Number Of Stem Cell Transplantations Research Articles

Identifying and Overcoming Racial Disparities in Multiple Myeloma Care: Results from a Large-Scale Equity-Focused Quality Improvement Initiative

Background A prior quality improvement (QI) initiative (Mikhael ASH 2020) was conducted to address root causes of racial disparities in care delivery among patients with relapsed/refractory (R/R) multiple myeloma (MM) in 2 large oncology systems. Preliminary survey data suggested discordant beliefs regarding patients’ primary treatment concerns. Thus, this study was scaled up to 4 community-based oncology practices to greater evaluate disparities with electronic medical record (EMR) audits and team-based audit-feedback (AF) sessions to identify factors which could enhance more equitable care. Methods This QI initiative included patient and provider surveys, baseline and follow-up EMR audits, and small-group, team-based AF sessions at each participating clinic. Surveys were completed by 59 hematology/oncology healthcare providers (HCPs) and 100 R/R MM patients (Table 1; N=47 Black, N=50 White/Non-Hispanic) to examine alignments and discordances in attitudes, beliefs, perceptions, and practices regarding MM care. A baseline EMR audit of 200 R/R MM patients (Table 1; N=32 Black, N=122 White/Non-Hispanic) was conducted to identify patient/disease characteristics, treatment history, clinical practice metrics, and patient-centered measures (e.g., shared decision-making). During 1-hour AF sessions, HCP cohorts (Table 1) (a) assessed clinic-specific practice gaps identified by the patient-provider surveys and baseline EMR audit, (b) prioritized areas for improvement, and (c) developed action plans to address root causes. Surveys completed before (N=59) and after (N=41) the AF sessions measured changes in participants’ beliefs and confidence in care delivery. A follow-up EMR audit after completion of the AF sessions was performed to assess behavioral and practice change. Results Patient and HCP tethered survey data revealed discordant beliefs about patients’ primary treatment concerns. HCPs overestimated patients concern regarding treatment cost (32% vs 9%) and treatmentrisks (55% vs 29%), but underestimated patient's largest reported challenge in feeling confident that their treatment plan is the best for their cancer (18% vs 32%). Providers reported the most challenging aspect of MM management was individualizing treatment plans. There was large divergence between HCPs and all patients’ top goals (Figure 1) and stark racial disparities were observed in improving quality of life, preventing progression or recurrence, and surviving as long as possible (Figure 1). Disparities also persisted among patients who reported being on track or somewhat on track to achieve their treatment goals (76% White vs 54% Black/Hispanic, p = 0.021). Regarding shared decision-making (SDM) with their HCP, only 14% of Black/Hispanic patients felt completely involved in treatment decision making compared to 54% of White patients (p = < 0.001). EMR audits revealed fewer Black patients using maintenance therapy (63% vs 71% non-Black) and greater numbers of stem cell transplants (53% Black vs 44% non-Black). Following AF sessions 55% of HCPs set action plans to incorporate strategies to eliminate disparities in care for diverse MM patient populations and 48% to develop personalized treatment plans incorporating patient-specific factors and preferences. To achieve these goals, providers committed to engage patients in shared decision-making (17% pre-AF vs 38% post-AF), and provide adequate patient education about treatments (17% pre-AF vs 28% post-AF). Participants’ views of the impact of race and socioeconomic factors on equitable MM care changed as a result of the program increasing from 37% to 54% reporting a considerable or a great deal of impact. Conclusions Barriers to equitable, patient-centered care in patients with R/R MM included inadequate education and personalizing of treatment plans by HCPs as well as ineffective SDM. Discordances were observed between providers and all patients in describing the goals of treatment, and between White and Black/Hispanic patients in the challenges faced in their MM care. Action plans developed during this QI initiative intend to address identified gaps and improve equitable care for patients with R/R MM. Study Sponsor Statement The study reported in this abstract was funded by independent educational grants from AbbVie, Inc. Bristol-Myers Squibb, and Janssen Biotech Inc., who had no role in the study design, execution, analysis, or reporting. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The Number of Stem Cell Transplantations During the COVID-19 Pandemic.

The Number of Stem Cell Transplantations During the COVID-19 Pandemic.

The Effect of Vascular Endothelial Growth Factor on Bone Marrow Mesenchymal Stem Cell Engraftment in Rat Fibrotic Liver upon Transplantation.

