Peripheral blood stem cell mobilization in multiple myeloma comparison of two consecutive regimens in a limited resources country.

This study compared retrospectively the effectiveness, toxicity and hematopoietic recovery after autologous peripheral blood stem cell transplantation (ASCT) of two consecutive peripheral blood stem cell mobilization regimens in newly diagnosed MM patients. Patients in group 1 (n=178) were treated with 4 g/m2 of cyclophosphamide (CY) plus G-CSF (5 µg/kg/day). Patients in group 2 (n=117) with 750 mg/m2 of VP16 plus G-CSF (10 µg/kg/day). Optimal mobilization, defined by a target number of 8 × 106 CD34+ cells/kg collected, was achieved in 62.4% and 89.7% of patients in groups 1 and 2, respectively (P<10-4). The median number of aphaeresis sessions was reduced from two in group 1 to one in group 2 (P<10-4). Grade4 neutropenia, febrile neutropenia and IV antibiotic use were significantly more frequent in group 1 than in group 2 (P<10-4). Red blood cell transfusion requirements were significantly greater in group 1 (P=0.007). The switch to VP16-G-CSF10 resulted in a significant reduction of the number of hospitalization days (P<10-4). Neutrophil and platelet recovery after ASCT occurred on days 11 and 12, respectively, in the two groups with no significant differences. VP16+G-CSF10 allowed liberation of resources in the clinical and aphaeresis departments and demonstrated a better effectiveness-safety profile than CY+G-CSF5.

[Significance and contribution to the diagnosis of multiple myeloma according to the IGF1-R gene expression profile]. / Profil d'expression du gène IGF1-R dans le myélome multiple: signification et apport au diagnostic.

Multiple myeloma (MM) is a still incurable adult's severe hematologic malignancy. It is characterized by deregulation of several cytokines and their receptors. Among these cytokines, Insulin growth factor 1 (IGF1) and its receptor (IGF1-R) are well documented as major factor of malignant plasma cells growth and survival in multiple myeloma. The objective of this study was to analyze the expression of IGF1-R in multiple myeloma at diagnosis in correlation with clinical and biological data. IGF1-R gene plasma cells expression was studied in 47 patients and 17 controls by Taqman technology RT-PCR. IGF1-R gene was down expressed in the malignant plasma cells of MM patients at diagnosis compared to normal plasma cells, isolated from healthy donors (p = 0.01). Expression decrease was accentuated in the disease advanced stage IIIB. A negative correlation was found between IGF1-R malignant plasma cells expression and the percentage of bone marrow invasion (p = 0.03). Bone marrow infiltration greater than 30% was significantly associated with a low level of IGF1-R gene expression (p = 0.04). Our results suggest that the decreased expression of IGF1-R by malignant plasma cells is a prognostic factor associated with severe disease. Understanding of mechanisms involved in IGF1-R expression negative regulation may contribute to the discovery of new targets therapy in myeloma. the discovery of new targets therapy in myeloma.

Monitorage de l'infection active a CMV par deux methodes : antigenemie PP65 et PCR qualitative sur plasma

Au cours de ce travail nous avons evalue deux methodes diagnostiques de l'infection active a CMV (antigenemie pp65 CMV et PCR qualitative) quant a leur utilite dans le monitorage de cette infection. Notre travail a porte sur 31 patients allogreffes de moelle osseuse dont 22 ont developpe une infection active a CMV. Le pourcentage des antigenemies positives etait de 59contre 28PCR positives. En mediane; les PCR se sont positivees 14 jours apres l'antigenemie. La duree de positivite de l'antigenemie etait de 5 semaines contre une semaine pour la PCR et la positivite de la PCR n'etait jamais isolee. Le taux de concordance de 61;5entre les deux techniques et le coefficient ( = 0.50) modere temoignerait d'un degre moyen de precision des resultats. La PCR sur plasma a presente une association plus importante avec la maladie a CMV (p= 0;014). La GVHD etait le seul facteur favorisant l'infection active a CMV (p=0;02). Cette derniere (p= 0;001) et la maladie a CMV (p= 0;04) ont presente des facteurs de mauvais pronostic chez nos patients. L'antigenemie constitue une methode de choix pour le diagnostic et le monitorage de l'infection active a CMV. Alors que la PCR qualitative sur plasma ne presente pas d'interet dans ce contexte

Allogeneic hematopoietic stem cell transplantation for acquired aplastic anemia using cyclophosphamide and antithymocyte globulin: a single center experience.

