Allogeneic Bone Marrow Transplant Patients Research Articles

Central Line Associated Blood Stream Infection Incidence and Outcomes in a Large Autologous and Allogeneic Bone Marrow Transplant Cohort

<h3>Background</h3> Patients undergoing bone marrow transplant (BMT) requiring central venous access are at high risk of central line associated blood stream infections (CLABSI) due to prolonged immunosuppression. Currently, there is limited literature directly comparing outcomes and incidences of CLABSIs in the autologous and allogeneic BMT populations. Here, we describe the incidence and outcome of CLABSIs in a large prospective cohort of allogeneic and autologous BMT patients at a quaternary adult oncology center. <h3>Methods</h3> A descriptive analysis was performed on a prospectively assembled cohort of BMT patients collected over a 30-month period between 2017 and 2019. CLABSI determination was made by infection control practitioners and physicians using standardized definitions. Outcomes, including 30-day hospitalization, ICU admission, and all-cause mortality were determined through chart reviews. Chi-square tests were used to assess statistical significance to compare simple proportions. <h3>Results</h3> Of 1278 patients in the cohort, 136 (11%) developed CLABSIs. A significantly higher proportion of allogeneic BMT patients developed CLABSI compared to the autologous BMT patients (21% and 5% of their respective populations, p<0.001). Of 136 patients, 43.4% required admission, 7.4% required ICU admission and 7.7% died within 30-days of the CLABSI onset. Although there were no significant differences between allogeneic and autologous cases in these outcomes, allogeneic cases had a significantly longer time to developing a CLABSI from transplant than autologous cases (median 53 days vs 10 days). <h3>Conclusions</h3> In this large prospective study of patients receiving bone marrow transplants, we found that allogeneic BMT patients are at higher risk for developing a CLABSI compared with autologous BMT patients. Furthermore, these infections are associated with a high degree of morbidity and mortality in both populations. Review of clinical and infection control protocols regarding central line access and maintenance are needed in order to reduce the incidence of this highly morbid complication.

ATO (Arsenic Trioxide) Effects on Promyelocytic Leukemia Nuclear Bodies Reveals Antiviral Intervention Capacity.

Human adenoviruses (HAdV) are associated with clinical symptoms such as gastroenteritis, keratoconjunctivitis, pneumonia, hepatitis, and encephalitis. In the absence of protective immunity, as in allogeneic bone marrow transplant patients, HAdV infections can become lethal. Alarmingly, various outbreaks of highly pathogenic, pneumotropic HAdV types have been recently reported, causing severe and lethal respiratory diseases. Effective drugs for treatment of HAdV infections are still lacking. The repurposing of drugs approved for other indications is a valuable alternative for the development of new antiviral therapies and is less risky and costly than de novo development. Arsenic trioxide (ATO) is approved for treatment of acute promyelocytic leukemia. Here, it is shown that ATO is a potent inhibitor of HAdV. ATO treatment blocks virus expression and replication by reducing the number and integrity of promyelocytic leukemia (PML) nuclear bodies, important subnuclear structures for HAdV replication. Modification of HAdV proteins with small ubiquitin‐like modifiers (SUMO) is also key to HAdV replication. ATO reduces levels of viral SUMO‐E2A protein, while increasing SUMO‐PML, suggesting that ATO interferes with SUMOylation of proteins crucial for HAdV replication. It is concluded that ATO targets cellular processes key to HAdV replication and is relevant for the development of antiviral intervention strategies.

Pediatric Acute Gvhd: Transcriptome Analysis of Gastrointestinal Biopsies Reveal a Unique Signature in Pediatric Acute GI Gvhd with Involvement of the ERK Pathway and Similarities with Pediatric Inflammatory Bowel Disease

