Regular monitoring of cytomegalovirus-specific cell-mediated immunity in intermediate-risk kidney transplant recipients: predictive value of the immediate post-transplant assessment.

OBJECTIVE: Previous studies on monitoring of post-transplant cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) are limited by single-centre designs and disparate risk categories. We aimed to assess the clinical value of a regular monitoring strategy in a large multicentre cohort of intermediate-risk kidney transplant (KT) recipients. METHODS: We recruited 124 CMV-seropositive KT recipients with no T-cell-depleting induction pre-emptively managed at four Spanish institutions. CMV-specific interferon-γ-producing CD4+ and CD8+ T cells were counted through the first post-transplant year by intracellular cytokine staining after stimulation with pp65 and immediate early-1 peptides (mean of six measurements per patient). The primary outcome was the occurrence of any CMV event (asymptomatic infection and/or disease). Optimal cut-off values for CMV-specific T cells were calculated at baseline and day 15. RESULTS: Twelve-month cumulative incidence of CMV infection and/or disease was 47.6%. Patients with pre-transplant CMV-specific CD8+ T-cell count <1.0 cells/µL had greater risk of CMV events (adjusted hazard ratio (aHR) 2.84; p 0.054). When the CMI assessment was performed in the immediate post-transplant period (day 15), the presence of <2.0 CD8+ T cells/µL (aHR 2.18; p 0.034) or <1.0 CD4+ T cells/µL (aHR 2.43; p 0.016) also predicted the subsequent development of a CMV event. In addition, lower counts of CMV-specific CD4+ (but not CD8+) T cells at days 60 and 180 were associated with a higher incidence of late-onset events. CONCLUSIONS: Monitoring for CMV-specific CMI in intermediate-risk KT recipients must be regular to reflect dynamic changes in overall immunosuppression and individual susceptibility. The early assessment at post-transplant day 15 remains particularly informative.

Effect of long-term prophylaxis in the development of cytomegalovirus-specific T-cell immunity in D+/R- solid organ transplant recipients.

BACKGROUND: This study aimed to characterize the dynamics of acquisition of cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) in CMV donor positive/recipient negative solid organ transplant (SOT) patients receiving long-term antiviral prophylaxis, and to determine whether development of CMI confers protection against CMV disease. METHODS: A prospective multicenter study was conducted in Spain from September 2009 to September 2012. Whole blood specimens were prospectively collected at 30, 90, 120, 200, and 365 days after SOT, and CMI was determined by enumeration of CMV pp65 and IE-1-specific CD69(+) /interferon-γ-producing CD8(+) and CD4(+) T cells by flow cytometry for intracellular cytokine staining. As part of a simultaneous clinical trial, patients received either early prophylaxis (in the first 3 days after transplantation) in the first period of the study or delayed prophylaxis (initiated at day 14) during the second period of the study. The impact of the dynamics of acquisition of CMV-specific CMI on the incidence of CMV disease was evaluated by Kaplan-Meier survival analysis. RESULTS: A total of 95 SOT recipients were recruited. CMV infection and disease occurred in 38 (40%) and 26 (27.4%) patients, respectively. The proportion of patients achieving any detectable CMV-specific CMI response at each of the different monitoring points was higher in liver transplant recipients, as compared to kidney or heart transplant recipients. The presence of any detectable response at day 120 or 200 was protective against the development of CMV disease (positive predictive values 92% and 93%, respectively). CONCLUSIONS: The rate of acquisition of CMV-specific CMI in SOT recipients undergoing antiviral prophylaxis differed significantly between different SOT populations. Patients developing any detectable CMI response were protected against the occurrence of CMV disease.

Effect of delaying prophylaxis against CMV in D+/R- solid organ transplant recipients in the development of CMV-specific cellular immunity and occurrence of late CMV disease.

OBJECTIVES: Evaluate the protective effect against late CMV disease of delaying antiviral prophylaxis initiation in D+/R- patients receiving solid organ transplant (SOT). METHODS: Prospective multicenter study in D+/R- SOT recipients in Spain (Sept/09-Sept/12). Whole blood specimens were prospectively collected after Tx for CMV-specific cell-mediated immunity (CMI) determination. Two prophylaxis strategies were compared: early prophylaxis (EP; starting within the first 3 days after Tx) and delayed prophylaxis (DP; starting 14 days after Tx). Risk factors for the occurrence of CMV disease were determined by survival analysis and proportional risk Cox regression models. RESULTS: We included 95 patients (50 EP V 45 DP). Twenty six patients (27.4%) developed CMV disease: 32.7% EP vs. 20% DP; (p = 0.2). No cases of CMV disease were reported previously to beginning delayed prophylaxis. The percentage of individuals with detectable CMI response was higher in patients with DP although differences did not reach statistic significance (42% vs 29.6% at day 200 after Tx; p = 0.4). There was a clear trend towards less end-organ CMV disease in patients receiving DP (18.2% EP vs 5% DP; p = 0.09) and DP was the only protective factor in the multivariate analysis (HR: 0.26; CI: 0.05-1.2; p = 0.09). CONCLUSIONS: A 14-day delay in CMV prophylaxis in D+/R- SOT recipients is safe and may reduce the incidence of late CMV end-organ disease although correlation of this effect with CMI responses was not complete.

