Low rejection rates with tacrolimus-based dual and triple regimens following liver transplantation

We studied the outcome of 345 liver transplant patients who received tacrolimus-based immunosuppressive therapy either as a dual regimen (with corticosteroids, n=172) or as a triple regimen (with corticosteroids and azathioprine, n=173) for 3 months after transplantation (3-month cohort). A further analysis was conducted for the first 195 patients randomised (dual n=100, triple n=95) who were followed up for 12 months after transplantation (12-month cohort). For the 3-month cohort, patient survival was 90.7% (dual) and 91.9% (triple), graft survival after 3 months was 88.4% (dual therapy) and 89.6% (triple therapy). Acute rejections were experienced by 67/172, 39.0% of patients on dual therapy and by 60/173, 34.7% of patients on triple therapy; corticosteroid-resistant rejections were reported in 9 patients (5.2%) in either treatment group. The overall safety profile was similar for the two treatment groups. Significant differences, however, were found for thrombocytopenia (dual 13/172, 7.6%, triple 37/173, 21.4%, p<0.001) and leukopenia (dual 4/172, 2.3%, triple 24/173, 13.9%, p<0.001). For the 12-month cohort, patient survival was 85.6% (dual) and 88.4% (triple) after 1 year. Graft survival was 81.7% (dual) and 85.2% (triple) 12 months after transplantation. Acute rejections were reported for 38/100, 38.0% of patients on dual therapy and 36/95, 37.9% of patients on triple therapy, corticosteroid-resistant rejections were 7/100, 7.0% (dual) and 7/95, 7.4% (triple) of patients. In the 12-month cohort, no significant differences in the safety profiles of the treatment groups were found. We conclude that both tacrolimus-based dual and triple drug regimens provide effective and safe immunosuppression following orthotopic liver transplantation.

[Liver transplantation in a patient with hemophilia A and end stage liver failure]

We report the case of a 50 year-old man factor VIII deficient haemophiliac and hepatitis C cirrhosis. The patient underwent orthotopic liver transplantation because of episodes of variceal bleeding and encephalopathy. He received factor VIII replacement therapy perioperatively. Factor VIII returned to normal within 24 hours postoperatively and factor VIII replacement was stopped. Liver transplantation can be considered as definitive therapy for haemophilia.

Importing biological materials

This overview discusses critical issues regarding importing of restricted biological materials along with criteria for handling these materials. Guidelines for importing non-restricted biological materials are also covered. Recommendations are given for packaging biological materials for export, and finally, the necessary steps for obtaining an import permit application are outlined.

Magnetic resonance imaging of intracranial tissue accumulations in domestic ducks (Anas platyrhynchos f. dom.) with feather crests

The crested breed of domestic duck (Anas platyrhynchos f. dom.) has been described as a variety which has high pre- and postnatal mortalities, malformations in skull and brain anatomy, and several central nervous deficiencies. In addition, intracranial tissue accumulations have been diagnosed in purebred Crested ducks. The incidence, heredity and inheritance of these accumulations as well as their pathogenesis are still generally unknown. The aims of this study were to examine the head of Crested ducks, plain-headed duck breeds, and their crossbreeding relating to the incidence of intracranial alterations. These examinations were performed using magnetic resonance imaging. We found a high incidence of intracranial tissue accumulations in domestic ducks with feather crests. Creasted ducks had more intracranial tissue deposits than plain-headed ducks (p < 0.001). In the present study a correlation between the volume of the crest cushion and the volume of the intracranial tissue deposit could not be found (r = 0.014). Some of the Crested ducks had encephaloceles in addition to the crest cushion.

Effects of retigabine on rhythmic synchronous activity of human neocortical slices

