Prevalence and risk factors associated with development of ocular GVHD defined by NIH consensus criteria.

We studied 172 patients for development of ocular graft-versus-host disease (GVHD) after allogeneic stem cell transplantation (allo-SCT) from 2002 to 2009. Ocular GVHD was diagnosed in 60 patients (38%), with 27 (16%) being diagnosed at days 100 and 33 (23%) beyond day 100 for a 2-year cumulative incidence of 35% (95% confidence interval (CI), 28-43). The positive and negative predictive values of a Schirmer I test score (using 5 mm as a cutoff) in predicting ocular GVHD (day 100) were 41 and 82%, respectively. In patients with ocular GVHD beyond day 100, extraocular manifestations of GVHD preceded the development of ocular GVHD in most patients (27 of 33, 81%). Prior acute skin GVHD (odds ratio 2.57, 95% CI 1.17-5.64, P=0.019) and male recipients of female donors (odds ratio 2.57, 95% CI 1.09-6.06, P=0.03) were independent risk factors for ocular GVHD. We recommend comprehensive ocular evaluation rather than a screening Schirmer's test to establish the diagnosis of ocular GVHD. Early diagnosis and preventive strategies in high-risk populations need to be studied in clinical trials to prevent devastating impact on quality of life in patients with prolonged ocular GVHD.

Extracorporeal photopheresis in patients with refractory bronchiolitis obliterans developing after allo-SCT.

Extracorporeal photopheresis (ECP) has been shown to be a promising treatment for chronic graft-versus-host disease; however, only a few case reports are available that examine the effectiveness of ECP for bronchiolitis obliterans (BO) after allo-SCT. Because of the poor response to traditional therapies, ECP has been explored as a possible therapeutic option for severe BO after allo-SCT. Nine patients received ECP between July 2008 and August 2009 after a median follow-up of 23 months (range 9-93 months) post transplant. The primary indication for ECP was the development of BO in patients who had failed prior multidrug regimens. The median number of drugs used for BO management before ECP was 5 (range 2-7); this included immunosuppressive therapy. Six of nine (67%) patients responded to ECP after a median of 25 days (range 20-958 days). No ECP-related complications occurred. ECP seemed to stabilize rapidly declining pulmonary function tests in about two-thirds of patients with severe and heavily pretreated BO that developed after allo-SCT. This finding supports the need for a larger prospective study to confirm the impact of ECP on BO, and to consider earlier intervention with ECP to improve the outcome of BO after allo-SCT.

Photofrin photodynamic therapy can significantly deplete or preserve oxygenation in human basal cell carcinomas during treatment, depending on fluence rate.

At high fluence rates in animal models, photodynamic therapy (PDT) can photochemically deplete ambient tumor oxygen through the generation of singlet oxygen, causing acute hypoxia and limiting treatment effectiveness. We report that standard clinical treatment conditions (1 mg/kg Photofrin, light at 630 nm and 150 mW/cm2), which are highly effective for treating human basal cell carcinomas, significantly diminished tumor oxygen levels during initial light delivery in a majority of carcinomas. Oxygen depletion could be found during at least 40% of the total light dose, but tumors appeared well oxygenated toward the end of treatment. In contrast, initial light delivery at a lower fluence rate of 30 mW/cm2 increased tumor oxygenation in a majority of carcinomas. Laser treatment caused an intensity- and treatment time-dependent increase in tumor temperature. The data suggest that high fluence rate treatment, although effective, may be inefficient.

Patient nutrition acuity as a predictor of the time required to perform medical nutrition therapy.

