Retrospective review of intravenous pentamidine for Pneumocystis pneumonia prophylaxis in allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) are at risk of numerous opportunistic infections. Pneumocystis jirovecii pneumonia (PJP) is a potentially life-threatening infection that can develop in immunocompromised individuals. Current prophylaxis for PJP includes trimethoprim-sulfamethoxazole (TMP-SMX), dapsone, atovaquone, or inhaled pentamidine (PEN), often with varying breakthrough rates. The use of intravenous (IV) PEN for PJP prophylaxis has been evaluated in pediatric patients. METHODS: A single-institution retrospective review of electronic medical records was conducted for patients who underwent allo-HSCT between January 2001 and May 2013 and who had received at least 1 dose of IV PEN for PJP prophylaxis. Data collected included patient demographics, diagnosis, previous chemotherapy, pre-transplant conditioning regimen, other medications, microbiology test results, and clinical outcomes. RESULTS: A total of 113 patients were included in the study. The median number of PEN doses administered per patient was 3 (range 1-23). IV PEN was primary PJP prophylaxis in 74 of the patients (65%) and second-line prophylaxis in 39 (35%) post transplant, with the majority switching from oral TMP-SMX. Side effects of IV PEN administration were minimal. No patients who received IV PEN prophylaxis developed PJP infection. No case of PJP was seen in patients who received other agents for PJP prophylaxis. CONCLUSION: This retrospective study showed that IV PEN is very effective and well-tolerated prophylaxis for PJP; IV PEN can be considered a favorable alternative for PJP in situations where other agents might be contraindicated. Our findings provide strong support for prospective studies of IV PEN for PJP prophylaxis in adult HSCT recipients.

A collagenase gel/physical defect model for controlled induction of superficial digital flexor tendonitis.

REASONS FOR PERFORMING STUDY: A consistent and clinically relevant model for the induction of core lesions confined to the mid-metacarpal superficial digital flexor tendon (SDFT) has not been previously reported. Injection of bacterial collagenase is commonly used but often results in large, irregular and inconsistent lesions that disrupt the superficial tendon layers and epitenon. OBJECTIVE: To develop and evaluate a new injection technique for collagenase induction of SDFT injury. METHODS: Collagenase gel was injected into a physical columnar defect created by longitudinally placing a curved 16 gauge 8.89 cm needle in the mid-metacarpal SDFT in a randomly selected forelimb of 10 horses. A placebo treatment injection was performed 1 week later. Serial ultrasound examinations were performed. Horses were subjected to euthanasia at 2 (n = 2), 4 (n = 2), 8 (n = 4) and 16 (n = 2) weeks post treatment injection. Post mortem magnetic resonance imaging and histological analysis were performed. Gene expression (18S, SCX, TNC, TNMD, COL1A1, COL3A1, COMP, DCN, MMP1, MMP3 and MMP13), total DNA, glycosaminoglycan and collagen content were determined for experimental tendons (n = 10) and unaffected tendons (n = 9). RESULTS: Mid-metacarpal SDFT core lesion induction was successful in all tendons with consistent lesion cross-sectional area and minimal epitenon disruption. Histology confirmed loss of normal tendon architecture after tendonitis induction and subsequent healing of the tendon core lesion. Compared with gene expression in unaffected tendons, several tested genes were significantly upregulated (COL1A1, COL3A1, TNMD, SCX, TNC, MMP13), while others showed significant downregulation (COMP, DCN, and MMP3). CONCLUSION: Compared with the previously used direct injection of collagenase, this injection technique was easily performed and induced more consistent lesions that were mid-metacarpal and did not disrupt the epitenon. POTENTIAL RELEVANCE: This model will allow for objective assessment of therapies for tendon regeneration in the mid-metacarpal SDFT prior to clinical trials and routine clinical application.

Ultrasonography of the equine larynx.

