Use of intravenous FK506 to treat acute rejection in simultaneous pancreas-kidney transplant recipients on maintenance oral FK506

Most recipients of simultaneous pancreas-kidney transplants experience acute rejection in the early postoperative course. We report our experience with four recipients of simultaneous pancreas-kidney transplants with acute rejection who were effectively treated with the combination of intravenous and oral FK506 therapy. This spared these patients an extra course of monoclonal or polyclonal antibody.

Modulatory effects of human donor bone marrow cells on allogeneic cellular immune responses

BACKGROUND

In order to evaluate whether immunoregulatory mechanisms are brought about by human donor bone marrow cell infusions accompanying organ transplantation, we established in vitro culture systems analogous to the transplant model.

METHODS

Cell-mediated lympholysis (CML) and mixed lymphocyte culture (MLC) responses of peripheral blood lymphocytes or spleen cells stimulated with irradiated cadaver donor spleen cells in the presence of specific donor vertebral-body bone marrow cell (DBMC) modulators were tested.

RESULTS

When compared with spleen cells as modulator controls, DBMC inhibited both the proliferative and cytotoxic responses in a dose-dependent manner. Use of unirradiated and T cell-depleted DBMC was required for detection of the inhibitory activity. Furthermore, DBMC had to be added within the first 2 days after the initiation of the cultures for the down-regulation of CML (MLC) to occur. The down-regulation of MLC responses could not be shown to be antigen (donor) specific. Physical separation of DBMC from the responder-stimulator cells using the transwell system abrogated modulation of the CML (and MLC) reactions, suggesting the requirement of cell-cell contact for modulatory effect. The inhibitory activity by DBMC could not be overcome by addition of up to 200 U/ml of exogenous recombinant interleukin 2 to the cultures. However, it could be abrogated by restimulation with donor spleen cells, indicating that donor reactive cells were not deleted by DBMC in short-term cultures.

CONCLUSIONS

These results showed a regulatory role for DBMC in cellular immune responses against donor cell alloantigens, supporting the rationale for DBMC for facilitating clinical allograft acceptance.

[Maggot therapy for gangrene and osteomyelitis]

5 patients with diabetic-foot were treated by maggot therapy. The most serious case was in a 75-year-old man who had gangrene and osteomyelitis of the right foot. Proteus mirabilis, Enterococcus sp., Providencia stuartii and Staphylococcus spec. (coagulase positive) were isolated from lesions which did not respond to antibiotic therapy. The patient had twice refused amputation but agreed to maggot therapy. Larvae of the sheep blowfly Phoenicia (Lucilia) sericata were used for twice-weekly treatment over a period of 7 months. Sterile larvae were applied to the wound and replaced every 3-4 days. After 4 months of treatment, the necrotic tissue around the toes and on the sole of the foot detached from the healthy tissue. During the last 3 months of treatment the larvae removed the remaining infected tissue. As therapy progressed, new layers of healthy tissue covered the wound. The offensive odor associated with the necrotic tissue and the intense pain in the foot decreased significantly. At the end of therapy, during which there were no complaints of discomfort, he was able to walk. In the 4 other patients who had relatively superficial gangrene, the maggots debrided the wounds within 2-4 weeks. Thereafter treatment was continued with antibiotics. Maggot therapy can be recommended in cases of intractable gangrene and osteomyelitis, when treatment with antibiotics and surgical debridement have failed.

The immune reactivity role of HCV-induced liver infiltrating lymphocytes in hepatocellular damage

Liver infiltrating lymphocytes (LIL) were isolated from HCV-positive (+) and HCV-negative (-) end-stage livers. Phenotypic analysis and functional studies using proliferative and lymphocytotoxic assays were performed with the isolated LIL. Two CD3+ lymphocyte populations were found in LIL using FITC anti-CD3 monoclonal antibodies (mAb). One was a bright fluorescence intensity population (as in PBL), and the other dim. We calculated the number of FITC-anti-CD3 mAbs bound per lymphocyte on PBL and LIL and found 80,040 +/- 4628 and 39,615 +/- 3932, respectively. Therefore, HCV+ and HCV- patient PBL contained approximately twice the number of CD3 molecules per cell than patient CD3+ LIL. LIL also contained approximately a threefold higher concentration of TCR alpha beta +, CD4-CD8-, and CD56,16 (NK) cells than the patient PBL. Thus, a major subset of LIL is phenotypically similar to mouse NK1.1+ "intermediate" T cells. LIL freshly isolated from HCV+ livers exhibited weak CTL activity against EBV- or Con A-transformed lymphoblast targets infected with vaccinia-HCV recombinant virus (rHCV) or primary hepatocyte cultured cells. However, after in vitro coculture of LIL with rHCV, these cells developed a strong cytotoxicity for the above targets. In contrast, LIL from HCV- livers were not cytotoxic against the same targets. Histochemical studies (in situ) demonstrated that these hepatocytes express CD95, and stains demonstrated apoptosis. The HCV+ hepatocytes also express class I MHC molecules and ICAM-1. The addition of mAb specific for these adhesion molecules inhibited CML activity. Short-term cultured hepatocytes (targets) from HCV+ and HCV- patients produced low levels of cytokines IL-1 beta, IL-2, IL-6, TNF alpha, and IFN-gamma but a high level of IL-8. It is speculated that LIL expressing reduced numbers of CD3 molecules may even function as immune regulators as proposed for intermediate T cells in mice.