OBJECTIVE: To determine if patient nutrition acuity accurately predicts the time required to perform medical nutrition therapy (MNT). DESIGN: Data detailing demographic characteristics, patient nutrition acuity, and time spent performing MNT were collected for 12 consecutive days. Random systematic sampling was used to select 25%, or a minimum of 20 patients, from daily admissions to the hospital. Nutrition acuity was categorized using a 27-item patient acuity tool. SUBJECTS/SETTING: Analysis included data from 92 acute-care hospitals nationwide; the median census was 271 patients. Of the 7,289 patients in the survey, 3,321 were included in this data analysis. All subjects were assigned an acuity rating and received MNT. Mean age (+/- standard deviation [SD]), was 55 +/- 24 years, and the sample was 48% male and 52% female. Time spent delivering MNT ranged from 5 to 285 minutes (mean +/- SD = 43.3 +/- 34.2 minutes). STATISTICAL ANALYSES PERFORMED: Stepwise multiple regression analysis (P < .05), with independent variables of age, gender, and 27 acuity descriptors, determined time required to perform MNT. RESULTS: The number of acuity descriptors assigned to patients ranged from zero (53 patients) to 20 (1 patient); the mean (+/- SD) for all patients was 5.6 +/- 3.1. Gender and 21 of the 27 acuity descriptors were statistically significant in predicting the time required to perform MNT. APPLICATIONS/CONCLUSIONS: A formula was developed to determine medical nutrition therapy time (MNTT) as minutes per patient sampled. When extrapolated to a facility's patient census, MNTT is the basis for predicting staffing requirements. The MNTT formula is crucial in the present environment of managed care where fiscal accountability challenges staffing rationales.

Parabolic quantitative structure-activity relationships and photodynamic therapy: application of a three-compartment model with clearance to the in vivo quantitative structure-activity relationships of a congeneric series of pyropheophorbide derivatives used as photosensitizers for photodynamic therapy.

An open three-compartment pharmacokinetic model was applied to the in vivo quantitative structure-activity relationship (QSAR) data of a homologous series of pyropheophorbide photosensitizers for photodynamic therapy (PDT). The physical model was a lipid compartment sandwiched between two identical aqueous compartments. The first compartment was assumed to clear irreversibly at a rate K0. The measured octanol-water partition coefficients, P(i) (where i is the number of carbons in the alkyl chain) and the clearance rate K0 determined the clearance kinetics of the drugs. Solving the coupled differential equations of the three-compartment model produced clearance kinetics for each of the sensitizers in each of the compartments. The third compartment was found to contain the target of PDT. This series of compounds is quite lipophilic. Therefore these drugs are found mainly in the second compartment. The drug level in the third compartment represents a small fraction of the tissue level and is thus not accessible to direct measurement by extraction. The second compartment of the model accurately predicted the clearance from the serum of mice of the hexyl ether of pyropheophorbide a, one member of this series of compounds. The diffusion and clearance rate constants were those found by fitting the pharmacokinetics of the third compartment to the QSAR data. This result validated the magnitude and mechanistic significance of the rate constants used to model the QSAR data. The PDT response to dose theory was applied to the kinetic behavior of the target compartment drug concentration. This produced a pharmacokinetic-based function connecting PDT response to dose as a function of time postinjection. This mechanistic dose-response function was fitted to published, single time point QSAR data for the pheophorbides. As a result, the PDT target threshold dose together with the predicted QSAR as a function of time postinjection was found.

Potentiation of photodynamic therapy antitumor activity in mice by nitric oxide synthase inhibition is fluence rate dependent.

The effects of systemic administration of the nitric oxide synthase (NOS) inhibitor NG-nitro-L-arginine (L-NNA) in combination with photodynamic therapy (PDT) on tumor response, tumor oxygenation and tumor and normal skin perfusion were studied in C3H mice bearing subcutaneous radiation-induced fibrosarcoma tumors. Photodynamic therapy was carried out using the photosensitizer Photofrin (5 mg/kg) in conjunction with a low fluence rate (30 mW/cm2) and a high fluence rate (150 mW/cm2) protocol at a total fluence of 100 J/cm2. Low fluence rate PDT produced approximately 15% tumor cures, a response not significantly altered by administration of 20 mg/kg L-NNA either 5 min before or after PDT. In contrast, high fluence rate PDT produced no tumor cures by itself, but addition of L-NNA either pre- or post-PDT resulted in approximately 30% and approximately 10% tumor cures, respectively. The L-NNA by itself tended to decrease tumor pO2 levels and perfusion, but statistically significant differences were reached only at one time point (1 h) with one of the oxygenation parameters measured (% values < 2 mm Hg). Photodynamic therapy by itself decreased tumor oxygenation and perfusion more significantly. Addition of L-NNA before PDT further potentiated this effect. The L-NNA exerted its most striking effects on the PDT response of the normal skin microvasculature. Low fluence rate PDT caused severe and lasting shut-down of skin microvascular perfusion. With high fluence rate PDT, skin perfusion was initially decreased but recovered to persistent normal levels within 1 h of treatment. Administration of L-NNA reversed this response, converting it to complete and lasting vascular shut-down identical to that achieved with low fluence rate PDT. This effect was somewhat L-NNA dose dependent but was still marked at a dose of 1 mg/kg. It occurred whether L-NNA was given before or after PDT. The L-NNA did not alter the long-term vascular response of skin to low fluence rate PDT. The ability of L-NNA to correspondingly improve tumor response and severely limit skin vascular perfusion following high fluence rate PDT, while providing no benefit for the low fluence rate protocol, suggests that vascular changes in the tumor surrounding normal tissue contribute to the enhanced tumor curability with adjuvant L-NNA treatment.

