Autologous Bone Marrow Transplantation In Patients Research Articles

IMPACTO DA MUCOSITE ORAL EM PACIENTES TRANSPLANTADOS DE MEDULA ÓSSEA AUTÓLOGO E O PAPEL DO CIRURGIÃO DENTISTA

The Haematopoietic Stem Cell Transplantation (HSCT) is a form of treatment used for some types of hematological cancers in which the patient is both a donor and recipient. The most relevant side effect of this therapy for dentistry is oral mucositis, which in addition to causing mucosal irritation, delay and interruption of the chemotherapy cycle, can be a gateway to opportunistic infections and lead to a death outcome. As a dental surgeon increasingly active in the multidisciplinary team, the importance of dental care in the trans-HSCT phase has been widely reported in the literature. Thus, the general objective of the present work was to carry out a literature review on the impacts of oral mucositis in autologous bone marrow transplant patients, as well as the specific objective of highlighting the importance of the dental surgeon in the care of these patients. Thus, for the design of the research, the descriptors Stomatitis, Hospital Dental Team, Hematopoietic Stem Cell Transplantation, Autologous Transplantation, through DeSC; PubMed, Scielo and Lilacs databases and the Boolean operators AND, OR and NOT were used as a search strategy in the time period from 2004 to 2022. Concluding that the impacts of oral mucositis in patients undergoing auto-HSCT are pathophysiological, of morbidity, mortality and financial loss. However, the presence of the dental surgeon in the multidisciplinary team brought clinical relevance to reduce the impacts caused by oral mucositis, acting, even in a preventive way, with qualitative and quantitative reduction of the condition.

Nursing Intervention for Caregivers of Post Autologous Bone Marrow Transplantation Patients at Home

Background: Autologous bone marrow transplantation is a curative procedure for hematological diseasesand immune deficiencies. The unique and intensive nature of this treatment requires distinctive care duringand post the entire transplant course. Nursing intervention for caregivers post autologous bone marrowtransplantation patients at home is an important component of the care that improves and develops knowledgeand practice of the caregivers, to take care of the patients in order to help them follow the demandingtreatment plan to reach recovery. Aim to evaluate the effect of nursing intervention for caregivers of postautologous bone marrow transplantation patients at home. Material and Method: A Quasi-experimentalstudy was carried out among convenient sample of 143 patients and their caregivers who attended the followup clinic during the first six months post autologous bone marrow transplantation. The study was conductedamong patients and their caregivers in three different hospitals Sheikh Zayed Specialized Hospital, Nationaloncology institute, and Nasser institute at outpatient’s follow-up clinics. A self-administered questionnaireof patients and their caregivers’ demographic data, and reported checklist of caregivers’ knowledge andpractices toward post-autologous bone marrow transplantation patients at home. Results: there was astatistically significant difference between pre and post nursing intervention, which indicate improvement incaregivers’ knowledge and practice post implementation of the nursing intervention program, and positivecorrelation between their knowledge and practice. Conclusion and Recommendations: Although caregivershad adequate knowledge, practice on some aspects, gaps were identified. There is a need for educationalinterventions and discharge plan to upgrade knowledge and practices of the caregivers of post autologousbone marrow transplantation patient at home.

Nursing Intervention for Caregivers of Post Autologous Bone Marrow Transplantation Patients at Home

