Cognitive problems following hematopoietic stem cell transplant: relationships with sleep, depression and fatigue

Sleep Quality in Patients With Ocular Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation

OBJECTIVES

To investigate the sleep quality in patients with ocular graft-versus-host disease (oGVHD) compared with patients without oGVHD after allogeneic hematopoietic stem cell transplantation (alloHCT) and healthy controls.

METHODS

This cross-sectional study analyzed 142 patients after alloHCT including 94 patients with oGVHD and 48 without. Fifty healthy controls were also enrolled. oGVHD was diagnosed according to International Chronic Ocular GVHD Consensus Group (ICOGCG) criteria. Sleep quality was assessed by the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI). Poor sleep quality was defined as CPQSI score greater than 6.

RESULTS

Patients after alloHCT demonstrated a significantly higher CPQSI score than those of controls {7.0 [interquartile range (IQR) 5.0-10.0] vs. 5.5 [IQR 4.8-7.0], P =0.002}, especially in the oGVHD subgroup (7.5 [IQR 5.0-11.0] vs. 6.0 [IQR 5.0-8.0], P =0.04) with nearly double prevalence of poor sleep quality (58 [62%] vs. 18 [37%], P =0.006). Poor sleep quality was strikingly correlated with oGVHD diagnosis (adjusted odds ratio [OR]=2.55, 95% confidence interval [CI]: 1.02-6.34, P =0.04) and systemic immunosuppressants (adjusted OR=2.61, 95% CI: 1.32-5.71, P =0.02). Among the ocular parameters, poor sleep quality was significantly associated with higher ICOGCG score (adjusted OR=1.20, 95% CI: 1.03-1.39, P =0.02) and lower tear film break-up time (adjusted OR=0.85, 95% CI: 0.74-0.99, P =0.05).

CONCLUSIONS

Poor sleep quality was associated with an increased severity of oGVHD and tear film instability in the long-term alloHCT survivorship.

Short-Term Impact of Hematopoietic Stem Cell Transplantation on Depressive Behavior, Cognition and Quality of Life in Leukemia Patients

Hematopoietic stem cell transplantation (HSCT) or Bone Marrow Transplantation (BMT) has significantly improved the survival rates of patients suffering from hematological malignancies. However, the cure can only be achieved at the price of morbidity and long-term complications. Thus, this study aimed to evaluate the short-term effect of HSCT on depressive behavior, cognition, and quality of life (QoL) in leukemia patients. Sixty patients were included in this prospective observational study. The current study assessed depression using Patient Health Questionnaire (PHQ-9) scale, cognition using Montreal Cognitive Assessment (MOCA) scale and QoL using European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30) before 7 days of the therapy i.e., preconditioning/baseline (TP1) and after 30 days of the treatment (TP2) in leukemia patients undergoing HSCT. At TP2, there was a significant improvement in PHQ-9 (p = 0.001), MOCA (p < 0.0001), functional scale (p < 0.0001) and global health & QoL scale (p = 0.001) of EORTC QLQ C30 scores whereas there was a significant decrease in symptom scale of EORTC QLQ C30 score (p = 0.005). Furthermore, at TP2 a statistically significant (p < 0.05) negative correlation was observed between MOCA and symptom scale of EORTC QLQ C30 after Pearson correlation analysis. In conclusion, post-30 days of HSCT there was alleviation in depressive behavior, cognition, and QoL in leukemia patients compared to before therapy.

Graphical abstract

Common mental disorders in hematopoietic stem cell transplant patients: a scoping review

OBJECTIVE

to map common recurrent mental disorders in patients undergoing hematopoietic stem cell transplantation.

METHODS

this is a scoping review carried out in January 2022 in electronic databases and repositories of dissertations and thesis. Studies that answered the research question, met the objective of the study and were available in full electronically, in any language, were included.

RESULTS

the sample consisted of 28 studies, 14 of which were published in the United States of America. The common mental disorders found were depressive, anxiety, post-traumatic stress and mood disorders. Twenty symptoms were mentioned, among the most prevalent are fatigue and sleep disorders/insomnia.

CONCLUSIONS

the difficulty and importance of carrying out the differential diagnosis of these disorders were highlighted, since their symptoms can be confused with other health problems and have a strong potential to interfere with patients' evolution.

Returning to employment following allogeneic hematopoietic stem cell transplant: A major problem among survivors

Quality of life (QoL) is an important aspect of cancer survivorship. One of the most acute problems that impact survivors in many aspects of activities of daily living and compromise their QoL is the inability to return to employment following successful cancer therapy. This is most prominent among survivors after allogeneic hematopoietic stem cell transplant (allo-HSCT). More than 50% of the survivors following allo-HSCT remain unemployed one year after the procedure. This problem extends beyond the initial few years; unemployment rates among those who underwent allo-HSCT during their childhoods or adolescence have remained high. The inability to return to employment imposes a financial burden. Survivors following allo-HSCT also experience a multitude of chronic psychosocial complications that may be both contributing and consequential to the inability to return to employment. However, many transplant programs and cancer centers do not have return-to-employment programs. In this review paper, we discuss the prevalence of unemployment following allo-HSCT. We examine the psychosocial symptoms experienced by survivors and how they may affect survivors' ability to return to employment. Finally, we propose a multi-disciplinary multi-pronged occupation-focused approach to address the complex and inter-related psychosocial symptoms to help alleviate the problem.

