Publications by authors named "Sheryl McDiarmid"

30 Publications

  • Page 1 of 1

Autologous Hematopoietic Stem Cell Transplantation for Liver Transplant Recipients With Recurrent Primary Sclerosing Cholangitis: A Pilot Study.

Transplantation 2021 May 25. Epub 2021 May 25.

Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada. Blood and Marrow Transplant Program, The Ottawa Hospital, Ottawa, ON, Canada. Department of Pathology, University of Pittsburgh, Pittsburgh, PA. Department of Medical Imaging, University Health Network, Toronto, ON, Canada. Ottawa Stem Cell Program, Canadian Blood Services, Ottawa, ON, Canada.

Background: Primary sclerosing cholangitis (PSC) is an indication for liver transplantation, but recurrence after liver transplantation is associated with poor outcomes often requiring repeat transplantation. We investigated whether autologous hematopoietic stem cell transplantation (aHSCT) could be used to stop progression of recurrent PSC and promote operational tolerance.

Methods: Twelve patients with recurrent PSC were fully evaluated and 5 were selected for aHSCT. Autologous hematopoietic stem cells were collected, purified by CD34 immunomagnetic selection and cryopreserved. Immunoablation using busulfan, cyclophosphamide and rabbit anti-thymocyte globulin was followed by aHSCT. The primary endpoint of the study was the establishment of operational tolerance defined as lack of biochemical, histologic and clinical evidence of rejection while off immunosuppression at 2 years post-aHSCT.

Results: Two of the 5 patients achieved operational tolerance with no clinical or histological evidence of PSC progression or allo-rejection. A third patient developed sinusoidal obstruction syndrome following aHSCT requiring repeat liver transplantation but has no evidence of PSC recurrence while on sirolimus monotherapy now more than 3 years after aHSCT. A fourth patient was weaned off immunosuppression but died 212 days after aHSCT from pericardial constriction. A fifth patient died from multiorgan failure. Immunosuppression-free allograft acceptance was associated with deletion of T cell clones, loss of autoantibodies and increases in regulatory T cells, transitional B cells, and programmed cell death protein-1 expressing CD8+ T cells in the 2 long-term survivors.

Conclusions: Although operational tolerance occurred following aHSCT, the high morbidity and mortality observed renders this specific protocol unsuitable for clinical adoption.
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http://dx.doi.org/10.1097/TP.0000000000003829DOI Listing
May 2021

Autologous Hematopoietic Stem Cell Transplantation for Chronic Inflammatory Demyelinating Polyradiculoneuropathy.

Can J Neurol Sci 2021 Feb 26:1-7. Epub 2021 Feb 26.

Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, Canada.

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) refractory to conventional therapy can lead to marked disability and represents a therapeutic challenge.

Objective: To report five cases of treatment-refractory disabling CIDP treated with autologous hematopoietic stem cell transplantation (AHSCT).

Methods: This was a retrospective cohort study from a tertiary care referral center for both neuromuscular disease and AHSCT. Patients with CIDP treated with AHSCT between 2008 and 2020 were included. All patients had major persistent and disabling neuropathic deficits despite combinations of intensive immunosuppressive therapy. The primary outcome measures were: Medical Research Council sum score, Overall Neuropathy Limitations Scale and requirement for ongoing CIDP immunotherapy after transplantation. We also analyzed safety outcomes by documenting all severe AHSCT-related complications.

Results: Five patients with refractory CIDP underwent AHSCT. Three were classified as manifesting a typical syndrome, two were classified as the multifocal Lewis Sumner variant. The mean age at time of CIDP diagnosis was 33.4 years (range 24-46 years), with a median delay of 46 months (range 21-135 months) between diagnosis and AHSCT. The median follow-up period was 41 months. All five patients were able to wean off CIDP-related immunotherapy. Marked improvements in Medical Research Council scale and overall Neuropathy Limitations Scale were noted in 4/5 patients. One patient with longstanding neurogenic atrophy showed no improvement in disability scales. There were no treatment-related deaths or critical illnesses.

Conclusions: AHSCT can achieve marked sustained clinical improvement of refractory CIDP and may allow for weaning off long-term complex immunotherapies.
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http://dx.doi.org/10.1017/cjn.2021.30DOI Listing
February 2021

Time to rethink vascular access in patients with breast cancer.

Br J Nurs 2020 Jul;29(14):S32-S38

Nurse Practitioner (NP) in the Wellness Beyond Cancer Program, at the Ottawa Regional Cancer Centre. She completed her Nurse Practitioner's program at the University of Ottawa, and her Masters of Nursing at Charles Sturt University, New South Wales, Australia.

Breast cancer management is a rapidly evolving field. Diagnosis and treatment options have changed dramatically over the years, as have options for vascular access devices used to administer therapies. We now need to critically rethink vascular access device options for our breast cancer patients. Breast cancer (BC) is the most commonly diagnosed cancer among Canadian women. Although BC incidence continues to rise, the overall mortality rate in Canada is the lowest it has been for 70 years. The five-year net survival is 87%, and 83% of women are alive at 10 years. New oral therapies, shorter dose-dense treatments, and decreased use of anthracycline-base regimens are reducing the need for central venous access devices during acute treatment phases. However, these survivors go on to develop other health issues requiring routine venipuncture and insertion of vascular access devices. Breast cancer-related lymphedema (BCRL) is a chronic complication that has no cure and no proven prevention strategies. Approximately 21% of breast cancer survivors are at risk of developing BCRL. Of those patients who do develop BCRL, 70% do so within two years of surgery, 90% within three years, and another one percent per year thereafter. The literature supports axillary lymph node dissection, mastectomy, administration of chemotherapy or radiotherapy, and obesity, as risk factors for the development of BCRL. However, 40% of patients who develop BCRL have no identifiable risk factors. Broader risk reduction strategies developed are not evidence based, the most commonly cited being avoidance of needle sticks. Large cohort studies have found no significant association between blood draws and intravenous infusion in the surgical arm with the development of BCRL. Recommendations that effectively eliminate vascular access on the surgical side for the patient's entire lifetime are neither necessary nor realistic. Vascular access specialists can provide leadership by developing standardized, evidence-informed recommendations for safe vascular access and infusion practices for this patient population.
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http://dx.doi.org/10.12968/bjon.2020.29.14.S32DOI Listing
July 2020

The legacy of lymphedema: Impact on nursing practice and vascular access.

Can Oncol Nurs J 2019 1;29(3):194-203. Epub 2019 Jul 1.

Advanced Practice Nurse, The Ottawa Hospital.

