Discovery of 4-[(Z)-(4-bromophenyl)- (ethoxyimino)methyl]-1'-[(2,4-dimethyl-3- pyridinyl)carbonyl]-4'-methyl-1,4'- bipiperidine N-oxide (SCH 351125): an orally bioavailable human CCR5 antagonist for the treatment of HIV infection

Structure-activity studies on piperidino-piperidine 3 led to the discovery of SCH 351125 (1), a selective CCR5 antagonist with potent activity against RANTES binding (K(i) = 2 nM), which possesses subnanomolar activity in blocking viral entry and has excellent antiviral potency versus a panel of primary HIV-1 viral isolates. Compound 1, which has good oral bioavailability in rats, dogs, and monkeys, is proposed as a potential therapeutic agent for the treatment of HIV-1 and has entered human clinical trials.

Piperazine-based CCR5 antagonists as HIV-1 inhibitors. II. Discovery of 1-[(2,4-dimethyl-3-pyridinyl)carbonyl]-4- methyl-4-[3(S)-methyl-4-[1(S)-[4-(trifluoromethyl)phenyl]ethyl]-1-piperazinyl]- piperidine N1-oxide (Sch-350634), an orally bioavailable, potent CCR5 antagonist

Truncation of the original piperidino-2(S)-methyl piperazine lead structure 2, from a family of muscarinic antagonists, gave compound 8 which has improved selectivity for the HIV-1 co-receptor CCR5 over muscarinic receptors. Further optimization for pharmacokinetic properties afforded Sch-350634 (1), a prototypical piperazine-based CCR5 antagonist, which is a potent inhibitor of HIV-1 entry and replication in PBMCs. The title compound (1) has excellent oral bioavailability in rat, dog, and monkey.

Evidence-based medicine and everyday reality

Everyday-life judgements are "fast and frugal" and not numerically rigorous. Clinicians do not (yet) incorporate numerical evidence into their "thinking on the run". Evidence-based medicine is important in generating accurate data, but the existence of data doesn't ensure their use. Only "real time" observation of clinical events and the thinking that shaped them can provide plausible data on how external evidence and internal experience do, or don't, meld within clinical care.

Stories as case knowledge: case knowledge as stories

INTRODUCTION

Every case contains a human story of illness and a medical story of disease, which together cover person management, case management, health system management and self-management. Much of that management can be learned via a thorough set of stories of typical and atypical core cases compiled by clinical teachers. Stories provide a highly flexible framework for illustrating the lessons of experience, the tips and traps for young players, and the dilemmas requiring careful judgement in the trade-offs between benefits and risks. Listening to real stories unfold is much more fun than being lectured (and better remembered).

DISCUSSION

Stories illustrate 'what can happen' in a case as a guide to 'what to do'. A story begins with a real world situation with some predicament and a (causal) sequence of events or plot in which things are resolved one way or another. Patients tell their illness story; their clinician translates that into a disease story. Stories sort out what is important in such a predicament, consider the strategy and tactics of what to do, and speak about the outcomes. Each local situation provides relevance, context and circumstantial detail. Stories about case management can encapsulate practical knowledge, logical deduction, judgement and decision making, sharing with the student all the ingredients that develop expertise. Sometimes it is the plot that is important, sometimes the detail, sometimes it is the underlying message, the parable that resonates with the listener's experiences and feelings.1 Stories can also accommodate the complexity of multiple variables and the influence of other stakeholders, the uncertainties and dilemmas within the trade-offs, and the niceties of 'informed judgement'.

CONCLUSION

This paper makes four points. First, clinical stories recount pointed examples of 'what happened' that expand our expertise in handling 'a case like that'. Second, cases are the unit of clinical work. Case stories expand the dimensions and details of case knowledge, case-based reasoning and case management. Carefully collated case stories can comprise the 'real life' clinical curriculum. Third, stories provide a framework for 'web' or 'net' thinking that links all the objective and subjective details within the multifaceted complexity of case management. Fourth, personal stories explain how both numerical and non-linear influences determined what decision was actually made in that case.