Between February 1998 and October 2007, 97 (69 male, 28 female) patients with acquired aplastic anemia and a median age of 18 years (range, 2-39) received related allogeneic hematopoietic stem cell transplantation. Ninety-five patients received bone marrow grafts and two patients G-CSF primed peripheral blood stem cell transplantation. The donors were genotypically HLA-identical siblings in 94 cases, HLA-matched parents in 2 cases and a syngeneic twin in 1 case. Median time from diagnosis to transplantation was 2 months (range, 1-15). Conditioning regimen consisted of cyclophosphamide combined with antithymocyte globulin in all patients. For graft versus host disease (GVHD) prophylaxis, all patients received methotrexate and cyclosporine. Eighty-six patients showed evidence of hematopoietic engraftment. Eight patients died before engraftment. Rejection rate was 14.8% with three primary graft failures and eight secondary graft rejections occurring between 2 and 27 months post transplantation. Of the 11 rejecting patients, 3 died from infection and 8 proceeded to a second transplantation. Among the eight patients re-transplanted, seven are alive with successful second engraftments and one died from acute grade III GVHD. Acute GVHD occurred in 15.5% and extensive chronic GVHD in only 5.3% of patients. The 4-year overall probability of survival was 76.8%. Infection was the cause of 81.1% of deaths. The major factor affecting survival was onset of infection before transplantation. Major ABO donor-recipient incompatibility, disease severity and acute GVHD had also negative impact on survival. These results could be improved by reducing the time to transplant and by a more efficient supportive care policy.Bone Marrow Transplantation advance online publication, 27 July 2009; doi:10.1038/bmt.2009.175.

[Epidemiological retrospective survey intestinal parasitism in the Provincial Hospital Center (Kenitra, Morocco): review of 10 years (1996-2005)]. / Enquête épidémiologique rétrospective sur les parasitoses intestinales au Centre hospitalier provincial El Idrissi (Kénitra, Maroc) : bilan de 10 ans (1996-2005).

The survey drew up the epidemiological situation of intestinal parasitism in the center of health El Idrissi (Kenitra, Morocco). The number of reviews has decreased between 1996 and 2005. A correlation between the number of examinations and years of the study period was observed (p <0.001). 4285 stool specimens collected in 1996-2005 were tested by parasitologic examination. Among the persons examined, 606 of them were parasited by one or several species, say an infestation index of 14.15%. Amoeba were frequently observed (47.04%) with prevalence of Entamoeba histolytica (23.74%), followed by Flagella (28.79%) represented by: Giardia intestinalis (22.71%), Trichomonas intestinalis (5.49%) and Chilomastix mesnilii (0.60%). Helminthes were less found. Ascaris lumbricoides was frequent among helminthes (11.87%), followed by Trichuris trichiura (5.64%), Hymenolepis nana (2.68%), Enterobius vermicularis (2.08%), Taenia saginata (0.75%) and Stronyloides stercoralis (0.45%). The clinical symptoms were observed in 110 subjects with parasites (110/606 or 18.15%) characterized by abdominal pain (75 cases) and association diarrhea more abdominal pain (35 cases). The relationship between the infestation index calculed, sex, age, the annual and seasonal changes, polyparasitism and intestinal parasitic infection is discussed.

Allogeneic hematopoietic stem cell transplantation in Tunisia.

In 1998, the Tunisian team of the 'Centre National de Greffe de Moelle Osseuse' initiated allogeneic hematopoietic SCT (AHSCT) in Tunisia. As of June 2007, information was collected about 299 patients with a first AHSCT and 12 additional retransplants. The median age was 19 years (range 2-49 years). The main indications were aplastic anemia (n=106, 36%), leukemia and nonmalignant disorders (n=153, 51%), Fanconi anemia (n=26, 9%) and other nonmalignant disorders (n=14, 4%). Preparative regimens depended on indication. All donors were HLA geno-identical. The stem cell sources were BM (87%) and PBSCs (13%). At the time of analysis, 200 patients (67%) were alive after a median follow-up of 42 months (range 3-112 months). The overall TRM rate was 17%. Outcome depended on indication. According to our results, allogeneic HSCT is potentially curative for hematological diseases, but it is a toxic approach for malignant disorders.

