Graft-versus-host reactivity and graft-versus-leukemia effect in murine allogeneic bone marrow chimeras conditioned with total body irradiation or total lymphoid irradiation

To investigate whether graft-versus-host reactivity (GVHR) and the graft-versus-leukemia (GVL) effect can be differentiated, C3H-->AKR mixed bone marrow (BM) chimeras were prepared using two different conditioning regimens. Total body irradiation (TBI) chimeras were induced by infusing 5 x 1O(6) T cell depleted syngeneic AKR BM cells together with 15 x 1O(6) non T cell depleted allogeneic C3H BM cells 1 day after a single fraction of 10.5 Gy TBI. Total lymphoid irradiation (TLI) chimeras were prepared by injecting only 15 x 10(6) non T cell depleted C3H BM cells after 10 daily fractions of 2 Gy TLI Both groups of chimeras were healthy, without clinical or histological signs of graft-versus-host disease (GVHD). In both groups, clonal deletion of antihost-reactive donor type T lymphocytes was found. Whereas TBI chimeras did resist rejection by host type splenocytes injected 2 months after transplantation, TLI chimeras did not. As the latter phenomenon is believed to reflect remaining GVHR, TLI chimeras did have a lower remaining GVHD capacity than TBI chimeras. Nevertheless, TLI chimeras survived significantly longer after host type leukemia challenge (injection of 6 x 10(6) AKR lymphoma cells). The better survival of the TLI chimeras was not due to the radiation regimen, because TLI or TBI conditioned syngeneic AKR-->AKR BM recipients did succumb equally rapidly after AKR lymphoma injection. Donor type (CM) lymphokine-activated killer cell activity, however, was higher in TLI chimeras and may explain the better GVL activity in TLI mice. This model thus illustrates that GVHD and GVL effects can be dissociated and are differentially influenced by the conditioning regimen used for BM transplantation.

Induction of CD80 expression in low-grade B cell lymphoma--a potential immunotherapeutic target

The CD80 antigen (B7) is expressed on activated B lymphocytes. It is thought to be important in eliciting a T cell response via its ligands CD28 and CTLA-4 when antigen is presented in the presence of the MHC-1 peptide. Low-grade B cell lymphomas analysed by flow cytometry express CD80 very poorly. However, when grown in vitro using the IL-4/anti-CD40 stromal cell culture system, following depletion of T and IgD-bearing cells, a monoclonal B cell expansion occurs. Cells harvested at days 10-13 express the antigen strongly, regardless of the histological subtype of lymphoma. Further investigation of CD80-mediated immune functions may be possible using this system as a basis for testing immunotherapy.

Why treatment centres failed to prevent cholera deaths among Rwandan refugees in Goma, Zaire

In July, 1994, in one of the worst cholera outbreaks in recent times, an estimated 12,000 Rwandan refugees died in Goma in eastern Zaire. The Vibrio cholerae strains were resistant to tetracycline and doxycycline, the commonly used drugs for cholera treatment. Despite the efforts of international organisations, which provided medical relief by establishing treatment centres in Goma, mortality from the disease was much higher than expected. In the area of Muganga camp, which had the largest concentration of refugees and where most of the medical aid organisations were active, the highest reported case-fatality ratio for a single day was 48%. The slow rate of rehydration, inadequate use of oral rehydration therapy, use of inappropriate intravenous fluids, and inadequate experience of health workers in management of severe cholera are thought to be some of the factors associated with the failure to prevent so many deaths during the epidemic. In one of the temporary treatment centres with the worst case-fatality record, our team showed that improvement of these factors could increase the odds of survival of cholera patients even in a disaster setting.

Myelo-ablative therapy with peripheral blood progenitor cell (PBPC) support in patients with haematological malignancy

BACKGROUND

Myelo-ablative therapy with peripheral blood progenitor cell (PBPC) support is increasingly being used in patients with haematological malignancy considered to be at high risk for recurrence. The results of this approach, in comparison with the previous experience at St. Bartholomew's Hospital (SBH) using autologous bone marrow transplantation form the basis of this report.

PATIENTS AND METHODS

42 patients (age range 18-63 years, median 42 years), deemed to have a poor prognosis with conventional therapy received myelo-ablative therapy with PBPC support. Diagnoses comprised: non-Hodgkin's lymphoma (NHL): 16 patients, Hodgkin's disease (HD): 9, Multiple Myeloma (MM): 12, and solid tumours (ST): 5. PBPC were mobilised using adriamycin: 35 mg/m2 i.v. on day 1 and etoposide 100 mg/m2 orally, days 1-5, followed by G-CSF: 5 micrograms/kg, subcutaneously, for a median of 7 days (range 6-9 days).

