Immune reconstitution after combined haploidentical and umbilical cord blood transplant

Umbilical cord blood (UCB) stem cells are frequently employed for allogeneic stem cell transplant, but delayed myeloid and lymphoid immune reconstitution leads to increased risk of infections. We recently reported the clinical results of 45 patients enrolled on a pilot study combining UCB with a human leukocyte antigen (HLA)-haploidentical donor with reduced-intensity conditioning who showed rapid neutrophil and platelet recovery. We report here preliminary immune reconstitution data of these patients. Patients were assessed for lymphocyte subsets, T-cell diversity, Cylex ImmuKnow assay and serological response to pneumococcal vaccination. Natural killer (NK)-cell and B-cell reconstitution were rapid at 1 month and 3 months, respectively. T-cell recovery was delayed, with a gradual increase in the number of T-cells starting around 6 months post-transplant, and was characterized by a diverse polyclonal T-cell repertoire. Overall, immune reconstitution after haplo-cord transplant is similar to that seen after cord blood transplant, despite infusion of much lower cord blood cell dose.

Prevalence of cerebral palsy in Quebec: alternative approaches

AIM

To provide an estimate of the period prevalence of cerebral palsy (CP) in the province of Quebec.

METHODS

Children with CP were identified from three consecutive birth cohorts (1999-2001) from the Quebec CP Registry, covering 6 of the 17 administrative health regions of the province. Two inferential approaches were applied for period prevalence estimation, frequentist and bayesian.

RESULTS

228 children were identified with CP. Using a frequentist approach, the overall prevalence of CP was 1.84 per 1,000 children aged 9-11 years living in those areas in 2010 (95% CI 1.60-2.08). Using a bayesian approach taking into account the uncertainty about the registry's sensitivity in capturing all cases, the overall prevalence is higher at 2.30 per 1,000 children with a 95% CI (1.99-2.65).

CONCLUSION

Using a bayesian approach to adjust for the registry's known high specificity and lower sensitivity, the prevalence estimate is in concordance with worldwide estimates and estimates using administrative databases in western Canadian provinces. Future studies are needed to validate the diagnosis of CP within administrative databases and to evaluate possible regional trends across Canada in both prevalence and health service utilization, which may highlight disparities in healthcare delivery.

Vitamin supplementation and blood pressure in Type 2 diabetes

AIMS

Vitamin D levels are inversely related to blood pressure. Given that low sun exposure can create a greater reliance on dietary sources of vitamin D, we aimed to determine whether dietary vitamin D and blood pressure associations differ between periods of low and high sun exposure.

METHODS

Dietary intake, vitamin supplementation, blood pressure, and anthropometric parameters were assessed each season for 1 year (174 adults with Type 2 diabetes). Separate linear regression models were constructed for high and low sun exposure periods to examine associations of systolic blood pressure with dietary vitamin D intake and vitamin supplement use (adjusted for age, gender, BMI, ethnicity, smoking, alcohol, physical activity, antihypertensive medication and nutrient intake). Robustness of findings was confirmed with within-subject repeated measures analysis, including an interaction term for sun exposure period.

RESULTS

Vitamin D intake from food sources was low year-round and no conclusive association with blood pressure was identified during either period. Systolic blood pressure was 5.1 mmHg lower during the low sun exposure period (95% CI 0.5-9.7) in daily supplement users compared with non-users. The interaction term between supplement use and sun exposure period was significant (low sun exposure* no supplement, P = 0.02). Systolic blood pressure was relatively stable in users (low and high sun exposure periods, respectively, mean ± SE: 135.2 ± 2.6 mmHg and 134.2 ± 2.5 mmHg), but not in non-users (140.2 ± 2.7 mmHg and 130.5 ± 2.5 mmHg).

CONCLUSIONS

Vitamin supplementation may stabilize systolic blood pressure in adults with Type 2 diabetes across seasons.