Background According to existing related experiments and research reports, stem cell transplantation therapy has been shown to have a positive effect on the recovery of liver fibrosis/cirrhosis, but for some reason, this therapy still cannot be widely used in clinical work. One of the reasons that cannot be ignored is the low quantity of exogenous stem cells transplanted into the liver in vivo. Thus, we investigated whether the use of the vascular endothelial growth factor (VEGF) can increase the number of stem cell transplants and improve the efficacy of stem cell transplantation therapy. Methods Using a Sprague-Dawley rat liver fibrosis model, we transplanted into fibrosis liver allograft bone marrow mesenchymal stem cells (BMSCs) which were labelled with chlormethylbenzamido-1,1-dioctadecyl-3,3,3′3′-tetramethylin-docarbocyamine (CM-DiI) or injected VEGF adenovirus solution through the tail vein or conducted the above two operations simultaneously. The cell surface receptor profile of BMSC was examined by flow cytometry and immunofluorescence staining. Hepatic sinusoidal vascular leakage was measured with Evan's blue dye assay. Paraffin section staining, immunofluorescent staining, RT-qPCR (quantitative reverse transcription polymerase chain reaction), and Western blot were used to evaluate hepatic pathological changes and physiology function. Result The in vivo study indicated that, comparing with other groups of rats, the rats with combined treatment of BMSC transplantation and VEGF injection exhibited obvious reduction in liver fibrosis. Evan's blue dye assay suggests that after injecting with VEGF adenovirus solution, the rat's hepatic sinusoidal permeability would be increased. We confirmed the expression of very late antigen-4 (VLA4, integrin α4β1) on rat BMSCs and the elevated expression of vascular adhesion molecule-1 (VCAM-1) in the hepatic sinusoidal endothelial cells. In addition, the analysis of CM-DiI-labeled BMSCs showed that the BMSC+VEGF group exhibited better cell engraftment and that the engrafted cells were mainly distributed in the hepatic parenchyma. Furthermore, compared with the other situation, it is best to reconstitute the liver secretion and regeneration function of rats after combined application of VEGF and BMSC. Conclusion We showed that VEGF promotes the engraftment of BMSCs in liver fibrosis, enhances liver regeneration, and improves liver function. These outcomes may be related to the increasing hepatic sinusoidal endothelium permeability and VCAM-1-increased expression.

Dermatologic Urgencies and Emergencies: What Every Pathologist Should Know.

Fatal dermatologic diseases and ones with high morbidity can occur in the inpatient setting. In such cases, prompt and accurate assessment of a bedside skin biopsy is required. This may be challenging for many pathologists who are not familiar with the complexity of skin pathology and skin terminology within the fields of dermatopathology and dermatology. To provide the pathologist with a practical, up-to-date, and "must-know" reference guide on dermatologic urgencies and emergencies from a real-world perspective, highlighting diagnostic pearls, diagnostic pitfalls, and commonly encountered practice gaps. This review will focus on key diseases with which every pathologist should be familiar, including angioinvasive fungal infections, Stevens-Johnson syndrome/toxic epidermal necrolysis, staph-scalded-skin syndrome, acute graft-versus-host disease, bullous pemphigoid, calciphylaxis, Sweet syndrome and its histiocytoid variant, pyoderma gangrenosum, and leukocytoclastic vasculitis, as well as those in their clinical and histopathologic differential. This review is based on peer-reviewed literature and our personal experiences with these diseases at major academic institutions, including one where a large number of stem cell transplants are performed. This review is unique as it represents collaborative expert opinion from both a dermatopathology and a dermatology standpoint. This review outlines the critical role that the pathologist plays in the outcomes of patients with dermatologic urgencies and emergencies. Improved patient care will result from prompt and accurate histopathologic diagnoses as well as an open line of communication with the dermatologist.

A Rare Consequence of Chronic Graft Versus Host Disease - Peyronie's Disease.

