Early infections in adult patients undergoing unrelated donor cord blood transplantation

Early transplant-related mortality after cord blood transplantation from unrelated donors (UD-CBT) is close to 50%, mainly due to infectious complications. We have studied the incidence and characteristics of early infections (before day 100) in a series of 27 adult patients (median age 30 years, range 16-46) undergoing UD-CBT at a single institution. All 27 patients experienced at least one infectious episode and 18 (66%) suffered a severe infection. Bacteremia occurred in 55% of patients (13 with Gram-positive and 11 with Gram-negative microorganisms). Eleven of 19 CMV-seropositive patients (58%) developed CMV antigenemia and one patient had CMV disease. Fungal infections were documented in three patients (11%), comprising invasive fungal infections in two cases and a localized esophagitis in one. Ten patients (37%) died before day 100 after transplantation. Infection was considered the primary cause of death in four patients (sepsis by Acinetobacter spp. bacteremia in three cases) and contributed to death in another four. The most striking findings in this series were the high incidence of, and mortality due to multiresistant Acinetobacter spp. and the low incidence of and lack of mortality due to CMV disease. This report confirms that infection is a major complication in adults undergoing UD-CBT.

Effects of antihypertensive therapy on progression of diabetic nephropathy

There is a clear relationship between hypertension and the microvascular complications of diabetes. Genetic predisposition to hypertension has been correlated to the risk of diabetic nephropathy in type I diabetes, and hypertension is a well known risk factor for developing nephropathy in patients with type II diabetes. Multiple studies have emphasized the importance of hypertension on renal disease progression, and blood pressure control with conventional antihypertensive drugs slows the rate of renal function loss in diabetic nephropathy. Furthermore, evidence of the role of renin-angiotensin system (RAS) on progression of renal damage has focused much interest on the therapeutic action of the RAS blockade. In patients with type I diabetes, blocking the RAS with angiotensin converting enzyme (ACE) inhibitors prevents progression from microalbuminuria to overt nephropathy, and in overt nephropathy decreases the gradual loss of renal function beyond its blood pressure lowering effect. Less clinical information is available in type II diabetic nephropathy, but our experience and some recent studies suggest that ACE inhibitors also have a renoprotective action in type II diabetes. The role of calcium channel blockers in diabetic nephropathy is not clear. Several short-term studies with the first generation dihydropyridine calcium antagonists showed a lower effect on urinary albumin excretion and a more rapid progression to renal failure than with ACE inhibitors. However, other calcium channel blockers, particularly of the non-dihydropyridine type, have been shown to have a beneficial effect on diabetic nephropathy, decreasing proteinuria and slowing progression.

Spontaneous skin ulceration and defective T cell function in CD18 null mice

A null mutation was prepared in the mouse for CD18, the beta2 subunit of leukocyte integrins. Homozygous CD18 null mice develop chronic dermatitis with extensive facial and submandibular erosions. The phenotype includes elevated neutrophil counts, increased immunoglobulin levels, lymphadenopathy, splenomegaly, and abundant plasma cells in skin, lymph nodes, gut, and kidney. Very few neutrophils were found in spontaneously occurring skin lesions or with an induced toxic dermatitis. Intravital microscopy in CD18 null mice revealed a lack of firm neutrophil attachment to venules in the cremaster muscle in response to N-formyl- methionyl-leucyl-phenylalanine. A severe defect in T cell proliferation was found in the CD18 null mice when T cell receptors were stimulated either by staphylococcal enterotoxin A or by major histocompatibility complex alloantigens demonstrating a greater role of CD11/CD18 integrins in T cell responses than previously documented. The null mice are useful for delineating the functions of CD18 in vivo.

