The strength of donor-specific antibody is a more reliable predictor of antibody-mediated rejection than flow cytometry crossmatch analysis in desensitized kidney recipients

The aim of this study was to evaluate the utility of donor-specific antibodies (DSA) and flow cytometry crossmatch (FCCM) as tools for predicting antibody-mediated rejection (AMR) in desensitized kidney recipients. Sera from 44 patients with DSA at the time of transplant were reviewed. Strength of DSA was determined by single antigen Luminex bead assay and expressed as mean fluorescence intensity (MFI). T- and B-cell FCCM results were expressed as mean channel shift (MCS). AMR was diagnosed by C4d deposition on biopsy. Incidence of early AMR was 31%. Significant differences in the number of DSAs (p = 0.0002), cumulative median MFI in DSA class I (p = 0.0004), and total (class I + class II) DSA (p < 0.0001) were found in patients with and without AMR. No significant difference was seen in MCS of T and B FCCM (p = 0.095 and p = 0.307, respectively). The three-yr graft survival in desensitized patients with DSA having total MFI < 9500 was 100% compared to 76% with those having total MFI > 9500 (p = 0.022). Desensitized kidney transplant recipients having higher levels of class I and total DSA MFI are at high risk for AMR and poor graft survival. Recipient DSA MFI appears to be a more reliable predictor of AMR than MCS of FCCM.

High flow extra-cranial to intra-cranial bypass for complex internal carotid aneurysms

Cerebral revascularisation with extracranial - intracranial (EC-IC) bypass is generally indicated in patients with complex anterior circulation aneurysms who have failed parent artery occlusion. We report on the process and outcome of our early experience of performing high flow bypass in patients with complex anterior circulation aneurysms. We have reviewed patients who have undergone an EC-IC bypass for treatment of complex anterior circulation aneurysms, and report our outcome on graft patency, surgical complications, discharge destination, and obliteration rates. Nine patients that underwent 11 bypasses are described. Seven patients had a giant saccular aneurysm of the carotid, and these were all obliterated on post-operative imaging. Two patients presenting with an intracranial carotid dissection required trapping of the diseased segment following the bypass. The overall graft patency rate was 88%. One patient developed a post operative subdural collection (managed conservatively), and one patient required early graft revision. Discharge destination was home in 8/9 patients. There was no mortality. Although EC-IC bypass is a technically challenging procedure, it provides a valuable treatment option for patients with complex anterior circulation aneurysms. Good graft patency rates can be achieved with low surgical morbidity in patients with a disease process that otherwise attracts a highly unfavourable natural history.

Subtypes of immunoglobulin (Ig)-G antibodies against donor class II HLA and cross-match results in three kidney transplant candidates

Preexisting donor-specific antibodies (DSA) play a critical role in the success of solid-organ transplantation. Cross-match (CM) between donor lymphocytes and recipient serum is a pivotal methodology for detecting these antibodies. Luminex platform based solid-phase methodology for anti-human leukocyte antigen (HLA) antibody analysis has revolutionized the approach to antibody detection and HLA specificity identification. In this study, we have reported three cases of successful living donor kidney transplantations performed against strongly positive B lymphocyte flow cytometry (FC) CM owing to highly reactive DSA directed to HLA class II. IgG solid-phase subtype analysis showed that more than 50% of these antibodies were represented by non-complement binding IgG2/IgG4 subtypes. These findings account for antibody mediated rejection (AMR) free long-term post-transplant course in these patients despite, the high level of DSA. Thus, we conclude that routine application of single HLA-coated beads (SAB) IgG subtype assay may provide new insights regarding transplantation or desensitization of patients presenting with negative B-cell complement dependent cytotoxic (CDC) and positive FC CM.

Pandemic H1N1 influenza surveillance in Victoria, Australia, April - September, 2009

Victoria was the first Australian state to report widespread transmission of pandemic H1N1 2009 influenza. Notifiable laboratory-confirmed influenza and a general practitioner sentinel surveillance system measuring influenza-like illness (ILI), including laboratory confirmation of influenza as the cause of ILI, were used to assess the pandemic. The pandemic influenza A(H1N1)v virus quickly became the dominant circulating strain and notification rates were highest in children and young adults. Despite a high number of notified cases, comparison of ILI rates suggested the season peaked in late June, was similar in magnitude to 2003 and 2007 and less severe than 1997. The majority of clinical presentations were mild, but one quarter of hospitalised cases required admission to intensive care. Given the low proportion of imported cases in the Victorian pandemic, the rapid increase in cases with no travel history and the low median age of cases notified during the phases of intense surveillance, we suggest there may have been silent importations of pandemic virus into Victoria before the first case was recognised. The usefulness of a general practitioner sentinel surveillance system to provide a comparable assessment of influenza and ILI activity over time was clearly demonstrated, and the need for similar hospital and mortality surveillance systems for influenza in Victoria was highlighted.

