OBJECTIVES:There is a severe economic crisis in Lebanon that has significantly impacted its healthcare system, particularly pediatric oncology. With a high cancer incidence rate and increasing pediatric cancer burden, it remains inequitable to access specialized care, particularly among rural and refugee communities. Pediatric oncology services are centralized in few tertiary care centers within Beirut, with no access to specialized healthcare professionals. METHODS:This review addresses the provision of care for pediatric oncology in Lebanon through the deployment of healthcare personnel, the availability of diagnostic and therapeutic services, and the operation of national and international assistance systems. Information was gathered from hospital records, government reports, and studies on child cancer care in Lebanon with a focus on the availability of services, workforce, and barriers to equal access. RESULTS:The economic crisis has severely limited access to treatment, diagnostics, and basic supportive care, including psychosocial and palliative support. Although centers such as the Children's Cancer Institute of the American University of Beirut Medical Center provide high-quality, donor-funded care, financial and logistical barriers deprive many children of timely therapy. In addition, maintaining cancer registries is also an issue, particularly for refugees, and therefore planning services and distributing resources is even more challenging. CONCLUSIONS:Scaling up decentralized pediatric oncology care, integrating digital health technologies, and strengthening international partnerships are essential to bridging these gaps. Further, investment in healthcare workforce capacity building, particularly in nursing and psychosocial support, is crucial to sustaining care delivery. Lebanon's National Cancer Plan provides a framework for bridging these disparities, but greater governmental investment and long-term international partnerships are required. IMPLICATIONS FOR NURSING PRACTICE:This review highlights the urgent need for systemic reforms to ensure equitable access to pediatric oncology care, improve patient outcomes, and mitigate the long-term impact of Lebanon's healthcare crisis.

Several factors affect the outcome of allogeneic stem cell transplantation (Allo-SCT) in hematologic malignancy patients. The disease type, treatment modality and patients’ clinical profile largely determine the outcomes of Allo-SCT; however, the latter may vary among patients with similar aforementioned variables. Proximity to the transplant center could be an independent factor that affects the clinical outcome of Allo-SCT in patients. This is a retrospective study conducted at American University of Beirut Medical Center (AUBMC). Aims: Aims: The aim of this study is to determine the differences in the clinical outcome between Allo-SCT patients residing at different distances from the transplant center. Methods: Methods: We identified a total of 275 adult patients receiving Allo-SCT between January 2007 and June 2021. The patients were divided into three groups: patients residing within 20 km from AUBMC N=120 (44%) labeled as Urban, patients residing beyond 20 km from AUBMC N=111 (40%) labeled as Rural and patients who arrived from countries abroad N=44 (16%) labeled as Abroad. All patients received Allo-SCT along with the required follow up medical care at AUBMC. Using univariate and multivariate analysis, we examined the impact of distance from the transplant center along with other independent variables on the outcomes of Allo-SCT. Kaplan-Meier curves were also exploited to identify overall survival (OS), progression free survival (PFS) and transplant-related-mortality (TRM). Results: Results:

