Abstract Background: Pain is usually common patients who undergo high-dose treatment in combination with HSCT. Pain is usually associated with side effects as for example mucositis. The purpose of this study was to examine patients’ experiences of pain in relation to stemcellstransplantation. The purpose was also to examine how patients experience that they have been treated by the personnel regarding their pain, and also if the pain relief correspond to the patients expectations. Method: The study is a descriptive, longitudinal study. Eight patients who underwent HSCT were interviewed. The study implemented in three parts, whereof two interviews and one questionnaire. The interview material was analyzed by means of content analysis. Results: The result shows that five of eight patients experienced pain during HSCT treatment. Three of these informants experienced pain in their mouth, their head and in their stomach. This is usually commonly side effects of the treatment. Back pain occurs in two of the patients and this pain hasn’t proceeded during the treatment. Three informants did not experience any pain at all during the time of nursing. The result even shows that the all of the informants had experienced a well refutation of the personnel in terms of their pain. All informants reported that it was important to be well pain relieved. Those informants who had pain during their treatment were very satisfied with the pain relief they have got.   Keywords: stem cell transplantation, oral pain, pain treatment, oral mucositis, satisfaction with care. / Sammanfattning Bakgrund och syfte: Smärta är vanligt förekommande bland patienter som genomgår högdosbehandling i kombination med HSCT. Smärta är vanligtvis förknippad med biverkningar som t ex mucosit. Syftet med denna studie var att undersöka patienters upplevelse av smärta i samband med stamcellstransplantation. Syftet är även att undersöka hur patienterna upplever att de blir bemötta av personalen angående sin smärta, samt om smärtlindringen motsvarar patientens förväntningar. Metod: Studien är en deskriptiv, longitudinell studie. Åtta patienter som skulle genomgå stamcellstransplantation intervjuades. Studien genomfördes i tre delar, varav två intervjuer och ett frågeformulär. Intervjumaterialet analyserades med innehållsanalys. Resultat: Resultatet visar att fem av åtta patienter upplevde smärta i samband med HSCT. Tre av dessa informanter upplevde smärtor i munnen, huvudet och i magen. Ryggsmärta förekom hos två av informanterna och denna smärta hade inte uppstått i samband med behandlingen. Tre informanter upplevde ingen smärta alls under hela vårdtiden. Resultatet visar även att samtliga informanter upplevt ett bra bemötande av personalen vad gäller deras smärta. Alla informanter uppgav att det var viktigt att vara bra smärtlindrad. De informanter som hade smärta under behandlingen var mycket nöjda med den smärtlindring de fick.   Nyckelord: stamcellstransplantation, oral smärta, smärtbehandling, oral mucosit, tillfredsställelse med vård.

Bakgrund:Oral mukosit (OM) är en toxisk biverkan efter högdos cytostatikabehandling (HDC) och hematopoietisk stemcellstransplantation (HSCT). OM orsakar kliniska komplikationer samt negativa följder för patienten, som längre sjukhusvistelse, oral smärta, viktförlust och parenteral nutrition (PN).Syfte:Att undersöka om det föreligger skillnad i viktförändring och nutritionsstatus hos patienter som använder munsköljmedlet, Caphosol ® i tillägg till standardbehandling i jämförelse med standardbehandling vid behandling med HDC och HSCT.Metod:En randomiserad kontrollerad öppen studie där patienter > 16 år (n=40), behandlades med HDC, inför HSCT på Akademiska universitetssjukhuset, Uppsala. Patienterna randomiserades, 1:1, till oral standardbehandling och munsköljmedlet Caphosol® (EXP n=20) eller oral standardbehandling (KTR n=20). OM, oral smärta, viktförlust och dagar av PN registrerades och analyserades från baseline till 21 dagar efter avslutad HDC.Resultat:Caphosol ® hade ingen signifikant betydelse för viktförändringar mellan EXP- och KTR-grupperna. OM-smärta debuterade senare i EXP än i KTR-gruppen. KTR gruppen använde mer PN jämfört med EXP-gruppen.Konklusion:Caphosol ® hade obetydlig inverkan på förekomst, duration och svårighetsgrad av OM under HCT vid HSCT och därmed liten effekt på nutrition och vikt. Det förelåg ingen fördel att addera Caphosol ® till oral standardbehandling. / Background:Oral mucositis (OM) is a result of cytotoxic effects of high dose chemotherapy (HDCT) administered before hematopoietic stem cell transplantation (HSCT). It is a source of negative consequences for the patient, such as longer hospitalization, oral pain, weight loss, and use of parenteral nutrition (PN).Objective:To investigate whether there is differences in weight changes and nutritional status in patients receiving mouth rinse, Caphosol®, in addition to standard oral care (OC) compared to standard OC for HDCT and HSCT.Method:A randomized, controlled open study with patients > 16 years, treated with HDCT before HSCT at Akademiska University Hospital, Uppsala, Sweden. Patients randomized 1:1 to standard OC and Caphosol® (EXP, n=20) or standard OC (CTR n = 20). Oral pain, weight loss and days of PN was recorded and analysed from baseline to day 21 post HDCT.Result:Caphosol ® had no significant impact on weight changes between EXP and CTR groups. OM-pain peaked later in the EXP group than in CTR. No significance in weight change between settings. CTR group had higher use of PN compared to EXP.Conclusion:Caphosol® had little effect on frequency, duration and severity of OM and thereby little effect on nutrition and weight. There was no advantage to add Caphosol ® to standard OC.

