Exploring The World of Medicine 

A-Z

The Hunt : The Research     

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What do I need to know in order to conduct a successful and meaningful research? To commence, I need to first dissect my essential question. Break it up in comprehensible chunks. Therefore, I should start with the five W’s. What are bone marrow transplants? What are non-myeloablative stem cell transplants? Who created these techniques and who first used these methods? Where were these methods first used?  When were these methods first put into practice? Why was there a need for these methods to be created? What did these methods contribute to the world of medicine and the people affected by its works? How do these to methods compare? What distinguishes them? By asking myself these fundamental questions, I will be able to develop the base of my research and expose myself to more complicated and insightful questions that will deepen my research.

 

In addition to asking myself what do I need to know, I had to ask myself what do I know or assume? I knew bone marrow was associated with blood and its components. I also knew that bone marrow transplants were used to treat blood cancers and I assumed it was used to treat other conditions too. Along with this, I assumed that since non-myeloablative stem cell transplant was a technique recently created it must have some benefit or advantage over the conventional method for transferring bone marrow. Overall my previous knowledge prior to my research over both techniques was very limited, meaning I had lots to uncover and understand. 

 

My first drive into my research finally began after I determine what I knew and what I needed to know. I began hunting for answers. The topic of bone marrow transplants was first introduced to me by Physician Assistant Mrs.Cherlly after I observed her perform a bone marrow biopsy . Mrs. Cheryll had a background working with leukemia patients at John Hopkins Hospital. Therefore she was filled with experience and  knowledge over bone marrow transplants. Mrs. Cheryll caught my attention by describing to me that a bone marrow transplant along with a couple other procedures is like an immune system transplant. She then was the one to educate me on the existence of the non-myeloablative stem cell transplant method. After this conversation with Mrs. Cheryl, I was inspired to look further into non-myeloablative stem cell transplant procedure. This influenced my article choice for my second annotated bibliography, “A Review of Myeloablative vs Reduced Intensity/Non-Myeloablative Regimens in Allogeneic Hematopoietic Stem Cell Transplantations”, this article mainly spoke of the benefits this procedure brought to the elderly population. Something the more traditional method of bone marrow transplant was not able to really do.  My third annotated bibliography is, “The importance of stem cell therapy”, this article breaks down into comprehensible parts what stem cells are and how they can be used for various conditions. Along with using scholarly reviewed articles, I sought knowledge from professionals, so I could ask my own questions. I interviewed an oncology registered nurse over the specifics of bone marrow. Below is my interview.

• ​key: a.) interviewee response b.) interviewer reflection

• 1.) What is bone marrow?

  •     a.) Bone marrow is a spongy substance that is the origin of blood cells, where white and red blood cells are born. Chemo tends to kill bone marrow first. This depletes white blood cells to none and patients enter neutropenia. These patients are susceptible to any infection.

  •     b.) Neutropenia is a concept I was not familiar with before what are the symptoms, signs, and side effects of you body being in this stage. Does the use of chemotherapy target on the immune system or organs of the body also?

• 2.) Where is bone marrow located?

  •   a.)Bone marrow is located within the spinal cord above the scrotum. Bone marrow is located within your bones.

  •     b.) Based of the answer I was given above I would like to further investigate if all bones have bone marrow in them and if yes what is the difference of the composition of spinal cord bone marrow and other bone's bone marrow. Along with asking how often is bone marrow produced by your body and what it is composed of. I would also like to further ask if there has been any progress in making artificial bone marrow to use for patients in dire need of a transplants.

• 3.) What is a bone marrow transplant?

  •     a.) A bone marrow transplant is essentially you whip out the whole immune system by using chemo, so chemo kills both cancer cells and good cells. Then you transplant bone marrow from either the patient himself or a donor to the patient. This bone marrow acts like stem cells, cells that have yet to be determined their function. Essentially giving the patient a whole new immune system  If a patient receives their own bone marrow it is better as they are less likely to develop graft vs host disease.

  •     b.) The complexity of this process blows my mind. The professional who invented the process of chemotherapy and then supporting it with a bone marrow transplant has to have a mind of one of a kind. How could somebody think of such a thing, to whip out an immune system and then just generate a patient a whole new immune system. Its an extraordinary process. The immune system is in charge of attacking anything that is foreign, but after a bone marrow transplant a new immune system is put in place. Therefore the whole body is now foreign and the immune system goes off clean and healing the body. Along with this what is the process of extracting bone marrow from a patient and then using that same bone marrow as their transplant. Is the bone marrow cleansed and how is the bone marrow reinserted. I would also follow up this question with what qualifies a bone marrow as healthy.