Food acquisition habits, nutrient intakes, and anthropometric data of Havasupai adults.

OBJECTIVE: To describe the dietary patterns, anthropometric data, and food sources of Havasupai adults (> or = 18 years old) and determine the effect of age and gender. DESIGN: Dietary intakes (one 24-hour recall), anthropometric measures (body mass index [BMI], waist-to-hip ratio [WHR]) and demographic data, including sites of food purchases, were obtained. Food sources of selected nutrients were calculated from diet recalls. SETTING/SUBJECTS: 92 adults (60 women, 32 men) from the Havasupai Reservation, Supai, Ariz. STATISTICAL ANALYSES: Descriptive statistics were generated for demographic data. Nutrient intakes, BMI, and WHR were compared across gender and age groups ("Younger" [18 to 59 years old] vs "older" [> or = 60 years old]) by one-way analysis of variance. Two-tailed t tests identified significant differences in selected food practices by age group. RESULTS: Diets were moderately high in fat (35% of energy), saturated fat (12%), and sugar (14%); intakes of zinc, calcium, vitamin A, vitamin B-6, and folate were frequently inadequate (less than two thirds of the Recommended Dietary Allowance). Of the 92 subjects, 76 (83%) were obese (BMI > or = 27). Fifty-four of the 60 women (90%) and 24 of the 32 men (75%) exhibited abdominal obesity (no age effect). Thirty-nine of the subjects (42%) consumed at least one food item purchased off the reservation on the day of the recall; the remaining 53 subjects (58%) consumed only food purchased or acquired on the reservation. Older Havasupai were significantly more dependent on the tribal store and other village food sources than were younger adults. Food sources of key nutrients did not differ by age or gender. APPLICATIONS: The dietary patterns of isolated populations may be shaped by the unique limitations of their food sources as well as by factors such as age and gender. Individual and community-wide efforts to improve nutrient intakes and food patterns must recognize these geographic limitations. For populations such as the Havasupai, cooperative marketing and health promotion efforts between tribal officials, health care providers, and managers of the cafe and tribal store could improve the availability and consumption of a wider range of health-promoting foods.

An in vivo quantitative structure-activity relationship for a congeneric series of pyropheophorbide derivatives as photosensitizers for photodynamic therapy.

An in vivo quantitative structure-activity relationship (QSAR) study was carried out on a congeneric series of pyropheophorbide photosensitizers to identify structural features critical for their antitumor activity in photodynamic therapy (PDT). The structural elements evaluated in this study include the length and shape (alkyl, alkenyl, cyclic, and secondary analogs) of the ether side chain. C3H mice, harboring the radiation-induced fibrosarcoma tumor model, were used to study three biological response endpoints: tumor growth delay, tumor cell lethality, and vascular perfusion. All three endpoints revealed highly similar QSAR patterns that constituted a function of the alkyl ether chain length and drug lipophilicity, which is defined as the log of the octanol:water partition coefficient (log P). When the illumination of tumor, tumor cells, or cutaneous vasculature occurred 24 h after sensitizer administration, activities were minimal with analogs of log P < or = 5, increased dramatically between log P of 5-6, and peaked between log P of 5.6-6.6. Activities declined gradually with higher log P. The lack of activity of the least-lipophilic analogs was explained in large part by their poor biodistribution characteristics, which yielded negligible tumor and plasma drug levels at the time of treatment with light. The progressively lower potencies of the most lipophilic analogs cannot be explained through the overall tumor and plasma pharmacokinetics of photosensitizer because tumor and plasma concentrations progressively increased with lipophilicity. When compensated for differences in tumor photosensitizer concentration, the 1-hexyl derivative (optimal lipophilicity) was 5-fold more potent than the 1-dodecyl derivative (more lipophilic) and 3-fold more potent than the 1-pentyl analog (less lipophilic), indicating that, in addition to the overall tumor pharmacokinetics, pharmacodynamic factors may influence PDT activity. Drug lipophilicity was highly predictive for photodynamic activity. QSAR modeling revealed that direct antitumor effects and vascular PDT effects may be governed by common mechanisms, and that the mere association of high levels of photosensitizer in the tumor tissue is not sufficient for optimal PDT efficiency.

