Laboratory Features of Hospitalised Patients with COVID-19 in Jersey, UK

COVID-19 is an acute respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To date, more than 550 million cases and 6 million deaths have been reported worldwide. This study investigated the laboratory features in hospitalised patients with COVID-19 and determined risk factors for in-hospital mortality. This retrospective observational study included laboratory results of confirmed cases of hospitalised patients with SARS-CoV-2 infection in Jersey (UK) between March-December 2020 (subject to inclusion criteria), and a control group. Furthermore, COVID-19 patients were split into two sub-groups, based on outcome (non-survivors vs. survivors). Logistic regression was used to determine risk factors for in-hospital mortality. A total of 81 COVID-19 cases and 100 controls were included in this study. In the COVID-19 group, 59.3% of subjects were male, and the overall mortality was 33.3%. The main laboratory changes were the following: 95.1% of patients presented with raised C-reactive protein (p<0.001), 85% showed increased fibrinogen (p<0.001), 70% had prolonged prothrombin time (p=0.014), 51.9% suffered from lymphopenia (p<0.001), 42% had elevated gamma glutamyl transferase (p=0.011) and 35.8% demonstrated raised creatinine concentration (p=0.002). Non-survivors were older than survivors (median age: 82 vs. 74 years, p=0.003) with substantial lymphopenia (p=0.018), high creatinine level (p=0.009), and leukocytosis (p=0.018). Increased in-hospital mortality risk was 6.7-fold in patients presenting with a lymphocyte count <0.85 x10⁹/L, 5.3-fold with red blood cell distribution width >14%, 4.9-fold with white cell count >9.5 x10⁹/L, and 3.3-fold for those presenting with creatinine >100 μmol/L. Age ≥82 years was significantly associated with death, and male gender a risk factor for hospital admission in COVID-19. These results demonstrate that routine haematology and biochemistry tests may allow for risk-stratification of hospitalised patients with COVID-19.

Hematopoietic stem cell transplantation in qatar: One-year anniversary

Hematopoietic stem cell transplantation (HSCT) offers potentially curative therapy for many hematologic and nonhematologic conditions. As a successful outcome of Qatar's National Cancer Strategy, the HSCT program was started in the National Center for Cancer Care and Research (NCCCR) in October 2015. The HSCT program in NCCCR is the only transplant program in Qatar and self-sufficient with all three core components: the stem cell collection facility, the stem cell processing facility, and the clinical program, which are locally available at Hamad Medical Corporation. In this paper, we report on the outcomes of the first 16 patients who underwent autologous stem cell transplantations (ASCTs) in our center. A total of 17 ASCT have been performed for 16 adult (≥14years) patients. Thirteen of the 16 patients were eligible for disease evaluation at Day 100 post-ASCT. Among these patients, the overall response rate on Day 100 was 92% (complete remission, 61%; very good partial remission/partial remission, 31%) and stable disease occurred in 6%. The procedure was very well tolerated by all patients. At the time of writing this report, all patients are alive; however, one patient (6%) had disease relapse. The Day 100 post-ASCT nonrelapse mortality rate was 0%. Launching the HSCT program represents a historic milestone in the development of the health-care sector in Qatar. The 1st year of this program was very fruitful with the accomplishment of 17 successful transplants. We are in the process of starting the allogenic HSCT early next year. This would represent the next significant milestone for cancer care in Qatar.

Precision Medicine and Non-Colorectal Cancer Liver Metastases: Fiction or Reality?

BACKGROUND

Non-colorectal liver metastases (nCRLM) constitute a variety of heterogeneous diseases and a considerable therapeutic challenge. Management is based on the primary tumor and the clinical course. In the era of precision medicine (PM) we know that cancer is heterogeneous within the tumor and across different sites.

METHODS

We give an overview of the path to PM through 'omics' beyond genomics. We refer to the experience gained to date from models such as colorectal cancer and we discuss the opportunity offered by PM for the management of nCRLM.

RESULTS

In order to best characterize and track tumor biological behaviors as well as to understand mechanisms of response to therapy and survival we suggest the application of novel clinical trial designs, a dynamic approach with serial monitoring involving evaluation of primary and metastatic sites. Quality and standardization of tissue acquisition and biobanking is a precondition for the reliability of this approach.

