Intra-abdominal pulmonary sequestration associated with congenital cystic adenomatoid malformation of the lung: just an unusual combination of rare pathologies?

A case of intra-abdominal pulmonary sequestration associated with histological features of congenital cystic adenomatoid malformation (CCAM) of the lung is reported. The lesion consisted of a Stocker type II CCAM in which numerous striated muscle cells were present. A review of the literature of this rare combination of congenital pulmonary anomalies is presented.

Treating skin tears in nursing home residents: a pilot study comparing four types of dressings

A pilot study was conducted to compare four types of dressings used to treat skin tears in nursing home residents. Wounds treated with a non-occlusive dressing healed more quickly than those dressed with occlusive dressings. The results suggest that ease of use and product wastage are important considerations when treating skin tears. The pilot study also highlights the need for further research into skin tear management and the need for ongoing education for nurses regarding skin integrity risk assessment and product information.

Reproducibility in retrospective grading of acute graft-versus-host disease after allogeneic marrow transplantation

We have undertaken a formal study to evaluate the reproducibility of retrospective assessments for grading the severity of acute GVHD. Using criteria previously established by the Seattle group, three reviewers independently assigned GVHD severity grades for a set of 100 marrow transplant patients. Significant differences were found in the distribution of GVHD grades assigned by one of the reviewers as compared to the other two reviewers. In only 40% of cases did all three reviewers assign the same GVHD grade, and in only 68-71% of cases did all three reviewers assign the same grade within 0-I vs II-IV or 0-II vs III-IV categories. Despite the high rate of disagreement between any two reviewers, at least two reviewers assigned the same overall GVHD grade in 93% of cases. These results suggest that current criteria for assessing the severity of GVHD by a single reviewer are not sufficiently reliable for rigorous clinical studies. As an alternative to the original criteria, we have developed and tested simplified criteria that summarize the clinical course of GVHD as reflected by the progression of disease and the amount of immunosuppressive treatment used to control the disease. Our results suggest that the revised criteria might yield more reproducible retrospective grading than the original criteria. Although the original criteria and the revised criteria might produce different results for individual patients, the overall distributions of grades with the two systems were similar. The proposed revised criteria could be implemented without disrupting the continuity and consistency with previous grading assigned by the original criteria.

Tacrolimus pharmacokinetics in BMT patients

The pharmacokinetics of tacrolimus following its administration as monotherapy or in combination with corticosteroids or methotrexate to 31 BMT patients are presented. All patients received i.v. tacrolimus initially and were subsequently switched to p.o. dosing. Patients received methotrexate by i.v. bolus on post-transplantation days 1, 3, 6 and 11. Patients were started on i.v. corticosteroids beginning on post-transplantation day 7. The noncompartmental pharmacokinetics of tacrolimus based on whole blood concentrations were determined following the i.v. and p.o. doses and were not different at steady-state compared to a single dose. The mean terminal elimination half-life of tacrolimus was 18.2 h following i.v. administration; the total body clearance was 71 ml/h/kg, the volume of distribution was 1.67 1/kg. Co-administration of methylprednisolone or methotrexate did not significantly alter tacrolimus pharmacokinetics. The p.o. bioavailability was 31-49%. Trough blood concentrations (Cmin) at 0 h (pre-dose) and 12 h (post-dose) correlated well to AUC(0-12)indicating that, as in solid organ transplantation, Cmin was a good index of drug exposure. Correlation at 0 h (r = 0.92) and at 12 h (r = 0.93) indicate that either time point can be used for therapeutic drug monitoring in patient management.

