Spine bone texture assessed by trabecular bone score (TBS) to evaluate bone health in thalassemia major.

Due to the increasing survival of thalassemic patients, osteopathy is a mounting clinical problem. Low bone mass alone cannot account for the high fracture risk described; impaired bone quality has been speculated but so far it cannot be demonstrated noninvasively. We studied bone quality in thalassemia major using trabecular bone score (TBS), a novel texture measurement extracted from spine dual-energy X-ray absorptiometry (DXA), proposed in postmenopausal and secondary osteoporosis as an indirect index of microarchitecture. TBS was evaluated in 124 adult thalassemics (age range 19-56 years), followed-up with optimal transfusional and therapeutical regimens, and in 65 non-thalassemic patients (22-52 years) undergoing DXA for different bone diseases. TBS was lower in thalassemic patients (1.04 ± 0.12 [range 0.80-1.30]) versus controls (1.34 ± 0.11 [1.06-1.52]) (p < 0.001), and correlated with BMD. TBS and BMD values correlated with age, indicating that thalassemia negatively affects both bone quality and quantity, especially as the patient gets older. TBS was 1.02 ± 0.11 [0.80-1.28] in the osteoporotic thalassemic patients, 1.08 ± 0.12 [0.82-1.30] in the osteopenic ones and 1.15 ± 0.10 [0.96-1.26] in those with normal BMD. No gender differences were found (males: 1.02 ± 0.13 [0.80-1.30], females 1.05 ± 0.11 [0.80-1.30]), nor between patients with and without endocrine-metabolic disorders affecting bone metabolism. Our findings from a large population with thalassemia major show that TBS is a valuable tool to assess noninvasively bone quality, and it may be related to fragility fracture risk in thalassemic osteopathy.

Analysis of nosocomial acquired Clostridium difficile infection in an Italian research and teaching hospital.

BACKGROUND: Clostridium difficile (Cd) infection is a nosocomial plague which is correlated with several clinical and medical factors such as antibiotics intake. It is known that prevention is possible through infection control measures both clinical and epidemiological. METHODS: We examined the data from a study about Cd infection in four internal medicine wards in a teaching and research hospital in the north part of Italy in a two years period. The wards are only slightly different in size, plan, structures, nursing staff and patient's characteristics but have a different room' organization, lay out and different level of continuous education programs for nursing personnel. RESULTS: We reported a high incidence of the infection and a non-significant difference between wards also looking to the different possibility-capacity of taking preventive measures and the different level of nursing staff continuous educational performance. CONCLUSION: The analysis of the data we obtained was the basis to write a protocol and to start a training course for the medical and nursing personnel of the four wards on the managing of patients infected with Cd infection. On March 2011 we started a one year longitudinal study about the Cd infections in the same wards with the purpose of evaluating the adherence to the protocol, monitoring the incidence of infection and studying the risk factors of the infected patients related to the proper use of the protocol on Cd.

Clinical outcomes of Clostridium difficile infection according to strain type. A prospective study in medical wards.

OBJECTIVES: To describe clinical characteristics and outcome of Clostridium difficile infection (CDI) patients in Internal Medicine, to identify ribotypes (RTs); to evaluate the association between RT and patient clinical characteristics and report outcome. METHODS: One year prospective cohort study. Clinical data, Barthel Index (BI) and outcomes were collected for all inpatients suffering from CDI (n = 148) in hospital wards in Northern Italy. 84 fecal samples were analysed for molecular typing. RESULTS: 12 RTs were identified, predominantly RT018 (42.9%, n = 36/84) and RT356/607 (40.5%, n = 34/84). Patients with dementia were more frequent among those infected by RT018 [55.6% (n = 20/36) vs. 32.4% (n = 11/34), p = 0.05]. The median BI score of patients with RT018 was lower than BI score of patients with RT356/607 [10 (IQR 0-32) vs. 15 (IQR 5-50), p = 0.06]. RT018 infection was associated to higher levels of C-reactive protein [7.2 mg/dl (IQR 4.1-14.7) vs. 4.0 mg/dl (IQR 2.2-6.8), p = 0.01] and white blood cells ≥15,000/dl [33.3% (n = 12/36) vs. 14.7% (n = 5/34) of patients, p = 0.07]. Higher mortality was noted among RT018 infected patients. We found a continuous mortality increase according to the ATLAS score. CONCLUSIONS: Our results confirm that RT018 and RT356/607 are the two major RTs causing CDI in older patients with a high degree of disability in Northern Italy and RT018 is associated with more serious outcomes.

Clostridium difficile infection epidemiology and management: Comparison of results of a prospective study with a retrospective one in a reference teaching and research hospital in Northern Italy.

BACKGROUND: Clostridium difficile-associated disease (CDAD) is the most common infectious antibiotic-associated diarrhea and is a growing health care problem. Prevention of Clostridium difficile infection focuses on clinical and epidemiologic infection control measures. METHODS: Between 2008 and 2009, we conducted a retrospective study that showed an incidence of CDAD among the highest reported in the literature. Subsequently, we developed a preventive protocol that was adopted in our hospital in 2010. We then conducted a prospective study to investigate prevalence, incidence, and mortality of CDAD and to compare the results with those of the retrospective study, evaluating adherence to preventive measures and their efficacy. RESULTS: In both studies, prevalence and incidence significantly increased in older patients. Crude prevalence was similar in the 2 studies. The incidence rate increased by 36%, with a significant increase only in the C and D wards. In-hospital mortality rose in both prevalent and incident cases. Regarding adhesion to hospital protocol, 77% of prevalent cases were treated with the required procedure. The highest percentage of isolated patients was achieved in C and D wards. In these wards we detected lower training hours per nurse. However, in 2013, we observed a significant decrease in incidence of CDAD and found a hospital prevalence of 0.33%. CONCLUSIONS: Health care personnel education could be more important than the possibility of isolating infected patients in single rooms.

