Ruxolitinib in corticosteroid-refractory graft-versus-host disease after allogeneic stem cell transplantation: a multicenter survey

Despite major improvements in allogeneic hematopoietic cell transplantation over the past decades, corticosteroid-refractory (SR) acute (a) and chronic (c) graft-versus-host disease (GVHD) cause high mortality. Preclinical evidence indicates the potent anti-inflammatory properties of the JAK1/2 inhibitor ruxolitinib. In this retrospective survey, 19 stem cell transplant centers in Europe and the United States reported outcome data from 95 patients who had received ruxolitinib as salvage therapy for SR-GVHD. Patients were classified as having SR-aGVHD (n=54, all grades III or IV) or SR-cGVHD (n=41, all moderate or severe). The median number of previous GVHD-therapies was 3 for both SR-aGVHD (1-7) and SR-cGVHD (1-10). The overall response rate was 81.5% (44/54) in SR-aGVHD including 25 complete responses (46.3%), while for SR-cGVHD the ORR was 85.4% (35/41). Of those patients responding to ruxolitinib, the rate of GVHD-relapse was 6.8% (3/44) and 5.7% (2/35) for SR-aGVHD and SR-cGVHD, respectively. The 6-month-survival was 79% (67.3-90.7%, 95% confidence interval (CI)) and 97.4% (92.3-100%, 95% CI) for SR-aGVHD and SR-cGVHD, respectively. Cytopenia and cytomegalovirus-reactivation were observed during ruxolitinib treatment in both SR-aGVHD (30/54, 55.6% and 18/54, 33.3%) and SR-cGVHD (7/41, 17.1% and 6/41, 14.6%) patients. Ruxolitinib may constitute a promising new treatment option for SR-aGVHD and SR-cGVHD that should be validated in a prospective trial.

Noncontact Atomic Force Microscope Dissipation Reveals a Central Peak of SrTiO_{3} Structural Phase Transition

The critical fluctuations at second order structural transitions in a bulk crystal may affect the dissipation of mechanical probes even if completely external to the crystal surface. Here, we show that noncontact force microscope dissipation bears clear evidence of the antiferrodistortive phase transition of SrTiO_{3}, known for a long time to exhibit a unique, extremely narrow neutron scattering "central peak." The noncontact geometry suggests a central peak linear response coupling connected with strain. The detailed temperature dependence reveals for the first time the intrinsic central peak width of order 80 kHz, 2 orders of magnitude below the established neutron upper bound.

Neuroligin 2 deletion alters inhibitory synapse function and anxiety-associated neuronal activation in the amygdala

Neuroligin 2 (Nlgn2) is a synaptic adhesion protein that plays a central role in the maturation and function of inhibitory synapses. Nlgn2 mutations have been associated with psychiatric disorders such as schizophrenia, and in mice, deletion of Nlgn2 results in a pronounced anxiety phenotype. To date, however, the molecular and cellular mechanisms linking Nlgn2 deletion to psychiatric phenotypes remain completely unknown. The aim of this study was therefore to define the role of Nlgn2 in anxiety-related neural circuits. To this end, we used a combination of behavioral, immunohistochemical, and electrophysiological approaches in Nlgn2 knockout (KO) mice to expand the behavioral characterization of these mice and to assess the functional consequences of Nlgn2 deletion in the amygdala. Moreover, we investigated the differential activation of anxiety-related circuits in Nlgn2 KO mice using a cFOS activation assay following exposure to an anxiogenic stimulus. We found that Nlgn2 is present at the majority of inhibitory synapses in the basal amygdala, where its deletion affects postsynaptic structures specifically at perisomatic sites and leads to impaired inhibitory synaptic transmission. Following exposure to an anxiogenic environment, Nlgn2 KO mice show a robust anxiety phenotype as well as exacerbated induction of cFOS expression specifically in CaMKII-positive projection neurons, but not in parvalbumin- or somatostatin-positive interneurons. Our data indicate that Nlgn2 deletion predominantly affects inhibitory synapses onto projection neurons in basal amygdala, resulting in decreased inhibitory drive onto these neurons and leading to their excessive activation under anxiogenic conditions. This article is part of the Special Issue entitled 'Synaptopathy--from Biology to Therapy'.

In vivo porcine lipopolysaccharide inflammation models to study immunomodulation of drugs

