Early Hematopoietic Reconstitution after Autologous Transplantation with Blood-Derived Stem Cells in a Patient with Advanced Lymphoma

A 30-year-old man with advanced non-Hodgkin lymphoma underwent repeated leukaphereses for harvesting blood-derived hemopoietic stem cells. Collection was started 8-10 days after the end of L-VAMP therapy (3 cycles). Nine procedures were performed and a total of 65.4× 109 mononuclear cells (0.87× 109/Kg) were collected, processed, cryopreserved and stored in liquid nitrogen. The yields of CFU-GM, BFU-E and CFU-GEMM were respectively 964× 104 (12.4× 104/Kg), 249× 104 (3.2× 104/Kg) and 798× 104 (10.4× 104). The patient received a myeloablative regimen consisting of fractionated total body irradiation (1200 cGy) and cyclophosphamide (120 mg/kg) followed by infusion of his own thawed cells. Early trilineage hematopoietic recovery was first observed on day +8; 1× 109/l WBC were reached on day + 11, 0.5× 109/l PMN on day + 13 and 50× 109/l platelets on day + 11. Course was uneventful and the patient was discharged from hospital on day + 21. Eight months after transplant the patient is in continuous unmaintained complete remission with normal blood cell counts. This reports suggests that complete and sustained engraftment can be achieved with peripheral stem cells recruited after “soft” chemotherapy.

Survival after PBSC Transplantation and Comparison of Engraftment Speed with Autologous and Allogeneic Marrow Transplantation: Results of a Multicenter Study

We have analyzed the results of a multicenter study on peripheral blood stem cell transplantation (PBSCT) performed on 55 patients suffering from various neoplastic diseases. After myeloablative therapy, they received a mediam of 6.8x108/kg MNC and 11.4x104/kg CFU-GM harvested by a median of 9 apheresis after mobilization with chemotherapy alone. As of date, 34 of the 55 patients are alive and 28 of them are in continuous complete remission after a follow-up of 30 months. The probability of survival was related to the disease status at transplant, CR/PR vs. PD (p= 0.0001) and the bone marrow involvement, BM-vs. BM+ (P=0.009). Furthermore, a comparative study on speed of engraftment and clinical management was conducted on the 55 PBSCT patients as well as on 41 autoBMT and 52 alloBMT patients. Days to reach WBC> 1.0x109/L, PMN> 0.5x109/L and PLT> 50x109/L was 12/14/33 for PBSCT, 17/20/23 for ABMT and 15/16.5/18 for BMT, respectively. Days with fever >38° C, systemic antibiotic therapy and length of hospitalization was 3/12/36 for PBSCT, 5/18.5/42 for ABMT and 9/25/46 for BMT respectively.

Concentration of Human Hematopoietic Stem Cells in Bone Marrow Transplantation: Results of a Multicenter Study Using Baxter CS 3000 plus Cell Separator

Preliminary BM processing to produce an enriched MNC fraction from large BM volumes improves subsequent pharmacological and/or immunological “ex vivo” treatment and cryopreservation. We detail on a multicenter study (6 Transplant Centers) performed to establish an effective and reliable protocol using a CS 3000 continuous flow separator on a large series of BM processed for autologous (96) and allogeneic (12) transplantation. The reduction in volume was 78.6+7.2% while 28.9+12.4% of the original nucleated cells were found in the final product. A mean of 84.3+13.2% of the starting MNC was yielded in a fraction containing over 81% MNC. Cloning efficiency indicated than the final graft was highly enriched in progenitor cells committed to the granulocyte/macrophage pathway (> 100%) as assessed in vitro (CFU-GM). Removal of RBC and PLT was 98.3+1.1 and 37.7+14.6%, respectively. The mean dose of MNC and CFU-GM was 0.6+0.37 x 108 and 0.96+1 x 108 recipient weight. The entire process was accomplished in 87.5+20 min. We concluded that this automated device is a simple and reproducible method for BM processing suitable as first step for further “ex vivo” automated negative and/or positive cell selections.

Treatment of Multiple Myeloma with Autologous Blood Stem Cell Transplantation. Preliminary Results of an Italian Multicentric Pilot Study

Starting from May, 1991, 35 untreated myeloma patients entered a multicentric pilot study to evaluate the feasibility of a program of PBSC transplantation for previously untreated myeloma patients. The schedule was as follows: 2 cycles of VAD followed by CY, 7 g/mq + G-CSF (Granulokine, Roche) for 14 days, to increase and collect PBSC. The subsequent conditioning regimen was Melphalan + Busulfan followed by G-CSF. As maintenance R alpha-2 IFN was given, until relapse. The median follow-up is 14 months (4-22). On April 1993, 34 patients received at least 2 cycles of VAD, 27 were submitted to PBSC collection, 22 received conditioning regimen plus PBSC and 16 of them are in the maintenance treatment with IFN. Considering 28 patients for an intention to treat evaluation (35 -7 in treatment), responding patients are 71% with 46% who achieved CR. White cells and platelets raised to > 1000/mmc and >50,000/mmc after a median period of 10 and 13 days, from CY, and 11 and 14 days from transplant, respectively. Two patients relapsed, 2 others died while in PR because of CMV epatitis and candida pneumonia. The median number of CD34+ cells and CFU-GM was 24.75 x 106/kg b.w. and 28.1 x 104/kg b.w. respectively. In conclusion this treatment seems to be feasible and with low toxicity, but a longer follow-up is needed to evaluate the progression free survival of the high proportion of responding patients that we observed.