Both stromal cell and colonocyte epidermal growth factor receptors control HCT116 colon cancer cell growth in tumor xenografts

Colon cancer growth requires growth-promoting interactions between malignant colonocytes and stromal cells. Epidermal growth factor receptors (EGFR) are expressed on colonocytes and many stromal cells. Furthermore, EGFR is required for efficient tumorigenesis in experimental colon cancer models. To dissect the cell-specific role of EGFR, we manipulated receptor function on stromal cells and cancer cells. To assess the role of stromal EGFR, HCT116 human colon cancer cells were implanted into immunodeficient mice expressing dominant negative (DN) Egfr(Velvet/+) or Egfr(+/+). To assess the role of cancer cell EGFR, HCT116 transfectants expressing inducible DN-Egfr were implanted into immunodeficient mice. To dissect EGFR signals in vitro, we examined colon cancer cells in monoculture or in cocultures with fibroblasts for EGFR transactivation and prostaglandin synthase 2 (PTGS2) induction. EGFR signals were determined by blotting, immunostaining and real-time PCR. Tumor xenografts in Egfr(Velvet/+) mice were significantly smaller than tumors in Egfr(+/+) mice, with decreased proliferation (Ki67) and increased apoptosis (cleaved caspase-3) in cancer cells and decreased stromal blood vessels. Mouse stromal transforming growth factor alpha (TGFA), amphiregulin (AREG), PTGS2 and Il1b and interleukin-1 receptor 1 (Il1r1) transcripts and cancer cell beta catenin (CTNNB1) and cyclin D1 (CCND1) were significantly lower in tumors obtained from Egfr(Velvet/+) mice. DN-EGFR HCT116 transfectants also formed significantly smaller tumors with reduced mouse Areg, Ptgs2, Il1b and Il1r1 transcripts. Coculture increased Caco-2 phospho-active ERBB (pERBB2), whereas DN-EGFR in Caco-2 cells suppressed fibroblast PTGS2 and prostaglandin E2 (PGE2). In monoculture, interleukin 1 beta (IL1B) transactivated EGFR in HCT116 cells. Stromal cell and colonocyte EGFRs are required for robust EGFR signals and efficient tumor growth, which involve EGFR-interleukin-1 crosstalk.

Mortality in diabetes compared with previous cardiovascular disease: a gender-specific meta-analysis

AIMS

Diabetes has been described as a cardiovascular disease (CVD) risk equivalent. There is evidence, however, that its impact may differ between women and men. For this reason, our study aimed to obtain gender-specific hazard ratios (HRs) comparing diabetes and CVD patients in terms of all-cause, CVD and coronary heart disease (CHD) mortality.

METHODS

Individuals with diabetes (without CVD) and those with CVD (without diabetes) were examined through a systematic review of articles that provided gender-specific HRs for mortality. Searches included Medline, Embase and the Cochrane Library database (from January 1998 to December 2009) and exploded MeSH headings [cardiovascular diseases, risk, epidemiologic studies, case-control studies, cohort studies, mortality, outcome assessment (health care), sex factors, survival analysis and diabetes mellitus, type 2]. Two observers selected and reviewed the studies and hierarchical Bayesian random-effects models were used to combine HRs, thereby accommodating any between-study differences through inclusion of a between-study variance in HRs.

RESULTS

Out of 5425 studies, nine were relevant (0.17%). CVD and CHD mortality in men was lower for diabetes alone (CVD mortality HR: 0.82, 95% CrI: 0.69-0.98; CHD mortality HR: 0.73, 95% CrI: 0.65-0.83). In contrast, rates appeared to be higher in women with diabetes alone (CVD mortality HR: 1.29, 95% CrI: 0.79-2.26; CHD mortality HR: 1.28, 95% CrI: 0.75-2.22), although wide credible intervals precluded any definitive conclusions. All-cause mortality in men was similar for diabetes and previous CVD (HR: 1.02, 95% CrI: 0.93-1.12) whereas, among women, it was at least as high and possibly higher for diabetes alone (HR: 1.25, 95% CrI: 0.89-1.76).

CONCLUSION

Compared with previous CVD, diabetes alone leads to lower CVD and CHD mortality risk in men, and similar all-cause mortality. In contrast, although further studies are needed, it is possible that diabetes leads to higher CVD, CHD and all-cause mortality in women.