Analysis of cytomegalovirus (CMV) viremia using the pp65 antigenemia assay, the amplicor CMV test, and a semi-quantitative polymerase chain reaction test after allogeneic marrow transplantation.

A pp65 antigenemia assay for polymorphonuclear leukocytes (PMNLs) (CINAkit Rapid Antigenemia), and a qualitative polymerase chain reaction (PCR) test for plasma 'PCR-P qual' (Amplicor cytomegalovirus [CMV] test) were performed for 126 samples (blood and plasma) obtained from 18 bone marrow transplant patients, over a 9-month surveillance period. Among those samples, 92 were assayed with a semi-quantitative PCR test for PMNLs 'PCR-L quant.' The number of samples with a positive CMV test for antigenemia and PCR-P qual assays was 20.63% and 12.7%, respectively, whereas the PCR-L quant assay was positive in 48 of the 92 samples assayed (52.17%). The rates of concordance of the results of PCR-P qual and antigenemia, PCR-P qual and PCR-L quant, antigenemia and PCR-L quant were 92%, 65.2% and 66.8%, respectively. The analysis of the results for the 92 specimens tested by all 3 methods showed a rate of concordance of 63% among all methods. Good agreement (kappa=0.72) was found only between pp65 Ag and PCR-P qual assays. Clinical disease correlates with an antigenemia high viral load. Three patients had CMV disease despite preemptive therapy, and all of them had graft-versus-host-disease (GVHD). PMNLs-based assays are more efficient in monitoring CMV reactivation, but for high-risk patients with GVHD, more sensitive assays (real-time PCR) must be done.

[Prognosis value of the pp65 antigenemia and semi-quantitative PCR in the detection of the CMV reactivation in bone marrow grafted patients]. / Valeur pronostique de l'antigénémie pp65 et de la PCR semi-quantitative dans la détection de la réacti- vation du CMV chez les greffés de moelle osseuse.

In this article a Cytomegalovirus (CMV) antigenemia and semiquantitative PCR retrospective evaluation of 26 bone marrow allo-grafted patients for different haematological disease is reported. Eighteen patients had a CMV reactivation despite a prophylactic treatment, seven of those patients had both positive antigenemia pp65 and positive semi-quantitative CMV PCR. During CMV reactivation, 3 patients developed a CMV disease despite a pre-emptive therapy. The follow up of the antigenemia was performed since D21 until D100 post transplantation, the antigenemia positivity occurred at D53 and was preceded about 7 days by CMV PCR positivity The CMV disease wasn't associated with a high viral load. All patients that had CMV reactivation had a positive CMV serology before the graft, whereas only 37.5% of the patients who did not reactivate had a positive CMV serology. Respectively half patients who reactivated and only 12.5% of those who didn't had a Graft versus host disease (GVHD), witch preceded the reactivation about 21 days in six of the formers. Clinical and biological signs presented by our patients in this cases report, seems to be associated more with the GVHD than with CMV reactivation.

Detection of catheter-related bloodstream infections by the Gram stain-acridine orange leukocyte cytospin test in hematopoietic stem cell transplant recipients.

In patients with central venous catheters (CVCs), catheter-related bloodstream infections (CRBI) are a prominent cause of morbidity, excess hospital costs, and in some cases mortality. The aim of this prospective study was to assess the validity of the Gram stain-acridine orange leukocyte cytospin (AOLC) test for the diagnosis of CRBI in hematopoietic stem cell transplant (HSCT) recipients with nontunnelled CVCs, using the differential-time-to-positivity (DTP)/clinical criteria as the criterion standard to define CRBIs. CVCs were externalized, nontunnelled, polyurethane double lumen catheters (Arrows, Readings, USA). All CVCs were placed in the subclavian vein by the infraclavicular approach, in the operating room. Catheters were inserted percutaneously, using the Seldinger technique. Study catheters were not exchanged over guidewires. Between May 2002 and December 2004, a total of 245 consecutive patients were included. Twenty-six of the 245 patients (10.6%) had CRBI as determined by the DTP method. The Gram stain-AOLC was positive in only two patients (7.6%) with a CRBI. Our results suggest that the Gram stain-AOLC test is not useful for the diagnosis of catheter-related bloodstream infection in HSCT recipients.2006.

Prospective randomised comparison of the COBE spectra version 6 and haemonetics MCS(+) cell separators for hematopoietic progenitor cells leucapheresis in patients with multiple myeloma.

