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NCT01529827 · REGISTRY CONDITION SEARCH

Fludarabine Phosphate, Melphalan, and Low-Dose Total-Body Irradiation Followed by Donor Peripheral Blood Stem Cell Transplant in Treating Patients With Hematologic Malignancies

Found through the registry condition index, not selected as a treatment recommendation. This discovery collection was restricted to studies with posted results.

Phase
PHASE2
Status at capture
COMPLETED
Registry last update
2019-09-24

This phase II trial studies how well giving fludarabine phosphate, melphalan, and low-dose total-body irradiation (TBI) followed by donor peripheral blood stem cell transplant (PBSCT) works in treating patients with hematologic malignancies. Giving chemotherapy drugs such as fludarabine phosphate and melphalan, and low-dose TBI before a donor PBSCT helps stop the growth of cancer and abnormal cells and helps stop the patient's immune system from rejecting the donor's stem cells. When the healthy stem cells from the donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cell from a donor can make an immune response against the body's normal cells. Giving tacrolimus, mycophenolate mofetil (MMF), and methotrexate after transplant may stop this from happening

Open the original ClinicalTrials.gov record → · Download preserved record

What did the study report?

Outcomes, safety and baseline populations are separate source sections. Quality-of-life measures appear under their original outcome titles.

flow

Participant flow

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baseline

Baseline characteristics

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outcome · POSTED

Transplant Related Mortality (TRM)