Rapid Diagnosis of Bacterial Contamination of Blood: Comparison of Three Automated Microbial Detection Systems

Rapid methods of determining microbial contamination are needed in suspecting contaminated banked blood or other blood products. In this study, we experimented contaminated blood units with 122 strains of bacteria and fungi. After innoculation, a comparison between ESP Blood Culture Sytem (Difco Laboratories Inc., Detroit Ml), BacT/Alert (Organon Teknica, Durham NC) and Bactec 9240 System was made for their efficiency in the detection of microbial contamination. Experimental data showed a diagnostic relevance of these automated systems with no significant differences in time detection of microbial contamination between the three methods under comparison.

Hyperviscosity Syndrome in Hematological Diseases and Therapeutic Apheresis

The hyperviscosity syndrome classified into pleiocytosic, sclerotic and sieric syndromes according to the blood components involved are characterized by a different degree of clinical signs and symptoms related to rheological modification of blood. Therapeutic management of these syndromes is complex and the choice of apheresis treatment is generally restricted to emergency episodes in order to overcome the acute phase and to reverse the symptoms until definitive therapy is effective.

TRAIL promotes a pro-survival signal in erythropoietin-deprived human erythroblasts through the activation of an NF-kB/IkBalpha pathway

The biological activity of TNF-related apoptosis inducing ligand (TRAIL) was analyzed in primary human erythroblasts derived from mononuclear cells of blood donors, kept in culture in the presence of 20 percent foetal calf serum, growth factors (EPO, SCF, IL-3) and glucocorticoids (10-6 M dexamethasone, 10-6 M oestradiol) or under growth factor and serum starvation. In the presence of growth factors and serum, primary erythroblasts showed a differential expression of TRAIL-Receptors (Rs) at various degrees of maturation and responded to TRAIL treatment with a mild cytotoxicity. On the other hand, in the absence of serum and growth factors, TRAIL treatment unexpectedly up-regulated TRAIL-R4 decoy receptor and promoted erythroblast survival. The concomitant activation of NF-kB/IkB survival pathway was detected with Western blotting and immunofluorescence procedures and confirmed by experiments performed with SN50, a pharmacological inhibitor of the NF-kB/IkB pathway. Our study indicates that TRAIL has a twofold activity on erythroid lineages: it induces a mild erythroid cell cytotoxicity in the presence of serum and growth factors, while it promotes erythroid cell survival through the activation of the NF-kB/IkB pathway under starvation conditions.

Autologous Blood Stem Cell Transplantation in Malignant Lymphomas: An Italian Cooperative Study

Twenty-three patients with malignant lymphoma, (7 Hodgkin's, and 16 non-Hodgkin's) in different phases of disease were autografted in 4 Italian Haematology institutions using only chemotherapy-mobilized blood stem cells (BSC) collected by apheresis. Clinical and laboratory data were analysed centrally and showed mean collection yields of 8.1 x 10(8) kg mononuclear cells (MNC) (SE 0.5; range 2.6-13.8) and 24.1 x 10(4) kg CFU-GM (SE 7.4; range 1.4-162.9). The mean times required to attain 0.5 x 10(9)/l neutrophils and 50 x 10(9)/l platelets after marrow-ablative high-dose chemo+radiotherapy and BSC reinfusion were 14.9 days (SE 1.5; range 7-38) and 18.6 days (SE 2.6; range 6-49) respectively. The incidence of early deaths was < 5% and the requirement for support with blood product transfusion was moderate. The progression free survival (PFS) is > 50% at 3 years with a median follow-up of 17.3 months. Results were significantly better for patients autografted in remission. These results suggest that autologous blood stem cell transplantation (ABSCT) may be proposed for the primary treatment of poor prognosis malignant lymphomas. However, ABSCT needs to be compared with autologous bone marrow transplantation (ABMT) followed by infusion of growth factors to accelerate recovery.