Lipopolysaccharide (LPS), a structural part of the outer membrane of Gram-negative bacteria, is one of the most effective stimulators of the immune system and has been widely applied in pigs as an experimental model for bacterial infection. For this purpose, a variety of Escherichia coli serotypes, LPS doses, routes and duration of administration have been used. LPS administration induces the acute phase response (APR) and is associated with dramatic hemodynamic, clinical and behavioral changes in pigs. Pro-inflammatory cytokines, including tumor necrosis factor α (TNF-α), interleukin (IL)-1 and IL-6 are involved in the induction of the eicosanoid pathway and the hepatic production of acute phase proteins, including C-reactive protein (CRP), haptoglobin (Hp) and pig major acute phase protein (pig-MAP). Prostaglandin E2 (PGE2) and thromboxane A2 (TXA2) play a major role in the development of fever and pulmonary hypertension in LPS-challenged pigs, respectively. The LPS-induced APR can be modulated by drugs. Steroidal and nonsteroidal anti-inflammatory drugs ((N)SAIDs) possess anti-inflammatory, antipyretic and analgesic properties through (non)-selective central and peripheral cyclooxygenase (COX) inhibition. Antimicrobial drugs, especially macrolide antibiotics, which are commonly used in veterinary medicine for the treatment of bacterial respiratory diseases, have been recurrently reported to exert clinically important immunomodulatory effects in human and murine research. To investigate the influence of these drugs on the clinical response, production of pro-inflammatory cytokines, acute phase proteins (APP) and the course of the febrile response in pigs, in vivo LPS inflammation models can be applied. Yet, to date, in vivo research on the immunomodulatory properties of antimicrobial drugs in these models in pigs is largely lacking. This review provides acritical overview of the use of in vivo porcine E. coli LPS inflammation models for the study of the APR, as well as the potential immunomodulatory properties of anti-inflammatory and antimicrobial drugs in pigs.

Eigenschappen en toekomstperspectieven van mesenchymale stamcellen bij honden

Het therapeutisch gebruik van caniene mesenchymale stamcellen (cMSC) kent de laatste jaren een sterke toename binnen de diergeneeskunde. MSC zijn stromale cellen die in vitro multipotente stamceleigenschappen vertonen. Endogeen bezitten ze trofische, immunoregulerende, antimicrobiële en hematopoïese-ondersteunende functies. Exogeen toegediende MSC vertonen bovendien een opmerkelijk migrerend vermogen naar hypoxische en inflammatoire regio’s. Er zijn in stijgende mate indicaties dat MSC ook uit pericyten kunnen ontstaan. Zowel de verschillende invloeden die het micromilieu uitoefent op deze adulte stamcellen, als het gebruik van niet-gestandaardiseerde methoden voor isolatie en expansie leiden tot heterogene celpopulaties. Bijkomend onderzoek is nodig om deze beloftevolle therapieën in de toekomst zonder voorbehoud toegepast kunnen worden bij de hond.

Is stamceltherapie voor orthopedische aandoeningen bij de hond reeds inzetbaar?

In navolging van de humane geneeskunde is de interesse in stamceltherapie ook in de diergeneeskunde sterk toegenomen. Door de toenemende media-aandacht is stamceltherapie voor velen zelfs een bekende term geworden. In de diergeneeskunde is de toepassing van stamceltherapie voornamelijk gericht op orthopedische aandoeningen bij paarden en honden, aangezien klassieke medicamenteuze en chirurgische therapieën voor vele bot-, kraakbeen- en ligamenteuze aandoeningen vaak niet resulteren in een volledig functioneel herstel...

The reduction of nosocomial MRSA infection in Germany: an analysis of data from the Hospital Infection Surveillance System (KISS) between 2007 and 2012

BACKGROUND

Infections with multiresistant Gram negative pathogens are rising around the world, but many European countries have recently seen a decline in infections due to methicillin resistant Staphylococcus aureus (MRSA). We determined the percentage of nosocomial Staphylococcus aureus infections in Germany that were accounted for by MRSA in the past six years and looked for regional differences in the overall downward trend.

METHODS

Data from the German Hospital Infection Surveillance System (Krankenhaus-Infektions-Surveillance-System, KISS) from the years 2007-2012 were analyzed. In intensive care units, data on the following nosocomial infections were registered: primary sepsis, lower respiratory tract infections, and urinary tract infections; in surgical wards, data on postoperative wound infections were collected.

RESULTS

The number of participating intensive care units varied from 465 to 645, while the number of participating surgical wards varied from 432 to 681. Over the period 2007-2012, the percentage of nosocomial Staphylococcus aureus infections that were due to MRSA dropped significantly, from 33% to 27%. More specifically, the percentage of infections due to MRSA dropped from 36% to 31% for primary sepsis and from 36% to 30% for lower respiratory tract infections. Regression analysis revealed significantly lower MRSA fractions in the German states of Brandenburg (odds ratio [OR] 0.41), Bavaria (OR 0.73), and Saxony-Anhalt (OR 0.53), with higher fractions in Berlin (OR 1.59), Mecklenburg-West Pomerania (OR 1.91), Lower Saxony (OR 1.85), and North Rhine-Westphalia (OR 1.55). There were no significant differences in the remaining German states.

CONCLUSION

In Germany, the percentage of nosocomial Staphylococcus aureus infections due to MRSA dropped significantly over the period 2007-2012. The causes of this decline are unclear; it may have resulted from human intervention, pathogen biology, or both.

