Splenectomy and antiviral treatment for thrombocytopenic patients with chronic hepatitis C virus infection

Thrombocytopenic patients with chronic hepatitis C virus (HCV) infection are poor candidates for antiviral treatment with interferon (IFN), but no standard treatment for thrombocytopenia has yet been established. We evaluated the safety of splenectomy and its efficacy for the initiation and continuation of antiviral therapy. From March 2003 to April 2006, 10 patients (mean age 62.5 years) with HCV-related cirrhosis, low platelet count (<==106 000/mm(3)) and splenomegaly (spleen size >==10 cm) underwent splenectomy. Platelet counts significantly increased at 4-8 weeks after splenectomy [pre: 64 200 +/- 6900/mm(3)vs post 209 000 +/- 40 600/mm(3) (P = 0.004)]. No severe operative complications were observed. All patients subsequently received antiviral therapy. Of the eight patients who were infected with HCV genotype 1 and had a high viral load (>==100 KIU/mL), four received combination therapy with pegylated IFNalpha-2b plus ribavirin, and the other four received standard IFNalpha-2b plus ribavirin. One patient infected with HCV genotype 2 and another with HCV genotype 1 and a low viral load (<100 KIU/mL) were treated with pegylated IFNalpha-2a. Six patients achieved sustained virologic response (SVR). Among four patients who failed to achieve SVR, one was given retreatment with pegylated IFN plus ribavirin, and the other three received low-dose long-term IFN therapy. Although this study was small, the treatment results were similar to those for patients without thrombocytopenia and suggested that splenectomy would not reduce the antiviral efficacy of IFNalpha-based treatment.

The intervals between miniature end-plate potentials in the frog are unlikely to be independently or exponentially distributed

1. It has been suggested that spontaneous quantal release of transmitter at the neuromuscular junction is a Poisson process. One logical argument against accepting the Poisson hypothesis is that so far relatively few intervals between miniature end-plate potentials (min.e.p.p.s) have been studied in any single experiment. Release is known to occur from many sites on the nerve terminal, so many intervals must be studied before drawing any conclusions about the timing of release from the individual sites. Moreover, the statistical methods that have been used are relatively insensitive to deviations from Poisson predictions.2. The Poisson hypothesis is evaluated with respect to three major criteria:(a) The fit to the exponential distribution is analysed by five goodness of fit tests which were applied to eleven sets of data, showing that it is unlikely that the data sets were generated by an exponential distribution.(b) The independence of intervals is assessed in two ways. First, the autocorrelogram of intervals is constructed. This shows an excess of significant positive correlations beyond the 5% limits of the Poisson expectation. Secondly, the unsmoothed power spectrum is calculated, and compared to the Poisson prediction by means of the modified mean test. Again, most sets deviate significantly from the Poisson expectation. It is unlikely that the intervals are independent.(c) The possibility of simultaneous occurrences is evaluated by construction of the amplitude histogram of min.e.p.p.s. In all sets the Poisson prediction for the frequency of multiples of the unit height was exceeded by the empirical data sets. The over-all conclusion is that the process which generates spontaneous releases is unlikely to be Poisson.

The stochastic properties of spontaneous quantal release of transmitter at the frog neuromuscular junction

1. Earlier results showed that it is unlikely that spontaneous quantal release of transmitter at the frog neuromuscular junction is produced by a Poisson process.2. Data sets were tested, by using the u statistic, to see whether if they are assumed to be generated by a Poisson process, the mean interval is changing monotonically with time. By this critieria, some of the data sets are stationary, others are not.3. A variety of mathematical transforms are employed on empirical data sets to characterize the properties of the spontaneous quantal release.(a) The intensity function, which calculates the frequency distribution of all possible combinations of intervals, shows an excess of short intervals, without any sign of periodicity.(b) The variance-time curve, which estimates the accumulated variance of the series as a function of time into the series, lies significantly above the Poisson prediction.(c) The power spectrum, whether calculated on the intervals or on the number of intervals in time bins, deviates significantly from the Poisson prediction at the low frequencies.(d) The ln-survivor curve has two phases: a concave section for the short intervals, and a roughly linear section for the intervals of greater length.These transforms indicate that the min.e.p.p.s are clustered.4. A series of models for spontaneous quantal release were considered.(a) A Poisson model. Rejected because of consistent failure to fit the data.(b) A periodic model. Rejected because the intervals should be ordered rather than clustered.(c) A time-dependent model, in which quantal release is governed by a Poisson process with a mean interval that is oscillating in time. This model will generate clustering; by the transforms the model can be shown to closely fit the data. However, an autocorrelation of min.e.p.p. amplitudes shows that there is a relationship between the amplitudes and their position in the series. This is not predicted by the time-dependent oscillating model.(d) A branching Poisson model, in which a primary release, generated by a Poisson process, is likely to be followed by one or more subsidiary releases from the same site. The parameters of the branching model can be determined from ln-survivor curves. Theoretical curves, created with these parameters, give power spectra, variance-time curves, and ln-survivor curves that strongly resemble those calculated from the data. The model also predicts a significant autocorrelation of amplitudes.5. Min.e.p.p.s recorded with an extracellular electrode also fit well to a branching Poisson model.6. The effects of raised [Ca(2+)](o) on the intervals between min.e.p.p.s were studied. In our experiments the change in extracellular solution did not produce any notable change in release statistics.7. The effects of elevated [K(+)](o) on the intervals between spontaneous releases were studied. Depolarization of the nerve terminal increases the frequency of primary releases and decreases the chance of having subsidiary releases.8. Possible physical mechanisms by which quantal release of transmitter from a nerve terminal would fit a branching Poisson model are described.

