Bone Marrow Transplantation Center Research Articles

Leveraging the electronic health record (EHR) to support survivorship care planning for bone marrow transplant (BMT) survivors.

57 Background: BMT survivors are underrepresented in survivorship research, yet are at high risk for complications. Practice guidelines are vague, non-BMT clinicians are inadequately informed, and communication between BMT and non-BMT clinicians is inconsistent. Our objective is to develop EHR-integrated survivorship care planning that is user-centered, supports non-BMT clinician and survivor needs, but does not adversely impact clinical workflow. Methods: A multidisciplinary team of clinicians (primary care, oncology, BMT), engineers, and EHR analysts used a systems engineering approach to identify barriers and facilitators to BMT survivorship care planning. The team identified patient data categories to include in BMT survivorship care plan (SCP) templates, as well as examined tasks, technology, workflows and individual roles and responsibilities necessary to support care planning. Results: Facilitators include: potential for EHR to discretely capture individual diagnosis and treatment data to create accurate SCPs addressing survivor and primary care information needs. Barriers are: lack of EHR inter-operability which prevents sharing of patient data outside the BMT center’s EHR system, reliance on manual entry of critical data elements into the SCP (i.e. majority of the 88 patient data categories, identified by the team, are non-discrete in the EHR), inefficient or absent survivorship workflows, lack of resources (including time, dedicated clinical staff, space, SCP content), poorly defined roles and responsibilities for survivorship care provision, and lack of evidence-based BMT survivorship guidelines. Conclusions: Work system barriers impede use of the EHR to support survivorship care planning. Steps to overcome barriers: design discrete fields in the EHR to support patient-level data capture, re-engineer existing workflows to support survivorship care planning, obtain BMT program consensus on SCP content, and evaluate user-centeredness of SCPs. This research has the potential to improve feasibility and sustainability of survivorship care planning activities, resulting in improved communication and care coordination for BMT survivors.

Bone Marrow Transplantation and Medical Tourism at Erciyes University - A Single Center Experience

Medical tourism emerged when people were challenged with high costs and slow service in medical care. As a consequence of these issues, people started to look for medical treatment in other countries. Globalization accelerated the growth of medical tourism. Several “push” and “pull” factors play roles in the motivation of patients to become a medical tourist. This review addresses the different aspects of medical tourism in general, describes the development of medical tourism in Turkey, and describes experiences with medical tourism in the Bone Marrow Transplantation Center (BMTC) at Erciyes University, Kayseri, Turkey. Since January 2016, an international collaboration has existed between BMTC and the King Hamed University Hospital (KHUH) in Bahrain. Ten allogeneic stem cell transplantations (SCTs) have been performed on patients from Bahrain with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), Hodgkin lymphoma, and myelofibrosis. Furthermore, ten autologous SCT have been conducted on patients from Bahrain with multiple myeloma (MM), Hodgkin lymphoma (HL), and non-Hodgkin lymphoma (NHL). In 2016, transplant-related mortality (TRM) at 100 days among Bahrain patients was 0% compared to 2.6% in all patients. Although these numbers are small, the first results show that the outcomes of international patients are similar to those of non-international patients. In our experience, the key to a successful collaboration between international hospitals is having close communication regarding the treatment of the international patient. The outcome of a large group of international compared with non-international patients should be further studied.

Molecular characterisation and epidemiology of extended-spectrum β-lactamase-producing Klebsiella pneumoniae isolates from immunocompromised patients in Tunisia.