The antiepileptic effects of the novel antiepileptic drug retigabine (D-23129) [N-(2-amino-4-(4-flurobenzylamino)phenyl) carbamid acid ethyl ester] were tested in neocortical slice preparations (n=23) from 17 patients (age, 3-42 years) who underwent surgery for the treatment of intractable epilepsy. Epileptiform events consisted of spontaneously occurring rhythmic sharp waves, as well as of epileptiform field potentials (EFP) elicited by superfusion with Mg(2+)-free solution without or with addition of 10 micromol/l bicuculline. (1) Spontaneous rhythmic sharp waves (n=6), with retigabine application, the repetition rate was decreased down to 12-47% of initial value (10 micromol/l, n=3) after 180 min or suppressed completely within 12 min (50 micromol/l, n=3). (2) Low Mg(2+) EFP (n=9), with retigabine application, the repetition rate was decreased down to 50 and 65% of initial value (10 micromol/l; n=2) after 180 min or suppressed completely after 9-55 min (10, 50 and 100 micromol/l; n=2 in each case). In one slice only a transient reduction of the repetition rate was seen with 10 micromol/l retigabine. (3) Low Mg(2+) EFP with addition of bicuculline (n=8), with retigabine application, the repetition rate was decreased down to 12-55% of initial value (10 micromol/l; n=4) after 180 min or suppressed completely after 6-30 min (50 and 100 micromol/l; n=2 in each case). The depressive effect of retigabine was reversible in all but one slice. The results show a clear antiepileptic effect of retigabine in human neocortical slices on spontaneously occurring rhythmic sharp waves and different types of induced seizure activity.

Importing biological materials

Scientific cooperation between laboratories in the United States is no longer confined to those at the same institution, nor even within the boundaries of the country. More than ever, scientists are forming collaborations with their peers outside the U.S., leading not only to the exchange of knowledge and ideas, but also to the exchange of biological reagents. This unit discusses issues involved with international transfer of these reagents, such as packaging and import restrictions.

Long-term results in the treatment of vitiligo with oral khellin plus UVA

This study was performed to assess the effectiveness and short-term and long-term safety of oral khellin plus UVA (KUVA) in patients with vitiligo. Twenty-eight patients (13 males and 15 females; mean age, 34 years; [age range, 15-51 years]) most with extensive generalized vitiligo of more than 6 months duration had received KUVA at sometime during a 14-year period. The response to treatment (i.e. repigmentation of depigmented areas) was rated retrospectively comparing photographs taken before and after therapy and correlation analysis revealed that it was statistically significantly linked to the number of KUVA treatments (r = 0.833, P = 0.001) and to total cumulative UVA dose (r = 0.840, P = 0.001). Of 17 patients who had continued therapy for longer than 3 months, 7 (41%) had a good response (i.e., more than 70% repigmentation of lesional skin) after a mean of 194 treatments (range, 69-386 treatments) and a mean cumulative UVA dose of 2,036 J/cm2 (range, 690-4,411 J/cm2), whereas lower response grades were observed in the patients with lower treatment numbers. The most common short-term side effect was mild nausea, occurring in 8 of 28 patients (29%), and mainly in the first week(s) of treatment. Follow-up assessment at a mean of 40 months (range, 4-110 months) after the end of KUVA therapy available in 23 of 28 patients revealed no skin cancers or actinic skin damage in any patient. These data indicate that KUVA seems to be safe as well as effective for vitiligo, provided treatment is administered long enough.

Importing biological materials

Scientific cooperation between laboratories in the United States is no longer confined to those at the same institution, nor even within the boundaries of the country. More than ever, scientists are forming collaborations with their peers outside the U.S., leading not only to the exchange of knowledge and ideas, but also to the exchange of biological reagents. This unit discusses issues involved with international transfer of these reagents, such as packaging and import restrictions.

Effect of topically applied T4 endonuclease V in liposomes on skin cancer in xeroderma pigmentosum: a randomised study. Xeroderma Pigmentosum Study Group

BACKGROUND

In patients with xeroderma pigmentosum the frequency of all forms of skin cancer is higher than in the general population, owing to a genetic defect in DNA repair. The bacterial DNA repair enzyme, T4 endonuclease V, delivered intracellularly, increases the rate of repair of sunlight-induced DNA damage in human cells. We tested the ability of this enzyme in a liposomal delivery vehicle applied topically (T4N5 liposome lotion) to lower the rate of new skin cancers in patients with xeroderma pigmentosum.

METHODS

30 patients were enrolled in this prospective, multicentre, double-blind study. Patients were randomly assigned T4N5 liposome lotion or a placebo liposome lotion, to be applied daily for 1 year. At 3-monthly visits, new actinic keratoses and basal-cell carcinomas were identified and removed. Analyses were by intention to treat.

