Benedetta Bartolozzi

Human striatal neuroblasts develop and build a striatal-like structure into the brain of Huntington's disease patients after transplantation.

Rebuilding brain structure and neural circuitries by transplantation of fetal tissue is a strategy to repair the damaged nervous system and is currently being investigated using striatal primordium in Huntingtons disease (HD) patients. Four HD patients underwent bilateral transplantation with human fetal striatal tissues (9-12 week gestation). Small blocks of whole ganglionic eminencies were processed to obtain cell suspension and then stereotactically grafted in the caudate head and in the putamen. Follow-up period ranged between 18 and 34 months (mean, 24.7 months). Surgery was uneventful. Starting from the fourth month after grafting, neo-generation of metabolically active tissue with striatal-like MRI features was observed in 6 out of 8 grafts. The increase in D2 receptor binding suggested striatal differentiation of the neo-generated tissue in 3 patients. New tissue, connecting the developing grafts with the frontal cortex and, in one case, with the ventral striatum, was also observed. The new tissue growth halted after the ninth month post transplantation. All patients showed stabilization or improvement in some neurological indices. No clinical and imaging signs, suggestive of graft uncontrolled growth, were seen. This study provides the first evidence in humans that neuroblasts of a striatal primordium can develop and move into the brain after neurotransplantation. Primordium development resulted in the building of a new structure with the same imaging features as the corresponding mature structure, combined with short- and long-distance targeted migration of neuroblasts. The results of this study support both the reconstructive potential of fetal tissue and the remarkably retained plasticity of adult brain. Further studies are necessary to assess the clinical efficacy of the human fetal striatal transplantation.

Percutaneous vertebroplasty and kyphoplasty in patients with multiple myeloma

To the Editor: Multiple myeloma (MM) is a plasma cell neoplasm characterized by osteolytic lesions with bone pain and pathological fractures. Vertebral involvement, mainly between the sixth thoracic and fourth lumbar is present in about 60% of patients at diagnosis (1). Treatments for pain management including chemotherapy, bisphosphonates, analgesic drugs and radiotherapy are often effective, but in some patients pain is refractory. Percutaneous cement augmentation, initially used in vertebral haemangiomas, has been employed also in osteoporotic and metastatic disease fractures and more recently in MM (2, 3). Vertebroplasty and kyphoplasty represent the main techniques performed in vertebral fractures with pain and/or neurological compression. Both (4) are employed to reinforce and stabilise vertebral fractures, whereas the latter has the advantage of creating one or more cavities in the collapsed vertebral body, which are later filled for stabilisation, thus reducing the risk of cement leakage and sometimes allowing the restoration of vertebral height (5). Both vertebral plastic techniques have been reported to be effective in terms of pain relief and functional outcome, and the major complications are cement leakage in the epidural or foraminal area (6) and pneumonia or venous thromboembolism (7). Herein, we report the outcome of 14 MM patients treated for one or more vertebral body fractures with vertebroplasty and/or kyphoplasty. In a prospective study, from September 2003 to January 2005, 19 procedures (10 kyphoplasty and nine vertebroplasty) were performed in 14 patients affected by MM, with vertebral pain refractory to conventional medical therapy (analgesics, bed rest and bracing with orthopaedic devices) because of vertebral body fractures documented by magnetic resonance imaging (MRI) or spiral computed tomography (CT) scan. Patients characteristics were: median age 54 years (range 49–72), 10 male/ four female, 13 patients were in stage IIIA and one in stage IIA (Durie Salmon), 11 IgG and three IgA. Five patients were at diagnosis, six under chemotherapy, one after autologous transplantation, two relapsed after allogeneic stem cell transplantation. The median pretreatment Karnofsky performances status (8) and Visual Analog Scale Pain Scores (VAS score) (9) were 50 (range 30–70) and 9(range 8–10) (0 no pain to 10 maximal pain), respectively. The levels involved ranged from T6 to S1. None of the patients had evidence of spinal cord compression at the time of vertebro/kyphoplasty. The technique was chosen on the basis of MRI and spiral CT scan: vertebroplasty was preferred in collapsed vertebral body, in case of wide destruction of the posterior lamina or in any case of increased bone density. Kyphoplasty was chosen when the risk of cement leakage was high for the vertebral instability. The procedures were performed via a percutaneous extrapedicular or transpedicular approach under local anaesthesia and light sedation with intravenous benzodiazepines and opioids under medical anaesthesiological observation. A bone biopsy, with the aim of confirming the nature of the lesions, was performed in each vertebra before the procedure. A total volume of 1–7 mL polymethylmethacrylate (PMMA) was injected under fluoroscopic guidance directly into each of the involved vertebra. In kyphoplasty, two inflatable bone tamps were inserted into the fractured vertebral body and the balloons were inflated at a maximum pressure of 200 psi to restore the vertebral body height; after deflating and withdrawing the balloons, the cavity was filled with PMMA. After 12 h of the procedure, all patients were monitored with spiral CT scan (Fig. 1A,B). Nineteen vertebra were treated; the maximum number of levels treated in one patient was three and all patients were discharged from hospital the day after the surgical treatment. All patients reported marked pain relief as soon as 24 h after the procedure; median Karnofsky grade and VAS score were 70 (range 60–90) and 3 (range 2–5), Eur J Haematol 2006: 76: 180–181 doi:10.1111/j.1600-0609.2005.00573.x All rights reserved Copyright Blackwell Munksgaard 2005