Blood pressure responses of white men with hypertension to two low-sodium metabolic diets with different levels of dietary calcium.

OBJECTIVE: To compare the blood pressure responses of men with hypertension consuming low-sodium (Na) metabolic diets differing in dietary calcium (Ca) for two 6-week periods. SUBJECTS: White men who had hypertension, were nonsmokers, and were sedentary. INTERVENTION: This study consisted of two separate 6-week metabolic feeding periods. In the first period, a high-Ca group (n = 6) was fed 1,400 mg Ca per day. In the second period, a low-Ca group (n = 5) was fed 400 mg Ca per day. Both groups were fed 1,500 mg Na per day. MAIN OUTCOME MEASURES: Blood pressure; urine and blood measured for electrolyte, calcitriol, renin, and parathyroid hormone (PTH) levels. To measure typical nutrient intakes, 3-day dietary records were collected before the beginning of each treatment period. STATISTICAL ANALYSES PERFORMED: Repeated-measures analysis of variance and split-plot analysis of variance were used to analyze, respectively, blood pressure responses and response variables over time. RESULTS: In both groups, serum Na level decreased (P < .05) over the 6-week period; urine Na decreased (P < .05) only in the low-Ca group. Serum PTH level decreased (P < .05) in the high-Ca group and increased (P < .05) in the low-Ca group; no change occurred in serum calcitriol level. Diastolic blood pressure decreased (8 mm Hg) in the low-Ca group (P < .05). The low-Ca group showed an 8% to 9% decrease in both systolic and diastolic blood pressure vs a 2% to 3% decrease in the high-Ca group. We also examined how the metabolic diet differed from subjects' typical diet. Results showed a positive correlation between the change in Na intake (usual to metabolic diet) and the change in systolic and diastolic blood pressure in both groups (P < .04). Results also showed a negative correlation between the change in the ratio of Na to Ca (usual to metabolic diet) and the change in diastolic blood pressure in the low-Ca group (P < .03). Directional change in blood pressure (either increase or decrease) could be predicted on the basis of how much the Na and Ca in the metabolic diet differed from subject's typical diet. APPLICATIONS: Results of this study suggest that in the dietary management of hypertension it may be more important to focus on specific changes in a person's diet (eg, decreasing Na intake by 1,000 mg/day and increasing Ca intake by 400 mg/day) rather than setting specific levels of Na and Ca to be consumed.

The validation of a new vascular damage assay for photodynamic therapy agents.

The therapeutic effect of photodynamic therapy (PDT: photodynamic sensitizer + light) is partly due to vascular damage. This report describes a new vascular photodamage assay for PDT agents and a validation of the assay. The method described here quantitates changes in tissue blood perfusion based on the relative amount of injected fluorescein dye in treated and untreated tissues. A specially designed fluorometer uses chopped monochromatic light from an argon laser as a source for exciting fluorescein fluorescence. The fluorescent light emitted from the tissue is collected by a six element fiberoptic array, filtered and delivered to a photodiode detector coupled to a phase-locked amplifier for conversion to a voltage signal for recording. This arrangement permits a rather simple, inexpensive construction and allows for the simultaneous use of the argon laser by other investigators. The routine assay for characterizing a specific photosensitizer at a standard dose consists of the sequential allocation of eight mice to a set of different light doses designed to span the dose-response range of fluorescein fluorescence exclusion (measured 8-10 min after fluorescein injection). The assay validation experiment used an anionic photosensitizer, 2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a at a dose of 0.4 mumol/kg. The parameter estimates (n = 34 mice) from fitting the standard Hill dose-response model to the data were: median fluorescence exclusion light dose FE50 = 275 +/- 8.3 J/cm2 and Hill sigmoidicity parameter m = -3.66 +/- 0.28. Subsets of the full data set randomly selected to simulate a standard eight mice experiment yielded similar parameter estimates. The new assay provides reliable estimates of PDT vascular damage with a frugal sequential experimental design.

