Cross-cutting view of current challenges in paediatric solid organ and haematopoietic stem cell transplantation in Europe: the European Reference Network TransplantChild.

The low prevalence of European paediatric transplanted patients and scarcity of resources and expertise led to the need for a multidisciplinary network able to improve the quality of life of paediatric patients and families requiring a solid organ or haematopoietic stem cell transplantation. The European Reference Network (ERN) TransplantChild is one of the 24 ERNs established in a European legal framework to improve the care of patients with rare diseases. ERN TransplantChild is the only ERN focused on both solid organ and haematopoietic stem cell paediatric transplantation, based on the understanding of paediatric transplantation as a complex and highly specialised process where specific complications appear regardless the organ involved, thus linking the skills and knowledge of different organ disciplines. Gathering European centres of expertise in paediatric transplantation will give access to a correct and timely diagnosis, share expertise and knowledge and collect a critical mass of patients and data that increases the speed and value of clinical research outcomes. Therefore, the ERN TransplantChild aims for a paediatric Pan-European, Pan-transplant approach.

Diagnosis and severity criteria for sinusoidal obstruction syndrome/veno-occlusive disease in pediatric patients: a new classification from the European society for blood and marrow transplantation.

The advances in hematopoietic cell transplantation (HCT) over the last decade have led to a transplant-related mortality below 15%. Hepatic sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) is a life-threatening complication of HCT that belongs to a group of diseases increasingly identified as transplant-related, systemic endothelial diseases. In most cases, SOS/VOD resolves within weeks; however, severe SOS/VOD results in multi-organ dysfunction/failure with a mortality rate >80%. A timely diagnosis of SOS/VOD is of critical importance, given the availability of therapeutic options with favorable tolerability. Current diagnostic criteria are used for adults and children. However, over the last decade it has become clear that SOS/VOD is significantly different between the age groups in terms of incidence, genetic predisposition, clinical presentation, prevention, treatment and outcome. Improved understanding of SOS/VOD and the availability of effective treatment questions the use of the Baltimore and Seattle criteria for diagnosing SOS/VOD in children. The aim of this position paper is to propose new diagnostic and severity criteria for SOS/VOD in children on behalf of the European Society for Blood and Marrow Transplantation.

[End-of-life debate: Citizen's point of view about deep and continuous sedation]. / Débat sur la fin de vie en France : regard du citoyen sur la sédation profonde et continue.

INTRODUCTION: Sedation in palliative care meets a precise definition and corresponds to a medical practice. We assessed the comprehension of this practice by the French population. METHOD: In 2015, citizen expressed their views on the Claeys-Leonetti bill by means of a consultative forum made available on the Internet site of the National Assembly. The content of the messages filed, regarding the right to deep and continuous sedation until death was analyzed using the ALCESTE textual data analysis software, supplemented by a thematic analysis in order to identify the perception that Internet users had of this practice. RESULTS: Among the 1819 Internet users who participated in the forum, 67 expressed their views as Health professionals, 25 of whom were directly involved in palliative care, as well as 10 sick persons. Analysis with the ALCESTE software highlighted two classes of statements. The first dealing with deep and continuous sedation, reflecting the specificity of the discourse of the Internet users. The second one consisted of textual units in which the modal verbs were dominant and overrepresented, thus providing information on the participants' perceptions. The thematic analysis highlighted four themes: death, intent, treatment and fear. CONCLUSION: Deep and continuous sedation is perceived as a euthanasic practice or raises fear of such a drift. Provision of extended and accurate information to the population and health professionals is essential to ensure that this new model of sedation is integrated into the care of the terminally ill patients and their families.

Ancient microbial activity recorded in fracture fillings from granitic rocks (Äspö Hard Rock Laboratory, Sweden).