Breast cancer is the most common cancer in women. Breast cancer related lymphedema (BCRL) is a chronic condition characterized by an abnormal accumulation of protein-rich fluid in tissues resulting in swelling of the upper limb or trunk after treatment. Lack of consensus on definition, classification and grading of BCRL has led to subjective and objective parameters estimating incidence and severity. Prospective studies estimate the risk of BCRL to be approximately 21.4% (14.9-29.8). In patients with axillary lymph node dissection (ALND), the estimated risk of 19% (13.5-28.2) was about four times higher than those patients who had sentinel lymph node biopsy (5.6%, 6.1-7.9). Seventy percent of these patients will experience BCRL within two years of surgery, 90% within three years, and a 1% rate per year thereafter. Many patients who have no high-risk variables such as mastectomy, ALND and radiation therapy develop BCRL. Patients fear this complication, which has no cure and no proven prevention strategies. Risk reduction strategies, primarily focused on reducing trauma to the surgical arm, are based on anecdotal information and effectively restrict the use of the at-risk limb for the patient's lifetime. Although broad risk reduction strategies have been recommended, the avoidance of needle sticks has become the most common strategy practised, enforced through institutional policies and procedures and reinforced through patient education initiatives and breast cancer support groups. Large cohort studies have found no significant association between blood draws and intravenous infusions in the surgical arm and the development of BCRL. Current literature supports that approximately 21% of patients will develop BCRL, leaving 79% free of the complication. Due to increased survival, breast cancer survivors go on to develop other healthcare issues that may require vascular access. Therefore, long-held beliefs with regards to risk factors and preventative measures need to be challenged. Education of healthcare providers, patients and support groups through the dissemination of evidence-based information on the diagnosis, prevention and treatment of BCRL is necessary to ensure that patients receive the best care possible with the least risk.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970461PMC
July 2019

Anaphylaxis and anaphylactoid reactions associated with the insertion of peripherally inserted central catheters: A multiyear comparative retrospective cohort study.

Infect Control Hosp Epidemiol 2019 11;40(11):1215-1221

Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.

Objective: Peripherally inserted central catheters (PICCs) are a mainstay of nonpermanent vascular access devices. In this study, we assessed patients displaying anaphylaxis or anaphylactoid reactions to the PowerPICC SOLO and Groshong PICC (Bard Access Systems) using the Sherlock tip locating system (TLS).

Methods: Patients from 2 tertiary-care hospitals were systematically monitored over 4 years for adverse events following the insertion of a PICC using the Sherlock TLS. Insertion data were also collected using the BioFlo PICC (Angiodynamics)from a third hospital site and from The Ottawa Hospital over 4 years as an additional comparator. Three definitions of anaphylaxis and anaphylactoid reactions were utilized, and the Cohen κ was used to assess interrater agreement. Analysis of reactions among the patient cohorts was performed using the χ2 test with Yates correction or the Fisher exact test as appropriate.

Results: Among 8,257 insertions using the TLS PICCs, 37 potential reactions (0.45%) were recorded. Using specific definitions for anaphylaxis or anaphylactoid reactions, 54.1%-91.9% met criteria. Comparator populations using data from Calgary (n = 491) and Ottawa (n = 7,889) using the BioFlo PICC insertion found no reactions. Anaphylactic or anaphylactoid reactions were significantly associated with the PowerPICC SOLO and Groshong PICC with the TLS compared to the BioFlo PICC (P < .0001) across all definitions. The largest subset of patients experiencing adverse reactions had cystic fibrosis (CF) (n = 4, 10.8%).

Conclusion: Our study results demonstrate significant adverse events associated with the PowerPICC SOLO and Groshong PICC using the Sherlock TLS inserted across a range of patient populations. The incidence rate of anaphylaxis or anaphylactoid reactions in the CF population at our center is significantly higher than in non-CF patients (P < .001).
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http://dx.doi.org/10.1017/ice.2019.237DOI Listing
November 2019

Comparison of complication rates and incidences associated with different peripherally inserted central catheters (PICC) in patients with hematological malignancies: a retrospective cohort study.

Leuk Lymphoma 2020 01 7;61(1):156-164. Epub 2019 Aug 7.

The Ottawa Hospital Research Institute, Ottawa, ON, Canada.

Patients with hematological malignancies (HM) or undergoing hematopoietic cell transplantation (HCT) require reliable vascular access. Peripherally inserted central catheters (PICC) meet this need, however, studies suggest these patients have higher rates of PICC-associated complications. This retrospective cohort study evaluates the influence of PICC type on the rates and incidences of complications. Four hundred and eighty-five dual lumen PICCs were inserted into 469 complex patients with HM or undergoing HCT: 161 Groshong, 60 PowerPICC Solo, 165 BioFlo, and 99 Arrow. The rates and incidences of complications differed significantly across the PICC types. The overall rate of complication ranged from 7.40 to 26.4/1000 catheter days (CDs). The rate of deep vein thrombosis (0.31-1.48/1000 CDs) and occlusion differed across the PICC types, while the rate of central line-associated bloodstream infection (0.53-0.74/1000 CDs) did not. Following multivariate adjustment, PICC type was associated with complication rate. This highlights that PICC type should be considered in clinical decisions.
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http://dx.doi.org/10.1080/10428194.2019.1646908DOI Listing
January 2020

Implanted vascular access device related deep vein thrombosis in oncology patients: A prospective cohort study.

Thromb Res 2019 May 6;177:117-121. Epub 2019 Mar 6.

The Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, Ontario K1Y 4E9, Canada; The Ottawa Hospital, Box 710, 501 Smyth Rd., Ottawa, Ontario K1H 8L6, Canada. Electronic address:

Background: Implanted vascular access devices (IVADs) have significantly improved the management of cancer patients. These patients are at an increased risk of venous thromboembolism and IVADs are a known risk factor. We sought to assess the incidence of IVAD-related upper extremity deep vein thrombosis (IVAD-related UEDVT) associated with BioFlo® IVADs (Angiodynamics, Inc.).

Methods: A total of 394 cancer patients were enrolled over 12 months. The primary outcome was the incidence of IVAD-related UEDVT confirmed by diagnostic imaging. IVAD-related UEDVT was defined as symptomatic ipsilateral upper extremity (axillary vein or proximal) deep vein thrombosis and symptomatic pulmonary embolism (PE). Patients were followed until initiation of therapeutic anticoagulation, catheter removal, death, or up to 12 months.

Results: 389 patients were included in the analysis. The median age of the cohort was 58.2 years; 68% (n = 273) were females. Sixty-six percent had gastrointestional cancer (including pancreatic cancer) and 68% had metastases. Eighty four percent of IVADs were right sided insertions. Ninety eight percent of catheter tip placements were distal superior vena cava (n = 237), cavo-atrial junction (n = 67) or atrium (n = 90). Overall, 5 patients had symptomatic IVAD-related UEDVT (1.29%, 95% CI 0.2 to 2.4%).