CONCLUSION

The application of PM is increasingly becoming a reality. Elucidating the mysteries of tumors in complex settings can only be achieved with the approach PM offers. nCRLM may serve as a model for the application of PM principles and techniques in understanding individual diseases and also cancer as an entity and therapeutic challenge.

Can we deconstruct cancer, one patient at a time?

Patients with cancer face an ever-widening gap between the exponential rate at which technology improves and the linear rate at which these advances are translated into clinical practice. Closing this gap will require the establishment of learning loops that intimately link lab and clinic and enable the immediate transfer of knowledge, thereby engaging highly motivated patients with cancer as true partners in research. Here, we discuss the goal of creating a distributed network that aims to place world-class resources at the disposal of select patients with cancer and their oncologists, and then use these intensively monitored individual patient experiences to improve collective understanding of how cancer works.

The granulocytes in neutropenia 1 (GIN 1) study: a safety study of granulocytes collected from whole blood and stored in additive solution and plasma

OBJECTIVE/AIM

To evaluate the safety of transfusing pooled, whole blood-derived granulocytes in additive solution and plasma (GASP) in 30 recipients.

BACKGROUND

Demand for granulocytes in England has increased five-fold. With the advantages of reduced red cell, plasma and overall volume, GASP maintains function in vitro.

METHODS AND MATERIALS

Observations were recorded prior to and post transfusion. Increments were recorded at 1 h and the following morning. Leucocyte antibody screening was undertaken prior to and at 1-6 months following transfusion.

RESULTS

Thirty patients aged between 8 months and 68 years received 221 GASP in 148 transfusion episodes. GASP contained an average of 1.0 × 10(10) granulocytes in 207 mL. Adults usually received two packs and children 10-20 mL kg(-1). Children and adults received a median [interquartile range (IQR)] dose of 12.5 (9.1-25.3) and 19.7 (12.0-25.8) × 10(9) granulocytes per transfusion, respectively. There was one episode of transfusion-associated circulatory overload (TACO) in a patient with chronic cardiac failure following 600 mL of unpooled granulocytes, other fluids and one GASP. New leucocyte alloimmunisation occurred in 3/30 recipients 10%. No other significant reactions were reported. Median peripheral blood neutrophil increments at 1 h post transfusion were 0.06 (IQR, 0.01-0.17) in children and (0.03) (IQR, 0-0.16) in adults.

CONCLUSION

GASP has a similar safety profile to other sources of granulocytes for patients with refractory infection or in need of secondary prophylactic transfusion. Further studies are required to clarify the role of GASP in the treatment of neutropenic patients.

Unrelated donor peripheral blood stem cell transplants incorporating pre-transplant in-vivo alemtuzumab are not associated with any increased risk of significant acute or chronic graft-versus-host disease

There is little information published comparing peripheral blood stem cells (PBSC) with bone marrow (BM) as the stem cell source in the long-term outcome in recipients of T-cell depleted (TCD) unrelated donor (UD) transplants. We present retrospective outcome data on 306 recipients of myeloablative, human leucocyte antigen-matched UD allografts using pre-transplant in-vivo Alemtuzumab. Transplants were performed between 2000 and 2007 for chronic myeloid leukaemia in first chronic phase and acute leukaemia in first or second complete remission; 184 patients received BM and 122 PBSC. The median age was 28·9 years (<1-58) and the median follow-up was 48 months. Overall survival at 8 years was 53%. The incidence of acute graft-versus-host disease (GvHD) was significantly higher in PBSC (65%) than BM recipients (49%; P=0·012). This represented only grade 1 GvHD with no difference in grade II-IV aGvHD (BM 23% PBSC 24%). The incidence of chronic GvHD, either overall (BM 47%, PBSC 49%) or extensive (BM 15%, PBSC 13%) was not increased with PBSC. The incidence of relapse, non-relapse mortality and survival were not significantly different. Whilst accepting the limitations of retrospective analyses, we suggest the increased risk of GvHD in recipients of PBSC in T-replete transplants is offset by in-vivo Alemtuzumab, and that either stem cell source can be used with good outcomes in this setting.

Voriconazole for secondary prophylaxis of invasive fungal infections in allogeneic stem cell transplant recipients: results of the VOSIFI study

BACKGROUND

Recurrence of prior invasive fungal infection (relapse rate of 30-50%) limits the success of stem cell transplantation. Secondary prophylaxis could reduce disease burden and improve survival.