Functional patterns of cytomegalovirus (CMV) pp65 and immediate early-1-specific CD8(+) T cells that are associated with protection from and control of CMV DNAemia after allogeneic stem cell transplantation.

BACKGROUND: The functional profile of cytomegalovirus (CMV)-specific CD8(+) T cells that associate with protection from and control of CMV DNAemia in allogeneic stem cell transplant (allo-SCT) recipients remains incompletely characterized. METHODS: We enumerated pp65 and immediate early (IE)-1-specific CD8(+) T cells expressing interferon-gamma, tumor necrosis factor-alpha, and CD107a, by flow cytometry in 94 patients at days +30 and +60 after allo-SCT. RESULTS: Fifty of 94 patients had CMV DNAemia within the first 100 days after transplant. CMV-specific CD8(+) T-cell responses (of any functional type) were more likely to be detected in patients who did not display CMV DNAemia than in those who did (P = 0.04). Qualitatively, no major differences in the functional signature of CMV-specific CD8(+) T cells were noted between patients who had or did not have CMV DNAemia. Patients displaying levels of polyfunctional CD8(+) T cells at day +30 >0.30 cell/µL had a lower risk of CMV DNAemia (positive predictive value 76%, and negative predictive value 43%). CONCLUSION: The presence of polyfunctional CD8(+) T cells (either expressing CD107a or not) was associated with lower levels of CMV replication, and higher frequency of self-resolved episodes. The data reported further clarify the role of polyfunctional CD8(+) T cells in control of CMV DNAemia in allo-SCT recipients.

Photodynamic therapy to treat choroidal neovascularisation in highly myopic patients: 4 years' outcome.

AIMS: To report the visual outcome in a series of eyes with myopic choroidal neovascularisation treated by photodynamic therapy (PDT) followed during 48 months. METHODS: Prospective, consecutive, non-randomised interventional case series. Thirty-nine eyes from 36 highly myopic patients treated by PDT were evaluated. Best corrected visual acuity (BCVA) and fluorescein angiography were performed every 3 months. Multiple regression analysis was used to analyse changes in BCVA in relationship with initial BCVA, spherical equivalent, age, diameter of CNV and chorioretinal atrophy. RESULTS: Mean initial BCVA was 9.0 Early Treatment Diabetic Retinopathy Study lines (SD 4.3). BCVA was 10.4 lines (3.6) at month 12, 9.7 lines (SD 3.9) at month 24, 9.6 lines (SD 3.8) at month 36 and 9.6 lines (SD 4.2) at month 48. BCVA improvement was associated with initial BCVA (p<0.002), lesion diameter (p<0.04) and age (p<0.04) (multiple regression analysis). CONCLUSIONS: Our results suggest a better visual outcome for those eyes with better initial BCVA and larger lesions in younger patients treated by PDT. The poorer results for elderly patients with lower initial BCVA might lead us to consider other therapeutic approaches.

Optical coherence tomography predictive factors for macular hole surgery outcome.

AIM: To evaluate the use of preoperative optical coherence tomography (OCT) findings as predictive factors for macular hole (MH) surgery outcomes. METHODS: 46 eyes from 46 patients with a diagnosis of MH were included in this study. In all cases, a pars plana 25-gauge vitrectomy with peeling of the internal limiting membrane was performed. Before and after surgery, a complete clinical examination and a detailed macular analysis, which included the MH minimum and base diameter, the MH height, the Macular Hole Index (MHI), Diameter Hole Index (DHI) and Tractional Hole Index (THI), were performed. Predictive factors for visual prognosis after surgery were obtained by receiver operating characteristic curve analysis. RESULTS: Minimum and base diameter as well as THI and MHI correlated significantly (p<0.01, p = 0.01, p = 0.04, p = 0.03, respectively) with postoperative best spectacle corrected visual acuity at 3 months, but DHI and MH height did not. Cut-off values of 311 microm and 1.41 were obtained for the minimum diameter and THI, respectively, from receiver operating characteristic curve analysis, providing an acceptable sensitivity and specificity. CONCLUSION: An MH minimum diameter of <311 microm or a THI >1.41 are predictive factors for a good visual prognosis after MH surgery.

Purified allergens vs. complete extract in the diagnosis of plane tree pollen allergy.