Randomized trial of sequential administration of G-CSF and GM-CSF vs. G-CSF alone following peripheral blood progenitor cell autograft in solid tumors

A trial was conducted to investigate whether the sequential administration of recombinant human granulocyte colony-stimulating factor (G-CSF) and recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) could accelerate reconstitution of hematopoiesis, compared with G-CSF alone following high-dose chemotherapy (HDCT). A group of 34 consecutive patients with solid tumors undergoing HDCT and autologous peripheral blood progenitor cell (PBPC) transplantation was studied. Conditioning regimen included carboplatin, etoposide, mitoxantrone, and melphalan for breast cancer and cyclophosphamide or ifosfamide, carboplatin, and etoposide for the other tumors. HDCT was delivered from day -3 to day -1. PBPC were infused on day 0, and on the same day growth factors were administered subcutaneously (s.c.) 5 microg/kg each. Seventeen patients were randomized to receive G-CSF from day 0 to day 13 after HDCT (arm A), and 17 patients received G-CSF from day 0 to day 6 and GM-CSF from day 7 to day 13 (arm B). Patients were stratified, and their characteristics were homogeneous in both arms for age, performance status, and number of previous chemotherapy courses and CD34+ infused. The median time to absolute neutrophil count (ANC) >500/microl was 10 days in arm A and 9 days in arm B (p = 0.96). Days to platelet (PLT) count >20,000 were not different in the two treatment arms (p = 0.1), but patients randomized to arm A had a lower platelet count compared with patients in arm B. One month after PBPC transplantation, a statistically significant difference in PLT count was observed (arm A median 150x10(3)/microl (90-310), arm B median 254x10(3)/microl (117-387),p = 0.0013). The days patients had fever >38 degrees C were 39 in arm A and 26 in arm B (p = 0.18). The difference in the length of hospital stay was not statistically significant between the groups (Mann-Whitney sum rank test). After a median follow-up of 30 months, 21 patients were alive and 20 were disease free. These data show that the two growth factors are associated with different patterns of hematopoietic recovery, and larger randomized trials in groups of more homogeneous patients will be needed to define the effects and benefits of combination growth factor therapies.

Onychomycosis caused by Blastoschizomyces capitatus

Blastoschizomyces capitatus was cultured from the nail of a healthy patient with onychomycosis. The identity of the isolate was initially established by standard methods and ultrastructural analysis and was verified by molecular probing. Strains ATCC 200929, ATCC 62963, and ATCC 62964 served as reference strains for these analyses. To our knowledge, this is the first case of nail infection secondary to paronychia caused by this organism reported in the English literature.

Plateletapheresis with the New Baxter-Amicus Blood Cell Separator: An Italian Multicenter Study

The efficiency and quality of platelet (PLT) collection were evaluated in a preliminary study using a new cell separator: Baxter-Amicus. The new fully automated blood cell separator combines centrifugation with elutration to obtain higher PLT efficiency with a lower white blood cell (WBC) contamination. We compared procedures performed with the first software version 2.13 and the more recent 2.37 version, then with and without plasma collection. Data from 262 plateletapheresis procedures were analyzed. The mean value of the PLT yield was 4.5±1.0x1011, collection efficiency: 69.4±12%; WBC contamination: 0.8±2.x106; and procedure time: 73± 19 minutes. The use of the new software vs the former permitted the collection of a higher number of platelets: 4.9± 1.1 vs. 4.5± 1.9 x1011 (=ns), with a lower WBC contamination: 0.6± 1.0 vs 0.7± 1.2 x106 (p=ns), in less time: 63± 10 vs 73± 19 minutes (p=0.002). The efficiency of platelet harvesting with simultaneous plasma collection was higher than the standard procedure: 73± 13 vs. 67± 10% (p=0.003).

Quality Assurance in Ex Vivo Progenitor Cell Manipulation

Over the past few years, hemopoietic transplant has evolved from an investigational phase to routine therapy, thus becoming a potentially curative strategy for a large variety of diseases. Several transplant situations are still outstanding and the need for ex vivo graft manipulation for different transplantation products is growing. To obtain an ideal graft, many different methods, even sophisticated manipulations, may be required. Since transplantation products play an important role in disease outcome, the assessment of graft quality to ensure standard compliance is needed. The development of a regulatory approach to these new manipulated hematopoietic products is very complex and should come under current Good Manufacturing Practices (cGMPs). Manufacturing approach to these new blood products must be urgently introduced to accounting Quality System in Transfusion Medicine. The best way to develop compliance with standards, in agreement with internationally accepted criteria, is, likely, an accreditation system in transplantation programs.

Comparative analysis of two systems for HCV genotyping

The HCV genotype can be determined by PCR using nested primers to structural or non-structural HCV regions, followed by hybridization analysis of the amplified products. In this study, two different systems, both based on PCR and hybridization analysis, were used to determine HCV genotype in 32 HCV positive patients at the Clinic of Infectious Diseases, University of Chieti. The main difference between these commercially available systems lies in the different PCR target. Amplification of PCR targets was obtained from all samples. Hybridization analysis gave unequivocal results for all samples with both methods, yielding a 100% rate of genotype determination, with a complete correlation at the genotype level. A lower concordance at subtype level (65% concordance) was found, due only to two types of discrepancies. Both methods proved easy to use in our hands, adding evidence to their potential usefulness and reliability in clinical settings.

