C. Th. Smit Sibinga

Cyclophosphamide and VP 16-213 with autologous bone marrow transplantation. A dose escalation study

In 13 patients with therapy-resistant solid tumors the feasibility of high-dose cyclophosphamide (7 g/m2) in combination with increasing doses of VP 16-213 with autologous bone marrow transplantation was studied. Dose-limiting extramedullary toxicity appeared to be mucositis and occurred after 2.5 g/m2. Two toxic deaths were observed in patients older than 55 yr. Responses were seen in eight out of nine evaluable patients. Two patients with ovarian cancer still have no signs of disease progression after 12+ months. High-dose cyclophosphamide (7 g/m2) can be combined with VP 16-213 1.5 g/m2 without important extramedullary toxicity. Age is probably a limiting factor for this kind of therapy.

Intensive chemotherapy with autologous bone marrow transfusion as primary treatment in women with breast cancer and more than five involved axillary lymph nodes

Patients with breast cancer and a high number of involved axillary lymph nodes have a poor prognosis, despite adjuvant chemotherapy. The 5-year disease-free survival (DFS) in this group amounts to 30-40% and the 10-year DFS is only 15-20%. Therefore, new treatment modalities are being sought for this group of patients. The aim of the present study was the evaluation of the efficacy of high-dose chemotherapy combined with autologous bone marrow support. 24 patients with a primary breast cancer with more than five involved axillary lymph nodes received, after surgery, six courses of induction chemotherapy followed by ablative chemotherapy and reinfusion of autologous bone marrow. All patients were premenopausal or less than 2 years postmenopausal. Induction chemotherapy consisted of methotrexate (MTX) 1.5 g/m2 intravenous (i.v.) and 5-fluorouracil (5-FU) 1.5 g/m2 i.v. on day 1, prednisone 40 mg/m2 orally on days 2-14, doxorubicin 50 mg/m2 i.v. and vincristine 1 mg/m2 i.v. on day 14. Courses were repeated six times every 4 weeks. 10 patients received cyclophosphamide 7 g/m2 i.v. and etoposide 1.5 g/m2 i.v. as intensive regimen, in 14 patients this comprised mitoxantrone 50 mg/m2 i.v. and thiotepa 800 mg/m2 i.v. Reinfusion of autologous marrow followed on day 7. Finally, patients received locoregional radiotherapy for extranodal disease and tamoxifen 40 mg daily orally over a period of 2 years. The median age of patients was 42 years, range 29-54. The median number of involved nodes was 10. During induction therapy, fever requiring i.v. antibiotics occurred in 4% of 144 courses, 14% of patients suffered from mucositis WHO grade 2-3, and the other patients had mucositis grade 1. During the ablative chemotherapy, 1 patient died, 6 developed septicaemia, 5 showed mucositis grade 3-4 and the other patients had mucositis grade 1 or 2. In the follow-up, 1 patient died from acute cardiac failure. Reversible radiation-induced pneumonitis occurred in 7 out of 14 irradiated patients; symptoms started directly following radiotherapy and lasted for several weeks, but disappeared in due course. During follow-up, 2 patients with six and > 10 positive nodes, respectively, have relapsed after 18 and 36 months, both in the cyclophosphamide/etoposide regimen. Median observation is 3 years, disease-free survival at 5 years is predicted to be 84%. Intensive treatment in these patients with high numbers of involved axillary lymph nodes is a toxic regimen, but may improve the chance of surviving free of disease.

Bedside practice of blood transfusion in a large teaching hospital in Uganda: an observational study

Background: Adverse transfusion reactions can cause morbidity and death to patients who receive a blood transfusion. Blood transfusion practice in Mulago Hospital, Kampala, Uganda is analyzed to see if and when these practices play a role in the morbidity and mortality of patients. Materials and Methods: An observational study on three wards of Mulago Hospital. Physicians, paramedics, nurses, medical students and nurse students were observed using two questionnaires. For comparison, a limited observational study was performed in the University Medical Centre Groningen (UMCG) in Groningen, The Netherlands. Results: In Mulago Hospital guidelines for blood transfusion practice were not easily available. Medical staff members work on individual professional levels. Students perform poorly due to inconsistency in their supervision. Documentation of blood transfusion in patient files is scarce. There is no immediate bedside observation, so transfusion reactions and obstructions in the blood transfusion flow are not observed. Conclusion: The poor blood transfusion practice is likely to play a role in the morbidity and mortality of patients who receive a blood transfusion. There is a need for a blood transfusion policy and current practical guidelines.

Effect of EDTA on Platelet Count and Other Platelet Parameters in Blood and Blood Components Collected with CPDA-1

We have shown in this study that addition of dried K2EDTA (1.5 mg/ml) to blood samples anticoagulated with CPDA‐1 increases significantly the platelet count and mean platelet volume (MPV) of whole blood, red cell concentrate (RCC) and platelet concentrate (PC), but not of platelet‐rich plasma (PRP) or of platelet‐poor plasma (PPP). Transmission and scanning electron microscopy illustrated that platelet aggregates which are present in some components are dispersed on mixing of the sample with EDTA and that this is accompanied by a change in platelet morphology. Determination of the platelet distribution width (PDW) indicated that the platelet populations in whole blood and RCC seem to be more uniform in size than the populations in PRP, PPP and PC. The determination of MPV and PDW changes after addition of EDTA may provide a new approach to quality control of PC.