This study investigated the prevalence of extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) strains in the National Bone Marrow Transplant Center of Tunis between 2002 and 2011 as well as their associated antimicrobial resistance patterns and molecular features. Antimicrobial susceptibility was determined by the disk diffusion method according to CA-SFM guidelines. All of the strains were screened for β-lactamase genes, plasmid-encoded AmpC genes and integrons. Carbapenemase genes were analysed by PCR and sequencing for strains showing reduced susceptibility to ertapenem. Genetic relatedness was determined by pulsed-field gel electrophoresis (PFGE) and multilocus sequencing typing (MLST). A total of 128 non-repetitive ESBL-KP strains (23.4%) responsible for infection or colonisation were recovered among 548 K. pneumoniae strains. The isolates were also multidrug-resistant. Molecular analysis revealed the prevalence of blaSHV-type (92.2%), followed by blaOXA-1 (81.3%) and blaCTX-M-1 group (73.4%). Four ertapenem-resistant ESBL-KP strains (3.1%) carried the blaOXA-48 gene associated with the blaCTX-M-15 gene. Class 1 integrons were the most prevalent among the isolates (85.2%). High diversity was demonstrated by PFGE with limited clonal dissemination of 1 major (n=13 strains) and 11 minor clusters (each comprising 2-3 strains). MLST of representative strains also showed high diversity with two main epidemic clones: ST15, associated with the major cluster; and ST101, associated with five minor clusters (n=11 strains). This study provides relevant information on the epidemiology of ESBL-KP strains in oncohaematology patients, of which 18.8% belonged to the specific CTX-M-15 K. pneumoniae clones ST15 and ST101.

Low-cost matched sibling bone marrow transplant for standard-risk thalassemia in a limited-resource setting

Thalassemias are the most common inherited genetic disorder in India and a major public health burden with bone marrow transplant (BMT) considered the only established curative therapy. We describe outcomes for patients (n = 71) with standard-risk thalassemia (liver size < 2 cm and age <15 years), receiving BMT in 6 low-cost start up BMT centers in the Indian sub-continent from August-2013 to July-2016. Patients received HLA-matched sibling donor unmanipulated BMT. Conditioning was with busulfan (14 mg/kg oral total over days −10 to −7, serum levels not measured), cyclophosphamide (200 mg/kg total over days −5 to −2) and anti-thymocyte globulin (Genzyme 4 mg/kg or Fresenius 16 mg/kg over days −12 to −10). Kaplan Meier survival analysis revealed thalassemia free survival (TFS) of 83% with overall survival (OS) of 93% with a median follow up of 17.5 months (IQR 13.4–22.6). Twelve percent of the patients rejected, 12% had severe GVHD (7% acute grade 3–4 GVHD and 4% had moderate/severe chronic GVHD). All 3 patients with acute GVHD Grade 3 are off immunosuppression, and those with chronic GVHD are well with Lansky score >80 at the last follow up. 5 patients (7%) died, mortality related to transplant. Enough data existed for 2 centers in India (36/71 transplants) to analyze overall costs from admission up to one-year post-BMT which revealed a median cost of Rs 7,30,445 ($11519) [Range Rs 4,52,821–10,32,842 ($ 7079–16147)]. In conclusion, children with thalassemia in resource limited settings can achieve good outcomes with BMT at a reasonable cost.

Patient mobility as a quality index of a bone marrow transplant center

Patient mobility as a quality index of a bone marrow transplant center

Brentuximab Vedotin Consolidation Therapy after Autologous Stem-Cell Transplantation in Patients with High-Risk Hodgkin’s Lymphoma: The Real World Experience of a Single Bone Marrow Transplant Center in Salvador/Bahia

Brentuximab Vedotin Consolidation Therapy after Autologous Stem-Cell Transplantation in Patients with High-Risk Hodgkin’s Lymphoma: The Real World Experience of a Single Bone Marrow Transplant Center in Salvador/Bahia

Opportunity for Collaboration Between Radiation Injury Treatment Network Centers and Medical Toxicology Specialists.

The Radiation Injury Treatment Network (RITN) comprises >50 centers across the United States that are poised to care for victims of a radiation emergency. The network is organized around bone marrow transplant centers because these facilities excel in both radiation medicine and the care of patients with severe bone marrow depression. A radiation emergency may cause not only irradiation from an external source but also internal contamination with radioactive material. Because medical toxicologists are trained in radiation injury management and have expertise in the management of internal contamination, RITN centers may benefit from partnerships with medical toxicology resources, which may be located at academic medical centers, hospital inpatient clinical services, outpatient clinics, or poison control centers. We determined the locations of existing RITN centers and assessed their proximity to various medical toxicology resources, including medical toxicology fellowship programs, inpatient toxicology services, outpatient toxicology clinics, and poison control centers. Data were derived from publicly available Internet sources in March 2015. The majority of RITN centers do not have a medical toxicology fellowship, an inpatient toxicology service, or an outpatient toxicology clinic within the same institution. Fifty-seven percent of RITN centers have at least one of these resources located in the same city, however, and 73% of centers have at least one of these resources or a poison control center within the same city. Ninety-five percent of RITN centers have at least one medical toxicology resource within the state. Most RITN centers are located in the same city as at least one medical toxicology resource. Establishing relationships between RITN centers and medical toxicologists needs to be explored further.