Associations of Germline Genetic Variants With Depression and Fatigue Among Hematologic Cancer Patients Treated With Allogeneic Hematopoietic Cell Transplantation

OBJECTIVE

Depression and fatigue are common among cancer patients and are associated with germline genetic variation. The goal of this pilot study was to examine genetic associations with depression and fatigue in the year after allogeneic hematopoietic cell transplant (HCT).

METHODS

Blood was collected from patients and their donors before HCT. Patients completed self-report measures of depression and fatigue before HCT (T1), 90 days post-HCT (T2), and 1 year post-HCT (T3). Of the 384 genetic variants genotyped on a custom Illumina BeadChip microarray, 267 were retained for analysis based on quality control. Main effects of patient and donor variants as well as their interaction were examined using regression analyses. Significant variants were defined as those with a false discovery rate-adjusted p value of <.05.

RESULTS

The sample consisted of 59 patient-donor pairs. Mean levels of depression and fatigue did not change significantly over time ( p values of > .41). Increases in depression from T1 to T2 were associated with patient-donor interactions at rs1928040 ( p = 3.0 × 10 -4 ) and rs6311 ( p = 2.0 × 10 -4 ) in HTR2A . Increases in fatigue from T1 to T2 were associated with patient rs689021 in SORL1 ( p = 6.0 × 10 -5 ) and a patient-donor interaction at rs1885884 in HTR2A ( p < 1.0 × 10 -4 ).

CONCLUSIONS

Data suggest that variants in genes regulating the serotonergic system ( HTR2A ) and lipid metabolism ( SORL1 ) are associated with changes in depression and fatigue in allogeneic HCT patients, implicating patients' own genetic inheritance as well as that of donors. Additional studies are warranted to confirm these findings.

Delirium and Healthcare Utilization in Patients Undergoing Hematopoietic Stem Cell Transplantation

Delirium, a common neuropsychiatric syndrome among hospitalized patients, has been associated with significant morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). Although delirium is often reversible with prompt diagnosis and appropriate management, timely screening of hospitalized patients, including HSCT recipients at risk for delirium, is lacking. The association between delirium symptoms and healthcare utilization among HSCT recipients is also limited. We conducted a retrospective analysis of 502 hospitalized patients admitted for allogeneic or autologous HSCT at 2 tertiary care hospitals between April 2016 and April 2021. We used Natural Language Processing (NLP) to identify patients with delirium symptoms, as defined by an NLP-assisted chart review of the electronic health record (EHR). We used multivariable regression models to examine the associations between delirium symptoms, clinical outcomes, and healthcare utilization, adjusting for patient-, disease-, and transplantation-related factors. Overall, 44.4% (124 of 279) of patients undergoing allogeneic HSCT and 39.0% (87 of 223) of those undergoing autologous HSCT were identified as having delirium symptoms during their index hospitalization. Two-thirds (139 of 211) of the patients with delirium symptoms were prescribed treatment with antipsychotic medications. Among allogeneic HSCT recipients, delirium symptoms were associated with longer hospital length of stay (β = 7.960; P < .001), fewer days alive and out of the hospital (β = -23.669; P < .001), and more intensive care unit admissions (odds ratio, 2.854; P = .002). In autologous HSCT recipients, delirium symptoms were associated with longer hospital length of stay (β = 2.204; P < .001). NLP-assisted EHR review is a feasible approach to identifying hospitalized patients, including HSCT recipients at risk for delirium. Because delirium symptoms are negatively associated with health care utilization during and after HSCT, our findings underscore the need to efficiently identify patients hospitalized for HSCT who are at risk of delirium to improve their outcomes. © 2023 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Fatigue as Mediator Factor in PTSD-Symptoms after Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND

Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) is a valid treatment for hematological oncological or metabolic diseases. Despite its therapeutic efficacy, it is an aggressive treatment that impacts negatively on quality of life (QoL) and may result in Post-Traumatic Stress Disorder (PTSD) symptoms. The aim of this study is to explore rates and risk factors for PTSD symptoms, and fatigue in post-HSCT patients with hematological malignancies.

METHODS

A total of 123 patients after HSCT were evaluated for PTSD symptoms, QoL and fatigue. PTSD symptoms were assessed with the Impact of Event Scale- Revised (IES-R), QoL was measured with Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) and fatigue symptoms were assessed with Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F).

RESULTS

A total of 58.54% of the sample developed PTSD symptoms after transplant. Patients with PTSD symptoms reported significantly lower QoL total scores and significantly higher fatigue than those without PTSD symptoms (p < 0.001). The SEM analysis showed that worse QoL and fatigue affected PTSD symptomatology along different pathways. Fatigue was found as a major influencing factor of PTSD symptoms directly (β = 0.31 **), while QoL only through the mediation of fatigue at a lesser extent. (β = 0.33 *).

CONCLUSIONS

Our findings indicate that QoL is a concurrent causative factor to the development of PTSD symptomatology through the mediating role of fatigue. Innovative interventions before transplantation to prevent PTSD symptoms should be investigated to improve survival and QoL in patients.

Patient-reported cognitive function among hematopoietic stem cell transplant and cellular therapy patients: a scoping review

PURPOSE

Cognitive dysfunction is a known complication following cellular therapies (CT), which can be assessed through performance based and patient-reported measures. We performed a systematic scoping review to assess self-reported cognitive function measures used among adult CT patients and describe long-term results, including associations with clinical outcomes.