Thesis (M.S.)--University of South Florida, 2009. / Title from PDF of title page. Document formatted into pages; contains 52 pages. Includes bibliographical references.

CD28 co-stimulation is required for the generation of naturally occurring regulatory T cells (nTregs) in the thymus through Lck-signaling. However, high level of CD28 suppresses the generation of induced Tregs (iTregs) from naïve CD4 T cells, although underlying mechanism(s) has not been defined. Here we investigated the role of CD28-mediated signaling pathways in the suppression of Treg generation. We used a series of transgenic (Tg) mice on CD28-deficient background that bears WT CD28 or mutated CD28 in its cytosolic tail incapable of binding to Lck, PI3K or Itk. Regardless of exogenous IL-2, strong CD28 costimulation suppressed iTreg generation through Lck signaling. Using a GVHD model to test the role of CD28-mediated iTreg suppression in T cell pathogenicity in vivo, we found that CD28-Lck T cells induced significantly less GVHD than T cells from CD28-WT mice. Furthermore, we found that the recipients of T cells from CD28-Lck mice generated significantly more iTregs than those with T cells from CD28-WT, which contribute to reduced graft-versus-host disease (GVHD) development in recipients of CD28-Lck T cells. These results indicate that CD28 costimulation can negatively regulate Treg generation and may provide an avenue for control of T-cell immunity or tolerance by regulating Tregs using the CD28 signal as a target. We went a step forward and investigated the therapeutic potential of antigen-specific iTregs in the prevention of GVHD. Donor hematopoietic stem cells and mature T cells are transplanted into a lymphopenic host to potentially cure many cancers and hematopoietic diseases like leukemia in bone marrow transplantation (BMT) or hematopoietic stem cell transplantation (HCT), but the frequent development of GVHD is the main drawback of this treatment. nTregs suppress the development of GVHD and may spare graft-versus-tumor effect. However, nTregs are a minor (~5%) subpopulation of CD4 helper T cells in healthy individuals, and using in vitro expanded nTregs is a common strategy to test their therapeutic potential in BMT. The concern of in vitro expanded nTregs may include their stability of Foxp3 (master regulatory gene for the development and function of regulatory T cell) expression and suppressive function, survival in vivo, and the non-selective suppression of the pre-activated nTregs. Antigen-specific activation of the regulatory T cells is important for optimal function. In this study, we used an alternative strategy to generate antigen-specific, iTregs and assessed their suppressive potential by comparing their effectiveness in preventing GVHD with polyclonal iTregs. We found that antigen-specific iTregs prevented GVHD lethality in recipients that expressed the target antigen, but were not protective of recipients who did not express the target antigen. Furthermore, antigen-specific iTregs were significantly more efficient than those polyclonal Tregs in the prevention of GVHD. These results reveal the therapeutic potential of antigen-specific iTregs to prevent GVHD efficiently and selectively, and provide the rationale to use antigen-specific iTregs in clinical HCT.

No description available.