First Report on Stem Cell Transplant From Iraq.

The Iraqi Bone Marrow Transplantation Center is located in the medical city complex of Bab Almuadham in Baghdad, Iraq. It was established on March 11, 2002, and performed its first mini-allotransplant for acute myeloid leukemia on January 24, 2003. Among 16 patients who received hematopoietic stem cell transplant between January 2003 and January 2010, one patient underwent allogeneic bone marrow transplant for acute myeloid leukemia and 15 patients received autologous bone marrow transplant for the following indications: 5 had multiple myeloma, 9 had lymphoma (8 with Hodgkin disease and 1 with non- Hodgkin lymphoma), and 1 had rhabdomyosarcoma. Median age was 34 years (range, 10-56 y), and our patient group included 8 females and 8 males. Of the 16 patients, 12 are still alive. The mortality rate was 25% as measured during our follow-up from 2 to 96 months. Of the 9 patients with lymphoma, 1 died and 2 relapsed after transplant. Therefore, our survival rate in lymphoma was 88%, with progression-free survival in lymphoma ranging from 2 to 66 months (mean survival of 13 mo, mode of 13 mo). For the 5 patients with multiple myeloma who received transplants, 1 died and 2 relapsed, with effective-free survival of 6 to 13 months. Our results show that high-dose chemotherapy followed by autologous stem cell transplant can induce long-term disease control in this cohort of patients with refractory or advanced Hodgkin disease; progression-free survival for our cohort was 50%, with survival comparable to those reported in the literature.

Three-year analysis of repeated laboratory tests for the markers total cholesterol, ferritin, vitamin D, vitamin B12 , and folate, in a large research and teaching hospital in Italy.

The increasing number of diagnostic tests requests all over the world is a problem that can partially be explained by inappropriate testing. Impact on the total costs of health systems becomes relevant when tests are performed in a large amount. In this paper, retesting of total cholesterol, ferritin, vitamin B12 , vitamin D, and folate is assessed. The Quality Unit of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano (Fondazione) decided to perform a first assessment of the appropriate use of the laboratory tests cholesterol, ferritin, vitamin B12 , vitamin D, and folate focusing on the retesting interval for the same patient in the time period January 1, 2012, to December 31, 2014, in every care setting. The minimum retesting intervals were chosen following the ACB recommendations. The Fondazione is a research and teaching hospital with 3 emergency units (adult, pediatric, and obstetric), kidney, liver, lung, cornea, and bone marrow transplant centers and a medical school. Record linkage of laboratory records selected for the time interval January 1, 2012, to December 31, 2014, was applied using tax code. For each marker, the distribution of retesting intervals was evaluated for every year and the total period. With the same record linkage variable, requests on inpatients were identified from hospital discharge records. A cost analysis of inappropriate retesting was performed for every test. We examined 466035 requests for 113019 patients. Proportions of tests judged potentially inappropriate varied between 8.1% for 1,25-dihydroxy vitamin D and 37.1% for total cholesterol. The rates of inappropriate tests from year to year never showed significant decrease, and the maximum increase corresponded to an odds ratio of 1.85 (95% CI, 1.36-2.51) for 1,25-dihydroxy vitamin D from 2012 to 2013. Calculated loss of money was approximately €500000 in the 3years. Inappropriate requests represent a waste of time and money resources. Our analysis highlighted economically unacceptable rates of inappropriate retesting, with no evidence of decreasing trend. Actions to raise awareness in clinicians or automated electronic solutions are necessary to limit unnecessary test repetitions.