Conclusion: IVAD-related UEDVT is an infrequent complication in cancer patients with BioFlo® IVADs.
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http://dx.doi.org/10.1016/j.thromres.2019.02.033DOI Listing
May 2019

Optimal vascular access strategies for patients receiving chemotherapy for early-stage breast cancer: a systematic review.

Breast Cancer Res Treat 2018 Oct 4;171(3):607-620. Epub 2018 Jul 4.

Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada.

Importance: Systemic chemotherapy can be administered either through a peripheral vein (IV), or centrally through peripherally inserted central catheter (PICC), totally implanted vascular access devices (PORTs) or tunnelled cuffed catheters. Despite the widespread use of systemic chemotherapy in patients with breast cancer, the optimal choice of vascular access is unknown.

Objective: This systematic review evaluated complication rates and patient satisfaction with different access strategies for administering neo/adjuvant chemotherapy for breast cancer.

Evidence Reviewed: Ovid Medline, EMBASE and the Cochrane Central Register of Controlled Trials were searched from 1946 to September 2017. Two reviewers independently assessed each citation. The Newcastle-Ottawa scale was used to assess the quality of cohort and case-control studies.

Findings: Of 1584 citations identified, 15 unique studies met the pre-specified eligibility criteria. There were no randomised studies comparing types of vascular access. Reports included six single-institution retrospective cohort studies, one retrospective multi-institution cohort, one retrospective cohort database study, five prospective single-institution studies, one prospective multi-institution study and one nested case-control study. Median complication rates were infection: 6.0% PICC (2 studies) versus 2.1% PORT (8 studies); thrombosis: 8.9% PICC (2 studies) versus 2.6% PORT (9 studies); extravasation: 0 PICC (1 study) versus 0.4% PORT (4 studies) and mechanical issues: PICC 3.8% (1 study) versus 1.8% PORT (9 studies). Satisfaction/quality of life appeared high with each device.

Conclusion: In the absence of high-quality data comparing vascular access strategies, randomised, adequately powered, prospective studies would be required to help inform clinical practice and reduce variation.
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http://dx.doi.org/10.1007/s10549-018-4868-xDOI Listing
October 2018

Outcomes in a nurse-led peripherally inserted central catheter program: a retrospective cohort study.

CMAJ Open 2017 Jun;5(3):E535-E539

Affiliations: The Ottawa Hospital (McDiarmid), Ottawa Hospital Research Institute (McDiarmid, Scrivens, Sabri); Department of Medicine (Carrier), Ottawa Hospital Research Institute at the University of Ottawa; Division of Microbiology and Infectious Diseases (Toye), University of Ottawa, The Ottawa Hospital; Department of Medicine (Huebsch), University of Ottawa, The Ottawa Hospital; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute; Department of Medicine (Fergusson), University of Ottawa, Ottawa, Ont.

Background: Peripherally inserted central catheters (PICCs) provide enormous benefit to patients. However, recent publications have highlighted relatively high PICC-associated complication rates. We report on patient and device outcomes from a nurse-led program.

Methods: We performed a retrospective analysis of a prospective cohort of consecutive patients undergoing PICC insertion at The Ottawa Hospital between Jan. 1, 2013 and Dec. 31, 2014. Of the 8314 BioFlo PASV PICCs inserted, we randomly selected a sample of 700 and obtained a complete data set for 656. We measured the cumulative incidence of major complications (catheter-related bloodstream infections and deep vein thrombosis) and use of a thrombolytic to alleviate occlusions.

Results: The total number of catheter days was 58 486, and the median dwell time 45 days. We observed 4 cases of catheter-related bloodstream infection (0.6% [95% CI 0.17%-1.55%]) (0.07/1000 catheter days). Ten patients (1.5% [95% CI 0.83%-2.78%]) (0.17/1000 catheter days) had catheter-related deep venous thrombosis. At least 1 dose of thrombolytic was required in 75 catheters (11.4% [95% CI 8.61%-13.39]), 31 (7.1%) of the 436 single-lumen catheters and 113 (25.7%) of the 440 lumina of dual-lumen catheters ( < 0.001).

Interpretation: We attribute our low rates of major complications to a nurse-led expert insertion team, standardized care and maintenance protocols, high insertion volumes, novel catheter material and continuous quality-improvement initiatives that are implemented and evaluated regularly. We conclude that the considerable benefits PICCs provide to patients are attained with a low risk of major complications.
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http://dx.doi.org/10.9778/cmajo.20170010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5621949PMC
June 2017

Immunoablation and autologous haemopoietic stem-cell transplantation for aggressive multiple sclerosis: a multicentre single-group phase 2 trial.

Lancet 2016 Aug 9;388(10044):576-85. Epub 2016 Jun 9.

Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital MS Clinic, Ottawa, ON, Canada.

Background: Strong immunosuppression, including chemotherapy and immune-depleting antibodies followed by autologous haemopoietic stem-cell transplantation (aHSCT), has been used to treat patients with multiple sclerosis, improving control of relapsing disease. We addressed whether near-complete immunoablation followed by immune cell depleted aHSCT would result in long-term control of multiple sclerosis.

Methods: We did this phase 2 single-arm trial at three hospitals in Canada. We enrolled patients with multiple sclerosis, aged 18-50 years with poor prognosis, ongoing disease activity, and an Expanded Disability Status Scale of 3.0-6.0. Autologous CD34 selected haemopoietic stem-cell grafts were collected after mobilisation with cyclophosphamide and filgrastim. Immunoablation with busulfan, cyclophosphamide, and rabbit anti-thymocyte globulin was followed by aHSCT. The primary outcome was multiple sclerosis activity-free survival (events were clinical relapse, appearance of a new or Gd-enhancing lesion on MRI, and sustained progression of Expanded Disability Status Scale score). This study was registered at ClinicalTrials.gov, NCT01099930.

Findings: Between diagnosis and aHSCT, 24 patients had 167 clinical relapses over 140 patient-years with 188 Gd-enhancing lesions on 48 pre-aHSCT MRI scans. Median follow-up was 6.7 years (range 3.9-12.7). The primary outcome, multiple sclerosis activity-free survival at 3 years after transplantation was 69.6% (95% CI 46.6-84.2). With up to 13 years of follow-up after aHSCT, no relapses occurred and no Gd enhancing lesions or new T2 lesions were seen on 314 MRI sequential scans. The rate of brain atrophy decreased to that expected for healthy controls. One of 24 patients died of transplantation-related complications. 35% of patients had a sustained improvement in their Expanded Disability Status Scale score.