<h3>Introduction</h3> Studies of target organs at the time of acute graft versus host disease (GVHD) are needed to identify novel inflammatory and regulatory pathways. <h3>Methods</h3> We performed a prospective transcriptome analysis of gastrointestinal (GI) biopsies at diagnosis of acute GI GVHD and compared these to bone marrow transplant (BMT) patients without GVHD. Allogeneic BMT patients ≥2 years old undergoing endoscopy for clinical indications had 2 additional rectosigmoid mucosal biopsies for transcriptome analysis. Transcriptome data from 211 ulcerative colitis (UC) patients were included to uncover genes and pathways shared between GVHD and UC. Rectal biopsies from 20 children without inflammatory bowel disease (IBD) served as controls. <h3>Results</h3> Twenty-one patients underwent endoscopy pre (n=5) or post BMT (n=16). Median age of patients was 13.5 years (range 4.5 -25 years). Four patients were excluded from analyses (pre BMT colitis n=3, no lower GI biopsy n=1). Nine patients had acute GI GVHD, while 8 patients did not (Table 1). Principal component analysis shows patient clustering of those with and without GVHD, suggesting distinct transcriptomic mechanisms driving disease (Figure 1A). We identified 1310 significant genes, 144 of which were downregulated and 1266 upregulated in acute GVHD compared to no GVHD (Figure 1B). Top upregulated biological processes in GVHD revealed an innate antimicrobial response and associated cytokine signaling, notable for interferons. Top 20 differentially expressed genes in acute GVHD (Table 2), include CXCL9, CXCL10 and CXCL11, which are chemokines involved in GVHD, and IDO1 which regulates tryptophan metabolism. Four hundred and ninety shared genes were upregulated, and 126 genes were downregulated in GVHD and UC. Notable shared downregulated pathways involved butyrate metabolism (Table 3). DUOXA2, a gene involved in regulating innate antimicrobial responses in IBD, was the top upregulated genes in pediatric IBD and was the second highest differentially expressed gene in the acute GVHD, providing additional rationale for intestinal microbiome modulation in both diseases. Genes involving the ERK1/2 cascade (Table 4) were upregulated in acute GVHD (p=1.67 × 10 ⁻³) providing rationale for exploring ERK1/2 inhibition as novel acute GVHD treatment. <h3>Conclusions</h3> Acute GI GVHD has a distinct transcriptome signature which includes pathways of innate antimicrobial responses highlighting the role for microbiome modulation. The ERK1/2 cascade pathway is upregulated, suggesting a novel target in acute GI GVHD. Acute GI GVHD has important similarities with the UC transcriptome, including upregulation of DUOXA2 and downregulation in butyrate metabolism in both.

P.14Immune-mediated neuromuscular complications of graft-versus-host disease

Graft-versus-host disease (GVHD) is a known complication of allogeneic bone marrow transplantation (ABMT) for hematological malignancies occurring in 33-64% of patients. However, little is known regarding immune-mediated neuromuscular complications (INMC) of GVHD: their pathophysiology, treatment response and survival outcomes. We conducted a retrospective review of ABMT patients seen at our institution between 2013 and 2018 to identify patients with active GVHD and concomitant INMC. Patients were excluded if their neuromuscular condition preceded ABMT or had an alternative etiology. Among 688 patients with active GVHD, 20 (2.9%) had an INMC preceded by acute GVHD in 15 patients and chronic GVHD in 13. Median age at symptom onset was 56 years, and median time from transplant to neurological diagnosis was 9 months (range 2-42). Reduced intensity conditioning was used in 17 (85%) patients, all of whom received fludarabine as part of the regimen. Myopathy was the most common INMC (17 patients) manifesting with predominantly axial and/or proximal weakness. 11 patients had a muscle biopsy showing diffuse perimysial, predominantly macrophagic, infiltration in 9 specimens; lymphocytic infiltration in 3; and perifascicular atrophy in 3. Other INMC consisted of Guillian-Barré syndrome (n=1), myasthenia gravis (n=1), and brachial plexitis (n=1). 19 patients were treated and responded to treatment with immunosuppressive agents; however 14 of them relapsed and required escalation of therapy. After a median follow-up of 83 months, 7 (35%) patients died: 5 from progressive GVHD and 2 from infections. The 5-year overall survival from time of transplant was 68%. INMC of GVHD can markedly impact patient's life, yet they are treatable if accurately and timely diagnosed. Our novel histopathologic findings support the growing evidence for the role of macrophages in the pathogenesis of GVHD.

Interleukin-27 enhances the function of regulatory T cells to prevent Graft-versus-host diseases

Abstract Graft-versus-host diseases (GvHD) remain life-threatening complications after allogeneic stem cell transplantation. Foxp3+Tregs can inhibit GvHD, while preserving graft-versus-tumor activity, making Tregs a promising candidate for GvHD treatment. Yet, the clinical application is hampered by the limited numbers and ineffective functions during treatment. Conventional CD4 T cells acquire Foxp3 expression and regulatory functions by stimulating them with IL-2 and TGFb (iTregs). Unlike thymus-derived Tregs (tTreg), ineffective regulatory functions and phenotypic instability of iTregs remain areas of improvement. We reported that IL-27 is able to enhance Treg functions to reduce autoimmune and allergic inflammation. Herein, we sought to test if IL-27-stimulation in Tregs improves therapeutic efficacy of Tregs in a murine model of MHC-mismatched allogeneic GvHD. IL-27-pretreated tTregs efficiently reduced acute GvHD-associated mortality, whereas the efficacy of IL-27-pretreated polyclonal iTregs to prevent GvHD was marginal. We hypothesized that elevating antigen specificity in iTregs would increase the therapeutic functions of iTregs. Indeed, IL-27-pretreated allogeneic iTregs exhibited highly improved therapeutic function, equivalent to that of tTregs. IL-27-induced iTreg functions were also tested using human cells. IL-27 prestimulated third party human iTregs partially rescued mice from xenogeneic GvHD. Our data suggest that IL-27 stimulation in Tregs may play an important role in regulating Treg functions during GvHD, raising the hypothesis that defects in Treg functions (possibly via IL-27) may underlie different susceptibility of allogeneic bone marrow transplant patients who develop GvHD or not.