Nasopharyngeal and laryngeal evaluation is important when examining horses with upper airway signs for poor performance. Currently endoscopy is the most common method to evaluate the equine upper airway. Ultrasonography of the equine larynx has not previously been described. Using six cadaveric specimens and four standing horses, the ultrasonographic appearance of the equine larynx was established. A scanning technique, including useful acoustic windows and the normal ultrasonographic appearance at each site, is described. Ultrasound allowed visualization of portions of the hyoid apparatus, laryngeal cartilages, associated soft tissues, and intrinsic and extrinsic laryngeal musculature, that are not seen using endoscopy. Additionally, real-time ultrasound allowed observation of the movement of the vocal folds and the arytenoid cartilages during respiration. In three horses with arytenoid chondritis, ultrasonography aided in the diagnosis and localization of arytenoid abcessation and perilaryngeal inflammation. The establishment of this technique will serve as the basis for future investigations in the evaluation of clinical patients with upper airway abnormalities.

The rationale behind autologous autoimmune hematopoietic stem cell transplant conditioning regimens: concerns over the use of total-body irradiation in systemic sclerosis.

Hematopoietic stem cell transplantation (HSCT) is becoming an increasingly recognized indication for treatment of autoimmune diseases and severe immune-mediated disorders. However, multicenter registry data have demonstrated higher than anticipated early toxicity, approximately 10% for autoimmune diseases in general, and 20-27% for diffuse systemic sclerosis (scleroderma). If uncorrected, this high treatment-related mortality will hinder development of stem cell therapy for immune-mediated diseases. In order to develop safer regimens, we address some pitfalls and concepts involved in design and selection of conditioning regimens for autoimmune diseases in general, and because it is associated with the highest regimen-related toxicity, scleroderma in specific.

Transplantation of unrelated placental blood cells in children with high-risk sickle cell disease.

The lack of healthy HLA-identical sibs limits the use of allogeneic hematopoietic cell transplantation in children with high-risk sickle cell disease (SCD). We evaluated unrelated placental blood cell transplantation (UPBCT) after a preparative regimen of busulfan, cyclophosphamide and antithymocyte globulin in three children with SCD who had cerebrovascular accidents (CVAs) and did not have HLA-matched sib donors. The placental blood cell units were matched with the recipients at four of six HLA-A, HLA-B and HLA-DRB1 antigens. Neutrophil levels above 0.5 x 10(9)/l occurred at 23, 38 and 42 days after UPBCT, and platelet levels above 50 x 10(9)/l without transfusions occurred at 62, 81 and 121 days after UPBCT. All patients developed acute graft-versus-host disease (GVHD; two grade II, one grade III), and one developed extensive chronic GVHD. One patient had graft failure and autologous hematopoietic recovery. Two patients have complete donor hematopoietic chimerism without detectable hemoglobin S or symptoms of SCD at 40 and 61 months, respectively, after UPBCT. These observations demonstrate the feasibility of UPBCT in children with SCD. Further studies of UPBCT for SCD are needed but, because of risks of procedure-related morbidity and graft rejection, should be restricted to pediatric patients with high-risk manifestations of SCD.

Generation of alloreactive anti-leukemic cytotoxic T lymphocytes with attenuated GVHD properties from haploidentical parents in childhood acute lymphoblastic leukemia.

We sought to generate alloreactive leukemia-reactive cytotoxic T lymphocytes from haploidentical parents by culture of peripheral blood mononuclear cells in vitro with irradiated leukemic blasts and IL-2 from children with ALL. After 21 days in culture the mean cytotoxicity of haploidentical lymphocytes against ALL blasts was 38% (n = 11). Cultured parental CTL were not leukemia specific but alloreactive as evidenced by equivalent cytotoxicity against stimulating ALL blasts and ConA-stimulated blasts from the other parent. The cultures yielded primarily CD8(+) T cells (59%). Irradiation of CTL limited proliferation by 96% but had no short-term effects on leukemia reactive cytotoxicity, suggesting a means to limit GVHD potential in vivo. One patient was treated for relapse of ALL post-haploidentical transplant with CTL generated from the original donor. A total of nine infusions were given: the first three were irradiated, while the last six were not due to disease progression. The patient experienced clearance of peripheral blasts, and despite concomitant infusion of IL-2 with the last three CTL infusions, did not experience immediate GVHD reactions. We conclude that ALL blasts are sufficiently immunostimulatory to generate in vitro CTL with provision of exogenous IL-2, and that these CTL could exert an anti-leukemia effect in vivo.

