Seasonal human coronaviruses respiratory tract infection in recipients of allogeneic hematopoietic stem cell transplantation.
Jose Luis Piñana et al
J Infect Dis. 2020 Aug 29. doi: 10.1093/infdis/jiaa553. Online ahead of print.
Remember the days before COVID-19 when coronaviruses were generally a seasonal and generally less problematic infection? Perhaps they evaded our focus and therefore relatively little was known about them and their impact on HSCT patients. In this excellent joint EBMT/Spanish Society study, 402 allogeneic paediatric and adults patients with 449 episodes seasonal human coronoviruses (HCoV) infection of upper and/or lower respiratory tract from 2012 to 2019 were analysed. HCoV OC43 was the most common subtype and lower respiratory tract involvement was present in 121 episodes. The clinical impact of HcoV was significant; hospitalisation in 18%, oxygen in 13%, ITU in 3% and overall mortality at 3 months was seen in 7% rising to 16% in those with lower tract infection. Three percent died specifically from infectious respiratory failure from HCoV infection. No differences were seen in outcomes among paediatric and adult patients in terms of rate of lower respiratory tract disease, hospital admission, requirement for oxygen support and overall mortality. Mortality was linked to lower lymphocyte count and steroid usage (as well as ITU admission as expected). Although there were limitations of this retrospective study, including low proportion of bronchoalveolar lavage sampling, absence of lung tissue analysis and variation in PCR methods for diagnosis, this large multi-center cohort of HCoV cases provides a worthwhile observation supported by detailed clinical and molecular testing data. Despite the COVID-19 pandemic, seasonal coronoviruses will inevitably continue - and maybe going forwards there will also be some useful lessons for management of the novel coronovirus SARS-CoV-2?
Setting up and sustaining blood and marrow transplant services for children in middle-income economies: an experience-driven position paper on behalf of the EBMT PDWP
Lawrence Faulkner et al
Bone Marrow Transplant. 2020 Sep 7. doi: 10.1038/s41409-020-0983-5. Online ahead of print.
Severe blood disorders, especially severe haemoglobinopathy, and cancer are major causes of death and disability from non-communicable disease in middle income countries (MICs) yet there are potentially major health and, ultimately, economic, benefits if good quality HSCT programmes can be established within the constraints of such health services. This is an important position paper from the PDWP aiming to overcome these challenges whilst proposing solutions for the planning and practicalities needed to establish BMT services for paediatric patients in MICs. The co-authors cover the groundwork for getting started with the programme, including well-considered and detailed listings of essential workforce, equipment, tests, drugs and other consumables. For example, they propose that a core team consisting of 2 physicians, 10 nurses, 1 manager/secretary, 1 psychosocial coordinator or psychologist, 2 housekeeping staff may be sufficient for a basic HSCT service. Design and infection control, support services, transplant costs, training strategy, personnel and core competencies are all discussed and practical proposals made. Recommendations are made to aspire to accreditation systems such as JACIE, but the focus of this position paper is to provide some clear, practical directions for starting up and initial development of services in MICs. Clearly, there is ‘no one size fits all’, but the feeling from reading this position paper is that it comes from a team of BMT practitioners with real hands-on experience of the challenges of working within MIC healthcare systems, who are able to offer practical solutions and templates for service development. How can the rest of us in EBMT support these initatives? They conclude by promoting ‘outreach’. If EBMT wishes to be effective in supporting HSCT in MICs, there will need to be a sustained and effective outreach programme, as there is evolving within the PDWP. Of course, working with the local infrastructure of MICs as well as other international organisations will be essential as well. Well done to this this team of co-authors, and it would be welcome to see EBMT continue to evolve their support for similar developments across all ages of patients.
Investigation and Management of Bone Mineral Density Following Hematopoietic Cell Transplantation: A Survey of Current Practice by the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation
Nina Salooja et al
Biol Blood Marrow Transplant. 2020 Oct;26(10):1955-1962. doi: 10.1016/j.bbmt.2020.06.022. Epub 2020 Jul 3.
It is well recognised that bone health may be compromised from an early stage following HSCT. For many years international guidelines have made recommendations for maintenance of bone mineral density (BMD), which can be adversely impacted by a wide range of transplant-related factors such as corticosteroids and other drugs, endocrine factors, diet, lack of sunlight and exercise, prolonged hospitalisation and immobility, as well as underlying diagnosis and, inevitably, the ageing process in our long term HSCT survivors. This EBMT study surveyed current practices in the prevention, investigation and management of low BMD across our transplant centres. Although a significant limitation was that only around 20% of centres responded during the year it was open, the study is important in highlighting considerable heterogeneity in practice across European centers in relation to a range of issues; advice on maintaining/improving bone health after HSCT (dietary, vitamin D supplementation and exercise), indications and triggers for DXA scanning (for example, corticosteroid history), frequency of DXA scanning, clinical management of reduced bone density (including use of bisphosphonates and other interventions), and, more broadly, variable implementation of guidelines and role of national policy and payers for our highly specialised group of patients. Overall, this study highlights a need for better implementation of guidelines and harmonisation of practice across HSCT centres across many countries. Perhaps reflected by the relatively low level of responses (potentially from only the most proactive centers), one feels that this area of ‘late effects’ remains poorly scoped and inconsistently implemented within our EBMT community and our health services, despite the major health and economic consequences of low BMD, fractures and other disability occuring later in the transplant journey.