A nosocomial cluster of Candida inconspicua infections in patients with hematological malignancies

Candida inconspicua was recovered from three patients with hematological malignancies. Two patients had intravenous-catheter-associated fungemia, whereas the third had fungal hepatitis. The three cases of infection occurred over a period of 1 month in patients staying in adjacent single rooms. In vitro susceptibility testing of fungal strains showed all isolates to be resistant to fluconazole, with MICs greater than 32 microg/ml. All of the strains had identical DNA restriction profiles and randomly amplified polymorphic DNA fingerprints. These data suggest a nosocomially acquired infection emanating from a common source within the hospital environment.

Necrotizing pneumonia caused by Penicillium chrysogenum

We report a case of necrotizing pneumonia due to Penicillium chrysogenum in a 57-year-old woman operated on for lung cancer. The residual right lower pulmonary lobe was infiltrated by Penicillium chrysogenum. The patient underwent a second pulmonary right lobectomy and was successfully treated with oral itraconazole. To our knowledge, this is the first case of pneumonia due to P. chrysogenum.

Growth factor administration following autologous peripheral blood progenitor cell transplantation

Hematopoietic growth factor (HGF) administration following autologous peripheral blood progenitor cell transplantation (APBPCT) is a current approach for shortening the duration of high-dose chemotherapy-induced transient peripheral pancytopenia. Several published clinical experiences and a retrospective study reported here show that recombinant human granulocyte colony stimulating factor (rhG-CSF) or recombinant human granulocyte-macrophage colony stimulating factor (rhGM-CSF) administration potentiates polymorphonuclear leukocyte (PMN) and white blood cell (WBC) recovery with some clinical benefits mainly related to the reduction of infectious complications during the shortened period of neutropenia. However, this therapeutic strategy does not produce any enhancement of platelet (PLT) recovery or potentiation of red cell production. Conversely, a recent phase I/II study carried out in our institution showed that the combined administration of rhG-CSF and recombinant human erythropoietin (rhEPO) is able to potentiate trilineage hematopoietic recovery with a reduction of PLT transfusions and to considerably simplify the clinical management of patients as compared to patients treated with APBPCT alone. The post-APBPCT administration of rhEPO with rhGM-CSF decreased the number of days with WBC < 1 x 10(9)/L but failed to produce any appreciable effect on PLT recovery. Both combined treatments significantly reduced the patients' hospital stay and allowed the abrogation of systemic antibiotic administration following APBPCT. A further group of patients were treated with the combined administration of rhEPO, rhG-CSF and rhGM-CSF; they did not show a faster hematopoietic recovery than rhG-CSF plus EPO treated patients and a consistent hyperthermia was observed in most patients as a prominent side effect. Future prospective randomized studies will clarify the efficacy of HGF administration following APBPCT. Moreover, further improvements in the hematopoietic support of transplanted patients may be obtained when stem cell factor, flt3/flk2 tyrosine kinase ligands or megakaryocyte growth and development factor will become clinically available.

Purified unfractionated G-CSF/chemotherapy mobilized CD34+ peripheral blood progenitors and not bone marrow CD34+ progenitors undergo selective erythroid differentiation in liquid culture in the presence of erythropoietin and stem cell factor

A combination of erythropoietin (EPO) plus stem cell factor (SCF) drove purified unfractionated granulocyte colony stimulating factor (G-CSF)/chemotherapy mobilized peripheral blood CD34+ cells to selective erythroid differentiation in liquid culture with an average 28-fold increase in the total cell number after 21 d. From day 6 of culture cytologic and cytofluorimetric characterization revealed that cultured cells belonged to the erythroid lineage with a gradual wave of maturation along the erythroid pathway to terminal cells. A similar pattern of erythroid differentiation was observed when the same peripheral blood CD34+ cells were culture with EPO plus SCF in serum-free medium. This cytokine combination produced selective erythroid differentiation with the complete exhaustion of the clonogenic potential on day 21. In parallel experiments the same circulating CD34+ cells underwent granulocytic/ monocytic differentiation in liquid culture in response to granulocyte-macrophage colony stimulating factor (GM-CSF), interleukin-3 (IL-3) and SCF, demonstrating that these CD34+ progenitors had intact pluripotent differentiating potential. Conversely, bone marrow CD34+ cells isolated from bone marrow allografts were unable to selectively differentiate along the erythroid pathway when they were exposed to EPO plus SCF combination. However, these cells maintained a greater number of colony forming cells on day 21 of culture compared to mobilized peripheral blood CD34+ cells. This model is a simple and reliable way to obtain selective erythroid differentiation of peripheral blood G-CSF/ chemotherapy mobilized CD34+ progenitor cells in liquid culture. The absence of cytokines such as GM-CSF and IL-3 in the culture medium permits studies on in vitro erythropoiesis without disturbance of prevalent myelopoiesis.