DESIGN AND METHODS

A prospective, open-label, multicenter trial was conducted evaluating voriconazole (4 mg/kg/12 h intravenously or 200 mg/12 h orally) as secondary antifungal prophylaxis in allogeneic stem cell transplant recipients with previous proven or probable invasive fungal infection. Voriconazole was started 48 h or more after completion of conditioning chemotherapy and was planned to be continued for 100-150 days. Patients were followed for 12 months. The primary end-point of the study was the incidence of proven or probable invasive fungal infection.

RESULTS

Forty-five patients were enrolled, 41 of whom had acute leukemia. Previous invasive fungal infections were proven or probable aspergillosis (n=31), proven candidiasis (n=5) and other proven or probable infections (n=6); prior infection could not be confirmed in three patients. The median duration of voriconazole prophylaxis was 94 days. Eleven patients (24%) died within 12 months of transplantation, but only one due to systemic fungal disease. Three invasive fungal infections occurred post-transplant: two relapses (one candidemia and one fatal scedosporiosis) and one new zygomycosis in a patient with previous aspergillosis. The 1-year cumulative incidence of invasive fungal disease was 6.7±3.6%. Two patients were withdrawn from the study due to treatment-related adverse events (i.e. liver toxicity).

CONCLUSIONS

Voriconazole appears to be safe and effective for secondary prophylaxis of systemic fungal infection after allogeneic stem cell transplantation. The observed incidence of 6.7% (with one attributable death) is considerably lower than the relapse rate reported in historical controls, thus suggesting that voriconazole is a promising prophylactic agent in this population.

Factors predicting long-term survival after T-cell depleted reduced intensity allogeneic stem cell transplantation for acute myeloid leukemia

BACKGROUND

Reduced intensity conditioning regimens permit the delivery of a potentially curative graft-versus-leukemia effect in older patients with acute myeloid leukemia. Although T-cell depletion is increasingly used to reduce the risk of graft-versus-host disease its impact on the graft-versus-leukemia effect and long-term outcome post-transplant is unknown.

DESIGN AND METHODS

We have characterized pre- and post-transplant factors determining overall survival in 168 patients with acute myeloid leukemia transplanted using an alemtuzumab based reduced intensity conditioning regimen with a median duration of follow-up of 37 months.

RESULTS

The 3-year overall survival for patients transplanted in CR1 or CR2/CR3 was 50% (95% CI, 38% to 62%) and 44% (95% CI, 31% to 56%), respectively compared to 15% (95% CI, 2% to 36%) for patients with relapsed/refractory disease. Multivariate analysis demonstrated that both survival and disease relapse were influenced by status at transplant (P=0.008) and presentation cytogenetics (P=0.01). Increased exposure to cyclosporine A (CsA) in the first 21 days post-transplant was associated with an increased relapse risk (P<0.0001) and decreased overall survival (P<0.0001).

CONCLUSIONS

Disease stage, presentation karyotype and post-transplant CsA exposure are important predictors of outcome in patients undergoing a T-cell depleted reduced intensity conditioning allograft for acute myeloid leukemia. These data confirm the presence of a potent graft-versus-leukemia effect after a T-cell depleted reduced intensity conditioning allograft in acute myeloid leukemia and identify CsA exposure as a manipulable determinant of outcome in this setting.

Favorable outcomes with alemtuzumab-conditioned unrelated donor stem cell transplantation in adults with high-risk Philadelphia chromosome-negative acute lymphoblastic leukemia in first complete remission

BACKGROUND

Approximately 40% of adults with Philadelphia chromosome-negative acute lymphoblastic leukemia achieve long-term survival following unrelated donor hematopoietic stem cell transplantation in first complete remission but severe graft-versus-host disease remains a problem affecting survival. Although T-cell depletion abrogates graft-versus-host disease, the impact on disease-free survival in acute lymphoblastic leukemia is not known.

DESIGN AND METHODS

We analyzed the outcome of 48 adults (median age 26 years) with high-risk, Philadelphia-chromosome-negative acute lymphoblastic leukemia undergoing T-cell depleted unrelated donor-hematopoietic stem cell transplantation (67% 10 of 10 loci matched) in first complete remission reported to the British Society of Blood and Marrow Transplantation Registry from 1993 to 2005.