Background: Autologous bone marrow transplantation is a curative procedure forhematological diseasesand immune deficiencies. The unique and intensive nature of this treatment requires distinctive care duringand post the entire transplant course. Nursing intervention for caregivers post autologous bone marrowtransplantation patients at home is an important component of the care that improves and develops knowledgeand practice of the caregivers, to take care of the patients in order to help them followthe demanding treatmentplan to reach recovery.Aim to evaluate the effect of nursing intervention for caregivers of post-autologous bone marrowtransplantation patients at home.Material and Method: A Quasi-experimental study was carried out among convenient sample of 143patients and their caregivers who attended the follow up clinic during the first six months post autologousbone marrow transplantation. The study was conducted among patients and their caregivers in three differenthospitals Sheikh Zayed Specialized Hospital, National oncology institute, and Nasser institute at outpatient’sfollow-up clinics.A self-administered questionnaire of patients and their caregivers’ demographic data,and reported checklist of caregivers’ knowledge and practices toward post-autologous bone marrowtransplantation patients at home.Results: There was astatistically significant difference between pre and post nursing intervention, whichindicate improvement in caregivers’ knowledge and practice post implementation of the nursing interventionprogram, and positive correlation between their knowledge and practice.Conclusion and Recommendations: Although caregivers had adequate knowledge, practice on someaspects, gaps were identified. There is a need for educational interventions and discharge plan to upgradeknowledge and practices of the caregivers of post autologous bone marrow transplantation patient at home.

Karyotype in Acute Myeloblastic Leukemia: Prognostic Significance for Bone Marrow Transplantation in First Remission: A European Group for Blood and Marrow Transplantation Study

AbstractThe presentation cytogenetic result was correlated with outcome for 999 patients with acute myeloblastic leukemia (AML) having bone marrow transplantation (BMT) in first complete remission (CR1). The karyotype at diagnosis was classified according to the modified Chicago classification. Allogeneic BMT (AlloBMT) was performed in 500 patients and autologous BMT (ABMT) in 499 patients. For both groups, an abnormal chromosome (abn) 5 and/or 7 or a hypodiploid karyotype had a poor outcome, whereas t(15; 17), pseudodiploidy, hyperdiploidy and diploidy were associated with a standard prognosis. Abn (16) and t(8; 21) were also of standard prognosis for ABMT, but favorable for AlloBMT. When comparing AlloBMT and ABMT in patients with favorable or standard cytogenetics, AlloBMT was of benefit for remission duration and leukemia-free survival (LFS). Patients with an unfavorable karyotype had a similar outcome, regardless of type of BMT. By multivariate analysis, cytogenetics at diagnosis had the strongest prognostic value for relapse, LFS, and survival in AlloBMT. In ABMT, cytogenetics influenced relapse and LFS. We concluded that the karyotype at diagnosis had important prognostic implication in AML grafted in CR1.

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.

Effect of a Nurse-Led Protocol on Time to Treatment of Partial Occlusions in Central Venous Access Devices in Pediatric Oncology.

Central venous access devices (CVADs) are the standard of care in pediatric oncology. Occlusion is a common complication that can lead to delays in therapy, readmission, and CVAD removal and reinsertion. Early treatment of partial occlusions using a standardized protocol may restore patency and increase life span of CVADs. The objective of this study was to develop and evaluate a nurse-led protocol to manage partial CVAD occlusions in pediatric oncology and autologous bone marrow transplant patients. The protocol enabled nurses to manage partially occluded CVADs by administering thrombolytic therapy following an algorithm and patient-specific standing order. The primary outcome was time from recognition of the partial occlusion to instillation of a thrombolytic. Secondary outcomes were thrombolytic dwell time, number of complete occlusions, and CVAD life span. We used a quasi-experimental, after-only, nonequivalent control group design to compare patients not exposed (retrospective cohort, n = 137) and patients exposed (prospective cohort, n = 101) to the nurse-led protocol. Mann-Whitney U tests were used to compare time to treatment, dwell time, and CVAD life span between cohorts, and χ2 was used to compare the proportion of occlusions classified as complete. Time to treatment was significantly lower in the prospective cohort (M = 99.9 minutes) versus the retrospective cohort (M = 483.7 minutes), U = 1366.50, p < .01, as was thrombolytic dwell time, U = 282.50, p < .01. Proportion of complete occlusions and CVAD life span did not differ between cohorts. The nurse-led protocol was effective to manage partial CVAD occlusions in pediatric oncology patients.

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.