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outcome · POSTED

Clinical Response

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outcome · POSTED

Progression Free Survival (PFS) at One Year

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outcome · POSTED

Median Time to Neutrophil Engraftment

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adverse events

Adverse events

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more info

Limitations, agreements, and source contact

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Who could take part
eligibility Criteria
Inclusion Criteria: * Diagnosis of a histology documented hematologic malignancy or marrow disorder BONE MARROW FAILURE DISORDERS: * Acquired bone marrow failure disorders include aplastic anemia, paroxysmal nocturnal hemoglobinuria (PNH) \* Primary allogeneic HSCT is appropriate for selected patients with severe aplastic anemia; however, patients with aplastic anemia must have failed at least one cycle of standard immunosuppressive therapy with calcineurin inhibitor plus anti-thymocyte globulin (ATG) if a fully matched donor is available \* Patients with PNH should not be eligible for a myeloablative HSCT * Hereditary bone marrow failure disorders include Diamond-Blackfan Anemia, Shwachman-Diamond Syndrome, Kostmann Syndrome, congenital Amegakaryocytic Thrombocytopenia; Fanconi Anemia or related chromosomal breakage syndrome, Dyskeratosis Congenital are excluded from this study die to their poor deoxyribonucleic acid (DNA) repair capacity \* Fanconi anemia or related chromosomal breakage syndrome: positive chromosome breakage analysis using diepoxybutane (DEB) or mitomycin C if applicable \* Dyskeratosis Congenita: diagnosis is supported by using either telomerase RNA component (TERC) gene mutation in autosomal dominant Dyskeratosis Congenita or X-linked DKC1 gene mutation * Other non-malignant hematologic or immunologic disorders that require transplantation \* Quantitative or qualitative congenital platelet disorders (including but not limited to congenital amegakaryocytopenia, absent-radii syndrome, Glanzmann's thrombasthenia) \* Quantitative or qualitative congenital neutrophil disorders (including but not limited to chronic granulomatous disease, congenital neutropenia) \*Congenital primary immunodeficiency syndrome, Wiskott-Aldrich syndrome, CD40 ligand deficiency, T-cell deficiencies) ACUTE LEUKEMIAS: * Subjects must be ineligible for or unable to receive a conventional myeloablative transplantation * Resistant or recurrent disease after at least one standard combination chemotherapy OR first remission patients at high risk of relapse \* Acute myeloid leukemia (AML) * antecedent myelodysplastic syndrome, secondary AML, high risk cytogenetic abnormalities or normal cytogenetics with high-risk molecular mutations (e.g., fms-like tyrosine kinase3-internal tandem duplication \[Flt3-ITD\] mutation) \* Acute lymphocytic leukemia (ALL) * high or standard risk ALL CHRONIC MYELOID LEUKEMIA (CML): * Chronic phase (intolerant or unresponsive to imatinib and/or other tyrosine kinase inhibitors), second chronic phase or accelerated phase who are ineligible for conventional myeloablative transplantation MYELOPROLIFERATIVE AND MYELODYSPLASTIC SYNDROME (MDS): * Myelofibrosis (with/without splenectomy) with intermediate to high risk features * Advanced polycythemia vera nor responding to standard therapy * MDS with lower International Prognostic Scoring System (IPSS) score of intermediate (Int)-2 or higher * MDS with lower IPSS score Int-1 or less with severe clinical features such as severe neutropenia or thrombocytopenia or high risk chromosome abnormalities such as monosomy 7 * Secondary MDS with any IPSS scores * Chronic myelomonocytic leukemia LYMPHOPROLIFERATIVE DISEASE: * Chronic lymphocytic leukemia (CLL), low-grade non-Hodgkin lymphoma (NHL) (recurrent or persistent) fludarabine refractory or with less than 6 months duration or complete remission (CR) between courses of conventional therapy * Multiple myeloma (progressive disease after autologous stem cell transplant, tandem allogeneic transplant after prior autologous stem cell transplant) * Waldenstrom's macroglobulinemia (failed one standard regimen) * High grade NHL and diffuse large B-cell lymphoma (DLBCL) * Not eligible for conventional myeloablative HSCT OR failed autologous HSCT * First remission lymphoblastic lymphoma, or small, non-cleaved cell lymphoma or mantle cell lymphoma HODGKIN LYMPHOMA: * Received and failed front-line therapy * Failed or were not eligible for autologous transplantation DONOR: Permissible human leukocyte antigen (HLA) matching: related donors * single antigen mismatch at HLA A, B, or DRB1; unrelated donors * a single antigen mismatch at HLA A, B, or C, +/- additional single