Haemophilia management: time to get personal?

The possibility of alloimmunization in patients receiving protein replacement therapy depends on (at least) three risk factors, which are necessary concomitantly but insufficient alone. The first is the degree of structural difference between the therapeutic protein and the patient's own endogenous protein, if expressed. Such differences depend on the nature of the disease mutation and the pre-mutation endogenous protein structure as well as on post-translational changes and sequence-engineered alterations in the therapeutic protein. Genetic variations in the recipients' immune systems comprise the second set of risk determinants for deleterious immune responses. For example, the limited repertoire of MHC class II isomers encoded by a given person's collection of HLA genes may or may not be able to present a 'foreign' peptide(s) produced from the therapeutic protein - following its internalization and proteolytic processing - on the surface of their antigen-presenting cells (APCs). The third (and least characterized) variable is the presence or absence of immunologic 'danger signals' during the display of foreign-peptide/MHC-complexes on APCs. A choice between existing therapeutic products or the manufacture of new proteins, which may be less immunogenic in some patients or patient populations, may require prior definition of the first two of these variables. This leads then to the possibility of developing personalized therapies for disorders due to genetic deficiencies in endogenous proteins, such as haemophilia A and B. [Correction made after online publication 11 July 2011: several critical corrections have been made to the abstract].

Effect of tiotropium on sputum and serum inflammatory markers and exacerbations in COPD.

Chronic obstructive pulmonary disease (COPD) patients experiencing frequent exacerbations demonstrate increased stable-state airway inflammation. Tiotropium has been shown to reduce exacerbation frequency, but its effect on airway inflammation is unknown. The aim of the present study was to investigate the effect of tiotropium on sputum inflammatory markers and exacerbation frequency. Patients (n = 142) were randomised to receive tiotropium or placebo in addition to their usual medication for 1 yr. Sputum and serum cytokines were assayed by ELISA and exacerbation frequency calculated using a symptom-based diary. There was no difference in the area under the curve for sputum interleukin (IL)-6 or myeloperoxidase between the groups, but sputum IL-8 level was increased in the tiotropium arm. There was no difference between start and end of study in serum IL-6 or C-reactive protein level. Tiotropium was associated with a 52% reduction in exacerbation frequency (1.17 versus 2.46 exacerbations.yr(-1)). Of patients on tiotropium, 43% experienced at least one exacerbation, compared with 64% on placebo. The total number of exacerbation days was reduced compared with placebo (17.3 versus 34.5 days). Tiotropium reduces exacerbation frequency in chronic obstructive pulmonary disease, but this effect does not appear to be due to a reduction in airway or systemic inflammation.

Genetic determinants of normal variation in coagulation factor (F) IX levels: genome-wide scan and examination of the FIX structural gene.

BACKGROUND: High-normal and elevated plasma FIX activity (FIX:C) levels are associated with increased risk for venous- and possibly arterial-thrombosis. OBJECTIVE: Because the broad normal range for FIX:C involves a substantial unknown genetic component, we sought to identify quantitative-trait loci (QTLs) for this medically important hemostasis trait. METHODS: We performed a genome-wide screen and a resequencing-based variation scan of the known functional regions of every distinct FIX gene (F9) in the genetic analysis of idiopathic thrombophilia project (GAIT), a collection of 398 Spanish-Caucasians from 21 pedigrees. RESULTS: We found no evidence for linkage (LOD scores <1.5) despite genotyping more than 540 uniformly-spaced microsatellites. We identified 27 candidate F9 polymorphisms, including three in cis-elements responsible for the increase in FIX:C that occurs with aging, but found no significant genotype-specific differences in mean FIX:C levels (P-values > or = 0.11) despite evaluating every polymorphism in GAIT by marginal multicovariate measured-genotype association analysis. CONCLUSIONS: The heritable component of interindividual FIX:C variability likely involves a collection of QTLs with modest effects that may reside in genes other than F9. Nevertheless, because the alleles of these 27 polymorphisms exhibited a low overall degree of linkage disequilibrium, we are currently defining their haplotypes to interrogate several highly-conserved non-exonic sequences and other F9 segments not examined here.

Glutathione and glutathione peroxidase in sputum samples of adult patients with cystic fibrosis.