Fracture minerals within the 1.8-Ga-old Äspö Diorite (Sweden) were investigated for fossil traces of subterranean microbial activity. To track the potential organic and inorganic biosignatures, an approach combining complementary analytical techniques of high lateral resolution was applied to drill core material obtained at -450 m depth in the Äspö Hard Rock Laboratory. This approach included polarization microscopy, time-of-flight secondary ion mass spectrometry (ToF-SIMS), confocal Raman microscopy, electron microprobe (EMP) and laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS). The fracture mineral succession, consisting of fluorite and low-temperature calcite, showed a thin (20-100 µm), dark amorphous layer lining the boundary between the two phases. Microscopic investigations of the amorphous layer revealed corrosion marks and, in places, branched tubular structures within the fluorite. Geochemical analysis showed significant accumulations of Si, Al, Mg, Fe and the light rare earth elements (REE) in the amorphous layer. In the same area, ToF-SIMS imaging revealed abundant, partly functionalized organic moieties, for example, C(x)H(y)⁺, C(x)H(y)N⁺, C(x)H(y)O⁺. The presence of such functionalized organic compounds was corroborated by Raman imaging showing bands characteristic of C-C, C-N and C-O bonds. According to its organic nature and the abundance of relatively unstable N- and O- heterocompounds, the organic-rich amorphous layer is interpreted to represent the remains of a microbial biofilm that established much later than the initial cooling of the Precambrian host rock. Indeed, δ¹³C, δ¹8O and 87Sr/86Sr isotope data of the fracture minerals and the host rock point to an association with a fracture reactivation event in the most recent geological past.

Analysis of archaeal core ether lipids using Time of Flight-Secondary Ion Mass Spectrometry (ToF-SIMS): Exploring a new prospect for the study of biomarkers in geobiology.

The capability of Time of Flight-Secondary Ion Mass Spectrometry (ToF-SIMS) of analysing molecular archaeal biomarkers in geobiological samples was tested and demonstrated. Using a bismuth cluster primary ion source, isopranyl glycerol di- and tetraether core lipids were detected in small amounts of total organic extracts from methanotrophic microbial mats, simultaneously and without further chemical treatment and chromatographic separation. ToF-SIMS was also employed to track the distribution of fossilized ether lipids in a massive carbonate (aragonite) microbialite that precipitated as a result of the microbial anaerobic oxidation of methane. An unambiguous signal was obtained when analysing a freshly broken rock surface (base of a microdrill core). Though some limitation occurred due to µm-topographical effects (sample roughness), it was possible to display the abundance of high molecular weight (C86 ) of tetraethers exposed in particular regions of the rock surface. 'Molecular mapping' revealed that a part of these molecules was encased within the rock fabric in a cluster-like distribution that might trace the arrangement of the calcifying microbial colonies in the once active mat system. The results reveal promising perspectives of ToF-SIMS for (i) the quasi-nondestructive analysis of lipids in extremely small geobiological samples at low concentrations; (ii) resolving the spatial distribution of these compounds on a µm2 - to cm2 -scale; and (iii) the more exact assignment of lipid biomarkers to their biological source.

Allogeneic hematopoietic cell transplantation from alternative donors in children with myelodysplastic syndrome: is that an alternative?

Allogeneic hematopoietic cell transplantation (HCT) in children with myelodysplastic syndrome (MDS) remains a challenge due to the toxic conditioning regimens administered to minimize the risk of relapse in the HLA-matched or of graft rejection in the HLA-mismatched settings. In the absence of matched sibling donors, alternative donors such as unrelated and/or partially matched family sources remain risky, yet the only available, options. Herein we report the results of HCT from alternative donors in 14 children with different subtypes of MDS (juvenile myelomonocytic leukemia [JMML] n = 9; myelodysplastic syndrome [MDS] refractory anemia n = 3; MDS refractory anemia with excess of blasts in transformation n = 2) transplanted at our institution. The median time from diagnosis to HCT was 9 months (range 4 to 90 months). The variety of HCT types included: unrelated peripheral blood progenitor cell transplantation (PBPCT) (n = 2), partially matched family donor T-cell-repleted BMT/PBPCT (n = 6), and haploidentical T-cell-depleted PBPCT (n = 6). Five of 14 patients remain alive at 7 to 37 months posttransplant (including two patients after partially matched family donor BMT, two patients after haploidentical T-cell-depleted-PBPCT, and one after unrelated-PBPCT, respectively). The major complications were: primary graft failure in the haploidentical T-cell-depleted-setting or graft-versus-host disease (GvHD) in T-cell-repleted partially matched family or unrelated settings, respectively. Despite the high transplant-related mortality rate in this series, allogeneic HCT from alternative donors remains an interesting solution for children with MDS who lack matched sibling donors. Due to improved immune reconstitution, despite an increased risk of GvHD, T-cell-repleted transplants from single HLA-mismatched family donors remain a valuable option for children without matched donors. Splenectomy prior to HCT may positively affect the posttransplant course in patients with overt splenomegaly for example those afflicted with JMML.