Comparison of transcranial color Doppler imaging (TCDI) and transcranial Doppler (TCD) in children with sickle-cell anemia

BACKGROUND

Transcranial Doppler (TCD) has been demonstrated to identify those at highest risk of stroke among children with sickle-cell disease. Based on a randomized clinical trial [Stroke Prevention in Sickle-Cell Anemia Trial (STOP)], which ended in 1997, the National Heart Lung and Blood Division of NIH has recommended TCD screening and chronic blood transfusion based on Nicolet TC 2000 dedicated Doppler (TCD). Studies performed using TCD imaging modalities need to be correlated to that used in the clinical trial to provide information for treatment decisions when screening with TCDI.

OBJECTIVE

To correlate transcranial arterial time-averaged mean velocities obtained from an Acuson Transcranial Doppler Imaging to those obtained using the TCD as the gold standard for treatment decisions based on STOP.

MATERIALS AND METHODS

A total of 29 children with sickle-cell disease, age 3-16 years, were studied at one of two scanning sessions using both techniques and a scanning protocol based on that used in STOP performed and read independently. The average difference in the measured velocities for each arterial segment was tested to determine difference from zero. Differences were compared before and after modifications to the TCDI technique were made to mimic the STOP protocol more closely.

RESULTS

TCDI velocities were generally lower than TCD velocities for the same segment, but the difference was reduced (from 15 % to 10% for the middle cerebral artery) by modifications to the TCDI protocol.

CONCLUSIONS

Measurements using the Acuson system are modestly lower than those obtained with dedicated Doppler using the Nicolet TCD.

Muscarinic agonists and antagonists in the treatment of Alzheimer's disease

Alzheimer's disease (AD) is a neurodegenerative disease characterized by cognitive impairment and personality changes. The development of drugs for the treatment of the cognitive deficits of AD has focused on agents which counteract loss in cholinergic activity. Although symptoms of AD have been successfully treated with acetylcholinesterase inhibitors (tacrine, donepezil. rivastigmine, galanthamine), limited success has been achieved with direct M1 agonists, probably due to their lack of selectivity versus other muscarinic receptor subtypes. Muscarinic M2 antagonists have been reported to increase synaptic levels of acetylcholine after oral administration to rats (e.g. BIBN-99, SCH-57790), but their selectivity versus other muscarinic receptor subtypes is modest. Exploration of a series of piperidinylpiperidines has yielded the potent and selective M2 antagonist SCH-217443. This antagonist has excellent bioavailability in rats and dogs and shows activity in a rat model of cognition.

Evaluation of the effects of omeprazole on physiological indices of performance of horses during incremental treadmill exercise

Omeprazole is a proton-pump inhibitor recently approved in the United States for the treatment of gastric ulcer disease in horses. A study was designed to determine the effects of omeprazole treatment on the physiological indices of performance of horses during incremental treadmill exercise. In a crossover-design study carried out over 2 weeks, five horses completed standardized incremental exercise tests on a high-speed treadmill either with no treatment or treatment with omeprazole. No statistically significant effects of omeprazole were found on the mean maximum responses for specific oxygen consumption, specific carbon dioxide production, number of steps completed, concentration of plasma lactate, heart rate achieved, or total run time during the standardized incremental exercise protocol. The results indicate omeprazole treatment is unlikely to be associated with marked enhancement of athletic performance.

Bone morphogenetic protein-3 is a negative regulator of bone density

Bone morphogenetic proteins (BMPs) are members of the transforming growth factor-beta (TGF-beta) superfamily. Many BMPs are produced in bone and show osteogenic activity, suggesting that they may be determinants of bone mass. BMP3 was originally purified from bone as osteogenin, which induces osteogenic differentiation. Recombinant BMP3 (rhBMP3) has no biological activity, however, leaving its role in skeletal growth unclear. Here we show that BMP3 is an antagonist of osteogenic BMPs: BMP3 dorsalizes Xenopus laevis embryos, inhibits BMP2-mediated induction of Msx2 and blocks BMP2-mediated differentiation of osteoprogenitor cells into osteoblasts. These effects appear to be mediated through activin receptors. Finally, Bmp3(-/-) mice have twice as much trabecular bone as wild-type littermates, indicating that BMP3, the most abundant BMP in adult bone, is a negative determinant of bone density.