Single center experience treating adults with FLT3-mutated acute myeloid leukemia (AML)

6562

Background: Activating mutations of the fms-like tyrosine kinase-3 (FLT3) gene are common in AML. Depending upon the allele mutation fraction, these mutations have been associated with poor outcomes in prospective multi-center trials. Methods: We studied a consecutive series of adults with FLT3-mutated leukemia at our institution since we began testing in 2006 through Sept 2011. Clinical characteristics and patient (pt) outcomes were extracted through a retrospective chart review and analyzed using logistic regression and Cox proportional hazard models. Results: We identified 73 pts with a FLT3 mutation (71 with AML and 2 with myelodysplasia with <20% blasts). 62 (85%) presented to our institution at initial diagnosis; 11 (15%) were diagnosed elsewhere and seen by us only at relapse. 44 (60%) were men and 51 (70%) were white. Median age was 62 yrs (range, 19-90); 48% were <60 yrs old. 63 (86%) had an internal tandem duplication (ITD) mutation, 9 (12%) had the D835 point mutation (TKD), and 1 had both. An NPM1 mutation was also present in 26 (36%). Median white blood cell count at diagnosis was 53 x 103/µL (range, 0.8 - 466). 34 (47%) had monocytic morphology (M4 or M5). 8 (11%) pts had favorable karyotypes; 50 (68%) had normal karyotypes; 13 (18%) had unfavorable karyotypes. 58 (79%) received standard induction therapy (anthracycline + cytarabine for most; ATRA + arsenic trioxide for 3 with APL); 46/58 (79%) achieved a complete remission (CR). Including the 15 pts who received only low intensity therapies, 40/64 (63%) with an ITD and 6/9 (67%) with a TKD mutation achieved CR. 31 (42%) pts received an allogeneic transplant, 21 in first CR (CR1) and 10 after relapse. Median overall survival (OS) for the whole group was 417 days (95% CI: 291-780); it was 684 days for those diagnosed at our institution and 285 days for those seen only after relapse. Median disease-free survival (DFS) in CR1 was 417 days. Median OS for pts transplanted in CR1 was 1262 days from initial diagnosis and 416 days for those transplanted after relapse. DFS did not differ with or without a transplant (median, 526 vs 305 days; p=.64). Conclusions: FLT3-mutated AML is heterogeneous. Our single center experience is similar to that reported from multi-center trials.

Abdominal adiposity and daily step counts as determinants of glycemic control in a cohort of patients with type 2 diabetes mellitus

Objective:

Favorable effects of walking levels on glycemic control have been hypothesized to be mediated through reductions in abdominal adiposity, but this has not been well studied. We addressed this issue in patients treated for type 2 diabetes.

Design:

Cross-sectional analysis.

Subjects:

A total of 201 subjects with type 2 diabetes underwent assessments of pedometer-measured daily step counts, blood pressure, A1C and anthropometric measures (2006–2010). Associations of anthropometric indicators of abdominal adiposity (that is, waist circumference; waist-to-hip ratio (WHR)) with A1C were evaluated through linear regression models adjusting for age, ethnicity, sex and the use of insulin and oral hypoglycemic agents. Models including waist circumference were additionally adjusted for body mass index (BMI). A similar approach was used to examine A1C and daily step associations.

Results:

Among the 190 subjects (mean age 60 years; mean BMI 30.4 kg m⁻²), mean values (s.d.) for waist circumference and WHR were respectively, 99.1 cm (13.3) and 0.88 (0.07) in women, and 104.5 cm (13.1) and 0.97 (0.06) in men. Mean A1C and daily step count were respectively, 7.6% (1.4) and 5 338 steps per day (2609), and were similar for both sexes.

There was a 0.51% (95% confidence interval (CI): 0.10, 0.93) A1C increment per s.d. increase in waist circumference and a 0.32% (95% CI: 0.08, 0.56) A1C increment per s.d. increase in WHR in fully adjusted models. Each s.d. increase in daily step count was associated with clinically significant reductions in waist circumference and BMI. Each s.d. increase in daily steps was associated with a 0.21% (95% CI: 0.02, 0.41) A1C decrement that declined to 0.16% (95% CI: −0.35, 0.04) with further adjustment for anthropometric indicators of abdominal adiposity.