Effect of the current antimicrobial therapeutic strategy on fungal colonization in patients with hematologic malignancies

A "quasi-experimental" trial was carried out to investigate the effect of three antimicrobial regimens on oral and fecal yeast colonization in patients with hematologic malignancies. Fifty-four patients received ciprofloxacin and oral amphotericin B (group 1); 45 received ceftazidime, amikacin, vancomycin, and oral amphotericin B (group 2); and 30 received ceftazidime, amikacin, vancomycin, and intravenous amphotericin B (group 3). The oral yeast isolation rate showed a decrease in group 1 (from 59.3% to 40.7%) and group 3 (from 56.7% to 46.7%), and a marked increase in group 2 (from 51.1% to 84. 4%). All the groups showed a reduction in their fecal yeast isolation rate. An overgrowth of Candida parapsilosis, C. krusei, and C. tropicalis was observed in all the groups, but it was much higher in group 2. Our findings provide evidence that ceftazidime, amikacin, and vancomycin, given with oral amphotericin B, induce an overgrowth/persistence of Candida species in the mouth and gut, which might be attributable to inclusion of vancomycin. Treatment with intravenous amphotericin B has at least the capacity of counterbalancing yeast proliferation induced by that antibacterial regimen.

Emergence of fluconazole-resistant strains of Blastoschizomyces capitatus causing nosocomial infections in cancer patients

Blastoschizomyces capitatus strains resistant to fluconazole were isolated in three cancer patients. All of the strains had identical genomic DNA restriction profiles. Our findings give evidence for the emergence of fluconazole-resistant B. capitatus and suggest a nosocomial acquisition emanating from a common source within the hospital environment.

Patterns of recovery phase infection after autologous blood progenitor cell transplantation in patients with malignancies. The Gruppo Italiano di Studio per la Manipolazione Cellulare in Ematologia

Recovery phase infection patterns in 55 patients who had undergone autologous blood progenitor cell transplantation (ABPCT) were evaluated retrospectively. The results were compared to those obtained in a group of 41 patients who received autologous bone marrow transplantation (ABMT). Fever related to documented or suspected infection developed in 38 of 55 patients in the ABPCT group and in 37 of 41 in the ABMT group (p < 0.05). The percentages of patients with positive blood cultures did not differ significantly (ABPCT, 8/55 vs. ABMT, 8/41, p > 0.05). However, fewer acquired systemic fungal infections (1/55 vs. 5/41, p < 0.05) as well as fewer days of antibiotic usage were observed in the ABPCT group.

Comparison of ciprofloxacin, ofloxacin and pefloxacin for the prevention of the bacterial infection in neutropenic patients with haematological malignancies

The efficacy of oral prophylaxis with ciprofloxacin, ofloxacin or pefloxacin was assessed in preventing bacterial infection in neutropenic patients with treatment being allocated randomly before beginning chemotherapy. Bacteraemia developed in six of 78 episodes (8%) treated with ciprofloxacin, in eight of 80 (10%) allocated to ofloxacin and in 12 of 77 (16%) when pefloxacin was given. However, there were no episodes involving Gram-negative bacilli among those given ciprofloxacin whereas three and seven episodes occurred in patients given ofloxacin or pefloxacin respectively (P = 0.013). With the exception of Pseudomonas aeruginosa, all potential pathogens isolated were resistant to all three fluoroquinolones. Faecal anaerobes were not affected by treatment with pefloxacin whereas their total numbers were reduced in 12 cases who had received ofloxacin and in nine cases who had been given ciprofloxacin (P = 0.002). Fourteen patients (18%) were colonized with pefloxacin resistant P. aeruginosa at the end of treatment with this agent compared with only two and five of those given ciprofloxacin or ofloxacin respectively. A similar trend was seen with other resistant Gram-negative bacilli colonizing 14%, 20% and 23% of patients for ciprofloxacin, ofloxacin and pefloxacin, respectively. Ciprofloxacin was therefore superior to the other two fluoroquinolones in preventing infections due to Gram-negative bacteria in this population of neutropenic patients.

Osteomyelitis and intervertebral discitis caused by Blastoschizomyces capitatus in a patient with acute leukemia

We describe the first known case of vertebral osteomyelitis and discitis caused by Blastoschizomyces capitatus in a leukemic patient and the results of therapy. We also reconfirm the microbiological characteristics which differentiate this species from other yeastlike pathogens.

Haemopoietic reconstitution after autologous blood stem cell transplantation in patients with malignancies: a multicentre retrospective study

A retrospective study was undertaken to evaluate the efficacy of autologous blood stem cell transplantation (ABSCT) in terms of haemopoietic reconstitution after ablative chemotherapy or chemo-radiotherapy. 55 patients with malignancies, observed in four Italian institutions from January 1987 to June 1991, were eligible for evaluation. This series included 19 non-Hodgkin's lymphoma, 11 multiple myeloma, nine ovarian cancer, seven Hodgkin's disease, seven non-lymphocytic leukaemia, one acute lymphoblastic leukaemia, one neuroblastoma. 522 PBSC collections were performed on 55 patients. Following ABSCT, the rate of engraftment was positively related to the dose of CFU-GM infused and negatively to the presence of bone marrow involvement at conditioning. 48 patients out of 55 transplanted (87%) had rapid, complete and sustained engraftment. Three patients (5%) died of transplant-related complications. Considering that 60% of the patients in this series were in partial remission or in progressive disease at the time of ABSCT, we conclude that ABSCT is a safe approach for the use of ablative conditioning therapy in patients with a wide scope of malignancies, provided that a large number of CFU-GM have been collected after mobilizing treatment.