Viability of cryopreserved BM progenitor cells stored for more than a decade.

BACKGROUND: PBPC or BM is increasingly being harvested in remission for possible use in the event of relapse. Although the value of this approach has not been demonstrated, the long-term storage of progenitor cell components has become commonplace in many facilities. METHODS: We used multi-parameter flow cytometry to determine the viability of 11 long-term cryopreserved BM components (mean = 11.8 years) in liquid phase nitrogen. The components, prepared for autotransplantation but deaccessioned after confirming patient death, were carefully thawed, washed, and assayed immediately. The flow cytometry assay was performed according to the ISHAGE protocol, modified by the addition of 7AAD for analysis of progenitor viability (CD45+ CD34+ 7AAD-) and total leukocyte viability (CD45+ 7AAD-). In addition, total viability was assessed by fluorescence microscopy using acridine orange dye exclusion; granulocyte-monocyte colony-forming units (CFU-GM) were measured after 14 days culture. RESULTS: Leukocyte viability by flow cytometry and fluorescence microscopy agreed well (r2 = 0.55, slope = 0.83, P < 0.0005 by linear regression). CFU-GM did not correlate with CD34% or any of the viability parameters. Compared with short-term stored (mean = 33 days) PBPC assayed at infusion, long-term stored BM had a comparable percentage of CD34+ cells, comparable CFU-GM activity, increased CD34 viability, but decreased total cell viability, the latter most likely due to an increased proportion of differentiated myeloid cells. DISCUSSION: The results indicate that BM products can be cryopreserved for more than a decade without apparent loss of progenitor activity, as measured by these laboratory surrogates. This agrees with clinical anecdotes describing successful engraftment with long-term stored BM, and argues that expiration dates cannot be set for cryopreserved hematopoietic stem-cell components stored in liquid phase nitrogen.

Allogeneic hematopoietic cell transplantation for inborn metabolic diseases.

Clinical experience for more than two decades has shown that allogeneic HCT may benefit some but not all patients with inherited metabolic diseases. The HCT procedure is most effective in presymptomatic patients and those with indolent forms of storage diseases but is ineffective in those with overt neurological symptoms or aggressive neonatal or infantile forms. HCT alone does not correct skeletal dysplasia in MPSs and may not prevent development or progression of the peripheral neuropathy in sphingolipidoses and ALD. Decisions regarding HCT in patients with storage diseases should be made by investigators knowledgeable about these diseases, with judicious use of laboratory and clinical resources necessary to reach the best therapeutic decision for the individual patient.

Influence of patient positioning on sensitivity of mesenteric portography for detecting an anomalous portosystemic blood vessel in dogs: 34 cases (1997-2000).

OBJECTIVE: To determine whether sensitivity of detecting an anomalous portosystemic blood vessel during operative mesenteric portography varied with patient positioning. DESIGN: Retrospective study. ANIMALS: 34 dogs with a portosystemic shunt diagnosed via scintigraphy or surgery. PROCEDURE: Portograms were evaluated for a portosystemic blood vessel. Sensitivity was calculated from results obtained with dogs in left lateral, right lateral, and dorsal recumbency and from results obtained with dogs in 2 or 3 positions. Differences in sensitivity among positions and between 2 examiners were evaluated. RESULTS: Sensitivity was 85, 91, and 100% in dorsal, right lateral, and left lateral recumbency, respectively. Sensitivity was lower in dorsal recumbency than in left lateral recumbency, although differences were not significant. There was no significant difference between sensitivity of results obtained in dorsal and right lateral recumbency or right lateral and left lateral recumbency. Sensitivity for combined right lateral and dorsal positions was 97%, which was better than that in dorsal recumbency alone, although the difference was not significant. Because sensitivity in left lateral recumbency was 100%, there was no need to evaluate the improvement obtained by combining the result of this position with the results of other positions. CONCLUSION AND CLINICAL RELEVANCE: Results of mesenteric portography varied with patient positioning. The optimal position varied among patients but left lateral recumbency may be better and dorsal recumbency worse. Sensitivity may be improved by performing the test with the patient in orthogonal recumbent positions.

