[Use Of Hospital Services By The Immigrant Population In Umbria, Italy]

The aim of this study was to identify possible inequalities in the quality of health care services for the management of conditions such as cardiovascolar diseases, psychiatric disorders, appendectomy, and hysterectomy, offered to the immigrant population in the Umbria region (central Italy). Hospital discharge data covering the period 2009-2012 were analysed and crude and standardized hospitalization rates per 100,000 calculated. Immigrants were found to have an increased risk of undergoing procedures such as appendectomy and hysterectomy for benign disease, indicating a greater degree of nonappropriateness in this category of users. In the young immigrant population, admissions were mainly due to reproductive health problems in women, and injuries/trauma in men. The results of this study confirm that, despite regional efforts to reduce social inequalities and consequently inequalities in health, through regional legislation, information to the population, training of healthcare personnel, and cultural mediation, some inequalities are present in the quality of health care delivered to foreign-born persons in the region. Hence, there is a need to strengthen information campaigns for immigrants, to keep them informed of their rights, and to strengthen training courses among healthcare and social workers.

The care of pregnant women and their babies: empirical data from Umbria region

BACKGROUND

The promotion of the concept of evidence-based health care in the field of maternity care began in the 1980s; the indicators in this field were devised to enable us to know key components of care for mothers and babies and to relate them to health outcomes.

METHODS

The study is based on data from the Standard Certificate of Live Birth (SCLB) forms of the Umbria region (Italy) during 2012, which merges data from each mother and her baby for a total of 7964 records. We followed the healthcare indicators recommended by World Health Organization for monitoring and evaluating maternal and child health services. We considered number of prenatal medical visits and timing of first antenatal visit such as indicators of Antenal care, and mode of delivery and place of birth by volume of deliveries such as indicators of Intrapartum care in healthcare maternal and child services. Odds ratios were calculated to indicate the likelihood of some individual and social variables across appropriate access to prenatal care.

RESULTS

It is present an association between social disadvantage (mothers' educational level and mothers' country of birth) and inappropriate access to prenatal care, low number of prenatal medical visits (below 4) and late timing of first visit (after more than 12 gestational weeks). In Umbria there are 11 place of birth, 9 of I level and 2 of II level. Overall, 29.3% births occurred in 6 maternity units with fewer than 500 births in 2012 (in Italy is 7.3%). The average rate of cesarean section observed in the NTSV sample (Nulliparous, Terminal, Single, Vertex), was 28.2%. This value was higher than expected, especially in this class with an indication for the physiological birth. The World Health Organization recommends that the caesarean section rate should not be higher than 10% to 15%. Moreover there is a wide variability between birth centers (7.2% -41.4%).

CONCLUSIONS

The use of mother and child prenatal care services was associated with individual characteristics of the mothers from less advantage social classes (i.e., unemployed or poorly educated); cesarean section was higher than expected, especially in the NTSV sample; we foresee an important role for application of indicators that proactively help health-care professionals to deliver the right care at the right time.

Bronchiolitis obliterans in patients undergoing allogeneic hematopoietic SCT

Bronchiolitis obliterans (BO) is a severe pulmonary complication of allo-SCT. This study evaluated the incidence of BO in patients undergoing allo-SCT in Hospital Universitário da Universidade Federal do Paraná, risk factors for developing this complication and prognostic factors for those patients who developed this entity. The study included 1286 patients transplanted between 1979 and 2009 who survived for 100 days or more. We diagnosed 53 cases of BO. The cumulative incidence was 2.9% in 1 year and 3.7% in 3 years. Among patients with chronic GVHD, the cumulative incidence at the same intervals was 8.4% and 9.9%, respectively. The median time between transplantation and diagnosis of BO was 260 days (49-3877 days). In the multivariate analysis the risk factors for BO were female donor, older recipients and acute GVHD. The main prognostic factor was the severity of pulmonary impairment. Patients who developed BO earlier than 260 days had a worse prognosis than those who did so later. At least 80% of deaths were directly related to BO.