Interpretation: We describe the first treatment to fully halt all detectable CNS inflammatory activity in patients with multiple sclerosis for a prolonged period in the absence of any ongoing disease-modifying drugs. Furthermore, many of the patients had substantial recovery of neurological function despite their disease's aggressive nature.

Funding: Multiple Sclerosis Scientific Research Foundation.
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http://dx.doi.org/10.1016/S0140-6736(16)30169-6DOI Listing
August 2016

Myasthenia Gravis Treated With Autologous Hematopoietic Stem Cell Transplantation.

JAMA Neurol 2016 06;73(6):652-8

Division of Hematology, University of Ottawa, Ottawa, Ontario, Canada2The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada3The Bone Marrow Transplant Programme, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.

Importance: Some patients with myasthenia gravis (MG) do not respond to conventional treatment and have severe or life-threatening symptoms. Alternate and emerging therapies have not yet proved consistently or durably effective. Autologous hematopoietic stem cell transplant (HSCT) has been effective in treating other severe autoimmune neurologic conditions and may have similar application in MG.

Objective: To report 7 cases of severe MG treated with autologous HSCT in which consistent, durable, symptom-free, and treatment-free remission was achieved.

Design, Setting, And Participants: This retrospective cohort study reports outcomes at The Ottawa Hospital, a large, Canadian, tertiary care referral center with expertise in neurology and HSCT, from January 1, 2001, through December 31, 2014, with a median follow-up of 40 months (range, 29-149 months). Data collection and analysis were performed from February 1 through August 31, 2015. All patients with MG treated with autologous HSCT at The Ottawa Hospital were included. All had persistent severe or life-threatening MG-related symptoms despite continued use of intensive immunosuppressive therapies.

Interventions: Autologous hematopoietic stem cell grafts were mobilized with cyclophosphamide and granulocyte colony-stimulating factor, collected by peripheral blood leukapheresis, and purified away from contaminating lymphocytes using CD34 immunomagnetic selection. Patients were treated with intensive conditioning chemotherapy regimens to destroy the autoreactive immune system followed by graft reinfusion for blood and immune reconstitution.

Main Outcomes And Measures: The primary outcome was MG disease activity after autologous HSCT measured by frequency of emergency department visits and hospitalizations and Myasthenia Gravis Foundation of America (MGFA) clinical classification, MGFA therapy status, and MGFA postintervention status. Safety outcomes included all severe autologous HSCT-related complications.

Results: Seven patients underwent autologous HSCT, 6 for MG and 1 for follicular lymphoma with coincident active MG. Mean (SD) ages at MG diagnosis and at autologous HSCT were 37 (11) and 44 (10) years, respectively. Five patients (71%) had concurrent autoimmune or lymphoproliferative illnesses related to immune dysregulation. All patients had distinct clinical and electromyographic evidence of MG (MGFA clinical classification IIIb-V). All patients achieved durable MGFA complete stable remission with no residual MG symptoms and freedom from any ongoing MG therapy (MGFA postintervention status of complete stable remission). Three patients (43%) experienced transient viral reactivations, and 1 (14%) developed a secondary autoimmune disease after autologous HSCT, all of which resolved or stabilized with treatment. There were no treatment- or MG-related deaths.

Conclusions And Relevance: Autologous HSCT results in long-term symptom- and treatment-free remission in patients with severe MG. The application of autologous HSCT for this and other autoimmune neurologic conditions warrants prospective study.
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http://dx.doi.org/10.1001/jamaneurol.2016.0113DOI Listing
June 2016

Improved Prediction of CD34+ Cell Yield before Peripheral Blood Hematopoietic Progenitor Cell Collection Using a Modified Target Value-Tailored Approach.

Biol Blood Marrow Transplant 2016 Apr 28;22(4):763-767. Epub 2015 Nov 28.

Ottawa Hospital Research Institute, Ottawa, Canada.

The most commonly used stem cell source for both autologous and allogeneic transplantation is mobilized peripheral blood hematopoietic progenitor cells collected by apheresis. In the 1990s, an Italian group used the correlation between the preapheresis peripheral blood CD34+ cell count and the final number of CD34+ cells collected to devise a formula for "target value-tailored" (TVT) apheresis. Using local patient data, the Canadian Blood Services Stem Cell Laboratory created a similar model to determine the blood volume to process during apheresis collection. The objectives of this study were to determine the correlation between the number of CD34+ cells predicted by the TVT formula and the actual number of CD34+ cells collected and to determine whether the TVT formula remains predictive when applied to an external data set. All apheresis collections performed at the Ottawa Hospital between January 1, 2003 and October 2, 2013 were reviewed. The primary outcome was the correlation between the number of CD34+ cells predicted by the TVT formula and the actual number of CD34+ cells collected on day 1 of apheresis. For the external data set, all autologous collections performed at the London Health Sciences Centre between December 1, 2008 and December 1, 2013 were reviewed. The external data set was divided into test and validation sets to determine whether a model could be created to predict the final number of CD34+ cells collected on day 1 based on the preapheresis CD34+ count. A total of 1252 collections were included in the analysis. The Ottawa data set included 1012 collections, 836 of which were autologous and 176 of which were from donors. Of the autologous collections in Ottawa, 764 (92.5%) were first collections. In 759 (91%) collections, chemotherapy plus granulocyte colony-stimulating factor (G-CSF) was used as the mobilization regimen. In 747 collections (89%), only 1 collection day was required to achieve the desired number of CD34+ cells. The TVT estimate was highly predictive of the number of CD34+ cells × 10(6)/kg actually collected on apheresis day 1 (r = .90, P < .0001). The London data set included 240 autologous collections. All mobilizations were with G-CSF alone. For the test set, the precollection CD34+ count was highly predictive of the number of CD34+ cells × 10(6)/kg collected on day 1 of apheresis. Applying this model to the validation set, the correlation between the predicted and final and day 1 CD34+ cells × 10(6)/kg count was .9186 (P < .0001). Using a modified TVT approach, the preapheresis CD34+ count can be used to accurately predict the number of CD34+ cells × 10(6)/kg collected on day 1. This approach can be applied at other centers and for different diseases and mobilization regimens. This method can be used to individualize the blood volume processed and, thus, optimize resource utilization.
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http://dx.doi.org/10.1016/j.bbmt.2015.11.016DOI Listing
April 2016

Outcomes of both abbreviated hyper-CVAD induction followed by autologous hematopoietic cell transplantation and conventional chemotherapy for mantle cell lymphoma: a 10-year single-centre experience with literature review.

