The use of reduced-intensity stem cell transplantation in haemophagocytic lymphohistiocytosis and Langerhans cell histiocytosis

Allogeneic stem cell transplant is curative for haemophagocytic lymphohistiocytosis (HLH) and refractory Langerhans cell histiocytosis (LCH). However, patients frequently have significant pre-transplant morbidity and there is high TRM. Because HLH is caused by immune dysregulation, we surmised that a reduced-intensity conditioned (RIC) regimen might be sufficient for cure, while decreasing the TRM. In 2006, we reported the outcome of 12 patients treated with RIC SCT from a matched family/unrelated or haploidentical donor. Here we discuss the update of these patients, including a total of 25 patients treated with RIC SCT for HLH and three for LCH. Twenty-one of the twenty-five patients with HLH (84%) are alive and well with remission at a median of 36 months from SCT. Mortality included pneumonitis (n=3) and hepatic rupture (n=1). All three patients treated with RIC SCT for LCH remain alive and in remission at a median of 5.1 years from SCT. Seven of twenty-four survivors (one with LCH) have mixed chimerism but remain disease-free. These data are supported by other groups including 100% survival in seven patients with HLH and 78% survival of nine patients with LCH. In summary, RIC compares favourably with conventional SCT with long-term disease control in surviving patients with both HLH and LCL, despite a significant incidence of mixed chimerism.

An assessment of post-tsunami psychosocial training programmes in Tamilnadu, India

BACKGROUND

After the Tsunami struck Tamilnadu in India in 2004, a spate of psychosocial training programmes were held by a host of agencies, both government and non-government.

AIM

This study is an empirical approach to the assessment of the psychosocial training programmes held after tsunami. The nature and quality of training received by the community level workers (CLWs) and the interventions carried out by them are described.

METHODS

CLWs were interviewed using a questionnaire to assess details about training and interventions carried out by them. Qualitative information was also gathered both from CLWs and the community. A comparison was made between CLWs of government, non-governmental organizations (NGOs) and those belonging to self-help groups.

RESULTS

While most CLWs seemed to have benefited greatly from the training programmes, they had several suggestions to make about refining its quality. Multiple programmes, not well coordinated, resulted in a lot of overlap. The community was generally happy with the interventions provided and felt that they were necessary for about six months at least. One-to-one interventions are preferred to group activities, except in the case of children.

CONCLUSIONS

Psychosocial support (PSS) training programmes after a disaster situation will need to be coordinated by a nodal agency. Too many players on the field with their own agenda do not benefit the community and can well be a waste of resources.

Reduced intensity conditioning and allogeneic stem cell transplantation in childhood malignant and nonmalignant diseases

Allogeneic hematopoietic SCT is well established as a potentially curative therapy for children and adults with both malignant and nonmalignant diseases. However, myeloablative SCT is associated with significant short- and long-term complications. The goals of a reduced intensity-conditioning (RIC) regimen are to prevent graft rejection and establish stable donor-derived hematopoiesis at a level sufficient for cure of the underlying disease and, in patients with hematologic malignancy, to provide a GVL effect, while decreasing the short- and long-term complications associated with myeloablative conditioning therapy. RIC regimens have enabled SCT to be performed in children with preexisting comorbidities that preclude conventional conditioning. RIC-SCT has been most extensively studied in patients with nonmalignant disorders and for some of these, including primary immunodeficiencies and hemophagocytic lymphohistiocytosis, sufficient data now exist to support its routine use even in patients without comorbidity. Less data exist on RIC-SCT for children with hematologic malignancies and at present this should be restricted to children who are not candidates for, or have relapsed after, myeloablative SCT. Here we review available data on the use of RIC-SCT in pediatric patients, highlighting important clinical lessons and areas that require further study.

Cotyledonoid leiomyoma in pregnancy

BACKGROUND

Benign smooth-muscle tumors (leiomyomata) are the most frequent tumors found in the female genital tract. They are easy to diagnose in pregnancy and usually managed conservatively. Some variant forms with unusual infiltrative growth pattern have been known, but they are rare in pregnancy. The variant forms pose diagnostic and management difficulties.

CASE

An unusual type of leiomyoma (cotyledonoid), adhering to the bowels and occupying the whole left broad ligament, was excised completely at 14 weeks of gestation, and the pregnancy continued to term.

CONCLUSION

Familiarity with benign uterine smooth-muscle tumors with unusual growth patterns by gynecologists and pathologists is essential in avoiding over-treatment.

Aetiology and outcome of burns in the elderly

INTRODUCTION

This retrospective study, analyses aetiology and factors affecting the outcome of burns in patients over 65 years of age.