Elevated pentose cycle and glucuronyltransferase in daunorubicin-resistant P388 cells.

Anthracycline resistance of P388 daunorubicin-resistant cells cannot be accounted for merely by differences in drug uptake and retention; protection against intracellular drug was also indicated. Cytotoxicity of daunorubicin may be partially due to the formation of free radicals and reactive oxygen species (hydrogen peroxide, hydroxyl radical, singlet oxygen, and superoxide anion radical). Protection against free radicals and peroxides is largely dependent upon the availability of reduced glutathione, which in turn requires NADPH for its continual regeneration. Pentose phosphate cycle (also called hexose monophosphate shunt) is known to provide NADPH for maintenance of glutathione. Activities of the two NADPH-producing dehydrogenases of the cycle, glucose-6-phosphate and 6-phosphogluconate dehydrogenase, were 40% higher (P less than 0.05) and activity of the cycle in intact cells was 2-fold higher in the resistant than the sensitive cells. The cycle was as active in these cells as it is known to be in macrophages, indicating a very effective protection against oxidative stress, free radicals, and alkylating electrophiles. Elevated activity of the pentose phosphate pathway in drug-resistant cells can represent a mechanism of resistance against multiple structurally unrelated drugs. Efflux of daunorubicin may be aided by further metabolism to glucuronides. Daunorubicinol, a known active metabolite of daunorubicin, can be metabolized to a glucuronide by the cells and eliminated into the surrounding medium. Glucuronidation of daunorubicinol was evidenced by (a) release of daunorubicinol following glucuronidase hydrolysis of media from cell incubations with 1.8 microM daunorubicin and (b) production of radioactive glucuronide when cell homogenates were incubated with UDP-[14C]glucuronic acid plus daunorubicinol. Glucuronyltransferase activity with a broad substrate specificity was found in the cells. Using model substrates, 1-naphthol and o-aminophenol, it was determined that glucuronyltransferase activity was 4 times higher in daunorubicin-resistant than -sensitive P388 cells. Elevated glucuronyltransferase could contribute to daunorubicin and multidrug resistance.

Contribution of various food groups to dietary vitamin B-6 intake in free-living, low-income elderly persons.

Elderly persons are reported to have low dietary intakes of vitamin B-6. Knowing which foods are the primary contributors of dietary vitamin B-6 may be useful to health professionals working to improve the nutritional status of the elderly. Therefore, we examined the contribution of five food groups--flesh foods (including all meat/fish/poultry), grains/cereals, legumes/nuts, fruits/vegetables, and dairy products/eggs--to dietary vitamin B-6 intake in 198 free-living elderly persons aged 60 years or older. Subjects were primarily Caucasian, low-income non-smokers; their mean age was 72 years. Mean dietary vitamin B-6 intake, determined from 3-day diet records, was 1.6 +/- 0.6 mg/day. The fruit/vegetable group was the largest dietary contributor of vitamin B-6 (0.69 mg/day). Flesh foods and cereals/grains contributed equally to the vitamin B-6 intake (0.35 and 0.34 mg/day, respectively). The lowest contributors were dairy products/eggs and legumes/nuts. Approximately 96% of the vitamin B-6 intake could be accounted for by the five food groups. Twenty percent of the population (no. = 39) consumed less than 66% of the Recommended Dietary Allowance (RDA) for vitamin B-6; their vitamin B-6 intake from fruits/vegetables and grains/cereals was 0.36 and 0.10 mg/day, respectively. Individuals with vitamin B-6 intakes greater than or equal to 100% of the RDA (no. = 69) consumed greater amounts of fruits/vegetables (primarily bananas) and grains/cereals (primarily breakfast cereal) than did persons who consumed less than 66% of the RDA for vitamin B-6; their vitamin B-6 intake from fruits/vegetables and grains/cereals was 0.98 and 0.55 mg/day, respectively. In the elderly population studied, plant foods were the major dietary contributors of vitamin B-6.