Chronic graft versus host disease (GvHD) after allogeneic stem cell transplantation (SCT) may involve any organ system, but male genital involvement is rare. Peyronie's Disease (PD) is an acquired, localized fibrotic disorder of the tunica albuginea, which leads to penile deformity, pain, and eventually to erectile dysfunction. We report the case of a 52 year old African American male with Acute Myeloid Leukemia who underwent human leucocyte antigen (HLA) matched sibling allogeneic peripheral blood SCT. His post transplant course was complicated by development of acute and multi-organ chronic GvHD requiring prolonged immunosuppression. He developed progressive dorsal curvature of the penis with erections within 1 year of ultra low dose interleukin -2 (IL2) treatment for his chronic GvHD but concealed symptoms for several months. Color Doppler Duplex ultrasound evaluation of the erect penis revealed a 75-degree curvature and appropriate hemodynamic response to prostaglandin injection. He underwent successful incision and grafting of the penile plaque. There is no significant residual curvature and is now able to engage in intercourse. A strong temporal association between GVHD (or its treatment) and Peyronie's is documented here. Awareness of the possible link between PD and chronic GVHD is required in this era of rapid growth in numbers of SCT.

Role Of Double Stem Cell Transplantation For Newly Diagnosed Multiple Myeloma In The Era Of Novel Agents

BackgroundAutologous stem cell transplantation (ASCT) has been a part of the standard therapy for newly diagnosed multiple myeloma and several studies showed double ASCT improved the outcome in comparison with single ASCT, especially the patients who failed to achieve very good partial remission (VGPR). Recently, the introduction of novel agents significantly improved the response rate of the treatment for the multiple myeloma. Although ASCT is still crucial for newly diagnosed myeloma patients, the role of the double ASCT is unclear in the era of novel agents. We performed a single institution-based retrospective study. MethodsWe reviewed the medical records of patients who treated with ASCT for multiple myeloma between January 2001 and April 2013 in National Center for Global Health and Medicine, Tokyo, Japan. The regimen of the remission induction therapy, number of stem cell transplantations, survival after the first ASCT, progression free survival, the response after the induction therapy and the first ASCT were analyzed. ResultsSince 2001, we performed ASCT for 167 patients. Ninety-three patients were treated with double ASCT, and 2 patients were treated with tandem ASCT–allogeneic SCT. In 127 patients were treated with vincristine, adriamycin, and dexamethasone (VAD) as an induction therapy, and 40 patients were treated with bortezomib and dexamethasone (BD). Very-good-partial-remission (VGPR) or complete remission (CR) was obtained in 25.2%, 34.6% of the patients treated with VAD, and in 45.7%, 54.3% with BD regimen before and after the transplantation respectively. Overall survival (OS) and progression free survival (PFS) did not differ significantly between VAD and BD induction, the estimated 2 year-OS was 89.8% vs. 79.5%, and the 2 year-PFS was 43.2% vs. 63.5% respectively. Double transplantation improved PFS and OS in VAD induction than single transplantation (p=0.000, p=0.002). In BD induction, patients who failed to achieve VGPR or better after the first ASCT, double transplantation improved OS (p=0.010) but not PFS. In both VAD induction and BD, there was no significant survival benefit in double transplantation in patients who achieved VGPR or better. ConclusionThe achievement of VGPR or better after the ASCT resulted in significantly better PFS. The role of double transplantation is still crucial for patients with inadequate response after the first ASCT even in the era of novel agents. Disclosures:No relevant conflicts of interest to declare.

Second donation of hematopoietic stem cells from unrelated donors for patients with relapse or graft failure after allogeneic transplantation

Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative approach for a variety of hematologic malignant and non-malignant disorders. With the rising number of stem cell transplantations from unrelated donors over the last years,[1][1] the occurrence of graft failure or disease

Osteonecrosis of the Jaw in Multiple Myeloma Patients (the IFM Registry).

PURPOSE: to describe the incidence, characteristics and risk factors for osteonecrosis of the jaw (ONJ) in multiple myeloma (MM).PATIENTS AND METHODS : retrospective review of 51 ONJ collected from the IFM centers. For MM, age at diagnosis, isotype, DS staging, nature of chemotherapy and number of Stem-Cell Transplantation were the same that expected.RESULTS: ONJ occurred predominantly in the mandible (70%). The median time of exposure to biphosphonates (BP) was 45 months (4 to 144 months). BP therapy included: zoledronate (85%), pamidronate (10%), clodronate (5%), all of the patients have received intravenous BP before, two patients have no BP at the time of diagnosis of ONJ.RISK FACTORS: dental extraction (59%) other dental care (5%), dental infection (24%), others (30%), no risk factor (10%). SYMPTOMS: pain (92%), purulent discharge (37%), presence of exposed bone (60%), fracture (2%).MANAGEMENT: BP discontinuation (84%), medical treatment (86%), removal of sequestra (51%), extensive surgery (20%).EVOLUTION: improvement (55%), chronical symptoms (70%).INCIDENCE: we have not the number of exposed patients but: 46 centers/73 reported no ONJ.The first report was march 2001. In the same period, 1695 patients where included in IFM trials and only 16 ONJ where observed. Year of diagnosis: before 2004: 5 cases; 2004: 11 cases; 2005:26 cases; 2006: 7 cases; 2007(6 months): 2cases.CONCLUSION: ONJ is an adverse side effect of amino BP therapy (zoledronate>pamidronate), is time dependant and often after dental extraction. Preventive recommandations applied in 2005 can explain the decreasing incidence of ONJ in our study.