BACKGROUND: Reduced glutathione (GSH) is a major antioxidant in the lung. In cystic fibrosis (CF) patients, extracellular GSH levels of lower airways, obtained by bronchoalveolar lavage (BAL), were reported to be lower than non-CF individuals. METHODS: Upper airway secretions of stable adult CF patients (29 spontaneous and 13 induced sputum) and non-CF individuals (14 healthy and 12 asthmatics; all induced sputum) were analyzed for total glutathione (i.e. the sum of reduced, GSH, and oxidized, GSSG, forms), GSH and GSSG levels by enzymatic kinetic assay. RESULTS: In CF, both spontaneous and induced sputum samples were comparable in total glutathione levels which were surprisingly high (median concentration of 9.2 (range 1.4-65.2) and 11.6 (1.1-69.8) microM, respectively). In non-CF individuals, total glutathione levels were significantly lower (healthy 2.8 (1.0-12.3), asthmatics (5.3 (1.3-19.2) microM; p<0.001, both vs. CF). In CF, more than 90% of total glutathione was represented by GSH, whereas in non-CF controls, GSH made up less than 50% of total glutathione (p<0.001). CONCLUSIONS: In contrast to BAL, CF sputum contains high levels of GSH. Sputum induction is a potentially useful procedure to monitor antioxidant levels in upper airways of CF patients.

Glutathione in induced sputum of healthy individuals and patients with asthma.

BACKGROUND: Glutathione is central to the antioxidant defences of the lung. The aim of this study was to determine whether sputum induction can be used for the measurement of glutathione in the respiratory tract. METHODS: Saliva and induced sputum (3% NaCl, 20 minutes) samples were collected from 10 healthy individuals and 10 patients with stable asthma receiving treatment with inhaled corticosteroids. Samples were chilled on ice and dispersed by dilution with ice cold phosphate buffered saline and pipetting. Cell-free supernatants were obtained by centrifugation of samples and filtration of supernatants and analysed for total glutathione, glutathione disulfide, and albumin content. The cells were treated with dithiothreitol and cell numbers, cell viability, and differential cell patterns were determined. RESULTS: As judged by cell viability and percentage of non-squamous cells, adequate sputum samples were obtained from nine healthy and nine asthmatic subjects. The salivary total glutathione content was low (median concentration 1.2 microM (range 0.8-1.5) in healthy subjects and 0.9 microM (0.7-1. 2) in asthmatic subjects). The sputum total glutathione content of both healthy and asthmatic subjects was within the same range (3.9 (1.0-12.3) microM and 6.4 (1.3-19.2) microM, respectively; p=0.35). Surprisingly, and in marked contrast to results obtained with bronchoalveolar lavage, sputum levels of glutathione disulfide represented more than 50% of the total glutathione in both groups (50.9% (range 24.6-83.1) and 72.3% (range 36.5-97.4), respectively; p=0.2). CONCLUSIONS: The results of this study indicate that sputum induction can be used to measure the glutathione content of bronchial secretions. Sputum glutathione levels of stable asthmatic patients did not differ significantly from healthy controls.

[Mediastinal lymphadenopathy: an extrahepatic manifestation of chronic hepatitis C?]. / Mediastinale Lymphadenopathie: Eine extrahepatische Manifestation der chronischen Hepatitis C?

Normal and enlarged perihepatic and mediastinal lymph nodes are detectable by ultrasonography. Aim of the present study is to determine the detection rate, size, and correlation of mediastinal and perihepatic lymphadenopathy in patients with chronic hepatitis C, healthy controls, and patients with inflammatory or neoplastic mediastinal lymphadenopathy. The mediastinum and liver hilus of 89 patients with chronic hepatitis C as well as of 34 healthy volunteers and 20 patients with mediastinal lymphadenopathy of different origin with adequate sonographic visualization were screened for the number and size of lymph nodes by high resolution ultrasonography. Lymph nodes were detectable in the mediastinum of 75/89 (84%) patients with chronic hepatitis C and 22/34 (65%) healthy volunteers (total lymph node volume [LNV]: 1.0 +/- 0.8 mL versus 0.3 +/- 0.4 mL, p < 0.001). In all patients with mediastinal lymphadenopathy, the mediastinal lymph node volume was above 15 mL. In patients with chronic hepatitis C a trend could be observed, that patients with larger perihepatic lymph nodes reveal also larger mediastinal lymph nodes. High resolution ultrasonography is able to detect enlarged mediastinal lymph nodes in patients with chronic hepatitis C. Mediastinal lymphadenopathy is considered as an extrahepatic manifestation of chronic hepatitis C. In general, the mediastinal lymph node volume differs in size to patients with lymphadenopathy related to neoplasia or sarcoidosis. The mechanism of lymphadenopathy in the liver hilus and mediastinum in patients with chronic hepatitis C is yet unknown.