Changes in the Stool Virome and Fungome of Children Undergoing Bone Marrow Transplant

Background Bacterial dysbiosis is associated with acute graft versus host disease (GVHD) and blood stream infections (BSI) after bone marrow transplant (BMT). Intestinal viral and fungal changes after BMT are unknown in children. Methods Metagenomic shotgun paired reads sequencing was performed for 56 patients who underwent a BMT at Cincinnati Children's Hospital Medical Center. Stool samples were collected pre BMT and at least one post BMT time point (range day+1-day+35). Metagenomics data were analyzed using DIAMOND / MEGAN6 CE and NCBI RefSeq database. Results Demographics are shown in Figure 1. A total of 180 stool samples were analyzed. Twelve of 56 patients had stool samples analyzed at 2 time points (pre BMT and post BMT) while 44 patients had stool analyzed at > 2 time points with one being a pre BMT sample. All patients were on fungal and viral prophylaxis. Fungome Fungi were detected in 19 of 56 patients' stool samples (Fig 2A). The most frequent fungi isolated from stool were Candida sp. Nine of 56 patients had evidence of clinical fungal infection after BMT (Candida N=7, Malassezia N=1, Rhizopus N=1). One patient with clinical Candida infection had Candida detected from stool pre BMT but the remaining patients did not have a fungal infection similar to the fungi isolated from stool. BSI occurred in 7/19 in patients with fungi isolated from stool compared to 11/37 in patients without fungi in stool. GI GVHD occurred in 7/16 (43%) in allogeneic BMT patients with fungi in stool compared to 5/35 (14%) patients without fungi isolated in stool. likely reflecting antibiotic exposure and resultant dysbiosis. Virome Viruses were identified in 31 of 56 patients' stool samples (Fig 2B). Caudalovirales (bacteriophages) were the most frequent organisms seen in stool (n=20). Interestingly Caudalovirales in stool were detected in 18 patients who were on human milk as their nutritional source. Mastadenovirus sp. (adenovirus in clinical practice) was observed in 5 patients. Mastadenoviruses in stool were seen with ATG (n=1) or alemtuzumab (n=4) exposure. Ten of 56 patients had clinical adenoviral reactivation. Four of the 10 patients with clinical adenoviral reactivation had adenovirus isolated in the stool prior to onset of clinical viremia (pre BMT n=1; day+1 n=2; day+13 n=1). Conclusion We observed that fungi were not frequently detected from stool, and presence of fungi did not always imply clinical fungal infection with the same organism but could reflect antibiotic exposure and contribute to intestinal dysbiosis leading to acute GVHD. Presence of bacteriophages in stool is a novel observation, which could be reflective of a diet of human milk. We have previously shown that human milk lowers intestinal inflammation after BMT and these findings will be explored in independent studies. Mastadenovirus was detected in stool before or early after BMT and frequently heralded clinical viral reactivation.

Incidence, Histopathological Features and Differential Diagnosis of Cutaneous Graft Versus Host Disease in Allogeneic Bone Marrow Transplantation.

Objectives:Hematopoietic stem cell transplantation by allogeneic bone marrow transplantation is a method used in the treatment of various genetic, immunological disorders, hematologic and solid organ malignancies. Graft versus Host Disease is one of the major and fatal complications of allogeneic bone marrow transplantation. It is a systemic disease affecting five main areas: skin, gastrointestinal tract, liver, lung and hematopoietic system. Diagnosis of cutaneous Graft versus Host Disease is made by the correlation between clinical and histopathological findings of the patient. The present study aims to investigate the incidence of cutaneous graft versus Host Disease in allogeneic bone marrow transplantation patients in our center, to discuss the histopathological features and differential diagnosis of cutaneous graft versus Host Disease in the light of the literature.Methods:The pathology slides of allogeneic bone marrow transplantation patients who were diagnosed as graft versus Host Disease in our pathology department between January 2015 and January 2019 were re-evaluated. Epidermal and dermal histomorphological findings of the disease were classified; the patients’ clinical and demographic information was obtained from the files. The incidence of cutaneous Graft versusHost Disease was calculated.Results:In our center, between January 2015 and January 2019, 273 pediatric and 100 adult patients underwent allogeneic and 181 autologous bone marrow transplantation. Twenty-three patients who underwent allogeneic bone marrow transplantation had cutaneous Graft versus Host Disease whereas and 21 patients had gastrointestinal Graft versus Host Disease. The incidence of cutaneous and gastrointestinal Graft versus Host Disease was 16.1% whereas the incidence of cutaneous Graft versus Host Disease was 8.42%. The most common clinical differential diagnosis of cutaneous Graft versus Host Disease was drug reaction (74%). The most common epidermal histomorphologic finding in our cases was keratinocyte necrosis (87%). In our cases, the most common epidermal histomorphologic finding was keratinocyte necrosis (87%). This was followed by vacuolar degeneration in basal keratinocytes (63%), acanthosis and spongiosis (61%), respectively. The most common finding in the dermis was pigment incontinence (59%). Of the patients with Graft versus Host Disease, 56% had transplantation from unrelated donors, whereas 44% of them had transplantation from their relatives.Conclusion:Cutaneous Graft versus Host Disease is a common complication of allogeneic hematopoietic stem cell transplantation. It is associated with high mortality rates and has a significant negative impact on the patient’s quality of life. Dermatological early recognition of the disease; histopathological evaluation and verification with differential diagnosis plays a key role in preventing patient morbidity and mortality.