METHODS

Library databases were searched from inception to February 2020 according to PRISMA guidelines. Additional studies were identified through reference lists and trial protocols. Two members of the research team screened titles and abstracts and resolved discrepancies. Articles that met eligibility criteria continued to full-text review, with 25% double screening. Articles were removed if they (1) were not original research, peer-reviewed articles; (2) were the wrong disease, age, or treatment-specific patient population; (3) did not use patient-reported outcomes; (4) did not separately report cognitive function outcomes.

RESULTS

Of the1952 articles, 56 were included. Twenty-one patient-reported measures of cognitive function were used; most frequently the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30), which includes a two-item cognitive function subscale (57%; n = 32). Thirteen studies collected performance-based and self-reported measures and of those (n = 6) who assessed associations found moderate correlations (range r = .13-.58). Longitudinal patterns showed declines in cognitive function soon after treatment (< 1 month) returning to baseline at 1 year. Cognitive function was often associated with other quality of life measures, chiefly depression (n = 5).

CONCLUSIONS

EORTC-QLQ-C30 is the most commonly used to measure, though there remain numerous measures used, including several measures with little previous validation and investigator developed items.

Fatigue in Hematopoietic Cell Transplantation Survivors: Correlates, Care Team Communication, and Patient-Identified Mitigation Strategies

With improved survival after hematopoietic cell transplantation (HCT), the number of individuals at risk for persistent or late effects is increasing. The importance of optimizing HCT survivor health and well-being is mounting. Fatigue is a common post-transplantation symptom that impairs quality of life, yet it remains poorly understood and inadequately addressed. Multiple challenges to addressing fatigue exist, including its multidimensional presentation, multiple (often concomitant) causes, patient-clinician communication barriers, and few highly effective, evidence-based interventions that can be readily implemented. To address these challenges, we sought to better describe the impact and potential causes of fatigue in the post-transplantation setting, fatigue-related communication with clinicians, and the most effective patient-identified mitigation strategies (PIMS) for fatigue. A total of 1703 adult HCT recipients from a single center completed a survey including the Medical Outcomes Survey Short Form-36 (SF-36), PROMIS Fatigue, and other fatigue-related items between July 2017-June 2018. The survey was offered to recipients at their post-transplantation anniversary occurring during this interval. Two independent raters categorized free-text responses about fatigue PIMS. PROMIS Fatigue scores were dichotomized into low (≤55) or high (>55). Associations between high fatigue and participant characteristics and health outcomes were evaluated using the Fisher exact test for categorical variables and the Student 2-sample t test for continuous variables. Among the 1660 respondents with evaluable fatigue scores, 67% underwent allogeneic HCT. The majority of these (n = 1588; 96%) had a malignancy, with hematologic malignancy the most common diagnostic category (n = 1555; 94%). The median time post-transplantation was 11 years (interquartile range, 4 to 20 years). PROMIS item responses indicate that 44% of patients were at least somewhat fatigued and 37% were at least somewhat bothered by it. The mean fatigue score was 50.2 ± 11; 591 patients (36%) had high fatigue, which was associated with worse SF-36 scores across all domains (General Health, Physical Functioning, Emotional Well-being/Mental Health, Social Functioning, Role Limitation due to Physical Health, Role Limitation due to Emotional Health, Vitality [eg, energy], and Bodily Pain). High fatigue also was associated with self-reported chronic graft-versus-host disease, anxiety, depression and sleep problems. Diagnosis of plasma cell disorder and receipt of an autologous transplant were associated with high fatigue (P = .001). Among the 553 individuals who received an autologous transplant, 226 (41%) had multiple myeloma. Compared with the autologous transplant recipients without myeloma group, those with multiple myeloma were significantly more likely to have high fatigue (109 of 226 [48%] versus 118 of 325 [36%]; P < .01). Twenty percent of the patients with high fatigue did not discuss it with their care team. Among the 89 different reasons provided for not discussing it, the most common was "thought they already knew the answer" (n = 21). The 370 survivors with high fatigue who identified at least 1 most effective PIMS generated a total of 639 PIMS. Although the PIMS for fatigue spanned a wide array of strategies, most PIMS were related to sleep/rest (n = 192; 30%) or exercise (n = 139; 22%). Although fatigue is associated with worse HCT survivor-reported outcomes, it is only sometimes discussed with care teams. Survivors identify specific strategies that are most effective. Given its prevalence and impact, clinicians should promote communication about fatigue, treat underlying causes, and recommend sleep/rest and exercise, recognizing that individualized approaches also may be beneficial.