METHODS

Sixty-three consecutive patients, over 65 years of age, were admitted to a Burns Unit over a period of 3 years. Retrospective data was analyzed, taking into account aetiology, burn thickness and area, co-morbid factors. Also, surgery as a factor-affecting outcome was examined.

RESULTS

There was a significant difference of total body surface area burn (TBSA), Abbreviated Burn Severity Index (ABSI), Baux score and the number of pre-existing co-morbid factors between survivors and non-survivors. Age and surgery were not significant to the outcome. Patients undergoing surgery had increased hospital stay without any difference in mortality. The timing of surgery did not have any impact on hospital stay or survival.

CONCLUSION

This study shows a positive correlation between the number of co-morbid conditions and mortality. Early surgery after careful patient selection does not have any negative impact on patient survival.

Phase I study utilizing an intravenous busulfan test dose to prospectively target and determine the maximum tolerated systemic exposure (MTSE) of a continuous intravenous infusion

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Background: Busulfan systemic concentration has correlated with toxicity and efficacy. We previously demonstrated that administration of intravenous high-dose busulfan (HD-Bu) as a 90 hour continuous infusion (CIV) has efficacy, safety, and mean daily area under the concentration curves (AUC) comparable to intermittent dosing regimens and that it is possible to use a test dose of busulfan to predict the systemic exposure with less than 10% variability. The objective of this study is to identify the MTSE of CIV HD-Bu utilizing a test dose for AUC targeting. Methods: Prior to HD-Bu, patients received a single test dose of Bu (0.8 mg/kg) by two hour infusion with blood concentrations obtained at 0, 2.5, 4, 5, and 6 hours. Serum concentrations were analyzed using GC-MS. Non-compartmental PK analysis was used to determine clearance using WIN-NONLIN software. The systemic clearance (dose/AUC) of the test dose was used to predict the 90 hour CIV dose of Bu needed to achieve the desired AUC. On days -7 to -3, the treatment dose was administered and blood samples were collected at 0, 12, 16, 18, 48, 60, 72, and 89.5 hours to verify that the desired AUC was reached. Dose adjustments were made after 18 hours if necessary. A blood sample was obtained for evaluation of polymorphisms in genes associated with busulfan metabolism and transport. Results: Five patients (4 MUD, 1 matched-sibling donor) were enrolled at the 24 hour Bu target AUC of 4800 uM*min ± 15%. One patient was not able to be evaluated due to errors in PK acquisition. 3 of the 4 patients required CIV doses different than that based on weight alone (i.e. 12.8 mg/kg). All 4 patients had AUCs within the desired range (mean 24 hour busulfan AUC of 4708 uM*min) with a mean bias and precision of −1.9% and 8.7%, respectively. No adjustments were required after 18 hours. No grade 3 or greater chemotherapy related toxicity has been identified. Conclusions: The systemic clearance determined by a busulfan test dose may be used to prospectively target the desired AUC of a 90 hour CIV. Enrollment on this Phase I study will continue beyond the first dose level which is at the upper limit of the normal range (4800 uM*min).

No significant financial relationships to disclose.

Self-inflicted burns, outcome and cost

INTRODUCTION

Self-inflicted burns represent a small number of total admissions to a burns unit, yet they constitute a major workload.

METHODS

A retrospective analysis of self-inflicted burns admitted between 1998 and 2002.

RESULTS

One thousand six hundred and fifty six patients were admitted with acute burn injuries, of these 56 were self-inflicted. 24 patients had a previous history of self-harming and 22 were unemployed. History of a psychiatric illness was found in 46 patients. Flames caused 46 out of 56 injuries. Mean total body surface area (TBSA) was 27%. Approximately 39% needed admission to intensive care unit (ICU). The mortality rate was 25%. On discharge, 29% of the patients re-self harmed.

CONCLUSION

Self-inflicted burns have a poorer outcome. Improving the psychiatric and social support can reduce the incidence of self-harming behaviour, its repetitiveness and subsequently the cost of burn care.

Chemotherapy for prostate cancer

Androgen deprivation in patients with metastatic prostate cancer produces palliation of symptoms, reduction in PSA levels, and temporary regression of tumor in most patients. Following a brief period of disease regression that lasts an average of eighteen to twenty-four months, the disease becomes hormone refractory and progresses. Second line hormonal manipulation includes anti-androgen withdrawal, glucocorticoids, estrogens, aminogluthetimide, and ketoconazole. The response from these drugs is usually very short. Once these measures have been exhausted, the clinician is left with limited treatment options that include radionuclides and cytotoxic chemotherapy. It is the objective of this article to review the experience with chemotherapy in prostate cancer and then to discuss the role of radionuclide agents, emerging agents, and herbal therapies.