Epstein–Barr virus-associated post-transplant lymphoproliferative disease with central nervous system involvement after unrelated allogeneic hematopoietic stem cell transplantation

Post-transplant lymphoproliferative disorders (PTLD) represent an heterogeneous group of abnormal lymphoid proliferation related to Epstein–Barr virus (EBV) reactivation that arise early after allogeneic hematopoietic stem cell transplant (HSCT). PLTD with central nervous system (CNS) involvement has been reported in few cases. We describe the case of a 31-year-old-man who developed an EBV-related PTLD with CNS involvement 2 months after an allogeneic unrelated HSCT for acute myeloid leukemia in first complete remission who was successfully treated with rituximab, cidofovir and intrathecal infusion of methotrexate and methylprednisolone.

Increase in FOXP3+ regulatory T cells in GVHD skin biopsies is associated with lower disease severity and treatment response.

In animal models, CD4+/CD25+ T-regulatory cells (Tregs) have been reported to prevent/delay the onset of graft-versus-host disease (GVHD). Recently, an insufficient upregulation of Tregs was found in target organ (intestinal) biopsies from patients with GVHD. We have analyzed by immunohistochemistry the number of CD3+ T lymphocytes and FOXP3+ Tregs in skin biopsies from (1) recipients of allogeneic hematopoietic stem cell transplantation (HSCT, n = 26), (2) nontransplanted patients diagnosed with cutaneous drug reaction (n = 12), and (3) healthy donors (n = 10). Infiltrating CD3+ cells were significantly higher in both transplanted patients showing acute GVHD (aGVHD) and drug reaction when compared to healthy donors and patients without GVHD. Tregs number in aGVHD was higher than in patients without GVHD or healthy subjects and lower than in drug reaction. Interestingly, the number of infiltrating FOXP3+ Tregs was significantly higher in patients responding to GVHD treatment and with a low GVHD grade. Increase in FOXP3+ Tregs in GVHD skin biopsies correlates with less severe GVHD and is associated with response to GVHD treatment. Larger studies are required to confirm that evaluation of Tregs in minimally invasive skin biopsies assists the diagnosis and prognosis of GVHD patients.

Event-free survival and cost-effectiveness in adult acute lymphoblastic leukaemia in first remission treated with allogeneic transplantation.