After the revolution that has been carved by autologous CAR T-Cell in the management of R/R aggressive B-Cell Lymphomas, T-Cell engaging Bispecific antibodies (CD3xCD19/CD20/CD22) are now paving the way for a new era. Indeed, those BsA harbor several interesting features such as immediate availability for patients, very good tolerability and toxicity profiles and overwhelming effectiveness in several trials[1–3]. While bearing overall similar outcomes, very little is known regarding the outcomes of patients with aggressive B-Cell Lymphomas that are refractory to these BsA strategies, and whether they can undergo alternative approaches afterwards.We retrospectively report the outcomes of patients having documented progressive disease during BsA treatment. Only patients with aggressive B-Cell lymphomas were reported, namely Diffuse Large B-Cells lymphomas, High Grade B-Cells Lymphomas, Primary Mediastinal B Lymphoma and transformed Follicular Lymphoma/grade 3B Follicular Lymphomas. PFS was estimated as starting at the end of BsA treatment (at progression). Overall survival (OS) was estimated from BsA failure. Patients without treatment after BsA were only evaluated for OS.Ten patients were identified in our database, 8 DLBCL and 2 tFL (Table 1). The median number of previous lines was 4 (1-8), all patients had received BsA as monotherapy and 7 out of 3 patients were treated with anti-CD20 BsA. Median PFS during BsA treatment was 1.8m [95%CI=0.8-NA]. Best responses were PR for 2 patients, one patient had a SD and 7 patients didn't respond. After failure of BsA, 5 patients received non-intensive chemotherapy and/or corticosteroids, 3 patients received an association with Lenalidomide and 2 patients were not deemed eligible to any treatment and received palliative care (Table 2). After failure, median PFS and OS were 2m (95%CI=.8-NA) and 2.1m (95%CI=.8-NA), respectively, Figure 1. Reasons for death were PD in all the patients, no toxic death were recorded.In this retrospective single-center series, we demonstrate that heavily pre-treated patients with Aggressive B-Cell Lymphomas failing BsA harbor a particularly dismal prognosis with a median OS inferior to 3 months. It is to be noted that no patient was treated intensively afterwards, either because of a limited state of fitness, or by the absence of efficacious treatment at hand, with only 2 out of 10 patients having previously received CAR T-Cells therapy . These results highlight the need for ambitious programs for those patients, by the development of combination studies (BsAb+Drug) and by using the BsA sooner in the medical history of patients with agressive B-lymphoma. Although the cohort of patients is limited, those survivals are similar to patients failing anti-CD19 CAR T-Cells therapies [4].Our analysis highlights that patients who are refractory to BsA are of particular concern for the physicians, and preemptive interventions should be looked for.

Background: Oral mucositis (OM) is a significant complication occurring in approximately 40 to 80% of patients receiving chemotherapy regimens. Although a wide variety of agents have been tested to prevent OM or reduce its severity, none have provided conclusive evidence.Objectives: To determine the efficacy of honey or olive oil on the severity and OM pain in children with leukemia and suffering from OM compared to placebo (standard care) and, to assess which of the two interventions is more beneficial.Methods: A single blind randomized controlled study (RCT) was used to evaluate the effect of Manuka honey or olive oil, in the treatment of chemotherapy-related OM in 42 children with leukemia. The primary outcome was the severity of mucositis, using the World Health Organization (WHO) scale and the secondary outcome was the pain assessed using the Visual analogue scale (VAS).Results: Children who received the honey had less severe OM (assessed on the (WHO) scale), p = 0.00 and less pain (assessed on the VAS scale), p = 0.00, compared to the control group. Children who received the olive oil had less pain than the control group, p = 0.00), although not lower than the honey group.Conclusion: Manuka honey or olive oil can be used as alternative therapies by nurses to children with leukemia and suffering from OM, especially in low and middle-income countries where more expensive therapies may not be available or economical.Practice implications: Pediatric nurses may recommend Manuka honey to treat OM in children with leukemia as it is safe and inexpensive compared to other treatment modalities.& COPY; 2023 Elsevier Inc. All rights reserved.

This letter describes the experience of the American University of Beirut Medical Center in Lebanon with haploidentical stem cell transplant (haplo-SCT) for hematological malignancies in adult patients. Haplo-SCT made it possible through universal and rapid donor availability for most of the adult patients with leukemia or lymphoma not only in the Middle East but also globally. Moreover, the use of post-transplant cyclophosphamide (PTCy) and reduced intensity conditioning (RIC) regimens when indicated improved the outcome and decreased the toxicity of haploidentical stem cell transplant.RIC regimens also allowed its use in the elderly population. Patients from throughout the Middle East come to our center, the American university of Beirut Medical Center, to receive this transformative type of stem cell transplant. In this paper, we discuss the results of haplo-SCT with PTCy done on adult patients with hematological malignancies in our center from 2015 to 2021. The results are encouraging and show that haplo-SCT should be considered more often in the Middle Eastern countries. The subgroup analysis showed the importance of achieving complete remission of the disease prior to transplant to improve outcomes in our center. There is a paucity of literature on the outcomes of haplo-SCT in the Middle East which may contribute to the limited number of centers that offer this type of SCT. Herein, we aim to fill this gap in the hopes of encouraging the implementation of this potentially curative modality of treatment to a larger extent in the Middle East.