Assessment of Iron Overload in the Pediatric Allogeneic HSCT Recipient

Background: Owing to improved strategies in pediatric bone marrow transplantation, a larger number of transplanted children are now becoming long term survivors. These post-transplant patients remain at risk for late complications including iron overload, which has the potential to impair quality of life and adversely affect later outcomes. While literature has previously focused on iron overload in the adult sickle cell patient, there has been minimal research into its effect on the pediatric bone marrow transplant recipient. Thus, no current guidelines exist for screening, management or treatment of iron overload in this patient population. Our study focuses specifically on this population and reports the relationship between number of PRBC transfusions and current diagnostic tools.Objectives: To identify the presence or absence of correlation between the number of red blood cell transfusions and indicators of iron overload via two different modalities: ferritin values and the T2* MRI liver iron concentration (Ferriscan).Methods: A retrospective chart review of the allogeneic pediatric bone marrow transplant patients over the past 5 years at a single center (n = 32). Quantitative data obtained which included number of PRBC transfusions, ferritin, and T2* MRI LIC. Correlation analysis subsequently performed between pre-and post-transplant values.Results: There was significant (p < 0.001) moderate correlation (r = 0.62) between the number of pre-transplant PRBC transfusions and the pre-transplant ferritin value. No significant (p >0.1) correlation between the number of pre-transplant PRBC transfusions and the pre-transplant T2* LIC. Also, no significant (p > 0.1) correlation between pre-transplant ferritin and T2* LIC. The total number of PRBC transfusions up to 100 days post-transplant did have significant (p = 0.008) moderate correlation (r= 0.62) with post-transplant ferritin values. There was significant (p = 0.01) strong correlation (r= 0.87) between the total number of PRBC transfusions up to 100 days post-transplant with post-transplant T2*LIC values. No significant correlation (p > 0.1) between post-transplant ferritin and T2* MRI LIC values.Conclusions: In terms of modalities utilized for evaluation of iron overload in the pediatric allogeneic BMT population, no significant correlation exists between ferritin values and T2* MRI liver iron concentration values. While ferritin is an acceptable screening tool the post-transplant T2*MRI LIC is a more accurate diagnostic indicator of transfusion burden. Future studies will be used to explore associated adverse outcomes of patients diagnosed with iron overload. DisclosuresNo relevant conflicts of interest to declare.

Vaccination in oncology practice and predictors.

Despite, vaccination is a highly effective and widely recommended for prevention of certain infections, vaccination coverage is very low. The purposes of this study were to evaluate the attitudes of medical oncologists towards vaccination and to identify predictors of intention to recommend vaccination in patients with cancer. A structured questionnaire is formed to evaluate the daily practice of vaccination. Turkish medical oncologists were invited to this study via email, SMS, or phone call. Questionnaire was filled out and the data were stored in an online survey platform. Two hundred seventy-three medical oncologists participated in the survey. Influenza, Pneumococcus, and hepatitis B were the most commonly recommended vaccines (87.1, 72.8, 67.0%, respectively). Patients with lung cancer, lymphoma and breast cancer were the main malignancies that medical oncologists suggest vaccination (68.1, 68.1, 24.6%, respectively). The most common times for vaccination were during remission/follow-up period (68.4%) or before beginning chemotherapy (64.1%). Only 23.4% of the physicians thought that their recommendation for vaccination was efficient and adequate. Lack of time and lack of knowledge or experience about vaccination are the most common limitations. There is a positive correlation between experience in the field and evaluating patients for vaccination (r=0.390, p<0.001); on the other hand, there is negative correlation between number of patients seen per day and evaluating patients for vaccination (r=-0.080, p=0.18). Experience with autologous or allogeneic bone marrow transplant patients is related with more tendency to evaluate patients for vaccination (p<0.001). Degree of experience in oncology especially in bone marrow transplant units and total number of patients seen per day are important predictors of vaccination practice in oncology. The frequency of recommendation increases with degree of experience, knowledge, and visit time per patient.