Preventing or attenuating amphotericin B nephrotoxicity with dopamine receptor agonists: a literature review

Nephrotoxicity is generally considered as the most clinically significant and dose-limiting adverse reaction of amphotericin B. Currently, only the clinical effectiveness of salt loading and administering lipid formulations of amphotericin B have been clearly demonstrated to prevent its nephrotoxicity. In this review, we collected the published data related to dopamine receptor agonists in preventing amphotericin B nephrotoxicity. A literature search was conducted by the relevant keywords like ‘‘amphotericin B”, “nephrotoxicity’’, and ‘‘dopamine’’ in databases such as Scopus, Medline, Embase and ISI Web of Knowledge. Four relevant articles were considered. Results of all the 3 experimental studies demonstrated that co-administration of dopamine (0.5-10 μg/kg/min) as continuous intravenous infusion, SK&F R-105058 (10 mg/kg twice daily), a prodrug of fenoldopam, orally, or fenoldopam, a relatively selective dopamine receptor type 1 agonist, (0.5 or 1 μg/kg/min) as continuous intravenous infusion can at least significantly mitigate the decrease in creatinine clearance caused by amphotericin B. Furthermore, fenoldopam and SK&F R-105058 can also protect against or delay amphotericin B-induced tubular damages. In contrast, the only clinical trial published until now found that simultaneous continuous intravenous infusion of low dose dopamine (3 μg/kg/min) had no beneficial effects on the incidence, severity, as well as time onset of developing amphotericin B-induced nephrotoxicity in autologous bone marrow transplant and leukemia patients. Considering the lack of beneficial effects in different settings such as acute kidney injury of any cause, negative results of the only clinical trial, and risk of significant adverse reactions, continuous intravenous infusion of low dose dopamine (1-3 μg/kg/min) or selective dopamine receptor type 1 agonists (e.g., fenoldopam) currently appears to have no real clinical role in preventing or attenuating amphotericin B nephrotoxicity.

Phase II Laser Photobiomodulation in The Prevention of Mucositis in Autologous BMT Patients

For patients undergoing bone marrow transplant (BMT), clinicians must consider risk factors affecting overall health status, particularly with respect to allogeneic and autologous treatments. Sepsis can lead to death in immunosuppressed individuals. One of the side effects commonly found in immunosuppressive regimens is oral mucositis (OM). Since dentists have been added to oncohematologic centers, oral care programs have effectively improved the outcomes of OM. This phase II study reports a preventive protocol using laser photobiomodulation (660 nm, 20 mW, 5.0 J/cm2,10 s/point) for the onset of OM in 20 transplant patients who received MEL200 and BEAM regimens. The results indicate improved symptoms of pain in the oral cavity, reduced severity and onset of OM lesions, and a better quality of convalescence for patients treated at the Hospital of the Federal University of Bahia.

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.

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.

Frequency of CD4 +CD25 hiFOXP3 + Regulatory T Cells Has Diagnostic and Prognostic Value as a Biomarker for Acute Graft-versus-Host-Disease

The relationship between regulatory T cells (Tregs) and acute graft-versus-host disease (aGVHD) in clinical allogeneic bone marrow transplantation (BMT) recipients is not well established. We conducted a prospective analysis of peripheral blood Tregs as determined by the frequency of CD4(+)CD25(hi)FOXP3(+) lymphocytes in 215 BMT patients. Autologous BMT patients (N = 90) and allogeneic BMT patients without GVHD (N = 65) had similar Treg frequencies, whereas allogeneic patients with GVHD (N = 60) had Treg frequencies that were 40% less than those without GVHD. Treg frequencies decreased linearly with increasing grades of GVHD at onset, and correlated with eventual maximum grade of GVHD (P < .001). In addition, frequency of Tregs at onset of GVHD predicted the response to GVHD treatment (P = .003). Patients with Treg frequencies less than the median had higher nonrelapse mortality (NRM) than patients with Tregs greater than the median, but experienced equivalent relapse mortality, resulting in an inferior survival at 2 years (38% versus 63%, P = .03). Treg frequency may therefore have important prognostic value as a biomarker of aGVHD.

