Allogeneic Hematopoietic Stem Cell Transplantation in Severe Aplastic Anemia: A Single Centre Experience in Malaysia

Background

Hematopoietic stem cell transplantation (HSCT) provides curative therapy in almost 90% of patients with severe aplastic anemia (SAA). Older age, long duration of disease with consequent heavy exposure to transfusion, and active infection at the time of HSCT have a negative influence on the outcomes, causing graft failure (GF) and graft versus host disease (GVHD).

Purpose

To describe the outcomes of all patients with SAA who received hematopoietic stem cell transplantation at a tertiary center in Malaysia.

Materials and methods

We included a 20 y cohort of patients who underwent transplantation from January 1, 1999 to December 31, 2019. Data were obtained from electronic medical records. Demographics, clinical characteristics, and treatment outcomes were analyzed using descriptive statistics. Overall survival (OS) was analyzed using Kaplan-Meier curves. All analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 25.

Results

Eighty patients were analyzed. The median age at diagnosis was 19 years, and 59% patients were male (n = 47). Malay ethnicity was the highest (52.5%), followed by Chinese (20.0%) and Native Sabah (15.0%). The median duration from diagnosis to transplantation was 13.5 weeks. A majority of patients received Cy-ATG conditioning (n = 51, 63.8%). Forty-one patients (51.2%) used peripheral blood as stem cell source, 36 patients (45.0%) used granulocyte colony stimulating factor (G-CSF) primed marrow graft and 3 patients (3.8%) used both. The mean nucleated mononuclear cell and CD34 cell doses were 4.7 ± 1.7 × 10⁸/kg and 4.6 ± 1.9 × 10⁶/kg, respectively. Median engraftment for WBCs and platelets was 14 and 15 days, respectively. There was no difference in WBC and platelet engraftment in patients who received peripheral blood stem cell transplantation or bone marrow transplant. At a median follow-up of 54 months, 49 patients (61.3%) achieved complete remission and 8 patients (10.0%) achieved partial remission. The estimated 5 y OS was 63% and higher among those who received HSCT within 3 months of diagnosis. Twenty-two patients (27.5%) died within 100 d of transplantation, and a majority of these died due to pre-engraftment death.

Discussion and conclusions

Our study found that patients who received early allogeneic transplantation for SAA had better outcomes. Pre-engraftment failure was the major cause of transplant-related mortality within 100 d. Further studies are required to identify the factors responsible for delaying transplantation to improve treatment outcomes.

Occult Disseminated Metastatic Breast Carcinoma Presenting as Acquired Thrombotic Thrombocytopenic Purpura

Cancer-related microangiopathic hemolytic anemia (MAHA) is a rare and life-threatening condition. We present a patient who had been treated for invasive lobular breast carcinoma in clinical remission with fever and hemolytic anemia. The peripheral blood film showed MAHA and thrombocytopenia, and a functional deficiency of ADAMTS13 activity of 23% consistent with acquired thrombotic thrombocytopenic purpura. Bone marrow aspirate and trephine biopsy confirmed metastatic carcinoma. Further evaluation revealed the involvement of multiple bone sites without recurrence of the primary tumor. The patient received a daily plasma exchange with cryosupernatant and was pulsed with corticosteroids. MAHA related to breast cancer appears to be a rare occurrence.

Autologous stem cell transplantation (ASCT) outcome for multiple myeloma in a tertiary referral centre in Malaysia

Background

Multiple Myeloma (MM) is characterized by the presence of clonal plasma cells. These often result in complications including bone destruction, hypercalcemia, renal insufficiency, and anaemia. Induction with a triplet or quadruplet regimen followed by autologous stem cell transplantation (ASCT) has been the standard of care for transplant eligible patients to achieve durable remission.

Purpose

This is a retrospective analytical study to determine the outcome of Multiple Myeloma patients who underwent ASCT in Ampang Hospital.

Materials and Methods

We included a 5-year cohort of patients transplanted from 1st July 2014 to 30th June 2019. Data were obtained through electronic medical records. Prognostic factors for progression-free survival (PFS) and overall survival (OS) were analyzed using simple and multiple Cox proportional hazard regression analysis. All analyses were done using software R version 3.6.2 with validated statistical packages.