The budget impact and cost-effectiveness of defibrotide for treatment of veno-occlusive disease with multi-organ dysfunction in patients post-hematopoietic stem cell transplant

Background: A Phase-3 study of defibrotide compared with historical controls demonstrated a 23% improvement in 100-day survival post-hematopoietic stem cell transplantation (HSCT) among patients with veno-occlusive disease with multi-organ dysfunction (VOD with MOD).Aim: To estimate the budget impact and cost-effectiveness of introducing defibrotide to a transplant center.Methods: The authors developed a budget impact model from the perspective of a bone-marrow transplant center. It was estimated that 2.3% of adults and 4.2% of children would develop VOD with MOD following HSCT based on a retrospective hospital database analysis and the effect that treating patients with defibrotide would have on costs for adult and pediatric centers was estimated. A cost-utility analysis (CUA) was also developed to capture the long-term cost-effectiveness of defibrotide. Projected life expectancies in the two groups were estimated based on trial data, transplant registry data, studies of long-term survival among HSCT patients, and US population life-tables.Results: There was an estimated 3% increase ($330,706) per year in total adult transplantation center costs associated with adopting defibrotide, and a <1% increase ($106,385) for pediatric transplant centers, assuming 100 transplants per year. In the CUA, the lifetime increase in cost per patient was $106,928, life expectancy increased by 3.74 years, and quality-adjusted life-years (QALYs) increased by 2.24. The incremental cost-effectiveness ratio (ICER) was $47,736 per QALY gained; 88% probability defibrotide was cost-effective at a $100,000/QALY threshold.Conclusion: The budget impact of defibrotide for a transplant center is relatively modest compared to the overall cost of transplantation. Defibrotide provides an important survival advantage for VOD with MOD patients, and the life years gained lead to defibrotide being highly cost-effective.

Direct cost analysis of the second year post-allogeneic hematopoietic stem cell transplantation in the Bone Marrow Transplant Centre of Tunisia

ABSTRACTBackground: Hematopoietic stem cell transplantation (HSCT) is a medically complicated therapy with a long recovery time. In Tunisia, the National Health Insurance Fund (CNAM) covers only the first year post-transplantation, after which the costs are borne by the hospital.Objective: Describe complications that can occur during the second year post-allogeneic HSCT and calculate direct costs in different groups of patients.Methods: In this pharmacoeconomic study, medical records of the second year post-allogeneic HSCT were collected. Studied variables included frequent observed complications and medical and non-medical direct costs.Results: The average total direct cost in the population during the second year post-transplantation was $11,571, 97% of which represents direct medical costs Drugs accounted for the largest share (80%) of total direct costs, dominated by the cost of antifungals (52%) and antivirals (26%) drug . Cytomegalovirus status was seen in 9.3% of patients and was associated with a seven-fold increase in direct costs (p < 0.001).​​In patients who developed chronic GVHD, the average direct cost was three times higher than for those who did not (p = 0.032).Conclusion: Given the importance of direct costs in the post-transplantation period a review of the hospital financing mechanism and a new convention with the CNAM is crucial.​​

Overview of Genetic Background Beyond Polysaccharide Intercellular Adhesion Production in Staphylococcus epidermidis

Background: An important observation during quantification experiments of Staphylococcus epidermidis biofilm is that there is a great difference in the biofilm biomass of different strains despite the same experimental conditions. Objectives: This study aimed to study the genotypic background beyond differential rates of Polysaccharide Intercellular Adhesion (PIA) production in S. epidermidis biofilm forming strains. Methods: A number of 126 strains were isolated from blood cultures (n = 40), catheter cultures (n = 50), and other specimens (n = 36). The strains were obtained from patients hospitalized at the bone marrow transplant center of Tunis. Biofilm micro-plate assay, hemagglutination, and susceptibility to proteinase K methods were used to assess biofilm characteristics in the studied strains. Conventional and real time PCR were used to assess genotypic background of biofilm formation. Results: Using PCR method, we demonstrated that there is a significant difference in ica genes (P < 0.01) and not in adhesion rsb and sar genes distribution between biofilm forming and non-biofilm forming strains. Almost all strains harbored agr type I. None of studied strains harbored IS256 inside ica operon. Ica-independent biofilm formation was detected in 11 strains that were confirmed to have proteinaceous matrix. Using Kernel density estimation, we established that biofilm biomass was higher in ica-dependent than ica-independent biofilm forming population. Using qRT-PCR, we found a significant correlation between biofilm biomass and RNAIII expression level (r2 = 0.95); but no correlation was found for biofilm biomass neither with icaA nor with ccpA genes. Conclusions: Data reported here indicated that there is no specific genetic combination beyond the quantity of biofilm biomass in S. epidermidis. Biofilm biomass seemed to be controlled by RNAIII expression level. Further interest should be directed to biofilm dispersal since it seems that the key difference in biofilm biomass ability of S. epidermidis strains relates to factors regulating this stage.