[Evaluation of the healthcare continuity quality in Umbria (Italy)]

The aim of the study was to evaluate the quality of hospital-territorial services relationship and community care to ensure continuity of care and to avoid, or reduce, the risk of hospitalization for complications or problems in the Health Districts of Umbria region (Italy). They are considered some of the outcome indicators proposed by the Assessment Document on Determinants of Health and the Strategies of the SSR, sponsored by the Region of Umbria in 2004 and based on Agency for Healthcare Research and Quality Indicators : the rate of unplanned readmission to hospital within 28 days after hospitalization for hip fracture, stroke, acute myocardial infarction, asthma, and the rate of hospitalization for chronic complications of diabetes, pneumonia and influenza. The most significant feature is the marked variability between different districts of the region. This variability requires careful verification, as well as the quality of intra-hospital, also the quality of the relationship hospital-territorial services and the different skills and ways of taking care of patients by the health district. To reduce the risk of rehospitalization/readmission not programmed for specific diseases, even considering that this risk is influenced by various determinants, it is desirable to improve the quality of community services.

[Hospital-territorial services and integration of health care: the Protected Discharge program in the Umbria Region from 2005 to 2010]

In order to address the management of patients with chronic diseases, national and international regulatory guidelines have developed policies and operational tools aimed at integration and implementation of pathways of continuity of health care between different healthcare settings. "Protected Discharge" programs have been developed for the organized transfer of patients from one setting of care (hospital) to another (territory) in order to ensure their continuity of care and assistance. The aim of this study was to assess the degree of implementation the program in the context of continuity of healthcare in the Umbria region (Italy). An analysis of the regional archive of hospital discharge records was performed to examine trends of the various types of hospital discharges during the years 2005 to 2010. A slow but steady increase of protected discharges was observed from 2005 (0.9%) to 2010 (1.9%). The percentages observed are higher than those at the national level (except for transfer to RSA); however, results indicate insufficient implementation of hospital-territorial services integration and hence of the principle of continuity of health and social care.

Cyclophosphamide-based in vivo T-cell depletion for HLA-haploidentical transplantation in Fanconi anemia

Allogeneic hematopoietic cell transplantation (HCT) is the only known cure for patients with Fanconi anemia (FA) who develop aplasia or leukemia. However, transplant regimens typically contain high-dose alkylators, which are poorly tolerated in FA patients. Furthermore, as many patients lack human leukocyte antigen (HLA)-matched family donors, alternative donors are used, which can increase the risk of both graft rejection and graft-versus-host disease (GVHD). To improve on these three concerns, we developed a multi-institutional clinical trial using a fludarabine (FLU)-based conditioning regimen with limited alkylators/low-dose radiation, HLA-haploidentical marrow, followed by reduced-dose cyclophosphamide (CY) to treat three FA patients with aplasia. All three patients engrafted with 100% donor CD3 chimerism at 1 month. One patient died early from disseminated toxoplasmosis infection. Of the two survivors, one had significant pretransplant co-morbidities and inadequate immunosuppression, and developed severe acute GVHD. The other patient had only mild acute and no chronic GVHD. With a follow-up of 2 and 3 years, respectively, both patients are doing well, are transfusion-independent, and maintain full donor chimerism. The patient with severe GVHD has resolving oral GVHD and good quality of life. We conclude that using low-intensity conditioning, HLA-haploidentical marrow, and reduced-dose CY for in vivo T-cell depletion can correct life-threatening aplasia in FA patients.

An epidemiologic survey of celiac disease in the Terni area (Umbria, Italy) in 2002-2010