Setting the context for research: exploring the philosophy and environment of a cancer clinical trials unit

This paper describes a process of context setting that was undertaken prior to designing a study to assess the psychosocial impact of participation in phase I and II anticancer drug trials from the patient's perspective. The paper outlines how and why this context setting was undertaken and highlights important aspects of the culture and organization of cancer clinical trials that may influence patients' experiences in trial recruitment and participation. In this way, the context setting proved to be an invaluable tool for providing an orientation to the environment where patients received their care and treatment as well as identifying issues that would need to be taken into consideration later in the research study design.

Enhancing cancer clinical trial management: recommendations from a qualitative study of trial participants' experiences

Using a qualitative approach, a total of 55 adult patients with advanced cancer were interviewed to examine their perceptions of participating in early phase anti-cancer drug trials. Patients' views and experiences were explored, primarily through the use of in-depth interviews, with additional information accessed through two widely-used quality of life questionnaires, at the beginning of, during and after trial participation. The picture of trial participation established from this work suggests that it is a dynamic process, that has a different meaning and impact according to the stage of trial involvement the patient is experiencing. The findings identify how patients perceived the offer of the trial, dealt with the trial treatment, and came to terms with trial conclusion. The insight and understanding that this work provides in terms of the impact of trial involvement over time as well as details of patients' information, decision-making and support needs has significant implications for cancer clinical trial management. The recommendations put forward in this paper focus on acknowledging the contribution trial participants make to cancer research, enhancing the process of preparing patients for trial participation, recognizing the need for continuing care, the incorporation of patients and potential patients' views into the clinical trials system, and educating the public about clinical trials.

The heat-stable antigen determines pathogenicity of self-reactive T cells in experimental autoimmune encephalomyelitis

Induction of myelin-specific CD4 T cells is a pivotal event in the development of experimental autoimmune encephalomyelitis (EAE). Other checkpoints in EAE pathogenesis have not been clearly defined, although multiple genetic loci are known to influence EAE development. We report here that targeted mutation of the heat-stable antigen (HSA) abrogates development of EAE despite a complete lack of effect on induction of autoimmune T cells. To test whether T-cell expression of HSA is sufficient, we created transgenic mice in which HSA is expressed exclusively in the T-cell lineage. We found that these mice remain resistant to EAE induction. Adoptive transfer studies demonstrate that both T cells and non-T cells must express HSA in order for the pathogenic T cells to execute their effector function. Moreover, HSAIg, a fusion protein consisting of the extracellular domain of the HSA and the Fc portion of immunoglobulin, drastically ameliorates the clinical sign of EAE even when administrated after self-reactive T cells had been expanded. Thus, identification of HSA as a novel checkpoint, even after activation and expansion of self-reactive T cells, provides a novel approach for immunotherapy of autoimmune neurologic diseases, such as multiple sclerosis.

Endotracheal lidocaine administration via an esophageal combitube

The purpose of this study was to test the hypothesis that lidocaine is systemically absorbed after administration via a Combitube placed in the esophagus, and that therapeutically significant plasma lidocaine concentrations can be attained using this route with standard endotracheal doses (2.0 mg/kg). During general anesthesia, 27 elective surgical patients received 2.0 mg/kg lidocaine (diluted as necessary with 0.9% saline to a minimum total volume of 10 mL) via a Combitube (study group, n = 13) or an endotracheal tube (control group, n = 14). Venous blood samples were drawn for 3 h after lidocaine administration and plasma concentrations determined by gas chromatography using a nitrogen-phosphorus detector (NPD). Overall, average lidocaine concentrations were maximal after 5 min, reaching 0.8+/-0.7 and 1.7+/-0.7 microg/mL in the Combitube and endotracheal tube groups, respectively. Individual patient peak concentrations averaged 1.0+/-0.7 and 2.2+/-1.1 microg/mL in the same two groups, 19+/-16 and 10+/-15 min after lidocaine administration, respectively. No patients reported chest discomfort or dyspnea upon awakening, and no other side effects were noted. In support of the hypothesis, administration of lidocaine via an esophageal Combitube results in systemic drug uptake; however, at conventional endotracheal doses, plasma concentrations are subtherapeutic. It remains to be determined whether higher doses of lidocaine administered via an esophageal Combitube will result in therapeutic plasma concentrations.

