Health-related quality of life in Crohn's disease: a prospective longitudinal study in 231 patients

OBJECTIVE

The aim of this work was to assess the quality of life (QoL) of patients with Crohn's disease (CD) prospectively over 1 yr and to determine factors of influence.

METHODS

A total of 231 CD patients were included. At month 0 (M0), M3, M6, M9, and M12, patients were given a validated QoL questionnaire (self-administered) to fill in and a clinical form referring to the period of 3 months before the visit. The QoL questionnaire was made up of the Short-Form-36 and the Rating Form of Inflammatory Bowel Disease Patients Concerns. The impact on QoL of the following factors was analyzed: age, gender, CD duration and localization, presence of extradigestive manifestations or concomitant disease, disease course, medical treatments, and surgery. We studied the correlations between QoL and disease activity assessed by both patients and investigators by a visual analog scale.

RESULTS

At M0, all the scores of the Short-Form-36 were significantly lower than those of a standard population, nevertheless improving between M0 and M12. Patients' main worries were first "having an ostomy bag" followed by "uncertain nature of the disease," "energy level." and finally "having surgery." QoL was better correlated with assessment of disease course by the patient than by the investigator. Significant factors of impairment in QoL were female gender, tobacco, active CD, involvement of the colon, hospitalization, corticoid treatment, and surgery in the past 3 months. Conversely, intake of immunosuppressors improved QoL.

CONCLUSION

Patients' QoL is impaired by CD and is underestimated by doctors. Tobacco, hospitalization, and use of corticoids have a negative impact on QoL. Conversely, the use of immunosuppressors is associated with a better QoL.

Clinical course and predictive factors for cyclosporin-induced autologous graft-versus-host disease after autologous haematopoietic stem cell transplantation

The administration of cyclosporin A (CyA) after autologous haematopoietic stem cell transplantation (HSCT) induces a systemic autoimmune syndrome mimicking graft-vs.-host disease (GVHD). This syndrome, termed autologous GVHD has notable anti-tumour activity in animal studies. We intended to induce autologous GVHD with CyA in patients undergoing an autologous HSCT. We prospectively studied 118 patients with miscellaneous malignancies undergoing an autologous HSCT with low-dose CyA to characterize the clinical syndrome, its frequency and clinical course, and to determine the factors affecting its incidence. Patients received CyA from d -1 through to d 28, first starting at 2 mg/kg intravenously and then orally as soon as feasible. The dose was adjusted to achieve pre-dose blood levels around 100 ng/ml. A skin biopsy was performed when a skin rash was observed. Thirty-three percent of the patients developed clinical GVHD: clinical stage 1 in 21 patients, stage 2 in seven patients, and stage 3 in three patients. Although total body irradiation (TBI) or high-dose cyclophosphamide were previously thought to be needed, autologous GVHD occurred in five out of 12 patients (42%) after a preparative regimen with high-dose melphalan alone. Autologous GVHD was significantly more frequent in patients older than 33 years, in patients who had received high doses of granulocyte-macrophage colony forming units (CFU-GM) and in those with a diagnosis of myeloid malignancy, compared with those with lymphoid malignancies or solid tumours. A significant negative association was also found with HLA-DR6. In lymphoma patients, GVHD occurred more frequently in advanced disease than in first or second complete remission (CR1-2) patients. All other factors studied were not predictive for GVHD. In conclusion, CyA-induced GVHD is reproducibly and safely induced with doses of CyA adapted to achieve blood levels around 100 ng/ml. In retrospective analysis, there was no survival advantage for patients with GVHD. Phase III trials with this approach are needed to evaluate its anti-tumoral effect.

Donor lymphocyte infusion to eradicate recurrent host hematopoiesis after allogeneic BMT for sickle cell disease

BACKGROUND

Donor lymphocyte infusion (DLI) is currently standard therapy for relapse of malignancies after allogeneic BMT. Several observations suggest that both normal and leukemic progenitor cells of host origin constitute effective target cells for donor-derived lymphocytes. To prevent relapse of sickle cell disease (SCD), a child with evidence of decreasing mixed chimerism received DLIs 8 months after allogeneic BMT for SCD.

CASE REPORT

A 4-year-old child who was homozygous for SCD underwent a transplantation of bone marrow from his fully HLA-matched sister. Routine detection of sex chromosomes in bone marrow cells evidenced decreasing mixed chimerism, which heralded a probably imminent recurrence of the disease. The patient received two DLIs in graded incremental doses on Days 234 and 267. One month later, he developed grade 2 acute GVHD that responded well to corticosteroids and cyclosporine.