The effects of chimeric cells following donor bone marrow infusions as detected by PCR-flow assays in kidney transplant recipients

40 recipients of first cadaver kidney transplants were given perioperative donor vertebral bone marrow infusions (DBMC), compared with 100 controls who did not receive donor bone marrow. The immunosuppressive regimen included OKT3, Tacrolimus, and steroid maintenance therapy, and, in some patients, newly introduced mycophenolate mofetil. This report describes the 24-mo actuarial follow-up and several immunological monitoring studies including sequential measurements of donor bone marrow lineage subset chimerism by the recently reported PCR-flow assay. This is a sensitive in situ PCR detection system for donor versus recipient histocompatibility genes as well as cell surface CD epitope markers using flow cytometry. The results indicate (a) the stabilization of the donor CD3+ and CD34+ cells in recipient peripheral blood at levels below 1% between 6 mo and 1 yr postoperatively, with a 10-fold higher level of donor cell chimerism of these lineages in recipient iliac crest marrow; (b) significantly lower levels of chimerism in peripheral blood up to 6 mo postoperatively in patients who had early acute (reversible) rejection episodes compared with those who did not; (c) a higher degree of chimerism seen in patients who were class II MHC HLA DR identical with their donors; (d) the identification of a high proportion of the donor bone marrow derived CD3 dimly staining subset of T cells (to which regulatory functions have been ascribed) in recipient peripheral blood and especially in recipient bone marrow; and (e) an unexpectedly increased susceptibility to clinically significant infections (primarily viral), and even death in the DBMC-infused group, compared with controls, but no graft losses because of rejection in the DBMC-infused group. Mixed lymphocyte culture assays showed a trend toward a greater number of nonspecifically low reactors in the DBMC group, as well as a greater number of nonspecifically high reactors in the controls (P = 0.058). The autologous mixed lymphocyte reaction also indicated a trend towards nonspecific immune activation in the DBMC group. Finally, anti-cytomegaloviral IgG antibody reactivity was significantly inhibited in the DBMC group 4-6 mo postoperatively (P = < 0.05). In the controls, there were no donor cell lineages detected by PCR-flow in the peripheral blood. These rather unexpected findings, indicating a more depressed cellular and humoral immune capacity in the DBMC cadaver kidney transplant recipients in this relatively early follow-up period, are discussed relevant to chimerism, MHC restriction, and suppressor activity brought about by specialized DBMC subsets, which still need to be defined.

Depression in primary care: patient factors that influence recognition

BACKGROUND

Recognition of depression in primary care is both important and difficult. To study recognition of depression, we monitored care delivered to new adult patients randomly assigned to primary care providers.

METHODS

At study entry, 508 patients completed the Beck Depression Inventory (BDI) and the Medical Outcomes Study Short-form Health Survey-36 (SF-36), a measure of health status. Chart notes were reviewed at the end of 1 year.

RESULTS

Only 36 of 130 patients with elevated BDI scores > or = 9 (moderate-to-severe depression) were noted as depressed on the chart. Patient characteristics predicting chart notation of depression included BDI scores, health status, gender, and education. When controlling for these factors, neither age nor race were statistically significant in the prediction of the recognition of depression. Female patients were more likely to be diagnosed as depressed than men with comparable BDI and SF-36 scores. Greater patient education was associated with enhanced likelihood of diagnosis of depression. Both BDI scores and health status were important predictors of diagnosis of depression. All SF-36 subscales correlated highly with BDI scores, suggesting that these measures may lack adequate discriminant validity.

CONCLUSIONS

Identifying diagnostic tendencies may help primary care providers improve detection of depression, a critical first step toward effective management.