Spontaneous resolution of p58/EB6 antigen restricted NK-type lymphoproliferative disease of granular lymphocytes: role of Epstein Barr virus infection

We describe a patient with a CD3- lymphoproliferative disease of granular lymphocytes (LDGL) characterized by proliferation of CD3-CD16+ GL, restricted to the expression of p58/EB6 antigen and lacking the p58/GL183 antigen. Using PCR analysis we demonstrated the presence of EBV DNA in the peripheral blood mononuclear cells and purified CD16+ GL from the patient; a monoclonal episomic configuration of the virus could not be demonstrated with Southern blot analysis. The presence of EBV DNA was also detected by PCR in the serum; this finding was associated with a serological pattern consistent with a previous, already seroconverted, EBV infection. During a 4-year follow-up the lymphocytosis spontaneously disappeared; interestingly, in terms of the p58 antigen expression, we provided evidence of the reconstitution of a normal pattern of circulating NK subsets (i.e. p58/EB6+ p58/GL183-, p58/EB6+ p58/GL183+, p58/EB6- p58/GL183-, p58/EB6-p58/GL183+). At the time of resolution of lymphocytosis, EBV-PCR analysis still demonstrated the persistence of EBV DNA in peripheral blood mononuclear cells, but not in the patient's serum. By indicating that inciting agents (in this case EBV) are involved in inducing the GL proliferation, our data contribute insights into the pathogenetic mechanisms accounting for in vivo GL accumulation in LDGL. It appears that a second, still unknown, event is required to determine the neoplastic transformation.

Cyclosporine or cyclosporine plus methylprednisolone for prophylaxis of graft-versus-host disease: a prospective, randomized trial

Patients with a lymphohematopoietic malignancy considered to be at high risk for posttransplant relapse were enrolled in a study to compare the use of cyclosporine (CSP) as a single agent with a combination of methylprednisolone (MP) and CSP for graft-versus-host disease (GVHD) prophylaxis after marrow transplantation from an HLA-identical sibling donor. Sixty patients were randomized to receive CSP only and 62 were randomized to receive CSP plus MP. Daily CSP was started on day -1 (5 mg/kg/d intravenously) and administered at gradually reduced doses until day 180. MP was started on day 7 at 0.5 mg/kg/d, increased to 1.0 mg/kg/d on day 15, started on a taper schedule on day 29, and discontinued on day 72. All 104 evaluable patients (surviving > or =28 days) had sustained engraftment. The incidence rates of grades II-IV acute GVHD were 73% and 60% for patients receiving CSP and CSP plus MP, respectively (P = .01). No difference was seen for grades III-IV GVHD. However, chronic GVHD occurred somewhat more frequently in patients receiving CSP plus MP (44%) than in patients receiving only CSP (21%; P = .02). The incidence of de novo chronic GVHD was marginally higher in patients receiving CSP plus MP (P = .08). No significant differences in the risk of infections were observed. There was a suggestion that the risk of relapse was lower in patients receiving CSP plus MP (P = .10) and, although the overall survival in the two groups was not different (P = .44), there was a slight advantage in favor of CSP plus MP-treated patients for relapse-free survival (P = .07). These results suggest that prophylactic MP, when combined with CSP, has only limited efficacy in acute GVHD prevention and may increase the probability of chronic GVHD.

Marrow transplantation for chronic myeloid leukemia: the influence of plasma busulfan levels on the outcome of transplantation

The influence of busulfan (BU) plasma concentration on outcome of transplantation from HLA identical family members for the treatment of chronic myelogenous leukemia (CML) was examined in 45 patients transplanted in chronic phase (CP) (n = 39) or accelerated phase (AP) (n = 6). All patients received the same regimen of BU, 16 mg/kg orally and cyclophosphamide (CY), 120 mg/kg intravenously. Plasma concentrations of BU at steady state (C(SS)BU) during the dosing interval were measured for each patient. The mean C(SS)BU was 917 ng/mL (range, 642 to 1,749; median, 917; standard deviation, 213). Of patients with C(SS)BU below the median, seven (five of 18 in CP and two of four in AP) developed persistent cytogenetic relapse and three of these patients died. There were no relapses in patients with C(SS)BU above the median. The difference in the cumulative incidence of relapse between the two groups was statistically significant (P = .0003). C(SS)BU was the only statistically significant determinant of relapse in univariable or multivariable analysis. The 3-year survival estimates were 0.82 and 0.64 for patients with C(SS)BU above and below the median (P = .33). There was no statistically significant association of C(SS)BU with survival or nonrelapse mortality, although the power to detect a difference in survival between 0.82 and 0.64 was only 0.24, similarly C(SS)BU above the median was not associated with an increased risk of severe regimen-related toxicity. We conclude that low BU plasma levels are associated with an increased risk of relapse.