Results

139 patients were analyzed. The median age at transplant was 56 years old and 56.1% are males (n＝78). The most common subtype is IgG Kappa (n＝67, 48.2%). Only 93 patients in which the International Staging System (ISS) could be determined, and among them, 33.3% of patients (n＝31) have advanced stage Ⅲ disease. The most common induction received before ASCT was a bortezomib based regimen and/or an immunomodulatory (IMiD) based regimen. 63.3% of patients achieved at least a very good partial response (VGPR) before ASCT. Most patients received myeloablative conditioning (MAC) (n＝119, 85.6%). The mean cell dose is 3.68×10⁶/kg. The median time to engraftment was 11 days for both platelet and absolute neutrophil count (ANC). With the median follow-up of 17.3 (range, 6.2-33.4) months, the median OS and PFS were not reached. The 1-year and 2-year PFS were 75% (95% CI 66-82%) and 52% (95% CI 42-62%), respectively. The 1-year and 2-year OS were 82% (95% CI 74-88%) and 70% (95% CI 60-78%), respectively. 6 patients (4.3%) had transplant-related mortality (TRM). IgA subtype was found to adversely affect PFS. Maintenance therapy and the absence of renal impairment was associated with better PFS and OS.

Discussion and Conclusions

Our study found that ASCT following induction treatment is safe and beneficial to achieve a deeper remission status. In our study, the addition of maintenance therapy is associated with an improved outcome in PFS and OS.

87 Epidemiology Study of Elderly Patients with Acute Myeloid Leukaemia at a Haematological Tertiary Referral Centre

Introduction

Acute Myeloid Leukemia (AML) is a rare disease with a high incidence in the elderly. Our aim is to report the incidence of elderly patients with AML at a haematological tertiary referral centre.

Method

We have collected data from 2007 till 2017 from the main Malaysian haematological tertiary referral centre involving all the 1225 AML patients. Out of those, 182 elderly patients aged 65 and above with AML were examined. The patients had at least 2 years follow-up.

Results

The elderly represented 14.9% of the 1225 patients who presented with acute myeloid leukemia to the centre. There were 182 elderly patients with AML which were subdivided to the unspecified AML of 154 patients, 1 patient with M1, 4 patients with M2, 6 patients with M3, 5 patients with M4, 8 patients with M5, 2 patients with M6 and 2 patients with M7. There were 109 males and 73 females. The majority of the patients were Chinese (n=85) representing 46.7% of the patients, followed by the Malay (n=76), Indian (n=19) and lastly others (n=2). The average age at diagnosis was 71 years. There were 136 deaths and the mortality rate was 74.7%. The average age of the patients who had passed away (n=136) was 71.4 years. The average age of the patients who are still living (n=42) was 76.5 years.

Conclusion

The incidence of elderly AML is increasing. The younger patients with AML are known to have better survival rate in comparison to the elderly. More research is needed to explore the reasons for the higher mortality in the elderly and the ways to improve the outcome of this elderly population as our lifespan increases and Malaysia heads towards an ageing nation.

Advances in hematopoietic stem cell transplantation in the Asia-Pacific region: the second report from APBMT 2005-2015

Between 2005 and 2015, 138,165 hematopoietic stem cell transplantation (HSCT) were reported in 18 countries/regions in the Asia-Pacific region. In this report, we describe current trends in HSCT throughout the Asia-Pacific region and differences among nations in this region and various global registries. Since 2008, more than 10,000 HSCTs have been recorded each year by the Asia-Pacific Blood and Marrow Transplantation Group Data Center. Between 2005 and 2015, the greatest increase in the number of HSCTs was observed in Vietnam. Allogeneic HSCT was performed more frequently than autologous HSCT, and a majority of cases involved related donors. Regarding allogeneic HSCT, the use of cord blood has remained steady, especially in Japan, and the number of cases involving related HLA non-identical donors has increased rapidly, particularly in China. The incidence of hemoglobinopathy, a main indication for allogeneic HSCT in India, China, Iran, and Pakistan, increased nearly six-fold over the last decade. Among the 18 participating countries/regions, the transplant rate per population varied widely according to the absolute number of HSCTs and the national/regional population size. We believe that this report will not only benefit the AP region but will also provide information about HSCT to other regions worldwide.

