OKT3 induction and steroid-free maintenance immunosuppression for treatment of high-risk heart transplant recipients

A group of high-risk heart transplant patients (n = 35) were treated from May 1987 through June 1990, with murine-derived monoclonal CD3 antibody (OKT3) induction therapy and steroid-free maintenance immunosuppression. This group was compared with a group of transplant patients (n = 47) who were not considered high risk and who were treated simultaneously with triple-drug immunosuppression (cyclosporine, azathioprine, and prednisone). The 1- and 3-year actuarial survival rates were similar: 97% and 91% for the OKT3 and 92% and 85% for the triple-drug immunosuppression groups, respectively. The overall incidence of rejection was equal for both groups (56%). No rejection occurred during the OKT3 course and rejection episodes occurred significantly later in patients treated with OKT3, with a mean first rejection episode of 111 +/- 104 days versus 27 +/- 21 days for the triple-drug immunosuppression group (p less than or equal to 0.05). Bacterial infections were seen more frequently (29% vs 6% of the patients treated) in the early period (less than 3 months) in the OKT3 group (p = 0.01) and were associated with the use of mechanical assistance in this group. The incidence of late infections or cytomegalovirus disease was similar for both groups. Patients treated with OKT3 and subsequent steroid-free maintenance immunosuppression had no significant posttransplantation increases of serum cholesterol levels, and hypertension was less common. Initial hospitalization was longer (p less than or equal to 0.05) in the OKT3 group (23 +/- 19 vs 13 +/- 5 days) but after the initial discharge the number of hospital days for the first year was similar for both groups (8 +/- 14 vs 9 +/- 13 days). Ventricular function at 1 year after transplantation was similar for both groups with average ejection fraction of 57% and 59% for the OKT3 and triple-drug immunosuppression groups, respectively. In conclusion, high-risk patients treated with OKT3 and steroid-free maintenance immunosuppression were managed on smaller doses of immunosuppressive drugs in the early postoperative period, and had excellent long-term survival rates. In this group of patients, rejection was delayed and the incidence of hypercholesterolemia, hypertension, and steroid-induced complications was decreased. Such a regimen offers a relatively drug-free period in the early posttransplant stages and freedom from the long-term complications of steroids.

Disseminated Scedosporium inflatum infection in a patient with acute myeloblastic leukemia

A case of disseminated Scedosporium inflatum infection occurring in a neutropenic patient with acute myeloblastic leukemia is reported. Scedosporium inflatum was isolated from skin lesions, blood, urine and vitreous cultures. Amphotericin B treatment was ineffective in avoiding hematogenous spread. At autopsy, hyphae and ovoid conidia with truncate bases consistent with the morphology of Scedosporium inflatum were found in the lungs, kidneys, myocardium, liver, thyroid, spleen, lymph nodes, brain and the left eye. This is the first report of disseminated Scedosporium inflatum infection and the first time this organism has been isolated from a patient in Europe.

Acquired von Willebrand disease in multiple myeloma secondary to absorption of von Willebrand factor by plasma cells

A case of acquired von Willebrand disease (AvWD) associated with an IgA lambda multiple myeloma is reported. No form of inhibitor could be detected. SDS-agarose gel electrophoresis patterns of von Willebrand factor (vWF) both in plasma and platelet lysates were normal but a decrease in all-sized multimers with a type IA pattern was seen. After 1-deamino-8-D arginine vasopressin (DDAVP) infusion, vWF multimers larger than those seen in the resting state appeared in patient plasma, which were progressively cleared. Indirect immunofluorescence studies with a monoclonal antibody to vWF showed that vWF was selectively absorbed into myelomatous cells. This is the first case of AvWD associated with multiple myeloma resulting from the selective absorption of vWF into abnormal plasma cells. This feature established a new pathophysiological mechanism of AvWD in multiple myeloma and probably in other lymphoproliferative diseases.