Background Autologous hematopoietic stem cell transplantation (ASCT) has become the mainstay treatment for many hematological malignancies and solid tumors. An adequate number of stem cells must be collected for better ASCT outcomes, which is challenging in 5%–30% of patients. To improve mobilization, plerixafor is used along with granulocyte colony-stimulating factor (G-CSF). Patients and methods We conducted a retrospective single center study involving patients who received plerixafor pre-ASCTs between January 2013 and December 2020 at a tertiary care center in Lebanon. We identified a total of 84 consecutive adult patients. All patients identified were poor mobilizers and have eventually received plerixafor either as pre-emptive use before first apheresis in those with peripheral CD34 + of less than 20 cells/ul, or after failure of first apheresis in those with peripheral stem cells (PSC) >2.0 × 106 cells/Kg. Results The median age at ASCT was 52.7 years (22–74) with 61% male predominance. Multiple myeloma was the most prevalent disease 64% followed by Lymphoma 32%. The majority of patients were in complete remission 64% at the time of ASCT. Most patients received proteasome inhibitor-based induction therapy 67% and Melphalan-based conditioning therapy 68%. The median follow-up from ASCT was 9 months (1–59). It was noted that greater body mass index (BMI) is a significant factor for better PSC collection whether premobilization (P = 0.003), or post plerixafor mobilization (P = 0.024). Moreover, Multiple Myeloma patients showed better mobilization using Plerixafor (P = 0.049). Using Plerixafor along with G-CSF in poor mobilizers post G-CSF alone showed a statistically significant increase in the collected PSC mean from 0.67 × 106 cells/Kg to 4.90 × 106 cells/Kg (P < 0.001) with a failure rate only for 12 patients (15%). The infusion of PSC > 2.5 × 106 cells/Kg has shown 3 days decrease in time to platelet engraftment (P = 0.021) and a 36% decrease in progression/relapse rate (P = 0.025). Conclusion Plerixafor is effective in increasing the PSC yield in poor mobilizers. Low BMI and hematologic malignancies other than Multiple Myeloma are risk factors for poor mobilization. More studies should be performed to establish more risk factors, helping us to identify poor mobilizers more accurately and initiate plerixafor mobilization early on.

Clofarabine (Clo) is an immunosuppressive purine analog that may have better anti-leukemic activity than fludarabine (Flu). The addition of total body irradiation (TBI) to conditioning regimens has been widely investigated. However, the use of single agent Clo in combination with intermediate doses of TBI ranging from 4 to 8 Gy has not been studied yet. This study is a double center, observational, retrospective study of patients with high-risk hematological malignancies diagnosed from 2012 to 2021, treated at the American University of Beirut Medical Center in Beirut (AUBMC), Lebanon, and Saint-Antoine Hospital (SAH) in Paris, France. It aims to identify the outcome of patients with high-risk hematological malignancies who underwent allogeneic stem cell transplant (allo-SCT) and received Clo and TBI (4–8 Gy) before transplant. Data regarding patient baseline characteristics, disease-related factors, and transplant outcomes including graft-versus-host disease (GVHD), Non-relapse mortality (NRM), progression-free survival (PFS), and overall survival (OS), were collected. We identified 24 high-risk patients diagnosed with a hematological malignancy. The median age at transplant was 37 years (range 22–78). At the time of the transplant, only 15 patients (63%) were in complete remission (CR). All patients received Clo/TBI (4–8 Gy). After a median follow-up of 40 months, the cumulative incidences of grade II-III acute GVHD, grade IV acute GVHD, and chronic GVHD were 50%, 4%, and 8%, respectively. NRM at 100 days, and 1 year after transplant was 4% and 25%, respectively. 17% of the patients had a relapse or progression of the disease by the end of the study. The 2-year PFS and OS were 50% and 56%, respectively. The median PFS and OS were 66 and 68 months respectively. As a conclusion, Clo/TBI (4–8 Gy) as a conditioning regimen for allo-SCT in high-risk patients confers disease control with an acceptable toxicity profile.