The present work is an epidemiology survey of celiac disease in the province of Terni (Umbria, Italy) in 2002-2010. Data were collected from the Local Health Unit (LHU) 4 (ASL 4), Terni database and were extrapolated from the overall population of 232,540 (as of 2010) by identifying residents with prescription charge exemptions for celiac disease-oriented drugs. Prevalence and incidence analysis over the timeframe being examined showed that prevalence (330 cases in 2010) has consistently been increasing from 2002 to 2010, whereas incidence has remained essentially the same with minor, yearly fluctuations. Both prevalence and incidence were higher in females than in males. Most patients were diagnosed as young adults, with the highest rates in the 10-14, 35-40 and 55-60 age groups. Thus, in the area of investigation, there is evidence for consistent delayed diagnosis, raising the possibility that the atypical form the disease, more difficult to recognize and more likely to escape early diagnosis, may have become increasingly commoner overtime. Because the current prevalence of the disease in the Terni area is estimated to approximate 1%, the anticipated number of cases should amount to 2325, which value contrasts with the currently reported 330 diagnoses. It is suggested that the current illness-defining criteria should be revised so to implement early diagnosis and improve the patients' quality of life and access to treatment.

Modulatory activity of a Lactobacillus casei strain on 1,2-dimethylhydrazine-induced genotoxicity in rats

The present study was designed to investigate the putative antigenotoxic effects of supplementing the diet of rats treated with the colon carcinogen 1,2-dimethylhydrazine hydrochloride (DMH) with a Lactobacillus casei strain using an in vivo approach. The antigenotoxic response was evaluated in colon and liver cells using the alkaline comet assay. Since the balance between the bioactivation and detoxification metabolic pathways is crucial for the formation of toxic and genotoxic metabolites, alterations in the level of some xenobiotic metabolizing enzymes (XME) were studied in liver preparations. In the challenge group (L. casei + DMH), lactobacilli-supplemented diet, there was a decrease in the extent of DMH-induced DNA damage, especially in colon cells. Compared with control rats, there was less basal DNA damage in colon cells of rats fed on a lactobacilli-supplemented diet. These findings are the first to give clear evidence of DNA-protective effects of lactobacilli against basal DNA damage. Moreover, the chemopreventive effects were accompanied by changes in the activities of several XME. The observed decrease in the concentration of nonenzymatic antioxidants (i.e. GSH) and the reduced activity of enzymatic antioxidants (i.e., GST, GPx, and SOD) in liver could reflect an overall reduction in the level of oxidative stress in rats on a diet supplemented with the L. casei suspension compared with control rats (basal state). Thus, the concentrations of GSH and the activities of GST, GPx, and SOD could be downregulated by supplementing the diet with L. casei as a response to an improved antioxidant status.

Evaluation of primary DNA damage, cytogenetic biomarkers and genetic polymorphisms for CYP1A1 and GSTM1 in road tunnel construction workers

In tunnel construction workers, occupational exposure to dust (alpha-quartz and other particles from blasting), gases (nitrogen dioxide, NO(2)), diesel exhausts, and oil mist has been associated with lung function decline, induction of inflammatory reactions in the lungs with release of mediators that may influence blood coagulation, and increased risk of chronic obstructive pulmonary disease. The present molecular epidemiology study was designed to evaluate whether occupational exposure to indoor pollutants during road tunnel construction might result in genotoxic effects. A study group of 39 underground workers and a reference group of 34 unexposed subjects were examined. Primary and oxidative DNA damage, sister-chromatid exchanges (SCE), and micronuclei (MN) were measured in peripheral blood cells. The possible influences of polymorphisms in gene encoding for CYP1A1 and GSTM1 xenobiotic-metabolizing enzymes were also investigated. Exposure assessment was performed with detailed interviews and questionnaires. There were no significant differences in the level of primary and oxidative DNA damage and frequency of SCE between the tunnel workers and controls, whereas the frequency of MN showed a significant increase in exposed subjects compared to controls. No effects of CYP1A1 or GSTM1 variants were observed for the analyzed biomarkers. Since MN in peripheral blood lymphocytes are recognized as a predictive biomarker of cancer risk within a population of healthy subjects, the genotoxic risk of occupational exposure to various indoor environmental pollutants during road tunnel construction cannot be excluded by this biomonitoring study.