[Transurethral laser ablation of the prostate in high risk patients with obstructive benign prostatic hyperplasia. Perioperative morbidity and 6 month outcome in 72 patients]

Between November 1993 and September 1995, we carried out visual laser ablation of the prostate (VLAP) in 72 high-risk patients (ASA 3-4; severe cardiovascular and/or pulmonary diseases) aged 60-88 years (mean 76.7 years); the prostate volume was 22-136 ml (mean 56 ml). The urinary peak flow rates (Qmax.) ranged from 2 to 15 ml/s (mean 4.4 ml/s) preoperatively; 42 patients (58.3%) suffered from acute urinary retention for up to 2 weeks and had an indwelling catheter. The residual urinary volume (RUV) was 0-320 ml (mean 142.3 ml) in those 30 patients with spontaneous micturition. The International Prostate Symptom Score (IPSS) ranged from 10 to 33 (mean 21.8). In the first 37 patients, pressure-flow studies were carried out only in cases of doubt to verify obstruction. In the last 35 patients, pressure-flow studies were carried out in every case. Perioperatively, there was no appearance of blood loss of absorption of irrigation fluid. None of our patients needed transfusions or intensive care perioperatively. Further complications were not severe and could be handled without problems. In two patients with large benign prostate hypertrophy (BPH) a second operation (VLAP, no conventional transurethral prostatectomy) was necessary. After 6 weeks, 29.4% of the patients suffered from symptomatic urinary tract infections (UTI). After 6 months, only 7.1% of the patients had symptomatic UTI. After 6 weeks (n = 61), Qmax. was 6-34 ml/s (mean 15.3 ml/s), RUV was 0-230 ml (mean 51.5 ml), and the IPSS was 12.3 (8-28). After 3 months (n = 54), Qmax. was 9-45 ml/s (mean 19.8 ml/s), RUV was 0-96 ml (mean 31.6 ml), and the IPSS was 1-23 (mean 7.4). After 6 months (n = 52) Qmax. was 12-33 ml/s (mean 20.4 ml), RUV was 0-53 ml (mean 26.4 ml), and the IPSS was 1-12 (mean 4.1). VLAP provided no further risks for our high-risk patients, while Qmax., RUV, and IPSS were improved noticeably (improvement of more than 75%). It represents a step forward in the treatment of obstructive BPH in high-risk patients. Particularly in high-risk patients with cardiac diseases, this procedure lessens the perioperative risk. Despite the minimal appearance of UTI after 6 months, UTI seemed to be the most important complication during the first few weeks after VLAP by virtue of the bothersome symptoms.

[Urologic tumors in Germany. Initial data of 56,013 cases from clinical cancer registers]

Since 1985 a special work group involved in the coordination of hospital cancer registries in Germany (AKKK) has been collecting, storing and analysing data on tumour patients, received from cancer centres, oncological departments and specialised practices. The documentation of tumour patients is based, among other things, on information concerning localisation, histological findings and tumour spread. The data are stored in a central database administered by the work group. At present it contains data on approximately 500,000 oncological patients. In the period from 1987 to 1992, 56,013 initial entries were made concerning patients with urological tumours. Of these cases, tumours of the kidney (n = 11,424) constituted 20.4%. In 94.6% of the cases, histological investigation revealed a renal cell carcinoma-pT1: 5.8%; pT2: 53.6%, pT3: 37.2% and pT4: 3.4%. Tumours of the urinary bladder (n = 16,246) constituted 29.0% of all urological tumours. In 93.8% of the cases a transitional cell carcinoma was detected-pTis: 1.0%; pTa: 36.9%; pT1: 29.6%; pT2: 16.9%; pT3: 11.4%; pT4: 4.4%. Transitional cell carcinomas of the ureter or of the collecting system (n = 1,846) constituted 3.3% of the cases. The proportion of testicular tumours (n = 6,594) amounted to 11.8%; 53.6% of these germ-cell tumours (n = 6,281) were seminomas and 46.6% were non-seminomas. In all, 66.3% of the cases were lymph-node negative. Tumours of the prostate (n = 19,903) constituted 35.5% of the cases. In the period from 1987 to 1992, the proportion of lymph-node-positive prostate carcinomas decreased from 39.8% to 16.2%. The detailed analysis of these data shows how the hospital cancer registries can support the discussion regarding diagnosis and therapy of urological tumours.