Mice deficient in the alpha7 neuronal nicotinic acetylcholine receptor lack alpha-bungarotoxin binding sites and hippocampal fast nicotinic currents

The alpha7 subunit of the neuronal nicotinic acetylcholine receptor (nAChR) is abundantly expressed in hippocampus and is implicated in modulating neurotransmitter release and in binding alpha-bungarotoxin (alpha-BGT). A null mutation for the alpha7 subunit was prepared by deleting the last three exons of the gene. Mice homozygous for the null mutation lack detectable mRNA, but the mice are viable and anatomically normal. Neuropathological examination of the brain revealed normal structure and cell layering, including normal cortical barrel fields; histochemical assessment of the hippocampus was also normal. Autoradiography with [3H]nicotine revealed no detectable abnormalities of high-affinity nicotine binding sites, but there was an absence of high-affinity [125I]alpha-BGT sites. Null mice also lack rapidly desensitizing, methyllycaconitine-sensitive, nicotinic currents that are present in hippocampal neurons. The results of this study indicate that the alpha-BGT binding sites are equivalent to the alpha7-containing nAChRs that mediate fast, desensitizing nicotinic currents in the hippocampus. These mice demonstrate that the alpha7 subunit is not essential for normal development or for apparently normal neurological function, but the mice may prove to have subtle phenotypic abnormalities and will be valuable in defining the functional role of this gene product in vivo.

Reduced susceptibility to collagen-induced arthritis in mice deficient in intercellular adhesion molecule-1

Intercellular adhesion molecule-1 (ICAM-1) plays an important role in the firm adhesion of leukocytes to venular endothelium and facilitates leukocyte extravasation from the vasculature into inflamed tissue. In addition, ICAM-1 is an important costimulatory molecule during Ag presentation to lymphocytes. Using mice deficient in ICAM-1, we have investigated the role of this molecule in the development of collagen-induced arthritis. After immunization with type II collagen, 71% of wild-type mice developed arthritis compared with 50% of ICAM-1 heterozygote mutants and 18% of ICAM-1 homozygous mutants. In those ICAM-1 mutants that developed arthritis, the mean day of onset, the mean number of involved paws, and the severity of paw inflammation were not significantly different from those in wild-type mice. The reduced incidence of arthritis in the ICAM-1 homozygous mutant mice was not due to lack of immunity to type II collagen, since these mice developed similar levels of anti-type II collagen IgG compared with wild-type mice and had a positive delayed-type hypersensitivity reaction to type II collagen. The reduction of arthritis in heterozygous as well as homozygous deficient mice indicates that expression of ICAM-1 can be a pivotal variable in the pathogenesis of collagen-induced arthritis in mice. The results suggest that naturally occurring genetic variation in the expression of ICAM-1 or related inflammatory cell adhesion molecules might influence susceptibility to the complex disease of rheumatoid arthritis in humans and support the concept that pharmacologic approaches to chronic reduction in the expression or the function of ICAM-1 may be of therapeutic value.

Reduced susceptibility to collagen-induced arthritis in mice deficient in intercellular adhesion molecule-1

Intercellular adhesion molecule-1 (ICAM-1) plays an important role in the firm adhesion of leukocytes to venular endothelium and facilitates leukocyte extravasation from the vasculature into inflamed tissue. In addition, ICAM-1 is an important costimulatory molecule during Ag presentation to lymphocytes. Using mice deficient in ICAM-1, we have investigated the role of this molecule in the development of collagen-induced arthritis. After immunization with type II collagen, 71% of wild-type mice developed arthritis compared with 50% of ICAM-1 heterozygote mutants and 18% of ICAM-1 homozygous mutants. In those ICAM-1 mutants that developed arthritis, the mean day of onset, the mean number of involved paws, and the severity of paw inflammation were not significantly different from those in wild-type mice. The reduced incidence of arthritis in the ICAM-1 homozygous mutant mice was not due to lack of immunity to type II collagen, since these mice developed similar levels of anti-type II collagen IgG compared with wild-type mice and had a positive delayed-type hypersensitivity reaction to type II collagen. The reduction of arthritis in heterozygous as well as homozygous deficient mice indicates that expression of ICAM-1 can be a pivotal variable in the pathogenesis of collagen-induced arthritis in mice. The results suggest that naturally occurring genetic variation in the expression of ICAM-1 or related inflammatory cell adhesion molecules might influence susceptibility to the complex disease of rheumatoid arthritis in humans and support the concept that pharmacologic approaches to chronic reduction in the expression or the function of ICAM-1 may be of therapeutic value.

