Prophylactic red blood cell exchange for ABO-mismatched hematopoietic progenitor cell transplants.

BACKGROUND: To enhance donor availability, almost half of hematopoietic progenitor cell transplants (HPCTs) cross ABO blood type boundaries. ABO-incompatible HPCTs are well tolerated; however, there is an increased risk of delayed hemolysis in patients with minor and bidirectional ABO mismatches. Delayed hemolysis generally occurs 1 to 2 weeks after HPCT and is related to production of alloantibodies directed against recipient ABO red blood cell (RBC) antigens by passenger donor lymphocytes. One previous study has suggested that prophylactic RBC exchange in patients with minor and bidirectional ABO-mismatched HPCT reduces the risks of severe immune hemolysis, but this recommendation is controversial. STUDY DESIGN AND METHODS: Herein we describe our experience using prophylactic RBC exchange in patients with minor and bidirectional ABO-mismatched HPCTs who were deemed to be at high risk for immune hemolysis. We compare the group of patients that received prophylactic RBC exchange with a historical cohort of ABO-mismatched patients who underwent HPCT without prophylactic RBC exchange. RESULTS: Our study suggests that prophylactic RBC exchange in minor and bidirectional ABO-mismatched HPCT does not reduce severe immune hemolysis, nor does it improve 1-year survival, the number of RBC units transfused after transplant, or length of hospitalization after HPCT. CONCLUSION: This study failed to identify a clear role for selected prophylactic RBC exchange in patients who were deemed at risk for severe post-HPCT immune hemolysis.

Potential effects on groundwater quality associated with infiltrating stormwater through dry wells for aquifer recharge.

Dry wells (gravity-fed infiltration wells) have frequently been used to recharge aquifers with stormwater, especially in urban areas, as well as manage flood risk and reduce surface water body contamination from stormwater pollutants. However, only limited assessment of their potential adverse impacts on groundwater quality exists. Dry well recharge can bypass significant portions of the filtering-capacity of the vadose zone. Stormwater and groundwater monitoring data and analysis of transport of a wide range of historic and current-use stormwater chemicals of concern is lacking. To address these gaps, two dry wells were constructed with vegetated and structural pretreatment features to assess the likelihood of stormwater contaminants reaching the aquifer. We monitored, assessed, and compared the presence of contaminants in stormwater to water quality in the vadose zone and shallow groundwater after it passed through the dry well. The dry wells were installed at a suburban residential and at a suburban commercial site. The selected sites were overlying a regional, unconsolidated, and highly heterogeneous alluvial aquifer system. Stormwater, vadose zone, and groundwater samples were collected during five storms and analyzed for over 200 contaminants of concern. Relatively few contaminants were detected in stormwater, generally at low concentrations. Prior to stormwater entering the dry well, 50-65% of contaminants were removed by vegetated pretreatment. In groundwater, metals such as aluminum and iron were detected at similar concentrations in both upgradient and downgradient wells, suggesting the source of these metals was not dry well effluent. Naturally occurring metals such as chromium and arsenic were not detected in stormwater but were found at elevated concentrations in groundwater. A modeling assessment suggests that the travel time of metals and hydrophobic organic contaminants to the water table at these sites ranges from years to centuries, whereas water soluble pesticides would likely reach the water table within days to months. The modeling assessment also showed that more vulnerable sites with higher fraction of alluvial sands would have much shorter contaminant travel times. However, none of the contaminants assessed reached concentrations that pose a risk to human health across the scenarios considered. No evidence was found, either through direct measurements or vadose zone modeling, that contaminants present in suburban stormwater degraded or would degrade groundwater quality at the studied sites and site conditions. Future work is needed to address emerging contaminants of concern.

Extracorporeal photopheresis for the treatment of chronic graft versus host disease.

OBJECTIVES: Chronic graft versus host disease (chronic GVHD) still remains the leading cause of late morbidity and mortality for allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. In this retrospective study, 53 consecutive allo-HSCT patients with chronic GVHD refractory to corticosteroids were treated with extracorporeal photopheresis (ECP). METHODS: This study was performed as a retrospective single-center study. Medical records of a total of 59 patients treated with ECP for chronic GVHD were reviewed. RESULTS: Best organ responses to ECP were observed in skin, mouth mucosa, eyes and liver. Overall response rate (ORR) to ECP was 81.2% (CR 17% and PR 64.2%). Overall survival (OS) was 84.9% and 36.7%, at 1 and 3 years, respectively. Female sex appears to have an advantage on ORR. Patients achieving ORR were able to maintain their responses with a prolonged continuation of treatments for +6 and +12 months indicating the benefits of longer ECP treatment. DISCUSSION: We found that patients with chronic GVHD who were treated with ECP for 12 months or longer had a higher response rate. Our findings in line with the data reported previously suggest that patients responding to ECP should continue longer therapy schedules to achieve a better and sustained response. In our cohort, long-term ECP therapy was safe and well-tolerated with no significant adverse effects. Best responses were observed in the patients with skin, eye, liver and oral involvement. The ECP procedure offers the advantage relative to the problems with typical immunosuppressive agents. The female sex appeared to have an advantage based on the cumulative probability of the OR after ECP for chronic GVHD.

