Umbilical cord blood graft engineering: challenges and opportunities

We are entering a very exciting era in umbilical cord blood transplantation (UCBT), where many of the associated formidable challenges may become treatable by ex vivo graft manipulation and/or adoptive immunotherapy utilizing specific cellular products. We envisage the use of double UCBT rather than single UCBT for most patients; this allows for greater ability to treat larger patients as well as to manipulate the graft. Ex vivo expansion and/or fucosylation of one cord will achieve more rapid engraftment, minimize the period of neutropenia and also give certainty that the other cord will provide long-term engraftment/immune reconstitution. The non-expanded (and future dominant) cord could be chosen for characteristics such as better HLA matching to minimize GvHD, or larger cell counts to enable part of the unit to be utilized for the development of specific cellular therapies such as the production of virus-specific T-cells or chimeric-antigen receptor T-cells which are reviewed in this study.

Adenoviral infections in adult allogeneic hematopoietic SCT recipients: a single center experience

Disseminated adenoviral infection (AI) is associated with profound immunosuppression and poor outcome after allogeneic hematopoietic SCT (allo-HSCT). A better understanding of AI in allo-HSCT recipients can serve as a basis to develop more effective management strategies. We evaluated all adult patients who received allo-HSCT at MD Anderson Cancer Center between 1999 and 2008. Among the 2879 allo-HSCT patients, 73 (2.5%) were diagnosed with AI. Enteritis (26%) and pneumonia (24%) were the most common clinical manifestations; pneumonia was the most common cause of adenovirus-associated death. A multivariable Bayesian logistic regression showed that when the joint effects of all covariates were accounted for, cord blood transplant, absolute lymphocyte count (ALC) ≤ 200/mm(3) and male gender were associated with a higher probability of disseminated AI. The OS was significantly worse for patients with AI that was disseminated rather than localized (median of 5 months vs median of 28 months, P<0.001) and for patients with ALC ≤ 200/mm(3) (P<0.001). Disseminated AI, in patients who received allo-HSCT, is a significant cause of morbidity and mortality. Strategies for early diagnosis and intervention are essential, especially for high-risk patients.

Age at diagnosis does not adversely affect outcome in patients with Hodgkin's Disease (HD) after autologous transplantation

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Background: Age at diagnosis is a poor prognostic factor for overall survival after standard therapy for HD. Whether older age is a prognostic factor for outcome after autologous transplantation is not known. We sought to evaluate the effect of older age at diagnosis on transplant outcome. Patients and Methods: All patients with HD undergoing autologous transplantation with BEAM conditioning (BCNU, Etoposide, Cytarabine, and Melphalan) between January 1996 and December 2007 were included in this study. During these 12 years, 248 patients (103 males) underwent autologous transplantation. Seventy two patients (29%) were older than 40 years of age at the time of initial diagnosis. Median age at transplantation was 31 years (range 11–74). At transplantation, 63 (25%) were in complete remission (CR); 148 (60%) were in partial remission (PR); and 37 (15%) had stable (SD) or progressive disease (PD). Forty-six patients (19%) had received more than 3 courses of chemotherapy prior to transplantation. LDH was elevated in 131 (53%). Peripheral blood stem cells were used as stem cell source in 241 (97%) patients. Results: With a median follow up of 48 months (range, 1–143 months), the 48-month overall (OS) and event-free survival (EFS) were 72% (95% CI; 65%-77%) and 57% (95% CI; 50%-63%), respectively. The cumulative incidence of non-relapse mortality at 1 year was 1.6%. The cumulative incidence of secondary MDS or AML was 8%. In univariate analysis, disease status (p<0.001) and number of prior chemotherapy regimens (p=0.007) were the only factors significantly predicting OS. Disease status was the only factor significant (p<0.01) in a multivariate analysis with a hazard ratio of 2.7 (1.1–6.9) and 9.2 (3.4–25) for patients in PR, and SD/PD respectively (CR reference group). Age at diagnosis was not a significant factor (see table ). Conclusions: High-dose chemotherapy and autologous transplantation abrogate the adverse impact of age at diagnosis in patients with HD.

[Table: see text]

No significant financial relationships to disclose.