Context: Relapsed/refractory (R/R) acute myeloid leukemia (AML) patients have very poor prognosis. Myeloablative conditioning followed by allogeneic hematopoietic cell transplantation (allo-HCT) remains the only option to achieve disease control in such high-risk patients. Objective: The aim of this study is to evaluate the efficacy and safety of myeloablative conditioning followed by allo-HCT in patients with R/R AML in active disease. Design: This is a single center, observational, retrospective study of patients diagnosed with R/R AML (2016-2020) and treated at the American University of Beirut Medical Center in Lebanon. Main Outcome Measures: Data regarding patient baseline characteristics, disease-related factors, transplant outcomes, and complications were collected. Results: We identified 16 patients with R/R AML who underwent allo-HCT in active disease, with median three lines of treatments. The median age at transplant was 49 years (range 33-75). Of them, 8 (50%) were males, 9 (56%) had high-risk ELN, 12 (75%) had haploidentical donors and 4 (25%) had full matched related donors. Thirteen (81%) patients received sequential conditioning, two (13%) received clofarabine with total body irradiation, and one (6%) received fludarabine and busulfan. Fourteen (87%) patients received anti-thymocyte globulin. Neutrophil and platelet engraftment were seen in 14 (88%) and 9 (56%) patients, respectively. At day 30 post-allo-HCT, 11 (68%) patients had complete remission (CR). At day 100, 10 (63%) patients were alive, 7 out of them (44%) were disease free with full donor chimerism. After a median follow-up of 5.3 months (range 0.2 – 27.5) post-allo-HCT, the median overall survival was 2.9 months (range 0.3-27.5), with active leukemia being the primary cause of death (62%), only four patients (25%) died from transplant related complications. Univariate analysis of factors affecting OS showed improved survival in patients receiving post-allo HCT 5-azacitidine and donor lymphocyte infusion (p= 0.035 and p= 0.0341, respectively). Three patients (19%) developed acute GVHD and one of them died due to its complications. CMV and EBV reactivations were seen in 38% and 6% of cases. Conclusion: Myeloablative conditioning followed by allo-HCT for patients with R/R AML in active disease can confer a disease control in a subset of patients, with acceptable rate of transplant-related mortality. Relapsed/refractory (R/R) acute myeloid leukemia (AML) patients have very poor prognosis. Myeloablative conditioning followed by allogeneic hematopoietic cell transplantation (allo-HCT) remains the only option to achieve disease control in such high-risk patients. The aim of this study is to evaluate the efficacy and safety of myeloablative conditioning followed by allo-HCT in patients with R/R AML in active disease. This is a single center, observational, retrospective study of patients diagnosed with R/R AML (2016-2020) and treated at the American University of Beirut Medical Center in Lebanon. Data regarding patient baseline characteristics, disease-related factors, transplant outcomes, and complications were collected. We identified 16 patients with R/R AML who underwent allo-HCT in active disease, with median three lines of treatments. The median age at transplant was 49 years (range 33-75). Of them, 8 (50%) were males, 9 (56%) had high-risk ELN, 12 (75%) had haploidentical donors and 4 (25%) had full matched related donors. Thirteen (81%) patients received sequential conditioning, two (13%) received clofarabine with total body irradiation, and one (6%) received fludarabine and busulfan. Fourteen (87%) patients received anti-thymocyte globulin. Neutrophil and platelet engraftment were seen in 14 (88%) and 9 (56%) patients, respectively. At day 30 post-allo-HCT, 11 (68%) patients had complete remission (CR). At day 100, 10 (63%) patients were alive, 7 out of them (44%) were disease free with full donor chimerism. After a median follow-up of 5.3 months (range 0.2 – 27.5) post-allo-HCT, the median overall survival was 2.9 months (range 0.3-27.5), with active leukemia being the primary cause of death (62%), only four patients (25%) died from transplant related complications. Univariate analysis of factors affecting OS showed improved survival in patients receiving post-allo HCT 5-azacitidine and donor lymphocyte infusion (p= 0.035 and p= 0.0341, respectively). Three patients (19%) developed acute GVHD and one of them died due to its complications. CMV and EBV reactivations were seen in 38% and 6% of cases. Myeloablative conditioning followed by allo-HCT for patients with R/R AML in active disease can confer a disease control in a subset of patients, with acceptable rate of transplant-related mortality.