L’infection primaire au VZV et la réactivation du VZV latent sont fréquemment observées à la suite d’une GMO ou d’une GSCO, ce qui cause de sérieuses complications chez le patient. Pour prévenir ces infections, une prophylaxie antivirale est administrée systématiquement chez tous les greffés de MO ou de SCO, alors qu’il n’existe aucun consensus sur la durée optimale d’une telle prophylaxie. Pour résoudre ce problème, notre objectif est de développer et valider une méthode ELISpot-VZV-IFN- qui permettra de suivre la reconstitution de l’immunité à médiation cellulaire anti-VZV chez les receveurs de GMO ou de GSCO et ainsi déterminer le moment opportun pour réduire ou interrompe la prophylaxie chez les receveurs de greffes de CSH. Dans un premier temps, des valeurs-seuil de la réponse à médiation cellulaire anti-VZV chez la population pédiatrique saine ont dû être générées. À la lumière de nos résultats, un enfant avec un résultat ELISpot-VZV-IFN- > 190.0 SFU/106 PBMC devrait être protégé contre une possible infection à VZV. Pour valider cette étude, une étude prospective de la reconstitution immunitaire anti-VZV a été effectuée chez 9 enfants greffés de MO ou de SCO. Nos résultats préliminaires ont montré qu’il n’y avait eu aucune reconstitution significative de l’immunité à médiation cellulaire anti-VZV dans les 18 premiers mois post-transplantation chez 8 de ces 9 enfants. Les résultats de ces expériences vont fournir d’importantes informations quant à la reconstitution de l’immunité anti-VZV à la suite d’une GMO ou d’une GSCO et pourraient permettre l’amélioration des soins apportés aux receveurs de GMO ou de GSCO. / Primary infection with VZV and reactivation of latent VZV are commonly observed following BMT and UCBT, leading to serious complications in patients. As a result, antiviral prophylaxis is systematically administered to BMT and UCBT recipients, yet there is no consensus that defines its optimal duration. To resolve this problem, our objective was to develop and validate a VZV-IFN--ELISpot with which reconstitution of VZV immunity can be followed in BMT and UCBT recipients, providing clinicians a practical tool to gauge the need for and adjust antiviral prophylaxis in individual HSCT recipients. First of all, threshold values for anti-VZV immunity in healthy pediatric subjects were generated. Based on our results, a child exhibiting > 190.0 VZV-specific SFU /106 PBMC should be protected against a possible VZV infection. To validate these results, a prospective study on the recovery of VZV-specific T cell immunity was performed on 9 children following BMT or UCBT. Preliminary results demonstrated that there was no significant recovery of VZV-specific T cell immunity in the first 18 months post-transplantation in 8 of 9 cases. Results of these experiments will yield important new information regarding reconstitution of anti-VZV immunity following BMT and UCBT and could lead to improvements in clinical management of BMT and UCBT recipients.

Le busulfan (Bu) est un composé clé de la phase de conditionnement chez les enfants subissant une transplantation des cellules souches hématopoïétiques (TCSH). Les différences inter-individuelles de la pharmacocinétique (PK) du Bu pourraient affecter son efficacité et sa toxicité. Le Bu est principalement métabolisé par la glutathion-S-transférase (GST). Nous avons étudié la relation des génotypes GSTA1, GSTM1 et GSTP1 avec la PK de la première dose de Bu et la relation avec les résultats de la TCSH chez 69 enfants recevant un régime de conditionnement myéloablatif. Le génotype GSTM1 nul a corrélé avec une exposition élevée du Bu et une faible clairance (CL) chez les patients âgés de 4 ans (p ≤ 0,04). Dans le respect du rôle fonctionnel suggéré d’haplotype GSTA1 *A2, il a été associé à des niveaux plus faibles de médicaments et des niveaux élevés de CL (p ≤ 0,03). L’effet Gène-dose a également été observé (p = ≤ 0,007). L’haplotype de GSTA1 était associé avec les résultats de la TCSH. Les porteurs de deux copies d’haplotype *A2 avaient une meilleure survie sans événement (p = 0,03). En revanche, les individus homozygotes pour haplotypes * B et *B1 ont un risque plus élevé d’atteindre la maladie veino-occlusive (MVO) (p = 0,009). Les individus porteurs de GSTM1 nul âgés de 4 ans possèdent un risque plus fréquent d’avoir la maladie du greffon contre l'hôte (GvHD) (p = 0,03). En conclusion, nous avons montré que les variantes génétiques de GST influencent la PK du BU et les résultats de la TCSH chez les enfants. Pour l'ajustement de la posologie, un modèle avec l'inclusion des facteurs génétiques et non génétiques devrait être évalué et validé dans une étude prospective. / Busulfan (Bu) is a key compound of conditioning regimen in children undergoing hematopoietic stem cell transplantation (HSCT). Inter-individual differences in Bu pharmacokinetics might affect Bu efficacy and toxicity. Since Bu is mainly metabolized by glutathione S-transferase (GST), we investigated the relationship between GSTA1, GSTM1 and GSTP1 genotypes with first-dose Bu pharmacokinetics (PK), and relationship with HSCT outcomes in 69 children receiving myeloablative conditioning regimen. GSTM1 null genotype correlated with higher Bu exposure and lower clearance in patients older than 4 years (p≤0.04). In accordance with the suggested functional role GSTA1*A2 haplotype was associated with lower drug levels and higher drug clearance (p≤0.03). Gene-dosage effect was also observed (p=≤0.007). GSTA1 haplotypes were associated with HSCT outcomes Patients with two copies of haplotype *A2 had better event free survival (p=0.03). In contrast, homozygous individuals for haplotypes *B and *B1 had higher occurrence of veno-occlusive disease (p=0.009). GSTM1 null individuals older than 4 years had more frequently graft versus host disease (p=0.03). In conclusion, we showed that GST gene variants influence Bu PK and outcomes of HSCT in children. A model for the dosage adjustment with the inclusion of genetic and non-genetic factors should be evaluated in a future prospective validation cohort.