Purification and characterization of a calicivirus as the causative agent of a lethal hemorrhagic disease in rabbits

The causative viral agent of a lethal rabbit hemorrhagic disease has been purified and characterized. In negative-stained preparations, the virions were icosahedral, measured 27 to 35 nm in diameter, were without an envelope, and showed 10 peripheral cup-shaped depressions. The major structural protein was 60 kilodaltons, which constitutes a unique characteristic of the Caliciviridae.

Biovars of coagulase-positive staphylococci isolated from bovine mastitic milk

Fifty strains of coagulase-positive staphylococci associated with bovine mastitis were biotyped. Of them, 20 were identified as biovar C (cattle & sheep), 17 as biovar B (poultry & swine), 2 as biovar D (hares) and 1 as biovar F (pigeon & fox). Of the remaining strains, 2 were closely related to human biovar A, 2 failed one property to be classified as biovar B, 3 shared properties of biovars B and D and 3 could not be identified. Bovine strains belonging to biovar C formed an heterogeneous group showing differences in crystal violet growth type and production of alpha haemolysin. Only strains associated with biovar A were Tween 80 positive. The highest incidence of lytic reactions amongst all biovars was with phages 42 E (III) and 102 (IV). Antibiotic resistance was most frequently found in biovar C (65%). The 2 strains in biovar D, one classed as biovar C and one as intermediate, were enterotoxigenic (C or D toxins).

Effect of ivermectin treatment on anti-hypodermin C titers of Asturiana cattle naturally infected with Hypoderma lineatum

The collagenase (hypodermin C) from soluble crude extracts of Hypoderma lineatum 1st-instar larvae was purified by reverse-phase HPLC and used in a new indirect ELISA test. This pure protein had several advantages over the use of crude larval extracts allowing a much better discrimination between infested and non-infested cattle. The anti-hypodermin C titers of 19 Asturiana cattle were estimated over the course of a natural H. lineatum infestation cycle, in which the effect of ivermectin treatment was also investigated. The results showed differences in the onset and ending of the infestation with respect to those described for other European countries. The ivermectin treatment proved to be very effective and treated animals had relatively low anticollagenase titers.

Characteristics and regulation of a high conductance anion channel in GBK kidney epithelial cells

Single anion selective channels have been studied in membrane patches of GBK cultured epithelial cells from bovine kidney. High conductance anion channels are exclusively observed in excised patches after holding them at membrane potentials larger than +/- 30 mV for seconds or minutes. Once activated, the channels show a steep voltage dependence, complex gating properties and multiple conductance levels. The major unit conductance is 300 pS (+/- 28; n = 12) in symmetrical chloride. The discrimination among different anions and between anions and cations is poor. The activity of the channels remains unchanged after addition of 10 mM EGTA to the cytoplasmic face of the membrane, but it is irreversibly inhibited by application of 1 mM 4-acetamido-4'-isothiocyano-2,2'-disulphonic acid stilbene (SITS). Neither permeabilization of the cell membrane to Ca2+ using the Ca2+ ionophore A23187, treatments which increase the cyclic AMP content of the cells, nor hypoosmotic shocks, activate high conductance anion channels in cell-attached patches in which the activity of the channels is subsequently demonstrated upon patch excision. These results indicate that high conductance anion channels with the same characteristics as those reported in different cell types are present in GBK cells and suggest that the physiological role for these molecular entities may be different from those previously postulated.

[Intralobar pulmonary sequestration: diagnosis by intravenous digital subtraction angiography]

We present a boy five years old who after suffering recurrent pneumonia was transferred to own center for study. A diagnosis of Intralobar Pulmonary Sequestration was made, before surgery, by non invasive method, digital intravenous angiographic subtraction (DIVAS) and surgical management by anomalous arterial ligation and lobectomy was performed.