Addition of Bortezomib to High Dose Melphalan As Conditioning Regimen for Autologous Stem Cell Transplantation Improves the Response Rate in Newly Diagnosed Multiple Myeloma Patients

High-dose Melphalan (HDM) is the most commonly used conditioning regimen for autologous stem cell transplantation (ASCT) in newly diagnosed transplant-eligible Multiple Myeloma (MM) patients. Recent evidence suggests that the depth of response after induction therapy influences progression free survival (PFS) and, in most studies, overall survival (OS). Actually the effect of the inclusion of new drugs in the conditioning regimen for ASCT is still unknown. Phase I-II clinical study showed that the addition of Bortezomib (Bor) to HDM is safe and a promising conditioning regimen. Thus, in this study we analyzed a single center experience on the use of Bor in combination with HDM (Bor-HDM) as conditioning regimen before ASCT as frontline treatment in MM patients in order to evaluate the safety and the response rates of this combination regimen. We analyzed a total cohort of 48 newly diagnosed MM patients (25 females and 23 males; median age 60 years, range 42-70) admitted consecutively to our Bone Marrow Transplantation Center from 2008 to 2014. Regarding prognostic stratification, 25% of patients were classified as stage III according to International Staging System (ISS), and 12% exhibited high-risk cytogenetic features (defined by presence of del(17p) and/or t(4;14) and/or t(14;16)). All patients with the exception of three underwent to 3-drugs Bor-based induction therapy including Bor (median cumulative dose: 28.9 mg/m2), Thalidomide and Dexamethasone (VTD). After induction therapy and stem cell collection 28 out of 48 patients were treated with Bor-HDM, whereas 20 patients with HDM alone as conditioning regimen before ASCT. HDM was administered on day -2 (median dose: 200 mg/m2), and a single-dose Bortezomib at the dosage of 1.3 mg/m2 was administered on day -1 in the Bor-HDM group. Stem cells were reinfused on day 0 (median number of CD34+ infused: 3.3x106/Kg, range 1.86-6x106/Kg). Responses were evaluated at day 100 after ASCT, and definitions of response were used according to the International Myeloma Working Group (IMWG) Uniform Response Criteria for MM. Quantitative variables were compared by non-parametric Kruskal-Wallis and Mann-Whitney tests as appropriate and categorical variables were analyzed by Chi-square and Fisher’s exact test. pvalue of <0.05 was considered significant.Any significant difference was not observed between Bor-HDM group vs HDM group, regarding age at diagnosis (p=0.77), sex (p=0.24), cumulative induction dose of Bortezomib (p=0.42), dose of Melphalan used for conditioning (p=0.16) and the median number of CD34+ cells infused (p=0.12). Distribution of ISS stage was similar in the two groups (p=0.14), as well as that of high-risk cytogenetic (p=0.14). Moreover the response rates after the induction therapy was not statistically different in the two groups of patients analyzed (sCR + CR: 19% in Bor-HDM group vs 26% in HDM group; VGPR: 33% vs 48%; PR: 48% vs 26%, p=0.22). Any significant difference on hematopoietic recovery rates was not observed in Bor-HDM as compared to HDM alone with a mean time to neutrophil recovery of 12 days (range 9-18) and to platelet recovery of 12 days (range 9-21) in both groups. Bor-HDM conditioning was well tolerated, without increase of neuropathy occurrence.Then we analyzed the response rate after ASCT, showing that the overall response rate (ORR) was significantly higher in Bor-HDM group as compared to HDM (sCR+CR: 56% in Bor-HDM vs 17% in HDM; VGPR 30% vs 28%; PR: 15% vs 56%, p=0.0072) with a higher number of "good quality" response (sCR + CR + VGPR: 86% vs 45%; p=0.0075). The number of sCR was also significantly higher in Bor-HDM as compared to HDM alone (23% vs 0%, p=0.067). Moreover an improvement of the response rate after ABMT was seen more frequently in the Bor-HDM group as compared to the HDM group (p=0.0063). We then observed that the number of patients that underwent tandem ASCT was higher in the HDM group (66% vs 41%), even not reaching a statistical significance. In conclusion, this retrospective analysis suggests that BOR-HDM is safe as conditioning regimen with a higher response rate after ASCT as compared to the standard HDM regimen giving the rational design for randomized studies needed to assess whether this conditioning regimen is superior to HDM alone. DisclosuresGiuliani:Celgene: Research Funding; Janssen: Research Funding.