BACKGROUND: Plane tree pollen allergy is a clinical disorder affecting human population in cities of Europe, North America, South Africa, and Australia. OBJECTIVE: To compare IgE-reactivity of the natural and recombinant forms of two major plane allergens, Pla a 1 and Pla a 2, with the reactivity of Platanus acerifolia pollen extract. METHODS: Forty-seven patients with P. acerifolia allergy, 15 of them monosensitized, and 24 control subjects were included in the study. Natural Pla a 1 and Pla a 2 were purified by standard chromatographic methods and recombinant proteins were expressed in Escherichia coli. Skin prick test and determination of specific IgE were performed with commercial P. acerifolia extract and natural and recombinant purified allergens. RESULTS: Pla a 1 and Pla a 2 were responsible for 79% of the IgE-binding capacity against P. acerifolia pollen extract. A high correlation has been found between the IgE response to nPla a 1 (R = 0.80; P < 0.001) or nPla a 2 (R = 0.79; P < 0.001) vs. P. acerifolia extract as well as between natural and recombinant Pla a 1 (R = 0.89; P < 0.001). Skin testing showed no significant differences between extract and nPla a 2, whereas a higher reactivity was found with nPla a 1. In contrast, rPla a 1 revealed markedly reduced sensitivity in comparison with extract by skin prick test and specific IgE. The sensitivity of the mix Pla a 1+Pla a 2 was 100% and 87.5% for monosensitized and polysensitized patients, respectively, with no false-positive reactions detected. Conclusion Pla a 1 and Pla 2 are sufficient for a reliable diagnosis of P. acerifolia in most patients and induce comparable skin test reactivity as a whole extract.

Understanding contextual fear conditioning: insights from a two-process model.

Contextual fear conditioning is an important behavioral paradigm for studying the neurobiology of learning and memory and the mnemonic function of the hippocampus. We suggest that research in this domain can profit by a better theoretical understanding of the processes that contribute to this phenomenon. To facilitate this understanding, we describe a theory which assumes that physical elements of a conditioning context represented in the brain as either (a) a set of independent features or (b) features bound into a conjunctive representation by the hippocampus which supports pattern completion. Conditioning produced by shocking a rat in a particular context, in principle, can be produced by strengthening connections between the feature representations and/or the conjunctive representation and basolateral region of the amygdala. We illustrate how this theory clarifies some of the complexities associated with the existing literature and how it can be used to guide future empirical work. We also argue that the mechanisms (conjunctive representations and pattern completion) that mediate the contribution the hippocampus makes to contextual fear conditioning are the same ones that enable the hippocampus to support declarative memory in humans.

Microinjection of urocortin 2 into the dorsal raphe nucleus activates serotonergic neurons and increases extracellular serotonin in the basolateral amygdala.

The intra dorsal raphe nucleus (DRN) administration of corticotropin releasing hormone (CRF) inhibits serotonergic (5-HT) activity in this structure, an effect blocked by antagonists selective for the type 1 CRF receptor (CRF1). The DRN has a high density of the type 2 receptor (CRF2), and so the present experiments explored the impact of CRF2 activation within the DRN on 5-HT function. The intra-DRN administration of the selective CRF2 agonist urocortin 2 (Ucn 2) dose dependently increased 5-HT efflux in the basolateral amygdala, a projection region of the DRN. Intra-DRN Ucn 2 also increased c-fos expression in labeled 5-HT neurons. Both of these effects of Ucn 2 were completely blocked by intra-DRN antisauvagine-30 (ASV-30), a relatively selective CRF2 antagonist. These data suggest that CRF1 and CRF2 activation within the DRN affect 5-HT neurons in opponent fashion. Implications of these results for understanding the behavioral effects of CRF and other CRF-like ligands are discussed.

[Contribution of a functional orthopedic splint to the treatment of Class II malocclusions]. / Apport d'une gouttière fonctionnelle et orthopédique au traitement des malocclusions de classe II.

The numerous therapeutic, psychological and functional benefits that derive from using a two-stage approach to the treatment of Class II malocclusions can sometimes be partially offset by difficulties stemming from the choice of technique: patients may be reluctant to wear cumbersome appliances which, when they are worn, can interfere with speech production, the quality of therapeutic improvement may be reduced by undesirable dento-alveolar responses to orthopedic forces, treatment results may turn out to be unstable at the final finishing stage and continuation of treatment at the time of the appearance of the young adult dentition may be jeopardized. The author has designed a new appliance, a functional orthopedic splint whose slim design largely eliminates these problems. Suitable for use in a variety of techniques, this easily worn device greatly reduces unwanted dento-alveolar responses as it stimulates desirable functional improvement and gives orthodontists much improved control of their treatment of Class II malocclusions.