RESULTS

T-cell depletion was carried out by in vivo alemtuzumab administration. Additional, ex vivo T-cell depletion was performed in 21% of patients. Overall survival, disease-free survival and non-relapse mortality rates at 5 years were 61% (95% CI 46-75), 59% (95% CI 45-74) and 13% (95% CI 3-25), respectively. The incidences of grades II-IV and III-IV acute graft-versus-host disease were 27% (95% CI 16-44) and 10% (95% CI 4-25), respectively. The actuarial estimate of extensive chronic graft-versus-host disease at 5 years was 22% (95%CI 13-38). High-risk cytogenetics at diagnosis was associated with a lower 5-year overall survival (47% (95% CI 27-71) vs. 68% (95% CI 44-84), p=0.045).

CONCLUSIONS

T-cell depleted hematopoietic stem cell transplantation from unrelated donors can result in good overall survival and low non-relapse mortality for adults with high-risk acute lymphoblastic leukemia in first complete remission and merits prospective evaluation.

Reduced intensity conditioning allogeneic stem cell transplantation for Hodgkin's lymphoma: identification of prognostic factors predicting outcome

BACKGROUND

The role of reduced intensity conditioning allogeneic stem transplantation (RICalloSCT) in the management of patients with Hodgkin's lymphoma remains controversial.

DESIGN AND METHODS

To further define its role we have conducted a retrospective analysis of 285 patients with HL who underwent a RICalloSCT in order to identify prognostic factors that predict outcome. Eighty percent of patients had undergone a prior autologous stem cell transplantation and 25% had refractory disease at transplant.

RESULTS

Non-relapse mortality was associated with chemorefractory disease, poor performance status, age >45 and transplantation before 2002. For patients with no risk factors the 3-year non-relapse mortality rate was 12.5% compared to 46.2% for patients with 2 or more risk factors. The use of an unrelated donor had no adverse effect on the non-relapse mortality. Acute graft versus host disease (aGVHD) grades II-IV developed in 30% and chronic GVHD in 42%. The development of cGVHD was associated with a lower relapse rate. The disease progression rate at one and five years was 41% and 58.7% respectively and was associated with chemorefractory disease and extent of prior therapy. Donor lymphocyte infusions were administered to 64 patients for active disease of whom 32% showed a clinical response. Eight out of 18 patients receiving donor lymphocyte infusions alone had clinical responses. Progression-free and overall survival were both associated with performance status and disease status at transplant. Patients with neither risk factor had a 3-year PFS and overall survival of 42% and 56% respectively compared to 8% and 25% for patients with one or more risk factors. Relapse within six months of a prior autologous transplant was associated with a higher relapse rate and a lower progression-free.

CONCLUSIONS

This analysis identifies important clinical parameters that may be useful in predicting the outcome of RICaIICalloSCT in Hodgkin's lymphoma.

Successful treatment of refractory joint contractures caused by sclerodermatous graft versus host disease

Sclerodermatous or cutaneous chronic graft versus host disease is characterised by deposition of collagen in the skin and possibly other soft tissues, resulting in loss of range of motion and functional capabilities. A patient with refractory joint contractures caused by sclerodermatous graft versus host disease is presented, and the successful surgical management of the case described.

Use of autologous bone marrow cells following high-dose chemotherapy (HDCT) for patients (pts) with recurrent lymphoma in whom stem cell harvesting from the peripheral blood was inadequate