Vaccine-induced immune thrombocytopaenia purpura in autologous haematopoietic stem cell transplantation

Immune Thrombocytopenia Purpura (ITP) secondary to vaccinations is rare, especially after autologous hematopoietic stem cell transplantation (HSCT). A 31-yearold female received autologous HSCT for relapsed Hodgkin Disease, with platelet engraftment at Day+14. One week after receiving second scheduled vaccinations, she developed severe thrombocytopenia (3x10⁹/L) associated with pharyngeal hematoma. Bone marrow (BM) examinations were consistent with ITP, possibly secondary to Influenza vaccine. Platelet increment was poor despite high dose corticosteroids, intravenous immunoglobulin (IVIG), Danazol and Eltrombopag. A repeated BM biopsy was in agreement with ITP. Re-treatment with tapering doses of prednisolone resulted in stable platelet counts at 120x10⁹/L a year later.

Nilotinib dose-optimization in newly diagnosed chronic myeloid leukaemia in chronic phase: final results from ENESTxtnd

The Evaluating Nilotinib Efficacy and Safety in Clinical Trials-Extending Molecular Responses (ENESTxtnd) study was conducted to evaluate the kinetics of molecular response to nilotinib in patients with newly diagnosed chronic myeloid leukaemia in chronic phase and the impact of novel dose-optimization strategies on patient outcomes. The ENESTxtnd protocol allowed nilotinib dose escalation (from 300 to 400 mg twice daily) in the case of suboptimal response or treatment failure as well as dose re-escalation for patients with nilotinib dose reductions due to adverse events. Among 421 patients enrolled in ENESTxtnd, 70·8% (95% confidence interval, 66·2-75·1%) achieved major molecular response (BCR-ABL1 ≤ 0·1% on the International Scale) by 12 months (primary endpoint). By 24 months, 81·0% of patients achieved major molecular response, including 63·6% (56 of 88) of those with dose escalations for lack of efficacy and 74·3% (55 of 74) of those with dose reductions due to adverse events (including 43 of 54 patients with successful re-escalation). The safety profile of nilotinib was consistent with prior studies. The most common non-haematological adverse events were headache, rash, and nausea; cardiovascular events were reported in 4·5% of patients (grade 3/4, 3·1%). The study was registered at clinicaltrials.gov (NCT01254188).

Fludarabine, High Dose Cytarabine and Granulocyte Colony-Stimulating Factor (FLAG) as Consolidation Chemotherapy in Older Patients with Acute Myeloid Leukemia: A Retrospective Cohort Study

The study aimed to investigate the effect of consolidation treatment with fludarabine, high-dose cytarabine and granulocyte colony-stimulating factor or FLAG in older AML patients. The study included 41 eligible patients above 54 years old, who received both induction and consolidation chemotherapy for AML from 2008 to 2013. The study cohort had a minimum 24 months follow-up period. Survival analysis was carried out to assess patients' overall survival and disease free survival based on types of consolidation regimens. The consolidation treatment with FLAG exerted a protective effect to both overall survival and disease free survival in older patients. Patients who were consolidated with FLAG regimen had a significant longer overall survival (log-rank, p = 0.0025) and disease free survival (log-rank, p = 0.0026). The median overall survival was longer (18.70 months) with the use of FLAG when compared to non-FLAG group (8.09 months). The median disease free survival was also longer (13.84 months) with use of FLAG when compared to the non-FLAG group (4.44 months). Regression analysis with Cox model yielded hazard ratio of 0.245 (p = 0.0094) in overall survival and 0.217 (p = 0.0068) in disease free survival. The use of FLAG as consolidation treatment was associated with approximately 60-80% reduction in hazard rates. The result was adjusted for age, race and gender in regression analysis. Older AML patients had longer remission and survival when consolidated with FLAG regimen after the induction chemotherapy.