Prospective assessment of donor blood screening for antibody to hepatitis B core antigen as a means of preventing posttransfusion non-A, non-B, hepatitis

The relationship between donor status for antibody to hepatitis B core antigen and the occurrence of non-A, non-B posttransfusion hepatitis in the recipient was prospectively studied in 112 patients undergoing open-heart surgery who were followed for 6.5 months after surgery. Non-A, non-B posttransfusion hepatitis occurred in five (7.93%) of 63 patients who had received at least one anti-HBc-positive blood unit compared to seven (14.28%) of 49 patients who received anti-HBc-negative blood only. Statistical analysis revealed that the incidence of non-A, non-B posttransfusion hepatitis was independent of the use of blood positive for anti-HBc. Based upon these results and the high prevalence (17.3%) of anti-HBc among our blood donor population, the exclusion of anti-HBc-positive blood does not seem appropriate to achieve a reduction in the incidence of non-A, non-B posttransfusion hepatitis.

Method for home monitoring of urinary amylase after pancreas transplantation

Urinary amylase activity (UAA) is used for diagnosis of rejection in bladder-drained pancreas grafts. Unfortunately, most rejection episodes occur after the patient has been discharged. In those cases, an early diagnosis is often difficult, and a method for home UAA monitoring is needed. We have developed a method that can be used for this purpose. The method, based on Kodak dry-film technology, is shown to have good response to the wide range of UAA seen in these patients compared with responses to standard laboratory kinetic methods. The analysis (performed by the patient) involves 1) collecting urine for 24 h in a 4-L container, 2) diluting the urine with tap water to a total urine of 4 L, and 3) placing a drop of this dilution onto a slide. The slide is read by a handheld spectrophotometer that displays the UAA in secreted units per hour. The reliability of this system has been tested for wide changes of urine pH, volume of the drop applied to the slide, and tap water from different sources. Temperature coefficients have been determined to correct changes in ambient temperatures. The final handheld prototype is being developed based on these preliminary studies. This device could be of benefit for the early diagnosis of rejection episodes in recipients of bladder-drained pancreas grafts after hospital discharge.

Diagnosis of malignant ascites. Comparison of ascitic fibronectin, cholesterol, and serum-ascites albumin difference

The ascitic fluid concentrations of cholesterol and fibronectin and the serum-ascites albumin difference were compared with two conventional tests of ascitic fluid, total protein and LDH, in their diagnostic ability for detection of malignancy in ascitic samples from 69 patients with ascites: 54 with ascites due to liver disease and 15 whose ascites was caused by peritoneal metastases. Sixteen cirrhotic patients with superimposed hepatocellular carcinoma in whom ascites was of uncertain etiology were considered separately. The mean ascitic fluid total protein, LDH, cholesterol, and fibronectin values in the peritoneal metastases group were 3.70 +/- 1.20 g/dl, 247.26 +/- 148.14 units/liter, 109.06 +/- 29.85 mg/dl, and 91.57 +/- 41.52 micrograms/ml, respectively, and all were significantly higher than the corresponding values in the liver disease group (P less than 0.001), which were 1.37 +/- 0.59 g/dl, 75.40 +/- 110.70 units/liter, 23.75 +/- 11.22 mg/dl, and 31.86 +/- 10.51 micrograms/ml, respectively. Mean serum-ascites albumin difference in the peritoneal metastases group was 0.62 +/- 0.38 g/dl, which was significantly different from the corresponding value in the liver disease group (1.92 +/- 0.41 g/dl, P less than 0.001). Both ascitic cholesterol above 46 mg/dl and an ascitic fibronectin concentration greater than 50 micrograms/ml had high diagnostic accuracy (97%) for malignancy, being higher than that achieved using a serum-ascites albumin difference under 1.1 g/dl and an ascitic total protein above 2.5 g/dl, which had accuracies of 94% and 93%, respectively. Ascitic fluid LDH was the least reliable test. No differences in the ascitic fluid analysis were found between cirrhotic patients with and without hepatocellular carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple ex vivo organ preservation with warm whole blood