Human halothane metabolism, lipid peroxidation, and cytochromes P(450)2A6 and P(450)3A4

OBJECTIVE

Halothane undergoes both oxidative and reductive metabolism by cytochrome P450 (CYP), respectively causing rare immune-mediated hepatic necrosis and common, mild subclinical hepatic toxicity. Halothane also causes lipid peroxidation in rodents in vitro and in vivo, but in vivo effects in humans are unknown. In vitro investigations have identified a role for human CYPs 2E1 and 2A6 in oxidation and CYPs 2A6 and 3A4 in reduction. The mechanism-based CYP2E1 inhibitor disulfiram diminished human halothane oxidation in vivo. This investigation tested the hypotheses that halothane causes lipid peroxidation in humans in vivo, and that CYP2A6 or CYP3A4 inhibition can diminish halothane metabolism.

METHODS

Patients (n = 9 each group) received single doses of the mechanism-based inhibitors troleandomycin (CYP3A4), methoxsalen (CYP2A6) or nothing (controls) before a standard halothane anaesthetic. Reductive halothane metabolites chlorotrifluoroethane and chlorodifluoroethylene in exhaled breath, fluoride in urine, and oxidative metabolites trifluoroacetic acid and bromide in urine were measured for 48 h postoperatively. Lipid peroxidation was assessed by plasma F2-isoprostane concentrations.

RESULTS

The halothane dose was similar in all groups. Methoxsalen decreased 0- to 8-h trifluoroacetic acid (23 +/- 20 micromol vs 116 +/- 78 micromol) and bromide (17 +/- 11 micromol vs 53 +/- 49 micromol) excretion (P < 0.05), but not thereafter. Plasma F2-isoprostanes in controls were increased from 8.5 +/- 4.5 pg/ml to 12.5 +/- 5.0 pg/ml postoperatively (P < 0.05). Neither methoxsalen nor troleandomycin diminished reductive halothane metabolite or F2-isoprostane concentrations.

CONCLUSIONS

These results provide the first evidence for halothane-dependent lipid peroxidation in humans. Methoxsalen effects on halothane oxidation confirm in vitro results and suggest limited CYP2A6 participation in vivo. CYP2A6-mediated, like CYP2E1-mediated human halothane oxidation, can be inhibited in vivo by mechanism-based CYP inhibitors. In contrast, clinical halothane reduction and lipid peroxidation were not amenable to suppression by CYP inhibitors.

Examining and recording clinical performance: a critique and some recommendations

Clinical performance is too complex and interactive for measurement. Judgment is always necessary for its assessment. Experienced clinicians judge trainee performance on many small details. This clinical judgment turns on the trainee's handling of important details in the patient and the malady. But the recording of performance retreats to categories and checklists that contain nothing of those critical details or the trainee's judgment. Checklists are incapable of identifying what actually happened, and 'could do' categories have no predictive accuracy in asserting what cases a trainee can actually manage. Clinical examinations have even been subverted by the naive, pseudorational error that competence is defined by obedience to doing exactly what someone else expects you to do in every case, as in an OSCE examination. Cases are the unit of clinical practice. The clinical curriculum should be comprised of the critical core cases the trainee must be able to handle in each discipline. Case management, procedural skills and professional behavior can be assessed accurately only in the context of daily clinical work. Formal examinations lack the range of cases and open-ended time that allow examiners to explore a trainee's case knowledge and judgment. Habitual behavior can be assessed only by observing habitual behavior in everyday practice. Assessment and recording should take place only in real world settings, focused on performance on the core cases trainees must be competent to manage.

Workplace adjustment and intergenerational differences between matures, boomers, and xers

The authors explored the factors influencing occupational adjustment related to workplace stress among 413 nurses at a Midwestern pediatric hospital. Among critical factors found in responses to their questionnaire and follow-up focus groups were differences in work adjustment and intergenerational conflicts. Both real and perceived workplace stress can manifest itself both fiscal and human costs by increasing turnover, absenteeism and worker's compensation claims as well as "faulty products and negative behaviors." Baby boomers (those born between 1946 and 1964) and Generation Xers (those born between 1965 and 1981) reported quite different issues and perceptions of occupational stress.