FINDINGS

20 patients were assigned T4N5 liposome lotion and ten placebo lotion; one placebo-group patient withdrew before treatment and one withdrew with progressive disease at 9 months. The annualised rate of new actinic keratoses was 8.2 among the patients assigned T4N5 liposome lotion and 25.9 among those assigned placebo (difference 17.7 [95% CI 11.8-26.5]; p=0.004 by Poisson modelling). For basal-cell carcinoma, the annualised rates of new lesions were 3.8 in the treatment group and 5.4 in the placebo group (difference 1.6 [0.38-2.82]). No significant adverse effects were found among any of the patients.

INTERPRETATION

DNA damage has an important role in the development of skin cancer and precancerous skin lesions. The topical application of DNA repair enzymes to sun-damaged skin of patients with xeroderma pigmentosum lowered the rate of development of two forms of these lesions during a year of treatment.

Effects of nifedipine on rhythmic synchronous activity of human neocortical slices

The antiepileptic effect of the dihydropyridine calcium channel blocker nifedipine was tested in neocortical slice preparations (n=27) from patients ranging in age from four to 46 years (mean=25) who underwent surgery for the treatment of intractable epilepsy. Epileptiform events consisted of spontaneously occurring rhythmic sharp waves as well as of untriggered epileptiform field potentials induced by omission of Mg(2+) from the superfusate, or epileptiform field potentials elicited by application of bicuculline and triggered by single electrical stimuli. (1) Spontaneous rhythmic sharp waves (n=6): with nifedipine (40micromol/l), the repetition rate was decreased down to 30% of initial value, whereas the area under the field potential remained nearly unchanged. (2) Untriggered low Mg(2+) epileptiform field potentials (n=6): with nifedipine (40micromol/l) the area under the field potentials was reduced while the action on the repetition rate was ambiguous. (3) Triggered bicuculline epileptiform field potentials (n=15): with nifedipine (40micromol/l; n=4), no antiepileptic effect was found. There was, however, a marked increase in the area under the epileptiform field potentials. The area under the field potentials was reduced only at a dosage of 60micromol/l (n=11). This effect was stronger when nifedipine was applied with a K(+) concentration raised from 4 to 8mmol/l. The results show that the calcium channel blocker nifedipine is able to reduce differential epileptiform discharges in human neocortical tissue. These observations are in line with previous findings, suggesting that calcium flux into neurons is involved in epileptogenesis. The present results therefore support the idea that some organic calcium antagonists may be useful in human epilepsy therapy, although the etiology of epileptic seizures seems to be a critical factor for the efficacy of the drug.

Charge-process strategies for outpatient prospective payment

One of the most important strategies for operating successfully under the outpatient prospective payment system is to establish an effective charging process. Achieving control of the process begins with a thorough assessment of chargemaster coding, how charges are structured in the chargemaster, and how hospital departments use the charges. Once problems are identified and corrected, the next step is to develop a system to maintain and monitor both the chargemaster and the charging process. Perhaps the most important component of the monitoring system is to include a mechanism to provide the necessary feedback to departments regarding errors related to the charge process.

Engraftment and albumin production of intrasplenically transplanted rat hepatocytes (Sprague-Dawley), freshly isolated versus cryopreserved, into Nagase analbuminemic rats (NAR)

Banking of cryopreserved hepatocytes is a prerequisite for large-scale hepatocyte transplantation in the clinic. We compared the efficacy of intrasplenic transplantation into Nagase analbuminemic rats (NAR) of freshly isolated (FIH) and cryopreserved (CH) hepatocytes. Hepatocytes were cryopreserved using a controlled rate freezing protocol. Albumin production of thawed CH and FIH was measured in vitro in culture by ELISA and by Western blot. After in vivo intrasplenic transplantation of NAR with either FIH or CH we assessed 1) albumin in the serum of recipients by ELISA and by Western blotting analysis at different time intervals, and 2) hepatocyte engraftment by albumin immunohistochemical staining into spleens and livers at euthanasia. In vitro, albumin was produced up to day 4 of culture in both CH and FIH. In vivo, no intrasplenic engraftment of hepatocytes occurred. Intrahepatic engraftment of CH (cell number/mm2) was significantly (twofold) lower than that of FIH and appeared only as isolated cells and small (<10 cells) clusters, while bigger clusters (>10 cells) were observed with FIH. In the FIH group, serum albumin production was observed up to 32-49 days posttransplantation while in the CH group no serum albumin production was detected. Our results emphasize the need to improve 1) hepatocyte transplantation procedures either by repeated hepatocytes injections and/or by transplantation under a regeneration response, and 2) the freeze/thaw protocols of hepatocytes.