Cognitive functioning in survivors of hematopoietic stem cell transplantation compared with a matched general population sample – The MOSA study

Although cognitive problems can recover over time, a subgroup of hematopoietic stem cell transplantation (HCT) survivors experience persistent cognitive problems in the long term. Despite these implications, studies assessing cognitive functioning in HCT survivors are limited. The aim of the present study was (1) to quantify the prevalence of cognitive impairment in patients treated with HCT who survived at least 2 years and to compare these with a matched reference group representing the general population; (2) to identify potential determinants of cognitive functioning within the HCT survivor group. Within the single-center Maastricht Observational study of late effects after Stem cell trAnsplantation, cognitive performance was assessed by a neuropsychological test battery divided into 3 cognitive domains: memory, information processing speed, and executive function and attention. An overall cognition score was calculated as the average of the domain scores. A total of 115 HCT survivors were group-matched on a 1:4 ratio to the reference group by age, sex, and level of education. Regression analyses adjusted for different sets of covariates including demographic and health- and lifestyle-related factors were used to test for differences in cognition between HCT survivors and the reference group resembling the general population. A limited set of clinical characteristics (diagnosis, type of transplant, time since treatment, conditioning regimen with total body irradiation and age at time of transplantation) were assessed as potential determinants of neurocognitive dysfunction among HCT survivors. Cognitive impairment was defined as scores in the cognitive domains < -1.5 standard deviation (SD) from what can be expected based on someone's age, sex, and education. The mean age at time of transplantation was 50.2 (SD ± 11.2) years, and the mean number of years after transplant was 8.7 (SD ± 5.7) years. The majority of HCT survivors were treated with autologous HCT (n = 73 [64%]). The prevalence of cognitive dysfunction was 34.8% in HCT survivors and 21.3% in the reference group (p = .002.) When adjusted for age, sex, and level of education, HCT survivors had a worse overall cognition score (b = -0.35; 95% confidence interval [CI], -0.55 to -0.16; p < .001), translating into 9.0 years of higher cognitive age. Analyses of specific cognitive domain scores showed that HCT survivors scored worse on memory (b = -0.43; 95% CI, -0.73 to -0.13; p = .005), information processing speed (b = -0.33; 95% CI, -0.55 to -0.11; p = .003), and executive function and attention (b = -0.29; 95% CI, -.55 to -.03; p = .031) than the reference group. The odds of cognitive impairment were on average 2.4 times higher among HCT survivors than the reference group (odd ratio = 2.44; 95% CI, 1.47-4.07; p = .001). Within the HCT survivor group none of the tested clinical determinants of cognitive impairment were significantly associated with cognition. This cohort study showed evidence for worse cognitive functioning in HCT survivors encompassing all three cognitive domains, respectively memory, information processing speed, and executive & attention compared to a reference group that represents the general population translating into nine years of faster cognitive ageing in HCT survivors than can be expected based on their chronological age. It is important to increase awareness for signs of neurocognitive dysfunction after HCT in clinicians and HCT survivors.

Menopausal symptoms and quality of life in female survivors treated with hematopoietic stem cell transplantation

OBJECTIVES

To assess the severity of menopausal symptoms and the correlation among different quality of life questionnaires and compare the quality of life of patients who underwent hematopoietic stem cell transplantation (HSCT) for hematological disorders with the norm group in order to facilitate personalized and directed therapeutic intervention for patients.

METHODS

We recruited women who had premature ovarian failure (POF) after HSCT for hematologic diseases in the gynecological endocrinology outpatient clinic of Peking University People's Hospital. Women with HSCT were included in the study if they had 6 months of spontaneous amenorrhea with serum follicle-stimulating hormone levels greater than 40 mIU/mL taken 4 weeks apart. The patients who had other causes of POF were excluded. During the survey, all women were required to fill out the questionnaires [Quality of Life Questionnaire (MENQOL), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and 36-item Short-Form (SF-36)] online. We analyzed the severity of menopausal symptoms, anxiety, and depression in Participants. In addition, differences on the SF-36 scale scores between the study group and norm groups were examined.

RESULTS

In total, 227 (93.41%) patients completed the survey and were analyzed. The severity of all symptoms is "none and mild" in MRS, MENQOL, GAD-7, and PHQ-9. On the MRS, the most common symptoms were irritability, physical and mental exhaustion, and sleep problems. The severest symptoms were sexual problems (53, 73.82%), followed by sleep problems (44, 19.38%) and mental and physical exhaustion (39, 17.18%). In the MENQOL, the most common symptoms were psychosocial and physical symptoms. The severest symptoms were sexual symptoms (35, 48.75%) followed by psychosocial symptoms (23, 10.13%). Moderate-severe scores were shown in 11.89% (27) and 18.72% (42) cases in the GAD-7 and PHQ-9, respectively. Based on SF-36, in comparison with the norm group, the HSCT participants had higher vitality scores and lower role physical, physical functioning, and role emotional scores aged 18-45. In addition, the HSCT participants had lower mental health scores aged 18-25, and lower general health scores aged 25-45. No strong correlation was observed between questionnaires in our study.

CONCLUSION

Overall, menopausal symptoms are milder in female patients after HSCT. There is no single scale that comprehensively assesses the patient's quality of life after HSCT. We need to assess the severity of various symptoms in patients using different scales.

Effects of Exercise Programs on Psychoemotional and Quality-of-Life Factors in Adult Patients with Cancer and Hematopoietic Stem Cell Transplantation or Bone Marrow Transplantation: A Systematic Review

This review analyzed the effects of an exercise program on psychoemotional and quality-of-life (QoL) factors in adult patients with cancer and hematopoietic stem cell transplantation (HSCT) or bone marrow transplantation (BMT). Studies were identified from the PubMed and Web of Science databases (from inception to 24 August 2022), according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. The methodological quality of the included studies was assessed with the Physiotherapy Evidence Database (PEDro) scale, based in turn on the Delphi list. A total of 20 randomized controlled studies were included with 1219 participants. The main result of this systematic review is that exercise program interventions produce improvements on psychoemotional and QoL factors in adult patients with cancer and HSCT or BMT. Moreover, exercise programs may have a beneficial effect on health, maintaining or increasing the patient's QoL. Further, it has a positive effect on the prevention and control of transplant complications in combination with medical treatment.