Rhinosinusitis in autologous and allogeneic bone marrow transplantation: a retrospective study on the performance of imaging studies on severity and prognostic evaluation

The objective of this work was to evaluate the diagnostic and prognostic performance of a traditional imaging staging system for rhinosinusitis in the bone marrow transplantation (BMT) scenario. A retrospective cohort study was carried out at a bone marrow transplantation referral center involving subjects who underwent allogeneic or autologous BMT from September 1st 2005 to September 31st 2007 and later evolved with rhinosinusitis during the BMT inpatient period. Patients who had a previous history of sinusal disease or otolaryngologic surgery were excluded from the study. Data concerning mortality, the treatment of rhinosinusitis and BMT outcomes were extracted from medical files. The collected parameters were compared to the Lund-Mackay tomographic staging system score which was calculated based on available tomography films of each patient. A total of 85 BMT were performed and 23 allogeneic and 14 autologous (43.5%) BMT patients evolved with rhinosinusitis during transplantation. A significant association with LMS was found for the absolute neutrophil count (ANC), with a higher ANC (>500/mm3) correlating with a higher LMS (Mean LMS for lower ANC 6.08 and higher ANC 9.71 points, p<0.05). Need for surgical management and post-BMT admissions, the resolution of the rhinosinusitis and overall mortality had no significant correlation with LMS. Patients with less than 500 neutrophils/mm3 are known to be prone to more severe infections, but paradoxically showed lower LMS when developing rhinosinusitis. However, there were no differences in the main outcomes between those with higher and lower LMS. This would possibly lead to an equivocal assumption of a less severe disease. Severely neutropenic patients are probably not able to mount an effective inflammatory response capable of inducing significant tomographic abnormalities. So, this imaging study would not be able to adequately evaluate the extent of sinusal involvement. We thus conclude that LMS is not an adequate staging system to evaluate the severity of BMT sinusal disease. Rev. Bras. Hematol. Hemoter.

Frequency of CD4+CD25hiFOXP3+ Regulatory T Cells Has Diagnostic and Prognostic Value as a Biomarker for Acute Graft-Versus-Host Disease.

Abstract 514JMM and XQ contributed equally to this work.Regulatory T cells (Treg) play an important role in the maintenance of tolerance after bone marrow transplantation (BMT) in experimental models. However, the relationship between Treg and acute graft-versus-host disease (GVHD) in allogeneic BMT recipients is not well established. We conducted a prospective analysis of Treg frequency in 215 BMT patients (125 allogeneic, 90 autologous) at the University of Michigan. Fresh peripheral blood samples were acquired prior to therapy within 24 hours of GVHD onset and at equivalent time points in patients without GVHD. Treg frequency was measured in triplicate by three color cytometry analysis to determine the frequency of CD4+CD25hiFOXP3+ cells within total lymphocytes. There were no significant differences between patients with and without GVHD for median age, nonmalignant disease, conditioning intensity, and median day of sample acquisition. Recipients of grafts from donors who were not family members or who were not HLA-matched were overrepresented in the GVHD group. Autologous BMT patients (N=90) and allogeneic BMT patients without GVHD (N=65) had the same mean Treg frequency (1.09% ± 0.10 vs. 1.09% ± 0.11, p = 0.54), showing that the use of calcineurin inhibitors did not affect Treg frequency. Patients with GVHD (N=60) had 40% fewer Treg (0.66% ± 0.07, p < 0.001) than those without GVHD. Frequencies of Tregs decreased in a linear fashion with each increasing grade of GVHD at onset, and were significantly reduced in patients with ≥ grade II compared to patients without GVHD (p < 0.001) (Figure 1). The calculated Receiver Operating Characteristic (ROC) curve for Treg frequency as an independent biomarker of GVHD was 0.69 (95%CI, 0.55-0.83). Treg frequency also correlated with the eventual maximum overall grade of GVHD (p < 0.001), suggesting a prognostic value for this measurement. Therefore, we evaluated whether Treg frequency would correlate with non relapse mortality (NRM) in the 60 patients with GVHD. Patients with low Treg frequency (<0.5%, N=30) had a significantly greater NRM (41% vs. 8%, p = 0.03) than patients with high Treg frequency (≥0.5%, N=30), which resulted in an inferior survival at two years (38% vs. 63%, p = 0.03) (Table 1). Acute GVHD accounted for the majority of NRM in the low Treg frequency group. Relapse mortality was similar between groups (p = 0.9) (Table 1). This difference in survival remained significant after adjusting for other important prognostic factors such as age, degree of HLA-match, and conditioning intensity (p = 0.05). In this set of sixty patients, frequency of CD4+CD25hiFOXP3+ Tregs at onset of GVHD correlates with GVHD severity, eventual maximum grade and NRM. Treg frequency thus has important diagnostic and prognostic value as biomarker for acute GVHD. [Display omitted] Table 1Clinical outcomes according to CD4+CD25hiFOXP3+ frequency at GVHD onset.OutcomeTreg Frequency ≥ 0.5 %Treg Frequency <0.5%p valuen=30n=301 year Non-Relapse Mortality8% (95% CI, 2-27)41% (95% CI, 23-61)0.032 year Relapse Mortality25% (95% CI, 15-40)20% (95% CI, 11-35)0.92 year Overall Survival63% (95% CI, 43-91)38% (95% CI, 23-63)0.03 Disclosures:No relevant conflicts of interest to declare.