Cancer Med 2015 Dec 3;4(12):1817-27. Epub 2015 Oct 3.

Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, Ontario, Canada.

We retrospectively evaluated consecutive patients diagnosed with Mantle cell lymphoma (MCL) between 01 January 2000 and 31 December 2009. Eighty eight patients with MCL were included in the analysis of whom 46 (52%) received abbreviated Hyper-CVAD (a total of two cycles; with addition of Rituximab since 2005) with an intention of proceeding to autologous hematopoietic cell transplantation (auto-HCT), with a median age of 58 years. Response rate to induction at auto-HCT time was 89% and complete response was 61%. Forty four patients received an auto-HCT with a 5-year progression-free survival (PFS) and overall survival (OS) were 31.2% and 62.5%, respectively. There were 42 nontransplant eligible patients with a median age of 72 years, and 5-year PFS and OS were 0.0% and 39.9%, respectively. The median survival and PFS in the auto-HCT eligible group were 68 and 33 months, compared to 32 and 12 months in nontransplant eligible group, without a plateauing of the survival curves in either group. Treatment-related mortality in the auto-HCT eligible group was 10.9% (n = 5); two patients died during R-Hyper-CVAD and 3 (6.8%) experienced transplant-related mortality. An abbreviated R-Hyper-CVAD-based induction strategy followed by consolidative auto-HCT is feasible and provides moderate potential of long-term survival. Further research to define risk-adapted strategies; to optimize disease control, is required.
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http://dx.doi.org/10.1002/cam4.543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123787PMC
December 2015

Impact of platelet transfusion on toxicity and mortality after hematopoietic progenitor cell transplantation.

Transfusion 2015 Feb 15;55(2):253-8. Epub 2014 Aug 15.

Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

Background: Thrombocytopenia occurs commonly after hematopoietic progenitor cell transplantation (HPCT) and is associated with potential morbidity and mortality. Few studies have examined the impact of platelet (PLT) transfusion on clinical outcomes in HPCT while optimal PLT transfusion strategies after HSCT remain uncertain.

Study Design And Methods: A retrospective single-center cohort study was conducted on 522 patients undergoing HPCT between January 2002 and December 2007. Associations between PLT transfusion events and clinical characteristics with transplant-related outcomes were assessed using univariate and multivariate analysis.

Results: Mean number of PLT transfusion events before Day +60 posttransplant was 7.5 (95% confidence interval, 6.7-8.4) with greater number of events after allogeneic compared with autologous HPCT (p < 0.01). Univariate and multivariate analysis confirmed that the number of PLT transfusion events was associated with increased 100-day nonrelapse mortality (p < 0.01), posttransplant length of hospital stay (p < 0.01), need for intensive care unit admission (p < 0.01), and number of organs affected by severe toxicity (p < 0.01).

Conclusion: HPCT-related toxicity and mortality are associated with increased PLT transfusion events. Alternative strategies to reduce PLT transfusions after HPCT may warrant future study.
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http://dx.doi.org/10.1111/trf.12817DOI Listing
February 2015

Incidence and risk factors of symptomatic venous thromboembolism related to implanted ports in cancer patients.

Thromb Res 2014 Jan 23;133(1):30-3. Epub 2013 Oct 23.

Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada. Electronic address:

Introduction: The true incidence of symptomatic implanted port related venous thromboembolism (VTE) in cancer patients is unclear and there is very limited data on its associated risk factors.

Materials And Methods: We performed a retrospective cohort study of consecutive cancer outpatients who received an ultrasound guided implanted port insertion for the administration of chemotherapy. The primary outcome measure was symptomatic VTE. Univariable and multivariable logistic regression analyses were used to identify risk factors for symptomatic VTE.

Results: A total of 400 cancer patients with a newly inserted implanted port for deliverance of chemotherapy were included in the study. Median age was 58years (range of 21 to 85years) and 120 (30%) were males. Patients were followed for a median of 12months and none received thrombophrophylaxis. Of the 400 patients included in the analysis, 34 patients (8.5%; 95% CI: 6.0 to 11.7%) had symptomatic VTE (16 DVTs, 16 PEs, and 2 with both). In the univariate analyses, metastatic disease, male gender and right sided implanted port insertion were significantly associated with the risk of VTE. In the multiple-variable analysis, male gender (OR 2.17, p=0.04) and presence of metastases (OR 8.22, p<0.01) were the two significant independent predictors of implanted port related VTE.

Conclusion: Symptomatic VTE is a frequent complication in cancer patients with implanted port receiving chemotherapy. Gender and presence of metastatic disease are independent risk factors for symptomatic VTE. Future trials assessing the role of thromboprophylaxis among these higher risk patients are needed.
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http://dx.doi.org/10.1016/j.thromres.2013.10.026DOI Listing
January 2014

Is cytomegalovirus testing of blood products still needed for hematopoietic stem cell transplant recipients in the era of universal leukoreduction?

Biol Blood Marrow Transplant 2013 Dec 5;19(12):1719-24. Epub 2013 Oct 5.

Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.

Hematopoietic stem cell transplantation (HSCT) recipients are a high-risk, immunocompromised group of patients who receive frequent transfusions after transplantation. Transfusion of cytomegalovirus (CMV)-negative blood products has long been the standard of care to prevent transfusion-transmitted CMV in this patient population. Leukoreduction of blood products before transfusion has been shown to significantly reduce the risk of transfusion-transmitted CMV. In the era of universal leukoreduction in Canada, the need for CMV testing of blood products remains unclear. We sought to identify whether there is a difference in transfusion-transmitted CMV viremia in patients receiving only leukoreduced versus CMV-negative and leukoreduced blood products in HSCT recipients. Patients who were CMV negative and received an allogeneic HSCT from a CMV-negative donor between October 1, 1999 and June 30, 2012 were included in the analysis. Transfusion data were collected from The Ottawa Hospital Blood Bank and Canadian Blood Services. CMV viremia was defined as PCR positivity. One hundred sixty-six patients were identified who met the inclusion criteria. Of these, 89 patients received an HSCT before January 2007, during the time when patients received leukoreduced and CMV-negative blood products. Seventy-seven patients received an HSCT after this time, receiving only leukoreduced blood products. The 2 groups did not differ in terms of age, gender, diagnosis, graft type, graft source, conditioning regimen, or ABO compatibility (P > .05). CMV viremia was detected in 3 patients who received CMV-negative leukoreduced blood products (3.37%) and in 1 patient who received only leukoreduced blood products (1.30%, P = .6244). Of the patients who developed CMV viremia, 2 developed suspected CMV disease. Both of these patients were transfused with CMV-negative blood products. Secondary outcomes, including total length of stay in hospital, admission to the intensive care unit, acute and chronic graft versus host disease, and 100-day nonrelapse mortality, did not differ between the groups. In the era of universal leukoreduction of blood products, this study demonstrates that testing for CMV-negative blood products is not needed for HSCT recipients.
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http://dx.doi.org/10.1016/j.bbmt.2013.09.013DOI Listing
December 2013

The use of intravenous antibiotics at the onset of neutropenia in patients receiving outpatient-based hematopoietic stem cell transplants.