allele level mismatch at A, B, V or DRB1 * Minimum goal for peripheral blood stem cells (PBSC) dose is 2 x 10\^6 CD34+ cells/kg of recipient weight; minimum goal for the marrow dose is 1 x 10\^8 nucleated cells/kg of recipient weight * No serious uncontrolled psychiatric illness * No concomitant active malignancy that would be expected to require chemotherapy within 3 years of transplant (other than non-melanoma skin cancer) * Non-pregnant and non-nursing woman; (women or men with reproductive potential should agree to use an effective means of birth control) * Patients who have failed a prior autologous or allogeneic transplant are eligible; however, at least 90 days must have elapsed between the start of this reduced intensity conditioning regimen and the last transplant if patient had a prior autologous or myeloablative allogeneic bone marrow transplant (BMT) * At least 2 weeks since prior chemotherapy, radiation treatment and/or surgery * Informed consent DONOR: Compatibility at the four most informative HLA loci: A, B, C and DRB1 are important for reducing the risk of GVHD and successful transplant outcomes; the A, B, C and DRB1 loci comprise 8 possible alleles (a haplotype being inherited from each parent); one additional locus, HLA-DQ, is also typed to ascertain haplotypes and assist in the search for a compatible donor; however mismatching at DQ has not been shown to be associated with adverse outcomes; high resolution molecular typing (at the allele level) is now the standard of care for unrelated donor searches and allows greater refinement of the search strategy DONOR: Matched related donor: a single antigen mismatch at A, B, or the DR transplant from a family member is associated with a higher risk of GVHD but similar overall survival when compared to full identity at these 3 regions; related donor/recipient pairs must be matched at 5 of 6 HLA antigens (A, B, DRB1) DONOR: Unrelated Donor: When evaluating patients for unrelated donor transplant, the higher degree of matching, the lower risk of GvHD; the A, B, C, DRB1 and DQB1 loci, comprising 10 possible antigen (with alleles), will be typed for all unrelated transplants; given the higher risk of TRM in mismatched transplants, RIT is often the best way to mitigate the risk; data from the National Marrow Donor Program makes it possible to estimate the risk of donor-recipient HLA mismatch at the allele or antigen level; the higher risk from HLA-mismatching must be balanced against the clinical urgency and the patient's risk by the transplant team; at this time, antigen level mismatches at DQB1 do not affect outcomes and will not be used for matching purposes for donor selection; thus, the matching required will be at the HLA A, B, C and DRB1 (8 loci); for this protocol, a single antigen mismatch at the HLA A, B, C, with or without additional single allele level mismatch may participate in this protocol for voluntary unrelated donors (blood or marrow) DONOR: Donor must be healthy and have non-reactive test results for all infectious disease assays as required by state and federal regulations; donors who screen seropositive for hepatitis an/or syphilis must be cleared by infectious disease consultation DONOR: Donor must have no uncontrolled cardiopulmonary, renal, endocrine, hepatic or psychiatric disease to render donation unsafe DONOR: The donor (or parent in minor) must give informed consent for peripheral blood stem cell collection or bone marrow collection DONOR: Syngeneic donors are not eligible DONOR: Donors who have poor peripheral venous access, may require central venous line placement for stem cell apheresis Exclusion Criteria: * Uncontrolled central nervous system (CNS) disease (for hematologic malignancies) * Karnofsky (adult) or Lansky (for =\< 16 years) performance status \< 50% * Diffusing capacity of the lung for carbon monoxide (DLCO) \< 40% predicted, corrected for hemoglobin and/or alveolar ventilation * Left ventricular ejection fraction \< 40% - Bilirubin \>= 3 X upper limit of normal * Liver alkaline phosphatase \>= 3 x upper limit of normal * Serum glutamic oxaloacetic transaminase (SGOT) or serum glutamic pyruvate transaminase (SGPT) \>= 3 x upper limit of normal * Child's class B and C liver failure * Calculated creatinine clearance \< 40 cc/min by the modified Cockroft-Gault formula for adults or the Schwartz formula for pediatrics * Patients who have received maximally allowed doses (given in 2 Gy fractionations, or equivalent) of previous radiation therapy to various organs as follows: \* Mediastinum: adult -40, pediatric (=\<18 yrs) - 21 \* Heart: adult 36, pediatric - 26 \* Whole lung(s): adult - 12, pediatric - 10 \* Small bowel: adult - 46, pediatric - 40 \* Kidneys: adult - 12, pediatric - 10 \* Whole liver: adult - 20, pediatric - 20 \* Spinal cord: adult - 