Cytologic Findings in Allogeneic and Autologous Bone Marrow Transplant Patients with Pulmonary Symptoms

To evaluate cytologic findings in patients who underwent bone marrow transplant (BMT) and correlate with the clinical, radiologic and histologic findings.Cytologic findings of the BMT patients with pulmonary symptoms from 1998 to 2007 were reviewed for the presence of malignancies, infectious organisms, inflammation and reactive changes, including treatment-related cellular atypia. Corresponding clinical history, radiologic findings and histologic follow-up when available were also reviewed.In 313 patients who underwent BMT, 89 (71 allogeneic, 18 autologous) had pulmonary symptoms. Of these, 47 specimens from 28 patients had abnormal cytologic findings. Reactive bronchial epithelial cells were found in 4 specimens and reactive squamous cells in 1 specimen. Four patients had markedly atypical cells in 4 specimens-atypical epithelial and mesothelial cells in 3 and 1 specimens, respectively. No malignancy was seen in any specimens examined. Acute inflammation was present in 6 specimens. Candida was the most common microorganism found (21 specimens). The cytologic findings were felt to correlate with clinical and radiologic findings and histologic follow-up.Clinical and radiologic correlation and awareness of the range of cellular atypia are important for preventing potential diagnostic pitfalls and establishing an accurate cytologic diagnosis in BMT patients.

δ-Aminolevulinate dehydratase activity and oxidative stress during melphalan and cyclophosphamide–BCNU–etoposide (CBV) conditioning regimens in autologous bone marrow transplantation patients

Severe toxicity is associated with cytotoxic drugs used during the conditioning regimen (CR) preceding bone marrow transplantation (BMT). The aim of this study was to evaluate the involvement of oxidative stress and possible use of δ-aminolevulinate dehydratase (δ-ALA-D) activity as a marker of oxidative stress in autologous BMT patients. We have also compared common drugs that are used during CR, namely, melphalan (M-200) and cyclophosphamide–BCNU–etoposide (CBV), in order to determine whether either of them could be less toxic to patients in terms of oxidative stress. The sample consisted of 10 patients admitted for autologous BMT, 5 with M-200 CR and 5 with CBV CR and 10 healthy controls. Lipid peroxidation (estimated as thiobarbituric acid-reactive substances, TBARS), vitamin C, thiol levels, catalase, superoxide dismutase and δ-ALA-D activity were determined before CR, during CR and on days 10 and 20 after BMT. Signs of exacerbated oxidative stress were minimal before CR, except for the CVB group (patients with lymphoma) where an increase in TBARS and a decrease in P-SH were detected. Indices of oxidative stress changed in both groups (CBV and M-200) during CR and up to 20 days after BMT. There was a decrease in enzymatic and non-enzymatic antioxidant defenses and in δ-ALA-D activity and an increase in lipoperoxidation in the blood of both patient groups. In conclusion, CBV and, principally, M-200 caused oxidative stress in patients undergoing autologous BMT and blood δ-ALA-D activity seems to be an additional biomarker of oxidative stress in BMT patients.