Beac and BEAM High-Dose Chemotherapy in Patients with Mantle Cell Lymphoma Undergoing Autologous Stem Cell Transplantation Are Efficacious, with Comparable Toxicity

Introduction: Autologous stem cell transplantation (ASCT) is currently considered the standard first-line consolidation therapy for younger patients with mantle cell lymphoma (MCL). In general, there are limited data regarding a preferred high-dose therapy (HDT) regimen preceding ASCT to be used in patients with non-Hodgkin lymphoma (NHL). Although BEAM and BEAC regimens (including BCNU, etoposide, cytosar in both regimens and melphalan or cytoxan, respectively) have been commonly employed as conditioning HDT in patients with aggressive or recurrent NHL, there have been few reports comparing these two regimens. A retrospective analysis found the superiority of BEAM over BEAC in terms of overall survival (OS) and event-free survival (EFS). Regimen-related toxicities were similar, except that BEAM was associated with more frequent lower gastrointestinal mucositis. Other studies reported that these two regimens had equivalent efficacy and outcome, as measured by EFS and OS. Further studies are required to define the optimal regimen for each specific NHL subtype. The current study aimed to compare the efficacy and toxicity of BEAC versus BEAM as a consolidation HDT in young patients with MCL undergoing ASCT.Methods: This is a retrospective analysis of outcomes in patients with MCL who received high-dose chemotherapy with BEAM or BEAC regimen followed by ASCT in two bone marrow transplant centers in Israel. OS, progression-free-survival (PFS) and regimen toxicity were compared. Results: Fifty five patients with MCL who were diagnosed between 1995-1/2016 and received consolidation with BEAC or BEAM HDT regimen were included in the analysis. Twenty seven patients were treated with BEAM and 28 patients - with BEAC. No significant differences between the two groups were revealed in terms of age, sex, the Mantle Cell Lymphoma International Prognostic Index (MIPI), induction treatment protocol and percentage of patients who were transplanted at first complete response (CR1) (Table 1). The amount of infused CD34 cells was significantly higher in the BEAM group, and the number of days until platelet engraftment was significantly greater in the BEAC group. There were no differences in the number of blood transfusions or hospitalization days between the groups (Table 2). In terms of HDT toxicity, there was a trend to a higher rate of grade 3-4 upper mucositis with BEAM protocol; no other differences in toxicity between the regimens were observed (Table 3). Non-relapse mortality at day 30 post-transplant was 0% in both groups. A median follow-up of surviving patients was 31 (range 1-119) months. PFS at 3 years in patients receiving BEAM and BEAC was 65% and 78%, respectively (p=.75). In univariate analysis, age less than 60 years, low-to-intermediate MIPI and transplant at CR1 were found to significantly improve PFS, while no difference in PFS was found between the two treatment regimens. In multivariate analysis, low-to-intermediate MIPI and transplant at CR1 appeared to significantly increase PFS (P = 0.02 and 0.03, respectively). There was no difference in the 3-year OS between the two HDT regimens (58% in the BEAM group and 81% in the BEAC groups; p=.31). Conclusion: BEAC and BEAM high dose chemotherapy regimens followed by autologous stem cell transplantation have similar efficacy and toxicity in patients with MCL. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

First Description of KPC-2-Producing Escherichia coli and ST15 OXA-48-Positive Klebsiella pneumoniae in Tunisia.