Prompt initiation of immunotherapy in children with an increasing number of autologous cells after allogeneic HCT can induce complete donor-type chimerism: a report of 14 children.

Immunotherapy consisting of withdrawal of immunosuppression and/or donor lymphocyte infusions was initiated in 14 children (10 acute lymphoblastic leukemia, three acute myeloblastic leukemia and one myelodysplastic syndrome) with an increasing amount of autologous DNA (increasing mixed chimerism, inMC) detected after allogeneic hematopoietic cell transplantation (HCT). Two children were in relapse when inMC was detected, 12 remained in CR. Children with overt relapse at the time of cessation of cyclosporine A (CsA) received "debulking" chemotherapy. One of them developed acute grade III graft-versus-host disease, converted to complete donor chimerism (CC) and achieved remission. Another patient did not respond and died due to disease progression. Among 12 children treated in remission, 11 responded with conversion to CC, seven after CsA withdrawal and four after DLI. One patient did not respond, rejected the graft and died due to pulmonary aspergillosis. In one patient, the response was transient, inMC reappeared and frank relapse occurred. One patient developed isolated CNS relapse despite conversion to CC, but achieved CR after conventional treatment. One child died in CC due to infection. No graft-versus-host disease (GvHD)-related death occurred. A total of 10 patients are alive in remission with median follow-up of 338 days. Our results support the hypothesis that chimerism-guided immunotherapy after alloHCT may prevent progression to hematological relapse.

A prospective analysis of immune recovery in children following allogeneic transplantation of t-cell-depleted or non-T-cell-depleted hematopoietic cells from HLA-disparate family donors.

Transplantation of HLA-disparate hematopoietic stem cells from related donors is an alternative for the treatment of patients lacking an HLA-matched family or unrelated donor. In the cases of a single HLA antigen disparity, extensive T-cell depletion (TCD) is not required, yet antithymocyte globulin (ATG) must be administered to prevent GvHD or graft rejection. The major concern after HLA-mismatched transplants remains immune reconstitution. Therefore, we prospectively studied the recovery of lymphocyte subsets among 22 children transplanted from partially HLA-matched family donors. We compared two groups of patients: (1) the TCD group included children (n = 1.3) who received grafts after TCD (MACS) due to an HLA disparity for more than one antigen; (2) The non-TCD group included children with either one HLA-mismatched antigen, n = 7; or more than one disparate antigen (n = 2) who received T-cell-repleted grafts and ATG. The study demonstrated rapid NK cell reconstitution among the TCD group. TCD compromised T-cell reconstitution, thus preventing GvHD, but resulting in a higher incidence of severe infectious complications, graft rejection, and disease relapse. Increasing mixed chimerism required the application of donor T-cell addbacks, thus potentiating the risk of GvHD. Primary graft rejection occurred in eight children, who required further transplants. In the non-TCD group faster T-cell reconstitution (predominantly CD3+CD8+ cells) resulted in a lower rate of relapse and infection, yet a higher rate of GvHD, including two fatal cases. Due to improved immune reconstitution, in spite of an increased risk of GvHD, non-TCD transplants from single HLA-mismatched family donors remain a valuable option for children without matched donors.

Clinical value of the flow cytometric method for measuring lymphocyte subset activation: spontaneous activation of T-cell subpopulations is associated with acute GvHD.

