A Quasi-Experimental Study Analyzing the Effectiveness of Portable High-Efficiency Particulate Absorption Filters in Preventing Infections in Hematology Patients during Construction.

OBJECTIVE: The increased risk of infection for patients caused by construction and renovation near hematology inpatient clinics is a major concern. The use of high-efficiency particulate absorption (HEPA) filters can reduce the risk of infection. However, there is no standard protocol indicating the use of HEPA filters for patients with hematological malignancies, except for those who have undergone allogeneic hematopoietic stem cell transplantation. This quasi-experimental study was designed to measure the efficacy of HEPA filters in preventing infections during construction. MATERIALS AND METHODS: Portable HEPA filters were placed in the rooms of patients undergoing treatment for hematological malignancies because of large-scale construction taking place near the hematology clinic. The rates of infection during the 6 months before and after the installation of the portable HEPA filters were compared. A total of 413 patients were treated during this 1-year period. RESULTS: There were no significant differences in the antifungal prophylaxis and treatment regimens between the groups. The rates of infections, clinically documented infections, and invasive fungal infections decreased in all of the patients following the installation of the HEPA filters. When analyzed separately, the rates of invasive fungal infections were similar before and after the installation of HEPA filters in patients who had no neutropenia or long neutropenia duration. HEPA filters were significantly protective against infection when installed in the rooms of patients with acute lymphocytic leukemia, patients who were undergoing consolidation treatment, and patients who were neutropenic for 1-14 days. CONCLUSION: Despite the advent of construction and the summer season, during which environmental Aspergillus contamination is more prevalent, no patient or patient subgroup experienced an increase in fungal infections following the installation of HEPA filters. The protective effect of HEPA filters against infection was more pronounced in patients with acute lymphocytic leukemia, patients undergoing consolidation therapy, and patients with moderate neutropenia.

Intramesenteric steroid treatment for steroid- refractory gastrointestinal graft versus host disease.

UNLABELLED: Currently, steroid-refractory severe gastrointestinal (GI) graft versus host disease (GVHD) is among the most important complications of allogeneic transplantation, and as yet there is no standard approach to its treatment. Herein we report two cases with steroid-refractory GI GVHD that received intramesenteric steroid treatment. In both cases the frequency and volume of diarrhea resolved completely following intramesenteric methylprednisolone (MP) injection. In conclusion, intra-arterial steroid injection might be an alternative treatment approach for steroid-refractory GI GVHD. CONFLICT OF INTEREST: None declared.

How Does Influenza A (H1N1) Infection Proceed in Allogeneic Stem Cell Transplantation Recipients?

The clinical course of influenza A (H1N1) infection in allogeneic hematopoietic stem cell transplantation (AHSCT)recipients is not clearly known. We report 3 AHSCT recipients that were infected with influenza A (H1N1). Each of thepatients had a different hematological disease and was at a different post-transplantation stages. All the patients weretreated with oseltamivir, and zanamivir was switched to oseltamivir in 1 patient. All the patients survived without anycomplications. The course of swine flu can vary and progress with bacterial or other viral infections in immunosuppressedpatients.

Addition of thalidomide to oral melphalan/prednisone in patients with multiple myeloma not eligible for transplantation: results of a randomized trial from the Turkish Myeloma Study Group.

The combination of melphalan-prednisone-thalidomide (MPT) has been investigated in several clinical studies that differed significantly with regard to patient characteristics and treatment schedules. This prospective trial differs from previous melphalan-prednisone (MP) vs. MPT trials by treatment dosing, duration, routine anticoagulation, and permission for a crossover. Newly diagnosed patients with multiple myeloma (MM) (n=122) aged greater than 55 yr, not eligible for transplantation were randomized to receive 8 cycles of M (9 mg/m(2) /d) and P (60 mg/m(2) /d) for 4d every 6 wk (n=62) or MP and thalidomide (100 mg/d) continuously (n=60). Primary endpoint was treatment response and toxicities following 4 and 8 cycles of therapy. Secondary endpoints were disease-free (DFS) and overall survival (OS). Overall, MPT-treated patients were younger (median 69 yr vs. 72 yr; P=0.016) and had a higher incidence of renal impairment (RI, 19% vs. 7%, respectively; P=0.057). After 4 cycles of treatment (n=115), there were more partial responses or better in the MPT arm than in the MP arm (57.9% vs. 37.5%; P=0.030). However, DFS and OS were not significantly different between the arms after a median of 23 months follow-up (median OS 26.0 vs. 28.0 months, P=0.655; DFS 21.0 vs. 14.0 months, P=0.342, respectively). Crossover to MPT was required in 11 patients, 57% of whom responded to treatment. A higher rate of grade 3-4 infections was observed in the MPT arm compared with the MP arm (22.4% vs. 7.0%; P=0.033). However, none of these infections were associated with febrile neutropenia. Death within the first 3 months was observed more frequently in the MP arm (n=8, 14.0%) than in the MPT arm (n=2, 3.4%; P=0.053). Long-term discontinuation and dose reduction rates were also analyzed (MPT: 15.5% vs. MP: 5.3%; P=0.072). Although patients treated with MPT were relatively younger and had more frequent RI, better responses and less early mortality were observed in all age groups despite more frequent discontinuation.