Prognosis in Acute Myeloid Leukemia: A Population-Based Study on 5,809 Patients Diagnosed in Sweden 1973–2001.

BackgroundAML is an aggressive disease, which is rapidly fatal without specific therapy. Such treatment was not available until the early 1970's when combinations of anthracyclines and cytarabine were introduced. Since then major improvements have been made in chemotherapy, stem cell transplantation (SCT) and supportive care. The aim of this study was to define the impact of modern AML treatment strategies on outcome. Extrapolation of results from clinical trials may not be appropriate for estimation of outcome in the whole population because of a varying degree of patient selection. In this study relative survival rates (RSR) were estimated in relation to age, sex, calendar period and region of residence in a cohort of 5,809 AML patients.MethodsRecords on all patients with AML reported to the Swedish Cancer Register between 1973 and 2001 were linked to the nationwide Cause of Death Register. Information on the number of SCT in AML patients in Sweden during the study period was obtained from the EBMT register. Survival analysis were performed by computing relative survival rates (RSR), defined as the ratio of observed survival of the patients in the cohort versus the expected survival among individuals of the same age, sex, and calendar year of observation.Results5809 AML patients diagnosed between January 1, 1973 and December 31, 2001 were identified. The cases were divided into six age groups; 0–18, 19–40, 41–60, 61–70, 71–80, and 80+ years. The study period was arbitrarily divided into 7-year intervals. Improvement was seen in all age groups but the eldest. However, patients < 60 years benefited most from new treatment strategies (table 1).There was a marked increase in SCT during the study period with allogeneic SCT dominating in the last period (fig 1). A comparison between regions (with different therapeutical traditions) was made. The regions of Stockholm, Uppsala and Örebro have cooperated since 1971 within the Leukemia Group of Middle Sweden (LGMS) and was therefore considered as one region and compared with the rest of the country. During the first calendar period the 5-year RSR of residents with AML in LGMS counties was significantly higher than that of patients in remaining regions. However, this difference has disappeared with time.ConclusionImprovement in overall survival of AML patients was mainly confined to young patients (<60 years). However, among patients 60–71 years at diagnosis, a slightly improved RSR was observed. For patients above the age of 70 years, the prognosis remains very poor stressing the fact that the decision to use aggressive chemotherapy for this group of patients should consider the risk of iatrogenic morbidity and mortality as well as projected benefit. The early creation of a cooperative clinical AML group probably explains the improved RSR rates during the first study period (1973–1979).Table 1Five-year RSR (%) according to age group and calendar periodcalendar period/age group (years)1973–19791980–19861987–19931994–20000–181731526819–401417385841–60713223661–7068121571–80337681+1001 [Display omitted]

The international bone marrow transplant registry.

The first successful transplants of hematopoietic stem cells were done in 1968 in three children with congenital immune deficiency diseases. In each instance, stem cells were collected from the bone marrow of sibling donors who were genotypically HLA identical or closely HLA matched to the recipient. Since then, thousands of patients have received hematopoietic stem cell transplants to treat malignant and non-malignant diseases. Current estimates of annual numbers of stem cell transplants are about 50,000 worldwide, with growth at a rate of 10-15% per year. The reasons for increasing use include proven and potential efficacy in many diseases, better understanding of the appropriate timing of transplantation and patient selection, greater availability of donors and better techniques for determining HLA match, greater ease of stem cell collection, and improved supportive care resulting in less transplant-related morbidity and mortality. About two-thirds of hematopoietic stem cell transplants use autologous cells, generally collected from peripheral blood by leukapheresis. The remainder are allogeneic transplants, most commonly from HLA-identical sibling donors, and most often using cells collected directly from bone marrow.