Secreted phospholipase A2 inhibitor modulates fatty acid composition and reduces obesity-induced inflammation in Beagle dogs

Secreted phospholipase A2 inhibitor (sPLA2i) has been reported to have an anti-inflammatory function by blocking the production of inflammatory mediators. Obesity is characterized by low-grade inflammation and oxidative stress. The aim of this study was to investigate the effects of dietary supplementation of sPLA2i on inflammation, oxidative stress and serum fatty acid profile in dogs. Seven obese and seven lean Beagle dogs were used in a 28-day double blind cross-over design. Dogs were fed a control diet without supplemental sPLA2i or an sPLA2i supplemented diet. The sPLA2i diet decreased plasma fibrinogen levels and increased the protein:fibrinogen ratio in obese dogs to levels similar to those of lean dogs fed the same diet. Obese dogs had a higher plasma concentration of the lipophilic vitamin A with potential antioxidative capacity and a lower ratio of retinol binding protein 4:vitamin A compared to lean dogs, independent of the diets. A higher proportion of myristic acid (C14:0) and a lower proportion of linoleic acid (C18:2n-6) were observed in the dogs fed with the sPLA2i diet compared to dogs fed with the control diet. Furthermore, a higher ratio of n-6 to n-3, a lower proportion of n-3 polyunsaturated fatty acids and lower omega-3 index were observed in obese compared to lean dogs. The results indicate that obese dogs are characterized by a more 'proinflammatory' serum fatty acid profile and that diet inclusion of sPLA2i may reduce inflammation and alter fatty acid profile.

Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study

OBJECTIVES

Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS.

DESIGN

This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation.

SETTING

Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital.

PARTICIPANTS

Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days.

INTERVENTION

Implementation of a CDSS.

OUTCOME MEASURES

The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence.

MAIN RESULTS

Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31).

CONCLUSIONS

Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality.

TRIAL REGISTRATION NUMBER

ISRCTN54598675.

Adolescents with Type 1 diabetes mellitus experience psychosensorial symptoms during hypoglycaemia

AIM

To describe mood and psychosensorial symptoms of hypoglycaemia in adolescents with Type 1 diabetes mellitus in two countries with different cultures, Turkey and the USA.

METHODS

We developed a 68-item questionnaire assessing physical, behavioural, mood and psychosensorial symptom frequency and ratings ['good', 'bad', or 'both' (sometimes good, sometimes bad)]. Adolescents with Type 1 diabetes were recruited from paediatric diabetes clinics at the University of North Carolina at Chapel Hill in the USA and Kocaeli University in Turkey. The percentages of participants at each clinic who endorsed individual symptoms, symptom categories and symptom ratings were calculated and compared.

RESULTS

Cronbach's α values were > 0.7 for each real symptom category. No symptom items were excluded from the questionnaire analysis based on item-total correlation results which were all > 0.2. Data were collected from 132 participants (69 from University of North Carolina, 63 from Kocaeli University, 54% male). The mean (SD) age of the participants was 14.9 (1.9) years, HbA1c level was 8.7 (1.8) % and duration of Type 1 diabetes was 5.8 (3.7) years. On average, each physical symptom was experienced by 65.2% of participants, each behavioural symptom by 46.5%, each mood symptom by 42.8%, and each psychosensorial symptom by 48.9%. On average, each physical, behavioral, mood and psychosensorial symptom was rated as 'good' or 'both' by 23.0, 29.1, 36.9 and 37.2% of participants, respectively. There were no symptom differences between the groups in each country.

CONCLUSIONS

In addition to the classic physical symptoms experienced during hypoglycaemia, adolescents with Type 1 diabetes report psychosensorial, mood and behavioral symptoms, and some describe them as positive experiences. Symptom experiences were similar in these two countries with different cultures.

Patient and family factors associated with family accommodation in obsessive-compulsive disorder

AIM

Obsessive-compulsive disorder (OCD) impacts family functioning as family members modify their personal and family routines, participate in rituals, and provide reassurance. These behaviors have been identified as family accommodation (FA), a phenomenon that, if ignored, may facilitate OCD symptoms and lead to poorer prognosis. Because FA has been recognized as a predictor of treatment outcome, we examined the prevalence of FA and identified patient and family sociodemographic and clinical variables associated with FA in an outpatient sample.

METHODS

The study comprised 228 subjects, namely, 114 patients with OCD and 114 family members, assessed before the patients entered a 12-session cognitive behavioral group therapy program. A multivariate linear regression model was used to control for confounding factors and to evaluate variables independently associated with FA. FA was evaluated using the Family Accommodation Scale for Obsessive-Compulsive Disorder-Interviewer Rated.

RESULTS

FA was found to be highly prevalent among family members. Two patient factors positively associated with FA were OCD severity as measured by the Clinical Global Impressions Scale and higher scores on the Obsessions dimension of the Obsessive-Compulsive Inventory-Revised. Family members' characteristics that were positively associated with FA were higher scores on the Obsessive-Compulsive Inventory - Revised hoarding subscale and being the patient's spouse.

CONCLUSION

Our findings suggest that the early identification of patients and family members who could benefit from interventions aimed at reducing FA could improve treatment outcomes.