Fatty acid composition of lipoprotein lipids in hepatobiliary diseases

Liver damage and alterations in the exocrine function of the gland lead to a profound alteration of the plasma lipoprotein profile. To determine whether hepatic disease results in changes in the lipoprotein fatty acid composition, i.e. to determine whether liver function influences the homeostasis of complex lipids in plasma, we studied the fatty acid profile of lipids from VLDL, LDL and HDL, as well as from total plasma, in thirty-one patients of both sexes with hepatobiliary pathology (compensated liver cirrhosis, uncompensated liver cirrhosis, primary biliary cirrhosis, other intrahepatic cholestasis, and acute viral hepatitis). We also studied a group of healthy adults as controls. We present the lipoprotein profile and the fatty acid composition (myristic C14, palmitic C16, palmitoleic C16: 1, stearic C18, oleic C18: 1, linoleic C18: 2, eicosatrienoic C20: 3 omega 6 and arachidonic C20: 4) of lipoprotein and total plasma triacylglycerols, cholesteryl esters and phospholipids. The main observation of this study is that, despite the profound changes in the lipoprotein profile and the lower abundance of polyunsaturated fatty acids in complex lipids, the composition of all triacylglycerols, cholesteryl esters and phospholipids is very similar for the corresponding lipoproteins of patients with hepatobiliary disease and of control subjects. This indicates that in the controls as in the studied patients, the exchange of lipids between plasmatic lipoproteins is very rapid and demonstrates the possible importance of the extrahepatic synthesis of cholesteryl ester transfer protein.

Time course of reaction time and EEG while performing a vigilance task during total sleep deprivation

Nine young adult male (23-30 years old) paid volunteers were subjected to total sleep deprivation (TSD), after two consecutive nights in the laboratory, for 40 hours (from 0800 hours on the first day to 2400 hours on the following day). Oral temperature (OT), reaction time (RT) in a visual vigilance task, and electroencephalogram (EEG; C3, C4, T3, and T4) while performing the task were recorded every 2 hours during TSD and after recovery sleep. One second of EEG, before target and non-target stimuli for every subject and condition was visually inspected, and artifact-free epochs were Fourier transformed. Absolute power (AP) was calculated for 4-20 Hz (full band) and for theta, alpha 1, alpha 2, and beta 1. Analyses of variance (ANOVAs), with TSD and time-of-day as factors, showed the following significant results. TSD induced an increase in RT and AP of the full band at C3 and C4, of all bands at C3, of theta at T3, and of beta 1 at T4 (p < 0.009 for all comparisons). No time-of-day effects nor interactions were found. OT was not affected by TSD. All variables returned to baseline values after recovery sleep. RT and EEG power showed a linear increase with accumulating hours of wakefulness. The increment in RT also correlated with the increase in EEG power. The results demonstrate that the increment in RT is associated with the increase in AP, particularly in the left central cortex; that the EEG may be used to identify sleepiness; and that EEG during task performance is more sensitive to TSD than during relaxed wakefulness.