Significance of detecting Epstein-Barr-specific sequences in the peripheral blood of asymptomatic pediatric liver transplant recipients

Pediatric allograft recipients are at increased risk for Epstein-Barr virus (EBV)-associated illnesses. The early identification and diagnosis of EBV-associated disorders is critical because disease progression can often be curtailed by modification of immunosuppression. We have previously shown that detection of EBV-specific sequences in the circulation by polymerase chain reaction (PCR) correlated well with the clinical symptoms of EBV infection. The purpose of the current study is to determine the significance of detecting EBV-specific sequences by PCR in asymptomatic pediatric liver transplant recipients. Peripheral-blood DNA was analyzed for the EBV genes, coding from the nuclear antigen 1 (EBNA-1) and the viral capsid antigen (gp220) by PCR. Samples from asymptomatic pediatric liver transplant recipients were analyzed from the immediate postoperative period and at 2- to 4-month intervals thereafter. We followed up 13 of these asymptomatic recipients who tested positive for EBV compared with 7 asymptomatic recipients who tested negative for EBV during the early posttransplantation period. Follow-up ranged from 1.5 to 4 years posttransplantation. Nine patients (69%) initially positive for EBV and asymptomatic ultimately developed symptoms of EBV infection, including fever, lymphadenopathy, rash, respiratory and gastrointestinal symptoms, and/or hepatitis. Five of these patients (56%) went on to develop posttransplant lymphoproliferative disorder based on histological examination of biopsied tissue and immunohistochemical identification of the EBV antigen/DNA in tissue. This is the first report suggesting that detection of EBV-specific sequences in the absence of symptoms may herald impending EBV-associated disorders. Thus, routine monitoring for circulating EBV sequences in asymptomatic recipients may be useful in the early identification of those at risk for developing EBV-associated disease and its ultimate prevention.

Mapping and expression of a bifunctional thymidylate synthase, dihydrofolate reductase gene from maize

A bifunctional gene (ZmDHFR-TS) encoding dihydrofolate reductase (DHFR) and thymidylate synthase (TS) was cloned from a Zea mays cDNA library. Both of these enzymes are involved in nucleotide biosynthesis, specifically in the formation of thymidine monophosphate (TMP). Comparison of the deduced amino acid sequence with DHFR-TS sequences from three other plant sources revealed over 75% similarity and motifs typical of DHFR-TS proteins. Two copies of the gene were mapped to chromosomes 2 and 4. This represents the first DHFR-TS gene cloned from a monocotyledonous plant. Expression of ZmDHFR-TS was examined in developing kernels and various tissues of maize by RNA gel blot hybridization analysis in order to determine the relationship between expression of this gene and DNA synthesis. RNA transcripts for ZmDHFR-TS accumulated to high levels in developing maize kernels when endosperm cells were undergoing endoreduplication and cell division. Meristematic maize tissues had high levels of ZmDHFR-TS mRNA, but transcripts were barely detectable in RNA isolated from the root elongation zone and from mature leaf tissues.

Clinical isoflurane metabolism by cytochrome P450 2E1

BACKGROUND

Some evidence suggests that isoflurane metabolism to trifluoroacetic acid and inorganic fluoride by human liver microsomes in vitro is catalyzed by cytochrome P450 2E1 (CYP2E1). This investigation tested the hypothesis that P450 2E1 predominantly catalyzes human isoflurane metabolism in vivo. Disulfiram, which is converted in vivo to a selective inhibitor of P450 2E1, was used as a metabolic probe for P450 2E1.

METHODS

Twenty-two elective surgery patients who provided institutionally-approved written informed consent were randomized to receive disulfiram (500 mg orally, N = 12) or nothing (controls, N = 10) the evening before surgery. All patients received a standard isoflurane anesthetic (1.5% end-tidal in oxygen) for 8 hr. Urine and plasma trifluoroacetic acid and fluoride concentrations were quantitated in samples obtained for 4 days postoperatively.

RESULTS

Patient groups were similar with respect to age, weight, gender, duration of surgery, blood loss, and delivered isoflurane dose, measured by cumulative end-tidal isoflurane concentrations (9.7-10.2 MAC-hr). Postoperative urine excretion of trifluoroacetic acid (days 1-4) and fluoride (days 1-3) was significantly (P<0.05) diminished in disulfiram-treated patients. Cumulative 0-96 hr excretion of trifluoroacetic acid and fluoride in disulfiram-treated patients was 34+/-72 and 270+/-70 micromoles (mean +/- SD), respectively, compared to 440+/-360 and 1500+/-800 micromoles in controls (P<0.05 for both). Disulfiram also abolished the rise in plasma metabolite concentrations.