Biobehavioral Implications of Covid-19 for Transplantation and Cellular Therapy Recipients

A growing body of literature has emphasized the importance of biobehavioral processes - defined as the interaction of behavior, psychology, socioenvironmental factors, and biological processes - for clinical outcomes among transplantation and cellular therapy (TCT) patients. TCT recipients are especially vulnerable to distress associated with pandemic conditions and represent a notably immunocompromised group at greater risk for SARS-CoV-2 infection with substantially worse outcomes. The summation of both the immunologic and psychologic vulnerability of TCT patients renders them particularly susceptible to adverse biobehavioral sequelae associated with the Covid-19 pandemic. Stress and adverse psychosocial factors alter neural and endocrine pathways through sympathetic nervous system and hypothalamic-pituitary-adrenal axis signaling that ultimately affect gene regulation in immune cells. Reciprocally, global inflammation and immune dysregulation related to TCT contribute to dysregulation of neuroendocrine and central nervous system function, resulting in the symptom profile of depression, fatigue, sleep disturbance, and cognitive dysfunction. In this article, we draw upon literature on immunology, psychology, neuroscience, hematology and oncology, Covid-19 pathophysiology, and TCT processes to discuss how they may intersect to influence TCT outcomes, with the goal of providing an overview of the significance of biobehavioral factors in understanding the relationship between Covid-19 and TCT, now and for the future. We discuss the roles of depression, anxiety, fatigue, sleep, social isolation and loneliness, and neurocognitive impairment, as well as specific implications for sub-populations of interest, including pediatrics, caregivers, and TCT donors. Finally, we address protective psychological processes that may optimize biobehavioral outcomes affected by Covid-19.

Long-term patient-reported neurocognitive outcomes in adult survivors of hematopoietic cell transplant

Long-term adult HCT survivors reported average cognitive quality of life compared with the general population.

Survivors with hearing issues and sleep impairments were more likely to report lower quality of life and impaired neurocognitive function.

Survivors of hematopoietic cell transplant (HCT) are at risk for neurocognitive impairments, which can negatively affect quality of life. Given limited studies, we aimed to describe the neurocognitive outcomes in a cohort of long-term adult HCT survivors. Eligible survivors (age ≥21 years at HCT and alive ≥2 years following HCT) completed a 60-question survey of neurocognitive function and quality of life, which included the Neuro-Quality of Life Cognitive Function Short Form (Neuro-QoL) and the Childhood Cancer Survivor Study Neurocognitive Questionnaire (NCQ). Analyses of risk factors included univariate comparisons and multivariable logistic regression. Survivors (n = 1861, 47.7% female, 65.6% allogeneic HCT) were surveyed at a median age of 64.2 years (interquartile range [IQR], 56.8-70.5) and a median 12.0 years (IQR, 6.0-21.0) from HCT. Survivors reported average Neuro-QoL scores (50.0 allogeneic; 49.2 autologous survivors) compared with an expected mean of 50 in the general population. On the NCQ, 17.4% to 31.2% of survivors reported impairments (Z-score >1.28) in task efficiency, memory, emotional regulation, or organization, compared with an expected 10% in the general population (all P < .01). In multivariable regression analyses, impaired Neuro-QoL (T-score <40) was independently associated with hearing issues (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.46-3.10) and sleep impairment (OR, 4.41; 95% CI, 2.80-6.94) among allogeneic survivors, with comparable associations in autologous survivors. Overall, long-term adult HCT survivors reported average cognitive quality of life compared with the general population. Subsets of survivors with hearing issues and sleep impairments were more likely to report lower quality of life and impaired neurocognitive function, which may facilitate targeted monitoring or interventions following HCT.

Home-Based Hematopoietic Cell Transplantation in the United States

Patients undergoing allogeneic (allo) and autologous (auto) hematopoietic cell transplantation (HCT) require extensive hospitalizations or daily clinic visits for the duration of their transplantation. Home HCT, wherein patients live at home and providers make daily trips to the patient's residence to perform assessments and deliver any necessary interventions, may enhance patient quality of life and improve outcomes. We conducted the first study of home HCT in the United States to evaluate this model in the US healthcare setting and to determine the effect on clinical outcomes and quality of life. This case-control study evaluated patients who received home HCT at Duke University in Durham, North Carolina, from November 2012 to March 2018. Each home HCT patient was matched with 2 controls from the same institution who had received standard treatment based on age, disease, and type of transplant for outcomes comparison. Clinical outcomes were abstracted from electronic health records, and quality of life was assessed via Functional Assessment of Cancer Therapy-Bone Marrow Transplant. Clinical outcomes were compared with Student's t-test or Fisher's exact test (continuous variables) or chi-square test (categorical variables). Quality of life scores were compared using the Student t-test. All analyses used a significance threshold of 0.05. Twenty-five patients received home HCT, including 8 allos and 17 autos. Clinical outcomes were not significantly different between the home HCT patients and their matched controls; home HCT patients had decreased incidence of relapse within 1 year of transplantation. Pre-HCT quality of life was well preserved for autologous home HCT patients. This Phase I study demonstrated that home HCT can be successfully implemented in the United States. There was no evidence that home HCT outcomes were inferior to standard-of-care treatment, and patients undergoing autologous home HCT were able to maintain their quality of life. A Phase II randomized trial of home versus standard HCT is currently underway to better compare outcomes and costs.