Micronutrient intake among hematopoietic stem cell transplant (HSCT) recipients is poorly studied. This randomized control trial (RCT) assessed the effect of nutritional counseling on micronutrient intake post HSCT. Patients with hematological malignancies receiving HSCT were randomized at hospital discharge into an intervention group (IG) and a control group (CG) between 2016 and 2017. IG received individualized nutritional counseling in the first 3 months post HSCT while CG received general qualitative education without reinforcement. At assessment points (hospital admission, discharge, 30, 60, and 100 days post HSCT termed T4), 24-h recalls were analyzed, and micronutrient intake was compared to patients’ individual needs. Results were reported as percentages of dietary reference intake. Groups (IG, n = 22 and CG, n = 24) had similar characteristics pre HSCT. Copper and α-tocopherol intake at T4 were significantly better in IG. Many B vitamins, vitamin C, Manganese, Potassium, Zinc, and vitamin K improved in IG only at T4 compared to baseline intake. Median vitamin D intake remained low in both groups with <20% of patients meeting their individual needs post HSCT. In conclusion, counseling was associated with a trend of improved micronutrient intake. Vitamin D levels remained low irrespective of counseling.

Purpose: To evaluate polymorphisms in genes of drug metabolizing enzymes and transporters involved in cyclosporine and/or voriconazole disposition among patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT). Methods: DNA from forty patients was genotyped using the DMETPlus array. The average ratio of cyclosporine concentration/dose (C/D in (ng/mL)/(mg/kg)) per participant's weight was computed using available trough levels and daily doses. Results: The C/D cyclosporine ratio was significantly higher when it was administered with voriconazole as compared to when it was administered alone: median: 116.75 vs. 25.40 (ng/mL)/(mg/kg) with and without voriconazole respectively, (P <0.001). There was also a significant association between the C/D cyclosporine ratio combined with voriconazole and the ABCB1 2677 G > T > A (rs2032582) genetic polymorphism (P= 0.05). In parallel, ABCB1 variant allele carriers had higher creatinine in combination therapy with a median creatinine (mg/dL) of 0.74 vs. 0.56 for variant allele carriers vs. reference; P= 0.003. Interestingly, CYP2C9, CYP2C19, and CYP3A5 extensive metabolizers tended to be associated with lower cyclosporine C/D ratio when combined with voriconazole, but the results were not statistically significant. Conclusion: To the best of our knowledge, this is the first pharmacogenetic study on the interaction between voriconazole and cyclosporine in patients undergoing allo-HCT. Results suggest that the ABCB1 2677 G > T > A genetic polymorphism plays a role in this interaction with cyclosporine related nephrotoxicity. Pre-emptive genotyping for this genetic variant may be warranted for cyclosporine dose optimization. Larger studies are needed to potentially show significant associations with more candidate genes such as CYP3A4/5, CYP2C9, and CYP2C19, among others. (C) 2020 Elsevier Masson SAS. All rights reserved.

BACKGROUND:Most studies addressing the impact of hematopoietic stem cell transplantation (SCT) on pulmonary function test (PFT), and the various factors affecting that impact have been performed on the allogenic type. Few have addressed PFT changes in autologous SCT. This study describes PFT changes seen in autologous SCT recipients and addresses the various factors impacting these changes.PATIENTS AND METHODS:We reviewed the medical records of 223 consecutive adult autologous SCT recipients. We collected pre-transplant and post-transplant data, as well as PFT data and long-term mortality.RESULTS:A total of 123 patients with lymphoma receiving the BEAM (carmustine, etoposide, aracytin, and melphalan) conditioning regimen had a significant 5% drop in mean forced vital capacity and total lung capacity but no significant change in forced expiratory volume in one second/forced vital capacity ratio nor in diffusion lung capacity of carbon monoxide adjusted to volume. Fifteen percent of the patients with lymphoma had a clinically significant drop of 15% in their lung volume parameters. The patients with multiple myeloma receiving the melphalan conditioning regimen had no significant change in any of the PFT parameters. Smoking, baseline PFT parameters, and radiation did not affect lung function or mortality.CONCLUSIONS:Autologous SCT impact on lung function depends on the disease and conditioning regimen. It leads to a drop in lung volumes but no obstruction or decrease in diffusion in patients with lymphoma receiving the BEAM regimen. Autologous SCT did not affect lung functions in patients with multiple myeloma, and these patients may not need screening PFTs.

Patients with multiple myeloma (MM) who underwent autologous stem cell transplantation (ASCT) are known to benefit from maintenance therapy post-transplant. With signs of early relapse, physicians can either optimize maintenance therapy or use new therapeutic regimens.