Delay of radiation-induced decline and recovery of hematopoiesis following treatment with anti-HLA-DR antibody

A dose of 200 cGy of total-body irradiation (TBI) is nonlethal in dogs: Following a granulocyte nadir in the third week post-TBI, peripheral blood cell counts recover to normal values by about 5 weeks. In the context of studies on a potential role of major histocompatibility (MHC) class II antigens in the regulation of stress hematopoiesis, we tested the effect of anti-MHC class II monoclonal antibodies (mAbs) on hematologic recovery after TBI. Thirteen dogs were given 200 cGy of TBI not followed by marrow infusion. Five received no additional treatment (concurrent controls) and eight were given daily intravenous (IV) injections of anti-class II mAbs H81.9 (anti-HLA-DR; n = 6) or B1F6 (anti-HLA-DR and -DP; n = 2) at 0.6 (n = 4) or 1.2 mg/kg/d (n = 4) on days 0-4 (n = 7) or days 0-9 (n = 1). One control dog died early from an intercurrent infection and four recovered uneventfully. Dogs given mAbs after TBI showed significantly different granulocyte and platelet kinetics. The granulocyte nadir was lower (p = 0.09) and was reached later (p = 0.005), the duration of neutropenia was longer (p = 0.08), and recovery occurred later (p = 0.02) than among controls. Similarly the platelet nadir was lower (p = 0.05), thrombocytopenia lasted longer (p = 0.02), and recovery occurred later (p = 0.02) than among controls. Four of eight mAb-treated dogs died with marrow aplasia. We propose that following irradiation, HLA-DR mediated signals result in terminal differentiation in more mature hematopoietic precursors but interfere with replication or differentiation in early hematopoietic precursors. These observations suggest a role for MHC class II molecules in the regulation of stress hematopoiesis.

Treatment of acute graft-versus-host disease with humanized anti-Tac: an antibody that binds to the interleukin-2 receptor

Humanized anti-Tac is a genetically engineered human IgG1 monoclonal antibody specific for Tac, the alpha subunit of the interleukin-2 (IL-2) receptor, and blocks IL-2-dependent activation of human T lymphocytes. The safety, pharmacokinetics, and immunosuppressive activity of humanized anti-Tac were evaluated in 20 patients who developed acute graft-versus-host disease (GVHD) after allogeneic marrow transplantation. Patients had developed acute GVHD at 5 to 26 (median, 14) days after transplantation and had failed to respond to primary therapy with glucocorticoids. Sequential groups of 4 patients each received a single 1-hour infusion of antibody in escalating doses of 0.5, 1.0, or 1.5 mg/kg; 8 additional patients were then treated with 1.5 mg/kg. A second infusion of antibody was administered after 11 to 48 (median, 16) days in 8 patients who had transient improvement of GVHD after the first infusion. Acute side effects, limited to chills in 1 patient and diaphoresis in another, were observed during or shortly after the antibody infusion. Overall improvement of acute GVHD occurred in 8 patients, 6 of whom were treated with a single antibody infusion and 2 with two infusions. Four responses were complete and 4 were partial. Three additional patients had improvement in one organ but progression in another. Responses occurred in 9 of 16 cases with skin disease, 3 of 15 with liver disease, and 6 of 12 with gastrointestinal disease. Two patients survive at 529 and 645 days after antibody treatment. Two patients died after relapse of leukemia. Sixteen patients died of infection or organ failure between 5 and 211 (median, 55) days. The terminal elimination half-life of the antibody was 44 to 363 hours, with a harmonic mean of 79, 88, and 94 hours, respectively, for the three doses studied. Absolute peripheral blood T-lymphocyte counts remained unchanged during the 56 days after infusion of the antibody. A fraction of circulating T cells expressed the alpha chain of the IL-2 receptor that, in some patients, was bound by antibody in vivo up to 28 days after treatment. No patient developed a measurable antibody response to humanized anti-Tac. Humanized anti-Tac has a long half-life after intravenous injection in humans, superior to any rodent monoclonal antibody specific for human T cells, and does not appear to induce antibody formation in recipients of marrow transplants. Improvement of steroid-refractory GVHD in 40% of patients after only one or two antibody infusions indicates that humanized anti-Tac is immunosuppressive.

