{"version":"1.0.0","segments":[{"startTime":0.325,"endTime":3.495,"body":"[upbeat intro music]"},{"startTime":3.495,"endTime":5.59,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.495,"endTime":5.59,"body":"to Harrison's Podclass"},{"startTime":5.59,"endTime":8.72,"body":"where we discuss important"},{"startTime":5.59,"endTime":8.72,"body":"concepts in internal medicine."},{"startTime":8.72,"endTime":9.86,"body":"I'm Cathy Handy."},{"startTime":9.86,"endTime":11.743,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.86,"endTime":11.743,"body":"Wiener, and we're coming to you"},{"startTime":11.743,"endTime":13.74,"body":"from the Johns Hopkins School of Medicine."},{"startTime":16.91,"endTime":18.48,"body":"[Dr. Handy] Welcome to episode 68,"},{"startTime":18.48,"endTime":21.84,"body":"a 56-year-old patient post"},{"startTime":18.48,"endTime":21.84,"body":"bone marrow transplant."},{"startTime":21.84,"endTime":24.34,"body":"[Dr. Wiener] Hi Cathy."},{"startTime":21.84,"endTime":24.34,"body":"So, the question begins,"},{"startTime":24.34,"endTime":26.31,"body":"a 56-year-old woman undergoes"},{"startTime":26.31,"endTime":29.4,"body":"a haploidentical allogeneic"},{"startTime":26.31,"endTime":29.4,"body":"bone marrow transplant"},{"startTime":29.4,"endTime":31.94,"body":"from her 20-year-old"},{"startTime":29.4,"endTime":31.94,"body":"daughter to treat poor risk"},{"startTime":31.94,"endTime":33.87,"body":"acute myeloid leukemia."},{"startTime":33.87,"endTime":35.05,"body":"[Dr. Handy] That would"},{"startTime":33.87,"endTime":35.05,"body":"be standard treatment"},{"startTime":35.05,"endTime":37.58,"body":"after induction chemotherapy"},{"startTime":35.05,"endTime":37.58,"body":"and it represents"},{"startTime":37.58,"endTime":39.21,"body":"an allogeneic transplant."},{"startTime":39.21,"endTime":41.56,"body":"So, if we just want to"},{"startTime":39.21,"endTime":41.56,"body":"define terms to begin with,"},{"startTime":41.56,"endTime":43.61,"body":"allogeneic transplants are from a donor"},{"startTime":43.61,"endTime":45.66,"body":"that is not genetically identical,"},{"startTime":45.66,"endTime":48.12,"body":"a haploidentical allogeneic transplant"},{"startTime":48.12,"endTime":50.47,"body":"is from someone that is"},{"startTime":48.12,"endTime":50.47,"body":"matched at one haplotype,"},{"startTime":50.47,"endTime":52.47,"body":"such as a parent or a child."},{"startTime":52.47,"endTime":55.1,"body":"The other type of transplant"},{"startTime":52.47,"endTime":55.1,"body":"is an autologous transplant"},{"startTime":55.1,"endTime":57.18,"body":"and that involves removal and storage"},{"startTime":57.18,"endTime":60.37,"body":"of the patient's own stem cells"},{"startTime":57.18,"endTime":60.37,"body":"with subsequent reinfusion"},{"startTime":60.37,"endTime":63.83,"body":"after the patient receives high"},{"startTime":60.37,"endTime":63.83,"body":"dose myeloablative therapy."},{"startTime":63.83,"endTime":66.14,"body":"In these cases, you need to"},{"startTime":63.83,"endTime":66.14,"body":"do the transplant to be able"},{"startTime":66.14,"endTime":68.33,"body":"to give the high doses of chemotherapy."},{"startTime":68.33,"endTime":70.12,"body":"[Dr. Wiener] Anything else"},{"startTime":68.33,"endTime":70.12,"body":"to note that's important"},{"startTime":70.12,"endTime":72.31,"body":"as differences between"},{"startTime":70.12,"endTime":72.31,"body":"all these transplants?"