125-TW Ti:sapphire/Nd:glass laser system

We have demonstrated a Ti:sapphire/Nd:glass laser system that produces up to 51 J of energy in 395-fs pulses (125TW). Focusing at f/3 to a 2.5-times diffraction-limited spot results in a peak irradiance greater than 10(20) W/cm(2) . Our 40-cm-diameter gold diffraction gratings have a damage threshold of 0.42 J/cm(2) for 320-fs pulses.

Double-blind, placebo-controlled, randomized clinical trial of homoeopathic arnica C30 for pain and infection after total abdominal hysterectomy

Homoeopathic potencies of arnica have been used for many years to aid postoperative recovery. The effects of arnica C30 on pain and postoperative recovery after total abdominal hysterectomy were evaluated in a double-blind, randomized, controlled study. Of 93 women entered into the study, 20 did not complete protocol treatment: nine were excluded because they failed to comply with the protocol, nine had their operations cancelled or changed within 24 h and two had to be withdrawn because of the recurrence of previously chronic painful conditions. Those who did not complete protocol treatment were equally divided between the arnica (nine patients) and placebo groups (11 patients). 73 patients completed the study, of whom 35 received placebo and 38 received arnica C30. The placebo group had a greater median age and the arnica group had slightly longer operations; nevertheless, no significant difference between the two groups could be demonstrated. We conclude that arnica in homoeopathic potency had no effect on postoperative recovery in the context of our study.

The development of strains, forces and nociceptor activity in retrodiscal tissues of the temporomandibular joint of male and female goats

Chronic pain in the temporomandibular (TM) joint is predominantly manifested in women. We examined biomechanical and neural factors that could contribute to this differential representation. Relationships between jaw rotation, soft tissue strains and soft tissue forces were examined in the goat TM joint. Strains were minimal until the jaw was rotated beyond the normal range of motion (7.25 deg). There were no significant differences in rotation-strain patterns in males and females. Stress developed as strains were introduced by jaw rotation. Gender differences were observed. Males manifested higher failure loads (15.94 +/- 1.98 and 11.37 +/- 2.02 N, for males and females respectively) and higher elastic stiffness than females (5.62 +/- 1.19 N/mm and 1.64 +/- 0.31 N/mm, for males and females respectively). Recordings were made from cell bodies in the trigeminal ganglion whose distal processes innervated the retrodiscal tissue of the temporomandibular joint of the goat (n = 48). Nociceptor reactivity was characterized with respect to the capacity to transduce mandibular rotation (rotation-interval functions; n = 29). On the basis of established relationships between rotation, strain and tissue forces, rotation-interval functions were transformed into strain-interval and force-interval functions. Comparisons were made between nociceptor properties grouped by gender. No differences in properties were observed when nociceptors were characterized with respect to jaw rotation; however, gender differences were obtained when nociceptor reactivity was characterized with respect to retrodiscal strains or forces. Consistent with smaller failure loads, nociceptors of retrodiscal tissues of females manifested a smaller range (1.12 vs 4.33 N), force to average (1.51 vs 4.64 N), force to minimum (0.95 vs 2.48 N) and force to asymptotic discharge (2.07 vs 6.81 N). Consistent with lower elastic stiffness, nociceptors of female tissues manifested higher average strain (54.4% vs 41.9%) and peak strain (74.0% vs 58.1%) to asymptotic discharge relative to those sampled from male tissues. The implications of these findings for TM joint injury and chronic pain are considered.

The tyrosine photophysics of a primase-derived peptide are sensitive to the peptide's zinc-bound state: proof that the bacterial primase hypothetical zinc finger sequence binds zinc

A 35-amino acid peptide corresponding to the putative "zinc finger" sequence of primase was prepared to study its zinc binding properties. When zinc was added to the peptide, it was found that the fluorescence quantum yield of the single tyrosine increased by 46% and the average lifetime by 34%. The binding stoichiometry was one zinc per peptide. Below pH 6.0 and above pH 8.5, the zinc-peptide binding affinity was less than 1 microM and could be accurately determined. Interpolation from those binding constants suggested that the affinity at pH 7.5 was between 10 and 100 nM. The absorption spectrum of the cobalt(II)-peptide complex was consistent with tetrahedral metal coordination by three sulfur and one imidazole nitrogen ligands. The peptide affinity for cobalt was less than for zinc, indicating metal specificity. Analysis of the fluorescence intensity pH profile, circular dichroism spectra, the effect of extrinsic quenchers indicated that at neutral pH (1) the free peptide up into a structure to place the tyrosine in an environment protected from solvent, (2) the peptide bound zinc via its three cysteines and one of its histidines resulting in little change to the polypeptide secondary structure or to the tyrosine solvent accessibility, and (3) when the peptide bound zinc, it bound directly to or caused the immobilization of the groups that had been intramolecularly collisionally quenching the tyrosine which resulted in the observed increases in tyrosine quantum yield and lifetime.