PLoS One 2012 28;7(9):e46220. Epub 2012 Sep 28.

The Ottawa Hospital Blood and Marrow Programme, The Ottawa Hospital, Ottawa, Ontario, Canada.

Empirical antibiotics at the onset of febrile neutropenia are one of several strategies for management of bacterial infections in patients undergoing Hematopoietic Stem Cell Transplant (HSCT) (empiric strategy). Our HSCT program aims to perform HSCT in an outpatient setting, where an empiric antibiotic strategy was employed. HSCT recipients began receiving intravenous antibiotics at the onset of neutropenia in the absence of fever as part of our institutional policy from 01 Jan 2009; intravenous Prophylactic strategy. A prospective study was conducted to compare two consecutive cohorts [Year 2008 (Empiric strategy) vs. Year 2009 (Prophylactic strategy)] of patients receiving HSCT. There were 238 HSCTs performed between 01 Jan 2008 and 31 Dec 2009 with 127 and 111 in the earlier and later cohorts respectively. Infection-related mortality pre- engraftment was similar with a prophylactic compared to an empiric strategy (3.6% vs. 7.1%; p = 0.24), but reduced among recipients of autologous HSCT (0% vs. 6.8%; p = 0.03). Microbiologically documented, blood stream infections and clinically documented infections pre-engraftment were reduced in those receiving a prophylactic compared to an empiric strategy, (11.7% vs. 28.3%; p = 0.001), (9.9% vs. 24.4%; p = 0.003) and (18.2% vs. 33.9% p = 0.007) respectively. The prophylactic use of intravenous once-daily ceftriaxone in patients receiving outpatient based HSCT is safe and may be particularly effective in patients receiving autologous HSCT. Further studies are warranted to study the impact of this Prophylactic strategy in an outpatient based HSCT program.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0046220PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3460853PMC
February 2013

Incidence and predictive factors of symptomatic thrombosis related to peripherally inserted central catheters in chemotherapy patients.

Thromb Res 2012 Sep 22;130(3):323-6. Epub 2012 Mar 22.

Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

Introduction: The incidence of symptomatic catheter-related deep vein thrombosis (DVT) in cancer patients remains unclear and there is a lack of reliable data on the risk factors of PICC-related DVT.

Materials And Methods: We performed a retrospective cohort study of consecutive cancer patients who received an ultrasound guided PICC line for the administration of chemotherapy. Univariable and multivariable logistic regression analyses were performed to identify risk factors for symptomatic PICC-related DVT.

Results: In total, 340 cancer patients obtained PICC lines for the administration of chemotherapy. Of these patients, 19 (5.6%; 95% CI: 3.6-8.6) developed symptomatic PICC-related DVT. Factors previously associated with catheter-related DVT, including side of catheter placement, lumen size, tip location, need for repositioning, and number of insertion attempts, were not significant determinants in our analysis. Patients with diabetes were three times more likely to develop PICC-related DVT (OR 3.0, p=0.039), while the presence of COPD and metastatic cancer also increased the odds (OR 3.3, p=0.078 and OR 2.3, p=0.083 respectively). Diabetes remained a significant risk factor after adjustment for effect of metastases and COPD (OR 3.175, p=0.039). Further, the presence of metastases was a significant predictor (OR 3.34, p=0.024) in our multivariable model.

Conclusions: Symptomatic PICC-related DVT are frequent in cancer patients receiving chemotherapy. Previously described factors associated with catheter-related thrombosis were not predictive of PICC-related DVT in our study. Diabetes, advanced disease and COPD appear to increase the risk of developing PICC-related DVT in chemotherapy patients.
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http://dx.doi.org/10.1016/j.thromres.2012.02.048DOI Listing
September 2012

Vascular access devices in leukemia: a retrospective review amongst patients treated at the Ottawa Hospital with induction chemotherapy for acute leukemia.

Leuk Lymphoma 2012 Jun 13;53(6):1090-5. Epub 2011 Dec 13.

Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.

Patients with acute leukemia require reliable central vascular access to ensure delivery of intravenous therapy. Peripherally inserted central catheters (PICCs) and Hickman(®) catheters are two commonly inserted central vascular catheters (CVCs), providing access to the central vascular space. While there have been reports describing individual center experiences, no one has compared the two devices, retrospectively or prospectively. We analyzed patients diagnosed with acute leukemia between September 1996 and April 2009, who had a PICC or Hickman®, received induction chemotherapy and survived at least 20 days. Prior to 1 January 2007, PICCs were inserted by palpation (PICC-palp) and Hickman(®) catheters were inserted surgically (H-Surg). After this date, PICCs were inserted by ultrasound (PICC-U/S) and Hickman(") catheters were inserted by interventional radiology (H-IR). Fifty-five patients had a Hickman(®) catheter (18 H-Surg, 37 H-IR) and 92 patients had a PICC (69 PICC-palp, 23 PICC-U/S). Significant improvements from H-Surg to H-IR catheters include the reduction in exit-site inflammation and infection (27.8% to 5.4%) and in bacteremic episodes (72.2% to 27.0%). Compared to PICC-U/S, H-IR had fewer cases of thrombophlebitis (0.0% vs. 8.7%); H-IR also required fewer instillations of a thrombolytic agent than the PICC-U/S (8.1% vs. 69.6%). Both CVCs have shown improvements from pre- to post-2007 insertion methods. Our data suggest that there were fewer complications with post-2007 Hickman(®) catheters compared to PICCs, suggesting that Hickman® catheters provide a more reliable central vascular access in these patients.
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http://dx.doi.org/10.3109/10428194.2011.639879DOI Listing
June 2012

Continuous multi-parameter heart rate variability analysis heralds onset of sepsis in adults.

PLoS One 2009 Aug 14;4(8):e6642. Epub 2009 Aug 14.

Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Background: Early diagnosis of sepsis enables timely resuscitation and antibiotics and prevents subsequent morbidity and mortality. Clinical approaches relying on point-in-time analysis of vital signs or lab values are often insensitive, non-specific and late diagnostic markers of sepsis. Exploring otherwise hidden information within intervals-in-time, heart rate variability (HRV) has been documented to be both altered in the presence of sepsis, and correlated with its severity. We hypothesized that by continuously tracking individual patient HRV over time in patients as they develop sepsis, we would demonstrate reduced HRV in association with the onset of sepsis.