A case report of the Modified Malmö Protocol: an alternative therapeutic approach to refractory chronic idiopathic thrombocytopenic purpura.

Therapy in refractory chronic idiopathic thrombocytopenic purpura is usually a difficult and expensive procedure, with little benefit to the patient, and the results are typically only short-term improvements. In this case report, we study a patient with refractory chronic idiopathic thrombocytopenic purpura who was initially treated with a first line therapy with only partial and temporary benefit, and in whom none of the experimental therapies tried later on resulted in any long lasting effect. In the case study conducted, among all the second-line experimental treatment modalities, only the proposed new protocol (the Modified Malmö Protocol) resulted in a major response. Our results suggest that, the Modified Malmö Protocol may be a promising second-line treatment option for severely refractory idiopathic thrombocytopenic purpura cases.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) in acute myeloblastic leukemia (AML): A single center experience.

OBJECTIVE: We retrospectively analyzed the impact of pre- and post-transplant variables on the outcome of transplanta¬tion in 145 consecutive patients with acute myeloblastic leukemia (AML) allografted from their HLA-identical siblings in our single center cohort. RESULTS: The stem cell source used was bone marrow (BM) (36.6%) or peripheral blood (PB) (63.4%). Both neutrophil and platelet engraftments were observed on the median 14th day. Engraftment was faster in the PB group than in the BM group (p<0.0001). Severe acute graft versus host disease (aGvHD) was observed in 27.9% of the patients while chronic (c)GvHD developed in 61.2%. The use of PB was associated with more severe aGvHD. Estimated leukemia-free survival (LFS) and overall survival (OS) at 10 years were 43.4%±5.2% and 52.7%±4.6%, respectively. CONCLUSION: Both in univariate and multivariate analyses for LFS and OS, remission status at transplant and the presence of aGvHD were independent risk factors.

Monitoring of peripheral blood CD34+ cell counts on the first day of apheresis is highly predictive for efficient CD34+ cell yield.

The purpose of this study was to evaluate the correlation of preleukapheresis circulating CD 34+ cells/micro L, white blood cells (WBC), and platelet counts on the first day of apheresis with the yield of collected CD 34+ cell counts in 40 patients with hematological malignancies (n = 29) and solid tumors (n = 11). The median numbers of apheresis cycles, numbers of CD 34+ cells, peripheral blood (PB) mononuclear cells, and total nucleated cells collected were 2 (range, 1-4), 5.5 x 106/kg (range, 0.05-33.78), 2.59 x 108/kg (range, 0.04-20.68), and 7.36 x 108/kg (range, 0.15-28.08), respectively. There was a strong correlation between the number of preleukapheresis circulating CD 34+ cells/micro L and the yield of collected CD 34+ cells per kilogram (r = 0.962, p < 0.001). The threshold levels of PB C 34+ cell/micro L to obtain > or =1 x 106/kg and > or =2.5 x 106/kg CD 34+ cell in one collection were 12/micro L and 34/ micro L, respectively. Fifteen of 17 (88%) patients who had > or =34 CD 34+ cells/ micro L in the PB before collection reached the level of > or =2.5 x 106/kg in a single apheresis. Despite a low r value, WBC and platelet counts on the first day of apheresis also correlated with the yield of collected daily CD 34+ cells per kilogram (r = 0.482, p < 0.01 and r = 0.496 p < 0.01, respectively). These data suggest that preleukapheresis circulating CD 34+ cells/ micro L correlated significantly better with the yield of collected CD 34+ cells than WBC and platelet counts on the first day of apheresis. Using a value of 34/micro L preleukapheresis circulating CD 34+ cells as a guide for the timing of peripheral blood stem cells collections can be time saving and cost-effective.

The Role of ABO Incompatibility in Allogeneic Peripheral Blood Stem Cell Transplant.

ABO incompatibility is not a contraindication for allogeneic bone marrow transplantation, but this procedure requires an extra effort for erythrocyte or plasma depletion in certain well established conditions. Some acute or delayed immunohematological complications such as acute or chronic hemolysis and pure red cell aplasia may be encountered. In this study the outcome and transplant related complications of ABO incompatible and identical cases, who have received allogeneic peripheral blood stem cells from their HLA identical siblings were compared with each other. Ninety-one patients (CML 36, AML 37, other 18) were analyzed retrospectively including 51 (60.4%) ABO identical patients and 36 (39.6%) ABO mismatched (MM) patients, who have a bi-directional MM (n= 5), major MM (n= 16), minor MM (n= 9) and Rh MM (n= 6). Median follow up was 13 (0.5-43.0) months. We did not observed any significant differences between two groups (identical vs non-identical) in terms of acute hemolysis preceding stem cell infusion, peritransplant transfusion demand, acute- and chronic graft versus host disease. There was no change in estimated disease free survival and overall survival durations. We did not observed any influence of ABO/Rh incompatibility on short term outcome in allogeneic peripheral blood stem cell transplantation in our series and did not recommend further manipulation of the infused stem cells.