Infectious susceptibility and severe deficiency of leukocyte rolling and recruitment in E-selectin and P-selectin double mutant mice

During the initial phase of the inflammatory response, leukocytes marginate and roll along the endothelial surface, a process mediated largely by the selectins and their ligands. Mice with mutations in individual selectins show no spontaneous disease and have mild or negligible deficiencies of inflammatory responses. In contrast, we find that mice with null mutations in both endothelial selectins (P and E) develop a phenotype of leukocyte adhesion deficiency characterized by mucocutaneous infections, plasma cell proliferation, hypergammaglobulinemia, severe deficiencies of leukocyte rolling in cremaster venules with or without addition of TNF-alpha, and an absence of neutrophil emigration at 4 h in response to intraperitoneal Streptococcus pneumoniae peritonitis. These mice provide strong evidence for the functional importance of selectins in vivo.

Use of erythropoietin in emergencies: massive intoxication by chloramines

Recombinant human Erythropoietin (rHuEPO) is normally used to correct anaemia in patients with End Stage Renal Disease (ESRD), that are in Regular Dialysis Treatment (RDT). This anaemia is usually due to the existence of two factors: A decrease in the erythropoiesis of the bone marrow and an increase in peripheral haemolysis and, consequently, a decrease in the life span of the red cells.

Effects of current and former pacifier use on the dentition of 24- to 59-month-old children

Two hundred eighteen children ages 24-59 months participated in a study to examine the effect of pacifier use on the occlusion of the primary dentition. A questionnaire was used to gain information on habit history. Eighty-two children were current or former users of functional exercisers, 38 had a history of conventional pacifier use, and 98 had no history of oral habits. Compared to children with no habit, those with a history of pacifier use had a significantly larger mean overjet (P < 0.001), as well as significantly higher occurrences of Class II primary canines (P = 0.015), distal step molars (P = 0.014), openbite (P = 0.001), and posterior crossbite (P = 0.025). Compared to users of conventional pacifiers, users of functional exercisers had a significantly higher occurrence of Class II primary canines (P = 0.013) and distal step molars (P = 0.037). Pacifier use time in months was significantly higher for children with openbite (P = 0.02) and posterior crossbite (P = 0.019). Compared to former pacifier users, those with current habits had a significantly higher prevalence of openbite (P = 0.002) and posterior crossbite (P = 0.001), and a greater mean openbite (P = 0.19). The reported number of hours use per day was not related to any aspect of the occlusion of pacifier users. African-American and European-American children began their habits at about the same age and used their pacifiers for an equivalent number of hours per day. Among those who had discontinued their habits, African-American children had maintained theirs for a significantly shorter period (P < 0.001), leading to a longer elapsed time between habit discontinuation and the examination.

Effect of total sleep deprivation on reaction time and waking EEG activity in man

Nine paid volunteers were sleep deprived over a period of 40 hours. Every 2 hours during total sleep deprivation (TSD) and after recovery sleep, oral temperature (OT), reaction time (RT) in a vigilance task and electroencephalogram (EEG) with eyes open and closed (C3, C4, T3 and T4) were recorded. Ten artifact-free samples from each condition were Fourier transformed. Absolute power was calculated for six bands. Analyses of variance with deprivation and time of day as factors showed the following significant results: 1) TSD induced an increase in RT, of theta power in all derivations, of beta power in both centrals and a decrease of alpha power with eyes closed; OT was not affected. 2) All bands showed a peak of power at 1800 hours, 2 hours in advance of the OT acrophase at 2000 hours. All variables recovered baseline values after 1 night of sleep. Significant linear correlations of hours of wakefulness with EEG and RT, and of EEG power with OT and RT, were observed. The present findings show a linear increase in EEG power and RT with TSD, and a diurnal oscillation of EEG power, which is independent of TSD.