Stochastic properties of spontaneous transmitter release at the crayfish neuromuscular junction

1. Miniature excitatory junctional potentials (min.e.j.p.s) were recorded with an intracellular electrode from the adductor muscle of the dactyl of the first or second walking leg of the crayfish, Orconectes virilis.2. The intervals between the min.e.j.p.s were compared to the exponential prediction by five goodness of fit tests. The results indicate that the intervals are not exponentially distributed.3. The autocorrelogram of intervals shows that the intervals are unlikely to be independent.4. A stochastic analysis that includes the power spectrum of intervals, the variance-time curve, and the ln-survivor curve suggest that there is a clustering of min.e.j.p.s. The results are similar to those on the frog neuromuscular junction.5. An autocorrelogram of the min.e.j.p. amplitudes suggests that sizes are not independently distributed.6. These results, which are similar to those previously reported from the frog neuromuscular junction, support the use of the branching Poisson process as a theoretical model for the stochastic properties of spontaneous quantal release of transmitter.

Anti-interleukin-5 antibody treatment (mepolizumab) in active eosinophilic oesophagitis: a randomised, placebo-controlled, double-blind trial

OBJECTIVE

Eosinophilic oesophagitis (EoO) is a clinicopathological condition defined by proton pump inhibitor-refractory oesophageal symptoms combined with oesophageal eosinophilia. The pharmacodynamic effect of mepolizumab (a humanised anti-interleukin-5 monoclonal antibody) in EoO was evaluated.

METHODS

Eleven adults with active EoO (>20 peak eosinophil number/high power field (hpf) and dysphagia) were randomised to 750 mg of mepolizumab (n = 5) or placebo (n = 6) and received two intravenous infusions, 1 week apart. Those not in complete remission (<5 peak eosinophil number/hpf) after 8 weeks received two further doses 4 weeks apart, 1500 mg of mepolizumab or placebo. The effect of mepolizumab was assessed clinically, endoscopically, histologically, and via blood and tissue biomarkers.

RESULTS

As assessed by immunofluorescence, a marked reduction of mean oesophageal eosinophilia (p = 0.03) was seen in the mepolizumab group (-54%) compared with the placebo group (-5%) 4 weeks after initiation of treatment. No further reduction of eosinophil numbers was observed in response to the two additional infusions in either group. Mepolizumab reduced tenascin C (p = 0.033) and transforming growth factor beta1 (p = 0.05) expression in the oesophageal epithelial layer 13 weeks after initiation of treatment. Clinically, limited improvement of symptoms was seen, although a trend was seen between 4 and 13 weeks after initiation of mepolizumab treatment. Mepolizumab was well tolerated.

CONCLUSIONS

Mepolizumab significantly reduced eosinophil numbers in oesophageal tissues in adult patients with active EoO, and changes in the expression of molecules associated with oesophageal remodelling were reversed. Minimal clinical improvement was achieved in a subgroup of patients with EoO. Mepolizumab had an acceptable safety profile, even at the high 1500 mg dose level.

TRIAL REGISTRATION NUMBER

NCT00274703.

Allergic airway inflammation and susceptibility to pneumococcal pneumonia in a murine model with real-time in vivo evaluation

The relationship between allergic airway inflammation and pneumococcal pneumonia is not well understood. We assessed susceptibility to experimental pneumococcal pneumonia in mice with and without allergic airway inflammation. Susceptibility to pneumococcal pneumonia was evaluated by challenging mice with a bioluminescent Streptococcus pneumoniae strain after sensitization with ovalbumin (OVA), with subsequent monitoring of pneumococcal infection using real-time photonic imaging. Of 46 OVA-sensitized mice challenged with pneumococci, 13 (28%) developed imaging findings consistent with pneumococcal pneumonia. In comparison, 28 (57%) of 49 non-sensitized control mice developed pneumococcal pneumonia (P = 0.005). While none of the control group developed meningitis (0%, none of 28), two mice in the OVA-sensitized group developed meningitis (15.4%, two of 13) (P = 0.09). The mean bacterial count in the lung was significantly lower in the OVA-sensitized than the non-sensitized group (8.26 +/- 0.69 versus 9.21 +/- 0.67 log(10) colony-forming units (CFU)/g, P = 0.002). There was a trend towards the mean bacterial count in the spleen being higher in the OVA-sensitized versus the non-sensitized group (8.14 +/- 0.89 versus 7.45 +/- 1.07 log(10) CFU/g, P = 0.071). A high level of interleukin (IL)-4 in lung homogenates was associated with risk of pneumococcal infection independent of sensitization with OVA (odds ratio: 49.7, 95% confidence interval 2.92-846.5, per increment of 1.0 pg/ml). In the murine model studied, acute allergic airway inflammation reduced susceptibility to pneumococcal pneumonia. IL-4 may increase the risk of pneumococcal pneumonia independently of allergic airway inflammation.