Das Auftreten manifester transplantationsassoziierter thrombotischer Mikroangiopathie sowie das Auftreten leichterer, zumeist subklinischer mikroangiopathischer Veränderungen wurde in einem Kollektiv von Patienten untersucht, die zur Behandlung einer steroidrefraktären oder abhängigen akuten oder chronischen GvHD nach allogener Stammzelltransplantation eine Therapie mit extrakorporalen Photopheresen erhielten. Subklinische mikroangiopathische Schädigung wurde durch ein auf den Messwerten von Fragmentozyten, Thrombozyten sowie der LDH-Aktivität beruhendes Bewertungsschema festgestellt. Das Auftreten von ausgeprägten mikroangiopathischen Veränderungen (Schweregrad 2) ging mit einem erniedrigten Gesamtüberleben einher. Die Reduktion der Steroiddosis und die Verringerung der GvHD-Manifestationen wurden als Parameter für die Wirksamkeit der ECP analysiert. Ihre Effektivität wurde bestätigt. Trotz der nachgewiesenen Effektivität der ECP in der Kontrolle der GvHD zeigte sich eine Tendenz zur Zunahme mikroangiopathischer Veränderungen unter Therapie mit ECP, in Einzelfällen mit schwerwiegenden klinischen Konsequenzen.

Treatment results and clinical characteristics in adult acute lymphoblastic leukaemia (ALL) were evaluated regarding three issues: a new treatment with cytarabine up-front, stem cell transplantation and a comparison between adult and paediatric treatment protocols. All studies were conducted on a national basis. Furthermore, activity of imatinib was investigated by in vitro cytotoxicity assay. The national protocol was evaluated in 153 adult ALL patients. A high complete remission rate, 86%, was achieved with 29% overall survival at 3-years. Favourable outcome was identified in patients < 40 years with precursor B phenotype and continuous complete remission was higher for precursor B compared to T-ALL. Stem cell transplantation was evaluated in 187 patients. No differences in outcome between allogeneic and autologous transplantation were found, with the exception of Philadelphia-positive ALL, in which allogeneic transplantation was preferable. Limited chronic graft-versus-host disease (compared to none) resulted in superior disease free survival. The paediatric NOPHO-92 and the Adult protocols were evaluated for 243 ALL-patients. Superior remission rate and survival were achieved for 10-18 year-olds treated according to the Paediatric protocol compared to both 15-25 and 25-40 year-olds treated according to the Adult protocol. Treatment protocol was a significant prognostic factor for patients aged 15-20 years. Fluorometric Microculture Cytotoxicity Assey was used to analyze 15 tumour cell samples from ALL patients. High concordance was determined between in vitro sensitivity to imatinib and presence of BCR-ABL. Daunorubicin, prednisolone and cytarabine had the greatest benefit from a combination with imatinib. The national adult treatment protocol’s results were consistent with international trials regarding precursor B ALL but may be under performing for T-ALL. Adolescents may benefit from treatment according to the Paediatric protocol. No difference in outcome between allogeneic and autologous stem cell transplantation was determined except for Philadelphia-positive patients, despite the indication of a graft-versus-leukaemia effect.