Formation of Organic Molecular Nanocrystals under Rigid Confinement with Analysis by Solid State NMR

Crystallization in rigid confinement is a promising method to obtain organic molecular nanocrystals. However, the crystallization behavior and the related characterization methods are not well studied. Here we present a systematic study of the nucleation of organic molecular nanocrystals in rigid pores. Four different compounds were studied, ibuprofen, fenofibrate, griseofulvin, and indomethacin, which range from simple to complex molecules. Solid-state Nuclear Magnetic Resonance (NMR) was employed to analyse the structure of these compounds inside pores which are difficult to characterize by other analytical methods. We successfully demonstrated the production of nano-crystalline ibuprofen, fenofibrate and griseofulvin in porous silica particles with ~ 40 nm pores. These nanocrystals showed significant enhancement in dissolution rates. These results help advance the fundamental understanding of nucleation under rigid confinement and may lead to potential applications in developing new formulations in the pharmaceutical industry.

The Outcome of HyperCVAD Combined with Alemtuzumab for the Treatment of Aggressive T-Cell and NK-Cell Neoplasms

We report our experience in using six cycles of hyperCVAD in combination with alemtuzumab for the treatment of aggressive T-cell and NK/T-cell neoplasms. Seven females and six males with the median age of 41 (range 18-60) diagnosed with T-cell acute lymphoblastic lymphoma and peripheral T-cell and NK/T-cell neoplasms (n(PTCL) = 6, n(T-cell ALL) = 3, n(NK/T-cell neoplasms) = 4) from 2006 to 2008 were treated with alemtuzumab-hyperCVAD regimen. A total of nine patients (69%) responded to the regimen, with seven achieved complete remission and two achieved partial remission. The median progression free survival and overall survival duration among the responders with complete remission were 12.9 and 24.9 months respectively. The incidence of relapse among the responders was 44% and the overall survival rate was 23%. Only four (31%) patients completed the six cycles of alemtuzumab-hyperCVAD. Others were stopped earlier due to progressive disease (n = 2), cytomegalovirus (CMV) reactivation and/or disease (n = 3), death not due to disease (n = 2), and patient's refusal to continue alemtuzumab (n = 2). The incidence of death not due to disease, CMV reactivation and recurrent CMV reactivation were 50, 50 and 17%, respectively. This study shows that alemtuzumab in combination with hyperCVAD regimen is a feasible regimen but with high toxicity. The toxicity might be reduced with the incorporation of filgrastim and use of valganciclovir as CMV prophylaxis.

Collembola are unlikely to cause human dermatitis

Abstract There have been several unconfirmed case reports of dermatitis caused by Collembola (springtails). We recently investigated two nurses with dermatitis suspected to be caused by Drepanura Schött (Collembola: Entomobryidae). IgE antibodies to Collembola proteins were not detected in sera from the nurses and skin tests with the Collembola extract and crushed whole Collembola were negative in both the nurses and volunteers. This study suggests that the springtail Drepanura may not cause human dermatitis and that other organisms and organic matter that are also found in the moist environment inhabited by Collembola might instead be responsible.

National Cancer Patient Registry--Haematology Malignancy (NCPR-HM)

Treatment option of Haematological malignancies has expanded over the last decade. The outcome of treatment is expected to be better compare to previously. However, study of treatment outcome for haematological malignancies has not been carried out in Malaysia. The goal of this study is to measure the treatment outcome in patients with haematological malignancy.

Legal issues in the treatment of a violent manic patient in a non-gazetted setting: a case report

INTRODUCTION

Psychiatrists in non-gazetted treatment settings, like psychiatric wards in restructured general hospitals and private hospitals, face a major problem when psychiatric patients who require admission are either not competent or refuse to consent to admission and treatment, although they are clearly in need of such inpatient management. Admission to the state mental hospital is often refused by their relatives for a number of reasons, like the stigma attached to admission to such a hospital, and the fear that future employment prospects might be affected.