Successful implementation of a national HLA-B*5701 genetic testing service in Canada

Abacavir is a nucleoside reverse transcriptase inhibitor (NRTI) that is used in combination antiretroviral therapy in HIV-infected patients. It is currently recommended as a preferred or an alternative NRTI in antiretroviral-naïve patients. The major toxicity of abacavir is a hypersensitivity reaction (HSR), which occurs in approximately 5% of treated patients. There is a strong association between the human leukocyte antigen (HLA)-B*5701 allele and abacavir HSR, which has allowed for rapid acceptance of genetic screening for HLA-B*5701 in clinical use. Canadian clinicians working in hospital centers with HLA typing capacity opted to launch a pilot project in 2006 to offer the screening test as standard of care to HIV-infected patients. Currently, more than 11,000 HLA-B*5701 tests have been performed, among which 6.3% are positive. Continued efforts have been made to ensure that testing is available to all HIV-infected patients to widen the patients' therapeutic options. HLA-B*5701 screening shows clinical use and preliminary data suggest cost-effectiveness.

Concordance therapy: an intervention to help older people take antidepressants

BACKGROUND

Older people often do not adhere fully to antidepressant medication. Compliance Therapy improves adherence with antipsychotic medication.

OBJECTIVE

To adapt Compliance Therapy for use in older depressed patients, to pilot this 'Concordance Therapy' for feasibility and acceptability and to gain preliminary indications of its efficacy.

METHODS

Randomised controlled trial (RCT).

SETTING

Psychiatric services for older people in North London and Essex.

PARTICIPANTS

A total of 19 older depressed patients.

INTERVENTION

10 patients received Concordance Therapy over 3-4 sessions.

CONTROL

9 patients received treatment as usual.

MAIN OUTCOME MEASURE

medication adherence at 1 month.

SECONDARY OUTCOME MEASURES

medication adherence at 3 months; depression severity, beliefs about medication, quality of life at 1 and 3 months; patient feedback about the therapy.

RESULTS

The therapy was acceptable to patients. INTERVENTION patients were more likely to take antidepressants, had a higher quality of life, had less depressive symptomatology and were less likely to be cases of depression at 1 month. Beliefs around antidepressants at 1 month were more positive in the intervention group but this was not the case for medication in general.

LIMITATIONS

As a pilot, patient numbers were small and the findings did not reach statistical significance. Three patients (1 intervention, 2 control) were in hospital and therefore offered medication at follow-up.

CONCLUSION

Concordance Therapy for older people prescribed antidepressants is acceptable and feasible and shows sufficient promise of efficacy to justify an adequately powered RCT.

Conventional digital subtraction x-ray angiography versus magnetic resonance angiography in the evaluation of carotid disease: patient satisfaction and preferences

AIM

To compare conventional digital subtraction x-ray angiography (DSA) and contrast-enhanced magnetic resonance angiography (MRA) of the carotid arteries in terms of patient satisfaction and preferences.

METHODS

One hundred and sixty-seven patients with symptomatic carotid artery disease, who underwent both DSA and MRA, were prospectively recruited in this study. Patients' perceptions of each method were assessed by the use of a questionnaire after each procedure. Main outcome measures were anxiety, pain, satisfaction rate and patient preferences.

RESULTS

DSA generated more anxiety and pain during the procedure, but the severity of these ill-effects was mild. Satisfaction rates for each method were similar. More patients were, however, willing to have a repeat MRA compared with DSA (67 versus 41%). The majority of patients (62%) preferred MRA over DSA (31%). The shorter MRA imaging time was found to be a significant factor in patients' acceptance of the technique. The main reasons cited by patients for their dislike of a particular procedure was noise and claustrophobia for MRA and invasiveness, pain and post-procedural bed rest for DSA.

CONCLUSIONS

MRA is the method that is preferred by the majority of patients, although the actual disutility of DSA may be small. Assuming equal diagnostic accuracy, our data supports replacement of DSA by MRA for routine carotid imaging.

Rupture of an internal carotid artery aneurysm in the petrous temporal bone

A case of otorrhagia following the rupture of an aneurysm of the intrapetrous portion of the internal carotid artery is presented. The aneurysm was successfully treated by balloon occlusion of the parent artery. The problems associated with diagnosis and clinical management of these lesions is discussed and possible solutions suggested.