Allogeneic transplantation in patients with acute lymphoblastic leukaemia in first remission (ALL-CR1) has been studied in several clinical trials. However, no pooled survival analysis has yet been done. We conducted a survival meta-analysis to compare allogeneic transplantation vs chemotherapy or autologous transplantation using an intention-to-treat approach. Our study included the controlled clinical trials, wherein allocation to allogeneic transplant was based on donor availability. The event-free individual survival data were reconstructed on the basis of published information and Kaplan–Meier graphs. We then generated the meta-analytic event-free survival curves for the two treatments. The mean survival gain per patient was estimated and a simplified cost-effectiveness assessment was carried out. In the allogeneic transplantation group, 293 patients were examined and 479 as controls (four trials). The event-free survival difference was statistically significant (P=0.011). The relative risk for event occurrence was 0.79 for the experimental group vs the controls (95% CI: 0.66–0.96; P=0.017). The mean survival gain was 1 year per patient. The cost per life-year gained was less than the conventional threshold of [euro ]50 000. Allogeneic transplantation in ALL-CR1 improves event-free survival as compared to chemotherapy or autologous transplantation. Its cost-effectiveness profile is acceptable.

Safety of Bone Marrow Stem Cell Donation: A Review

Allogeneic hematopoietic stem cell transplantation (HSCT) represents the first choice of treatment or an important therapeutic option for several diseases, but it is still marked by morbidity and mortality. In contrast, the donation of hematopoietic stem cells (HSCs) is considered to be a safe procedure. The invaluable ethical source of donation and its central role in transplantation implies that the greatest attention be due to the donor and to the donation process through a serious monitoring protocol for donor safety. Both the Joint Accreditation Committee and the European Committee pay particular attention to the notification of adverse events and adverse reactions. Bone marrow donation is a well established procedure, that has now been performed for >30 years. Although it does not require drug administration, there is hospital admission for 1-3 days with 7-10 days off work. The main risk is related to the anesthesia. Pain in the aspiration area, together with astenia are considered to be the most frequent side effects, as shown by the USA National Marrow Donor Program experience in 1,193 donations. In the European Group for Blood and Marrow Transplantation analysis performed between 1993 and 2005 on 27,770 first HSCTs from bone marrow, only 1 fatal event (pulmonary embolism) and 12 serious adverse events were observed. The most frequent adverse events were cardiac. The incidence of adverse events was significantly lower (P < .05) compared with peripheral blood HSC donors, which confirms the necessity of accurate attention to donor selection and evaluation in bone marrow donation.

Molecular epidemiological investigation of an outbreak of Pseudomonas aeruginosa infection in an SCT unit

From May to October 2006, six severe Pseudomonas aeruginosa infections were diagnosed in patients undergoing SCT in the SCT unit of the Careggi hospital (Florence, Italy). Four of the infected patients were treated consecutively in the same room (room N). On the hypothesis of a possible environmental source of infection, samples were collected from different sites that had potential for cross-contamination throughout the SCT unit, including the electrolytic chloroxidant disinfectant used for hand washing (Irgasan) and the disinfectant used for facilities cleaning. Four of the environmental samples were positive for P. aeruginosa: three Irgansan soap samples and a tap swab sample from the staff cleaning and dressing room. The AFLP (amplified fragment length polymorphism) typing method employed to evaluate strain clonality showed that the isolates from the patients who had shared the same room and an isolate from Irgasan soap had a significant molecular similarity (dice index higher than 0.93). After adequate control measures, no subsequent environmental sample proved positive for P. aeruginosa. These data strongly support the hypothesis of the clonal origin of the infective strains and suggest an environmental source of infection. The AFLP method was fast enough to allow a ‘real-time’ monitoring of the outbreak, permitting additional preventive measures.