CLINICAL PICTURE

Mr X, a manic, violent patient, had no insight into his disorder and refused admission and treatment for his manic episode. He was the head of a large corporation, and his relatives were apprehensive he would make decisions that could jeopardize the company.

TREATMENT

He refused oral medication, could not tolerate parenteral haloperidol and had lithium nephrotoxicity. Inpatient electroconvulsive therapy had to be administered, after which he responded satisfactorily.

CONCLUSION

The legal implications in this case, like consent for treatment and admission, and ethical issues, are discussed.

A comparative study of the aerobic fitness of 421 healthy adult males in Singapore

The maximum oxygen consumption (VO2 max) of 421 healthy adult males from three ethnic groups (Chinese, Malay and Indian), aged 25-54 years, was assessed from direct analyses of their expired respiratory gases during all-out runs on a treadmill as a measure of aerobic fitness. The subjects were divided into three age groups: group 1, 25-34 years; group 2, 35-44 years; group 3, 45-54 years. Each group was further subdivided into non-exercisers (NE), non-regular exercisers (NRE) and regular exercisers (RE). Consistently within each age group, regular exercisers produced significantly higher VO2 max values compared to non-regular exercisers and non-exercisers. They also met the VO2 max requirements for heavy physical work and compared favourably with the standards of the National Physical Fitness Award of Singapore and Cooper's aerobic fitness classification standards based on North American males. Non-regular exercisers and non-exercisers only met the VO2 max requirements for moderate physical work and compared poorly in both of the aerobic fitness standards.

A comparative study of the maximum oxygen uptake of regularly exercising and non-exercising health adult men in sedentary occupations

This study aims to assess and compare the aerobic fitness (max VO2) of 210 healthy adult men in sedentary occupations in Singapore. All the subjects studied were in codes 0 to 2 of the Singapore Standard Occupational Classification, comprising professional, technical, administrative and related workers. Their max VO2 were determined from direct analyses of their expired respiratory gases during an all-out run on a treadmill. Of these 210 men, 71 (33.8 per cent) were recreation-related regular exercisers and their mean max VO2 of 40.9 ml/kg per min STPD (at standard temperature and pressure, dry) and 95 per cent confidence interval of 39.2-42.6 ml/kg per min was significantly higher (p less than 0.001) than that of the remaining 139 men (34.3 ml/kg per min STPD) with 95 per cent confidence intervals of 33.2-35.4 ml/kg per min who were not regular exercisers. The regular exercisers also met the max VO2 requirements for heavy physical work capacity and compared favourably with the recommended standards for aerobic fitness in the National Physical Fitness Award of Singapore as well as Cooper's Standards based on North American men while the non-regular exercisers did not. The study has shown that the recreation-related regular exercise of the study-defined type, intensity, duration and frequency can significantly improve the physical work capacity of healthy adult men in sedentary occupations in Singapore.

Distribution of microspheres in plantaris muscles of resting and exercising rats as a function of fiber type

The purpose of this study was to determine histologically the distribution of microspheres (MSs) (14 micron), and hence the relative distribution of blood flow, in rat plantaris muscle relative to the fiber types (fast-twitch-oxidative-glycolytic [FOG], fast-twitch-glycolytic [FG], and slow-twitch-oxidative [SO]). Three conditions were investigated: 1) preexercise standing; 2) treadmill locomotion at 15 m/min (fast walking); and 3) treadmill locomotion at 60 m/min (moderate galloping). The MS suspension (containing 1 x 10(6) MSs) was infused into the ascending aorta via a catheter in the carotid artery under each of the 3 conditions so that MSs were distributed to the tissues in proportion to their respective blood flows. Sections (20 micron) of the plantaris muscle were cut and assayed for reduced nicotinamide adenine dinucleotide tetrazolium reductase (NADH-TR) and myofibrillar adenosine triphosphatase (ATPase) activities so the fibers could be typed as SO, FOG, or FG. MSs were located in the NADH-TR sections, and the fibers next to the MSs were classified and counted. The observed numbers of fibers of each type in each condition that were adjacent to MSs were compared to the predicted number of adjacent fibers based on the assumption the MSs were randomly distributed in the tissue. This analysis demonstrated that MSs (and blood flows) were preferentially distributed to SO fibers during preexercise, to SO and FOG fibers during slow locomotion, and to FOG fibers during fast locomotion. The data support the contention that blood flow is distributed in muscles of conscious animals as functions of fiber type and exercise intensity.