Phenylbutyrate attenuates the expression of Bcl-X(L), DNA-PK, caveolin-1, and VEGF in prostate cancer cells.

Phenylbutyrate (PB) is a histone deacetylase inhibitor that has been shown to induce differentiation and apoptosis in various cancer cell lines. Although these effects are most likely due to modulation of gene expression, the specific genes and gene products responsible for the effects of PB are not well characterized. In this study, we used cDNA expression arrays and Western blot to assess the effect that PB has on the expression of various cancer and apoptosis-regulatory gene products. We show that PB attenuates the expression of the apoptosis antagonist Bcl-X(L), the double-strand break repair protein DNA-dependent protein kinase, the prostate progression marker caveolin-1, and the pro-angiogenic vascular endothelial growth factor. Furthermore, PB was found to act in synergy with ionizing radiation to induce apoptosis in prostate cancer cells. Taken together, our results point to the possibility that PB may be an effective anti-prostate cancer agent when used in combination with radiation or chemotherapy and for the inhibition of cancer progression.

Where will the genome lead us? Dentistry in the 21st century.

BACKGROUND: Recent announcements of the deciphering and analysis of the human genome signal the inception of a new era of gene-based medicine. During the 21st century, patient treatment will be transformed and dentistry will be affected profoundly. METHODS: The author explains the importance of the decoding of the genome and how--based on this now completely depicted molecular structure--genes build, maintain and control all the biological functions of humans and all other living organisms. The potential application of this knowledge to the practice of dentistry is addressed, as well as the ethical, legal and moral challenges to the profession engendered by this new technology. CONCLUSION: During the next several decades, many of the current materials and methods will be abandoned in favor of emerging bioengineered technologies, genetically programmed for the prevention and treatment of oral disease as well as for the repair of damaged dental tissues. PRACTICE IMPLICATIONS: The development and implementation of these innovative dental therapies will require intensive education of current practitioners. Considerable restructuring of dental school curricula will need to take place, and the emergence of a new dental specialty is anticipated.

Case study: a unique approach to compliance in a patient with venous ulcers.

Lower extremity venous ulcers affect 500,000 to 700,000 Americans, with a 10-week outpatient treatment cost of $1327 to $5289. Recurrence rates are reported as 57% within 10.4 months. Many types of treatments are available, but the most successful treatment continues to be the most basic-elevation and compression. Innovative ideas to increase patient compliance can be the key to successful therapy.

Stable mixed hematopoietic chimerism after bone marrow transplantation for sickle cell anemia.

A multicenter investigation of allogeneic bone marrow transplantation for children with sickle cell disease was conducted that included 27 European and North American transplant centers. Fifty-nine patients who ranged in age from 3.3 to 15.9 years (median, 10.1 years) received HLA-identical sibling marrow allografts between September 1991 and April 2000. Fifty-five patients survive, and 50 survive free from sickle cell disease, with a median follow-up of 42.2 months (range, 11.8 to 115 months) after transplantation. Of the 50 patients with successful allografts, 13 developed stable mixed donor-host hematopoietic chimerism. The level of donor chimerism, measured > or =6 months after transplantation in peripheral blood, varied between 90% and 99% in 8 patients. Five additional patients had a lower proportion of donor cells (range, 11% to 74%). Among these 5 patients, hemoglobin levels varied between 11.2 and 14.2 g/dL (median, 11.3 g/dL; mean, 12.0 g/dL). In patients who had donors with a normal hemoglobin genotype (Hb), the Hb S fractions were 0%, 0%, and 7%, corresponding to donor chimerism levels of 67%, 74%, and 11%, respectively. Among patients who had donors with sickle trait, the Hb S fractions were 36% and 37%, corresponding to donor chimerism levels of 25% and 60%, respectively. Thus, allograft recipients with stable mixed chimerism had Rb S levels similar to donor levels, and only 1 patient required a red blood cell transfusion beyond 90 days posttransplantation. None of the patients have experienced painful events or other clinical complications related to sickle cell disease after transplantation. These observations strongly suggest that patients with sickle cell disease who develop persistent mixed hematopoietic chimerism after transplantation experience a significant ameliorative effect.

