The need for endodontic treatment and systemic characteristics of hematopoietic stem cell transplantation patients

Abstract The aim of this study is to investigate the relationship between the epidemiological and clinical profiles of patients before and after hematopoietic stem cell transplantation (HSCT) and the need for endodontic treatment. The subjects included 188 individuals enrolled in the dental care program for transplanted patients of the School of Dentistry, Federal University of Minas Gerais (Faculdade de Odontologia da Universidade Federal de Minas Gerais, FO-UFMG) from March 2011 through March 2016. The patients were subjected to an HSCT conditioning dental regimen based on a thorough clinical and radiographic evaluation. Intraoral periapical and bite-wing X-rays were obtained, and after evaluation, specific dental treatment was planned and performed. The following demographic and clinical data were collected from the patients' medical records: age, gender, transplantation stage, primary disease, transplant type, medication used, complete blood count at the time of visit, and need for endodontic treatment. The Kolmogorov-Smirnov and the chi-square tests were used. Leukemia (31.3%) and multiple myeloma (17.9%) were the most prevalent primary diseases. Most patients were subjected to allogeneic-related transplantation (83.6%). Most patients exhibited platelet counts and hemoglobin concentrations below the reference values in the pre-transplantation stage, while the neutrophil and platelet counts and the hemoglobin levels were within the reference ranges in the post-transplantation stage. The proportions of individuals requiring endodontic treatment were similar between the pre- and post-transplantation groups: 24.3% and 24.7%, respectively. The systemic conditions of the patients referred for dental treatment were compromised.

Síndrome de Down y transplaste de médula ósea: un análisis desde la ética / Down syndrome and bone marrow transplantation: an analysis from ethics

En Chile, el cáncer infantil ocupa el 2° lugar en mortalidad en niños mayores de 5 años. Dentro del cáncer infantil, el más incidente es la Leucemia Linfoblástica Aguda. En relación al tratamiento de la Leucemia, el Trasplante de Médula Ósea puede ser indicación en determinados casos de Leucemia como última opción terapéutica. Al trabajar en el área de la salud, podemos atender a niños con cáncer con condiciones especiales. Dentro de ellos, tenemos a los niños con Síndrome de Down (SD), que por ser portadores de la Trisomía 21, tienen mayor riesgo de desarrollar Leucemia. En el siguiente artículo analizaremos el caso de una adolescente con Síndrome de Down, que al tener una Leucemia de alto riesgo deberá ser trasplantada de médula ósea, este procedimiento es de alto riesgo, única opción curativa para la paciente. Por ser el trasplante un tratamiento que puede conllevar graves complicaciones y ser los niños con Síndrome de Down particularmente frágiles al tratamiento previo al trasplante, analizaremos el caso desde una perspectiva bioética en base a un modelo de toma de decisiones en salud del Hastings Center de Filadelfia, a partir del siguiente problema ético: Dadas las consecuencias nocivas que podría conllevar el trasplante de médula para la paciente, considerando su condición de Síndrome de Down, ¿la paciente tendrá una mejor calidad de vida postrasplante? ¿es éticamente correcto no trasplantar a la paciente?

In Chile, cancer is the second cause of mortality in children with more than 5 year old. Inside this group of patients, Acute Linfoblastic Leukemia (ALL) is the most incidence type of cancer. For his treatment, the bone-marrow transplant is considered suitable as last option of therapy. Some special systemic conditions or certain previous diseases in children can increases the risk of develop ALL and, in the same time, represent a important risk-factor must be considered in the prognosis of ALL therapy. Down Syndrome (DS) is an example of this situation, because patients with DS are more susceptible of develop ALL, and the risks of treatment previous to transplant are higher in this group of patients than patients without DS. In this study we analyze the case of an adolescent with DS and ALL, with indication of bone-marrow transplant as the only option of treatment. For the high risk of this procedure, specially in patients with DS, we analyze the bioethics in relationship with this case using the Hasting Center of Philadelphia model designed for the make of decisions in health, with the next bioethics problem to analyze: in view of the potentially harmful consequences of bone-marrow transplant considering his DS condition, ¿his quality of life will be better after the treatment? ¿May be an ethic decision the choice of no realizes the transplant?