High-dose donor bone marrow infusions to enhance allograft survival: the effect of timing

BACKGROUND

The development of strategies to enhance survival of transplanted organs and to potentially lower or even discontinue immunosuppressive therapy would represent a significant advance in posttransplant patient care. The aim of this clinical trial was to determine the effect of timing and dose of peripheral donor bone marrow cell (DBMC) infusion on graft and patient survival after liver transplantation.

METHODS

DBMC, obtained from vertebral bodies, were administered in 101 recipients of liver allografts (OLTX). There were 107 patients for whom DBMC could not be obtained; they received OLTX alone (controls). A total of 5 x 10(8)/kg DBMC were infused at day 0 (group 1; n=9); at days 0 and 11 (group 2; n=26); or at days 5 and 11 (group 3; n=26). In group 4 (n=40), patients received up to five infusions of 2 x 10(8)/kg DBMC at days 5, 14, 21, 28, and 90 after OLTX.

RESULTS

When the results from patients receiving two or more DBMC infusions (groups 2, 3, and 4) are considered, both patient and graft survival were significantly improved compared with the control group (P=0.02 and P=0.01, respectively). In groups 3 and 4, 88.5% and 95% of patients were alive with mean follow-up of 536 and 265 days, respectively, compared with 77.6% of patients in the control group (average follow-up of 452 days) (P=0.02). Graft survival was also significantly improved in groups 3 (88.5%) and 4 (92.5%), compared with the controls (72%) (P=0.007).

CONCLUSIONS

The results suggest that dose and timing of DBMC infusions may be important variables affecting allograft survival. A randomized prospective trial is now in progress to compare group 3 DBMC infusion protocol with controls receiving OLTX alone.

Primary clientele as a predictor of interlibrary borrowing: a study of academic health sciences libraries

Statistics obtained from the Association of Academic Health Sciences Library Directors (AAHSLD) member libraries were studied during 1991/92 to determine whether the size of the primary client pool is a better predictor of a library's interlibrary loan (ILL) borrowing than is collection size. In libraries with collections of fewer than 70,000 serial and monograph titles, size of the client base explained 25% of the variation in ILL borrowing. No measure of collection size helped explain a greater percentage of the variability. This relationship was not found in libraries with collections of more than 70,000 titles. Further research into the predictors of ILL borrowing volume in the relatively controlled environment of the OhioLINK system is proposed.

Risk factors for the development of obliterative bronchiolitis after lung transplantation

BACKGROUND

Acute rejection has emerged as an important risk factor for obliterative bronchiolitis after lung transplantation. We performed a multivariate analysis to assess the impact of additional variables.

METHODS

Seventy-four recipients (48 heart-lung, 18 single-lung, and 8 bilateral-lung recipients) who survived longer than 90 days and underwent transplantation more than 15 months before data analysis were included in this study. Several variables were entered into a Cox regression analysis to determine their association with the development of bronchiolitis obliterans syndrome.

RESULTS

Bronchiolitis obliterans syndrome developed in 48 (65%) of 74 patients. Significant correlations were detected for acute rejection score, defined as the sum of pathologic grades of each separate acute rejection episode (p = 0.0004, likelihood ratio test value = 12.4) and for lymphocytic bronchiolitis (p = 0.03). In a bivariate model, episodes of organizing pneumonia and bacterial or fungal pneumonia significantly increased the likelihood ratio test value of the acute rejection score. The addition of the cytomegalovirus infection score, reflecting the frequency and severity of infection, to the combination of the acute rejection score and episodes of bacterial or fungal pneumonia resulted in a further significant increase in the likelihood ratio test value. Significant risk factors for moderate to severe stages of airflow limitation were at least one episode of acute rejection of grade > or = 2, younger recipient age, and any acute rejection episode 180 days or longer after transplantation.

CONCLUSIONS

Increasing frequency and severity of acute rejection episodes are strongly associated with the development of bronchiolitis obliterans syndrome. Lymphocytic bronchiolitis appeared to be significant by univariate analysis, but in a two-risk factor model, it did not augment the influence of acute rejection. Organizing pneumonia, bacterial or fungal pneumonia, and increasing severity and frequency of cytomegalovirus infections potentiate the effect of acute rejection. Late episodes of acute rejection and younger recipient age increase the risk for development of advanced disease.