RESULTS

DLI resulted in complete donor chimerism within 2 months of the second infusion. Now, 2 years after the second DLI, the patient is in excellent condition, with normal Hb and excellent growth and development.

CONCLUSION

This is the first report of successful use of DLI in a patient with probable imminent SCD recurrence after allogeneic BMT. It shows that DLI can displace residual host HPCs in case of recurrence of nonmalignant disease after allogeneic BMT.

Effective treatment of Jo-1-associated polymyositis with T-cell-depleted autologous peripheral blood stem cell transplantation

A patient with Jo-1 antibody-associated polymyositis (Jo-1 PM) had a Karnofsky score of 40% and severe muscle, liver and lung damage that was refractory to standard therapy. The female patient received an autologous T-cell-depleted haematopoietic stem cell transplant (HSCT) after myeloablative conditioning. The transplant procedure was complicated by severe adult respiratory distress syndrome (ARDS) and adenovirus-associated haemorrhagic cystitis as well as cytomegalovirus (CMV) reactivation. The patient's creatinine phosphokinase (CPK) and alanine transaminase (ALT) values were normal on day 21. The patient's strength has improved remarkably and her dyspnoea is subjectively improved. At 15 months after the transplant, the patient was well with a Karnofsky score of 80% and had been off any therapy, including steroids, for 14 months.

High intensity pulsed electric fields applied to egg white: effect on Salmonella Enteritidis inactivation and protein denaturation

High-intensity electric fields have been successfully applied to the destruction of Salmonella Enteritidis in diaultrafiltered egg white. The effects of electric field strength (from 20 to 35 kV x cm(-1)), pulse frequency (from 100 to 900 Hz), pulse number (from 2 to 8), temperature (from 4 to 30 degrees C), pH (from 7 to 9), and inoculum size (from 10(3) to 10(7) CFU x ml(-1)) were tested through a multifactorial experimental design. Experimental results indicate that, for Salmonella inactivation, the electric field intensity is the dominant factor with a strongly positive effect, strengthened by its positive interaction with pulse number. Pulse number, temperature, and pH have also significant positive effects but to a lesser extent. In the most efficient conditions, the pulsed electric field (PEF) treatment is capable of 3.5 log10 reduction in viable salmonellae. Simultaneously, the measure of surface hydrophobicity does not indicate any increase after PEF treatment. These results suggest that no protein denaturation occurs, unlike what is observed after comparable heat treatment in terms of Salmonella inactivation (55 degrees C for 15 min).

Rapid growth of Salmonella enteritidis in egg white reconstituted from industrial egg white powder

The aim of this study was to evaluate the consequences of the egg white-drying process on egg white ability to limit Salmonella Enteritidis growth in addition to the elucidation of the factors involved. We observed rapid growth of Salmonella Enteritidis inoculated in egg white reconstituted from industrial powder in comparison with that observed in liquid egg white collected in the laboratory: Salmonella cell counts rose from 10(3) to 10(8) cells/ml of egg white from powder during 24 h incubation at 30 degrees C. This rapid growth was observed in powder from all egg-breaking factories investigated, and it was comparable to that observed in optimum medium (tryptone soy broth). In view of the mechanism of egg white resistance and the major role played by iron availability and by ovotransferrin, we investigated several hypotheses to explain this rapid growth: iron provided during the drying process and/or denaturation of protein (especially ovotransferrin). The rapid growth observed in egg white reconstituted from powder was in relation to egg white protein denaturation and especially ovotransferrin denaturation during powder pasteurization that enhanced the availability of iron necessary for Salmonella growth. The major role played by ovotransferrin and iron deficiency on Salmonella growth in egg white was illustrated in this study.

Influence of marrow erythropoietic activity on serum erythropoietin levels after autologous hematopoietic stem cell transplantation

BACKGROUND AND OBJECTIVE

Serum erythropoietin (sEpo) concentration depends primarily on the rate of renal production in response to hypoxia. However, sEpo levels increase inappropriately after conditioning for autologous stem cell transplantation (ASCT) before progressively returning to adequate levels. We investigated the possible influence of erythropoietic activity on these observations.

DESIGN AND METHODS

Forty patients undergoing an ASCT, 8 with bone marrow (BMT) and 32 with peripheral blood stem cells (PBSC), were separated into 3 groups. Group 1 was formed of the 8 BMT patients (median time to 1% reticulocytes: 39 days), group 2 of 16 PBSC patients with relatively slow erythroid engraftment (> or = 15 days to 1% reticulocytes, median 19 days) and group 3 of 16 PBSC patients with prompt erythroid recovery (< 15 days to 1% reticulocytes, median 13 days). Marrow erythroid activity was assessed by serum transferrin receptor levels (sTfR). Serum Epo (sEpo) levels were expressed in relation to the degree of anemia as observed/predicted (O/P) ratios of (O/P) log (sEpo).