Anti-tumor necrosis factor-a for the treatment of steroid-refractory acute graft-versus-host disease

Allogeneic stem cell transplantation has been increasingly performed for a variety of hematologic diseases. Clinically significant acute graft-versus-host disease (GVHD) occurs in 9 to 50 percent of patients who receive allogeneic grafts, resulting in high morbidity and mortality. There is no standard therapy for patients with acute GVHD who do not respond to steroids. Studies have shown a possible benefit of anti-TNF-a (infliximab)for the treatment of acute GVHD. We report here on the outcomes of 10 recipients of related or unrelated stem cell transplants who received 10 mg/kg infliximab, iv, once weekly for a median of 3.5 doses (range: 1-6) for the treatment of severe acute GVHD and who were not responsive to standard therapy. All patients had acute GVHD grades II to IV (II = 2, III = 3, IV = 5). Overall, 9 patients responded and 1 patient had progressive disease. Among the responders, 3 had complete responses and 6 partial responses. All patients with cutaneous or gastrointestinal involvement responded, while only 2 of 6 patients with liver disease showed any response. None of the 10 patients had any kind of immediate toxicity. Four patients died, all of them with sepsis. Six patients are still alive after a median follow-up time of 544 days (92-600) after transplantation. Considering the severity of the cases and the bad prognosis associated with advanced acute GVHD, we find our results encouraging. Anti-TNF-a seems to be a useful agent for the treatment of acute GVHD.

Ocho años de experiencia con el Método Mexicano en la realización de trasplantes de células hematopoyéticas alogénicas / Eight years using the Mexican method for allogeneic hematopoietic stem cell transplants

En los últimos ocho años se han llevado a cabo, en diversas partes del país y en otros países en desarrollo, trasplantes de células hematopoyéticas alogénicas usando el “Método Mexicano” de acondicionamiento no ablativo que se desarrolló en nuestro país con base en otros métodos de acondicionamiento de intensidad reducida empleados en otras partes del mundo. Habiendo trasplantado ya más de 350 pacientes, se han hecho análisis de los resultados de acuerdo con los padecimientos que han motivado la práctica de los injertos. Los mejores resultados se han obtenido en pacientes con leucemia granulocítica crónica e hipoplasia medular, en tanto que los menos halagüeños se han obtenido en individuos con leucemia aguda linfoblástica, con resultados intermedios en pacientes trasplantados por leucemia aguda mieloblástica. La práctica de los trasplantes hematopoyéticos empleando el “Método Mexicano”, además de haber beneficiado a varios pacientes quienes no habrían podido trasplantarse, ha incidido en el incremento de la actividad académica relacionada con los trasplantes en el país.

In the past eight years, in Mexico and in other developing countries, over 350 patients have undergone allogeneic hematopoietic stem cell transplants using a non-myeloablative conditioning regimen developed in Mexico and based on international standards. The so called [quot ]Mexican method[quot ] to conduct allogeneic stem cell transplants is endowed with certain advantages which make it affordable and in turn, available to individuals living in resource-poor countries. The best results using this method have been observed among patients with stage 1 chronic myelogenous leukemia and aplastic anemia. The less favourable results have been observed among patients with acute lymphoblastic leukemia; mild to moderate results have been reported among patients with acute myelogenous leukemia. The [quot ]Mexican method[quot ] to conduct hematopoietic cells allografting has resulted not only in turning this method accessible to patients in developing countries, but also it has witnessed an increase in the academic activities of physicians from these countries involved in the field.

Second allogeneic peripheral blood stem cell transplants with reduced-intensity conditioning / Segundos trasplantes hematopoyéticos con esquemas de acondicionamiento de intensidad reducida

In two institutions in México, twelve patients were given a second allogeneic stem cell transplantation, using the "Mexican" non-myeloablative preparative regimen. Eight had a malignant condition (six acute leukemias, one myelofibrosis and one myelodysplasia), eleven individuals were allografted twice from the same donor and in one case, cells from two different umbilical cords were used. The median time to conduct the second allograft after the first one was 6 months (range 1-41). The five patients who failed to engraft after the first transplant failed also to engraft after the second one; all of them had been heavily transfused. Only three patients were successfully rescued with the second transplant, two with acute leukemia and one with aplastic anemia. Seven patients are alive 10-41 months (median 35) after the second transplant, but only three (25%) remain disease-free. The 52-month overall survival (SV) of the patients is 58%, whereas the median overall SV has not been reached, being above 52 months. Conducting a second allograft may be useful to rescue some individuals relapsing after a first hematopoietic allotransplant.

