The EBM Walk Around as a Tool of Accreditation in the CSE Transplantation Program.

F Rubba, D Borzacchiello, R Egidio, A Arenella, A Capasso, S Maiello, A Borrelli, S Avilia, C Andretta, G Battipaglia

1. Introduction

 Evidence-Based Medicine (EBM ) should be placed in the clinical and care process appropriately, also accommodating so-called bounded rationality models for those situations where noise or cognitive biases exist (1,2); the methodology has been enriched with participatory knowledge and person-assisted centered indicators (PROMPTs), focusing on perception and the particular view of the world.

This dimension can help support the quality system in the accreditation of complex pathways such as transplantation programs and those institutions in the health system, which also have an academic-scientific mission also defined as training centers.

The purpose of working on quality is to discover new and better treatments, make comprehensive care available, and improve patients' quality of life through evidence-based medicine with an interdisciplinary approach (3-5). In this configuration, the HSC Transplant Program in its three units (Clinical Unit, Laboratory and Apheresis) takes on the connotations of a Comprehensive Cancer Centre (CCC) .

2. From safety walk around to EBM walk around

The EBM walk around (EBMWA) modifies the traditional risk assessment technique of structured visits and interviews on safety issues and causes of adverse events or critical situations by adding the dimension of evidence of effectiveness and clinical impact and perception on the pathway (6).

The critical issues highlighted during The EBMWA fit into a database that can be configured into a digital directional dashboard, categorized on the basis of causal and contributing factors, obviously using the Levels of Evidence of the studies (1-3). 

3. Applications in the Quality system

There should ultimately be available for the implementation of EBMWA a Work Kit containing directions to be followed for the testing and introduction of the method along with related outcome and process indicators, this tool, possibly translated into a digital platform.

The following is the experimental introduction of EBM WA in the AOU Federico II Bone Marrow Transplantation and CAR-T Unit Program, where the Laboratory of Hematopoietic Stem Cell Manipulation and Cryopreservation and Cell Therapy performs procedures for immunophenotypic characterization, manipulation, cryopreservation of hematopoietic stem cells (HSCs) for transplantation use, and quality control.

Each mobilization and cryopreservation procedure is subjected to measurement of control parameters established in advance based on one's experience, and subsequent analysis of the data allows the potential negative impact on the 'outcome of the transplant to be reduced.

Factors affecting transplant take-up include the number and viability of reinfused hematopoietic stem cells (HSCs) this is because the freezing process as it is known causes the death of a fraction of cells, including also CD34+,CD45+ cells.

Quality controls of hematopoietic stem cells harvested from peripheral blood (apheresis) and cryopreserved consist of performing specific tests in order to demonstrate the functional characteristics of HSCs in terms of safety and efficacy. For proper qualitative assessment of the process of collection, handling, cryopreservation, the following indicators are examined:

• CD45+ Vitality;
• CD34+ viability;
• Polymorphonuclear Contamination (PMN)

Hemopoietic stem cells are characterized by the expression of the surface antigen CD34+ while total nucleated cells (WBCs) are characterized by the expression of the pan-leukocyte antigen CD45+.

Cell viability studies are carried out by using a nucleic acid dye (7-AAD- 7-amino actinomycin) that penetrates dead cells while quantitative assessment studies are carried out by using monoclonal antibodies directed against pan-leukocyte antigen CD45+ and against CD34+ antigen.

The technique used is flow cytometry (7-9), ISHAGE(International Society of Hematotherapy and Graft Engineering) logic gate protocol.

The Study of CD34+ Stem/Progenitor Cells after Cryopreservation is performed on representative sample (satellite segments) of the post-thaw unit in patients with various oncohematologic diseases to undergo stem cell transplantation with the aim of optimizing the qualitative-quantitative assessment of CD34+ stem cells present in aferetic cell products after thawing. This analysis was conducted on a total of 21 patients transplanted in the year 2024 for whom CD34+,viability CD45+, polymorphonuclear (PMN) cell viability data specific to each satellite segment representative of each reinfused bag was available. The results of dynamic assessment of cryopreserved hematopoietic stem cell viability and its correlation with polymorphonucleate (PMN) contamination are reported.

Table 1 shows the mean viability of hematopoietic stem cells detected in representative samples of post-thaw units, mean viability of white blood cells (WBCs) and contamination by polymorphonucleate population (PMN) of 19 patients undergoing stem cell transplantation. In addition, statistical analysis (arithmetic mean is chosen to describe the phenomenon/process) and reference values/standards of expected optimal parameters are reported.

                               table 1

                                     Reference value/standard:

In 2 of 21 patients undergoing stem cell transplantation, mean hematopoietic stem cell viability below standard reference values and increasing polymorphonucleate (PMN) contamination were observed. Table 2 shows the mean viability of hematopoietic stem cells detected in representative samples of the post-thaw units, mean viability of white blood cells (WBCs) and contamination by the polymorphonucleate population (PMN).

                             table 2

                                     Reference value/standard:

The observed data are consistent with a correlation between the two variables discussed, which can be characterized numerically with a generalized linear model, in prospective dimension.

4. Conclusion

The results of the cell viability assays of CD34+ hematopoietic stem cells in relation to the variable "polymorphonucleate contamination" point to the signal that increasing contamination by the polymorphonucleate (PMN) population negatively affects the viability of CD34+ cells post-thawing. Therefore, data analysis shows that in addition to freezing, there are numerous other variables that in a delicate and complex process such as mobilization, collection, handling, and cryopreservation can negatively affect the viability of CD34+ cells. EBM WA has allowed us to reveal an additional variable of impact on the indicator, which must then be sized through prospective verification.

FIG 1 Sheet of WA

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Acknowledgements

The authors thank Prof. Antonio Feliciello for the exact and capable multidisciplinary integration direction he has of the workshop; they are also deeply grateful to Writer Wanda Marasco for the attentive and fond eye that inspired the awareness of reasoning, evidence, and storytelling.

For more information, visit the magazine's AUTHORS page.