Inter- and intrahemispheric EEG correlation during sleep and wakefulness

Inter- (INTERr) and intrahemispheric (INTRAr) electroencephalographic (EEG) correlations were assessed in eight young male adults during wakefulness with eyes closed before going to sleep, and during stage 2, stage 4 and paradoxical sleep (PS) on the second night spent at the laboratory. Pearson product-moment correlations were calculated between EEG signals of every pair of electrodes (C3, C4, F3, F4, T3, T4) for six bands and for every 0.5 Hz from 1.5 to 15 Hz. Previous results of higher INTERr during sleep compared to during wakefulness were confirmed for the delta and theta bands during stage 2 sleep and PS and for sleep spindles during stage 2 sleep. The present results extend these findings to INTERr between F3 and F4 and during stage 4 sleep. INTRAr of 1.5-6.5 and 11-15 Hz was significantly higher during stages 2 and 4, whereas during PS INTRAr did not change. These data show that cortical changes during sleep are also observed in functional differentiation between cortical sites. Inter- and intrahemispheric differentiation is attenuated during stage 2 and 4 sleep, whereas during PS only inter-hemispheric differentiation is attenuated but intrahemispheric differentiation maintains similar levels of wakefulness. The attenuation of cortical differentiation may be of relevance for the understanding of mental activity changes during sleep.

P-selectin/ICAM-1 double mutant mice: acute emigration of neutrophils into the peritoneum is completely absent but is normal into pulmonary alveoli

Neutrophil emigration during an inflammatory response is mediated through interactions between adhesion molecules on endothelial cells and neutrophils. P-Selectin mediates rolling or slowing of neutrophils, while intercellular adhesion molecule-1 (ICAM-1) contributes to the firm adhesion and emigration of neutrophils. Removing the function of either molecule partially prevents neutrophil emigration. To analyze further the role of P-selectin and ICAM-1, we have generated a line of mice with mutations in both of these molecules. While mice with either mutation alone show a 60-70% reduction in acute neutrophil emigration into the peritoneum during Streptococcus pneumoniae-induced peritonitis, double mutant mice show a complete loss of neutrophil emigration. In contrast, neutrophil emigration into the alveolar spaces during acute S. pneumoniae-induced pneumonia is normal in double mutant mice. These data demonstrate organ-specific differences, since emigration into the peritoneum requires both adhesion molecules while emigration into the lung requires neither. In the peritoneum, P-selectin-independent and ICAM-1-independent adhesive mechanisms permit reduced emigration when one of these molecules is deficient, but P-selectin-independent mechanisms cannot lead to ICAM-1-independent firm adhesion and emigration.

[Familial hyperphosphatasemia of intestinal origin]

To clarify the diagnostic laboratory procedures before a case of unknown origin hyperphosphatasemia, we have studied the electrophoretic separation of serum alkaline phosphatase activity on agarose gel with and without neuraminidase. Sera were collected from a family, four of whom showed hyperphosphatasemia. Alkaline phosphatase isoenzyme patterns on agarose gel electrophoresis demonstrated that two persons out of the six members tested had unusual isozymes, the hydrophilic and the hydrophobic intestinal isozyme representing more than 50% of total alkaline phosphatase. The advantages of this method are its simplicity and low cost. The early recognition of this benign abnormality should help to avoid unnecessary diagnostic tests (i.e. image or radioisotopic examination).

Expression of human CD18 in murine granulocytes and improved efficiency for infection of deficient human lymphoblasts

The CD18 gene encodes the beta 2-subunit of leukocyte integrins, and mutations in this gene cause extreme host susceptibility to bacterial and fungal infection. Because expression of CD18 is restricted to bone marrow-derived cells, this disorder is considered an excellent candidate for somatic gene therapy utilizing ex vivo infection of bone marrow stem cells. We have constructed a retroviral vector expressing CD18 with the Moloney murine leukemia virus (Mo-MLV) long terminal repeat (LTR) as the promoter, and high-titer ecotropic and amphotropic producer cell lines were isolated using the GP+E-86 and GP+envAM12 safe packaging cell lines. Infection of CD18-deficient lymphoblasts resulted both in expression of immunodetectable CD18 at 35-40% of normal levels on 55-60% of cells and in functional restoration of CD18-dependent aggregation. All of 16 mice transplanted with syngeneic bone marrow infected with the CD18 retrovirus expressed human CD18 on 17-36% of granulocytes at 2 weeks after transplantation, and expression was appropriately up-regulated in response to stimulation with zymosan-activated serum. This recombinant retrovirus should prove useful for further studies of somatic gene therapy for CD18 deficiency.