Evaluation of mycology laboratory proficiency testing

Changes over the last decade in overt proficiency testing (OPT) regulations have been ostensibly directed at improving laboratory performance on patient samples. However, the overt (unblinded) format of the tests and regulatory penalties associated with incorrect values allow and encourage laboratorians to take extra precautions with OPT analytes. As a result OPT may measure optimal laboratory performance instead of the intended target of typical performance attained during routine patient testing. This study addresses this issue by evaluating medical mycology OPT and comparing its fungal specimen identification error rates to those obtained in a covert (blinded) proficiency testing (CPT) program. Identifications from 188 laboratories participating in the New York State mycology OPT from 1982 to 1994 were compared with the identifications of the same fungi recovered from patient specimens in 1989 and 1994 as part of the routine procedures of 88 of these laboratories. The consistency in the identification of OPT specimens was sufficient to make accurate predictions of OPT error rates. However, while the error rates in OPT and CPT were similar for Candida albicans, significantly higher error rates were found in CPT for Candida tropicalis, Candida glabrata, and other common pathogenic fungi. These differences may, in part, be due to OPT's use of ideal organism representatives cultured under optimum growth conditions. This difference, as well as the organism-dependent error rate differences, reflects the limitations of OPT as a means of assessing the quality of routine laboratory performance in medical mycology.

An aneurysm of the petrous internal carotid artery

Internal carotid artery aneurysms are a rare cause of pulsatile tinnitus and conductive hearing loss but should be borne in mind when there is a suspected diagnosis of glomus jugulare or high-riding jugular bulb. Most cases are congenital. We present a case of otorrhagia which was initially thought to be a glomus jugulare, the diagnosis of internal carotid artery aneurysm was made at angiography and treated by balloon embolization.

A controlled trial of twice daily triamcinolone oral inhaler in patients with mild-to-moderate asthma

BACKGROUND

National and international guidelines recommend inhaled anti-inflammatory medications for patients with all but the mildest forms of asthma. Patients may also be more compliant with twice daily dosing.

OBJECTIVE

To evaluate the efficacy and safety of triamcinolone acetonide (triamcinolone acetonide), 400 microg bid, in mild-to-moderate asthma patients.

METHODS

A multicenter, randomized, double-blind, placebo-controlled study with a 7- to 21-day baseline and 6-week treatment period. Adult mild-to-moderate asthma patients poorly controlled by beta2-agonists alone were randomized to receive placebo (48) or triamcinolone acetonide (53). Patients recorded daytime and nighttime asthma symptoms, albuterol use, and morning and evening peak expiratory flow (PEF) rates on diary cards. Clinic spirometry measures included FEV1, FEF25-75%, FVC, FEV1/FVC, and PEF.

RESULTS

Triamcinolone acetonide treatment resulted in improvement from baseline of 17% for FEV1 (P < .0001); 44% for albuterol use (P = .0009); 9% for FVC (P = .0185); 19% for PEF (P = .0011); 42% for FEF25-75% (P < .0001); 8% for FEV1/FVC (P = .0016); 36% for daytime, 39% for nighttime, and 38% for total asthma symptoms (P < or = .0001); and 12% for morning, and 10% for evening PEF (P < or = .001). These changes were highly significant when compared with placebo (P < or = .0185). Significant improvement for all variables was demonstrated within 1 to 2 weeks of active treatment, and maintained for most variables over the 6-week treatment phase. Both treatments were well tolerated. Respiratory adverse events occurred more frequently with placebo; pharyngitis was reported more frequently with triamcinolone acetonide.

CONCLUSIONS

Triamcinolone acetonide, administered twice daily, can effectively and safely treat patients with milder forms of asthma. In these patients, triamcinolone acetonide improves asthma symptoms and decreases the need for as-needed beta2-agonists.

Liquid nitrogen freezers: a potential source of microbial contamination of hematopoietic stem cell components

BACKGROUND

The recent report of hepatitis B transmission between hematopoietic progenitor and putative stem cell (HPC) components stored in liquid nitrogen led to the questioning of whether evidence existed for similar contamination by bacterial or fungal elements.

STUDY DESIGN AND METHODS

Microbial contamination rates were reviewed for 704 HPC components from 255 patients over an 18-month period. Five liquid nitrogen freezers were surveyed for microbial contamination. The literature was reviewed to ascertain the published experience of other laboratories with HPC component contamination first documented on thawing.