Impact of Graft-versus-Host Disease Prophylaxis on Outcomes after Myeloablative Single-Unit Umbilical Cord Blood Transplantation

Myeloablative single-unit umbilical cord blood transplantation (sUCBT) using busulfan, thiotepa, fludarabine, and antithymocyte globulin (Grupo Español de Trasplante Hematopoyético [GETH]-2005 protocol) resulted in high rates of engraftment and high antitumor activity. We designed a new graft-versus-host disease prophylaxis, substituting long-term steroids with mycophenolate mofetil together with a slight reduction of antithymocyte globulin (GETH/Gruppo Italiano Trapianto Midollo Osseo [GITMO]-2008 protocol). The results in 145 consecutive patients were compared with those obtained in 88 patients from the previous GETH-2005 trial. The cumulative incidence (CI) of myeloid engraftment at 60 days for patients in the GETH-2005 and GETH/GITMO-2008 trials was 94% and 88%, respectively, at a median time to neutrophil recovery of 19 and 23 days, respectively (P < .0001). In the multivariable analyses, platelet engraftment, acute and chronic graft-versus-host disease, nonrelapse mortality, relapse, and event-free survival were not significantly different. The 3-year event-free survival rate in the GETH/GITMO-2008 trial was 66%, 31%, and 25% for patients transplanted in early, intermediate, and advanced stages of the disease, respectively (P < .0001). This study confirms that myeloablative sUCBT using busulfan-based conditioning is a valuable strategy for patients with hematological malignancies. The use of mycophenolate mofetil apparently had an adverse effect on myeloid engraftment, and therefore a cautious use of this agent is warranted in the UCBT setting.

Molecular Surveillance and Population Structure Analysis of Methicillin-Susceptible and Methicillin-Resistant Staphylococcus aureus in High-Risk Wards

ABSTRACT In this study we report the results of analysis of 253 isolates of Staphylococcus aureus (132 methicillin [meticillin]-resistant S. aureus [MRSA] isolates and 121 methicillin-susceptible S. aureus [MSSA] isolates) from 209 patients admitted to 18 high-risk wards of six hospitals located in Florence, Italy, over an 8-month period during which a program of epidemiological surveillance of hospital-acquired infections was conducted. The majority (69%) of the 87 reported S. aureus infections were caused by MRSA. No outbreak events have been reported. All the isolates were typed by amplified fragment length polymorphism (AFLP), and AFLP profiles were analyzed in order to define similarity groups. The discriminatory power of AFLP is very high with MSSA (Simpson index of diversity [D], 95.9%), whereas its resolution capability with MRSA (D, 44.7%) is hampered by the well-known high clonality of these populations (the main MRSA group accounted for 74% of the MRSA isolates). Combining AFLP, improved by visual inspection of polymorphisms, with multiplex PCR greatly increases MRSA resolution (D, 85.5%), resolving the MRSA population to a level that is one of the highest reported in the literature. Widespread and sporadic clones of MSSA and MRSA were identified, and their diffusion in the different hospitals and wards over the surveillance period was studied. The understanding of MSSA and MRSA population structures should be the starting point for the design of a more rational surveillance program for S. aureus species, maximizing benefits and reducing the cost of infection control strategies.

A prospective, open-label noncomparative study with piperacillin-tazobactam monotherapy as management of fever in patients with acute leukemia.

Abstract We evaluated the efficacy of piperacillin-tazobactam monotherapy as empiric therapy of fever in acute leukemia patients in a total of 80 consecutive febrile episodes. The overall success rate was 75% with success without modification in 34% (afebrile at 72 h) and an overall death rate of 10%. No significant differences were seen in correlation between clinical outcome and phases of underlying disease. The success without modification was higher in patients with fever of unknown origin (FUO) than in those with documented infections (47% and 25% respectively). There were no significant differences in correlations between clinical response and degree of neutropenia. Our study suggests that empirical first-line monotherapy with piperacillin-tazobactam may be a reasonable option in patients with acute leukaemia, although in documented infections the response is frequently inadequate.