A randomised crossover trial of two separators was undertaken to compare the mononuclear cell, CD34(+) cell and CFU-GM yield, in patients (<61 years) with previously untreated symptomatic multiple myeloma. After first-line therapy, all patients received mobilising chemotherapy (cyclophosphamide 4 g/m(2)) and daily G-CSF. The first leucapheresis was performed on the first day the peripheral blood absolute CD34(+) cell count was > 20 cells/microl. All patients underwent 2 leucaphereses on consecutive days. The patients were randomised to undergo either the first or second leucapheresis using the COBE Spectra. The target duration of the procedure on the COBE Spectra was 2 total blood volumes, and for the Haemonetics MCS(+) it was 20 cycles with four recirculations. Between September 2003 and March 2005, 60 patients were entered in the study. COBE Spectra version 6 processed significantly larger volumes of blood than the Haemonetics MCS(+) (8,845 and 5,680 ml, respectively, P < 0.01). The absolute yield of mononuclear cells (2.1 vs. 1.5 x 10(8)/kg, P = 0.04), CFU-GM (11 vs. 3 x 10(4)/kg, P = 0.01) and CD34(+) cells (3 vs. 1.7 x 10(6)/kg, P = 0.02) were all significantly higher with the COBE Spectra version 6, as were the yields per unit volume of blood processed. In conclusion, our study shows that COBE Spectra Version 6 is faster and has a better yield than the Haemonetics MCS(+), in patients with multiple myeloma.

Bone marrow transplantation from matched related donors for patients with Fanconi anemia using low-dose busulfan and cyclophosphamide as conditioning.

Seventeen patients with Fanconi anemia (FA) underwent allogeneic bone marrow transplantation (BMT) from matched related donors (MRD) between January 1999 and June 2003. Median age at BMT was 11 years. Conditioning regimen consisted of low-dose cyclophosphamide (CY; 40 mg/kg) and busulfan (BU; 6 mg/kg) with the addition of lymphoglobulin (20 mg/kg) in two patients. Graft-versus-host disease (GVHD) prophylaxis included cyclosporine A (CsA) and methotrexate (MTX; 5 mg/m(2) at day 1, 3, 6). All patients engrafted (for an absolute neutrophil count >0.5 x 10(9)/L) after a median time of 12 days (range 10-16 days). Fourteen patients (82%) had sustained grafts, whereas three others (18%) rejected grafts between day +39 and +80 after transplantation. Two of them are still alive after successful second PBSC transplantation and one died. Acute and chronic GVHD occurred in 23% and 13% of patients, respectively. With a median follow-up of 16 months (range 3-53 months), survival rate was 72% and Karnofsky score was at least 90%. The low-dose BU/CY regimen, in FA patients allografted from an HLA-matched related donor, allowed engraftment with relative low toxicity. Early graft failure (GF) remains a problem and may require modification of this regimen.

Prevalence of inherited prothrombotic abnormalities and central venous catheter-related thrombosis in haematopoietic stem cell transplants recipients.

In this prospective study, we assessed the incidence of central venous catheter (CVC)-related thrombosis in haematopoietic stem cell transplant (HSCT) recipients. We determined the contribution of inherited prothrombotic abnormalities in blood coagulation to CVC-related thrombosis in these patients. The study was conducted between May 2002 and September 2004. CVCs were externalized, nontunneled, polyurethane double lumen catheters. Before catheter insertion, laboratory prothrombotic markers included factor V Leiden, the prothrombin gene Gly20210A mutation, plasma antithrombin levels, and protein C and S activity. All patients were systematically examined by ultrasonography just before, or <24 h after, catheter removal, and in case of clinical signs of thrombosis. A total of 171 patients were included during the 28-month study period. Five (2.9%) and three (1.7%) patients had evidence of protein C and protein S deficiency, respectively. Only one patient had an antithrombin deficiency (0.6%). In total, 10 patients (5.8%) were heterozygous for the factor V Leiden mutation, and one patient had heterozygous prothrombin G20210A mutation (0.6%). We observed a CVC-related thrombosis in 13 patients (7.6%). Thrombosis was diagnosed in four out of 20 patients (20%) with a inherited prothrombotic abnormality compared to nine of 151 patients (6%) who did not have a thrombophilic marker (relative risk 3.3 CI 95% 1.1-9.9). Our results suggest that inherited prothrombotic abnormalities contribute substantially to CVC-related thrombosis in HSCT recipients. In view of physicians' reluctance to prescribe prophylactic anticoagulant treatment in these patients, a priori determination of inherited prothrombotic abnormalities may form a basis to guide these treatment decisions.