Conclusion:

Higher daily steps may be associated with lower A1C values both directly and via changes in abdominal adiposity.

Primary carnitine deficiency and sudden death: in vivo evidence of myocardial lipid peroxidation and sulfonylation of sarcoendoplasmic reticulum calcium ATPase 2

OBJECTIVES

Primary carnitine deficiency is an autosomal recessive disorder caused by mutations in the SLC22A5 gene which results in impaired carnitine transport, cytosolic fatty acid accumulation and impaired beta oxidation. The disease is associated with cardiomyopathy and arrhythmias, but the mechanism is unknown. We hypothesized that carnitine deficiency results in increased myocardial oxidative stress.

METHODS

We evaluated a 22-year-old woman with primary carnitine deficiency and ventricular fibrillation, as well as her first-degree relatives.

RESULTS

Sequencing of SLC22A5 identified two deleterious mutations (A142S and R488H) and a novel mutation predicted to be a splice variant. Histology demonstrated increased myocardial lipid deposition and swollen mitochondria. Immunohistochemistry demonstrated accumulation of the reactive aldehyde 4-hydroxy-2-nonenal, indicative of increased lipid peroxidation, and sulfonylation of sarcoendoplasmic reticulum calcium ATPase 2 at cysteine 674.

CONCLUSIONS

These findings suggest that increased oxidant stress may contribute to myocardial dysfunction and arrhythmogenesis in this disorder.

Association of the Charlson comorbidity index with mortality in systemic lupus erythematosus

OBJECTIVE

To investigate whether comorbidity as assessed by the Charlson Comorbidity Index (CCI) is associated with mortality in a long-term followup of systemic lupus erythematosus (SLE) patients.

METHODS

Data were collected from 499 SLE patients attending the Lupus Clinic at the McGill University Health Center, Montreal, Quebec, Canada, and 170 SLE patients from the Department of Rheumatology at Lund University Hospital, Lund, Sweden. This included data on comorbidity, demographics, disease activity, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI), and antiphospholipid antibody syndrome (APS). Variables were entered into a Cox proportional hazards survival model.

RESULTS

Mortality risk in the Montreal cohort was associated with the CCI (hazard ratio [HR] 1.57 per unit increase in the CCI, 95% confidence interval [95% CI] 1.18-2.09) and age (HR 1.04 per year increase in age, 95% CI 1.00-1.09). The CCI and age at diagnosis were also associated with mortality in the Lund cohort (CCI: HR 1.35, 95% CI 1.13-1.60; age: HR 1.09, 95% CI 1.05-1.12). Furthermore, the SDI was associated with mortality in the Lund cohort (HR 1.40, 95% CI 1.19-1.64), while a wide CI for the estimate in the Montreal cohort prevented a definitive conclusion (HR 1.20, 95% CI 0.97-1.48). We did not find a strong association between mortality and sex, race/ethnicity, disease activity, or APS in either cohort.

CONCLUSION

In this study, comorbidity as measured by the CCI was associated with decreased survival independent of age, lupus disease activity, and damage. This suggests that the CCI may be useful in capturing comorbidity for clinical research in SLE.

Features associated with cardiac abnormalities in systemic lupus erythematosus

OBJECTIVES

To determine the prevalence of echocardiographic abnormalities and identify associated clinical and laboratory features in a large systemic lupus erythematosus (SLE) cohort.

METHODS

Patients fulfilling ACR criteria for SLE underwent a transthoracic echocardiogram (TTE) between January 2005 and June 2006. Variables used as potential correlates included age, sex, ethnicity, lupus duration, lupus disease activity (SLEDAI), cumulative damage (SLICC/ACR damage index (DI)), arterial hypertension, diabetes, current smoking, medication use and laboratory data. Multivariate logistic regression was used to examine the association between TTE abnormalities and potential determinants.