},{"startTime":72.31,"endTime":73.9,"body":"[Dr. Handy] Yeah, in"},{"startTime":72.31,"endTime":73.9,"body":"allogeneic transplants"},{"startTime":73.9,"endTime":76.51,"body":"because they're not exactly"},{"startTime":73.9,"endTime":76.51,"body":"immunologically matched,"},{"startTime":76.51,"endTime":79.57,"body":"there may be some graft versus"},{"startTime":76.51,"endTime":79.57,"body":"host disease as a side effect,"},{"startTime":79.57,"endTime":82.9,"body":"however, that's beneficial"},{"startTime":79.57,"endTime":82.9,"body":"because in addition to reacting"},{"startTime":82.9,"endTime":84.53,"body":"to the host, the graft will exert"},{"startTime":84.53,"endTime":86.96,"body":"a graft-versus-leukemia"},{"startTime":84.53,"endTime":86.96,"body":"effect to control the cancer,"},{"startTime":86.96,"endTime":88.68,"body":"and that's really why"},{"startTime":86.96,"endTime":88.68,"body":"you're doing the transplant"},{"startTime":88.68,"endTime":89.99,"body":"in the first place."},{"startTime":89.99,"endTime":92.24,"body":"In an autologous"},{"startTime":89.99,"endTime":92.24,"body":"transplant, there is no risk"},{"startTime":92.24,"endTime":94.39,"body":"of graft versus host"},{"startTime":92.24,"endTime":94.39,"body":"disease or graft rejection,"},{"startTime":94.39,"endTime":96.81,"body":"but these lack the"},{"startTime":94.39,"endTime":96.81,"body":"graft-versus-tumor effect."},{"startTime":96.81,"endTime":99.15,"body":"The autologous stem cell"},{"startTime":96.81,"endTime":99.15,"body":"product may be contaminated"},{"startTime":99.15,"endTime":101.76,"body":"with tumor cells as well"},{"startTime":99.15,"endTime":101.76,"body":"which could lead to relapse."},{"startTime":101.76,"endTime":103.51,"body":"But, keep going on this case."},{"startTime":103.51,"endTime":104.985,"body":"[Dr. Wiener] Okay. So the"},{"startTime":103.51,"endTime":104.985,"body":"question is going to be"},{"startTime":104.985,"endTime":107.4,"body":"about infections, and the question asks,"},{"startTime":107.4,"endTime":110.46,"body":"which of the following"},{"startTime":107.4,"endTime":110.46,"body":"infections is an acute,"},{"startTime":110.46,"endTime":113.68,"body":"defined as likely to happen"},{"startTime":110.46,"endTime":113.68,"body":"within the first 30 days,"},{"startTime":113.68,"endTime":117.68,"body":"complication of her allogeneic"},{"startTime":113.68,"endTime":117.68,"body":"bone marrow transplant?"},{"startTime":117.68,"endTime":119.22,"body":"And the options are,"},{"startTime":119.22,"endTime":121.24,"body":"A. Aspergillus;"},{"startTime":121.24,"endTime":123.2,"body":"B. Candida;"},{"startTime":123.2,"endTime":126.5,"body":"C. cytomegalovirus or CMV;"},{"startTime":126.5,"endTime":129.06,"body":"D. encapsulated bacteria;"},{"startTime":129.06,"endTime":131.3,"body":"or E. varicella zoster."},{"startTime":131.3,"endTime":133.355,"body":"[Dr. Handy] By the end of"},{"startTime":131.3,"endTime":133.355,"body":"one week post-transplant,"},{"startTime":133.355,"endTime":136.32,"body":"patients are usually"},{"startTime":133.355,"endTime":136.32,"body":"profoundly pancytopenic."