First-line thalidomide-dexamethasone therapy in preparation for autologous stem cell transplantation in young patients (<61 years) with symptomatic multiple myeloma.

Thalidomide-dexamethasone therapy was given in patients (<61 years) with previously untreated symptomatic multiple myeloma. The aim of this study was to assess the efficacy and toxicity of this combination as first-line therapy, and to determine its effect on stem cell collection and engraftment. During first-line therapy, thalidomide and dexamethasone were administered for 75 days (200 mg/day) and 3 months, respectively. The monthly dose of dexamethasone was 20 mg/m2/day for 4 days, with cycles repeated on days 9 to 12 and 17 to 20 on the first and the third month of therapy. After first-line therapy, a collection of peripheral blood stem cells (PBSC) was performed. Between May 2003 and September 2004, 60 patients were included. On an intent-to-treat basis, the overall response (> or =partial response) rate was 74%, including 24% of patients who obtained a complete remission. Grade 3-4 toxicities consisted of infections (12%), deep-vein thrombosis (3%), constipation (5%), and neuropathy (5%). A total of 58 patients (96%) proceeded to PBSC mobilisation and yielded a median number of 8 x 10(6) CD34+ cells/kg. First-line thalidomide-dexamethasone therapy is effective and relatively well tolerated in young patients with symptomatic multiple myeloma. This combination does not affect PBSC mobilisation.

Difference in time to positivity is useful for the diagnosis of catheter-related bloodstream infection in hematopoietic stem cell transplant recipients.

Catheter-related bloodstream infections are associated with recognized morbidity and mortality. Accurate diagnosis of such infections results in proper management of patients and in reducing unnecessary removal of catheters. We carried out a prospective study in a bone marrow transplant unit to assess the validity of a test based on the earlier positivity of central venous blood cultures in comparison with peripheral blood cultures for predicting catheter-related bacteremia. Between May 2002 and June 2004, 38 bloodstream infections with positive simultaneous central venous catheter and peripheral vein blood cultures were included. A total of 22 patients had catheter-related bacteremias and 16 had noncatheter-related bacteremias, using the catheter-tip culture/clinical criteria as the criterion standard to define catheter-related bacteremia. Differential time to positivity of 120 min or more was associated with 86% sensitivity and 87% specificity. In conclusion, differential time to positivity of 120 min or more is sensitive and specific for catheter-related bacteremia in hematopoietic stem cell transplant recipients who have nontunnelled short-term catheters.

[Bronchoscopy in the diagnosis of complicated pulmonary hydatid cyst in children]. / L'apport de la bronchoscopie pour le diagnostic du kyste hydatique pulmonaire compliqué de l'enfant.

The diagnosis of pulmonary hydatid cysts in children is generally easy and does not require endoscopic exploration, because the radiological aspects of an intact or a complicated cyst are most often suggestive. There are, nevertheless, some cases of pulmonary hydatids where the cyst is partially evacuated and then infected, whose radiological image is atypical showing parenchymatous opacities (systematised or not) which are readily associated with adenopathy. Usually immunology fails to aid the clinician in this later stage in the cyst's evolution. Two recent cases are reported of Tunisian children aged 5 and 10 years old with chronic pulmonary opacities posing a diagnostic problem. One child presented with a persistent cough, the other with recurrent haemoptysis and both had negative immunology. Bronchoscopy enabled a positive diagnosis to be made in both cases by showing the presence of an intra-bronchial membrane. A simultaneous bronchogram showed an arrest of the contrast in the affected bronchial segment. Although non specific, this image of arrested contrast should in our opinion be discussed in the differential diagnosis when the membrane could not be seen at bronchoscopy. At operation surgery confirmed the retention of infected membrane but in our two children infection had led to the destruction of a lower lobe which was removed. These situations where the diagnosis of pulmonary hydatids is difficult are far from being rare in countries of hgh endemiology such as Tunisia. Our observations show the advantage of bronchoscopy, which sometimes enable one to see or to remove a fragment of the membrane and thus entrust the child to a surgeon with a definitive diagnosis.