Graft conditioning with fluticasone propionate reduces graft-versus-host disease upon allogeneic hematopoietic cell transplantation in mice

Hematopoietic cell transplantation (HCT) treats many blood conditions but remains underused due to complications such as graft-versus-host disease (GvHD). In GvHD, donor immune cells attack the patient, requiring powerful immunosuppressive drugs like glucocorticoids (GCs) to prevent death. In this study, we tested the hypothesis that donor cell conditioning with the glucocorticoid fluticasone propionate (FLU) prior to transplantation could increase hematopoietic stem cell (HSC) engraftment and reduce GvHD. Murine HSCs treated with FLU had increased HSC engraftment and reduced severity and incidence of GvHD after transplantation into allogeneic hosts. While most T cells died upon FLU treatment, donor T cells repopulated in the hosts and appeared less inflammatory and alloreactive. Regulatory T cells (Tregs) are immunomodulatory and survived FLU treatment, resulting in an increased ratio of Tregs to conventional T cells. Our results implicate an important role for Tregs in maintaining allogeneic tolerance in FLU-treated grafts and suggest a therapeutic strategy of pre-treating donor cells (and not the patients directly) with GCs to simultaneously enhance engraftment and reduce GvHD upon allogeneic HCT.

The role of AMP-activated protein kinase in GVHD-causing T cells

Allogeneic stem cell transplantation is a curative therapy for multiple hematologic disorders. However, this life-saving procedure is often complicated by acute graft-versus-host disease (GVHD), where donor T cells attack tissues in the recipient’s skin, liver, and gastrointestinal tract. Previous research has demonstrated that GVHD-causing T cells undergo significant metabolic reprogramming during disease pathogenesis, with an increased reliance on oxidative metabolism. This dependence makes metabolic modulation a potential approach to treat and/or prevent GVHD. Here, we provide an overview on the metabolic changes adopted by allogeneic T cells during disease initiation, highlighting the role played by AMP-activated protein kinase (AMPK) and identifying ways in which these insights might be leveraged to therapeutic advantage clinically.

Response to "CAR T-Cell Therapy: Updates in Nursing Management"

I have found Clinical Journal of Oncology Nursing (CJON) articles to be enlightening and well written, and I look forward to reading CJON monthly to expand my general cancer care knowledge. I have been a blood and marrow transplantation (BMT) nurse since 1976; our BMT program birthed the chimeric antigen receptor (CAR) T-cell program. In October 2020, I retired as a BMT supervisor and policy keeper from the Seattle Cancer Care Alliance (SCCA), so I am very familiar with both specialties. I was lucky to spend my career at the Fred Hutchinson Cancer Research Center (FHCRC), which has emphasized research at its core. Clinical nutrition research has been a mainstay since the beginning of the program.

Genome-Wide Association Analyses Identify Variants in IRF4 Associated With Acute Myeloid Leukemia and Myelodysplastic Syndrome Susceptibility

The role of common genetic variation in susceptibility to acute myeloid leukemia (AML), and myelodysplastic syndrome (MDS), a group of rare clonal hematologic disorders characterized by dysplastic hematopoiesis and high mortality, remains unclear. We performed AML and MDS genome-wide association studies (GWAS) in the DISCOVeRY-BMT cohorts (2,309 cases and 2,814 controls). Association analysis based on subsets (ASSET) was used to conduct a summary statistics SNP-based analysis of MDS and AML subtypes. For each AML and MDS case and control we used PrediXcan to estimate the component of gene expression determined by their genetic profile and correlate this imputed gene expression level with risk of developing disease in a transcriptome-wide association study (TWAS). ASSET identified an increased risk for de novo AML and MDS (OR = 1.38, 95% CI, 1.26-1.51, Pmeta = 2.8 × 10-12) in patients carrying the T allele at s12203592 in Interferon Regulatory Factor 4 (IRF4), a transcription factor which regulates myeloid and lymphoid hematopoietic differentiation. Our TWAS analyses showed increased IRF4 gene expression is associated with increased risk of de novo AML and MDS (OR = 3.90, 95% CI, 2.36-6.44, Pmeta = 1.0 × 10-7). The identification of IRF4 by both GWAS and TWAS contributes valuable insight on the role of genetic variation in AML and MDS susceptibility.