},{"startTime":136.32,"endTime":139.0,"body":"Because the risk of bacterial"},{"startTime":136.32,"endTime":139.0,"body":"infection is so great,"},{"startTime":139.0,"endTime":142.11,"body":"most centers place patients"},{"startTime":139.0,"endTime":142.11,"body":"on broad spectrum antibiotics,"},{"startTime":142.11,"endTime":145.46,"body":"once the granulocyte"},{"startTime":142.11,"endTime":145.46,"body":"count falls below 500."},{"startTime":145.46,"endTime":148.27,"body":"So, I would be worried"},{"startTime":145.46,"endTime":148.27,"body":"about bacterial infection"},{"startTime":148.27,"endTime":150.82,"body":"in this point, but not"},{"startTime":148.27,"endTime":150.82,"body":"the encapsulated bacteria"},{"startTime":150.82,"endTime":152.52,"body":"that's mentioned in the question."},{"startTime":152.52,"endTime":155.3,"body":"But early on, because of the"},{"startTime":152.52,"endTime":155.3,"body":"neutropenia and mucositis,"},{"startTime":155.3,"endTime":157.55,"body":"patients are at high risk"},{"startTime":155.3,"endTime":157.55,"body":"of Candida infection,"},{"startTime":157.55,"endTime":159.88,"body":"so the answer to this question is B."},{"startTime":159.88,"endTime":161.07,"body":"[Dr. Wiener] What about"},{"startTime":159.88,"endTime":161.07,"body":"the other infections?"},{"startTime":161.07,"endTime":162.85,"body":"When do those typically come about?"},{"startTime":162.85,"endTime":165.12,"body":"[Dr. Handy] Aspergillus and"},{"startTime":162.85,"endTime":165.12,"body":"CMV infection tend to be"},{"startTime":165.12,"endTime":167.32,"body":"a bit later, starting around day 30"},{"startTime":167.32,"endTime":168.94,"body":"through about day 90."},{"startTime":168.94,"endTime":171.58,"body":"Encapsulated bacterial infections and VZV,"},{"startTime":171.58,"endTime":174.11,"body":"we worry most about starting around day 90"},{"startTime":174.11,"endTime":176.02,"body":"through the almost one year mark."},{"startTime":176.02,"endTime":178.191,"body":"[Dr. Wiener] Okay, well,"},{"startTime":176.02,"endTime":178.191,"body":"let's extend this discussion"},{"startTime":178.191,"endTime":180.28,"body":"a little bit, let's talk a"},{"startTime":178.191,"endTime":180.28,"body":"little bit about vaccines"},{"startTime":180.28,"endTime":182.58,"body":"and preventive measures"},{"startTime":180.28,"endTime":182.58,"body":"to prevent infections."},{"startTime":182.58,"endTime":184.53,"body":"What can be done to"},{"startTime":182.58,"endTime":184.53,"body":"prevent these infections"},{"startTime":184.53,"endTime":185.77,"body":"or other infections?"},{"startTime":185.77,"endTime":187.78,"body":"[Dr. Handy] For transplant"},{"startTime":185.77,"endTime":187.78,"body":"patients in particular,"},{"startTime":187.78,"endTime":191.04,"body":"bacterial, fungal and viral"},{"startTime":187.78,"endTime":191.04,"body":"prophylaxes are given initially"},{"startTime":191.04,"endTime":194.12,"body":"with stopping points that"},{"startTime":191.04,"endTime":194.12,"body":"reflect the risk of infection."},{"startTime":194.12,"endTime":196.57,"body":"So for example, bacterial"},{"startTime":194.12,"endTime":196.57,"body":"infection prophylaxis"},{"startTime":196.57,"endTime":199.142,"body":"can usually be de-escalated"},{"startTime":196.57,"endTime":199.142,"body":"or stopped once there's"},{"startTime":199.142,"endTime":201.703,"body":"engraftment and the white blood"},{"startTime":199.142,"endTime":201.703,"body":"cell counts are recovered,"},{"startTime":201.703,"endTime":204.19,"body":"whereas, fungal and some viral"},{"startTime":201.703,"endTime":204.19,"body":"prophylaxes will continue"},{"startTime":204.19,"endTime":205.77,"body":"for longer periods."