36, pediatric - 36 \* Whole Brain: adult 30, pediatric - 30 * Patients who previously have received a higher than allowed dose of radiation to a small lung, liver, and brain volume, will be evaluated by the radiation oncologist to determine if the patient is eligible for study * Uncontrolled diabetes mellitus, cardiovascular disease, active serious infection or other condition which, in the opinion of treating physician, would make this protocol unreasonably hazardous for the patient * Human immunodeficiency virus (HIV) positive * Patients who in the opinion of the treating physician are unlikely to comply with the restrictions of allogeneic stem cell transplantation based on formal psychosocial screening * Female of childbearing potential with a positive pregnancy test
healthy Volunteers
false
maximum Age
75 Years
minimum Age
3 Years
sex
ALL
std Ages
  1. CHILD
  2. ADULT
  3. OLDER_ADULT
Treatment arms and interventions
arm Groups
  1. description
    PREPARATIVE REGIMEN: Patients receive fludarabine phosphate IV over 30 minutes on days -5 to -2 and melphalan IV over 30 minutes on day -2. Patients undergo low-dose TBI BID on day -1. TRANSPLANTATION: Patients undergo allogeneic PBSCT on day 0. GvHD PROPHYLAXIS: Patients receive tacrolimus IV or PO BID on days -1 to 100 with taper over 4-6 months, MMF PO or IV every 6-8 hours on days -1 to 60, and methotrexate IV over 15 to 30 minutes on days 1, 3, and 6.
    intervention Names
    1. Drug: fludarabine phosphate
    2. Drug: melphalan
    3. Radiation: total-body irradiation
    4. Drug: tacrolimus
    5. Drug: mycophenolate mofetil
    6. Drug: methotrexate
    7. Other: laboratory biomarker analysis
    8. Procedure: allogeneic hematopoietic stem cell transplantation
    9. Procedure: peripheral blood stem cell transplantation
    label
    Treatment (reduced intensity allogeneic PBSCT)
    type
    EXPERIMENTAL
interventions
  1. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Given IV
    name
    fludarabine phosphate
    other Names
    1. 2-F-ara-AMP
    2. Beneflur
    3. Fludara
    type
    DRUG
  2. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Given IV
    name
    melphalan
    other Names
    1. Alkeran
    2. CB-3025
    3. L-PAM
    4. L-phenylalanine mustard
    5. L-Sarcolysin
    type
    DRUG
  3. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Undergo TBI
    name
    total-body irradiation
    other Names
    1. TBI
    type
    RADIATION
  4. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Given IV or PO
    name
    tacrolimus
    other Names
    1. FK 506
    2. Prograf
    type
    DRUG
  5. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Given IV or PO
    name
    mycophenolate mofetil
    other Names
    1. Cellcept
    2. MMF
    type
    DRUG
  6. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Given IV
    name
    methotrexate
    other Names
    1. amethopterin
    2. Folex
    3. methylaminopterin
    4. Mexate
    5. MTX
    type
    DRUG
  7. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Correlative studies
    name
    laboratory biomarker analysis
    type
    OTHER
  8. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Undergo allogeneic PBSCT
    name
    allogeneic hematopoietic stem cell transplantation
    type
    PROCEDURE
  9. arm Group Labels
    1. Treatment (reduced intensity allogeneic PBSCT)
    description
    Undergo PBSCT
    name
    peripheral blood stem cell transplantation
    other Names
    1. PBPC transplantation
    2. PBSC transplantation
    3. peripheral blood progenitor cell transplantation
    4. transplantation, peripheral blood stem cell
    type
    PROCEDURE
Study design
allocation
NA
intervention Model
SINGLE_GROUP
masking Info
masking
NONE
primary Purpose
TREATMENT
Enrollment
count
94
type
ACTUAL
Registered outcome plans (not posted results)
primary Outcomes
  1. description
    Day 100 transplant related mortality (TRM). An exact 95% confidence interval will be provided.
    measure
    Transplant Related Mortality (TRM)
    time Frame
    In the first 100 days from day 0 of transplant
secondary Outcomes
  1. description
    Patients will be followed according to response criteria as referenced in BMT SOP "Standards of Therapy" last updated 2008. Clinical Response = CR + PR. Complete Response Requires all of the following: * Serum and urine negative for monoclonal proteins by immunofixation * Normal free light chain ratio * Plasma cells in marrow \< 5% Partial Response (PR) Requires any of the following: \- ≥ 50% reduction in current serum monoclonal protein levels \> 0.5 g/dL or urine light chain levels \> 100 mg/day with a visible peak or free light chain levels \> 10mg/dL Progressive Disease (PD) Requires any of the following: * If progressing from CR, any detectable monoclonal protein or abnormal free light chain ratio (light chain must double) * If progressive from PR or SD, ≥ 50% increase in the serum M protein to \> 0.5 g/dL,or ≥ 50% increase in urine M protein to \> 200mg/day with visible peak present. * Free light chain increase of ≥ 50% to