1485P - Medical oncologists' attitudes towards vaccination in oncology practice

Despite of vaccination is a highly effective way of preventing certain infections and widely recommended in patients' with cancer, vaccination rate are not high enough. The purpose of this study was to evaluate the attitude of medical oncologists towards vaccination in their daily practice and predictors of vaccination practice in oncology. A structured questionnaire is formed to evaluate the daily practice of vaccination. Medical oncologists actively working in Turkey were invited to study by emails, SMS messages and direct phone calls. Questionnaires were filled and the data were stored with an online survey platform 273 medical oncologists participated the survey. Influenza, Pneumococcus and hepatitis B were the most commonly recommended vaccines (87.1%, 72.8%, 67.0%, respectively) in daily practice. Lung, lymphoma and breast cancer are the pathologies to which medical oncologists give priority while recommending vaccination (68.1%, 68.1%, 24.6%, respectively. Participants prefer to recommend vaccination to patients in remission/follow-up (68.4%) or before starting therapy 64.1%. Patients' age and comorbidities were not related with rate of vaccination. Only 23.4% of the participants thought that their recommendations on vaccination were efficient and satisfying. Lack of time during outpatient clinic visit and lack of knowledge or experience about vaccination are the most common limitations during recommending vaccination. There is a positive correlation between experience in the field and evaluating patients for vaccination (r = 0.390, p < 0.001), on the other hand, there is negative correlation between number of patients daily cared and evaluating patients for vaccination (r= -0.080, p = 0.18). Experience with autologous or allogeneic bone marrow transplant patients is related with more tendency to evaluate patients for vaccination (p < 0.001). Status of experience in oncology, especially in bone marrow transplant units and total number of patients exposed daily are important predictors of vaccination practice in oncology. Similar with the data in other fields, there is also a huge heterogeneity in medical oncologists' attitude towards vaccination.

İntestinal graft versus host hastalığının endoskopik bulgularının retrospektif değerlendirilmesi

Background and Aims: Acute graft-versus-host disease occurs after allogeneic hematopoietic stem cell transplantation and is a reaction of donor immune cells against host tissues. Activated donor T cells damage host epithelial cells. About 35%-50% of hematopoietic stem cell transplant recipients will develop acute graft-versus-host disease. The endoscopic findings varied markedly and included mild mucosal edema with focal erythema, diffuse erythema, and diffuse polypoid indurations with multiple bleeding ulcerations. We investigated endoscopic findings in a graft-versus-host disease patient population. Materials and Methods: A retrospective review of endoscopic data was performed in 18 adult allogeneic bone marrow transplant recipients at our institution. Results: In this study, 18 allogeneic bone marrow transplant patients (mean age 33.9 years; 62% male) were evaluated. In 6 graftversus- host disease patients, the endoscopic appearances of the esophagus, stomach and duodenum varied from subtle mucosal erythema and edema to frank ulceration. Colonoscopy was performed with biopsies in 12 graft-versus- host disease patients. The colonoscopic findings varied markedly and ranged from mild mucosal edema with focal erythema to multiple bleeding ulcerations. Conclusions: The diagnostic accuracy of endoscopy was high in gastrointestinal graft-versus-host disease. Accurate diagnosis of gastrointestinal graft-versus-host disease might be obtained with mucosal biopsies from either the upper or lower gastrointestinal tract. Endoscopy may play a significant role in establishing early diagnosis and treatment for gastrointestinal graft-versus-host disease patients.

Severe ocular graft versus host disease (GVHD): association with mortality in allogeneic bone marrow transplant (BMT) patients with severe systemic GVHD

Severe ocular graft versus host disease (GVHD): association with mortality in allogeneic bone marrow transplant (BMT) patients with severe systemic GVHD

Comparing the safety and efficacy of red blood cell transfusion dose in hematopoietic stem cell transplant patients: single versus double unit transfusions

Until recently, the national standard practice for blood transfusions in bone marrow transplant patients was two units of red blood cells (RBCs) per transfusion episode. This practice was called into question due to safety concerns, suggesting that one unit of RBCs per transfusion episode may be an equivalent or even safer and less costly practice (assuming factors such as amount of bleeding and hemoglobin level are equal). Following a thorough review of existing blood management practices and review of the literature, our academic medical center changed practice to routinely transfuse one unit of RBCs per low hemoglobin (7-8 g/dL) episode if certain clinical criteria were met. Following IRB approval, a retrospective medical record review began to evaluate this practice change among two groups of hematology-oncology patient populations (allogeneic and autologous bone marrow transplant). Patient records from these two groups of patients are being evaluated before and after the practice change (one vs two units of RBCs/transfusion) looking at average units of blood products transfused per patient, impact on length of stay, and estimate of nursing time costs. The project is expected to generate new knowledge regarding safe blood management practices in hematology oncology patients. The project is using the hematology oncology inpatient unit log of admissions and discharges to identify adult allogeneic and autologous bone marrow transplant patients who received a blood transfusion for a hemoglobin of 7-8g/dl and hematocrit above 21%; and were not actively bleeding, septic, experiencing a major infection, or pregnant. Patient data are being obtained from the University HealthSystem Consortium (UHC) database. 400 cases are being enrolled, 200 from pre-practice change (7-1-2009 to 6-30-2011) and 200 from post-practice change (9-1-2011 to 8-31-2013). A two-month gap was purposefully included between the two time periods to allow for full transition to the new practice standard of one unit of RBCs/transfusions. Data thus far suggests a reduction in red blood cell utilization at an average of 1.3 units per hospital discharge. Based on these utilization trends, we are estimating a cost savings of at least $1300 per month just in purchase cost ($200 per RBC unit X 1.3 units per discharge X an average of 5 patients/month). Additionally, we are estimating a savings in nursing hours of approximately 13 hours per month (2 hours per RBC transfusion X 1.3 units per discharge X an average of 5 patients/month). Preliminary project findings indicate promise for the standard practice of transfusing one unit of RBCs per low hemoglobin episode for allogeneic bone marrow transplant and autologous bone marrow transplant patients. After data collection is complete, formal statistics will be completed to compare the mean number of RBC units between the practice of routinely transfusing 1 RBC unit and the practice of routinely transfusing 2 RBC units, as well as comparing length of stay and costs. Early conclusions suggest the goal of improving the safety of blood transfusions and preserving a precious resource might be achieved with this important practice change for two groups of oncology patients. These results will inform other practice settings to improve their use of blood management products for oncology patients and promote patient safety and cost-effective practices. Use of the UHC database as a meaningful resource for practice improvement projects and research studies will be highlighted. Continued evaluation and ongoing improvement of blood management practices at the project site will be discussed with suggestions for other settings and practices. This will help improve the safety of blood transfusions. It could guide future studies with baseline information from this transfusion practice change. Other oncology areas could adopt a similar practice change, educate patients and clinicians on safe transfusion practices.