Primary DNA damage and genetic polymorphisms for CYP1A1, EPHX and GSTM1 in workers at a graphite electrode manufacturing plant

Background

The results of a cross-sectional study aimed to evaluate whether genetic polymorphisms (biomarkers of susceptibility) for CYP1A1, EPHX and GSTM1 genes that affect polycyclic aromatic hydrocarbons (PAH) activation and detoxification might influence the extent of primary DNA damage (biomarker of biologically effective dose) in PAH exposed workers are presented. PAH-exposure of the study populations was assessed by determining the concentration of 1-hydroxypyrene (1OHP) in urine samples (biomarker of exposure dose).

Methods

The exposed group consisted of workers (n = 109) at a graphite electrode manufacturing plant, occupationally exposed to PAH. Urinary 1OHP was measured by HPLC. Primary DNA damage was evaluated by the alkaline comet assay in peripheral blood leukocytes. Genetic polymorphisms for CYP1A1, EPHX and GSTM1 were determined by PCR or PCR/RFLP analysis.

Results

1OHP and primary DNA damage were significantly higher in electrode workers compared to reference subjects. Moreover, categorization of subjects as normal or outlier highlighted an increased genotoxic risk OR = 2.59 (CI95% 1.32–5.05) associated to exposure to PAH. Polymorphisms in EPHX exons 3 and 4 was associated to higher urinary concentrations of 1OHP, whereas none of the genotypes analyzed (CYP1A1, EPHX, and GSTM1) had any significant influence on primary DNA damage as evaluated by the comet assay.

Conclusion

The outcomes of the present study show that molecular epidemiology approaches (i.e. cross-sectional studies of genotoxicity biomarkers) can play a role in identifying common genetic risk factors, also attempting to associate the effects with measured exposure data. Moreover, categorization of subjects as normal or outlier allowed the evaluation of the association between occupational exposure to PAH and DNA damage highlighting an increased genotoxic risk.

Bax expression and apoptotic cell death in Fanconi anaemia peripheral blood lymphocytes

OBJECTIVE

Deregulated apoptosis might be involved in some of the features of Fanconi anaemia (FA). The possibility that the pro-apoptotic Bax protein could be involved in an increased susceptibility to apoptosis in FA patients was investigated.

MATERIALS AND METHODS

Intracellular Bax expression, Bcl-2 expression (an anti-apoptotic protein) and cell death were analysed in 26 FA peripheral blood lymphocyte samples.

RESULTS

Most FA samples (69%) displayed increased levels of Bax and were more susceptible to both spontaneous apoptosis and mitogen activation-induced cell death. Two subgroups were identified: one presented elevated levels of Bax (n = 18), whereas the other (n = 8), had Bax levels lower than controls. Two subgroups based on Bcl-2 expression were also identified: one with normal and another with high Bcl-2 expression. No inverse correlation was found between Bcl-2 levels and Bax expression. A clear difference in susceptibility to induced cell death could be observed between control and FA samples. The best correlation was observed between high levels of Bax and mitogen-induced apoptosis of cells; these displayed characteristics of necrosis secondary to apoptosis, suggesting that the intrinsic apoptotic pathway was being activated.

CONCLUSION

Despite increased susceptibility to cell death induction, there was no correlation between Bax levels, chromosome breakage, haematological parameters or androgen therapy. The importance of apoptosis and Bax expression in the clinical development of FA awaits clarification.

Dasatinib 140 mg QD compared to 70 mg BID in advanced-phase CML or Ph(+) ALL resistant or intolerant to imatinib: One-year results of CA180–035

