Certainty, wine and haematology

Pliny the Elder

Natural Philosopher AD 23/79.

In these matters the only certainty is that nothing is certain.

Pliny the Elder was a man of many opinions and he certainly had no difficulty in sharing them with others. Among many other things, he had opinions about wine! Fig. 1.

Fig. 1: Naturalis Historiae.

Naturalis Historiae by Pliny the Elder. Kept in the Marciana National Library in Venice, Italy.

Fashions change for no apparent reasons other than the decision by some ‘influencers’ to say something, wear something, but often for intangible reasons. In the FT Weekend [1] Jo Ellison, writing about taste, says, ‘the only real agreement between three pundits was that there are no longer any rules’. Well the same may be true when it comes to discussing wine. I have been living in Tuscany, Italy for the last 6 weeks where it was unusually cool and wet. In spite of this, it was difficult to obtain an opinion from oenologists about their predictions for the quality of this year’s vintage. The predominant grape grown in Tuscany, and of Chianti Classico, is Sangiovese, a grape that many wine drinkers hold in low esteem. However I was delighted to read in a recent New York Times interview by Kersten Moran with the well-known wine critic, Eric Asimov, where he is quoted as saying: ‘I’ll just mention a very well-known wine, Chianti Classico. To my surprise, it continues to be consigned to the stereotype of Italian restaurant wine. It’s one of the great wines of the world.’ [2]. I have written about this wine in the past and my wife and I spent a few pleasant hours at the tasting of Viticoltori di Castellina in Chianti (Wine makers of Castellina in Chianti) on March 27th 2023. We didn’t manage to taste all of the wines on offer (>20) but were introduced to many excellent wines during the tasting. The most important impression we both had was that the standard of wine-making was extremely high. We also tasted some Rosato, still and sparkling, with wines made predominantly from the Sangiovese grape, although a few oenologists add a little Colorino, Merlot or Cabernet Sauvignon to their Chianti Classico.

Rosato or Rosé as the Italians, rather surprisingly call it, has become a very fashionable drink, who knows why? A few years ago, it was consumed by a minority of wine drinkers but now it is not uncommon to see burly men consuming it. Admittedly, it is most suitable served well chilled on a sunny day but we have managed a glass or two in the rain! The only negative thing I can say is that the price of wine in Chianti has taken a steep increase in the last few years and probably will continue to do so, as everywhere else currently.

The clamour for wines from countries other than the traditional ones, continues to grow. My own tastes have included wines from Greece [2], many countries in South America, and recently, I had an opportunity to taste white wine from Moldova.

Jancise Robinson, writing in the FT, Weekend [3] on May 20th 2023, echoes the quest by many for wines from Portugal and Greece. Wines from Greece made from the Assyrtiko grape (originally from Santorini but now widely planted in Greece) Fig. 2 can be very appealing and Greek wine production has improved immensely from the old days of Retsina!

Fig. 2: Assyrtiko grapes.

Assyrtiko grapes were originally grown on the Island of Santorini. The vines were not infected with phylloxera. Whether this was due to inherent resistance influenced by volcanic soil is unclear.

A similar story is true of haemopoietic stem cell transplantation (HSCT). Originally we had bone marrow as a source of stem cells [4]. Now we have mobilized peripheral blood which is becoming more popular for reasons that do not always seem to have a sound haematological indication. Certainly bone marrow cells should always be used for HSCT for severe aplastic anaemia [5]. Haploidentical HSCT is also increasing in popularity as it increases the spectrum of possible donors.

The addition of immunotherapy to conditioning regimens may reduce the relapse rate and possibly toxicity of conditioning regimens. CAR-T cell therapy is having a huge impact on HSCT, [Fig. 3] especially in the treatment of childhood Acute Lymphoblastic Leukaemia (ALL). It may have uses in the treatment of other forms of Leukaemia, Lymphoma and Multiple Myeloma. Like all new therapeutic approaches it becomes fashionable very quickly. Unfortunately CAR-T cell therapy remains very expensive in many jurisdictions. What is now required is the collection of data from all centres using CAR-T cell therapy, in order to estimate toxicity and efficacy in the long term. Happily the EBMT’s (European Society for Blood and Marrow Transplantation) annual report has just been released and includes a CAR-T Data Collection Initiative. The EBMT wishes: To ensure that we have complete and accurate data, EBMT invites centres that treat patients with commercial CAR T-cell therapies to participate in a Data Collection Initiative to support Post Authorisation Safety (PAS) studies mandated by the European Medicines Agency (EMA). Centres that participate will be financially compensated [6].

Fig. 3: CAR-T cell therapy.

CAR-T cell therapy. Creative commons Attribution-Share Alike4.0 International license.

The International Academy for Clinical Haematology (IACH) in its May Newsletter: ‘Chimeric antigen receptor (CAR)-T cells’ claims that they are transforming the care of patients with hematologic and solid malignancies. The forthcoming applications for autoimmune and infectious diseases are at the forefront of translational research that may affect clinical practice. The newsletter states: ‘As part of our effort to promote good clinical practice and acquaint clinicians with these innovative therapy options, we are delighted to launch the first issue of IACH CAR-T News. Each month, we will highlight exciting developments and publications related to CAR-T cell therapy. Our focus will be on findings that have potential clinical applications and will bring hematologists and oncologists up-to-date with changes in the field’ [7].

Recently, guidelines have been published for nurses looking after patients receiving CAR-T Cells which hopefully will help to improve outcomes [8].

So, it looks as if two major organisations are going to try to find a precise role for CAR-T therapy and prevent haematologists going on an expensive wild goose chase.

If you can’t afford to drink magnums of champagne then I suggest a glass of Franciacorta before a meal as a reasonable option.