Survival after PBSC transplantation and comparison of engraftment speed with autologous and allogeneic marrow transplantation: results of a multicenter study

We have analyzed the results of a multicenter study on peripheral blood stem cell transplantation (PBSCT) performed on 55 patients suffering from various neoplastic diseases. After myeloablative therapy, they received a median of 6.8 x 10(8)/kg MNC and 11.4 x 10(4)/kg CFU-GM harvested by a median of 9 apheresis after mobilization with chemotherapy alone. As of date, 34 of the 55 patients are alive and 28 of them are in continuous complete remission after a follow-up of 30 months. The probability of survival was related to the disease status at transplant, CR/PR vs. PD (p = 0.0001) and the bone marrow involvement, BM-vs. BM+ (P = 0.009). Furthermore, a comparative study on speed of engraftment and clinical management was conducted on the 55 PBSCT patients as well as on 41 autoBMT and 52 alloBMT patients. Days to reach WBC > 1.0 x 10(9)/L, PMN > 0.5 x 10(9)/L and PLT > 50 x 10(9)/L was 12/14/33 for PBSCT, 17/20/23 for ABMT and 15/16.5/18 for BMT, respectively. Days with fever > 38 degrees C, systemic antibiotic therapy and length of hospitalization was 3/12/36 for PBSCT, 5/18.5/42 for ABMT and 9/25/46 for BMT respectively.

Concentration of human hematopoietic stem cells in bone marrow transplantation: results of a multicenter study using Baxter CS 3000 plus cell separator

Preliminary BM processing to produce an enriched MNC fraction from large BM volumes improves subsequent pharmacological and/or immunological "ex vivo" treatment and cryopreservation. We detail on a multicenter study (6 Transplant Centers) performed to establish an effective and reliable protocol using a CS 3000 continuous flow separator on a large series of BM processed for autologous (96) and allogeneic (12) transplantation. The reduction in volume was 78.6 + 7.2% while 28.9 + 12.4% of the original nucleated cells were found in the final product. A mean of 84.3 + 13.2% of the staring MNC was yielded in a fraction containing over 81% MNC. Cloning efficiency indicated than the final graft was highly enriched in progenitor cells committed to the granulocyte/macrophage pathway (> 100%) as assessed in vitro (CFU-GM). Removal of RBC and PLT was 98.3 + 1.1 and 37.7 + 14.6%, respectively. The mean dose of MNC and CFU-GM was 0.6 + 0.37 x 10(8) and 0.96 + 1 x 10(5) recipient weight. The entire process was accomplished in 87.5 + 20 min. We concluded that this automated device is a simple and reproducible method for BM processing suitable as first step for further "ex vivo" automated negative and/or positive cell selections.

Autologous blood stem cell collection after chemotherapy in patients with sensitive and refractory malignancies: a multicenter retrospective study

A retrospective study was undertaken to assess the factors affecting the yield of peripheral blood stem cell (PBSC) collections after chemotherapy. Fifty-five patients with malignancies, observed in 4 Italian Institutions from January 1987 to June 1991 were eligible for evaluation. This series included 19 non-Hodgkin lymphoma, 11 multiple myeloma, 9 ovarian cancer, 7 Hodgkin disease, 7 acute non-lymphocytic leukemia, 1 acute lymphoblastic leukemia, 1 neuroblastoma. Five hundred and twenty two PBSC collections were performed on 55 patients after a median of 18 days after the start of chemotherapy. The yields of PBSC collections were related to the dose of cytoreductive chemotherapy exploited for PBSC mobilization and to the number of circulating white blood cells, colony forming unit granulocyte/macrophage (CFU-GM) and the percentage of monocytes at the time of collection. Forty-eight patients out of 55 transplanted (87%) had rapid, complete and sustained engraftment. Three patients (5%) died of transplant related complications.

Rapid diagnosis of bacterial contamination of blood: comparison of three automated microbial detection systems

Rapid methods of determining microbial contamination are needed in suspecting contaminated banked blood or other blood products. In this study, we experimented contaminated blood units with 122 strains of bacteria and fungi. After innoculation, a comparison between ESP Blood Culture System (Difco Laboratories Inc., Detroit MI), BacT/Alert (Organon Teknica, Durham, NC) and Bactec 9240 System was made for their efficiency in the detection of microbial contamination. Experimental data showed a diagnostic relevance of these automated systems with no significant differences in time detection of microbial contamination between the three methods under comparison.