7025

Background: Dasatinib, an oral multi-targeted kinase inhibitor of BCR-ABL and SRC family kinases, has been shown to be safe and effective at 70 mg BID in advanced phase CML and Ph(+) ALL resistant or intolerant to imatinib. QD and BID schedules were equipotent in Phase I which led to this dose-optimization study. Methods: In this Phase-III, open-label, prospective study, patients with imatinib-resistant or intolerant advanced phase CML or Ph(+) ALL were randomized to dasatinib 140 mg QD or 70 mg BID. The primary objective compared the major hematologic response (HR) rate between the 2 regimens. Dose escalation was allowed for inadequate response and dose reduction for drug toxicity. Results: From June 2005 through March 2006, 611 patients (56% male) were randomized (median age 55 years). 42% of patients received imatinib at doses >600 mg/d and 37% were treated for >3 y. Response rates, with a median follow-up of 6.5 mo (range <1 to 17 mo), are summarized in the table below. Median durations of HR and progression-free survival were 10.2 and 7.9 mo for the 140-mg QD regimen vs 12.3 and 11.7 mo in the 70-mg BID arm. Drug-related toxicities in 140-mg QD (n=304) vs 70-mg BID (n=305) arms, respectively, listed as all grades (grade 3–4), were: pleural effusion 16% vs 23%, P=0.024 (5% vs 6%); peripheral edema 6% vs 13%, P=0.004 (<1%/1%); pericardial effusion <1% vs 4%, P=0.012 (0% vs 1%); neutropenia 85% vs 87% (65% vs 70%); thrombocytopenia 89% vs 92% (68% vs 70%). Dose reductions (24% vs 36%, P=0.002) and interruptions (47% vs 54%, P=0.105) were required less frequently for the 140-mg QD regimen, whereas dose escalations were more prevalent (33% vs 22%, P=0.005). Conclusions: Dasatinib 140 mg QD shows comparable hematologic and cytogenetic response and a trend for improved tolerability in relation to 70 mg BID. Further follow-up is ongoing to assess the long-term benefit of these two schedules in patients with ABP-CML or Ph(+) ALL; 1-year follow-up will be presented.

[Table: see text] [Table: see text]

Gemcitabine and cisplatin in metastatic breast cancer

1084

Background: Gemcitabine plus cisplatin have synergistic activity and have been tested in several schedules and doses in metastatic breast cancer. Our objectives were to assesss the efficacy and toxicity of gemcitabine and cisplatin in pretreated patients. Methods: Measurable disease and at least two prior anthracycline and /or taxane-containing regimen in either metastatic or adjuvant setting was required. Treatment consisted of gemcitabine 700mg/m(2) IV infusion over 30 min plus cisplatin 30mg(2) given on day1 and 8 every 3 weeks. Results: Seventy four patients with median age of 48 years (range 26- 73) were recruited. A median of six cycles of the study treatment was delivered. The overal response rate was 30% (95% confidence interval, 12–53%). Median time to progreesion was 30.6 weeks (95%CI, 12.6–44 weeks). Median survival was 73.2 weeks (95% CI, 47.1–93.2 weeks). Toxicities included grade 3 and 4 leukopenia in 27(36.4%), anemia in 19 (25.6%) and oral mucositis in 4 (5.4%). No grade 3 or 4 peripheral neurophaty, hepatic or renal dysfunction was observed. No treatment-related death ocurred. Conclusions: Gemcitabine plus cisplatin is a well tollerated and active treatment in heavily pretreated patients with metastatic breast cancer.

No significant financial relationships to disclose.

Epidemiology of bacteremia and factors associated with multi-drug-resistant gram-negative bacteremia in hematopoietic stem cell transplant recipients

The incidence of Gram-negative bacteremia has increased in hematopoietic stem cell transplant (HSCT) recipients. We prospectively collected data from 13 Brazilian HSCT centers to characterize the epidemiology of bacteremia occurring early post transplant, and to identify factors associated with infection due to multi-drug-resistant (MDR) Gram-negative isolates. MDR was defined as an isolate with resistance to at least two of the following: third- or fourth-generation cephalosporins, carbapenems or piperacillin-tazobactam. Among 411 HSCT, fever occurred in 333, and 91 developed bacteremia (118 isolates): 47% owing to Gram-positive, 37% owing to Gram-negative, and 16% caused by Gram-positive and Gram-negative bacteria. Pseudomonas aeruginosa (22%), Klebsiella pneumoniae (19%) and Escherichia coli (17%) accounted for the majority of Gram-negative isolates, and 37% were MDR. These isolates were recovered from 20 patients, representing 5% of all 411 HSCT and 22% of the episodes with bacteremia. By multivariate analysis, treatment with third-generation cephalosporins (odds ratio (OR) 10.65, 95% confidence interval (CI) 3.75-30.27) and being at one of the hospitals (OR 9.47, 95% CI 2.60-34.40) were associated with infection due to MDR Gram-negative isolates. These findings may have important clinical implications in the decision of giving prophylaxis and selecting the empiric antibiotic regimen.