Effects of granulocyte colony-stimulating factor and stem cell factor, alone and in combination, on the mobilization of peripheral blood cells that engraft lethally irradiated dogs

The effects of recombinant canine granulocyte colony-stimulating factor (rcG-CSF) and recombinant canine stem cell factor (rcSCF), a c-kit ligand, on the circulation of hematopoietic progenitor and stem cells were studied in a canine model. Administration of rcG-CSF (10 micrograms/kg) for 7 days led to a 5.4-fold increase in CFU-GM/mL of blood, while 7 days of rcSCF (200 micrograms/kg) led to an 8.2-fold increase. Although treatment with low-dose rcSCF (25 micrograms/kg) had no effect on the level of peripheral blood progenitors, 7-day exposure to a combination of G-CSF plus low dose SCF led to a 21.6-fold increase (P = .03). To assess the ability of these factors to increase the circulation of cells capable of rescuing animals after lethal total body irradiation (TBI), 1 x 10(8) peripheral blood mononuclear cells (PBMC)/kg were collected and cryopreserved from animals after 7 days of treatment with G-CSF, SCF or a combination of the two. One month later, animals were exposed to 9.2 Gy TBI and transplanted with the previously collected cells. Control animals transplanted with 1 x 10(8) PBMC/kg collected without pretreatment died with marrow aplasia 11 to 29 days after TBI as did animals treated with only low-dose SCF before cell collection. In contrast, all animals given PBMC collected after G-CSF, high-dose SCF, or a combination of G-CSF plus low-dose SCF recovered granulocyte function. Recovery to 500 granulocytes/microL after transplant took 17, 18.8, and 13.6 days, respectively, (P = .056 for the difference between the combination G-CSF-SCF group and the other two groups). In both the G-CSF and SCF groups, 4 of 5 animals completely recovered while 1 of 5 in each group died with prolonged thrombocytopenia. In the combination group, all 5 animals became long-term survivors. These studies demonstrate that both G-CSF and SCF dramatically increase the level of peripheral blood hematopoietic progenitor and stem cells and support the view that these factors can act synergistically.

Effect of attitudes, subjective norms and perceived control on nurses' intention to assess patients' pain

This study examines the underlying determinants of nurses' behaviour regarding the conduct of pain assessments. One hundred nurses in a variety of health care facilities were invited to complete an Attitude Intention Questionnaire based upon the theory of planned action which is an extension of the theory of reasoned action. Results provide some support for the theory of planned action, as nurses' intention to conduct pain assessment was shown to be predicted by attitude, subjective norms and perceived control, although the latter was the only variable to make an independent contribution to intention. Additional support for the importance of perceived control was provided by the analysis of 'intenders' and 'non-intenders' (to conduct pain assessments), as perceived control was the only variable which differed significantly between the groups. The findings are consistent with earlier studies which showed that the variables in the theory of planned behaviour provided reasonably accurate predictions of behavioural intention.