• 4.) How is a bone marrow extraction done?

  •     a.) It is done through a needle aspiration in biopsy, so they take you down for a bone marrow biopsy. The stem cells are transplanted in. We basically have to whip all their cells out which is when we give them their induction chemo. Kill their immune system completely and then transplant. They are then very very sick for very very long time. They are typically hospitalized for thirty days or even longer. They sometimes keep them for months and months at a time.

  •     b.) I would like to follow up this question with asking how long is a bone marrow harvest and is a harvest done through one needle in one position or multiple entry points with a needle. Does the size, age, and gender of the patient affect the quantity of bone marrow that must be harvest for a bone marrow transplant? Also do these same categories effect the advancement rate of the patient since the interviewed said patients can be hospitalized from a month to more. When a bone marrow transplant is done is a full blood transfusion also does to ensure that all cancerous blood cells have been eliminated with the chemo. How do physicians measure when a patient that has gone through chemo is ready for their bone marrow transplant.

• 5.) What patients are typically canadiets for a bone marrow transplant?

  •     a.) Leukemia and lymphoma patients are typically canadiets for bone marrow transplants, So basically mostly the blood cancers are canadiets for a bone marrow transplant. We mostly do these patients because that is the systemic area that is affected your body. Usually leukemia but sometimes lymphoma.

  •     b.) I understand why the majority of patients who receive blood transplants are blood cancer patients, but would bone marrow transplants help other types of oncology patients, or other type of patients with immune deficiency. Patients such a young children that have a weak immune system and get ill quite often. Also is a bone marrow transplant more effective in patients with acute myeloid leukemia or chronic myeloid leukemia.

• 6.) What are the benefits of having a bone marrow transplant?

  •     a.) Brand new bone marrow, so essentially with a brand new bone marrow you are producing normal healthy white red blood cells, and it is essentially a cure. The bone marrow is cancerous if you will and it is affecting everything, but with a new bone marrow transplant you are producing healthy blood cells. So it is a cure , but a lot of times people do get secondary cancer after just because chemo therapy and radiation can cause cancer, so it is not surprising to see someone post bone marrow transplant who develops secondary lymphoma secondary leukemia a couple years after their transplant just because of the damage was done with the chemo before hand.

  •     b.) It is unfortunate that the cure the medical field has to offer right now can cause secondary cancers as a side effect. I do realize that there are plenty of medication that can cause second hand conditions. How close is the medical field progressing to treatment that do not require radiation and chemo? However I am very amazed at abilities a bone marrow transplant has.

• 7.) Once a patient has one bone marrow transplant will they ever need another    one? If yes, is the frequency of bone marrow transplants a case to case base?

  •     a.) Yes sometimes. Yes this is a case to case base there is not like a number it is all very very individualized.

  •     b.) A follow up question I would like to ask is do pysicians at times administor secondary  bone marrow transplants to patients without having to do introductory chemo thearpy again or if a patient requires a second bone marrow transplant would they have to whip out their immune system again?

• 8.) What type of medication would a patient be required to take after a bone marrow transplant?

  •   a.) You have to take anti-rejection medication just like any other transplant. However, I can not remember the exact name of what those medications are. But yes you definitely go onto anti-rejection medicine to prevent graft vs host disease.

  •     b.) If a bone marrow transplant paired with chemo therapy is used to target and whip out the immune system and then completely replace it. Then is it the other organs and body cells that can attack the new immune system and cause rejection. Is rejection after a bone marrow transplant lack of progress of immune system being rebuilt and could a second bone marrow transplant help support and over come this? Or is a bone marrow rejection where the new immune system begins to attack healthy organs and other cells.

• 9.) What is non-myeloablative stem cell transplant?

  •     a.) Non-myeloablative stem cell transplant is a more modern method that is geared towards older or weaker patients. With this transplant the conditioning before is way more milder than for the conventional method. In the conventional method the immune system is destroyed while in this method the immune system is simply weaken. Patients receive the transplant through a catheter straight to the heart most times these patients do not have to be hospitalized. This type of transplant is like a mini transplant.