RESULTS

Serum sTfR levels decreased by more than 50% in all 3 groups after conditioning, reaching their nadir on day 7. Nadir values doubled by day 28 in group 3, day 60 in group 2, but not within 100 days in group 1. O/P sEpo ratios increased inappropriately in all 3 groups after conditioning but then declined at very differing speeds in the 3 groups. In group 1, ratios remained above 1.10 through to day 28 and above 1.00 through to day 42, before leveling off at around 1.00 thereafter. In group 2, ratios remained above 1.00 through to day 14, than decreased to a minimum of 0.89 by day 42 before returning to 1.00 by day 100. In group 3, ratios decreased to 0.84 by day 21 and remained below 0.90 thereafter.

INTERPRETATION AND CONCLUSIONS

We conclude that sEpo levels are not only influenced by tissue oxygenation but also depend on the mass of erythroid precursors in the bone marrow. This may be the main explanation for the observed changes in sEpo levels during ASCT.

[Clinical case of the month. Apropos of pancytopenia in a seropositive patient]

A 37-year old patient, HIV-1-infected, consulted for progressive weakness and dyspnea on exertion, increasing over three months. Complete blood count showed pancytopenia, while the bone marrow revealed severe hypoplasia. Other investigations, including serology for CMV, vitamin levels, Coombs test, gastroscopy and colonoscopy were non contributing. A diagnosis of zidovudine-induced medullary aplasia was made; the clinical course was favourable after this drug was replaced by triple therapy. The authors discuss the differential diagnosis of cytopenias in the patient infected by HIV and they suggest a diagnostic approach.

[Clinical case of the month. The association of Hodgkin's disease and nephrotic syndrome]

The nephrotic syndrome is a rare complication of Hodgkin's disease. The majority of the cases do not respond to corticosteroids but are cured by the treatment of the lymphoma. We describe a patient with a nephrotic syndrome at the time of diagnosis of mixed cellularity Hodgkin's disease and the resolution of this nephrotic syndrome by MOPP-ABV chemotherapy.

Video-thoracoscopic pericardial window in the diagnosis and treatment of pericardial effusions

Video-thoracoscopic pericardial window is a noninvasive method of pericardial drainage, allowing an excellent view of the pleural cavity and the pericardium and a precise selection of biopsy sites whether these are pericardial, pleural, lung or mediastinal. The results obtained in a series of 22 patients operated on using this technique are presented.

Myasthenia gravis without chronic GVHD after allogeneic bone marrow transplantation

A 20-year-old man with aplastic anemia developed myasthenia gravis (MG) 7 months after bone marrow transplantation (BMT) from an HLA one locus-mismatched sister. Proximal muscle weakness (predominant in the lower limbs) and dysphagia occurred without any other sign of graft-versus-host disease (GVHD), 1 month after cessation of immunosuppression with cyclosporine. The diagnosis of MG was based on clinical symptoms and on neurophysiologic investigations showing a significant increase of the Jitter in single-fiber electromyography and a significant decremental response during repetitive stimulation at slow rates, but antibodies against the acetylcholine receptor (AchRab) were negative. All clinical and neurophysiological signs normalized within 1 month of treatment with low-dose prednisolone and pyridostigmine, and the patient is perfectly well 1 year after cessation of all therapy. All cases of BMT-associated MG previously published are reviewed in comparison with ours. The originality of this new observation is that this case is the only one not associated with chronic GVHD and negative for AchRab. Alternatively, MG may have been the sole manifestation of chronic GVHD in this patient.

The veno-occlusive disease of the liver

BACKGROUND AND OBJECTIVE

The veno-occlusive disease of the liver (VOD) is a disorder caused by the non-thrombotic occlusion of the central veins of hepatic lobules. The clinical features are similar to those of intrahepatic portal hypertension (unexplained weight gain, ascites, painful hepatomegaly, jaundice). In the past, this disease was rather infrequent and was linked to the absorption of toxic agents, liver irradiation or chemotherapy. However, the intensification of treatment protocols before hematopoietic stem cell transplants has considerably increased its incidence. The strategies used for its prevention and treatment remain limited in efficacy. The present review was undertaken in order to assess progress in the diagnosis and management of this severe complication in stem cell transplantation.