Clonal studies of CD3- lymphoproliferative disease of granular lymphocytes

The lymphoproliferative disease of granular lymphocytes (LDGL) results from chronic proliferation of either CD3- or CD3+ large granular lymphocytes (LGLs). Most CD3+ LGLs have been well characterized as clonal LGL proliferations (LGL leukemia). In contrast, the clonal nature and clinical features of patients with CD3- LDGL have not been defined. In this study, we analyzed seven female patients with CD3- LDGL who were heterozygous at certain X-linked gene loci. Neutrophils and CD3- granular lymphocytes were isolated from peripheral blood. Clonal analysis was performed on genomic DNA from these cell fractions on six patients by conventional Southern techniques using probes to the X-linked genes, PGK and DXS255 (M27 beta). In four patients, three of whom were already studied by Southern analyses of genomic DNA and one in whom there were insufficient amounts of DNA, polymerase chain reaction (PCR)-based clonal analysis was performed with primer pairs flanking the BstXI polymorphism on the PGK gene. In six patients, a polyclonal expansion of CD3- granular lymphocytes was demonstrated and in one the result was indeterminate. In contrast to patients with CD3+ LDGL (LGL leukemia), a clonal disease could not be demonstrated with X-linked markers in patients with CD3- LDGL, suggesting a reactive rather than a neoplastic origin of the lymphocytes in these cases.

Hepatitis C antibody after kidney transplantation: clinical significance

The prevalence of antibodies to hepatitis C virus (HCV) was investigated in 231 renal transplantation recipients, by a first- and second-generation EIA assay and a second-generation immunoblot assay (4-RIBA). Before transplantation, prevalence of anti-HCV was 22.6% and was related to the time on dialysis (p < 0.01), transfusions (p < 0.01) and previous history of chronic liver disease (p < 0.01. Following transplantation, 32 patients (13.9%) were anti-HCV positive by the first-generation enzyme immunoassay (EIA) and it increased to 57 patients (24.7%) when anti-HCV was measured by the second-generation EIA. The 4-RIBA assay confirmed the positivity in 46 patients (80.7%), 11 patients (19.3%) were indeterminate. Seroconversion after grafting was observed in 7 negative patients, and another 7 patients became negative after the procedure. The presence of anti-HCV antibody after transplantation was determined by the patient status on dialysis, 80% of them being positive before surgery. Twenty-one 4-RIBA-positive transplantation patients (45.7%) had persistently or intermittently abnormalities on liver function tests, suggesting chronic liver disease. A liver biopsy performed on 10 of these patients showed; chronic active hepatitis in 6, chronic persistent hepatitis in 2, and chronic lobular hepatitis in the other 2 patients. Another 23 4-RIBA-positive transplantation patients had normal alanine aminotransferase levels despite long follow-up (66.2 +/- 32.2 months). The prevalence of anti-HCV antibody can be underestimated if the antibody is measured by first-generation EIA alone. About 50% of patients with anti-HCV had chronic liver disease, and the histological findings suggested a possible evolution to cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Isoelectric focusing patterns of beta-lactamases in the rapidly growing mycobacteria

beta-lactamases from 259 strains of rapidly growing mycobacteria that included the third biovariant complex of Mycobacterium fortuitum, M. peregrinum, M. abscessus, M. chelonae, the M. chelonae-like organisms (MCLO), and M. smegmatis were analyzed by isoelectric focusing (IEF). All isolates produced acidic beta-lactamases with major band isoelectric points (pIs) between 4.4 and 6.0. Each of the 6 taxonomic groups exhibited 1 or 2 characteristic beta-lactamase IEF patterns. Heterogeneity among IEF patterns was evident in 5 of the 6 groups, however, and was greatest among the third biovariant complex of M. fortuitum. beta-lactamase patterns correlated with previously identified taxonomic subgroups of M. smegmatis and the third biovariant complex of M. fortuitum. beta-lactamase IEF analysis of MCLO strains isolated from two outbreaks demonstrated its possible usefulness for epidemiologic evaluation.