Prevalence of respiratory illnesses of school children in the industrial, urban and rural areas of Singapore

An epidemiological survey of 3216 primary school children living in the industrial, urban and rural areas of Singapore revealed a high prevalence of various respiratory symptoms and illnesses, with 13.1% cough, 8.2% wheezy chest, 25.9% blocked/running nose, 4.3% sinusitis, 7.8% asthmatic attacks and 4.1% bronchitis/pneumonia. Differences in the prevalence of respiratory illnesses and lung function tests were observed among children in the three areas, but this could not be accounted for by the varying air pollution levels which have been maintained below the long-term standards set up by WHO. It was probably responsible for the differences noted.

Activation of prothrombin as measured by the conversion of Nalpha-benzoylarginine ethyl ester

The activation of prothrombin has been studied by using highly purified preparations of activated factor X1 and activated factor X2, factor V and prothrombin. The rate of prothrombin activation was followed using an esterase assay involving the conversion of N alpha-benzoylarginine ethyl ester (BAEE) by thrombin generated in the course of prothrombin activation. The rate of thrombin generation increased by about 26000-fold when factor V and phospholipid were added to prothrombin, factor Xa and calcium. A comparison of the rates of thrombin formation obtained with activated factor X1 and activated factor X2 showed that activated factor X1 had only 70% of the biological activity of activated factor X2. Attempts to explain the rate of prothrombin activation and the difference between the activity of activated factor X1 and activated factor X2 are discussed.

Preparation of bovine blood coagulation factors X1 and X2

A method is described for the preparation of both Factor X1 and Factor X2 from citrated bovine blood. The proteins from the plasma were first adsorbed on barium citrate by adding barium chloride solution. The precipitate formed was stirred with citrate/NaOH pH 6.9 buffer; barium and other clotting factors were removed by adding ammonium sulphate (up to 30% saturation) to the suspension. The Factor X was then precipitated by 65% ammonium sulphate, after resolution in citrate buffer chromatographed on DEAE-Sephadex and purified by rechromatography on DEAE-Sephadex and DEAE-Sepharose, respectively. This yielded Factor X1 and Factor X2 with respective purifications of about 16 000 and 24 000-fold that of the plasma. The apparent molecular mass of both Factor X1 and Factor X2 was 55 kDa as estimated by the sodium dodecyl sulphate-polyacrylamide gel electrophoresis. Factor X2 had a higher specific biological activity of about 340 000 units/mg compared to that of Factor X1 of about 230 000 units/mg.

Some possible benefits and dangers of non-aerobic exercise in cardiac rehabilitation programmes

This paper reviews several recent studies on the possible benefits and dangers of non-aerobic exercises in cardiac rehabilitation programmes. It presents the case for including in such programmes, exercises which specifically improve components of overall physical fitness other than aerobic or cardiorespiratory endurance fitness. This is because many of these other components of overall physical fitness are required in the daily lives of patients in cardiac rehabilitation programmes and can best be acquired through non-aerobic exercises. These non-aerobic exercises include judicious callisthenic and isometric exercises to specifically improve on joint flexibility, agility, muscular strength, muscular endurance and coordination.

Y-autosome translocation, gonadal dysgenesis, and gonadoblastoma

A 5-year-old girl was discovered to have an abnormal karyotype with a translocation involving the Y chromosome. The primary complaint was slight physical growth retardation. Cytogenetic and endocrinologic evaluations were performed. The chromosomal complement exhibited a mosaicism: 45,X,t(Y;18)(q11;p11)/45,X0. The gonads of this patient were typical streaks containing no ova or follicles. A gonadoblastoma was present bilaterally.