Perceptions and Experiences of Hematopoietic Cell Transplantation Patients During the COVID-19 Pandemic

Objectives

Data Sources

Conclusion

Implication for Nursing Practice

Insomnia in Post-Hematopoietic Stem-Cell Transplant Patients in Jordan: Prevalence and Associated Factors

Background and Objective Insomnia is a common symptom that is experienced by the patients post hematopoietic stem cell transplant that interfere with recovery outcomes and patients’ quality of life. Little is known about insomnia among post hematopoietic stem cell transplant in Jordan and in other Arab countries. The purpose of the current study was to identify the levels of insomnia and the related factors in post hematopoietic stem cell transplant.Methods A descriptive cross-sectional correlational design was used to guide this study. Data was collected from 163 patients by the Arabic version of the Insomnia Severity Index (ISI).Results The participant’s average ISI was 14.06 ± 7.71 indicating sub-threshold insomnia. Regarding the insomnia levels, 23.9% of the participants reported no insomnia, 27.6% had subthreshold insomnia, 31.3% had moderate clinical insomnia, and 17.2% had severe clinical insomnia. A significant difference in insomnia levels in some related factors was reported including the higher educated patients (t = 2.40, p = 0.018), patients who received allogeneic transplants (t = -2.932, p = 0.004), and patients within a 30 days’ post-transplant (F (160, 2) = 61.03, p < 0.001).Conclusions In conclusion, the overall prevalence of insomnia among post HSCT patients was 48.5% (n = 79) that suggested clinical insomnia, and it was affected by several clinical variables. Further studies are needed to provide appropriate interventions to decrease insomnia levels among patients.

Clinical characterization and cytokine profile of fatigue in hematologic malignancy patients with chronic graft-versus-host disease

Limited information is available regarding clinical and biological properties of fatigue in patients with chronic graft-versus-host disease (cGvHD). Patients with moderate-to-severe cGvHD per NIH criteria were enrolled on a cross-sectional study and categorized as "fatigued" if SF-36 vitality score was <40. Clinical and laboratory parameters of fatigued (n = 109) and nonfatigued patients (n = 72) were compared. In univariate analysis, walk velocity, NIH joint-fascia score, human activity profile, and SF-36 physical and mental health self-report scales were correlates of fatigue. No cGvHD biomarkers were associated with fatigue. NIH joint score, Lee sleep and depression questions, and PG-SGA activities and function score jointly predicted fatigue. Though higher rates of depression and insomnia were reported in the fatigued group, antidepressant or sleep aid use did not differ between groups. Survival ratio was not significantly different by fatigue status. Pathophysiology of fatigue in patients with cGvHD is complex and may involve mechanisms unrelated to disease activity. Patients with cGvHD experiencing fatigue had higher rates of untreated depression and insomnia, highlighting the need to focus clinical management of these conditions to improve health-related quality of life.

The Effect of Educational Intervention on Care Dependency and Symptom Management After Hematopoietic Stem Cell Transplantation: A Theory-Based Randomized Controlled Study

The objective of the research was to determine the effect of educational intervention based on Bandura’s Social Cognitive Learning Theory on care dependency and symptom management after hematopoietic stem cell transplantation. Methods. This randomized controlled trial was conducted between January 2019 and February 2020 at the Hematopoietic Stem Cell Transplantation Center. All the patients were randomly divided into two groups: 53 individuals in the intervention group and 53 individuals in the control group. The sociodemographic data collection form, the Edmonton Symptom Assessment Scale and the Care Dependency Scale were used for data collection. Data were collected from the patients one day after hematopoietic stem cell transplantation and 12 weeks later. Results. There were no statistically significant differences between the groups regarding the mean scores of the Edmonton Symptom Assessment Scale and the Care Dependency Scale at baseline. Twelve weeks after intervention, there were statistically significant differences between the groups regarding the mean scores of the Edmonton Symptom Assessment Scale and the Care Dependency Scale. Conclusions. Educational intervention along with telephone counseling based on Bandura’s theory was found to be an effective way to reduce symptom severity and care dependency in patients who underwent hematopoietic stem cell transplantation and is recommended for all patients after hematopoietic stem cell transplantation.

Biobehavioral Research and Hematopoietic Stem Cell Transplantation: Expert Review from the Biobehavioral Research Special Interest Group of the American Society for Transplantation and Cellular Therapy

Hematopoietic stem cell transplantation (HCT) is a potentially curative treatment for many hematologic conditions. Despite advances in conditioning and supportive measures, however, there remain significant comorbidities that threaten survivorship. Adverse effects of stress-related biobehavioral processes-defined here as the interactions of behavioral, psychological, and socioenvironmental factors with biology-impact immune recovery and function and are particularly salient in the HCT context, given the importance of immune reconstitution for improved survivorship. However, biobehavioral processes have been underinvestigated in this vulnerable group compared with other cancer populations. Here the Biobehavioral Research Special Interest Group (SIG) of the American Society for Transplantation and Cellular Therapy provides an expert review to inform research directions explicating the biological correlates of behavioral symptoms and evaluate the impact of these on HCT outcomes. The goal of this expert review is to provide a foundation for advancing science that effectively integrates behavioral and biological processes to optimize quality of life and improve clinical outcomes for HCT recipients.