The clinical and metabolic effects of rapid weight loss in obese pet cats and the influence of supplemental oral L-carnitine.

The efficacy, safety, and metabolic consequences of rapid weight loss in privately owned obese cats by means of a canned weight-reduction diet and the influence of orally administered L-carnitine on rate of weight loss, routine clinical evaluations, hepatic ultrasonography, plasma amino acid profiles, and carnitine analytes were evaluated. A double-blinded placebo-controlled design was used with cats randomly divided into 2 groups: Group 1 (n = 14) received L-carnitine (250 mg PO q24h) in aqueous solution and group 2 (n = 10) received an identical-appearing water placebo. Median obesity (body condition scores and percentage ideal body weight) in each group was 25%. Caloric intake was restricted to 60% of maintenance energy requirements (60 kcal/kg) for targeted ideal weight. The reducing formula was readily accepted by all cats. Significant weight loss was achieved by week 18 in each group without adverse effects (group 1 = 23.7%, group 2 = 19.6%). Cats receiving carnitine lost weight at a significantly faster rate (P < .05). Significant increases in carnitine values developed in each group (P < .02). However, significantly higher concentrations of all carnitine moieties and a greater percentage of acetylcarnitine developed in cats of group 1 (P < .01). The dietary formula and described reducing strategy can safely achieve a 20% weight reduction within 18 weeks in obese cats. An aqueous solution of L-carnitine (250 mg PO q12h) was at least partially absorbed, was nontoxic, and significantly increased plasma carnitine analyte concentrations as well as rate of weight loss.

Serum-effusion albumin gradient in dogs with transudative abdominal effusion.

A prospective clinical study in dogs with transudative abdominal effusions examined the clinical usefulness of the serum albumin-effusion albumin (SA-EA) gradient. In humans, the SA-EA gradient facilitates classification of abdominal effusion, with a gradient > or = 1.1 indicating the presence of portal hypertension. Gradient values proved useful for predicting therapeutic response to sodium restriction and diuresis in humans. Of 49 dogs evaluated, 25 had hepatobiliary disease (group 1) and 24 had other nonhepatobiliary conditions (group 2). Portal hypertension was clinically suspected in 24 of 25 dogs in group 1 and in 15 of 24 dogs in group 2. A broad range of SA-EA gradients was found. A gradient > or = 1.1 was found in 22 of 25 (88.0%) dogs with liver disease and in 14 of 24 (58.3%) dogs with other disorders. The median SA-EA gradient was higher in group 1 than in group 2, with values of 1.4 (range, 0.7-3.1) and 1.1 (range, 0.3-2.6), respectively (P < .04). Considerable overlapping of SA-EA gradients occurred between groups and among dogs with diverse conditions such that gradient values could not distinguish dogs with hepatobiliary disease from dogs with other conditions. The overall diagnostic accuracy of the SA-EA gradient in predicting portal hypertension in dogs with and without hepatobiliary disease (69.4%) exceeded that of hypoalbuminemia (57.1%). These findings suggest that portal hypertension is a predominant force in formation of transudative abdominal effusion in dogs with hepatobiliary disease and in dogs with other disorders. Whether the SA-EA gradient can be used to guide therapeutic mobilization of effusion in dogs remains to be proved.

Pulmonary lymphomatoid granulomatosis in a cat.

Pulmonary lymphomatoid granulomatosis was diagnosed in a 9-year-old castrated male domestic shorthair cat with a history of coughing, lethargy, and anorexia. Radiographic examination revealed multiple pulmonary opacities, consolidation of left lung lobes, and enlarged tracheobronchial lymph nodes. Cytologic examination of impression smears of abnormal pulmonary tissue revealed erythrocytes, lymphocytes, and macrophages, with scattered atypical lymphocytes and binucleate cells. Histopathologic evaluation of abnormal lung tissue revealed multiple, coalescing, densely cellular nodules composed of anaplastic and pleomorphic lymphocytes, with scattered binucleate and multinucleate cells. Marked infiltration and effacement of bronchiolar and vascular smooth muscle were present. These features are characteristic of lymphomatoid granulomatosis. To the authors' knowledge, this is the first report of pulmonary lymphomatoid granulomatosis in a cat.