},{"startTime":205.77,"endTime":208.78,"body":"Prophylaxis against fungal"},{"startTime":205.77,"endTime":208.78,"body":"infections reduces the rate"},{"startTime":208.78,"endTime":211.88,"body":"of infection and also"},{"startTime":208.78,"endTime":211.88,"body":"improves overall survival."},{"startTime":211.88,"endTime":214.69,"body":"Fluconazole is often used for"},{"startTime":211.88,"endTime":214.69,"body":"patients with standard risk"},{"startTime":214.69,"endTime":216.87,"body":"while prophylaxis with mold-active agents"},{"startTime":216.87,"endTime":220.11,"body":"such as voriconazole or"},{"startTime":216.87,"endTime":220.11,"body":"posaconazole should be considered"},{"startTime":220.11,"endTime":221.5,"body":"for patients at higher risk,"},{"startTime":221.5,"endTime":223.92,"body":"such as those with a"},{"startTime":221.5,"endTime":223.92,"body":"prior fungal infection."},{"startTime":223.92,"endTime":225.34,"body":"[Dr. Wiener] And what about vaccines?"},{"startTime":225.34,"endTime":226.81,"body":"[Dr. Handy] So in general, we advise"},{"startTime":226.81,"endTime":228.8,"body":"against live virus vaccines."},{"startTime":228.8,"endTime":231.02,"body":"These patients have a"},{"startTime":228.8,"endTime":231.02,"body":"risk of developing disease"},{"startTime":231.02,"endTime":232.64,"body":"because of their immune suppression."},{"startTime":232.64,"endTime":234.43,"body":"So, we wouldn't use those."},{"startTime":234.43,"endTime":237.0,"body":"Plus, cancer patients who"},{"startTime":234.43,"endTime":237.0,"body":"are undergoing chemotherapy"},{"startTime":237.0,"endTime":239.71,"body":"do not respond normally"},{"startTime":237.0,"endTime":239.71,"body":"to immunization and titers"},{"startTime":239.71,"endTime":242.56,"body":"of antibodies to infectious"},{"startTime":239.71,"endTime":242.56,"body":"agents fall more rapidly"},{"startTime":242.56,"endTime":244.2,"body":"than in healthy individuals."},{"startTime":244.2,"endTime":246.57,"body":"So, patients will need to be re-vaccinated"},{"startTime":246.57,"endTime":251.08,"body":"against Strep pneumonia, H."},{"startTime":246.57,"endTime":251.08,"body":"flu, and Neisseria meningitidis."},{"startTime":251.08,"endTime":254.35,"body":"For those vaccines that are"},{"startTime":251.08,"endTime":254.35,"body":"usually also given in childhood,"},{"startTime":254.35,"endTime":257.75,"body":"like Tdap, Hep A, Hep B,"},{"startTime":254.35,"endTime":257.75,"body":"and HPV, if age appropriate,"},{"startTime":257.75,"endTime":259.07,"body":"should also be given."},{"startTime":259.07,"endTime":262.55,"body":"And the polio vaccine should"},{"startTime":259.07,"endTime":262.55,"body":"be the inactivated form."},{"startTime":262.55,"endTime":264.88,"body":"[Dr. Wiener] What about flu"},{"startTime":262.55,"endTime":264.88,"body":"shots? Is that okay to give?"},{"startTime":264.88,"endTime":266.99,"body":"[Dr. Handy] Yes, typically"},{"startTime":264.88,"endTime":266.99,"body":"we will give it annually"},{"startTime":266.99,"endTime":268.84,"body":"with the inactivated vaccine."