En dos instituciones en México se llevaron a cabo doce segundos trasplantes de células hematopoyéticas usando el "método mexicano" de acondicionamiento no mieloablativo. Ocho pacientes tenían una enfermedad maligna (seis leucemias agudas, una mielofibrosis y una mielodisplasia). Once sujetos se retrasplantaron del mismo donador y en un caso se emplearon células hematopoyéticas de dos diferentes cordones umbilicales. La mediana del tiempo transcurrido entre los dos trasplantes fue de seis meses (rango 1 a 41). Los cinco pacientes que no se injertaron con el primer trasplante tampoco se injertaron con el segundo; todos ellos habían sido multitransfundidos antes de los trasplantes. Sólo tres pacientes se pudieron rescatar con el segundo trasplante, dos con leucemia aguda y uno con anemia aplástica. Siete pacientes están vivos 10 a 41 meses (mediana 35) después del segundo trasplante, pero sólo tres (25%) se encuentran libres de enfermedad. La supervivencia (SV) global a 52 meses es de 58%, en tanto que la mediana de SV no se ha alcanzado y es mayor de 52 meses. Hacer un segundo trasplante hematopoyético puede rescatar a algunos pacientes quienes recaen después de un trasplante de médula ósea.

Clinical observation of patients with hematologic malignancies treated with hematopoietic stem cell transplantation / 华中科技大学学报（医学）（英德文版）

To evaluate the therapeutic effect of hematopoietic stem cell transplantation (HSCT), we performed HSCT in 30 patients with hematologic maligancies. Of the 30 patients, 10 underwent autologous peripheral blood stem cell transplantation (auto-PBSCT), 13 underwent myeloablative allogeneic HSCT while 7 underwent nonmyeloablative allogeneic HSCT, which were designated as autologous group, myeloablative group and nonmyeloablative group, respectively. All patients except the one who underwent cord blood transplantation, were successfully engrafted. Median time for the granulocytes > or = 0.5 x 10(9)/L and platelets > or = 20 x 10(9)/L were 12 days and 13 days respectively in autologous group, 16 days and 19 days in myeloablative group, 15 days and 12 days in nonmyeloablative group. In myeloablative group, acute graft-versus-host diseases (aGVHD) was observed in 3 patients, all of which were I-II grade. Oral mucous cGVHD was observed in 1 patient. In nonmyeloablative group, 1 patient developed intestinal aGVHD grade IV and cutaneous cGVHD was induced by donor lymphocyte infusions (DLI) in 3 patients. 1 patient had hematological relapse in autologous group. 1 patient had cytogenetic relapse in myeloablative group. In nonmyeloablative group 3 patients had cytogenetic relapse and were cured by DLI, 1 patient had hematological relapse. 4 of the 30 patients died of infection (2 patients), grade IV aGVHD (1) and relapse (1) respectively. 26 patients are still alive. 3 years overall survival (OS) and 3 years disease free survival (DFS) were 100% and 64.81% respectively in autologous group, 78.75% and 63% respectively in myeloablative group while both 66.67% in nonmyeloablative group. In conclusion, autologous group had less transplant-related complications and mortality. Active prophylaxis of relapse could significantly promote DFS. The transplant-related mortality limited DFS in myeloablative group. More relapses occurred in nonmyeloablative group, but could be cured by DLI.

Ocho años de experiencia en una sola institución en transplante autólogo de células progenitoras hematopoyéticas en enfermedades hematológicas malignas y en tumores sólidos / Eight years of experience in a single institution in hematopoietic stem cell autologous transplantation in malignant hematological diseases and in solid tumors

Entre agosto 1991 y diciembre 1998, 400 pacientes (linfoma: 197, leucemia aguda: 86, mieloma múltiple: 70 y tumores sólidos 47) recibieron un trasplante autólogo. Todos los pacientes fueron movilizados con quimioterapia más G-CSF. Luego de la infusión se utilizó G-CSF. La recuperación de neutrófilos fue similar en todos los grupos; en pacientes con leucemia aguda y mieloma múltiple la recuperación de plaquetas fue más lenta. La muerte relacionada al tranplante fue 4.5 por ciento. El estado de la enfermedad al momento del procedimiento fue el principal factor pronóstico. Con una mediana de seguimiento de 23 meses la SLE a 60 meses fue de 46 por ciento para linfomas de bajo grado, 44 por ciento para linfomas de grado alto e intermedio, 58 por ciento para enfermedad de Hodgkin, 45 por ciento para leucemia mieloblástica aguda, 38 por ciento para tumores sólidos y 15 por ciento para mieloma múltiple. A 60 meses la probabilidad actuarial de supervivencia fue 67 por ciento para linfomas de bajo grado, 47 por ciento para linfomas de grado alto e intermedio, 75 por ciento para enfermedad de Hodgkin, 52 por ciento para leucemia mieloblástica aguda, 54 percent para tumores sólidos y 25 por ciento para mieloma múltiple. Se concluye que el trasplante autólogo de progenitores hematopoyéticos indujo una recuperación hematopoyética rápida y completa. Los resultados obtenidos son similares a los publicados en la literatura, siendo discutido el rol en pacientes con tumores sólidos. La muerte relacionada fue baja sin fallos tardíos del injerto.