Methodology/principal Findings: We monitored heart rate continuously in adult bone marrow transplant (BMT) patients (n = 21) beginning a day before their BMT and continuing until recovery or withdrawal (12+/-4 days). We characterized HRV continuously over time with a panel of time, frequency, complexity, and scale-invariant domain techniques. We defined baseline HRV as mean variability for the first 24 h of monitoring and studied individual and population average percentage change (from baseline) over time in diverse HRV metrics, in comparison with the time of clinical diagnosis and treatment of sepsis (defined as systemic inflammatory response syndrome along with clinically suspected infection requiring treatment). Of the 21 patients enrolled, 4 patients withdrew, leaving 17 patients who completed the study. Fourteen patients developed sepsis requiring antibiotic therapy, whereas 3 did not. On average, for 12 out of 14 infected patients, a significant (25%) reduction prior to the clinical diagnosis and treatment of sepsis was observed in standard deviation, root mean square successive difference, sample and multiscale entropy, fast Fourier transform, detrended fluctuation analysis, and wavelet variability metrics. For infected patients (n = 14), wavelet HRV demonstrated a 25% drop from baseline 35 h prior to sepsis on average. For 3 out of 3 non-infected patients, all measures, except root mean square successive difference and entropy, showed no significant reduction. Significant correlation was present amongst these HRV metrics for the entire population.

Conclusions/significance: Continuous HRV monitoring is feasible in ambulatory patients, demonstrates significant HRV alteration in individual patients in association with, and prior to clinical diagnosis and treatment of sepsis, and merits further investigation as a means of providing early warning of sepsis.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0006642PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721415PMC
August 2009

Utility of comorbidity assessment in predicting transplantation-related toxicity following autologous hematopoietic stem cell transplantation for multiple myeloma.

Biol Blood Marrow Transplant 2008 Sep;14(9):1039-1044

The Ottawa Hospital Blood and Marrow Transplant Program, University of Ottawa, Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Sprott Centre for Stem Cell Research, Ottawa Health Research Institute, Ottawa, Ontario, Canada. Electronic address:

Patients with coexisting medical problems may suffer increased toxicity and reduced quality of life after autologous hematopoietic stem cell transplantation (HSCT). The benefit of high-dose therapy for some patients with multiple myeloma (MM) is debatable. Decision tools that aid in identifying those patients with MM most suited for autologous HSCT may avoid the risk of excess toxicity. An objective assessment of comorbidities was performed in 126 patients with MM undergoing autologous HSCT using the Charlson comorbidity index (CCI), the hematopoietic cell transplantation comorbidity index (HCT-CI), and a modified pretransplantation assessment of mortality (mPAM) to determine the strength of association with increased transplantation-related toxicity and increased length of hospital stay (LOS). Any comorbidity scored using the CCI or HCT-CI (score > 0) was associated with an increased number of organ systems with serious toxicity (at least grade 2 toxicity using the Seattle criteria), an increased total sum of toxicity grades for all organs, and prolonged LOS. An mPAM score > or = 24 was associated with increased LOS. When considering autologous HSCT for a patient with MM, assessment of comorbidities using the CCI or HCT-CI may assist in predicting the risk of transplantation-related toxicity as an adjunct to physician judgment and patient preference.
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http://dx.doi.org/10.1016/j.bbmt.2008.06.019DOI Listing
September 2008

Reduced hemoglobin on day of peripheral blood progenitor cell collection is associated with low graft content of vascular progenitors and increased toxicity after autologous hematopoietic stem cell transplantation.

Transfusion 2008 Nov 30;48(11):2421-8. Epub 2008 Jul 30.

Division of Hematology, Blood and Marrow Transplant Program, The Ottawa Hospital, Ottawa Health Research Institute, Ottawa, Ontario, Canada.

Background: Tissue damage after hematopoietic stem cell transplantation (HSCT) occurs as a result of high-dose chemotherapy and radiation. The aim was to determine the importance of pretransplant anemia on toxicity and red blood cell (RBC) transfusion requirements after autologous HSCT.

Study Design And Methods: A total of 350 patients undergoing autologous HSCT were included in the analysis. Patient factors and pretransplant laboratory values of possible relevance were assessed in multivariate regression analysis.

Results: Reduced hemoglobin (Hb) on the first day of peripheral blood progenitor cell (PBPC) collection was significantly associated with increased organ toxicity after HSCT, as measured by the Seattle criteria. Lower Hb levels at baseline before transplantation, but not at PBPC collection, were significantly associated with increased RBC transfusion requirements. In a second cohort of 28 patients, higher Hb levels on the day of PBPC collection were significantly associated with increased levels of endothelial-like vascular progenitor cells in PBPC grafts.

Conclusion: Our observations suggest that higher Hb levels on the day of PBPC collection may be a marker of reduced toxicity associated with HSCT and increased vascular progenitors in PBPC collections. Further, baseline anemia before transplant may reflect an unfavorable hematopoietic microenvironment that leads to increased RBC transfusion requirements.
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http://dx.doi.org/10.1111/j.1537-2995.2008.01876.xDOI Listing
November 2008

Increased graft content of vascular progenitor cells is associated with reduced toxicity following autologous hematopoietic transplantation.

Exp Hematol 2008 Apr 8;36(4):506-12. Epub 2008 Feb 8.

Blood and Marrow Transplant Program, The Ottawa Hospital, Ottawa, Ontario, Canada.

Objective: Endothelial-like vascular progenitor cells (VPCs) can be collected in peripheral blood stem cell (PBSC) products that are used in hematopoietic stem cell transplantation (HSCT). The association between VPCs in PBSC products and transplant-related toxicity caused by high-dose chemo/radiotherapy was assessed to identify potential mediators of vascular repair.

Materials And Methods: PBSC grafts in 29 patients (mean age: 48 years; range, 20-67 years) undergoing autologous HSCT were analyzed using a cell culture assay for VPC cluster formation in fibronectin-coated dishes in serum-rich angiogenic conditions. Transplant toxicity was estimated using total length of hospital stay (LOS) following HSCT and the Seattle criteria for transplant-related organ toxicity for 8 organ systems (grade 0-4).