The Cln3-Cdc28 kinase complex of S. cerevisiae is regulated by proteolysis and phosphorylation

In Saccharomyces cerevisiae, several of the proteins involved in the Start decision have been identified; these include the Cdc28 protein kinase and three cyclin-like proteins, Cln1, Cln2 and Cln3. We find that Cln3 is a very unstable, low abundance protein. In contrast, the truncated Cln3-1 protein is stable, suggesting that the PEST-rich C-terminal third of Cln3 is necessary for rapid turnover. Cln3 associates with Cdc28 to form an active kinase complex that phosphorylates Cln3 itself and a co-precipitated substrate of 45 kDa. The cdc34-2 allele, which encodes a defective ubiquitin conjugating enzyme, dramatically increases the kinase activity associated with Cln3, but does not affect the half-life of Cln3. The Cln--Cdc28 complex is inactivated by treatment with non-specific phosphatases; prolonged incubation with ATP restores kinase activity to the dephosphorylated kinase complex. It is thus possible that phosphate residues essential for Cln-Cdc28 kinase activity are added autocatalytically. The multiple post-translational controls on Cln3 activity may help Cln3 tether division to growth.

Effect of Endotoxin on Serum Granulocyte and Granulocyte-Macrophage Colony-Stimulating Factor Levels in Dogs

The biologic effects of endotoxin are attributed to the release of several cytokines, including interleukin-1, interleukin-6, tumor necrosis factor, and the colony-stimulating factors. To investigate the mechanism of endotoxin-induced neutrophilia in dogs, several cell lines known to proliferate selectively in response to recombinant human colony-stimulating factors were examined to determine their responses to recombinant canine granulocyte colony-stimulating factor (rcG-CSF) or recombinant canine granulocyte-macrophage colony-stimulating factor (rcGM-CSF). The murine cell line NFS-60 was found to respond well to rcG-CSF and the human cell line TALL-101 to rcGM-CSF, and these responses were neutralized by antibodies to these recombinant proteins. These bioassays were then used to determine G-CSF and GM-CSF levels in dogs after intravenous endotoxin administration. G-CSF levels increased by 2 h, peaked at 4 h, and had not returned to normal by 24 h after endotoxin. In contrast, GM-CSF was not detectible before or after endotoxin administration.

[Prevalence of hepatitis C virus antibody in chronic HBsAg-negative non alcoholic hepatopathy]

The presence of antibody to hepatitis C virus was determined in 316 HBsAg-negative patients with non-alcoholic chronic hepatitis who did not receive any blood transfusion once the diagnosis was made. A titre of antinuclear antibodies of 1/40 or lower was found in 18 patients. Persistent chronic hepatitis was present in 21 patients, active chronic hepatitis in 145, hepatic cirrhosis in 128, and hepatocarcinoma in 22 patients. One hundred and three patients had previously received blood transfusion, 76 had undergone previous surgery without transfusion, a clinical episode of hepatitis could be traced in 14, 13 patients were drug addicts (all of them HIV negative), 1 patient had received multiples injections, another had been treated with acupuncture, and 108 patients were free of any of the above. Anti-HCV was present in 76.6% of patients; a significantly higher proportion (87.4%) was found among patients who had received blood transfusion than in patients with previous surgery (72.4%) (p = 0.012), clinical hepatitis (57.1%), or without previous hepatic disease (70.3%) (p = 0.003). The incidence of anti-HCV was lower among cirrhotics (70.3%) than in patients with active chronic hepatitis (84.1%) (p = 0.006); in contrast, previous blood transfusion was significantly higher (p = 0.001) among the latter (40.7%) than in cirrhotics (21.9%). The incidence of anti-HCV was similar among patients with (78.6%) and without (75.8%) type B infection. Our results suggest that infection with virus C may account for a high proportion of non-alcoholic non-B chronic hepatitis.