Effects of short-term inhaled fluticasone on oxidative burst of sputum cells in cystic fibrosis patients.

Inhaled corticosteroids have been proposed to decrease pulmonary inflammation in cystic fibrosis (CF). In this study the effects of therapy with inhaled fluticasone on clinical and sputum outcomes (leukocyte count, activity of myeloperoxidase, superoxide anion release) in adult CF patients were investigated in an open label design. Twenty-six stable patients (median+/-SD forced expiratory volume in one second (FEV1) 58.1+/-19.9% pred.) were randomly assigned to the study group (500 microg b.i.d., for three weeks) or the control group (n=14; nonsteroid medication). Sputum samples were obtained during inhalation of hypertonic saline (3%, 20 min), which was found not to alter the investigated sputum parameters. No significant changes in clinical parameters, sputum leukocyte count, activity of myeloperoxidase, and baseline superoxide anion release where observed following therapy. Surprisingly, stimulated superoxide anion release increased significantly after therapy (34.1+/-17.7 versus 25.2+/-17.4 nmol x hr(-1) x 10(6) cells, p<0.03) and exceeded spontaneous variability of this parameter (p=0.02 versus control group). In conclusion, in adult cystic fibrosis patients short-term fluticasone therapy had no evident effect on clinical and sputum parameters. Further investigations are necessary to evaluate whether the observed up-regulation of oxidative capacity of inflammatory cells is of concern or benefit in these patients.

Pulmonary lymphangioleiomyomatosis: high-resolution CT findings.

Lymphangioleiomyomatosis (LAM) of the lung is a very rare disease. There are obvious discrepancies in the literature concerning the appearance of LAM on CT scans of the lung. This study adds the imaging findings of 11 patients and demonstrates how the imaging findings changed over time in four patients. Twenty-two CT examinations, and radiographs that had been obtained close to the CT examinations, of 11 patients with LAM confirmed by open lung biopsy were retrospectively evaluated with particular attention to the size of cystic lesions and wall thickness. Furthermore the CT scans were analysed for the type of pulmonary infiltration process and its distribution, presence or absence of pleural effusion, pneumothorax and lymph node enlargement. Clinical and CT follow-up studies were available in four patients. The CT scans revealed an increase in the interstitial pattern in all patients. Architectural distortion was seen in two patients and cystic lesions were present in all. The size of the cysts varied from small lesions to bullous emphysema. The cystic lesions revealed a wall thickness up to 2 mm but a wall was not perceptible in all. Pneumothorax was seen in only two patients; pleural effusion was seen in two patients. CT examination of patients with LAM reveals neither a uniform nor a pathognomonic appearance. In the early stages of LAM or in cases with interstitial changes the differential diagnosis of centrilobular emphysema or idiopathic pulmonary fibrosis seems to be more difficult than most authors believe.

[Bronchial carcinoma developing in a tuberculous scar: computer tomographic follow up]. / Entwicklung eines Bronchialkarzinoms aus einer tuberkulösen Narbe: computertomographische Verlaufsbeobachtung.

The development of scar is a rare complication of lung tuberculosis which was yet not often demonstrated in the radiologic literature. We report on a 71 year old male suffering by lung tuberculosis in an active stage which developed lung cancer in the region of tuberculotic scar clearly depicted on computed tomography. To the best of our knowledge this is the first reported computed computed tomography control series dealing with this problem. Additionally we report on histopathologic findings showing an early cancer in the surrounding of a tuberculotic scar.

Short-term effects of regular salmeterol treatment on adult cystic fibrosis patients.