Allogeneic hematopoietic stem cell transplantation from an alternative stem cell source in Fanconi anemia patients: analysis of 47 patients from a single institution

We transplanted 47 patients with Fanconi anemia using an alternative source of hematopoietic cells. The patients were assigned to the following groups: group 1, unrelated bone marrow (N = 15); group 2, unrelated cord blood (N = 17), and group 3, related non-sibling bone marrow (N = 15). Twenty-four patients (51%) had complete engraftment, which was not influenced by gender (P = 0.87), age (P = 0.45), dose of cyclophosphamide (P = 0.80), nucleated cell dose infused (P = 0.60), or use of anti-T serotherapy (P = 0.20). Favorable factors for superior engraftment were full HLA compatibility (independent of the source of cells; P = 0.007) and use of a fludarabine-based conditioning regimen (P = 0.046). Unfavorable factors were > or = 25 transfusions pre-transplant (P = 0.011) and degree of HLA disparity (P = 0.007). Intensity of mucositis (P = 0.50) and use of androgen prior to transplant had no influence on survival (P = 0.80). Acute graft-versus-host disease (GVHD) grade II-IV and chronic GVHD were diagnosed in 47 and 23% of available patients, respectively, and infections prevailed as the main cause of death, associated or not with GVHD. Eighteen patients are alive, the Kaplan-Meyer overall survival is 38% at approximately 8 years, and the best results were obtained with related non-sibling bone marrow patients. Three recommendations emerged from the present study: fludarabine as part of conditioning, transplant in patients with < 25 transfusions and avoidance of HLA disparity. In addition, an extended family search (even when consanguinity is not present) seeking for a related non-sibling donor is highly recommended.

Effectiveness,safety and tolerability of codeine in cancer patients

18577

Background: In 1984 WHO guidelines for cancer pain was proposed. Codeine was selected among several others drugs when pain ladder step II was required. Since then very few comparative studies have been performed. Codein is a weak opioid and its analgesic action is not completely understood. A possible conversion into morphine is postulated. To determine efficacy, safety and tolerability of codein in advanced cancer patient we designed a prospective cohort study. Methods 150 metastatic cancer patients were studied during six months. A standard zero to then table scale for pain rating was used. The malignacies were: prostate 15 (10%), breast 42 (28%), lung 33 (22%), colon 37 (24.6%), other cancer 23 (15.3%). 62 patients were under treatment (41.3%). Results: There were: 83 M (55.3%) 67 F(44,7%) and the mean age was 62 years. Mean initial and final pain score were 7.1 and 1.3 respectively. Codein dose range from 30 mg/day to 270 mg/day (mean dose 180 mg/day). The average time of use was 13,7 months. Severe toxicity was 0% and the most often side effect was constipation (38.7%). Adjuvant drugs were used in 97 patients (64.7%) of patients. Uncontrolled pain ocurred in 17 patients (11.3%). Conclusions: During the last decade a great increase in the range of opioid agents and formulations available have emerged. Codein still represents an excellent drug for patients with long life expectancy. Side effects are manageable and are mainly constipation. Pain control was achieved in the majority of patients. Codein showed a low toxicity profile with a high compliance rate. Economic reasons must be strongly consider in poor countries and codein represents a good alternative option. Future comparative studies addressing also quality of life should be performed.

No significant financial relationships to disclose.