To determine the feasibility of en bloc removal of the heart, lungs, liver, kidneys, and pancreas for preservation with warm blood autoperfusion, organs from 34 dogs were preserved ex vivo for periods of between 3 and 22 hours. The lungs were ventilated with a Bird Mark 7 respirator, and the heart served as the pump to perfuse all organs of the multiple organ block. In the first group of 28 animals, surgical and pharmacologic techniques were developed to permit management of the ex vivo model. The last six experiments were conducted in a standardized fashion for a period of 6 hours and evaluated on the basis of hemodynamic, biochemical, and pathologic measurements. In this group the pH level remained stable and blood gas levels remained within normal limits for inspired oxygen of 0.2. Serum and urine electrolyte levels were easily maintained within normal limits. Serum enzyme values were elevated initially after operation, and this increase persisted throughout the preservation period in most animals. Continuing refinements in surgical technique, pharmacologic management, and chamber development resulted in a dramatic reduction of the edema and organ damage seen on pathologic studies of the initial experiments. The presence of focal lymphatic congestion, however, was noted even in the animals in group II and may have been related to ligation of major lymphatic channels or to endothelial loss. These changes could contribute to the development of the pathologic changes seen in irreversible shock. Preservation of the multiple organ block by warm autoperfusion is an important step in understanding the physiology of organ preservation and has potential for permitting prolonged organ preservation. Studies are continuing to further analyze this model and prolong the time of preservation. Final assessment of the model will be transplantation of the preserved organs and evaluation of function after implantation.

Behaviour of Staphylococcus aureus strains, producers of enterotoxins C1 or C2, during the manufacture and storage of Burgos cheese

Burgos cheese was manufactured from pasteurized ewes' milk inoculated with Staphylococcus aureus strains FRI 137 and FRI 361, at levels of ca 10(3) and 10(5) cfu/ml and stored at 4 degrees, 10 degrees and 15 degrees C and at room temperature (10 degrees-15 degrees C). Populations of Staph. aureus and mesophilic aerobes, pH, and production of thermonuclease and enterotoxins C1 and C2 were investigated. Aerobic counts increased during cheese-making and storage. With both test strains, important growth was observed only during the storage period, the larger levels corresponding to the higher temperatures. Although Staph. aureus strains attained populations of over 10(8) cfu/g, no enterotoxin was detected. Strain FRI 361 reached 10(7) cfu/g without production of a detectable amount of thermonuclease. With strain FRI 137, the minimal population associated with enzyme activity was influenced by the inoculum size. Staphylococcus aureus counts are better indicators of staphylococcal growth in Burgos cheese than the thermonuclease test.

Pancreas transplant results according to the technique of duct management: bladder versus enteric drainage

Between July 1978 and February 1987, 177 pancreas transplants were performed. The 1-year patient and graft survival rates for the first 100 transplants up to October 1984 were 88% and 27%, respectively. Since November 1984, duct drainage has been used for 74 of 77 transplants, bladder (BD) in 36 and enteric (ED) in 38, with 1-year patient survival rates of 89% and 92%, respectively, and graft survival rates of 58% and 42%. The technical failure rate was similar in both groups (31%). Immunosuppression was with antilymphocyte globulin, cyclosporine, azathioprine, and prednisone. Most recipients were nonuremic, without kidney transplants, and 1-year graft survival rates were 69% for BD (n = 21) and 42% for ED (n = 29). The diagnosis of rejection was based on a decline in urine amylase activity in the BD and on an increase in plasma glucose alone in the ED group. For technically successful (TS) grafts, the number of rejection episodes reversed per number diagnosed was 23 of 26 (18 patients) in BD (88%) and six of 15 (14 patients) (40%) in ED (p less than 0.05). The advantage of BD with monitoring of urine amylase activity is seen in TS cases; 1-year cadaveric graft survival rates were 90% for BD (n = 23) versus 47% for ED (n = 15) (p = 0.05). In recipients of segmental transplants with ED from living-related donors, 1-year graft survival rates were 57% overall (n = 18) and 88% for TS cases (n = 12), which is identical to cadaveric BD cases. A disadvantage of BD was metabolic acidosis induced by chronic bicarbonate loss in the urine from the pancreas graft. Nevertheless, we conclude that BD is the preferred technique for pancreas transplants from cadaver donors because of the ability to monitor exocrine and endocrine function continuously, thus leading to early diagnosis and treatment of rejection episodes.