Cognitive late effects following allogeneic stem cell transplantation in haematological cancer patients

OBJECTIVE

The objective of this exploratory study was to determine the presence and correlates of self-reported cognition in a sample of haematological cancer patients who had undergone allogeneic stem cell transplantation (SCT).

METHODS

Haematological cancer patients (n = 30) who had undergone allogeneic SCT between one and five years previously and age-matched control participants (n = 30) completed questionnaires assessing cognition, affect, sleep quality and fatigue and an assessment of premorbid IQ.

RESULTS

Patients reported significantly poorer perceived cognitive ability (d = 1.12) and greater perceived cognitive impairment (d = 0.96) than controls. Lower fatigue was significantly associated with greater perceived cognitive ability (r = 0.75 patients and controls) and less perceived cognitive impairment (r = 0.80 patients; r = 0.57 controls). Interestingly, depression was significantly correlated with perceived cognitive ability in the control group only (r = 0.80). Hierarchical multiple regressions showed that fatigue was a significant predictor of perceived cognitive ability in patients, accounting for 56% of the variance.

CONCLUSIONS

This study established that self-reported cognitive ability and cognitive impairment was significantly poorer in haematological cancer patients than controls. Furthermore, fatigue was significantly associated with perceived cognitive ability in patients. Future research should focus on identifying interventions that target fatigue in allogeneic SCT recipients in order to improve quality of life throughout survivorship.

Cognitive complaints by hematopoietic cell transplantation recipients and change in neuropsychological performance over time

PURPOSE

Hematopoietic stem cell transplant (HSCT) recipients are at risk for cognitive decline. Cross-sectional studies show patients' complaints of cognitive decline do not correlate well with concurrently measured objective neuropsychological performance, but rather with emotional variables and health-related quality of life. This longitudinal study investigated whether patient self-report of cognitive status would be concordant with objectively measured neuropsychological performance after accounting for change from their own pre-transplant objective baseline.

METHODS

Pre-HSCT and at 30 and 100 days post-HSCT, 46 patients underwent computerized neuropsychological testing (CogState) and completed surveys assessing patient-reported cognitive complaints, emotional symptoms (depression, anxiety), sleep quality, daytime sleepiness, and physical and functional well-being. Correlations were calculated between cognitive complaints and neuropsychological performance (at each time-point and across time-points), as well as all other patient-reported variables.

RESULTS

Patient-reported cognitive complaints were largely independent of concurrently assessed objective neuropsychological performance. Uniquely, our longitudinal data demonstrated significant medium to large effect size associations between subjective cognitive complaints post-HSCT with objectively measured change from pre-HSCT in attention, visual learning, and working memory (p < .05-.01). Subjective cognitive complaints post-HSCT were also associated with depression, anxiety, daytime sleepiness and physical well-being (p < .05-.001).

CONCLUSIONS

Patients appear better able to assess their cognitive functioning relative to their own baseline and changes across time rather than relative to community norms. Thus, patient complaints of cognitive compromise justify further in-depth neuropsychological, emotional, and functional assessment. Future research into relationships between cognitive complaints and neuropsychological performance should account for changes in performance over time.

Therapeutic Options for Mucopolysaccharidoses: Current and Emerging Treatments

Mucopolysaccharidoses (MPS) are inborn errors of metabolism produced by a deficiency of one of the enzymes involved in the degradation of glycosaminoglycans (GAGs). Although taken separately, each type is rare. As a group, MPS are relatively frequent, with an overall estimated incidence of around 1 in 20,000-25,000 births. Development of therapeutic options for MPS, including hematopoietic stem cell transplantation (HSCT) and enzyme replacement therapy (ERT), has modified the natural history of many MPS types. In spite of the improvement in some tissues and organs, significant challenges remain unsolved, including blood-brain barrier (BBB) penetration and treatment of lesions in avascular cartilage, heart valves, and corneas. Newer approaches, such as intrathecal ERT, ERT with fusion proteins to cross the BBB, gene therapy, substrate reduction therapy (SRT), chaperone therapy, and some combination of these strategies may provide better outcomes for MPS patients in the near future. As early diagnosis and early treatment are imperative to improve therapeutic efficacy, the inclusion of MPS in newborn screening programs should enhance the potential impact of treatment in reducing the morbidity associated with MPS diseases. In this review, we evaluate available treatments, including ERT and HSCT, and future treatments, such as gene therapy, SRT, and chaperone therapy, and describe the advantages and disadvantages. We also assess the current clinical endpoints and biomarkers used in clinical trials.

Worsening cognitive performance is associated with increases in systemic inflammation following hematopoietic cell transplantation

BACKGROUND

Cognitive decline is a frequently cited concern among patients receiving hematopoietic cell transplantation (HCT), and patients often experience neurocognitive deficits (i.e., stable or worsening neurocognitive performance) throughout the transplant course. Deficits can be most severe during the acute transplant period (i.e., 90 days after transplantation), when patients also typically experience elevated systemic levels of inflammation. Previous studies have identified inflammation as a likely mechanism underlying neurocognitive deficits, primarily in women with breast cancer; however, longitudinal studies have been limited. In this study, our aim was to evaluate the relationship between changes in systemic inflammation and changes in cognition from pre- to post-transplant in patients receiving allogeneic HCT.