The Role of Hemapheresis Technology in Allogeneic Bone Marrow Transplantation

In this paper the impact of hemapheresis technology on 238 allogeneic bone marrow transplants performed in Pescara from 1982 through 1993 is described. Granulocyte transfusions were limited to patients with neutrophil level <0.2x109/L. An average of 4 units of packed red blood cells were required to maintain adequate hemoglobin levels. Patients with major ABO incompatibility showed an increased requirement of red blood cell support as compared to patients ABO-matched and ABO minor mismatched. For platelet support single-donor platelets collected on a blood-cell separator were given. A total of 1548 platelet transfusions were examined. The median number of platelet transfusions for each patient was 5. Platelet refractoriness occurred in 44% of patients. The hemorrhage related mortality was 0.9%.

The advancement made in the field of hemapheresis technology, as well as the improved transplant technique, have contributed to increase the post-transplant survival from 17% in the early experience (1976-1982) to 88% in the recent years (1992-1993).

Autologous Blood Stem Cell Collection after Chemotherapy in Patients with Sensitive and Refractory Malignancies: A Multicenter Retrospective Study

A retrospective study was undertaken to assess the factors affecting the yield of peripheral blood stem cell (PBSC) collections after chemotherapy. Fifty-five patients with malignancies, observed in 4 Italian Institutions from January 1987 to June 1991 were eligible for evaluation. This series included 19 non-Hodgkin lymphoma, 11 multiple myeloma, 9 ovarian cancer, 7 Hodgkin disease, 7 acute non-lymphocytic leukemia, 1 acute lymphoblastic leukemia, 1 neuroblastoma. Five hundred and twenty two PBSC collections were performed on 55 patients after a median of 18 days after the start of chemotherapy. The yields of PBSC collections were related to the dose of cytoreductive chemotherapy exploited for PBSC mobilization and to the number of circulating white blood cells, colony forming unit granulocyte/macrophage (CFU-GM) and the percentage of monocytes at the time of collection.

Forty-eight patients out of 55 transplanted (87%) had rapid, complete and sustained engraftment. Three patients (5%) died of transplant related complications.

Hepatosplenic infection caused by Candida parapsilosis in patients with acute leukemia

Candida parapsilosis is an exceptional agent in hepatosplenic candidosis. Here we report two cases of hepatosplenic infection caused by Candida parapsilosis in two patients with acute leukaemia. Open liver-spleen biopsy and previously minimal exposure to systemic antifungal drugs led to a cultural diagnosis in both patients. This report confirms the importance of an early diagnosis of these diseases in order to undertake appropriate therapeutic regimens.

Occurrence of bacteremia in hematologic patients

In the present study we reviewed eighty-six episodes of bacteremia occurred in 60 neutropenic patients and thirty-one episodes occurred in 30 non-neutropenic patients. Twenty-four out of 60 neutropenic patients suffered from multiple episodes of bacteremia, while only one out of 30 non-neutropenic patients presented multiple episodes. In neutropenic patients, 29 episodes of bacteremia were polymicrobial, whereas only one non-neutropenic patient had polymicrobial bacteremia. Intravascular catheters were the most common source of bacteremia (23.2%) in neutropenic patients, as compared with infections of the genito-urinary tract (45.1%) among non-neutropenic patients. In both groups, aerobic gram-positive cocci were the microorganisms most frequently isolated (71.6%). Anaerobic microorganisms showed an higher incidence in polymicrobial episodes than in monomicrobial episodes x 2 = 5.39 p = 0.02 OR = 2.97 95% CI (1.2-7.7).

AIDS-related complex treated by antiviral drugs and allogeneic bone marrow transplantation following conditioning protocol with busulphan, cyclophosphamide and cyclosporin

A 26-year-old man with AIDS-related complex (ARC) was treated with high-dose busulphan and cyclophosphamide, followed by allogeneic bone marrow transplantation. For 3 months before transplantation he received a combination of four drugs considered active against human immunodeficiency virus (HIV) to reduce the viral burden: zidovudine, acyloguanosine, fusidic acid and phenylidantoin. Although in reduced doses in coincidence with marrow engraftment, zidovudine therapy was scheduled after transplantation in order to protect donor cells from infection with HIV. Engraftment rapidly occurred and was documented by cytogenetic analyses. The post-transplant course was characterized by severe acute GvHD with irreversible hepatorenal failure. The patient died on day 48 after transplantation. Polymerase chain reaction analyses for detecting HIV DNA showed the persistence of positivity at day +30 and +45 after transplantation. Antibodies to specific HIV proteins evaluated with Western blot testing also persisted at days +21 and +35 after transplantation. Circulating immunocomplexes disappeared on day +31, and an increase in the CD4/CD8 ratio occurred. The short survival of the patient, affected by chronic hepatitis too, does not allow final conclusions about the role of BMT in HIV disease.