INFORMATION SOURCES

The method used for preparing this review was an examination of 250 relevant articles or abstracts published in journals covered by Medline.

STATE OF ART

Despite the progress made toward the understanding of its physiopathology and the identification of its risk factors, VOD is still one of the leading causes of morbidity and mortality during the first two months post-BMT, and therefore often constitutes a limitation for the further increment of the dose of antineoplastic drugs. This may be explained by the difficulty in making an early diagnosis of this problem, at a time when therapeutic intervention may be more effective, and, on the other hand, the lack of a well-established prevention and treatment approach for patients with VOD.

PERSPECTIVES AND CONCLUSIONS

New diagnostic procedures, such as laparoscopic liver biopsy, and new therapeutic approaches, such as transjugular intrahepatic portosystemic shunting (TIPS) or defibrotide, are now being evaluated. However, additional studies will be needed to determine the most appropriate therapy for each VOD patient depending on the severity of the disease.

Age-independent assessment of abnormal fetal growth in the third trimester

This study assessed the use of the sonographic growth rate of a fetus in the third trimester independently of its gestational age as a tool to evaluate adequacy of fetal growth. Ultrasonographic records were reviewed to calculate our third trimester growth rate, and three rates of fetal growth were established. One hundred and thirty-three patients having two third trimester sonographic examinations were then studied, and our average, above average, and below average growth rate zones were found to be excellent predictors for fetal size at birth. The below-average zone identified fetuses who were not clinically suspected of having IUGR but were determined to be SGA at birth.

Diagnosis and surgical treatment of primary aldosteronism in pregnancy: a case report

BACKGROUND

Aldosterone-producing adrenal adenomas are rare, especially during pregnancy. We report a patient who presented in the early second trimester, was diagnosed with primary aldosteronism, and was treated successfully by adrenalectomy.

CASE

A 17-year-old black nulliparous woman was found to have a blood pressure (BP) of 150/82 mmHg when she registered for prenatal care at 14 weeks' gestation. Initial laboratory assessment revealed a markedly diminished serum potassium level of 2.1 mmol/L. Further laboratory evaluation detected decreased random plasma renin activity and an elevated aldosterone level. Magnetic resonance imaging revealed a 2-cm right adrenal lesion. She was diagnosed with an adrenal adenoma and successfully underwent an adrenalectomy at 17 weeks' gestation. Postoperatively, her BP and serum potassium level normalized. She spontaneously delivered a normal male infant at term.

CONCLUSION

Although primary hyperaldosteronism is a rare clinical entity, it must be considered when hypertension and hypokalemia are present concurrently. Antepartum medical management can be difficult, often resulting in poor obstetric outcome. Surgery in the second trimester is an effective option.

Glucose inhibits human placental GH secretion, in vitro

Human placenta specifically expresses the GH-V gene leading to the production of placental Growth Hormone (PGH). During pregnancy, PGH levels increase progressively in maternal blood, but its regulation remains unknown. In this study the effect of glucose on PGH secretion by human term placenta was tested, in vitro, by means of two different experimental models: organ culture of villous tissue and primary culture of isolated cytotrophoblasts. PGH was assayed in the culture medium by an immunoradiometric assay using a specific PGH monoclonal antibody. The presence of glucose (25 mmol/L) in the culture medium significantly inhibited (p < 0.001) the secretion of PGH by either placental villous explants or by cultured trophoblast cells. This inhibitory effect of glucose on PGH secretion was dose-dependent. More than 50% inhibition being observed with 5.5 mmol/L. In the same conditions, the daily production of hPL and hCG, were unmodified. Furthermore, the glucose-induced inhibition of PGH secretion was more effective when cultured trophoblast cells are differentiated into syncytiotrophoblast. This study demonstrates, for the first time, that among the gestational polypeptide hormones secreted by the human placenta, only PGH secretion is modulated by glucose, suggesting a key metabolic role for this hormone during pregnancy.

Cutaneous and extracutaneous neutrophilic infiltrates (Sweet syndrome) in three patients with Fanconi anemia

Three patients with coexistent Fanconi syndrome and Sweet syndrome (neutrophilic dermatosis) are presented. These sterile skin lesions responded to systemic corticosteroid therapy in all three cases, and recurred when treatment was discontinued. The association in children of Sweet syndrome with malignancy has previously been recognized; it has not been reported in the premalignant phase of Fanconi anemia. This report expands the differential diagnosis of the neutrophilic dermatoses. Children with Sweet syndrome and anemia should be examined for Fanconi anemia by diepoxybutane cytogenetic studies.