Results: LOS following graft reinfusion was lower (14.7 vs 20.0 days, p = 0.002) and the mean number of organs with any toxicity (1.0 vs 2.4, p = 0.016) or with toxicity grade > or = 2 was reduced (0.2 vs 1.6 organs, p = 0.007) in patients with high graft VPC content (n = 10, >2.0 x 10(3) VPCs/kg) compared with reduced VPC content (n = 19, < or = 2.0 x 10(3) VPCs/kg). An association between graft CD34(+) levels and LOS or organ toxicity was not observed. In addition, graft VPC levels were independent of graft CD34 counts, peripheral blood monocytes and hemoglobin levels, age, and disease (p = NS).

Conclusion: PBSC products enriched for VPCs are associated with reduced toxicity following HSCT. Identifying specific factors that contribute to high graft VPC levels is needed.
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http://dx.doi.org/10.1016/j.exphem.2007.12.005DOI Listing
April 2008

A 15-year analysis of early and late autologous hematopoietic stem cell transplant in relapsed, aggressive, transformed, and nontransformed follicular lymphoma.

Biol Blood Marrow Transplant 2007 Aug;13(8):956-64

The Ottawa Hospital Blood and Marrow Transplant Program, University of Ottawa, Ottawa, Ontario, Canada.

Autologous stem cell transplant (ASCT) has been shown to be an effective treatment for follicular lymphoma (FL). We explored our experience in ASCT for FL among all patients treated over a 15-year period from diagnosis through their entire treatment history including relapse post ASCT. All patients who underwent an unpurged ASCT for relapsed, advanced FL between June 1990 and December 2000 were analyzed. After salvage therapy they received melphalan/etoposide/total body irradiation, BCNU, etoposide, cytarabine, melphalan (BEAM), or cyclophosphamide BCNU etoposide (CBV) as conditioning for the ASCT. One hundred thirty-eight patients with a median age of 48 years and a median follow-up of 7.6 years were analyzed. The majority were of the subtype grade 1, nontransformed (FL-NT), having had 1 prior chemotherapy. The progression-free (PFS) and overall survival (OS) of the FL-NT at 10 years were 46% and 57%, respectively, and at 5 years for the transformed (FL-T) were 25% and 56%, respectively, of which only the PFS was significantly different (P=.007). The median OS from diagnosis was 16 years for the FL-NT. ASCT positively altered the trend of shorter remissions with subsequent chemotherapies, and there was no difference in OS between those who had 1, 2, or >2 chemotherapies prior to ASCT. Salvage therapy for relapse post ASCT was effective (OS>1 year) in a third of patients. Unpurged ASCT is an effective tool in the treatment of relapsed, aggressive FL-NT and FL-T, is superior to retreatment with standard chemotherapy, is effective at various stages of treatment, is likely to have a beneficial influence on the natural history of this disease, and the disease is amenable to salvage therapy post-ASCT relapse.
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http://dx.doi.org/10.1016/j.bbmt.2007.04.009DOI Listing
August 2007

Outpatient autologous hematopoietic stem cell transplantation for patients with relapsed follicular lymphoma.

Ann Hematol 2006 Oct 11;85(10):723-9. Epub 2006 Jul 11.

St. Paul's Hospital and University of British Columbia, 440-1144 Burrard Street, Vancouver, BC, Canada.

Autologous stem cell transplantation (ASCT) has emerged as a viable option for the treatment of relapsed follicular non-Hodgkin's lymphoma. We report on the outpatient experience of 60 patients who underwent ASCT for this condition. The median age was 51 years (30-65). Pre-transplantation conditioning regimens consisted of either etoposide/melphalan/TBI, CBV or BEAM. Patients participated in this transplant program for a median of 20.5 days (14-78), and 58.4% of the total program days were spent in the outpatient setting. Six patients were well enough to be treated solely as outpatients. Ninety percent of patients required at least one inpatient admission (median 7 days), and 70% of first inpatient transfers occurred within the first week following transplant and always before day +12. There were no predictors for prolonged inpatient stays. Febrile neutropenia and gastrointestinal toxicity were the main reasons for inpatient transfers. No outpatient required an urgent admission to the ICU or died in the outpatient setting. The treatment-related mortality at days 30 and 100 was 0 and 1.7%, respectively. The overall and progression-free survivals at 5 years were 65.7 and 56.1%, respectively. Outpatient ASCT with total body irradiation is feasible, safe, and effective for patients with relapsed follicular lymphoma.
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http://dx.doi.org/10.1007/s00277-006-0149-6DOI Listing
October 2006

Leading change: Retrospective evaluation of a nurse-led initiative in vascular access options for autologous stem cell transplant recipients ranging from Hickman catheters to peripherally inserted central catheters.

J Infus Nurs 2006 Mar-Apr;29(2):81-8

Blood and Marrow Transplant Program, Ottawa Hospital-General Campus, Ontario, Canada.

Central venous access is essential for patients undergoing autologous hematopoietic stem cell transplantation (ASCT). Traditionally, tunneled silastic catheters have been inserted in these patients. However, changes in resource allocation, resulting in reduced surgery and surgeon time and decreasing toxicity associated with ASCT, have caused changes in venous access needs and options. This led the advanced practice nurse in the transplant program to evaluate other central access devices, which resulted in the introduction of peripherally inserted central catheters (PICCs) for this patient population. This study reports the results of a retrospective analysis comparing efficacy and complication profiles between 50 patients with the traditional Hickman catheter and 70 patients with PICCs.
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http://dx.doi.org/10.1097/00129804-200603000-00005DOI Listing
May 2006

Nutritional support of the patient receiving high-dose therapy with hematopoietic stem cell support.

Authors:
Sheryl McDiarmid

Can Oncol Nurs J 2002 ;12(2):102-15

Ottawa Hospital, Ottawa, Ontario.

Hematopoietic stem cell transplantation (HSCT) is an intensive therapy that is being used increasingly in an attempt to cure certain malignancies. One of the major adverse effects of this treatment is an inadequate oral intake that may result in dehydration and malnutrition. Factors that may contribute to inadequate oral intake include mucositis, nausea, vomiting, and anorexia. In addition, prior to transplant, many patients may have experienced, or continue to experience malnutrition associated with malignancy and its therapy. Traditionally, total parenteral nutrition (TPN) has been the mainstay of nutritional support in this patient population. The blood and marrow transplant (BMT) team at the Ottawa Hospital has significantly decreased the use of TPN through the initiation of a comprehensive nutritional support program that uses a variety of interventions including oral supplementation and enteral feeding. Understanding the causes and implications of malnutrition, and using tools that allow risk assessment and timely implementation of appropriate nutritional interventions, may facilitate full patient recovery parallel to hematopoietic recovery in the HSCT patient population.
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http://dx.doi.org/10.5737/1181912x122102107DOI Listing
September 2002
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