Platelets for transfusion: Collection, processing and preservation aspects

As was true in cases of haemophilia, patients with severe thrombocytopenia or thrombocytopathy previously died of haemorrhage in a distressingly predictable manner. Over the past two decades such deaths could increasingly be prevented by increased availability and use of platelet transfusions. Platelet therapy has prevented fatal haemorrhage following treatment with drugs that temporarily suppress platelet production in cancer and leukaemia patients. However, collection, preservation and transfusion of platelets have introduced complex problems due to the specific nature and behaviour, both in vitro and in vivo, of the human thrombocyte. Biochemical and ultrastructural studies have revealed the principle conditions for ex vivo survival and preservation of function in order to guarantee adequate in vivo recovery and haemostatic capacity. However, controversies have arisen from the practice of collection, processing and preservation technology. The relative merits, therefore, of the various methods for obtaining and storing platelets remain unclear, although certain issues have been clarified such as temperature of storage, pH, volume to number relationship and the necessity of agitation. A number of problems remain, such as the advantages and disadvantages of platelets obtained from multiple and single donors, contaminating white cells, the effect of platelet preservation medium and the precise role of platelet transfusion in supportive haemotherapy.

Factor VIII:C assay: influence of buffer components used in immunoaffinity chromatography for purification of factor VIII/von Willebrand factor.

A monoclonal antibody purified factor VIII concentrate containing FVIII/vWF complex has been assayed by one-stage clotting (CA) and chromogenic substrate (CSA) methods. The influences of potassium iodide (KI) and albumin in combination with predilution buffers, standards and storage of samples have been examined. These components are compared for their effect on FVIII potencies in final product and in-process controls. FVIII:C purified by immunoaffinity chromatography can not be measured reliably by CA or CSA, because of KI which interfere on the assay. Overall yield of FVIII, efficiency of IAC step and purity of FVIII can be determined by assaying the desalted samples.

Bleeding Prophylaxis in Autologous Bone Marrow Transplantation for Solid Tumors

Bleeding prophylaxis with cryopreserved autologous thrombocytes was evaluated in 43 patients treated with high-dose chemotherapy and autologous bone marrow transplantation. Platelet transfusions were given prophylactically. Nineteen patients received only autologous, 10 only fresh allogeneic single-donor, and 14 both types of transfusions. The effects of 104 autologous versus 93 allogeneic thrombocyte transfusions were compared. The increment at 1 h was for allogeneic platelets twice that for autologous platelets (30.6 versus 15.2 x 10(9)/l), but the interval between transfusions in days (2.3) was the same. Twelve patients received alternating autologous platelet transfusion after washing out the cryoprotectant dimethyl sulfoxide (18 transfusions) and non-washed autologous platelets (24 transfusions). Platelet increments, corrected increments, and predicted recovery were not influenced by omitting the washing procedure, and no side effects of dimethyl sulfoxide occurred.

Cellular engineering and cellular therapies

Cellular Engineering and Cellular Therapies - an Overview.- Gene Therapy 2002: A New Start.- Stem Cells: Potential, Selection and Plasticity.- The Potential of Stem Cell Transplantation to Rescue the Failing Liver.- The New Regulatory Environment for Cellular Therapy Products: Challenges for Academic-Based Manufacturing Facilities.- Biological Modification of Lymphocytes on Auto- and Allo-Immune Diseases.- Cell Harvest and Purification Technology - State of the Art and Future Development.- Cell Manipulation and Engineering - State of the Art and Future Developments.- Cellular Immunotherapy - Towards Direct DC Activation for Licence to Kill.- From Research to Clinical Application - the Quality Concept.- Factors Controlling Expansion and Maturation of Haematopoietic Progenitor Cells.- Cell Processing for Gene and Cell Therapy Protocols: Limitations and Opportunities!.- State of the Art in Dendritic Cell Vaccination.- Reconstituting T Cell Immunity Following Hematopoietic Stem Cell Transplantation.- State of the Art in Gene Therapy.- New Horizons in Cellular Therapies.- Cellular Engineering and Cellular Therapies - Transfusion Medicine and the Academic World.

The Use of Fresh Plasma and a Plasma-free Medium to Enhance the Aggregation Response of Stored Platelets

Platelet aggregation in response to ADP (10 µM) and collagen (4 µg/ml) in fresh and stored platelet concentrates (PC) and the enhancement of aggregation of the stored platelets after resuspension in fresh plasma and plasma-free medium were measured. The ability of platelets in autologous plasma to respond to the two agonists decreased significantly on days 2 and 5 of storage to 18 and 4% (p < 0.001) respectively of that seen in platelet-rich plasma on day 0 (100%). A 2-fold or greater improvement (p < 0.01) in the aggregation response was achieved when the autologous plasma in stored PC was replaced by fresh allogeneic plasma just before testing. The effect was even greater (three-fold or more, p < 0.001) when the autologous plasma was first replaced by plasma-free medium followed by suitable dilution for the test in fresh allogeneic plasma. These observations indicate another way to rejuvenate stored platelets and enhance their residual capacity to aggregate ex vivo. They could provide a basis for a suitable test for use within a quality assurance programme for stored PC.

Bleeding During Orthotopic Liver Transplantation in Man

Severe non surgical bleeding has grave implications for the outcome of orthotopic liver transplantation (OLT) in man. Pathological fibrinolysis and consumption coagulopathy (1–5) have both been implicated. The use of E aminocapronic acid (E.A.C.A.) led to severe thromboembolic complications in man, and bleeding was not always prevented (1,2). Further,in dogs, neither E.A.C.A. nor heparin could influence changes in coagulation and fibrinolysis during OLT (3), while in man severe bleeding was seen from even small amounts of heparin (5). Both in animals and in men changes seemed related to the quality of the donor liver (2,3,5).