[Locally advanced non-small cell lung cancer completely resected after induction therapy]

We analyzed 8 patients with unresectable locally advanced non-small cell lung cancer who responded to chemotherapy or chemoradiotherapy and underwent complete resection between June 2003 and June 2005. The patients were all male with a mean age of 61 years (range, 42 to 72 years). Histological subtypes included adenocarcinoma in 4 patients and squamous cell carcinoma in 4 patients. Clinical staging included T2N2M0 in 3 patients, T2N3M0 in 2 patients, and 1 patient each for T3N2M0, T4N2M0, and T4N3M0. Preoperative treatment included chemotherapy in 5 patients and chemoradiotherapy in 3 patients, all of whom had a partial response. Surgical procedures included lobectomy in 6 patients and pneumonectomy in 2 patients. In addition, all of the patients underwent mediastinal lymph node dissection (ND2a). Pathological effect included Ef. 0 in 1 patient, Ef. 1 in 2 patients, Ef. 2 in 2 patients, Ef. 3 in 3 patients. The median survival time from initial treatment (or surgery) was 16 (14) months in all cases, 22 (19) for ycN0, 12 (8) for ycN2, 31 (27) for Ef. 3, 13 (9) for Ef. 0-2, 27 (23) for pN0, 13 (9) for pN1-3, 31 (27) for chemoradiotherapy, 16 (13) for chemotherapy, 24 (21) for adenocarcinoma, and 15 (11) for squamous cell carcinoma. Multimodality treatment, including surgery, is beneficial for patients with unresectable locally advanced non-small cell lung cancer who respond to chemotherapy or chemoradiotherapy, especially those patients with ycN0 or pN0.

[Risk factors of recurrence in resected stage I non-small cell lung cancer]

We reviewed risk factors of recurrence in resected pathological stage I non-small cell lung cancer (I NSCLC). Objective is 229 complete resected I NSCLC in our department. Risk factors of recurrence were carcinoembryonic antigen (CEA), histology, differentiation, lymphatic invasion, blood vessel invasion, pleural invasion and tumor size. By univariate analysis, lymphatic invasion (p=0.009), blood vessel invasion (p=0.008), pleural invasion, p1 (p=0.013), p2 (p=0.001), and tumor size (value of cut off was 2 cm) were significant risk factors of recurrence. By multivariate analysis, blood vessel invasion (p=0.004), pleural invasion (p1 or p2) [p=0.001], were significantly risk factors of recurrence. It was suggested that I NSCLC presenting pathological blood vessel invasion and/or pleural invasion should be recognized as cases with a high risk of recurrence, and a strict follow-up and adjuvant therapy should be in consideration.

Esophageal candidiasis as a side effect of inhaled fluticasone propionate dry powder: recovery by switching over to hydrofluoroalkane-134a beclomethasone dipropionate (HFA-BDP)

BACKGROUND

Esophageal candidiasis is one of the local side effects of inhaled corticosteroid treatment, and it is difficult to prevent this condition. Our previous report indicated that the prevalence of esophageal candidiasis among patients treated with inhaled fluticasone propionate dry powder (FP-dp) reached up to 37% in Japanese patients. Although a reduction in the daily dose of inhaled FP-dp can eliminate this infection, it may lead to asthma not being well-controlled in these patients.

OBJECTIVE

The aim of this study was to estimate whether switching to an equal daily dose of inhaled hydrofluoroalkane-134a beclomethasone dipropionate (HFA-BDP), the oropharyngeal deposition of which is very low, can eliminate the infection without deterioration of asthma.

METHODS

A total of 10 stable asthmatic patients with esophageal candidiasis, induced by inhaled FP-dp treatment (400 or 800 microg/ day), were enrolled in this study. A second upper GI endoscopy was performed, more than 1 month but less than 3 months after switching to an equal dose of inhaled HFA-BDP with a tube spacer device, Duopacer. The patients' medications were not changed during the study.

RESULTS

Esophageal candidiasis was eliminated in 9 of the 10 patients. The degree of candidiasis reduced in another patient. The forced expiratory volume in 1 sec (FEV1.0) did not worsen during the study.

CONCLUSION

Switching from FP-dp to HFA-BDP with Duopacer is useful in preventing esophageal candidiasis.