Survival of patients with poor prognosis or relapsed haematopoietic malignancies can be markedly improved by allogeneic haematopoietic stem cell transplantation (HSCT). HSCT reconstitutes the immune and haematopoietic systems after myeloablative conditioning and inhibits the recurrence of the malignancy by a graft-versus-leukaemia (GVL) response mediated by donor T cells. However, significant post-transplant complications such as graft-versus-host disease (GVHD) continue to plague the event-free survival of this curative procedure. GVHD is facilitated by donor T cells that recognise histocompatibility antigens on host antigen presenting cells (APC), such as dendritic cells (DC). Current treatment options for GVHD are focused on these T cells. However, these treatments result in an increased incidence of infection, graft rejection and relapse. A novel means of immunosuppression in GVHD is the use of multi-potent, mesenchymal stromal cells (MSC). MSC are non-immunogenic cells that actively suppress T cell function in vitro, and can resolve steroid-refractory GVHD in the clinic. Despite their use in the clinic, there is a paucity of pre-clinical data. Our aim was to investigate the in vivo efficacy of MSC to control GVHD while maintaining the beneficial GVL effect, and to begin to understand the mechanism by which MSC exert their immunosuppressive effects. We isolated and characterised MSC from murine bone/bone marrow and demonstrated that they suppressed T cell proliferation in vitro, even at low ratios of 1 MSC per 100 T cells. This was true of both donor-derived MSC, and MSC derived from unrelated donors (third party). Importantly, we observed that MSC significantly reduced T cell production of the pro-inflammatory cytokines TNFα and IFNγ in culture supernatants and that IFNγ plays a key role in the ability of MSC to suppress T cell proliferation. In vivo, we examined the effects of donor-derived MSC on GVHD severity and onset in two myeloablative murine models of HSCT. A major histocompatibility complex (MHC)-mismatched donor-recipient pair combination was used as a proof–of-principle model [UBI-GFP/BL6 (H-2b)àBALB/c (H-2d)], and an MHC-matched, minor histocompatibility antigen (miHA) mismatched donor-recipient pair combination was used to mimic MHC-matched sibling transplantation [UBI-GFP/BL6 (H-2b)àBALB.B (H-2b)]. We examined a number of variables related to MSC infusion including timing, dose and route of injection. We found that early post transplant infusion of MSC by the intraperitoneal injection was most effective at delaying death from GVHD, compared to pre-transplant infusion or intravenous injection. Furthermore, we found that the dose of MSC was critical, as infusion of too few MSC was ineffective and infusion of too many MSC exacerbated the development of GVHD. Taken together, these results suggest that timing, dose and route of injection are all important factors to be considered to ensure successful therapeutic outcome. To investigate the in vivo mechanism of action, we conducted timed sacrifice experiments in the MHC-mismatched model to determine if MSC altered cytokine secretion and cellular effectors, such as DC, known to play a key role in GVHD. Despite the fact that MSC given post-HSCT enter an environment full of activated DC and IFNγ levels, by day 3 and 6 post infusion, these activated DC and IFNγ levels are decreased compared to controls or mice infused with MSC pre-transplant (p<0.05). This confirmed our in vitro data that IFNγ played an important role in MSC-mediated immunosuppression. In addition, when we removed a major source of IFNγ production in vivo by administering the T cell depleting antibody KT3 to mice with or without MSC, we found that although T cell depletion prolonged survival, MSC were unable to further enhance this effect. This was also true when MSC were used in combination with the conventional immunosuppressant cyclosporine. Finally, we examined whether the infusion of MSC would compromise the GVL effect. We found that whilst MSC could delay the onset of GVHD, in our model they did not alter the anti-tumour effects of the donor T cells. Overall, we have shown that MSC can delay but not prevent death from GVHD when administered at an appropriate time and dose and that IFNγ is required for MSC-mediated immunosuppression in our model. These data suggest that patients undergoing HSCT should be monitored for IFNγ, and administered MSC when high levels are reached. Whilst MSC may be a promising therapy for patients with severe GVHD, we highlight that further investigation is warranted before MSC are accepted for widespread use in the clinic. The risks and benefits for transplant recipients should be carefully considered before utilising MSC to treat or prevent GVHD.