Total Hip Arthroplasty in Very Young Bone Marrow Transplant Patients

ABSTRACT Concerns remain about total hip arthroplasty (THA) performed in very young patients, especially those with complex medical history such as allogeneic bone marrow transplantation (ABMT). This study retrospectively reviews the perioperative courses and functional outcomes of ABMT patients &lt;21 years old undergoing primary uncemented THA. Nine THAs were performed in five ABMT patients at an average age of 19.7 years. The interval between ABMT and THA was 73.0 months with clinical follow-up of 25.8 months. Harris Hip Scores (HHS) increased dramatically from preoperatively 44.5 (31.1-53.4) to postoperatively 85.2 (72.0-96.0) and all patients subjectively reported a good (4 hips) to excellent (5 hips) overall outcome. There was one reoperation for periprosthetic fracture fixation but there were no infections or revisions performed. Despite the history of severe hematopoietic conditions requiring ABMT, these very young patients do appear to have improved pain and function following primary THA with short-term follow-up. These results are comparable to prior studies of adult ABMT patients undergoing THA and are encouraging given the complexity of the decision to perform hip arthroplasty in the medically complicated very young patient. Ledford CK, Vap AR, Bolognesi MP, Wellman SS. Total Hip Arthroplasty in Very Young Bone Marrow Transplant Patients. The Duke Orthop J 2014;4(1):19-23.

Total hip arthroplasty in very young bone marrow transplant patients.

Concerns remain about total hip arthroplasty (THA) performed in very young patients, especially those with complex medical history such as allogeneic bone marrow transplantation (ABMT). This study retrospectively reviews the perioperative courses and functional outcomes of ABMT patients <21 years old undergoing primary uncemented THA. Nine THAs were performed in five ABMT patients at an average age of 19.7 years. The interval between ABMT and THA was 73.0 months with clinical follow-up of 25.8 months. Harris Hip Scores (HHS) increased dramatically from preoperatively 44.5 (range, 31.1-53.4) to postoperatively 85.2 (range, 72.0-96.0) and all patients subjectively reported a good (four hips) to excellent (five hips) overall outcome. There was one reoperation for periprosthetic fracture fixation but there were no infections or revisions performed. Despite the history of severe hematopoietic conditions requiring ABMT, these very young patients do appear to have improved pain and function following primary THA with short-term follow-up.

Blocking VIP Signaling Abrogates Upregulation Of PD1 and Increases Proliferation Of Allo-Reactive T-Cells In a Mixed Lymphocyte Reaction