Efficacy of Oral Ciprofloxacin Prophylaxis in BMT Recipients: A Case-Control Study.

Bacterial infections remain a major source for morbidity and mortality in peripheral stem cell (PSC) and bone marrow (BM) transplant recipients. Despite the considerable number clinical trials, there is still no consensus of opinions for the use of antibiotic prophylaxis. In order to analyze the impact on bacteraemia of withdrawing ciprofloxacin prophylaxis from PSC and BM transplant patients during neutropenia, a total of 617 records were reviewed and found suitable for analysis; 310 autologous and 307 allogenic from Jan 4, 2001 to Dec 27, 2005. Ciprofloxacin was used as a prophylactic measure among all these autologous and allogenic stem cell and bone marrow transplant patients until January 31, 2004. As of February 1, 2004, it was no longer given as a prophylactic measure. Patient characteristics were found similar in the group with ciprofloxacin prophylaxis and the group without ciprofloxacin prophylaxis. Resistant bacteraemia was defined as either ciprofloxacin resistant gram negative bacteria, or VRE, or MRSA. For the analysis the two proportions were compared with a log binomial regression model using generalized estimating equations to account for the lack of independence in the observations. Bacteraemia was the dependent variable, and time periods prior transplant year and year of transplant were included as independent variables. The model was used to generate variance estimates for the proportions, and to check for confounding. Prior transplant year or year of transplant were not confounding variables so, there was no need for adjusted estimates. The analysis shows that the relative risk of developing bacteraemia in the autologous and allogenic groups after ciprofloxacin prophylaxis was discontinued compared with when it was used routinely in the same group was 0.6 (95% CI: 0.2–1.6) and 0.8 (95% CI: 0.4–1.6) respectively. The change in the proportion of patients developing bacteraemia was not statistically significant .The estimation of 100 day-survival from transplant was determined by time period using the Kaplan-Meier Method. The analysis was limited to patients who did not have a prior transplant. In the autologous group, no difference was found when ciprofloxacin prophylaxis was used routinely (n=155): 93.6 (95% CI: 88.3–96.5) versus ciprofloxacin prophylaxis not used (n=112): 94.1 (95% CI: 88.1–97.2). Likewise, no difference was found in the allogenic group when ciprofloxacin prophylaxis used routinely (n=135): 88.9 (95% CI: 82.3–93.2) versus Ciprofloxacin prophylaxis not used (n=106): 87.7 (95% CI: 79.8–92.7). The incidence of bacteraemia with resistant organisms was not statistically significant in both groups. In the autologous groups the incidence was 2 (18.2%) with ciprofloxacin prophylaxis and 1 (20.0%) without ciprofloxacin prophylaxis. In the allogenic group the incidence was 5 (2.8%) with ciprofloxacin prophylaxis and 3 (2.3%) without ciprofloxacin prophylaxis . Overall, in our institution, stopping ciprofloxacin prophylaxis did not significantly affect the incidence of bacteraemia, the 100 days all-cause mortality or the incidence of antibiotic resistant bacteraemia among allogenic and autologous transplant patients. As a result, ciprofloxacin prophylaxis has been suspended and a surveillance program has been adopted.