The aim of this study was to investigate the molecular features among Klebsiella pneumoniae and Escherichia coli strains showing a resistant/intermediate-resistant phenotype to ertapenem (R/IR-ERT), implicated in colonization/infection in patients of the Hematology and Graft Units of the National Bone Marrow Transplant Center of Tunisia (3-year period, 2011-2014). The major carbapenemase, extended-spectrum beta-lactamase, and plasmidic AmpC beta-lactamase genes were analyzed and characterized by PCR and sequencing. Genetic relatedness was determined by pulsed-field gel electrophoresis (PFGE) using XbaI and multilocus sequencing typing. The blaOXA-48 and blaKPC carbapenemase genes were detected among R/IR-ERT isolates. All R/IR-ERT K. pneumoniae strains (n = 19) had blaOXA-48 gene, and 14/19 strains also harbored the blaCTX-M-15 gene. Eight different PFGE patterns were detected among these K. pneumoniae isolates, and they showed eight different sequences types, ST11 and ST15 being the most prevalent ones. Two out of three R/IR-ERT E. coli isolates carried blaOXA-48 and one coproduced the blaCTX-M-15 gene. One E. coli strain, ascribed to the new sequence type ST5700, harbored the blaKPC-2 gene. E. coli isolates were not clonally related and belonged to different sequence types (ST5700, ST227, and ST58). To our knowledge, this is the first report in Tunisia of either KPC-2 carbapenemase in E. coli or OXA-48 carbapenemase in K. pneumoniae of lineage ST15.

ISQUA16-2082INTERGRATION OF QUALITY CONTROL CIRCLE AND PHS WIN-WIN CONCEPT TO PROMOTE THE MEDICAL QUALITY OF HEMATOPOIETIC MALIGNANCIES: Table 1

Infection and bleeding contribute to about 2/3 and 1/3 of mortality associated with hematopoietic malignancies in Nanfang Hospital, China. To promote the medical quality, two rounds of Quality Control Circle (QCC) were carried out, with the aim to solve the above mentioned complications. 1. The perianal infection is the most common infection for hematopoietic malignancies (up to 60%>100%, Ann Hematol. 2003; 82:S167). With severe immunodeficiency (agranulocytosis≥2w), the perianal infection rate was 17.2% in the bone marrow transplantation center (from Apr to Sep, 2013). Then QCC1 was carried out following the 10 steps of Plan-Do-Check-Action. Bacterial colony …

Evaluating the effect of Matricaria recutita and Mentha piperita herbal mouthwash on management of oral mucositis in patients undergoing hematopoietic stem cell transplantation: A randomized, double blind, placebo controlled clinical trial

ObjectivesTo investigate the effects of Matricaria recutita and Mentha piperita on oral mucositis (OM) in patients undergoing hematopoietic stem cell transplantation (HSCT). DesignRandomized double blind placebo controlled clinical trial. SettingFaculty of Pharmacy, Shahid Beheshti University of Medical Sciences, and Bone Marrow Transplantation Center at Taleghani Teaching Hospital, Tehran, Iran. ParticipantsSixty patients undergoing HSCT were randomly assigned to two groups: placebo (n=33), and herbal mouthwash group (n=27). InterventionsAll patients received the mouthwash one week before HSCT and were instructed to use it three times daily for at least 30s. Main outcome measuresOM was graded using National Cancer Institute Common Toxicity Criteria (NCI-CTC) scale (grade 0–5). The Numerical Rating Scale (NRS: 0–10 scale) measured the severity of OM symptoms. ResultsThe duration, maximum and average daily grade of OM were significantly reduced in the treatment group (P<0.05). The use of herbal mouthwash led to significant improvements in pain intensity (P=0.009), dryness (P=0.04) and dysphagia (P=0.009). Other significant results included: reduced need for complementary medications (P=0.03), narcotic analgesics (P=0.047), total parenteral nutrition (TPN) (P=0.02) and the duration of TPN (P=0.03). ConclusionThis study shows that patients receiving the herbal mouthwash experienced less complications and symptoms associated with OM. In summary, it seems that the use of our prepared herbal mouthwash is beneficial for patients undergoing HSCT.