IntroductionVasoactive intestinal peptide (VIP) is a neuropeptide hormone that suppresses Th1 immunity and inhibits antiviral immunity. Decreased Th1 immunity is problematic for allogeneic bone marrow transplant (allo-BMT) patients requiring T-cell immunity against blood cancers (Graft-versus-Tumor) and against secondary infections such as CMV. VIPhyb, a modified VIP peptide, is a VIP receptor antagonist that decreases VIP signaling. VIP-knockout mice and mice treated with VIPhyb after allo-BMT are known to have better antiviral immunity and survival after CMV infection without increasing GvHD (Li et al. PLoS One. 2013 May 27;8(5):e63381) (Li et al. Blood. 2013 Mar 21;121(12):2347-51.), thus making VIPhyb of interest for pharmacological use in humans to improve the efficacy of allo-BMTThe effects of VIPhyb on T-cell immunity are not yet fully profiled. This study aimed to analyze the effects of VIPhyb on CD4+ and CD8+ T-cell proliferation and activation in order to better understand the mechanistic implications of VIP inhibition on T-cell adaptive immunity. This study also aimed to show that mixed lymphocyte reactions (MLRs), an in vitro allo-BMT model, could be used to provide rapid and reliable results that are consistent with in vivo data. It was hypothesized that VIPhyb would increase T-cell immunity as profiled by: increased T-cell proliferation, CD69 and PD1 co-upregulation in early T-cell activation, and PD1 downregulation in T-cells after initial activation. MethodsSplenocytes from two histoincompatible mice were cultured together at 37°C in a 1:1 ratio in a one-way MLR. BALB/c splenocytes (stimulators) were irradiated at 20Gy, and Pepboy splenocytes (responders) were labeled with CFSE to trace proliferation. VIPhyb was added daily to the cell cultures in doses of 0.1μM, 0.3μM, 1μM, or 3μM. Treatment groups were compared to a PBS control. Proliferation, CD69, and PD1 were assessed by flow cytometry on the BD FACSAria. All results are shown as mean ± SEM (n=3). One-way ANOVA tests with Dunnett post-tests were calculated using Prism software. *p < 0.05; **p < 0.01; ***p < 0.001 ResultsVIPhyb increased CD4+ and CD8+ T-cell proliferation: 3, 5, and 7 days after initiating a one-way MLR, CFSE expression of Pepboy responder T-cells was assessed using flow cytometry (Figure 1). As the VIPhyb dose increased, the percentage of initial splenocytes that underwent proliferation increased in both CD4+ and CD8+ T-cells. [Display omitted] VIPhyb increased early T-cell CD69 expression and abrogated later PD1 upregulation in CD8+ T-cells: 3, 5, and 7 days after initiating a one-way MLR, expression levels of CD69 and PD1 on Pepboy responder T-cells were assessed by flow cytometry. Significant upregulation of CD69 on CD4+ and CD8+ T-cells on day 3 occurred with increasing VIPhyb doses (Figures 2A and 2B). PD1 was co-upregulated with CD69 during early activation, and VIPhyb significantly decreased PD1 expression on CD8+ T-cells on days 5 and 7 (Figures 2C and 2D). [Display omitted] ConclusionsVIPhyb increased T-cell proliferation; CD8+ T-cells were affected more significantly. VIPhyb increased early co-upregulation of CD69 and PD1 in all T-cells and significantly decreased later CD8+ T-cell PD1 expression, indicating that VIPhyb increases T-cell activation. We hypothesize that the decreased PD1 expression will be critical for understanding the pathways involved in VIP inhibition. Importantly, since it has been shown in vivo that VIPhyb does not increase GvHD, then it can be assumed that the VIPhyb-induced T-cell proliferation and activation will increase GvL and adaptive immunity without increasing alloreactivity. Notably, these results are consistent with published in vivo data, which demonstrates that the MLR can be used as a faster method of analyzing pharmacological compounds than in vivo experiments. Given these results, VIPhyb is still of interest as a potential therapy for allo-BMT patients. Disclosures:No relevant conflicts of interest to declare.

Functional Hyposplenism in Pediatric Chronic Graft-Versus-Host Disease

AbstractAbstract 4493 Introduction:Functional hyposplenism is a well-recognized complication of chronic graft versus host disease (cGVHD). Whether the hyposplenism in cGVHD is transient and if there is any association between the severity of cGVHD and degree of hyposplenism are not well understood. The pitted red cell count has been shown to be a simple and reliable biomarker of splenic function that correlates well to other tests such as quantitative Howell-Jolly bodies and 99mTc sulfur-colloid liver-spleen scans. It measures the ability of the splenic red pulp to pinch off intracellular vesicles, or pits, from red blood cells as they pass through narrow adjustable slits in an endothelial lining. Methods:We hypothesized that functional hyposplenism correlates with the severity of cGVHD in pediatric BMT patients. We performed a single-center, retrospective review of pediatric allogeneic bone marrow transplant (BMT) patients who had more then one pit count performed post-BMT and clinical diagnosis of cGVHD based on NIH consensus criteria. Results:We identified 9 pediatric BMT recipients (3 males, 6 females; average age at BMT = 9.6 years) that met our criteria. Indications for BMT were AML (2), ALL (1), biphenotypic acute leukemia (1), CML (2) and thalassemia (3). All 9 had functional hyposplenism with active cGVHD as determined by a pit count > 2%. We identified two distinct groups. In 7 of the 9 BMT recipients, there was a return to normal splenic function that lagged between 12 and 18 months after clinical improvement/resolution of cGVHD symptoms and successful weaning of immunosuppressive therapy. In the other 2 patients there was no correlation between abnormal pit count and cGVHD symptoms. Conclusions:Our single-centre retrospective cohort study provides evidence that the functional hyposplenism associated with cGVHD is not permanent but improvement in cGVHD symptoms and successful weaning of immunosuppressive therapy should not be used as indicators of return to normal splenic function and reasons to stop Penicillin prophylaxis. We propose that all patients post-BMT should have serial pit counts performed, as resolution of cGVHD clinical symptoms does not ensure normal splenic function. Disclosures:No relevant conflicts of interest to declare.