194 ESTABLISHMENT OF GOAT EMBRYONIC STEM CELL-LIKE LINES DERIVED FROM IN VIVO-PRODUCED BLASTOCYST-STAGE EMBRYOS

Pluripotent embryonic stem cells (ESC) derived from the inner cell mass (ICM) of mammalian blastocysts provide AN unlimited number of cells that can be used in gene targeting and be of great value to agriculture and medicine. Embryonic stem cells with capacity for germ line transmission have been verified only in mouse despite many efforts to derive ESC from other mammalian species. The methods for the derivation, propagation and differentiation of ESC from domestic animals have not been fully established. The objective of this study was the generation and initial characterization of goat embryonic stem cells (GESC) derived from in vivo-produced blastocyst-stage embryos. Goat compact morulae and blastocysts were collected from superovulated adult Saanen crossbreed donors 7 days after insemination with a fertile male. Embryos were collected by uterine flushing using a 12Fr. Foley catheter by means of a laparoscopically assisted mid-ventral laparotomy under general anesthesia. Twenty eight in vivo-derived blastosyst-stage embryos were cultured on a goat fetal fibroblast feeder layer (inactivated by Mitomycin C) in a medium of DMEM containing 0.1 mm �-mercaptoethanol, 0.1 mm MEM nonessential amino acids, 200 mm l-glutamine, and 10% FCS. Following three days in culture 25 of 28 embryos hatched. Ten embryos attached to the feeder layer, nine degenerated, and nine embryos were floating in the medium and expanding in size. After 5-7 days in culture four of the tehn attached embryos appeared with a prominent an ICM outgrowth and 3 of the nine floating embryos formed structures resembling ICM disc surrounded by trophectoderm cells. The ICM and the embryonic discs were isolated mechanically and cultured on goat feeder cells in DMEM medium containing 10 ng/mL horse leukemia inhibitory factor (hLIF) and 10% FCS. The ICM and embryonic disc outgrew into colonies on Day 4 post-culture. Compact colonies of cells from these outgrowths were isolated mechanically and passed onto fresh goat feeder cells every 4-5 days with the addition of 10 ng/mL hLIF to the culture media. Established colonies at passage 6 were tested for immunoreactivity against alkaline phosphatase (AP) and Oct-1 using standard protocols. The result was the estabilshment of embryonic stem cell-like colonies (57%) from both ICM and embryonic discs cultured on goat fetal fibroblast feeder cells. Colonies forming from these outgrowths (50%) of either ICM or embryonic disc stained positive for both AP and Oct-4. Embryoid bodies formed from colonies of either ICM or embryonic disc in suspension (DMEM containing 10% FCS with no hLIF). Two cell lines (one from ICM and one from embryonic disc) have been maintained so far through passage 8 and have been cryopreserved. These GESC-like lines will be used in further characterization and ultimately in transgenic animal production studies.

Improved outcome for children with disseminated adenoviral infection following allogeneic stem cell transplantation

Adenovirus (AdV) infections are a frequent cause of morbidity and mortality following allogeneic stem cell transplantation (SCT), and disseminated infection is associated with high mortality, particularly in paediatric SCT. Here, we describe an approach to reduce mortality from adenoviraemia by combining prospective monitoring for the occurrence of adenoviraemia using a sensitive polymerase chain reaction method, early antiviral therapy and prompt withdrawal of immunosuppression. A total of 155 consecutive paediatric SCT procedures were prospectively monitored, of which 113 (73%) transplants involved donors other than matched siblings and 126 (83%) employed T-cell depletion. Adenoviraemia was detected in 26/155 (17%) transplants and developed exclusively in patients who had received T-cell-depleted grafts. Withdrawal of immunosuppression coupled with early antiviral therapy led to resolution of adenoviraemia in 19/26 (81%) patients with only five patients succumbing to disseminate AdV infection. Survival from adenoviraemia was associated with lymphocyte recovery to above 0.3x10(9)/l. Mortality was closely linked with the absence of lymphocyte recovery because of profound T-cell depletion of the graft with CD34+ magnetic-activated cell sorting. Mortality from disseminated AdV infection was 5/26 (19%) in this study, which is significantly lower than previously reported.

Stem cell transplantation for congenital immunodeficiencies using reduced-intensity conditioning

The optimal preparation for stem cell transplantation (SCT) in children with congenital immunodeficiencies is currently unknown. In all, 81 children with immunodeficiency underwent 82 SCTs using reduced-intensity conditioning (RIC). The incidence of significant GVHD was low; viral reactivation was prominent with an unexpected increase in EBV reactivation; immune reconstitution was similar between different donor groups and comparable to conventional SCT. Overall, 68/81 (84%) survive with no significant difference between donor types or between severe combined immunodeficiency (SCID) and non-SCID diseases. Findings suggest a significant survival advantage in the unrelated donor setting for RIC compared to conventional SCT.