Dendritic cells in autologous hematopoietic stem cell transplantation for diffuse large B-cell lymphoma: graft content and post transplant recovery predict survival.

Allograft dendritic cell (DC) content has been identified as a predictor of relapse and event-free survival after allogeneic bone marrow transplantation. However, the prognostic importance of DCs has not been evaluated in the setting of autologous hematopoietic stem cell transplantation (HSCT). We prospectively determined pre-transplant and post transplant DC levels, including DC1 and DC2 subset levels, in 53 patients with diffuse large B-cell non-Hodgkin's lymphoma (DLBC NHL) undergoing autologous HSCT. Pre-transplant DCs were measured in the collected stem cell products and were therefore indicative of cell numbers infused directly into patients; post transplant analysis of DCs was performed on the peripheral blood of patients 6 weeks after the infusion of autologous stem cells. Higher pre-transplant levels of DC1 cells and total DCs were significantly associated with improved survival. Similarly, greater post transplant levels of total DCs and both subsets were significantly associated with survival. These findings suggest a relationship between DC reconstitution and survival following autologous HSCT for DLBC NHL. Strategies to increase autograft DC content or accelerate DC recovery after autologous HSCT might improve outcomes in this setting.

A simplified method of CD34+ cell determination for peripheral blood progenitor cell transplantation and correlation with clinical engraftment.

Enumeration of CD34+ cells by flow cytometry is the recognized standard for quantitating progenitor cells for peripheral blood progenitor cell (PBPC) transplantation. Although many clinical studies have confirmed that the time to neutrophil and platelet engraftment is inversely proportional to the number of CD34+ cells infused, the minimum number of CD34+ cells necessary to acheive rapid engraftment has not been satisfactorily determined. The lack of a standardized method for quantitation of CD34+ cells by flow cytometry (FCM) is often cited as the reason for this ambiguity. This report describes an FCM method for CD34+ cell determination that is simple, highly reproducible, comparatively inexpensive, and validated by excellent correlation with clinical engraftment. Pheresis samples are stained and fixed within 4 hours of collection. Two hundred fifty thousand events are acquired as list mode data using a forward scatter threshold. The discrete CD34+ population is enumerated using a CD34-phycoerythrin FL2 vs. side scatter plot and Paint-A-Gate Pro software. The method was validated by excellent statistical correlation with clinical engraftment. Using this method, we determined the number of CD34+ progenitor cells necessary to achieve rapid engraftment to be 2 x 10(6)/kg.

Etoposide (VP-16) plus G-CSF mobilizes different dendritic cell subsets than does G-CSF alone.

Dendritic cells (DCs) are antigen-presenting cells that are critical to the generation of immunologic tumor responses. Myeloid DCs (DC1) express myeloid antigen CD11c; lymphoid DCs (DC2) express CD123(+) and are CD11c(-). Analysis of DC subsets from peripheral blood progenitor cells (PBPC) collected from normal donors mobilized with G-CSF shows a predominance of DC2 cells. Whether PBPCs mobilization by chemotherapy yields different subsets of DCs has not been studied. We analyzed DC subsets in apheresis products from 44 patients undergoing autologous stem cell transplantation from 6/00 to 5/01. Patients received either G-CSF alone (10 microg/kg per day, n=11) or etoposide (2 g/m(2)) plus G-CSF (n=33) for progenitor cell mobilization. The patients were apheresed for 2-10 days (median 3) to reach a minimum of 2.0 x 10(6) CD34(+) cells/kg. Patients receiving G-CSF alone mobilized significantly more total DC2s than did those receiving etoposide plus G-CSF (median 6.2 x 10(6)/kg vs 2.9 x 10(6)/kg, P=0.001). The DC2/DC1 ratio was also significantly different in the two groups, with the G-CSF group having a higher ratio (median 1.2 vs 0.4, P<0.001). We conclude that the combination of chemotherapy plus G-CSF yields different mobilized dendritic cell subsets than does G-CSF alone.

Are backup BM harvests worthwhile in unrelated donor allogeneic transplants?

The Cleveland Clinic blood and marrow transplant program has routinely performed 'backup' autologous harvests in unrelated recipients with hematological malignancies in remission, lymphoma without marrow involvement and CML in chronic phase. We reviewed all adult or cord unrelated donor (URD) transplants performed from January 1995 through September 2008 to evaluate the value of this procedure. Of 130 patients who had backup harvests, 15 (11%) had their backup harvests re-infused, all for graft failure. No patients undergoing fully ablative preparation and unmanipulated or T-depleted grafts from well-matched adult donors required infusion of backup marrow. Nine of 42 patients who underwent T cell grafts from partially matched or mismatched donors, five patients undergoing partially matched ablative transplants from adult donors or cord blood, and one patient undergoing non-myeloablative transplant required infusion of their back-up harvest. Five of 15 patients who received their backup marrow are alive in CR 2-11.6 (median 7.6) years from infusion. Two of these five were bridged to a second URD transplant; the other three showed durable disease-free survival without a second allogeneic transplant. Backup harvest is unnecessary for HLA well-matched myeloablative transplants, but may be useful in patients at higher risk of graft failure.