Gestión técnica de una unidad de inmunoterapia / Technical gestion in the immunotherapy unit

Antecedentes y objetivos: La administración de inmunoterapia (IT) por vía subcutánea es un tratamiento no exento de riesgos, por lo que su administración debe llevarse a cabo siguiendo estrictos protocolos de actuación. El objetivo del estudio es establecer los criterios de monitorización de los pacientes en una Unidad de Inmunoterapia para reducir el riesgo de aparición de reacciones adversas. Material y métodos: Un total de 378 pacientes diagnosticados de rinitis y/o asma por sensibilización a distintos aeroalergenos (ácaros, pólenes, epitelios y hongos) fueron atendidos en nuestra Unidad durante un período de 15 meses. Todos ellos fueron tratados con extractos estandarizados biológicamente. La monitorización de los enfermos se llevó a cabo con la ayuda de un programa informático (InmunoWin®). Resultados: Se administraron un total de 4.383 dosis. Aparecieron un total de 34 reacciones adversas (0,8 por ciento), de las cuales sólo una fue sistémica (0,02 por ciento). Ésta consistió en un broncoespasmo leve, que se controló inmediatamente. Conclusiones: La correcta monitorización de los pacientes, en la cual la informática juega un papel destacado, en el momento en el que se les administra una dosis de IT, reduce drásticamente el porcentaje de reacciones sistémicas y se demuestra que la IT es un tratamiento seguro cuando se administra bajo las debidas condiciones (AU)

Influence in the quality of life of the respiratory patients by environmental control and the acaricide Frontac®.

The present prospective, open, observational study assessed the effect of the use of standard environmental control measures together with the application of an acaricide-containing aerosol of esbiol/benzyl benzoate/piperonyl butoxide/2-phenylphenol (Frontac) on several clinical and environmental parameters in patients suffering from perennial allergic rhinoconjunctivitis related to house dust mites (HDM). Fifty-five patients were enrolled and studied for one year. Both symptoms and the patients' quality of life (evaluated by the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ)) were assessed at several clinic visits. The amount of HDM antigen was semi-quantitatively estimated using the guanine test. We found a significant decrease (p < 0.001) in most nasal symptoms scores: sneezing, runny nose, stuffy nose and itching. The overall quality of life (QoL) score also showed a significant improvement during the study period; the mean score decrease found was 0.86 (CI 95 %, 0.54-1.17) (p < 0.001). Five of the seven domains included in the questionnaire decreased significantly: non-hayfever symptoms; practical problems; nasal symptoms; eye symptoms, and emotions. These QoL score decreases were found during the first 3 months and later remained stable at lower levels than at baseline. The content of guanine in dust samples decreased significantly from 2.17 0.75 to 1.43 0.68 (p < 0.001). No toxic adverse events were recorded. In conclusion, these results show an improvement in the quality of life and a clinical benefit of the long-term use of the new chemical acaricide tested, together with environmental measures, in the home of patients suffering from allergic respiratory pathology.

Asma ocupacional por polvo de espinaca / Asthma occupational to Spinach powder

Antecedentes y objetivos: Los alimentos pueden ser causa de enfermedades respiratorias como antígenos inhalados. Se presenta un caso de un varón de 45 años, panadero, sin antecedentes de atopia, que presenta síntomas de rinoconjuntivitis y asma bronquial en relación con la manipulación de polvo de espinaca deshidratada, que utiliza para el enriquecimiento de harinas integrales en la fabricación del pan integral. El paciente tolera la ingesta de espinaca, pan y bollería. Material y métodos: Se realizó prick test con extracto de polvo de espinaca deshidratada (30 mg/ml) y prueba de provocación nasal con extracto de espinaca deshidratada, así como determinación de IgE específica mediante el método HY-TEC-EIA e SDSPAGE-immunoblotting. Resultados: El prick test con extracto de polvo de espinaca deshidratada (30 mg/ml) fue positivo. La prueba de provocación nasal con el extracto de espinaca deshidratada fue positiva a una dilución 1/1000 desencadenándose de forma inmediata síntomas clínicos de rinitis; se pudo observar aumento de las resistencias y disminución en el flujo total mayor del 50 por ciento. La IgE específica fue de 1,64 kU/L y mediante la técnica SDS-PAGE immunoblotting se determinó una banda proteica fijadora de IgE de 29,6 KDa. Conclusiones: Se describe la hipersensibilidad mediada por IgE frente a polvo de espinaca en un paciente panadero que presentaba síntomas de rinitis y asma con su manipulación. El paciente se encuentra asintomático al evitar su contacto. La sensibilización a otros vegetales utilizados en la masa del pan puede ser la causa de asma ocupacional por antígenos ocultos y poco frecuentes (AU)