Cystic fibrosis (CF) is characterized by chronic lung inflammation leading to airways obstruction. Bronchodilators, particularly short-acting beta2-agonists, are, therefore, often used by CF patients. The aim of this study was to evaluate, prospectively, the effects of the long-acting beta2-agonist salmeterol in adult CF patients. Twenty six patients with CF (10 males and 16 females; mean age (+/-SEM) 28+/-2 yrs) with mild-to-moderate airways obstruction (baseline forced expiratory volume in one second/forced vital capacity (FEV1/FVC) 56+/-2%) were monitored in an open, cross-over trial for 4 weeks by means of peak expiratory flow rates (PEFR), self-recorded symptom scores and body plethysmography. During a 2 week run-in period, all patients continued their treatment, including regular short-acting beta2-agonists. In weeks 3 and 4, short-acting beta2-agonists were replaced by the long-acting beta2-agonist, salmeterol (50 microg b.i.d.). Salmeterol produced a significant increase in PEFR compared to the run-in period (morning 375+/-23 vs 332+/-23 L x min(-1), deltaPEFR +15.1+/-3.1%, p<0.003; evening 384+/-24 vs 349+/-24 L x min(-1), deltaPEFR +11.7+/-2.4%, p<0.04). Similarly, patients reported lower symptom scores, e.g. less dyspnoea during the day, fewer nocturnal awakenings, less intense cough, and fewer unscheduled puffs of short-acting beta2-agonists. Thus, the long-acting beta2-agonist salmeterol provided clinical benefit to a majority of adult cystic fibrosis patients with airways obstruction. These short-term results are promising enough to set up long-term controlled studies.

Inhibition of platelet deposition with local delivery of heparin using a double balloon catheter.

Heparin is an effective agent in the treatment of unstable angina and myocardial infarction. The clinical utility of heparin is limited by bleeding complications. This study was performed to determine whether static delivery of heparin could effectively inhibit further platelet deposition. Thrombogenic graft segments were incorporated into chronic arteriovenous shunts in pigs. Autologous platelets were labeled with 111Indium. Platelet deposition was quantitated with gamma camera imaging. The grafts were exposed to blood flow for 15 min in order to induce platelet deposition on the thrombogenic surface. Heparin was delivered locally either by direct exposure or with a double balloon catheter. After a 15 minute exposure period, the heparin solution was removed and subsequent platelet deposition was monitored for 90 minutes. Heparin, administered with the double balloon catheter in doses as low as 12.5 U, effectively inhibited further platelet deposition. An intravenous injection of 100 U of heparin, the highest dose use for local delivery, did not perturb bleeding time or the activated partial thromboplastin time. In conclusion, platelet deposition can be inhibited with static local delivery of heparin at doses that are not associated with systemic bleeding.

[Hamman-Rich syndrome in a goldsmith]. / Hamman-Rich-Syndrom bei einem Goldschmied.

We report the case of a 54-year old goldsmith admitted because of dyspnea on exertion, persistent cough, and weakness under the suspicion of exogenous allergic alveolitis. He rapidly developed progressive lung fibrosis with exitus letalis 7 weeks after admission. Radiological examination (chest X-ray and HRCT) first showed ground glass opacties, and later rapid development of severe interstitial pattern with architectural distraction. The findings were similar to idiopathic lung fibrosis; however, the rare Hamman-Rich syndrome was confirmed by progressive course of the disease. Correlations between Hamman-Rich syndrome and idiopathic lung fibrosis are discussed.

Comparison of the thrombogenicity of stainless steel and tantalum coronary stents.

This study was designed to compare the thrombogenicity of stainless steel and tantalum coronary stents of the same design. Stainless steel and tantalum coronary stents are being evaluated for their utility in treating acute closure and restenosis. A major disadvantage of stainless steel stents is radiolucency. To determine whether radioopaque tantalum stents may be safely substituted for stainless steel stents, we compared the relative thrombogenicity of these materials in stents of identical design. Total platelet and fibrin deposition on the stents were determined from measurements of indium 111-labeled platelet and iodine 125-labeled fibrinogen accumulation after deployment into exteriorized chronic arteriovenous shunts in seven untreated baboons. In another series of experiments, 111In-platelet deposition was compared 2 hours after stent implantation in coronary arteries of pigs. In baboons, platelet thrombus formation on stainless steel and tantalum stents was equivalent and plateaued at approximately 2.5 x 10(9) platelets after 1 hour (p > 0.05). Fibrin deposition averaged approximately 1 mg/stent and did not differ between the stainless steel and tantalum stents (p > 0.05). In the porcine coronary model there was no significant difference in 111In-labeled platelet deposition between the stainless steel and tantalum stents (p > 0.05). This result was confirmed by scanning electron microscopic analysis of the coronary stents. Based on these two models, we conclude that there is no significant difference in the thrombogenicity of stainless steel and tantalum wire coil stents.