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Background: HDCT with autologous stem cell rescue (ASCR) is an established treatment for recurrent Hodgkin and non- Hodgkin lymphoma (HL, NHL) but some of these pts fail to mobilise adequate numbers of CD34+ cells from the peripheral blood (PB). Harvest of bone marrow (BM) stem cells and use of these alone or in combination with PB derived cells is an option but there are concerns about feasibility and outcome. Methods: 29 pts who had HDCT after failed PB stem cell harvest between July 1999 and December 2005 were studied in terms of CD34+ cell yield (PB and BM), transfusion dependence, engraftment and survival. Results: There were 17 males and 12 females (median age 49yrs, range 19–66) with recurrent HL (n=16) or NHL (n=13). All had received at least 2 lines of chemotherapy (10 pts =3) and 7 had received radiotherapy (5 mediastinal, one neck and one abdominal field). Mobilisation of CD34+ cells from PB was attempted using chemotherapy followed by filgrastim. 22 pts proceeded to leukapheresis on the basis of predictive CD34+ counts (median collects 2; range 0–4) with a median total collect of 0.98×106 CD34+cells/kg (range 0.03–1.84). Subsequently, all pts had a BM harvest producing a median collect of 1.63x106 CD34+cells/kg (range 0.45–4.75). 29 pts then received BEAM/CBV followed by re-infusion of PB+BM cells except in 7 pts where only BM cells were available. In 26/29 pts surviving to day 100; total CD34+ cells infused, 2.37×106/kg (range 1.73- 5.0), time to neutrophils >0.5×109/L, 12 days (range 9–23), platelet units transfused, 6 (range 0–24), red cells units transfused 6 (range 0–18) (all medians). 2 pts continued to have red cell transfusions beyond day 100. 3/29 pts died due to severe neutropenia/septicaemia at days 23–25 (treatment related mortality 10.3%); the CD34+ dose received by these pts was 1.97×106/kg in 2 and 1.84×106/kg in 1. Beyond day 100, 9 pts have died from HL/NHL and 2 are lost to follow-up. Conclusions: In patients with HL/NHL who fail to mobilise adequate numbers of CD34+ cells from PB, a BM harvest can produce a combined BM/PB collect capable of producing haemopoeitic reconstitution following HDCT without excessive toxicity.

No significant financial relationships to disclose.

Rotavirus as a significant cause of prolonged diarrhoeal illness and morbidity following allogeneic bone marrow transplantation

Infective diarrhoea is common among allogeneic stem cell transplant (SCT) recipients, frequently caused by viruses and may be difficult to differentiate from acute graft-versus-host disease (GVHD). Viral pathogens may directly or indirectly impact upon transplant-related mortality. Rotavirus is one of the most common causes of diarrhoea worldwide, but one of the least studied causes of diarrhoea post SCT. In this retrospective study we describe 21 cases of confirmed rotavirus infection in allogeneic SCT recipients. Most of these cases may occur in clusters during the winter and spring period. Symptoms of rotaviral infection were diarrhoea (95%), vomiting (62%), abdominal pain (38%), weight loss and loss of appetite in 38 and 29% of the cases, respectively. Possible extraintestinal manifestations of rotavirus infection were observed. The duration of the symptoms in this series ranged from 4 days to 4 months with median of 15 days. Patients with rotavirus infection were invariably lymphopenic and/or on immunosuppression for GVHD. Of the patients diagnosed with rotavirus, 86% required hospitalisation. In 57% of the cases, other viral pathogens were isolated near to the rotavirus infection period. Rotavirus infection is an important cause of prolonged diarrhoea post SCT, causing significant morbidity and frequently requiring hospitalisation.

Induction of fetal hemoglobin by propionic and butyric acid derivatives: correlations between chemical structure and potency of Hb F induction

Short-chain fatty acids (C2-C9) induce fetal hemoglobin synthesis in primary cell cultures, primates, and patients. We carried out experiments to test whether relationships exist between chemical structure and the Hb F-inducing potential of several short-chain fatty acid derivatives. BFUe cultures were performed in the presence of propionic and butyric congeners, covering the full spectrum of substitutions of these molecules, including polar and non-polar groups, esters, and double bonds. We found that the fetal hemoglobin inducibility is related to the chemical structure of the inducing compound. This structure-activity relation depends on the length of carbon chain, the nature of the substitutions, and the position of more potent substitutions on the carbon chain. It appears that substitutions enhancing the inducibility of these compounds are (with decreasing potency): methyl > phenyl > hydroxy >> amino groups. Placement of these substitutions at a position distal to the carboxyl group enhances gamma-globin inducibility. Presence of the carboxyl group is prerequisite for gamma-globin inducibility.