Meningitis due to penicillin-resistant Streptococcus pneumoniae in patients with chronic graft-versus-host disease

Two episodes of meningitis due to penicillin-resistant Streptococcus pneumoniae occurring in two patients with chronic graft-versus-host disease (GVHD) are reported. Both patients were treated with ceftazidime. The first patient died, unresponsive to therapy. The second patient showed clinical improvement, reverting to her baseline mental status. This report draws attention to the fact that in chronic GVHD patients: (1) bacterial prophylaxis does not ensure protection against encapsulated bacteria; (2) rapid microbiological investigation is recommended with any upper respiratory tract infections.

Evaluation of four different methods for platelet freezing. In vitro and in vivo studies

This report describes our experience with various techniques for the freezing of platelet-rich plasma, removed from the final product after leukapheresis procedures performed on 14 hematological patients. A total of 194 platelet units were frozen for subsequent autologous transfusion, by the following four methods: (1) 6% dimethyl sulfoxide (DMSO); (2) a combination of 5% DMSO/6% hydroxyethyl starch; (3) 3% glycerol; (4) 5% glycerol/4% glucose. Each technique was evaluated by measuring the percentage of platelet recovery, malondialdehyde (MDA) production, and lactate dehydrogenase release. To investigate the safety and therapeutic effectiveness of the previously frozen platelets, in vivo comparison of four platelet freezing methods was made in 8 thrombocytopenic patients, using corrected platelet increment (CCI), determined at 24 h. Our in vitro results indicate that the cryopreservation with 6% DMSO, without controlled cooling rate, provides significantly (p less than 0.05) greater platelet recovery (75%) as compared to other systems. The decrease of MDA production and the increase in plasma lactate measured after the thawing process was less in the DMSO-frozen units than in the other platelet units. When platelets, cryopreserved by this method, were subsequently transfused into patients, a significantly better CCI (greater than 5,000/microliters) was obtained. In our series, 6 patients were entirely supported with frozen autologous platelets. It appears from this study that a better understanding of the physical and biochemical events occurring during the freezing process will improve platelet cryopreservation, allowing a more systematic use of frozen platelets in the support of thrombocytopenic patients.

Randomized comparison of ceftriaxone versus ceftriaxone plus amikacin for the empirical treatment of infections in patients with altered host defense: microbiological and clinical evaluation

Two hundred and eighty-four febrile episodes in immunocompromised patients were treated with ceftriaxone alone or in combination with amikacin. In the ceftriaxone-treated group, 60 out of 143 febrile episodes were microbiologically documented, while in the group receiving the combination therapy, there were 32 out of 140 (p = 0.0007). Gram-positive microorganisms were more common than gram-negative ones, accounting for 59 of the 101 isolated bacteria. The ceftriaxone regimen appeared to have a response rate comparable to the combination regimen (73.91 vs. 78.88%). Superinfections occurred under both regimens.

Patterns of infection in 41 patients with idiosyncratic drug-induced agranulocytosis

We examined the patterns of infection in 41 consecutive patients with idiosyncratic drug-induced agranulocytosis observed during the past 15 years. All patients were nursed in reverse isolation and treated prophylactically with oral antimicrobials and antifungal compounds. Nine of 41 patients remained without fever and did not need any parenteral antibiotic treatment for full recovery. The other 32 patients developed fever during the period of agranulocytosis and were treated with empirical antimicrobial therapy. Febrile episodes were documented microbiologically in 16 patients (eight with and eight without bacteremia) and clinically in six patients. In the other ten cases the fever was of unexplained origin. The observed pattern of infection was in accordance with the type of infection as reported in cancer patients during the granulocytopenic phase induced by cytotoxic drugs. Ten of 32 febrile patients showed improvement after empirical antimicrobial therapy, whereas three patients died, two of them of a lower respiratory tract infection and one of a massive hemorrhage due to necrosis of the carotid artery. In ten patients the signs and symptoms of infection resolved only after adjustment of the initial empirical scheme. In nine patients the fever persisted even after additional empirical antifungal therapy but subsided after recovery of the granulocytopenia.

Patterns of cytomegalovirus retinitis in immunocompromised patients treated with 9-(2-hydroxy-1-(hydroxymethyl)ethoxymethyl) guanine (ganciclovir)

Five immunocompromised patients, four with AIDS and one who had undergone bone marrow transplantation, showing ocular signs of cytomegalovirus retinitis, were treated with 9-(2-hydroxy-1-(hydroxymethyl)ethoxymethyl) guanine (Ganciclovir), given intravenously at the dose of 5 mg/kg twice daily for a period ranging from 10 to 20 days. At the end of the treatment, in 4 of 5 patients, the ophthalmoscopic picture had improved, with reduced exudation and an arrest in the progression of retinal necrosis, the pattern clearly indicating a trend towards organization and scarring. Complete resolution of the retinitis without subsequent relapse was observed only in the bone marrow transplant patient, who recovered immunologically, whereas improvement of the eye involvement was only transient in the three AIDS patients.