Phase 3 study comparing methotrexate and tacrolimus with methotrexate and cyclosporine for prophylaxis of acute graft-versus-host disease after marrow transplantation from unrelated donors.

After the transplantation of unmodified marrow from human leukocyte antigen-matched unrelated donors receiving cyclosporine (CSP) and methotrexate (MTX), the incidence of acute graft-versus-host disease (GVHD) is greater than 75%. Tacrolimus is a macrolide compound that, in previous preclinical and clinical studies, was effective in combination with MTX for the prevention of acute GVHD. Between March 1995 and September 1996, 180 patients were randomized in a phase 3, open-label, multicenter study to determine whether tacrolimus combined with a short course of MTX (n = 90), more than CSP and a short course of MTX (n = 90), would reduce the incidence of acute GVHD after marrow transplantation from unrelated donors. There was a significant trend toward decreased severity of acute GVHD across all grades (P =.005). Based on the Kaplan-Meier estimate, the probability of grade II-IV acute GVHD in the tacrolimus group (56%) was significantly lower than in the CSP group (74%; P =.0002). Use of glucocorticoids for the management of GVHD was significantly lower with tacrolimus than with CSP (65% vs 81%, respectively; P =. 019). The number of patients requiring dialysis in the first 100 days was similar (tacrolimus, 9; CSP, 8). Overall and relapse-free survival rates for the tacrolimus and CSP arms at 2 years was 54% versus 50% (P =.46) and 47% versus 42% (P =.58), respectively. The combination of tacrolimus and MTX after unrelated donor marrow transplantation significantly decreased the risk for acute GVHD than did the combination of CSP and MTX, with no significant increase in toxicity, infections, or leukemia relapse.

Bone marrow transplantation for infantile ceramidase deficiency (Farber disease).

Infantile ceramidase deficiency (Farber disease) is an uncommon, progressive lysosomal storage disease characterized by multiple ceramide-containing nodules (lipogranulomata) in the subcutaneous tissue and upper aerodigestive tract, painful periarticular swelling, psychomotor retardation, and varying degrees of ocular, pulmonary or hepatic involvement. Management of Farber disease has been limited to symptomatic supportive care, and few affected infants survive beyond 5 years of age. We performed an allogeneic bone marrow transplant (BMT) from an HLA-identical heterozygous sister in a 9.5-month-old female with minimally symptomatic Farber disease who received a pre-transplant regimen of busulfan and cyclophosphamide. Ceramidase activity in peripheral blood leukocytes increased from 6% before transplant to 44% (donor heterozygote level) by 6 weeks after BMT. By 2 months after transplant, the patient's subcutaneous lipogranulomata, pain on joint motion, and hoarseness had resolved. Despite modest gains in cognitive and language development, hypotonia and delayed motor skills persisted. Gradual loss of circulating donor cells with autologous hematopoietic recovery occurred; VNTR analyses showed 50% donor DNA in peripheral blood cells at 8.5 months after BMT and only 1% at 21 months after transplant. Interestingly, leukocyte ceramidase activity consistently remained in the heterozygous range despite attrition of donor cells in peripheral blood. This novel observation indicates ongoing hydrolase production by non-circulating donor cells, possibly in the mononuclear phagocytic system, and uptake by recipient leukocytes. Although lipogranulomata and hoarseness did not recur, the patient's neurological and neurocognitive status progressively declined. She died 28 months after BMT (age 37.5 months) with pulmonary insufficiency caused by recurrent aspiration pneumonias. Allogeneic BMT improves the peripheral manifestations of infantile ceramidase deficiency, but may not prevent the progressive neurological deterioration, even when carried out in minimally symptomatic patients.