RESULTS

A total of 67 PBPC collections were performed, 1 being 'sufficient' (i.e. mononuclear cells > or = 1.5 x 10(8)/kg and CD34+ cells > or = 1 x 10(6)/kg) in 21 of the 42 patients. The median time to haematological recovery following reinfusion of PBPC was 13 days for both neutrophils > 0.5 x 10(9)/l and platelets > 20 x 10(9)/l (ranges: 8-27, and 8-48 days, respectively) which is significantly shorter than for patients in the historical control group. Supportive care requirements were also significantly reduced, as was the duration of hospital stay i.e., median 19 days (range 12-73 days) compared with 29 days (range 9-180 days).

CONCLUSION

These results confirm rapid blood count recovery following myelo-ablative therapy with PBPC support and the feasibility of this approach.

Hepatic arterioportal fistula

Hepatic arterioportal fistula (HAPF) is uncommon, arising largely from either a ruptured hepatic artery aneurysm or from penetrating trauma. It is being encountered increasingly, secondary to rising numbers of percutaneous transhepatic procedures. We will describe five cases of HAPF seen at Emory University Hospital over the last 5 years and conclude with a review of the current status of treatment of this condition. HAPF occurred secondary to ruptured hepatic artery aneurysm in two patients, operative injury in two patients, and after trauma in one patient. The predominant clinical manifestation in these patients were complications of portal hypertension, most commonly gastrointestinal bleeding. Angiography remains the definitive diagnostic procedure and it was used to accurately diagnose HAPF in all cases. However, duplex ultrasonography is rapidly becoming a useful screening tool and was the initial imaging modality in the most recent case. Several factors determine the therapeutic approach including the location of the HAPF and associated comorbidity. Due to the development of portal hypertension even asymptomatic fistulas should be treated. In general, surgery is the procedure of choice for extrahepatic fistula, while embolization is optimal for intrahepatic fistulas. Embolization is also useful for patients in whom associated comorbidity prohibits surgical treatment. The goal of surgery is to interrupt the fistula, to maintain hepatic arterial flow, and to close the defect in the portal vein.

Simultaneous infection with multiple serotypes of Shigellae in a patient

We isolated three different serotypes of Shigella on admission from a patient with dysentery as well as a Shigella-like organism and Campylobacter jejuni upon follow-up. The patient produced serum antibodies to all three serotypes of shigellae.

Malignant Langerhans' cell histiocytosis of the clavicle: a rare pathological fracture

Langerhans' cell histiocytosis (LCH) is an extremely heterogeneous disorder which is uncommon, making therapeutic guidelines difficult. The malignant features seen in this case have been described presenting in the skin but not in the bone. Although pathological fractures through bone affected by eosinophilic granuloma have been described, this is the first reported case of LCH with malignant features presenting in such a way.

Infected aortobifemoral prosthesis--a dreaded complication

From 1980 to 1985 13 patients were identified with infected aortofemoral grafts. Potential predisposing factors identified included a history of multiple femoral arterial procedures (10 patients; 77%) as well as perioperative infections occurring at the time of a prior femoral operation (five patients; 38%). Patients presented with suppurative groin infections (11) or ruptured pseudoaneurysms (2). Two who had previously undergone bilateral amputations were managed by removal of their aortic grafts without revascularization. Eleven other patients were managed by excision of the entire prosthesis (6 aortic grafts), partial graft excision (five graft limbs) or local treatment alone (three graft limbs). Revascularization through uninfected tissue planes was performed on 14 limbs with salvage of 11 (limb salvage 79%); whereas three limbs not revascularized required major amputation (limb salvage 0%). Despite an aggressive surgical approach five patients (38%) required a major amputation and there were three deaths (23% mortality). Once the diagnosis of an infected graft is made, early graft excision and prompt revascularization are encouraged.

Femoral anastomotic aneurysms: a continuing challenge

The methods used in management of 102 femoral anastomotic aneurysms (FAAs) were analyzed, and a case control study was performed in an effort to define potential etiologic factors. Most FAAs resulted from host vessel degeneration, although broken sutures, infection, and prosthetic graft dilatation contributed in some cases. Patients forming FAAs after aortofemoral bypass more often were hypertensive, had progression of distal disease, and showed diffuse atherosclerosis when compared with control patients. The use of braided synthetic sutures, woven Dacron grafts, and concomitant femoral endarterectomy correlated with FAA development, whereas diabetes mellitus, multiple femoral operations, local wound-healing problems, and occlusion of the superficial femoral artery did not correlate with the formation of FAAs. Ninety FAAs (88%) were treated surgically with an operative mortality rate of 3%. The most common surgical technique was aneurysmectomy with interposition prosthetic graft replacement. Durability of the repair was better if a simultaneous outflow procedure was performed and if the reconstruction was done before complications developed. Complicated FAAs are still responsible for significant morbidity and loss of life despite aggressive surgical management. Elective FAA repair is the preferred method of treatment.