CONCLUSIONS

Disulfiram, a selective inhibitor of human hepatic P450 2E1, prevented 80-90% of isoflurane metabolism. These results suggest that P450 2E1 is the predominant P450 isoform responsible for human clinical isoflurane metabolism in vivo.

Menstrual cycle variability in midazolam pharmacokinetics

Activity of cytochrome P450 3A4 (CYP3A4), the most abundant human P450 isoform and responsible for metabolizing approximately half of all therapeutic agents, has been speculated to vary during the menstrual cycle. This investigation evaluated CYP3A4 activity during the menstrual cycle, using midazolam clearance as a metabolic probe. Midazolam (1 mg i.v.) was administered to nonsmoking, nonpregnant female volunteers (N = 11, age 26 +/- 5 years) with normal menstrual cycles on three separate occasions during the same cycle: days 2 (menstrual phase), 13 (estradiol peak), and 21 (progesterone peak). Venous plasma midazolam concentrations were determined by gas chromatography-mass spectrometry. Midazolam clearance was determined by noncompartmental and compartmental analysis. Midazolam plasma disposition did not differ between phases of the menstrual cycle. There was no significant difference in any measure of midazolam clearance. Noncompartmental clearances (mean +/- SD) were 7.36 +/- 2.73, 6.34 +/- 3.59, and 6.23 +/- 2.04 ml/kg/min, respectively, on days 2, 13, and 21 of the menstrual cycle. These results suggest no difference in hepatic CYP3A4 activity on menstrual cycle days 2, 13, and 21. Consideration of menstrual cycle variability in the metabolism of CYP3A4 substrates does not appear indicated in the dosing or design of clinical trials.

Development of an automated mass spectrometry system for the quantitative analysis of liver microsomal incubation samples: a tool for rapid screening of new compounds for metabolic stability

There is a continuing need for increased throughput in the evaluation of new drug entities in terms of their pharmacokinetic parameters. One useful parameter that can be measured in vitro using liver microsomal preparations is metabolic stability. In this report, we describe an automated system that can be used for unattended quantitative analysis of liver microsomal samples for a series of compounds. This system is based on the Sciex API 150 (single quadrupole) liquid chromatography/mass spectrometry system and utilizes 96-well plate autosampler technology as well as a custom-designed AppleScript which executes the on-line data processing and report generation. It has the capability of analyzing at least 75 compounds per week or 300 compounds per month in an automated fashion.

Posttransplant lymphoproliferative disorders and gastrointestinal manifestations of Epstein-Barr virus infection in children following liver transplantation

BACKGROUND

Epstein-Barr virus (EBV) infection is common after liver transplantation in children and is associated with the risk of posttransplant lymphoproliferative disorders (PTLD).

METHODS

This retrospective study examined the frequency of gastrointestinal (GI) symptoms and the risk of PTLD in pediatric liver recipients who developed symptomatic EBV infection. We reviewed 172 children who received orthotopic liver transplants between March 1988 to December 1994. Twenty-two cases were retransplants. The mean age at transplantation was 3.7 years (range, 0.1-17 years). The immunosuppressive regimens consisted of induction therapy with Minnesota antilymphocyte globulin/antithymocyte globulin/OKT3 in most cases and maintenance therapy with prednisone and either cyclosporine or tacrolimus (FK506).

RESULTS

After 1 year of minimum follow-up, 54 of 172 patients had symptomatic EBV infections (confirmed by serology, histology, or whole blood polymerase chain reaction. At the time of infection, 38.5% (21/54) had either diarrhea or GI bleeding or both. PTLD developed in 11 patients (6.4%). The incidence of PTLD was 42.9% (9/21) when GI bleeding or diarrhea was associated with EBV infections, compared with 6.1% (2/33) when EBV infection was not associated with GI symptoms. Seven of 10 (70%) patients with GI bleeding and 2 of 11 (18.2%) with diarrhea developed PTLD. Of seven patients examined by endoscopy for GI bleeding, two had biopsy-proven PTLD of the GI tract, whereas one of two patients examined by endoscopy for diarrhea had biopsy-proven PTLD.

DISCUSSION

In summary, a high incidence of PTLD was found in patients who developed GI bleeding or diarrhea associated with EBV infection after pediatric liver transplantation. In these patients, endoscopy and biopsy may lead to early diagnosis of PTLD.