Osteoporosis management in hematologic stem cell transplant recipients: Executive summary.

BACKGROUND: Treatment advances have reduced the adverse events associated with hematopoietic stem cell transplant (HSCT) and led to an increased number of transplants performed. HSCT patients are living longer with concerns on long-term outcomes. Bone fragility and fracture are at the forefront for long-term morbidities post-HSCT. RESULTS: In HSCT recipients, evidence has accumulated to support recommendations for more extensive monitoring of bone fragility and more appropriate administration of osteoporosis pharmacotherapies for patients at high risk of bone loss and/or fracture. CONCLUSION: This executive summary reports and summarizes the main recommendations published previously, including bone assessment, dietary and lifestyle recommendations and osteoporosis medication.

Bone management in hematologic stem cell transplant recipients.

Autologous and allogeneic hematopoietic stem cell transplantation (HSCT) is the treatment of choice for patients with some malignant and non-malignant hematological diseases. Advances in transplantation techniques and supportive care measures have substantially increased the number of long-term HSCT survivors. This has led to an increasing patient population suffering from the late effects of HSCT, of which, bone loss and its consequent fragility fractures lead to substantial morbidity. Altered bone health, with consequent fragility fractures, and chronic graft-versus-host disease (GVHD) are factors affecting long-term quality of life after HSCT. Hypogonadism, HSCT preparative regimens, nutritional factors, and glucocorticoids all contribute to accelerated bone loss and increased fracture risk. Management strategies should include bone mineral density examination, evaluation of clinical risk factors, and general dietary and physical activity measures. Evidence has accumulated permitting recommendations for more attentiveness to evaluation and monitoring of bone health, with appropriate application of osteoporosis pharmacotherapies to patients at increased risk of bone loss and fracture.

Effect of an antimicrobial stewardship programme on antimicrobial utilisation and costs in patients with leukaemia: a retrospective controlled study.

OBJECTIVES: To examine the effectiveness of an antimicrobial stewardship programme on utilization and cost of antimicrobials in leukaemia patients in Canada. METHODS: We conducted a multisite retrospective observational time series study from 2005 to 2013. We implemented academic detailing as the intervention of an antimicrobial stewardship programme in leukaemia units at a hospital, piloted February-July 2010, then fully implemented December 2010-March 2013, with no intervention in August-November 2010. Internal control was the same hospital's allogeneic haematopoietic stem-cell transplantation unit. External control was the combined leukaemia-haematopoietic stem-cell transplantation unit at another hospital. Primary outcome was antimicrobial utilization (antibiotics and antifungals) in defined daily dose per 100 patient-days (PD). Secondary outcomes were antimicrobial cost (Canadian dollars per PD); cost and utilization by drug class; length of stay; 30-day inpatient mortality; and nosocomial Clostridium difficile infection. We used autoregressive integrated moving average models to evaluate the impact of the intervention on outcomes. RESULTS: The intervention group included 1006 patients before implementation and 335 during full implementation. Correspondingly, internal control had 723 and 264 patients, external control 1395 and 864 patients. Antimicrobial utilization decreased significantly in the intervention group (p <0.01, 278 vs. 247 defined daily dose per 100 PD), increased in external control (p = 0.02, 237.4 vs. 268.9 defined daily dose per 100 PD) and remained stable in internal control (p = 0.66). Antimicrobial cost decreased in the intervention group (p = 0.03; $154.59 per PD vs. $128.93 per PD), increased in external control (p = 0.01; $109.4 per PD vs. $135.97 per PD) but was stable in internal control (p = 0.27). Mortality, length of stay and nosocomial C. difficile rate in intervention group remained stable. CONCLUSIONS: The antimicrobial stewardship programme reduced antimicrobial use in leukaemia patients without affecting inpatient mortality and length of stay.

Mycobacterium-avium-intracellulare complex infection following 2-chlorodeoxyadenosine therapy for hairy cell leukaemia.

2-Chlorodeoxyadenosine (2-CdA) is associated with prolonged suppression of CD4 lymphocytes. Cases of tuberculosis or mycobacterium avium intracellulare complex (MAC) infection complicating 2-CdA administration have not been reported despite the low CD4 counts. We report a patient with Hairy Cell Leukaemia (HCL) who developed MAC infection one month following 2-CdA treatment. This patient had been previously treated with prednisone for Sweets Syndrome. It would appear that the combination of 2-CdA and prednisone predisposes patients to MAC infection, and if possible this combination of treatment should be avoided.

Successful allogeneic bone marrow transplant for chronic myeloid leukaemia despite previous interferon-induced cardiomyopathy.

We report a patient with CML who developed a reversible dilated cardiomyopathy with cardiac failure following 10 months of IFN therapy. Despite the previous cardiomyopathy, he tolerated subsequent allogeneic BMT without any adverse cardiac events. Reversible IFN-induced cardiomyopathy should not be considered a contraindication to bone marrow transplantation.

Sleep during experimental trypanosomiasis in rabbits.

Trypanosoma brucei subspecies cause the human condition known as "sleeping sickness." In rabbits, these organisms induce a chronic and ultimately fatal disease characterized by periodic parasitemia. To characterize sleep alterations during a chronic infectious condition and to determine how immune stimulation of the host, as reflected by cyclic parasitemia, is related to altered somnolence, we monitored sleep and other clinical indices in rabbits inoculated subcutaneously with Trypanosoma brucei brucei. Within four days, infected rabbits developed fever, reduced food intake, and other signs of infectious illness concurrent with the onset of parasitemia were evident. The initial febrile episodes were transient, recurring in temporal correlation with parasitemia. Time spent in slow-wave sleep and delta-wave amplitude during slow-wave sleep increased significantly in association with the onset of febrile episodes, despite an overall trend toward decreases in these parameters. Because each episode of parasitemia presents an immune stimulus to the infected host, the periodic enhancement of sleep observed in this model is consistent with the hypothesis that immune stimulation is correlated with increased somnolence. The data further indicate that sleep alterations occur not only during acute infections, as previously reported, but during chronic infections as well.