Shigella septicemia: prevalence, presentation, risk factors, and outcome

The prevalence, presentation, and outcome of bacteremia due to Shigella and other gram-negative bacteria were determined by review of records of 2,018 inpatients with shigellosis who had their blood cultured in a Bangladeshi hospital in 1976-1983. Shigella bacteremia occurred in 82 (4.1%) patients; other bacteremia occurred in 102 (5.1%) patients. Patients with shigella sepsis more frequently (P less than .02) manifested severe dehydration, abdominal tenderness or ileus, agitation or lethargy, and leukocytosis than did nonbacteremic controls; they developed more frequently (P less than .05) renal failure (26%), leukemoid reaction (22%), thrombocytopenia (20%), and hemolytic-uremic syndrome (6%). The prevalence of all bacteremia was highest in the first year of life. Protein-energy malnutrition was a strong risk factor for shigella sepsis (P less than .01). The fatality rate in shigella bacteremia (21%) was higher (P less than .005) than in nonbacteremic shigellosis (10%) but lower (P less than .001) than in other bacteremia (51%). At highest risk of death from shigella bacteremia (P less than .01) were patients less than one year old, non-breast-fed, malnourished, and afebrile.

Transcatheter vascular occlusion therapy with isobutyl 2-cyanoacrylate (bucrylate) for control of massive upper-gastrointestinal bleeding

Transcatheter embolization with bucrylate, a tissue adhesive, was performed in 16 patients with massive upper-gastrointestinal bleeding. Control of arterial bleeding from the stomach was achieved in 6 of 8 patients, and from the duodenum in 3 of 4. Embolization of gastric veins resulted in temporary control of esophageal variceal bleeding in 3 of 4 patients. Histological study showed no evidence of bucrylate causing histotoxicity in 2 patients. Because bucrylate polymerizes rapidly, a localized vascular occlusion mimicking a surgical ligation is produced. Because collateral vessels are not occluded. localized tissue ischemia is unlikely. Tissue adhesives are, however, difficult to use.

Regulation of mammary gland metabolism: pathways of glucose utilization, metabolite profile and hormone response of a modified mammary gland cell preparation

1. A method for the preparation of isolated mammary gland cells of the rat is described. 2. The procedure involves disaggregation of the tissue in a collagenase-hyaluronidase mixture and subsequent purification of the heterogeneous population of cells by centrifugation in discontinuous Ficoll-400 gradients; the preparation takes 60 minutes. The yield of cells is approximately 14%. 3. The cells as prepared have high rates of metabolism and synthetic capacity and exhibit metabolic characteristics comparable to intact tissue. 4. Measurements of the content of metabolic intermediates show cells to have, and retain, outstandingly high levels of ATP and to have an energy charge close to 0.9. Levels of other intermediates approximate to those found in the intact tissue. The level of glycolytic intermediates below the triose phosphate stage indicate the highly aerobic state of the cells. 5. The pattern and scale of glucose utilization, measured using specifically labelled glucose incorporation into 14CO2 and 14C-labelled lipid production, approximates closely in isolated cells at 5 and 20 mM glucose and in tissue slices at 20 mM glucose concentration. Mammary gland slices incubated with 5 mM glucose have a considerably lower rate of metabolism. Isolated cells exhibit a higher proportionate rate of glucose utilization by way of the pentose phosphate pathway. 6. The isolated cells are hormone responsive. Insulin increases the oxidation of glucose by the pentose phosphate pathway and stimulates lipid synthesis. Addition of progesterone and cortisone in vitro (10 muM) leads to a marked and rapid decrease in the rate of glucose oxidation and conversion to lipid.

Activity of alpha-1, 4-glucosidase in furazolidone-induced glycogenosis

Furazolidone (FZ) at 700 and 800 p.p.m. was added to feed mixtures fed turkey poults two and three weeks posthatching, respectively, to induce acute experimental cardiomyopathy. Poults in the control pen received the same ration but without FZ. From EKG data obtained at 2, 4, and 5 weeks of age, control unaffected and experimental affected poults were selected for sacrifice. Poults were sacrificed by cervical dislocation and appropriate samples of hepatic tissue were removed for assays of activity of alpha-1, 4-glucosidase. Results indicate that enzyme activity in affected FZ-treated poults is similar to that in unaffected control poults. Lack of significant differences in activity of this lysosomal enzyme suggests that FZ-induced glycogenosis may be related to the adult form of idiopathic generalized glucogenosis, the etiology of which remains unidentified.

Preoperative diagnosis of pancreatic carcinoma by percutaneous aspiration biopsy

Carcinoma of the pancreas and chronic pancreatitis may be extremely difficult to differentiate by standard diagnostic methods preoperatively as well as at the operating table. Operative pancreatic biopsy may have a high morbidity, rare mortality, and can be misleading. Percutaneous aspiration biopsy may be of great potential benefit. It provides additional histological material not usually available, and an accurate diagnosis of malignancy can be made. In select patients a needless laparotomy may be avoided. It appears to be a safe procedure that should be considered in the evaluation of the patient with suspected pancreatic malignancy in which a mass lesion is demonstrated by ultrasonography, computerized tomography, angiography, or retrograde pancreatography.

The meso-spleno-renal shunt procedures: a comprehensive approach to portasystemic decompression

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