    measure
    Clinical Response
    time Frame
    In the first 100 days from day 0 of transplant
  2. description
    Assessed using Kaplan Meier and Proportional Hazards
    measure
    Progression Free Survival (PFS) at One Year
    time Frame
    day of transplant until progression up to 5 years
  3. description
    Median time to recovery of absolute neutrophil count \>=500/uL for 3 consecutive days. Summarized using standard descriptive statistics along with corresponding 95% confidence intervals.
    measure
    Median Time to Neutrophil Engraftment
    time Frame
    Day 100
Full study description
brief Summary
This phase II trial studies how well giving fludarabine phosphate, melphalan, and low-dose total-body irradiation (TBI) followed by donor peripheral blood stem cell transplant (PBSCT) works in treating patients with hematologic malignancies. Giving chemotherapy drugs such as fludarabine phosphate and melphalan, and low-dose TBI before a donor PBSCT helps stop the growth of cancer and abnormal cells and helps stop the patient's immune system from rejecting the donor's stem cells. When the healthy stem cells from the donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cell from a donor can make an immune response against the body's normal cells. Giving tacrolimus, mycophenolate mofetil (MMF), and methotrexate after transplant may stop this from happening
detailed Description
PRIMARY OBJECTIVES: I. To determine the transplant related mortality (TRM) of this reduced-intensity transplantation (RIT) combination, fludarabine (fludarabine phosphate), melphalan, and TBI in a patient population usually not eligible for a full a myeloablative allogeneic hematopoietic stem cell transplantation (HSCT). SECONDARY OBJECTIVES: I. To evaluate clinical response, progression free survival (PFS) at one year, engraftment rate, and graft-versus-host disease (GvHD) incidence with the proposed RIT regimen across a variety of hematological conditions. II. Correlative studies will include chimerism analysis by molecular analysis and evaluation of immune reconstitution by cytomegalovirus (CMV) dextramer analysis using flow cytometry. OUTLINE: PREPARATIVE REGIMEN: Patients receive fludarabine phosphate intravenously (IV) over 30 minutes on days -5 to -2 and melphalan IV over 30 minutes on day -2. Patients undergo low-dose TBI twice daily (BID) on day -1. TRANSPLANTATION: Patients undergo allogeneic PBSCT on day 0. GvHD PROPHYLAXIS: Patients receive tacrolimus IV or orally (PO) BID on days -1 to 100 with taper over 4-6 months, MMF PO or IV every 6-8 hours on days -1 to 60, and methotrexate IV over 15-30 minutes on days 1, 3, and 6. After completion of study treatment, patients are followed up periodically.
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      8b9a346048372591e3ee0de631ceead25528dc1d384a69971d454af93b26921d
      payload sha256
      5702a25aca09f21ee04612cd77c5a499b70b8188378ef31b77e2d713015a7e66
      payload
      clinical indication matching status
      condition_index_match_asserted_by_registry_not_reviewed
      end exclusive
      true
      id
      nct-edge-9f70dd75c7884763ddc3
      link basis
      returned_by_explicit_condition_and_posted_results_filter_query
      nct id
      NCT01529827
      occurrences
      1. context exact
        NCT01529827
        end
        11
        exact text
        NCT01529827
        start
        0
      offset unit
      unicode_code_points
      query cond
      Hairy Cell Leukemia
      query disease state id
      ds-hairy-cell-leukemia
      source file
      /Users/arunverma/Documents/ChatGPT/Cancer Statistics Website/research-data/2026-09-10/clinicaltrials-condition/round-0000/raw/cond-hairy-cell-leukemia-000.json
      source file sha256
      8b9a346048372591e3ee0de631ceead25528dc1d384a69971d454af93b26921d
      source json pointer
      /studies/3/protocolSection/identificationModule/nctId
      source kind
      ctgov_condition_query
      source record id
      Source null
      source string basis
      parsed_JSON_string_unmodified
      source string sha256
      3137f666e20d6ca8f0b8f1325369bc5621eb956621f79df33c338c3ad419e606
    7. release id
      ctgov-registry-1336d216cbd1bbff780dac70
      edge id
      nct-edge-b4455782cb390e3d4e72
      requested nct id
      NCT01529827
      primary nct id
      NCT01529827
      source kind
      ctgov_condition_query
      source record id
      Source null
      source file sha256
      1f6ffef8d557bd3ff6e7738a80f73b58dddfc3fab889f2661577c6dd238f078c
      payload sha256