Thymidine ((3)H-TdR) incorporation remains the most commonly used method to quantifying T-cell proliferation. This method, however, does not provide information about specific lymphocyte subpopulations responding to different stimuli. In our study, we modified previously described nonradioactive flow-cytometric T-cell activation assay measuring the expression of a CD69+ antigen on T-cell subsets and applied it to analysis of lymphocyte subsets activation/proliferation in children after allogeneic hematopoietic cell transplantation (HCT). We compared the percentage of spontaneously activated lymphocyte subpopulations (background) and the percentage of PHA-P, PWM, and SEB-stimulated cell subsets from two groups of patients: group 1, children with Graft versus Host Disease (GvHD) and group 2, children without any signs of GvHD at the time of analysis. High rate of spontaneous T-cell subset activation was found in group 1 with CD3+CD8+Ts cells being the most affected cell population. High background activation of Th and B cells correlated with the occurrence of autoimmune phenomena posttransplant. Rapid quantification of CD69+ expression on unstimulated and stimulated T-cell subsets proved to be a valuable method for monitoring children after allogeneic HCT. High proportion of activated, unstimulated Ts cells observed in the GvHD group may underline the critical role of CD3+CD8+ cells in the pathogenesis of GvHD. Thus in future immunosuppressive therapy may be adjusted according to the proportion of activated Ts cells.

Investigations into an unknown organism on the martian meteorite Allan Hills 84001.

Examination of fracture surfaces near the fusion crust of the martian meteorite Allan Hills (ALH) 84001 have been conducted using scanning electron microscopy (SEM) and atomic force microscopy (AFM) and has revealed structures strongly resembling mycelium. These structures were compared with similar structures found in Antarctic cryptoendolithic communities. On morphology alone, we conclude that these features are not only terrestrial in origin but probably belong to a member of the Actinomycetales, which we consider was introduced during the Antarctic residency of this meteorite. If true, this is the first documented account of terrestrial microbial activity within a meteorite from the Antarctic blue ice fields. These structures, however, do not bear any resemblance to those postulated to be martian biota, although they are a probable source of the organic contaminants previously reported in this meteorite.

Double haploidentical transplantation of hematopoietic progenitor cells in a boy with myelodysplastic syndrome.

A 12-year-old boy with myelodysplastic syndrome underwent a double transplantation of hematopoietic progenitor cells from his haploidentical brother. After conditioning with busulfan, cyclophosphamide, and Vepesid, the first bone marrow transplantation was performed using 3.53 x 10(6)/kg of CD34+ cells. Initial engraftment was followed by graft rejection. The second conditioning consisted of melphalan and anti-thymocyte globulin. The boy was then transplanted with 5.15 x 10(6)/kg of CD34+ cells, harvested from bone marrow (BM) and peripheral blood. Graft versus host disease (GvHD) prophylaxis consisted of cyclosporine A + short methotrexate. Hematological recovery was rapid and stable. Acute GvHD 1 degree (skin) resolved after 2 weeks of steroid treatment. A relapse occurred on day +140. At that time NK cells decreased from 20 to 7% with the lowest CD4+/CD8+ ratio, 0.07. Just after relapse, the percentage of cytokine-induced killer cells (CIK-CD3+CD56+) dropped from 3.34 to 0.1%. CsA treatment was stopped and the patient received T cell (CD3+ cells) add-back four times on days +146, +199, +234, and +262 in doses of 0.5 x 10(5), 1.0 x 10(5), 2.0 x 10(5), and 4.0 x 10(5)/kg, respectively. No acute GvHD occurred. Additionally, bone marrow biopsy before the second add-back showed complete remission. Analysis of lymphocyte subsets before the fourth add-back showed the highest values of CD4+, NK, and CIK cells and also the highest CD4+/CD8+ ratio.

High-dose chemotherapy with autologous hematopoietic progenitor cell transplantation in children with high-risk NHL and ALL-preliminary results.

Since May 95 to December 97 twenty children with NHL (n=14, NHL B = 11, NHL NB = 3) or ALL (n=6, high risk n=2, standard risk n=4) underwent high-dose chemotherapy with subsequent autologous hematopoietic progenitor cells transplantation. In 19 children progenitor cells were harvested with the use of Fenwal CS3000 Plus cell separator from the peripheral blood after cytotoxic mobilization with G-CSF (Neupogen 5 microg/kg). One patient received PBPC and autologous bone marrow. One patient received positively selected CD34+ cells (CeprateSC, CellPro). One patient received autologous marrow purged with mafosfamide. All patients with NHL received conditioning according to BEAM protocol. Patients with ALL were conditioned with BU,CY,VP, BU,CY or BU. The median number of transplanted CD34+ cells was 3.84x10(6) (0.51x10(6)-74.7x10(6)). Children transplanted with unmanipulated hematopoietic progenitor cells recovered in granulocytes >500/microl at a median time of 12 days (range from 9 to 28 days). Platelet recovery >50000/microl was observed at a median time of 26 days (range from 13 to 347days). Sixteen children (80 %) are alive and well in continuous complete remission from 4 to 36 months after transplantation (median +20). Three children (15%) relapsed and died because of the disease. One patient died in complete remission on day +41 because of aspergillosis. Transplant related mortality was 5,0%. Overall survival was 79%. Event free survival was 86% in NHL and 67% in ALL.