METHODS

Patients scheduled for allogeneic HCT (n = 85) were assessed prior to HCT and 90 days after HCT. Biomarkers of inflammation included IL-6, sTNF-RII, CRP, and IL-1ra, which have been previously associated with neurocognitive deficits in cancer patients. Patients completed neuropsychological testing and self-report questionnaires.

RESULTS

Mixed models demonstrated that from pre- to post-HCT, increases in IL-6 and sTNF-RII were associated with neurocognitive deficits, and decreases in CRP were associated with better neurocognitive performance. There were no significant associations between changes in inflammation and self-reported cognitive performance.

CONCLUSIONS

Our findings are the first to our knowledge to report a robust relationship between increasing inflammation and neurocognitive deficits from pre- to post-HCT. Additional studies are needed to confirm these findings in a larger sample.

Psychological Considerations in Hematopoietic Stem Cell Transplantation

BACKGROUND

In recent decades, advances in transplantation medicine, and improved posttransplant care have reduced morbidity and mortality from hematopoietic stem cell transplantations (HSCTs). However, patients undergoing HSCT report a high prevalence of psychological distress, which can negatively impact recovery, function, and health outcomes, including mortality and higher risk of graft vs. host disease. Appropriate assessment and management of these psychological symptoms lead to better engagement with treatment and a variety of superior health outcomes.

OBJECTIVE

We provide a narrative review of the psychological challenges that accompany HSCT and suggest management approaches to equip psychiatric consultants involved in the care of this patient population.

METHODS

We reviewed published work in PubMed, PsycInfo, and Scopus electronic databases on the common psychological challenges in HSCT, their vulnerability factors, as well as practical interventions for managing these challenges.

RESULTS

We outline the phases of the HSCT hospitalization and discuss common psychological challenges, such as depression, delirium, and post-traumatic stress reactions that accompany HSCT. We suggest an approach to psychiatric consults during the HSCT hospitalization and discuss practical interventions for managing psychological challenges in this population.

CONCLUSIONS

Though pharmacological and behavioral interventions have been successfully used to treat psychosocial challenges in HSCT, further research is needed to understand the optimal psychiatric assessment tools, treatment strategies, and the long-term psychiatric care needed to address psychiatric comorbidities in this growing patient population.

An mHealth Pain Coping Skills Training Intervention for Hematopoietic Stem Cell Transplantation Patients: Development and Pilot Randomized Controlled Trial

BACKGROUND

Pain is a challenge for patients following hematopoietic stem cell transplantation (HCT).

OBJECTIVE

This study aimed to develop and test the feasibility, acceptability, and initial efficacy of a Web-based mobile pain coping skills training (mPCST) protocol designed to address the needs of HCT patients.

METHODS

Participants had undergone HCT and reported pain following transplant (N=68). To guide intervention development, qualitative data were collected from focus group participants (n=25) and participants who completed user testing (n=7). After their input was integrated into the mPCST intervention, a pilot randomized controlled trial (RCT, n=36) was conducted to examine the feasibility, acceptability, and initial efficacy of the intervention. Measures of acceptability, pain severity, pain disability, pain self-efficacy, fatigue, and physical disability (self-report and 2-min walk test [2MWT]) were collected.

RESULTS

Participants in the focus groups and user testing provided qualitative data that were used to iteratively refine the mPCST protocol. Focus group qualitative data included participants' experiences with pain following transplant, perspectives on ways to cope with pain, and suggestions for pain management for other HCT patients. User testing participants provided feedback on the HCT protocol and information on the use of videoconferencing. The final version of the mPCST intervention was designed to bridge the intensive outpatient (1 in-person session) and home settings (5 videoconferencing sessions). A key component of the intervention was a website that provided personalized messages based on daily assessments of pain and activity. The website also provided intervention materials (ie, electronic handouts, short videos, and audio files). The intervention content included pain coping advice from other transplant patients and instructions on how to apply pain coping skills while engaging in meaningful and leisure activities. In the RCT phase of this research, HCT patients (n=36) were randomized to receive the mPCST intervention or to proceed with the treatment as usual. Results revealed that the mPCST participants completed an average of 5 out of 6 sessions. The participants reported that the intervention was highly acceptable (mean 3/4), and they found the sessions to be helpful (mean 8/10) and easy to understand (mean 7/7). The mPCST participants demonstrated significant improvements in pre- to post-treatment pain, self-efficacy (P=.03, d=0.61), and on the 2MWT (P=.03, d=0.66), whereas the patients in the treatment-as-usual group did not report any such improvements. Significant changes in pain disability and fatigue were found in both groups (multiple P<.02); the magnitudes of the effect sizes were larger for the mPCST group than for the control group (pain disability: d=0.79 vs 0.69; fatigue: d=0.94 vs 0.81). There were no significant changes in pain severity in either group.

CONCLUSIONS

Using focus groups and user testing, we developed an mPCST protocol that was feasible, acceptable, and beneficial for HCT patients with pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01984671; https://clinicaltrials.gov/ct2/show/NCT01984671 (Archived by WebCite at http://www.webcitation.org/6xbpx3clZ).