Plasma pyridoxal 5'-phosphate concentration and dietary vitamin B-6 intake in free-living, low-income elderly people.

Free-living, elderly persons (aged greater than or equal to 60 y, n = 198) were recruited to determine the effects of age, sex, health status, dietary vitamin B-6 intakes, and B-6 supplement use on plasma pyridoxal 5'-phosphate (PLP). Vitamin B-6 intakes were determined from 3-d diet records; supplementation was based on self-reported brand and frequency data. Fasting blood samples were analyzed for PLP. Subjects were primarily low-income Caucasians. There was no linear relationship between dietary vitamin B-6 intake, age, sex or health status, and PLP while accounting for supplemental vitamin B-6 use. PLP, however, was negatively correlated with age (p less than 0.001) in individuals with PLP values between 32 and 90 nmol/L. Vitamin B-6 status was low (PLP less than 32 nmol/L) in 32% of this elderly population (n = 198) and could be attributed to low dietary vitamin B-6 intakes and/or the presence of health problems reported to alter vitamin B-6 status. This research suggests that low vitamin B-6 status is prevalent in low-income, elderly persons, especially those with multiple health problems.

Development and testing of a statistical and graphics-enhanced nutrient analysis program.

The authors have developed and tested a nutrient analysis program that will compute and present graphically summary statistics of population and population subgroup nutrient intakes. The program analyzes for 44 nutrients from 5,800 separate food items. Capabilities of the program include: storage of large numbers of diet records and evaluations of their nutrients; calculation of nutrient means and standard deviations; data sorting based on subject characteristics, such as age, sex, and supplement use; and generation of bar graphs and line plots for individual and/or group data. To test this computerized nutrient analysis program, two sets of 3-day diet records from 200 elderly individuals were analyzed. The program was then used to generate means, differences between means, and distribution frequencies of designated nutrients for various population subgroups (e.g., men greater than or equal to 65 years vs. men greater than or equal to 80 years) as well as comparisons with individual files (e.g., Mr. Smith vs. all men greater than or equal to 65 years). The statistical and graphics capabilities also function within the context of recipe analysis and menu planning, which enhances the application of this program in institutional and community nutrition settings.

Bacterial safety of a closed-administration system for enteral nutrition solutions.

The purpose of this study was to investigate the bacterial integrity of a newly designed closed-administration system for enteral formula delivery. Three clinical simulations, designated Phases I, II, and III, were tested: dispersal of (I) 3 L formula over a 24-hour period, (II) 2 L formula over a 24-hour period, and (III) 2 L formula over a 48-hour period. Within each 24- or 48-hour simulation phase, a single administration set was used. Samples were withdrawn for bacterial analysis at 4- or 8-hour intervals. Simulations and samplings were completed under controlled, but not aseptic, conditions. Results indicated that bacterial growth was insignificant across all three simulation phases. Re-utilization of the administration set did not introduce bacterial contamination into subsequent liters of formula. Alcohol cleansing of the administration set was not found to be necessary for maintenance of bacterial closed integrity. Even when administered over a 24- or 48-hour period, the formula dispersed through this closed system did not develop any significant degree of bacterial growth. Results of this study suggest that this newly designed system for the administration of enteral formula significantly minimizes the risk of bacterial contamination.

Longitudinal changes in the mineral content of human milk.

Thirty-eight lactating women, from 1 to 31 months postpartum, provided monthly milk samples for determination of calcium, magnesium, manganese, copper, iron, and zinc. Subjects remained in the study an average of 4 consecutive months, with a maximum participation of 9 months. Subject variation accounted for the majority of variance in the raw data. After statistically controlling subject effect, copper, iron, and zinc levels were shown to be significantly related to duration of lactation. Prediction equations for these three minerals were developed, making it possible to calculate, on an individual basis, the copper, iron, and zinc levels of milk to be produced in future months. Data were also collected to determine possible correlations between breast milk mineral levels and the maternal dietary intake, serum levels, or hair concentration of these same minerals. No significant correlation was found between the milk mineral content and any of the three parameters under study.