Orthostatic Vital Signs Algorithm: Decreasing Falls in Patients Undergoing Blood and Marrow Transplantation or Treatment With Cellular Immunotherapy

BACKGROUND

Falls experienced by patients undergoing blood and marrow transplantation or treatment with cellular immunotherapy (BMT-CI) may result in injury or death. An algorithm was developed using the patient fall circumstances identified in a chart analysis from 2016.

OBJECTIVES

This study aimed to determine if the Moffitt BMT-CI Orthostatic Vital Signs Algorithm could decrease inpatient falls.

METHODS

A pre-/post-test program evaluation was conducted for one year pre- and postimplementation of the algorithm on newly admitted inpatients. Adherence rate of nurses using the algorithm was monitored.

FINDINGS

Overall falls decreased from 5.38% to 3.44%, with zero falls or injuries related to orthostasis for newly admitted patients. Adherence of nurses using the algorithm increased from 60% to 93%. The fall rate has been sustained less than baseline with 100% adherence, and the algorithm has been adopted as standard of practice.

Heparin Versus Normal Saline: Flushing Effectiveness in Managing Central Venous Catheters in Patients Undergoing Blood and Marrow Transplantation

BACKGROUND

Patients undergoing blood and marrow transplantation (BMT) use a central venous catheter (CVC); heparin is often employed to maintain patency but may increase the risk of complications. Research has not provided conclusive differences in efficacy and safety regarding heparin flushing versus normal saline flushing in CVC maintenance. Minimal research is specific to this patient population.

OBJECTIVES

This study aimed to determine if differences exist in CVC patency, tissue plasminogen activator usage, and the incidence of central line-associated bloodstream infections when flushing with normal saline only versus heparin and normal saline among patients undergoing BMT.

METHODS

A convenience sample of 30 patients undergoing allogeneic or autologous transplantation with a new non-port/non-peripherally inserted CVC were evaluated.

FINDINGS

Elimination of routine heparin use could positively affect outcomes in this patient population.

Blood and Marrow Transplantation RN Fellowship: Design, Outcomes, and Facilitating Transition to Practice

Recruiting and retaining blood and marrow transplantation (BMT) nurses remains challenging. In accordance with the Institute of Medicine recommendation to establish programs to prepare nurses for transition to specialty practice areas, a BMT fellowship program was designed and implemented at a large academic medical center. The yearlong fellowship program consists of monthly class sessions, observation experiences, case study presentations, and evidence-based project development. Outcomes related to retention, certification, and scholarship are presented.

Autologous haematopoietic stem cell transplantation (aHSCT) for severe resistant autoimmune and inflammatory diseases - a guide for the generalist

Autologous haematopoietic stem cell transplantation (aHSCT) is commonly used for the treatment of haematological cancers, but is increasingly used in the treatment of patients severely affected by autoimmune diseases (ADs). In fact, ADs have become the fastest growing indication for aHSCT. A wide range of diseases have been treated, but the field has focused on three areas: multiple sclerosis, diffuse cutaneous systemic sclerosis and Crohn's disease, where there are populations of patients for whom disease control remains unsatisfactory despite the advent of biological and targeted small molecule therapies. Scientific studies of immune reconstitution have provided support for a 'rebooting' of the immune system through a re-diversification of naive and regulatory immune effector cells. In addition, there may be health economic benefits from a single one-off procedure. Even so, the treatment with aHSCT is intensive with a range of toxicities and risks which, despite being routine to transplant haematologists, are less familiar to disease specialists. Close collaboration between transplant haematologists and relevant disease specialists in patient selection, clinical management and follow-up is mandatory. Ideally, patients should be treated on a clinical trial if available.

Forced deflation pulmonary function test: a novel method to evaluate lung function in infants and young children

We describe the safety and feasibility of a forced deflation pulmonary function test (dPFT) in infants and young children. Fifty-two dPFT studies were performed in 26 patients (median age, 1.4 years). Forced vital capacity (FVC) and forced expiratory flow (FEF₇₅ ) were normal in all except one case, but respiratory system compliance (Crs) was reduced in 24% patients. There were no significant differences in pre-blood and marrow transplantation FVC, FEF₇₅ , and Crs between those patients who did and those who did not have posttransplant pulmonary complications. A larger study is needed to determine the prevalence and significance of PFT abnormalities in this age group.