Effects of midsole hardness and shear-reduction structure on GRF and perception during sidestep cut

To investigate the effects of Matricaria recutita and Mentha piperita on oral mucositis (OM) in patients undergoing hematopoietic stem cell transplantation (HSCT).Randomized double blind placebo controlled clinical trial.Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, and Bone Marrow Transplantation Center at Taleghani Teaching Hospital, Tehran, Iran.Sixty patients undergoing HSCT were randomly assigned to two groups: placebo (n = 33), and herbal mouthwash group (n = 27).All patients received the mouthwash one week before HSCT and were instructed to use it three times daily for at least 30 s.OM was graded using National Cancer Institute Common Toxicity Criteria (NCI-CTC) scale (grade 0–5). The Numerical Rating Scale (NRS: 0–10 scale) measured the severity of OM symptoms.The duration, maximum and average daily grade of OM were significantly reduced in the treatment group (P < 0.05). The use of herbal mouthwash led to significant improvements in pain intensity (P = 0.009), dryness (P = 0.04) and dysphagia (P = 0.009). Other significant results included: reduced need for complementary medications (P = 0.03), narcotic analgesics (P = 0.047), total parenteral nutrition (TPN) (P = 0.02) and the duration of TPN (P = 0.03).This study shows that patients receiving the herbal mouthwash experienced less complications and symptoms associated with OM. In summary, it seems that the use of our prepared herbal mouthwash is beneficial for patients undergoing HSCT.

Impact of Socio-Economic Disparities and Distance to Bone Marrow Transplant Center on Transplantation Outcomes

Impact of Socio-Economic Disparities and Distance to Bone Marrow Transplant Center on Transplantation Outcomes

Allogeneic Haematopoietic Stem Cell Transplantation for Beta Thalassaemia Major in Pakistan: Outcome of 186 Cases

To analyse outcome of allogeneic haematopoietic stem cell transplantation (HSCT) in patients of beta thalassaemia major treated at Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan. The study included 186 consecutive beta thalassaemia patients undergoing HSCT from HLA matched related donors from October 2001 to December 2014. A comparison of conditioning regimens was made between long protocol (HU30mg/kg/day Azathioprine 3mg/kg/day, FLU 150, Bu14, Cy160) and Bu14/Cy200 both with or without Thiotepa, using overall and disease free survival (OS and DFS) as primary endpoints with rejection, acute and chronic GVHD as secondary end points. The study included 124 male and 62 female patients. Median age was 50 months (range 20 months to 13 years). Mean serum ferritin level before transplant was 1912 μg/L (range 426 to 5000). Patients were stratified as class I (n=49), II (n=62), and III (n=75) respectively as per Pesaro risk classification. Ninety three patients received conditioning with long protocol and same number of patients received Bu14/Cy200 conditioning regimen. Thiotepa was given to 38 patients (33 on long protocol and 5 on Bu14/Cy200). At a median follow up of 1683 days OS and DFS were 80.6 % and 69.4% respectively. In patients receiving long protocol OS, DFS and rejections were 85%, 72% and 15% respectively, whereas, in Bu14/Cy200 group OS, DFS and rejections were 76%, 66.7% and 11.8% respectively. Patients receiving Thiotepa during conditioning had lesser rejections (1/38) compared to those receiving conditioning without thiotepa (24/124) p=0.03. Eighty-five (45.7%) patients developed acute GVHD and 7 (3.8%) cases had chronic GVHD. Long conditioning protocol was found to be associated with better survival in beta thalassaemia patients undergoing allogeneic HSCT. Addition of thiotepa to conditioning regimen significantly reduced incidence of graft rejection.