Dasatinib (D) vs high dose imatinib (IM) in patients (pts) with chronic phase chronic myeloid leukemia (CP-CML) resistant to imatinib. Results of CA180017 START-R randomized trial

6507

Background: High dose imatinib (800 mg/day) has been shown to have efficacy in a subset of CML patients with resistance to IM, although the durability of responses is not well-established. Dasatinib (BMS-354825) is a novel, highly potent, oral multi-targeted kinase inhibitor of BCR-ABL and SRC with activity against 18/19 imatinib resistant BCR-ABL mutants tested in vitro. Methods: START-R is a multicenter randomized (2:1 ratio) trial of D 70 mg twice daily (bid) and IM 800 mg/day in pts with CP-CML resistant to prior IM 400 to 600 mg/day. Cross-over was allowed for lack of response or intolerance (grade 3–4 non hematologic toxicity). D dose escalation to 90 mg bid was allowed for inadequate response at 12 wks, and dose reduction to 50 or 40 mg bid for drug toxicity. IM dose reduction to 600 mg/day was allowed. Evaluations consisted of weekly blood counts for the first 12 wks, bone marrow cytology and cytogenetics every 12 wks. The primary endpoint was major cytogenetic response (MCyR) rate at wk 12. Results: From February 2005 to November 2005, 150 pts were randomized of whom the first 36 pts (D 22, IM 14) are reported. Median age was 57 yrs, with 12 males and 24 females. Treatment groups were balanced with respect to CML characteristics; median time from initial diagnosis was 61 months for D and IM; prior interferon 64% and 79%; no prior CyR on IM 36% and 57%. BCR-ABL mutations were documented in 10 D pts and 1 IM pt. Dose reductions were required in 8 D pts and 1 IM pt. Complete hematologic response was documented in 21 D and 13 IM pts. MCyR rate at 12 wks was 45% for D and 21% for IM (7 complete for D and 1 for IM). With a 95% CI on the difference between D and IM was - 9.9 to +51.2. Two (9%) D and 11 (79%) IM pts crossed over for intolerance (1 D and 6 IM) or no MCyR (1 D and 5 IM). Grade 3–4 neutropenia or thrombopenia occurred in 8 and 9 dasatinib pts and in 8 and 2 IM pts. Most common grade 1–2 non-hematologic toxicities in D and IM groups were diarrhea (7 and 1 pts), nausea (7 and 7 pts), and facial/peripheral edema (8 and 7 pts). Conclusions: Dasatinib was effective in pts with CP-CML resistant to IM 400 to 600 mg/day. Preliminary data suggest that D is more effective and better tolerated than high dose IM. An updated analysis of all randomized pts will be presented.

[Table: see text]

Bone marrow transplants from mismatched related and unrelated donors for severe aplastic anemia

For patients with acquired severe aplastic anemia without a matched sibling donor and not responding to immunosuppressive treatment, bone marrow transplantation from a suitable alternative donor is often attempted. We examined risks of graft failure, graft-versus-host disease and overall survival after 318 alternative donor transplants between 1988 and 1998. Sixty-six patients received allografts from 1-antigen and 20 from >1-antigen mismatched related donors; 181 from matched and 51 from mismatched unrelated donors. Most patients were young, had had multiple red blood cell transfusions and poor performance score at transplantation. We did not observe differences in risks of graft failure and overall mortality by donor type. The probabilities of graft failure at 100 days after 1-antigen mismatched related donor, >1-antigen mismatched related donor, matched unrelated donor and mismatched unrelated donor transplants were 21, 25, 15 and 18%, respectively. Corresponding probabilities of overall survival at 5 years were 49, 30, 39 and 36%, respectively. Although alternative donor transplantation results in long-term survival, mortality rates are high. Poor performance score and older age adversely affect outcomes after transplantation. Therefore, early referral for transplantation should be encouraged for patients who fail immunosuppressive therapy and have a suitable alternative donor.