Epilepsy and catalepsy in Anglo-American literature between romanticism and realism: Tennyson, Poe, Eliot and Collins

Epilepsy and catalepsy were not clearly separated in the minds of people in the early 19th century, and catalepsy may have been used as a diagnostic euphemism for epilepsy. Tennyson, in "The Princess" describes, under the diagnosis of catalepsy, probable temporal lobe epileptic dreamy states with derealization which serve as a metaphor of sexual and moral ambivalence, the poem's central theme. It seems that Tennyson knew such seizures from his own father who had been given a diagnosis of catalepsy. Poe gave his Berenice in the novella of the same title a diagnosis of epilepsy as a reason for a premature burial. However, there was a good deal of unlikelyhood in this, and when he came to this theme in "The Fall of the House of Usher" and in "The Premature Burial" he chose instead a diagnosis of catalepsy which fitted better with the plot. The fits of the title character in George Eliot's Silas Marner, diagnosed as catalepsy, would today rather be seen as epileptic twilight states. It would seem that this author drew from contemporary dictionary descriptions which described conditions similar to Marner's fits under the heading of catalepsy. In Eliot's "legend with a realistic treatment", the twilight states are a central factor in the plot and explain Marner's reclusion and passivity. In Poor Miss Finch by English realist Wilkie Collins, the post-traumatic seizures of Oscar, one of the main characters, their cause, their treatment with silver nitrate, and the subsequent discoloration of his skin are central supporting elements of a perfectly constructed plot. Collins gives an exact description of a right versive seizure with secondary generalisation, and how to deal with it. In none of these works seizures are seen in a negative light. They rather evoke reactions of sympathy and support.

Optical monitoring of neuronal activity during spontaneous sharp waves in chronically epileptic human neocortical tissue

Functional changes in neuronal circuitry reflected in spontaneously occurring synchronous sharp field potentials (SSFP) have been reported to occur in human brain suffering from chronic epileptogenicity but not in primary nonepileptic tissue from peritumoral resectates. Voltage sensitive dyes and fast imaging were used to visualize spontaneously occurring rhythmic depolarizations correlated to SSFP in chronically epileptic human neocortical slices obtained during epilepsy surgery. Localized and spatially inhomogeneous neuronal depolarizations were found to underlie spontaneous SSFP, which remained unchanged and spatially restricted to foci <750 micrometer diam even under epileptogenic (low-Mg(2+)) conditions. In cases where ictaform paroxysmal activity occurred in low-Mg(2+) medium, neuronal depolarizations were wide-spread but still spatially inhomogeneous, and the events were preferentially initiated at distinct foci. The findings suggest that small neuronal networks are able to establish and maintain synchronous rhythmic and epileptiform activity.

Extended extracorporeal photochemotherapy with extracorporeal administration of 8-methoxypsoralen in systemic sclerosis. An Austrian single-center study

BACKGROUND

Extracorporeal photochemotherapy (EXP) is an immunomodulating therapy that has been used in a limited number of patients with systemic sclerosis (SSC) with controversial results. The present study was performed to evaluate the efficacy and safety of extended EXP with extracorporeal application of liquid 8-methoxypsoralen (8-MOP) in the treatment of SSC.

METHODS

Eleven women with progressive SSC of recent onset were treated for a period of 16-57 months. Skin changes, physical performance, extracutaneous manifestations, and quality of life were evaluated before initiation of EXP and at regular intervals thereafter.

RESULTS

From the start to the last set of EXP, we observed an overall improvement and/or stabilization of skin changes and physical performance in 5 of 11 patients (45%). Extracutaneous manifestations deteriorated in 10 of 11 patients (91%) (P<0.05), and quality of life deteriorated in 9 of 11 patients (82%) from a mean score of 10 before, to 17 at the last set of EXP (P<0.05). No major side effects were noted.