  •     b.) One big thing I remember a PA Cheryl said is that most times after a conventional bone marrow transplant patient are quite sore as the harvest involves numerous needle holes into the hip bone to access bone marrow. Therefore it is definitely a great advancement to now have a way to access and transfer stem cells without having to be so invasive and be able to bring more comfort to the patient. This method also seems like it could bring comfort to older patients that do not have the strength to go through a full treatment of chemo by allowing them to get less intense treatment and still recive stem cells to help repair their immune system.

• 10.) What are the biggest benefits of the non-myeloablative method?

  •     a.) The biggest benefit of the non-myeloablative method is that patients who are older or weaker can still receive stem cell transplants. Also these patients immune systems do not have to be destroyed. They just have to have a mix of new immune system and weaken old immune system. Another great thing about this method is that most patients do not have to hospitalized.

  •     b.) This reduce intensity has I feel mostly helped older patients as the success of the conventional methods with older patients was much lower due to the need to deplete their immune system completely, but this modern method not only brings high success for older patients but also brings it in a less intense way with less invasion. A follow up question I would like to ask is if a patient receives this method would they be more likely to need another transplant in the future compared to a patient that received the conventional method.

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This interviewed helped me building my foundation of bone marrow and bone marrow transplants. By giving me this foundation my mentor lead me to be able to develop some more elaborate questions. I then began to search through the website of The National Cancer Society. This site was very helpful as it described the process of donating and receiving bone marrow. I will say overall the majority of my knowledge came from my various mentors throughout my hospital tour from radiologist tech to radiologist  to nurses to Physician assistants.

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I first discovered what bone marrow is, a spongy liquid tissue in the center of some bones that is rich in stem cells who eventually turn into blood cells that circulate in the body. Bone marrow can come mainly from three places: Pelvic bone, Umbilical Cord/Placenta, and Peripheral blood. Stem cells are harvested from the pelvic bone by inserting a needle and drawing the bone marrow.Then the bone marrow is filtered and given to the recipient through IV. Umbilical cords and placenta are frozen after the birth of a child this has no effect on the child as otherwise the cord would just be thrown away. Stem cells from cord form more blood cells then adult bone marrow, but also takes longer to take and work.  Stem cells are not normally found in peripheral blood. However donors are given growth hormone before the donation which will cause an overproduction of stem cells which will then over flow into the peripheral blood and thus can be drawn, filtered and administered to the patient through the IV. There are two general types of bone marrow transplants sources: Autologous and Allogeneic. Autologous means the donor and recipient are the same person. The bone marrow is harvested prior to conditioning then is filtered and frozen. The patient then goes through conditioning such as chemotherapy and full body radiation. Then the bone marrow is administered through IV. Some advantages of autologous transplants is there is no graft-vs-host disease. Meaning the transplanted bone marrow would not be attacked by the remaining bone marrow. Disadvantages is that because the bone marrow is also the recipients bone marrow therefore there is a possibility the new bone marrow will not attack the remaining cancer as it is the patient's immune system that did not detect the cancer in the first place, no graft-vs-cancer. Autologous transplants are often used for leukemia, lymphoma, myeloma, testicular cancer and neuroblastoma. The second source is allogeneic meaning the bone marrow comes from a donor. Some advantages of this source is the introduction of a whole new immune system. The bone marrow of a donor is a different immune system than the one in a recipients bone marrow. Therefore graft-vs-cancer exist and the donated bone marrow the graft attacks the cancer. Another advantage is that the donor can donate again in the future if necessary. A disadvantage of allogeneic transplant is that the graft might not take to the new host, graft-vs-host. The donor cells could die or be destroyed by the body. Also infections could rise from the donor. All the prior information I have talked about mostly refers to the traditional bone marrow transplant. However another more recent form of an allogeneic transplant is a non-myeloablative also referred to mini-transplant or reduced-intensity conditioning. This bone marrow transplant was developed in the 1990’s. The difference between this method and the traditional method is the conditioning before the transplant. This transplant is less intense as the patient endorse less radiation and chemotherapy prior to transplant. The patient's immune system is not completely whipped out leaving some of it behind.The patient and donor bone marrow exist together at the same time till new cells replace old ones, graft-vs-cancer. The main advantage of this method is that it gave patients such as elders who are not as strong still an opportunity to receive a bone marrow transplant. A secondary advantage is that the patients blood cell count does not drop as low as not all stem cells are killed  and the patient is not as susceptible to infections as a patient that receives a traditional bone marrow transplant. Some disadvantages are because the conditioning is not as intense it is more likely for the cancer to come back. Also this treatment is not very suitable for patients with lots o cancer or fast-growing cancer.