RESULTS

Seven (1.2%) of 583 thawed components were found to be contaminated with a variety of environmental or waterborne organisms, despite a meticulous protocol to prevent contamination during thawing. All of these components had been sterile on cryopreservation. Literature review revealed a similar incidence of post-thaw contamination from other centers. Microbial survey of liquid nitrogen freezers revealed low-level contamination in four of five. The organisms represented were similar to those cultured from thawed HPC components. One freezer was heavily contaminated by Aspergillus species.

CONCLUSION

Liquid nitrogen freezers are not sterile, and both the liquid and vapor phases are potential sources of microbial contamination of HPC components. While low-level contamination by environmental organisms may be common, the occurrence of heavy contamination by potential pathogens such as Aspergillus species suggests that monitoring of liquid nitrogen sterility may be indicated. Strategies to assess and prevent microbial transmission from liquid nitrogen to HPC components need further development.

Lineage commitment of HLA-DR/CD38-defined progenitor cell subpopulations in bone marrow and mobilized peripheral blood assessed by four-color immunofluorescence

We used four-color fluorescence analysis to compare lineage antigen expression in relationship to CD38 and HLA-DR on CD34+ progenitor cells in adult human bone marrow and mobilized peripheral blood. Each of four progenitor cell subpopulations defined by HLA-DR and CD38 intensity (CD38-/HLA-DR-, CD38-/HLA-DR+, CD38+/HLA-DR+, and CD38+/HLA-DR-) were present in both progenitor cell sources in similar ratios. The most prevalent subpopulation consisted of cells that expressed both CD38 and HLA-DR. Virtually all progenitor cells that lacked CD38 also lacked lineage antigens regardless of their HLA-DR expression. In contrast, the majority of the cells within both CD38+ progenitor cell subpopulations possessed either lineage antigens or the proliferation-associated antigen, CD71. Furthermore, CD71 was expressed on three times the number of CD38+/HLA-DR- cells when compared with the CD38-/HLA-DR- subpopulation. Within CD34+ progenitor cell subpopulations defined by the expression of CD38 and HLA-DR, the CD38+/HLA-DR- component appears to be the most mature, based on the expression of CD71 and various lineage-associated antigens, including representative markers characterizing early lymphoid, myeloid, and erythroid precursors. Thus, selection of the most immature CD34+ progenitor cells based solely on the lack of HLA-DR expression results in isolation of two distinct cell populations with markedly different maturation status and resultant growth characteristics.

Utilization of intravenous immunoglobulin to ameliorate alloantibodies in a highly sensitized patient with a cardiac assist device awaiting heart transplantation. Fluorescence-activated cell sorter analysis

Surgery surrounding the use of mechanical assistance in cardiac transplant candidates often leads to multiple blood/platelet transfusions and subsequent development of alloantibodies. This is a case report of a 50-year-old male patient who had received blood transfusions during coronary bypass grafting 9 years earlier. He presented in acute and chronic heart failure and, despite therapy, became moribund with multisystem organ failure. His ejection fraction was 10%. A Novacor ventricular assist device was implanted on May 19, 1995 (day 0). The patient received 44 U of blood and 20 U of platelets. Although his percent reactive antibodies (PRA) were negative before surgery by fluorescence-activated cell sorter analysis, the PRA 3 days after implantation of the ventricular assist device was 80%; it increased to 100% by day 7. In an attempt to decrease the PRA, intravenous immunoglobulin was given at 3-week intervals. The PRA became negative and the patient received a donor heart that was negative by fluorescence-activated cell sorter cross-match on day 64. On days 69-72, a dramatic increase in alloantibody activity was promptly reversed with additional intravenous immunoglobulin. Currently at posttransplant month 12, the patient shows no humoral, cellular, or vascular evidence of rejection.

Comparison of diaphragm strength between healthy adult elderly and young men

To test the hypothesis that aging is associated with a reduction in the diaphragm's force-generating capacity, we compared the maximum transdiaphragmatic pressure (Pdimax) obtained during voluntary maximal inspiratory efforts in nine young (19-28 yr) and ten elderly (65-75 yr) subjects. The relationship between Pdi and lung volume was compared in the two groups by having subjects make maximal inspiratory maneuvers at specified lung volumes (i.e., 20, 40, and 80% vital capacity). Subjects underwent symptom-limited exercise tests to characterize their aerobic capacities and evaluate the relationship between aerobic capacity and Pdimax. The average Pdimax of the elderly subjects (128 +/- 9 cm H2O) was significantly lower (p < 0.003) than the average Pdimax of the younger subjects (171 +/- 8 cm H2O). In the elderly, Pdi was lower across the range of lung volumes tested (p < 0.001), and Pdimax occurred at similar relative lung volumes (elderly, at 47% total lung capacity [TLC]; young, at 50% TLC) in both groups. The elderly subjects were quite fit based on their VO2max, and there was no significant relationship between Pdimax and VO2max. This study suggests that diaphragm strength is reduced in elderly individuals. This age-related decrease in diaphragm strength may predispose elderly patients to diaphragm fatigue in the presence of conditions that impair inspiratory muscle function or increase ventilatory load.