      56b110d0b70b721a460f5b015f4e9ba075f28bca892ed8f1f3ea599b44b338eb
      payload
      clinical indication matching status
      condition_index_match_asserted_by_registry_not_reviewed
      end exclusive
      true
      id
      nct-edge-b4455782cb390e3d4e72
      link basis
      returned_by_explicit_condition_and_posted_results_filter_query
      nct id
      NCT01529827
      occurrences
      1. context exact
        NCT01529827
        end
        11
        exact text
        NCT01529827
        start
        0
      offset unit
      unicode_code_points
      query cond
      Infant Acute Undifferentiated Leukemia
      query disease state id
      ds-infant-acute-undifferentiated-leukemia
      source file
      /Users/arunverma/Documents/ChatGPT/Cancer Statistics Website/research-data/2026-09-10/clinicaltrials-condition/round-0000/raw/cond-infant-acute-undifferentiated-leukemia-000.json
      source file sha256
      1f6ffef8d557bd3ff6e7738a80f73b58dddfc3fab889f2661577c6dd238f078c
      source json pointer
      /studies/2/protocolSection/identificationModule/nctId
      source kind
      ctgov_condition_query
      source record id
      Source null
      source string basis
      parsed_JSON_string_unmodified
      source string sha256
      3137f666e20d6ca8f0b8f1325369bc5621eb956621f79df33c338c3ad419e606
    8. release id
      ctgov-registry-1336d216cbd1bbff780dac70
      edge id
      nct-edge-cf5a682e916cc845caf0
      requested nct id
      NCT01529827
      primary nct id
      NCT01529827
      source kind
      ctgov_condition_query
      source record id
      Source null
      source file sha256
      193739e64f77123de4344901c9970a0996a667fa587f14135380bef3ae38e11d
      payload sha256
      7efd979f8bc504dbec19587797bbd45be165f561cbae1f2295c676d4c392e77b
      payload
      clinical indication matching status
      condition_index_match_asserted_by_registry_not_reviewed
      end exclusive
      true
      id
      nct-edge-cf5a682e916cc845caf0
      link basis
      returned_by_explicit_condition_and_posted_results_filter_query
      nct id
      NCT01529827
      occurrences
      1. context exact
        NCT01529827
        end
        11
        exact text
        NCT01529827
        start
        0
      offset unit
      unicode_code_points
      query cond
      Childhood Chronic Myeloid Leukemia
      query disease state id
      ds-chronic-myeloid-leukemia-pediatric
      source file
      /Users/arunverma/Documents/ChatGPT/Cancer Statistics Website/research-data/2026-09-10/clinicaltrials-condition/round-0000/raw/cond-childhood-chronic-myeloid-leukemia-000.json
      source file sha256
      193739e64f77123de4344901c9970a0996a667fa587f14135380bef3ae38e11d
      source json pointer
      /studies/6/protocolSection/identificationModule/nctId
      source kind
      ctgov_condition_query
      source record id
      Source null
      source string basis
      parsed_JSON_string_unmodified
      source string sha256
      3137f666e20d6ca8f0b8f1325369bc5621eb956621f79df33c338c3ad419e606
    9. release id
      ctgov-registry-1336d216cbd1bbff780dac70
      edge id
      nct-edge-e86026d5b6bf42a5fbd0
      requested nct id
      NCT01529827
      primary nct id
      NCT01529827
      source kind
      ctgov_condition_query
      source record id
      Source null
      source file sha256
      a6089e8b15d43633ec778b2a5c464ada1207289beea2ae90de3e4bbe04b32186
      payload sha256
      9ab3d876315ebb15127d9d94a29d389deefa8d2df13b4c0181f972d8883d8c9d
      payload
      clinical indication matching status
      condition_index_match_asserted_by_registry_not_reviewed
      end exclusive
      true
      id
      nct-edge-e86026d5b6bf42a5fbd0
      link basis
      returned_by_explicit_condition_and_posted_results_filter_query
      nct id
      NCT01529827
      occurrences
      1. context exact
        NCT01529827
        end
        11
        exact text
        NCT01529827
        start
        0
      offset unit
      unicode_code_points
      query cond
      Acute Undifferentiated Leukemia
      query disease state id
      ds-acute-undifferentiated-leukemia
      source file
      /Users/arunverma/Documents/ChatGPT/Cancer Statistics Website/research-data/2026-09-10/clinicaltrials-condition/round-0000/raw/cond-acute-undifferentiated-leukemia-000.json
      source file sha256
      a6089e8b15d43633ec778b2a5c464ada1207289beea2ae90de3e4bbe04b32186
      source json pointer
      /studies/6/protocolSection/identificationModule/nctId
      source kind
      ctgov_condition_query
      source record id
      Source null
      source string basis
      parsed_JSON_string_unmodified
      source string sha256
      3137f666e20d6ca8f0b8f1325369bc5621eb956621f79df33c338c3ad419e606

    Preserved source evidence · Not medical advice