Changes in the waking EEG as a consequence of sleep and sleep deprivation

Electroencephalographic (EEG) activity was monopolarly recorded during resting wakefulness in 10 volunteers under the following conditions: at night before going to sleep, at night before total sleep deprivation, in the morning after waking, in the morning after sleep deprivation and at night after having slept during the day. Absolute and relative power and inter- and intrahemispheric correlation were established. After diurnal and nocturnal sleep as compared to sleep deprivation, we obtained the following significant results: interhemispheric correlations were higher; intrahemispheric correlations were lower; absolute power of alpha 2, beta 1 and beta 2 was lower; and relative power of alpha 2 and beta 2 was lower. EEG changes as a consequence of sleep or lack of sleep are dependent on prior sleep and/or wakefulness and not on circadian phase. EEG activity during wakefulness is a sensitive parameter and a useful tool to assess the consequences of sleep on brain functional organization.

Long-term expression of human argininosuccinate synthetase in mice following bone marrow transplantation with retrovirus-transduced hematopoietic stem cells

Amphotropic and ecotropic packaging cell lines were used to obtain high titers (greater than 10(6) colony forming units/ml) of retroviruses encoding human argininosuccinate synthetase, and these viruses were used to transduce murine bone marrow cells using cocultivation in vitro. The bone marrow cells were transplanted into lethally irradiated recipient mice, and argininosuccinate synthetase activity was measured in peripheral blood. Transduction with amphotropic retrovirus resulted in short-term expression for a period of 1-8 weeks, and no animals expressed the human gene after 25 weeks. Over 60% of the animals transplanted with cells transduced with ecotropic retrovirus expressed the human gene 44 weeks post-transplant, although the level of expression varied over a wide range. Analysis of the DNA from transplanted animals demonstrated the presence of the human sequence in expressing animals, and S1 nuclease analysis of RNA confirmed the presence of the human RNA transcripts. Analysis of granulocyte/macrophage (GM) colonies derived from the bone marrow of transplanted, expressing animals revealed a correlation between the level of expression of the transduced gene with the percentage of GM colonies carrying the human gene sequence. These data demonstrate the feasibility of obtaining long-term expression of genes introduced into bone marrow cells using retroviral vectors and the feasibility of obtaining expression of a gene not normally expressed in bone marrow.

Acute promyelocytic leukemia. Therapy results and prognostic factors

From December 1976 to July 1986, 34 patients with acute promyelocytic leukemia (APL) were treated with daunorubicin (DNR) alone and simultaneous supportive therapy with low-dose heparin, platelet transfusions, and fresh frozen plasma. Two consecutive maintenance therapy regimens were employed in patients who achieved complete remission (CR): (1) a classical maintenance with methotrexate and 6-mercaptopurine, with DNR plus methyl-GAG re-inductions; (2) from 1982 an intensive sequential combination therapy regimen was administered. CR was achieved in 23 patients (68%). Only one patient had leukemic resistance. Other failures were a consequence of post-chemotherapy complications. A multivariate logistic regression analysis has been performed to evaluate the prognostic importance on response to remission induction of 25 patient and disease characteristics at diagnosis. The significant variables in decreasing order of significance were: serum albumin level, fever at diagnosis, serum creatinine level, and age. The median duration of remission and survival by Kaplan-Meier analysis were projected to be 24 and 25 months, respectively. Relapses occurred in 11 of 23 CR patients. Nine patients remained in the first remission from 5+ to 37+ months. Short-term (CR) and long-term results (duration of remission and survival) in APL treated for induction with DNR alone were similar to those obtained in other subtypes of acute myeloblastic leukemia by intensive combination chemotherapy.