Long-term survival of patients with AML in remission after reduced intensity allogeneic hematopoietic stem cell transplantation (RISCT)

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Background: RISCT was developed to harness graft versus leukemia effect to treat older patients (pts) and pts with comorbidities. Limited data are available on long term outcome of pts with high risk AML treated in complete remission (CR), a group most likely to benefit from this approach. Methods: Thirty six consecutive pts with AML in CR, treated between 1999 and 2006 with Fludarabine 120–125 mg/m2 and Melphalan 100–140 mg/m2 are included. Pts were not eligible for myeloablative transplantation because of age or comorbidity. Tacrolimus and Methotrexate were used as GVHD prophylaxis. Additionally pts receiving stem cells from an unrelated donor received rabbit antithymocyte globulin. Results: There were 24 males and 12 females with a median age of 57 (range 21–71). Eighteen(50%) pts had secondary AML. Thirty(83%) pts were in first CR and 6(17%) in second CR. Cytogenetic risk groups were as follows: 2 good risk (in CR2), 22 intermediate risk(61%), and 10(28%) poor risk. Source of stem cells was peripheral blood in 18 pts (50%) and bone marrow in 18 pts (50%). Donors were siblings in 21(58%) pts and unrelated in 15 (42%)pts. Hematopoietic cell transplant specific comorbidity score of 3 or higher was present in 26 pts (72%). All pts engrafted achieving full donor chimerism by day 30 with median time to neutrophil engraftment of 12.5 days (8–19 days). Cumulative incidence of grade 2–4 acute graft versus host disease (GVHD), grade 3–4 GVHD and chronic GVHD was 25% (95% CI; 14%–44%), 11% (95% CI; 4%–28%), and 63% (95% CI; 47%–84%) respectively. Cumulative incidence of nonrelapse mortality was 19% (95% CI; 8%–41%). With a median follow up of 852 days, 3 year overall and disease free survival is 75% (SE 9%) and 63% (SE 10%) respectively. Comorbidity scores didnot impact outcome. Conclusions: Reduced intensity allogeneic transplantation with Fludarabine and Melphalan conditioning produces durable long term remission in pts with high risk AML in complete remission. These results in older pts and/or pts with comorbidities are comparable to published results in younger pts receiving myeloablative transplantation. Comorbidity scores by themselves should not be used to exclude patients from receiving transplant.

No significant financial relationships to disclose.

Acute Campylobacter jejuni enteritis in 385 hospitalised patients

Twenty healthy controls and 385 adult patients suffering from acute enteritis or gastroenteritis were enrolled for the study of Campylobacter Jejuni infection over a period of 2 years. Thirty five stool samples showed C jejuni on stool culture. The isolation rates were at peak in the monsoon season and from watery and bloody stool specimens. Pure C jejuni culture was obtained in 18 of 35 samples; the other 17 samples showed polymicrobial infection or infestation. Nine of 35 patients were treated with erythromycin 1 g in divided doses for 7 days. Repeat stool cultures did not grow C jejuni. There was no resistance to erythromycin therapy. C jejuni are fastidious organisms and require special medium and microaerophilic environment for culture.

Association of peptic ulcer with Helicobacter pylori and the recurrence rate. A three year follow-up study

Helicobacter pylori is associated with 70-100% of peptic ulcers. Relapse of infection has been shown to cause recurrences of ulcers in a large number of studies. We diagnosed 137 cases of peptic ulcer (121 DU; 16 GU) during a 3 year period. Of these, 117 were positive for H pylori. Sixty six of the 117 cases staying in the vicinity of the Hospital were followed up for a minimum period of 3 months upto a maximum period of 3 years. In 91 examinations there was relapse of H pylori infection and ulcer recurrence was seen in 58 (63%), whereas ulcer recurred only in 6 out of 61 examinations where H pylori had not relapsed (10%). The difference was highly significant by Chi square test. (P less than 0.001).

Relapse of Helicobacter pylori infection after different treatment regimens. A 3-month follow-up study

Helicobacter pylori infection of gastric antrum is associated with a majority of cases of peptic ulcer (70-100%). Studies have shown that when this organism is eradicated, the recurrence of ulcer falls to less than one-third of those in whom the infection persists or relapses. Monotherapy with bismuth salts, tinidazone or amoxycillin has been shown to result in early relapse and recurrence of ulcers. However, dual or triple therapy regimens are more effective. We conducted a randomised controlled study using tripotassium dicitrato bismuthate (TDB) (10 patients); amoxycillin (combined with ranitidine for ulcer healing) (9 patients) and dual therapy with both amoxycillin and TDB (10 patients). Our study showed that relapse rates at the end of 3 months was significantly less if dual therapy with TDB and amoxycillin is used as compared to TDB alone (p less than 0.05).