},{"startTime":268.84,"endTime":271.58,"body":"And, given the COVID-19"},{"startTime":268.84,"endTime":271.58,"body":"pandemic, I will mention"},{"startTime":271.58,"endTime":273.99,"body":"that COVID vaccines are"},{"startTime":271.58,"endTime":273.99,"body":"currently recommended"},{"startTime":273.99,"endTime":276.16,"body":"for immunocompromised patients."},{"startTime":276.16,"endTime":278.79,"body":"The two vaccines that were"},{"startTime":276.16,"endTime":278.79,"body":"first approved here in the U.S."},{"startTime":278.79,"endTime":281.91,"body":"are the mRNA vaccines and"},{"startTime":278.79,"endTime":281.91,"body":"those are thought to be safe"},{"startTime":281.91,"endTime":284.21,"body":"to give, especially when"},{"startTime":281.91,"endTime":284.21,"body":"balancing the increased risk"},{"startTime":284.21,"endTime":287.62,"body":"of complications from COVID"},{"startTime":284.21,"endTime":287.62,"body":"in immunocompromised patients."},{"startTime":287.62,"endTime":290.545,"body":"[Dr. Wiener] Okay, great. So,"},{"startTime":287.62,"endTime":290.545,"body":"the teaching point in this case"},{"startTime":290.545,"endTime":293.85,"body":"is that after a bone marrow"},{"startTime":290.545,"endTime":293.85,"body":"transplant within 30 days,"},{"startTime":293.85,"endTime":296.48,"body":"bacterial and fungal,"},{"startTime":293.85,"endTime":296.48,"body":"particularly Candidal infections"},{"startTime":296.48,"endTime":297.95,"body":"are most common."},{"startTime":297.95,"endTime":300.68,"body":"Other infections such as"},{"startTime":297.95,"endTime":300.68,"body":"Aspergillus and varicella"},{"startTime":300.68,"endTime":302.62,"body":"are later complications."},{"startTime":302.62,"endTime":305.51,"body":"Most vaccines should be"},{"startTime":302.62,"endTime":305.51,"body":"repeated post-transplant."},{"startTime":305.51,"endTime":308.14,"body":"And the newest vaccine for COVID-19,"},{"startTime":308.14,"endTime":311.48,"body":"the messenger RNA vaccines,"},{"startTime":308.14,"endTime":311.48,"body":"generally are recommended,"},{"startTime":311.48,"endTime":314.05,"body":"although, of course, more"},{"startTime":311.48,"endTime":314.05,"body":"research is being done."},{"startTime":314.05,"endTime":316.1,"body":"[Dr. Handy] And to learn more,"},{"startTime":314.05,"endTime":316.1,"body":"I'll direct you to a couple"},{"startTime":316.1,"endTime":318.41,"body":"of different chapters"},{"startTime":316.1,"endTime":318.41,"body":"that cover these topics."},{"startTime":318.41,"endTime":321.73,"body":"First, the chapter on"},{"startTime":318.41,"endTime":321.73,"body":"hematopoietic cell transplantation"},{"startTime":321.73,"endTime":325.453,"body":"and also the chapter on infections"},{"startTime":321.73,"endTime":325.453,"body":"in transplant recipients."},{"startTime":325.453,"endTime":327.828,"body":"[outro music]"},{"startTime":329.69,"endTime":332.55,"body":"[Mr. Shanahan] This is Jim"},{"startTime":329.69,"endTime":332.55,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":332.55,"endTime":334.17,"body":"Harrison's Podclass is brought to you"},{"startTime":334.17,"endTime":336.16,"body":"by McGraw Hill's Access Medicine,"},{"startTime":336.16,"endTime":338.26,"body":"the online medical resource that delivers"},{"startTime":338.26,"endTime":341.502,"body":"the latest trusted content from"},{"startTime":338.26,"endTime":341.502,"body":"the best minds in medicine."},{"startTime":341.502,"endTime":344.023,"body":"Go to accessmedicine.com to learn more."}]}