A decision support software package for medical treatment of I.C.U. patients

Critically ill patients admitted in I.C.U. often have multiple complicated problems which necessitate the use of a large number of drugs. The multiple potential interactions between substances and underlying pathologies as well as between substances themselves, obviate the need for a decision support system. We therefore developed a software package for medical treatment support in I.C.U. environment which is based on Microsoft Visual Basic 3.0 and it is organised around the commercially available RDBMS Access 2.0. The database consist of: a) all available substances, b) all generic names of medications available in Greece for each substance, c) incompatibilities (2,300 cases), d) interactions (50,000 cases) and e) cost information for each drug. This system assures the safety of the administered treatment, helps to adjust the dose according to the situation of each patient (anthropometric data, laboratory result, prognostic/severity score e.t.c.) and screens for possible interactions and incompatibilities between the administered drugs. It could also be used for education, treatment algorithms application and it will serve cost-reduction policy. It is a useful and powerful tool for ICU staff which does not impose additional work to the daily practice routine and it is currently under evaluation in clinical settings.

Stimulation of fetal hemoglobin production by short chain fatty acids

Butyrate, a four-carbon fatty acid, and its two-carbon metabolic product, acetate, are inducers of gamma-globin synthesis. To test whether other short-chain fatty acids share this property, we first examined whether propionic acid, a three-carbon fatty acid that is not catabolized to acetate, induces gamma-globin expression. Sodium propionate increased the frequency of fetal hemoglobin containing erythroblasts and the gamma/gamma + beta mRNA ratios in adult erythroid cell cultures and F reticulocyte production in a nonanemic juvenile baboon. Short-chain fatty acids containing five (pentanoic), six (hexanoic), seven (heptanoic), eight (octanoic), and nine (nonanoic) carbons induced gamma-globin expression (as measured by increase in gamma-positive erythroblasts and gamma/gamma + beta mRNA ratios) in adult erythroid burst-forming unit cultures. There was a clear-cut relationship between the concentration of fatty acids in culture and the degree of induction of gamma-globin expression. Three-, four-, and five-carbon fatty acids were better inducers of gamma globin in culture as compared with six- to nine-carbon fatty acids. These results suggest that all short-chain fatty acids share the property of gamma-globin gene inducibility. The fact that valproic acid, a derivative of pentanoic acid, also induces gamma-globin expression suggests that short-chain fatty acid derivatives that are already approved for human use may possess the property of gamma-globin inducibility and may be of therapeutic relevance to the beta-chain hemoglobinopathies.

Fetal hemoglobin induction by acetate, a product of butyrate catabolism

Butyrate induces fetal hemoglobin (HbF) synthesis in cultures of erythroid progenitors, in primates, and in man. The mechanism by which this compound stimulates gamma-globin synthesis is unknown. In the course of butyrate catabolism, beta oxidation by mitochondrial enzymes results in the formation of two acetate molecules from each molecule of butyrate. Studies were performed to determine whether acetate itself induces HbF synthesis. In erythroid burst-forming unit (BFU-E) cultures from normal persons, and individuals with sickle cell disease and umbilical-cord blood, dose-dependent increases in gamma-globin protein and gamma mRNA were consistently observed in response to increasing acetate concentrations. In BFU-E cultures from normal adults and patients with sickle cell disease, the ratio of gamma/gamma + beta mRNA increased twofold to fivefold in response to acetate, whereas the percentage of BFU-E progeny staining with an anti-gamma monoclonal antibody (MoAb) increased approximately twofold. Acetate-induced increases in gamma-gene expression were also noted in the progeny of umbilical cord blood BFU-E, although the magnitude of change in response to acetate was less because of a higher baseline of gamma-chain production. The effect of acetate on HbF induction in vivo was evaluated using transgenic mouse and primate models. A transgenic mouse bearing a 2.5-kb mu locus control region (mu LCR) cassette linked to a 3.3-kb A gamma gene displayed a near twofold increase in gamma mRNA during a 10-day infusion of sodium acetate at a dose of 1.5 g/kg/d. Sodium acetate administration in baboons, in doses ranging from 1.5 to 6 g/kg/d by continuous intravenous infusion, also resulted in the stimulation of gamma-globin synthesis, with the percentage of HbF-containing reticulocytes (F reticulocytes) approaching 30%. Surprisingly, a dose-response effect of acetate on HbF induction was not observed in the baboons, and HbF induction was not sustained with prolonged acetate administration. These results suggest that both two-carbon fatty acids (acetate) and four-carbon fatty acids (butyrate) stimulate synthesis of HbF in vivo.