CONCLUSION

Extended EXP with extracorporeal administration of 8-MOP is a safe and well tolerated treatment modality. However, it provides only (minor) improvement of skin changes of a subset of SSC patients and does not beneficially influence extracutaneous manifestations and quality of life.

Transcatheter cryoablation of ventricular myocardium in dogs

INTRODUCTION

Surgical cryoablation, a highly effective technique used during antiarrhythmic surgery, produces voluminous, histologically uniform and discreet myocardial lesions. In contrast, radiofrequency (RF) catheter ablation, which as a result of its less invasive nature has largely supplanted antiarrhythmic surgery, produces smaller, histologically heterogeneous myocardial lesions. Since small lesion size and heterogeneity may reduce antiarrhythmic efficacy, we sought to reproduce the large, histologically homogeneous lesions created by surgical cryoablation, using a catheter cryoablation system (Cryogen, Inc., San Diego, CA) in the canine ventricle.

METHODS AND RESULTS

In seven dogs, nineteen ventricular lesions (two right and seventeen left) were created with a 10F cryoablation catheter with either a 2 or 6 mm tip. In one dog AV node ablation was also performed. For each 'freeze', catheter tip nadir temperature, lesion width, depth, and transmurality were recorded, and lesion volume calculated. Average tip nadir temperature was -79.6+/-4.9 degrees C. Cooler nadir tip temperature was associated with deeper (p=.007) and more voluminous lesions (p=.042), and a greater likelihood of lesion transmurality (p=.034). Average lesion volume was 500+/-356 mm(3). No other variables predicted lesion volume or transmurality. Histologically, the catheter cryoablation lesions were sharply demarcated and homogeneous. The single freeze performed at the AV junction produced complete AV block. One complication, catheter rupture following its repetitive use, resulted in a coronary air embolus and death.

CONCLUSION

Catheter cryoablation of canine ventricular myocardium produced voluminous, discrete, transmural lesions, which might be effective for ablation of ventricular tachycardia. Lesion volume and transmurality were dependent on catheter tip nadir temperature.

[Enzootic ulcer in the back of the tongue in cattle after ingestion of hay containing flower clusters of yellow bristle-grass]

Chronically recidivating enzootic ulcerations in the tongues of numerous milking cows in the Po river plain area in Italy. The animals were permanently kept indoors in cubicle houses and fed by hay containing high amounts of ripe yellow bristle grass (Setaria glauca (L.) Beauv. [= S. pumila Poiret]). The panicled parts of the culms were found to be the cause of the massive injuries.

Matrix metalloproteinase expression in nonrheumatic aortic stenosis

BACKGROUND

Nonrheumatic aortic stenosis (NAS) is considered to be a degenerative process characterized by valve thickening, fibrocalcific masses, collagen disarray, and an inflammatory infiltrate. The matrix metalloproteinases (MMPs) are a family of zinc- and calcium-dependent enzymes produced by inflammatory cells that are capable of degrading collagen, elastin, and proteoglycans. This study sought to test the hypothesis that MMPs are involved in the pathogenesis of NAS.

METHODS AND RESULTS

Aortic values were obtained from nine patients with NAS undergoing valve replacement and from four patients without NAS during autopsy. Microscopic analysis of NAS specimens revealed variable areas of calcium deposits, fibrosis, and an extensive cellular infiltrate consisting of macrophages, lymphocytes, and fibroblasts. Control aortic valves demonstrated normal architecture, a predominance of fibroblasts, occasional scattered macrophages, and no lymphocytes. Immunohistochemical staining with antibodies to MMP-1, -2, -3 and -9 revealed expression of each enzyme in macrophages, lymphocytes, and fibroblasts of all NAS patients. MMP-1, -2 and -3 were expressed by resident fibroblasts and macrophages in normal valves, but to a lesser degree. MMP-9 was not identified in normal valves.

CONCLUSIONS

The current study confirms an inflammatory infiltrate composed of macrophages and lymphocytes in NAS. Additionally, the increased expression of MMP-1, -2, and -3, along with the unique expression of MMP-9 in NAS valve leaflets was documented. These findings are consistent with the hypothesis that NAS is associated with chronic inflammation and that the increased expression of MMPs may contribute to the pathogenesis of this disease process.