right coronary artery abnormalities, explores difficulties in diagnosing coronary ostial atresia and distinguishing it from single coronary artery and coronary artery disease-related acquired occlusion. Factors underlying management decisions are also discussed.

Alemtuzumab And Cxcl9 Levels Predict Likelihood Of Sustained Engraftment After Reduced-Intensity Conditioning Hct, Ashley V Geerlinks, Brooks Scull, Christa Krupski, Ryan Fleischmann, Michael A Pulsipher, Mary Eapen, James A Connelly, Catherine M Bollard, Sung-Yun Pai, Christine N Duncan, Leslie S Kean, K Scott Baker, Lauri M Burroughs, Jeffrey R Andolina, Shalini Shenoy, Philip Roehrs, Rabi Hanna, Julie-An Talano, Kirk R Schultz, Elizabeth O Stenger, Howard Lin, Adi Zoref-Lorenz, Kenneth L Mcclain, Michael B Jordan, Tsz-Kwong Man, Carl E Allen, Rebecca A Marsh

Faculty, Staff and Students Publications

Overall survival after reduced-intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT) using alemtuzumab, fludarabine, and melphalan is associated with high rates of mixed chimerism (MC) and secondary graft failure (GF). We hypothesized that peritransplantation alemtuzumab levels or specific patterns of inflammation would predict these risks. We assessed samples from the Bone Marrow Transplant Clinical Trials Network 1204 (NCT01998633) to study the impact of alemtuzumab levels and cytokine patterns on MC and impending or established secondary GF (defined as donor chimerism < 5% after initial engraftment and/or requirement of cellular intervention). Thirty-three patients with hemophagocytic lymphohistiocytosis (n = 25) and other IEIs (n = 8) who underwent HCTs with T-cell–replete grafts were included. Patients with day 0 alemtuzumab levels ≤0.32 μg/mL had a markedly lower incidence of MC, 14.3%, vs 90.9% in patients with levels >0.32 μg/mL (P = .008). Impending or established secondary GF was only observed in patients with day …