Expression of the beta-adrenergic receptor-adenylylcyclase system in basal and columnar airway epithelial cells

Catecholamines acting through the beta-adrenergic receptor (beta AR) coupled-adenylylcyclase system stimulate a variety of responses by airway epithelial cells which affect airway caliber and the response to inflammatory stimuli. Although the tracheobronchial epithelium (TBE) is composed of several phenotypically differentiated cell types, surprisingly little is known about the expression of the beta AR system by the major subpopulations of TBE cells (i.e., basal and columnar). We, therefore, examined the function of the beta AR system in columnar and basal cell-enriched populations of rabbit tracheocytes. Cells were collected from 35 rabbits in 17 separate experiments and separated into basal and columnar cell-enriched fractions by centrifugal elutriation. The columnar fraction demonstrated a significantly greater (P < 0.005) adenosine 3',5'-cyclic monophosphate (cAMP) response to isoproterenol (10(-9)-10(-5) M) than the basal cell-enriched fraction (i.e., 74.7 +/- 5.1 and 49.4 +/- 2.8 pmol/10(6) cells, in columnar and basal cell-enriched fractions, respectively, P < 0.0001) as well as a higher beta AR density (i.e., 8,678 +/- 840 and 4,754 +/- 406 beta AR sites/cell, respectively, P < 0.0001). However, when corrected for differences in cell size assessed from measurements of total cell protein, cAMP production per milligram protein and beta AR density per milligram protein were similar in the two cell fractions (P > 0.50 for both comparisons). beta AR subtype assessed by beta 1AR and beta 2AR subtype selective antagonists demonstrated that the beta 2AR subtype predominated (i.e., > 90%) in both cell populations (P > 0.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Medial temporal lobe structures in schizophrenia: relationship of size to duration of illness

Reductions in the size of medial temporal lobe structures in schizophrenia have been demonstrated using magnetic resonance imaging. It is not clear whether these neuropathological changes are present premorbidly or if they reflect an adult-onset progressive process. In this study, quantitative measures were made of the lateral ventricles, third ventricle, amygdala, hippocampus, and cerebral hemispheres from coronal MRI images on 33 patients with schizophrenia and 41 normal controls. Images were selected a priori from the region of the temporal lobe in which we had previously demonstrated reduced volume of temporal lobe gray matter in a separate sample of patients. Results showed a decrease in amygdala, hippocampal, and amygdala-hippocampal size bilaterally and an increase in third and lateral ventricular volume. Advancing age in normals was associated with a decrease in the size of medial temporal structures and an increase in lateral ventricular size. In schizophrenia, there was a correlation between age and lateral ventricle size, but duration of illness was not associated with reductions in medial temporal tissue or ventricular enlargement. These results are consistent with prior evidence from neuroimaging and postmortem studies of medial temporal pathology in schizophrenia and support hypotheses that neuropathological changes in schizophrenia are not progressive.

Responses of liver metastases to radiotherapy and razoxane

Twenty-five patients with liver metastases, chiefly due to colorectal cancer, were given a loading dose of razoxane for 3 days before 5 consecutive days of radiotherapy to the whole liver. Patients also took razoxane during the radiotherapy and then for one month afterwards. Liver tumour volume was measured on CT scans using the ELSCINT 3D soft tissue imaging programme just before and 4 weeks after the end of radiotherapy treatment. Twelve of the 25 patients had tumour volume reductions of more than 50%. The overall major response rate therefore is 12/25 (48%). In two of the major responders the liver metastases were due to recurrent stomach cancer. In addition to the 12 responders, four patients had a reduction of more than 20% but less than 50%, thus giving an overall response rate of 16/25 (64%). These results can form the basis of a formal, randomized, controlled clinical trial of radiotherapy alone (or any other treatment) compared with radiotherapy and razoxane in the difficult and life threatening condition presented by liver metastases.