Development and Validation of Limited Sampling Strategies for Estimation of Cyclosporine Area Under the Concentration–Time Curve in Hematopoietic Stem Cell Transplant Patients

The aim of this study was to develop and validate limited sampling strategies for accurately predicting 12-hour area under the concentration-time curve (AUC(0-12 h)) to provide a practical method for more precise therapeutic drug monitoring of cyclosporine A in stem cell transplant patients. Steady-state cyclosporine blood concentrations were measured within a dosing interval (12 hours post administration) in 35 allogeneic bone marrow transplant patients receiving 238 mg (±117 mg) twice-daily dose of cyclosporine. Limited sampling strategies were developed by multiple linear regression analysis of relationship between cyclosporine A full AUC(0-12 h) values and different combinations of preselected blood concentrations. Validation of the estimating equations was done by a bootstrap-like cross-validation method. Cross-validation results showed that cyclosporine AUC(0-12 h) could be estimated using either 2 or 3 samples within the first 4 hours after drug administration with good accuracy and precision (absolute prediction error of less than 6.2%). The number of estimated area under the drug concentration-time curves within 15% of observed values was greater than 26 (74%) for models used predose concentration with either c(2h) and c(4h) or both. Most of the previously reported single-sample models showed a systematic error in predicting AUC(0-12 h). Although a statistically significant difference in precision of prediction was seen between 3-sample model using c(0), c(2h), and c(4h) and 2-sample models (c(0), c(2h) or c(0), and c(4h)), such a difference (2%) could not be of clinical importance. Other 2-sample estimating equations (models using c(2h) with either c(6h) or c(10h)) with the same degree of precision appear to be less feasible clinically. Cyclosporine AUC(0-12 h) in bone marrow transplant patients could be estimated using 2 or 3 samples within the first 4 hours after drug administration with good accuracy and precision.

Comparing Administration of Nutrition Support With Prescribed Dose

The aim of this study was to evaluate whether pediatric bone marrow transplant (BMT) patients receive the prescribed dose of nutrition support (NS). Data were obtained from electronic and paper charts at St. Jude Children's Research Hospital. The amount of NS received was compared with the amount prescribed. Data were collected on 32 patients for 63 hospital stays in which NS was administered. The mean percentage of nutrition prescription met and percentage of total estimated energy met were 69% and 72%, respectively. Allogeneic BMT patients received significantly more of their nutrition prescription (92%) than autologous BMT patients did (54%, P < .01). Malnourished patients were significantly more likely to receive the full dose of NS than patients who were considered nourished or obese (P < .05). This study showed that patients who were most in need of NS were more likely to receive the full dose.

HLA-Ig Based Artificial Antigen Presenting Cells for Efficient &lt;em&gt;ex vivo&lt;/em&gt; Expansion of Human CTL

CTL with optimal effector function play critical roles in mediating protection against various intracellular infections and cancer. However, individuals may exhibit suppressive immune microenvironment and, in contrast to activating CTL, their autologous antigen presenting cells may tend to tolerize or anergize antigen specific CTL. As a result, although still in the experimental phase, CTL-based adoptive immunotherapy has evolved to become a promising treatment for various diseases such as cancer and virus infections. In initial experiments ex vivo expanded CMV (cytomegalovirus) specific CTL have been used for treatment of CMV infection in immunocompromised allogeneic bone marrow transplant patients. While it is common to have life-threatening CMV viremia in these patients, none of the patients receiving expanded CTL develop CMV related illness, implying the anti-CMV immunity is established by the adoptively transferred CTL1. Promising results have also been observed for melanoma and may be extended to other types of cancer2. While there are many ways to ex vivo stimulate and expand human CTL, current approaches are restricted by the cost and technical limitations. For example, the current gold standard is based on the use of autologous DC. This requires each patient to donate a significant number of leukocytes and is also very expensive and laborious. Moreover, detailed in vitro characterization of DC expanded CTL has revealed that these have only suboptimal effector function 3. Here we present a highly efficient aAPC based system for ex vivo expansion of human CMV specific CTL for adoptive immunotherapy (Figure 1). The aAPC were made by coupling cell sized magnetic beads with human HLA-A2-Ig dimer and anti-CD28mAb4. Once aAPC are made, they can be loaded with various peptides of interest, and remain functional for months. In this report, aAPC were loaded with a dominant peptide from CMV, pp65 (NLVPMVATV). After culturing purified human CD8+ CTL from a healthy donor with aAPC for one week, CMV specific CTL can be increased dramatically in specificity up to 98% (Figure 2) and amplified more than 10,000 fold. If more CMV-specific CTL are required, further expansion can be easily achieved by repetitive stimulation with aAPC. Phenotypic and functional characterization shows these expanded cells have an effector-memory phenotype and make significant amounts of both TNFα and IFNγ (Figure 3).