[The role of local surgical and radiological control in the treatment of soft tissue sarcoma sensitive to chemotherapy in children. Report of Polish Pediatric Solid Tumors Treatment Group]. / Udzial lokalnej kontroli chirurgicznej i radiologicznej w wynikach leczenia nowotworów tkanek miekkich wrazliwych na chemioterapie u dzieci. Raport PPG/GL.

In this paper the role local surgical and radiological control in the treatment of soft tissue sarcomas in children was analyzed. All children were treated according to CWS-91 and SIOP-IV protocols. Eighty three children with RMS A + E, EES/PNET, SS, UDS were included in the analysis. The primary surgery consisted of R0 (5%), R1 (18%) or R2 (16%) resection. In majority of cases (61%) primary surgical intervention was limited to diagnostic biopsy. Conventional or hyperfractionated radiotherapy was performed in 42.8%, 73.8% and 75% of children with disease stage II, III and IV, respectively. Delayed surgery was performed in 20 out of 53 (37.7%) children with stage III of the disease. In 5 patients without primary focus (urinary bladder in 3 and prostate in 2 cases) removed, progression of the disease occurred. In 5 children (stage IV) with progression of the disease no secondary surgery was performed. In 4 of them the primary tumor exceeded 10 cm in diameter. No delayed surgery was performed in 69% of relapsed children with stage III of the disease. Planned radiation therapy was not performed in 15.9% of cases. Primary local surgical control of primary tumor is of great importance for remission duration. In children who underwent delayed surgery the estimated EFS was of 0.7, in comparison with 0.5 EFS of those without secondary surgical treatment.

Recovery of natural cytotoxicity after bone marrow transplantation.

Reconstitution of non-MHC restricted cytotoxicity was followed in 7 and in 4 cases after auto- and allotransplantation, respectively. In autografted cases a high level of natural cytotoxicity, which exceeded the pre-transplant values, was seen at the beginning of hematological reconstitution. At that time, the high percentage of DR+ peripheral blood mononuclear cells (PBMC) was found, while the percentage of CD16+ cells was in the range of the pre-transplant values. A high level of cytotoxicity was a transient phenomenon. In all cases, 40 days after grafting the natural cytotoxicity was again in the range of the pre-transplant values. In allotransplantation the peak of cytotoxicity was seen soon after the beginning of hematological recovery and the activity decreased after 24 to 48 days after grafting.

Aggressive chemotherapy with autologous bone marrow transplantation in small cell lung carcinoma.

16 patients with an advanced stage SCLC were treated with the use of aggressive chemotherapy with bone marrow transplantation. With the gaining of experience the doses have been increased from standard-dose induction and 7 g/m2 of CTX in intensification to more aggressive induction (160 mg/kg of bw of CTX and 1.6 g/m2 VP-16 in two courses in 28 days interval) and intensification (CTX 7 g/m2 and VP-16 from 1.5 to 2.0 g/m2. Most recently, we used the following intensification which, in addition to the high dose CTX (6 g/m2), consisted of VP-16 0.9 g/m2 and BCNU 0.5 g/m2. The procedure proved to be safe. Hematological recovery emerged in all patients at a very similar time after autografting, irrespective to the late intensification regime. All cases, except one, received, after the hematological recovery, prophylactic cranial and at the primary tumor site irradiation as well as 2 to 4 courses of standard dose maintenance chemotherapy. The response rate was higher in the group receiving more aggressive induction and intensification. Long-term survival was seen only in patient which received more aggressive induction and intensification. Median survival of all cases was 13 months including 3 cases which are disease-free 24, 21 and 14 months after the beginning of the treatment.