RESULTS

For the 217 subjects with a TTE performed during the study, the main abnormalities were of the mitral valve (37.3%) and included thickening (25.4%) and insufficiency (25.8%). Other findings included pulmonary artery pressure (PAP)  ≥  30( )mm( )Hg (10.1%), pericardial effusion (4.6%), hypokinesis (2.8%), and aortic insufficiency (3.7%). In multivariate analysis, mitral insufficiency was associated with the use of corticosteroids (OR 2.90; 95%CI 1.42-5.94) and hypokinesis with angiotensin-converting enzyme inhibitors (12.89; 1.06-157.18). Elevated PAP was associated with age (1.04; 1.01-1.07) and with DI (1.20; 1.01-1.42).

CONCLUSION

Valvular abnormalities are frequent in patients with SLE, with mitral valve lesions occurring in over one third. TTE screening may be indicated in patients with SLE, especially for those with identified risk factors such as corticosteroid use.

The effect of smoking cessation counselling in pregnant women: a meta-analysis of randomised controlled trials

BACKGROUND

Pregnant smokers are often prescribed counselling as part of multicomponent cessation interventions. However, the isolated effect of counselling in this population remains unclear, and individual randomised controlled trials (RCTs) are inconclusive.

OBJECTIVE

To conduct a meta-analysis of RCTs examining counselling in pregnant smokers.

SEARCH STRATEGY

We searched the CDC Tobacco Information and Prevention, Cochrane Library, EMBASE, Medline and PsycINFO databases for RCTs evaluating smoking cessation counselling.

SELECTION CRITERIA

We included RCTs conducted in pregnant women in which the effect of counselling could be isolated and those that reported biochemically validated abstinence at 6 or 12 months after the target quit date.

DATA COLLECTION AND ANALYSIS

Overall estimates were derived using random effects meta-analysis models.

MAIN RESULTS

Our search identified eight RCTs (n = 3290 women), all of which examined abstinence at 6 months. The proportion of women that remained abstinent at the end of follow up was modest, ranging from 4 to 24% among those randomised to counselling and from 2 to 21% among control women. The absolute difference in abstinence reached a maximum of only 4%. Summary estimates are inconclusive because of wide confidence intervals, albeit with little evidence to suggest that counselling is efficacious at promoting abstinence (odds ratio 1.08, 95% confidence interval 0.84-1.40). There was no evidence to suggest that efficacy differed by counselling type.

CONCLUSIONS

Available data from RCTs examining the isolated effect of smoking cessation counselling in pregnant women are limited but sufficient to rule out large treatment effects. Future RCTs should examine pharmacological therapies in this population.

EGFR signals downregulate tumor suppressors miR-143 and miR-145 in Western diet-promoted murine colon cancer: role of G1 regulators

Epidermal growth factor receptors (EGFR) contribute to colonic tumorigenesis in experimental models of colon cancer. We previously showed that EGFR was also required for colonic tumor promotion by Western diet. The goal of this study was to identify EGFR-regulated microRNAs that contribute to diet-promoted colonic tumorigenesis. Murine colonic tumors from Egfr(wt) and hypomorphic Egfr(wa2) mice were screened using micro RNA (miRNA) arrays and miR-143 and miR-145 changes confirmed by Northern, real-time PCR, and in situ analysis. Rodent and human sporadic and ulcerative colitis (UC)-associated colon cancers were examined for miR-143 and miR-145. Effects of EGFR on miR-143 and miR-145 expression were assessed in murine and human colonic cells and their putative targets examined in vitro and in vivo. miR-143 and miR-145 were readily detected in normal colonocytes and comparable in Egfr(wt) and Egfr(wa2) mice. These miRNAs were downregulated in azoxymethane and inflammation-associated colonic tumors from Egfr(wt) mice but upregulated in Egfr(wa2) tumors. They were also reduced in human sporadic and UC colon cancers. EGFR signals suppressed miR-143 and miR-145 in human and murine colonic cells. Transfected miR-143 and miR-145 inhibited HCT116 cell growth in vitro and in vivo and downregulated G(1) regulators, K-Ras, MYC, CCND2, cdk6, and E2F3, putative or established targets of these miRNAs. miRNA targets Ras and MYC were increased in colonic tumors from Egfr(wt) but not Egfr(wa2) mice fed a Western diet. EGFR suppresses miR-143 and miR-145 in murine models of colon cancer. Furthermore, Western diet unmasks the tumor suppressor roles of these EGFR-regulated miRNAs.