Effects of co-exposure to extremely low frequency (50 Hz) magnetic fields and xenobiotics determined in vitro by the alkaline comet assay

In the present study, we used human peripheral blood leukocytes from 4 different donors, to investigate in vitro the possible genotoxic and/or co-genotoxic activity of extremely low frequency magnetic fields (ELF-MF) at 3 mT intensity. Two model mutagens were used to study the possible interaction between ELF-MF and xenobiotics: N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) and 4-nitroquinoline N-oxide (4NQO). Primary DNA damage was evaluated by the alkaline single-cell microgel-electrophoresis ("comet") assay. Control cells (leukocytes not exposed to ELF-MF, nor treated with genotoxins) from the different blood donors showed a comparable level of basal DNA damage, whereas the contribution of individual susceptibility toward ELF-MF and the tested genotoxic compounds led to differences in the extent of DNA damage observed following exposure to the genotoxins, both in the presence and in the absence of an applied ELF-MF. A 3 mT ELF-MF alone was unable to cause direct primary DNA damage. In leukocytes exposed to ELF-MF and genotoxins, the extent of MNNG-induced DNA damage increased with exposure duration compared to sham-exposed cells. The opposite was observed in cells treated with 4NQO. In this case the extent of 4NQO-induced DNA damage was somewhat reduced in leukocytes exposed to ELF-MF compared to sham-exposed cells. Moreover, in cells exposed to ELF-MF an increased concentration of GSH was always observed, compared to sham-exposed cells. Since following GSH conjugation the genotoxic pattern of MNNG and 4NQO is quite different, an influence of ELF-MF on the activity of the enzyme involved in the synthesis of GSH leading to different activation/deactivation of the model mutagens used was hypothesized to explain the different trends observed in MNNG and 4NQO genotoxic activity in the presence of an applied ELF-MF. The possibility that ELF-MF might interfere with the genotoxic activity of xenobiotics has important implications, since human populations are likely to be exposed to a variety of genotoxic agents concomitantly with exposure to this type of physical agent.

Therapy for severe refractory acute graft-versus-host disease with basiliximab, a selective interleukin-2 receptor antagonist

Basiliximab is a chimeric monoclonal antibody that binds to the alpha chain of IL-2R on activated cytotoxic T-cells, inhibiting lymphocyte proliferation. We report 34 patients with refractory acute GVHD (grade III-IV) who received basiliximab from December 1998 to October 2003. Adults received 40 mg weekly (2-3 doses) and children received half of this dose. Median age was 13 years. Twenty-five donors were unrelated. The stem cell source was bone marrow in 30 and cord blood in four. Complete responses were seen in 27/32 patients (84%) with skin, 12/25 (48%) with gut and 6/23 (26%) with liver GVHD. Median duration of response was 38 days (5-1103). Overall survival at 5 years was 20%. Eleven patients (32%) are alive. The main causes of death were CMV (n=4), fungus (n=6), sepsis (n=8), hemorrhage (n=2), and relapse (n=2). Graft-versus-host disease flares were observed in 14 patients (41%), half being rescued by other therapies. In conclusion, basiliximab was able to induce complete responses in patients with refractory acute GVHD. Prospective studies are necessary to evaluate the optimal treatment schedule.

Engraftment capacity of mesenchymal cells following hematopoietic stem cell transplantation in patients receiving reduced-intensity conditioning regimen

The engraftment ability of mesenchymal cells was investigated in 26 patients receiving allogeneic transplantation from HLA-identical siblings with reduced-intensity conditioning (RIC). The stem cell source was bone marrow (BM) in eight patients and G-CSF-mobilized peripheral blood hematopoietic cells in 18 cases. A total of 32 patients engrafted very quickly and the chimerism evaluation (both on myeloid and on lymphoid subsets) showed that they were full donor by day 60. At the time of the study they were in complete hematological remission and displayed a full donor hematopoiesis. Two patients showed early disease progression while one did not engraft. Forty-eight out-marrow samples harvested from the 26 patients generated a marrow stromal layer adequate for the chimerism evaluation. Monocyte-macrophage contamination of marrow stromal layers was always reduced below 2% by repeated trypsinizations and treatment with the leucyl-leucine (leu-leu) methyl ester. The chimerism evaluation was performed by PCR analysis of STRs microsatellites and the amelogenin locus, by using capillary electrophoresis (CE) and by FISH analysis in case of the sex mismatch. In eight patients, a partial donor origin of stromal cells was shown (7-86% cells of donor). The source of hematopoietic cells was BM in three patients and mobilized peripheral blood in the other five.