Autologous hematopoietic stem cell transplantation as an intensive consolidation therapy for adult patients in remission from acute myelogenous leukemia.

Autologous peripheral blood stem/progenitor cell transplantation (APBSCT) has been investigated as a potential therapeutic option to improve outcome in patients with acute myelogenous leukemia (AML). However, its optimal role in treatment for adults in remission has not been clearly established. We performed a retrospective analysis on 45 patients aged 21 to 73 years (median 51 years) with de novo AML who underwent APBSCT stratified by age, complete remission status, and cytogenetic risk. The 5-year disease-free survival (DFS) for all patients was 33.9% (95% confidence interval [CI], 20.1%-53.7%) and overall survival (OS) was 43.6% (CI, 29.2%-62.8%). For patients under the age of 60 years, the 5-year DFS for intermediate and high cytogenetic risk was 53.3% (CI, 23.5%-85.6%) and 50.0% (CI, 16.1%-100.0%); the 5-year OS for patients under the age of 60 years with low, intermediate, and high cytogenetic risk was 80.0% (CI, 40.0%-100.0%), 60.0% (CI, 31.2%-90.7%), and 75.0% (CI, 39.0%-100.0%), respectively. For patients over the age of 60 years, the 5-year DFS and OS for intermediate cytogenetic risk was 21.4% (CI, 7.9%-58.4%) and 21.4% (CI, 7.9%-58.4%). The DFS and OS of these patients are comparable to the historic survival of those who underwent allogeneic stem cell transplantation when adjusted by age. In addition, there was no treatment-related mortality (TRM). We conclude that APBSCT is a reasonable and safe intensive consolidation for patients with AML who do not have a suitable HLA-matched donor.

Food insecurity and obesity: a comparison of self-reported and measured height and weight.

OBJECTIVES: We used self-reported and measured height and weight data to examine the relationship between food insecurity and obesity. METHODS: We defined food insecurity according to 3 different models. We used self-reported and measured height and weight from 2 versions of the Canadian Community Health Survey to calculate obesity rates. RESULTS: When self-reported height and weight data were used in calculating obesity prevalence rates, rates were significantly higher among food-insecure respondents than among food-secure respondents; by contrast, when measured height and weight data were used, there were no significant differences. Female respondents classified as food insecure and experiencing mild hunger were at greater risk of obesity than were food-secure female respondents when measured height and weight were used. CONCLUSIONS: Associations between obesity and food insecurity are more pronounced when self-reported data on height and weight are used than when measured height and weight data are used. Caution should be used when using self-reported data to examine the relationship between food insecurity and obesity.

The nature and correlates of unmet health care needs in Ontario, Canada.

Using data from the Canadian Community Health Survey (CCHS) Cycle 1.2, we examine the nature of unmet mental health care needs in Ontario, Canada and how this is associated with socio-demographic, social support, health status and mental health service use factors. Unmet mental health care needs result from experiencing barriers to three issues: acceptability, accessibility and availability. Unmet needs due to acceptability issues are the most frequent type; the largest proportion of people within this category report experiencing unmet needs because they "preferred to manage the problem themselves". Unmet needs are greater among the young and among females. Surprisingly, service users report higher rates of unmet needs than non-users. Some social support variables have associations with unmet needs. Based upon these results, unmet needs pose a major challenge to the health care system since they cannot be resolved solely by enhancing access to and availability of mental health services. Thus, to address unmet mental health care needs, efforts should be focused on the acceptability barriers that women and young people in particular face. Enhancing education and certain social support mechanisms are potential strategies.

Aboriginal health learning in the forest and cultivated gardens: building a nutritious and sustainable food system.

Sustainable food systems are those in which diverse foods are produced in close proximity to a market. A dynamic, adaptive knowledge base that is grounded in local culture and geography and connected to outside knowledge resources is essential for such food systems to thrive. Sustainable food systems are particularly important to remote and Aboriginal communities, where extensive transportation makes food expensive and of poorer nutritional value. The Learning Garden program was developed and run with two First Nation communities in northwestern Ontario. With this program, the team adopted a holistic and experiential model of learning to begin rebuilding a knowledge base that would support a sustainable local food system. The program involved a series of workshops held in each community and facilitated by a community-based coordinator. Topics included cultivated gardening and forest foods. Results of survey data collected from 20 Aboriginal workshop participants are presented, revealing a moderate to low level of baseline knowledge of the traditional food system, and a reliance on the mainstream food system that is supported by food values that place convenience, ease, and price above the localness or cultural connectedness of the food. Preliminary findings from qualitative data are also presented on the process of learning that occurred in the program and some of the insights we have gained that are relevant to future adaptations of this program.