The Influence of Diagnostic Bronchoscopy on Clinical Outcomes Comparing Adult Autologous and Allogeneic Bone Marrow Transplant Patients

<h3>Study objectives</h3> To review our experience with diagnostic bronchoscopy in the evaluation of pulmonary infiltrates in adult hematopoietic stem cell transplantation (HSCT) recipients in the era of Pneumocystis prophylaxis and cytomegalovirus antigen testing. The study focused on diagnostic yields and the influence of bronchoscopic findings on pharmacologic therapy and mortality, comparing allogeneic (allo) HSCT patients to autologous (auto) HSCT patients <h3>Design</h3> Case series review <h3>Setting</h3> Tertiary care academic urban medical centers <h3>Patients</h3> All adult allo-HSCT and auto-HSCT patients undergoing bronchoscopy for the evaluation of pulmonary infiltrates from January 1997 to September 2001 <h3>Measurements and results</h3> The review identified 169 bronchoscopies that had been performed on HSCT patients, representing 12.5% of all HSCT patients (allo-HSCT patients, 125 bronchoscopies; auto-HSCT patients, 44 bronchoscopies). Bronchoscopy was requested more often in allo-HSCT patients (18.7%) compared to auto-HSCT patients (6.6%). Findings at bronchoscopy provided a specific diagnosis more frequently in allo-HSCT patients (50%) compared to auto-HSCT patients (34%). For both allo-HSCT and auto-HSCT patients, most diagnoses were obtained by BAL alone, whereas transbronchial biopsy (TBBx) provided additional specific information in < 10% of cases. For select patients (n = 27), surgical lung biopsy following bronchoscopy provided unique diagnoses in 47 to 50% of cases. Information from bronchoscopy influenced clinical decisions more often in allo-HSCT patients (50%) than in auto-HSCT patients (36%), and allowed for the discontinuation or addition of antimicrobial, corticosteroid, or antineoplastic agents to treatment. Complications from bronchoscopy occurred in 9% of all HSCT patients (n = 15), and were associated with higher in-hospital mortality rates in allo-HSCT patients (82%; n=9) compared to auto-HSCT patients (50%; n=2). The overall in-hospital mortality rates for allo-HSCT and auto-HSCT patients having bronchoscopy was similar (38% vs 27%, respectively; p=0.25), and establishing a specific diagnosis by bronchoscopy did not improve the in-hospital mortality rate for allo-HSCT or auto-HSCT patients <h3>Conclusions</h3> Bronchoscopy may provide clinically useful information in the evaluation of adult allo-HSCT and auto-HSCT recipients with pulmonary infiltrates. The results of testing BAL fluid samples alone suggested an etiology in most cases, whereas the findings of TBBx provided unique diagnoses infrequently. Further studies are warranted to improve the utility of diagnostic bronchoscopy in the evaluation of HSCT patients

Autologous Bone Marrow Transplantation for Marginal Zone Non-Hodgkin's Lymphoma

The marginal zone non-Hodgkin's lymphomas are a recently defined group of related low-grade B cell malignancies whose natural history is heterogeneous. The optimal therapy is often unclear, particularly for the subset of patients with disseminated disease that behaves aggressively. We have retrospectively analyzed the outcomes of 11 patients with chemosensitive but disseminated marginal zone lymphomas who underwent uniform conditioning with cyclophosphamide and total body irradiation followed by bone marrow transplantation (BMT) with anti-B cell monoclonal antibody-purged autologous bone marrow between January 1994 and September 1999. All patients had stage IV disease and received multiple chemotherapy regimens prior to autologous BMT. Only 36% were in complete remission at the time of bone marrow harvest, and 36% had overt bone marrow infiltration at that time. Two treatment-related deaths occurred between 100 days and 6 months. Three patients relapsed and died of disease. One patient developed and died of myelodysplasia. Five patients remain in continuous complete remission at a median follow-up of 52 months (45%). The median progression-free survival for these patients was 56 months, with median overall survival 58 months. The only significant predictor of disease-free and overall survival was age at the time of transplant; no patient under 45 at the time of transplant has relapsed or died of any cause (P = 0.003). Outcomes of autologous BMT in patients with disseminated marginal zone NHL are similar to those in follicular NHL, and suggest that certain patients may experience prolonged disease-free survival.