A novel reduced intensity regimen for allogeneic hematopoietic stem cell transplantation associated with a reduced incidence of graft-versus-host disease

SUMMARY

In all, 55 patients at high risk or ineligible for a conventional allogeneic hematopoietic stem cell transplant (HSCT) received a regimen consisting of extracorporeal photopheresis, pentostatin, and reduced dose total body irradiation. The median age was 49 years (18-70 years); 44 received a sibling and 11 an unrelated HSCT; 44% were over the age of 50 years and 31% had undergone a prior HSCT. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine and methotrexate. Full donor chimerism was documented in 98% by day +100. The 1000-day nonrelapse mortality was 11%. The median follow-up is 502 days (154-1104 days). The 1- and 2-year overall survival (OS) and event-free survival (EFS) are 67, 58 and 55%, and 47%, respectively. Patients who had not received a prior HSCT or had less than three prior chemotherapy regimens had a 71% OS and 67% EFS at 1 year. Greater than grade II aGVHD developed in 9% and chronic GVHD (cGVHD) in 43%, and extensive in 12% and limited in 31%. Of the patients, 86% who engrafted had a disease response, 72% had complete and 14% partial responses. This novel reduced intensity preparative regimen was well tolerated and associated with a low incidence of transplant-related mortality and serious acute and cGVHD.

Severe pulmonary hypertension: a frequent complication of stem cell transplantation for malignant infantile osteopetrosis

This report describes eight infants who developed acute severe pulmonary arterial hypertension (PAH) at days -2 to +89 after allogeneic stem cell transplantation (SCT) for malignant infantile osteopetrosis (MIOP). They were taken from a total of 28 children (frequency 29%) transplanted for this disease at three institutions between 1996 and 2002. Typical presentations were acute dyspnoea, hypoxia and brady/tachycardia usually in the absence of fever, crepitations or other evidence of infection. Six patients (75%) required assisted ventilation and five (62%) died. There was clinical or pathological evidence of veno-occlusive disease (VOD) in three children, but absence of VOD in the remaining five suggests that a separate disease process may be responsible for the PAH. Responses to nitric oxide (NO), defibrotide (DF), nicardipine and steroids in varying combinations were disappointing. Three children showed sustained improvement after administration of epoprostenol (EP, prostacyclin) in conjunction with NO and/or DF and remain well and free of PAH 25, 31 and 32 months post-transplant. PAH must therefore be excluded in any child who becomes acutely breathless after SCT for osteopetrosis.

Bench to bedside molecular functional imaging in translational cancer medicine: to image or to imagine?

Ongoing research on malignant and normal cell biology has substantially enhanced the understanding of the biology of cancer and carcinogenesis. This has led to the development of methods to image the evolution of cancer, target specific biological molecules, and study the anti-tumour effects of novel therapeutic agents. At the same time, there has been a paradigm shift in the field of oncological imaging from purely structural or functional imaging to combined multimodal structure-function approaches that enable the assessment of malignancy from all aspects (including molecular and functional level) in a single examination. The evolving molecular functional imaging using specific molecular targets (especially with combined positron-emission tomography [PET] computed tomography [CT] using 2- [(18)F]-fluoro-2-deoxy-D-glucose [FDG] and other novel PET tracers) has great potential in translational research, giving specific quantitative information with regard to tumour activity, and has been of pivotal importance in diagnoses and therapy tailoring. Furthermore, molecular functional imaging has taken a key place in the present era of translational cancer research, producing an important tool to study and evolve newer receptor-targeted therapies, gene therapies, and in cancer stem cell research, which could form the basis to translate these agents into clinical practice, popularly termed "theranostics". Targeted molecular imaging needs to be developed in close association with biotechnology, information technology, and basic translational scientists for its best utility. This article reviews the current role of molecular functional imaging as one of the main pillars of translational research.

Experience with the Arndt paediatric bronchial blocker

Previously reported techniques for single lung ventilation in children have failed to provide consistent, single lung ventilation with relative ease and reliability. We report our experience with the use of a new device, the Arndt 5 French (Fr) paediatric endobronchial blocker, for single lung ventilation in a series of 24 children. We were able to achieve single lung ventilation in 23 of the 24 patients (aged 2-16 yr). Placement required approximately 5-15 min. Attempts at placement were aborted in one patient who was unable to tolerate even short periods of apnoea because of lung pathology. Although it has some limitations, our experience suggests that the paediatric bronchial blocker can be used as a consistent, safe method of single lung ventilation in most young children.

The predicted relative risk of premature ovarian failure for three radiotherapy modalities in a girl receiving craniospinal irradiation

In girls and young women, irradiation of the ovaries can reduce the number of viable ovarian primordial follicles, which may lead to premature ovarian failure (POF) and subsequently to sterility. One strategy to minimize this late effect is to reduce the radiation dose to the ovaries. A primary means of reducing dose is to choose a radiotherapy technique that avoids irradiating nearby normal tissue; however, the relative risk of POF (RRPOF) due to the various therapeutic options has not been assessed. This study compared the predicted RRPOF after craniospinal proton radiotherapy, conventional photon radiotherapy (CRT) and intensity-modulated photon radiotherapy (IMRT). We calculated the equivalent dose delivered to the ovaries of an 11-year-old girl from therapeutic and stray radiation. We then predicted the percentage of ovarian primordial follicles killed by radiation and used this as a measure of the RRPOF; we also calculated the ratio of the relative risk of POF (RRRPOF) among the three radiotherapies. Proton radiotherapy had a lower RRPOF than either of the other two types. We also tested the sensitivity of the RRRPOF between photon and proton therapies to the anatomic position of the ovaries, i.e., proximity to the treatment field (2 ≤ RRRPOF ≤ 10). We found that CRT and IMRT have higher risks of POF than passive-scattering proton radiotherapy (PRT) does, regardless of uncertainties in the ovarian location. Overall, PRT represents a lower RRPOF over the two other modalities.

Osteoradionecrosis of the mandible: through a radiologist's eyes

Head and neck malignancies constitute a major cause of morbidity and mortality all over the world. Radiotherapy plays a pivotal role in the management of these tumours; however, it has associated complications, with mandibular osteoradionecrosis (ORN) being one of the gravest orofacial complications. Early diagnosis, extent evaluation, and detection of complications of ORN are imperative for instituting an appropriate management protocol. ORN can closely mimic tumour recurrence, the differentiation of which has obvious clinical implications. The purpose of the present review is to acquaint the radiologist with the imaging features of mandibular ORN and the ways to differentiate ORN from tumour recurrence.

Total body irradiation, fludarabine, melphalan, and allogeneic hematopoietic stem cell transplantation for advanced pediatric hematologic malignancies

We evaluated the efficacy and toxicity of adding 9 Gy of total body irradiation (TBI), in three single daily fractions of 3 Gy, to the reduced intensity regimen of fludarabine 30 mg/m2 i.v. x 4 days and melphalan 140 mg/m2 i.v. x 1 day in advanced pediatric hematologic malignancies. Twenty-two acute lymphoblastic leukemia (ALL), six acute myeloid leukemia (AML), and one non-Hodgkin lymphoma patients were transplanted. Of these, 13 were beyond second remission, and five had prior hematopoietic stem cell transplant (HSCT). Twenty-one donors were unrelated, of which 19 were from cord blood (CB) units. Three of the eight related donors were genotypically disparate. Oral mucositis and diarrhea were the most common toxicities. Twenty-seven patients achieved neutrophil engraftment (median 16 days), and 23 had platelet engraftment (median 42 days). One patient had primary graft failure. Seven patients died of non-relapse causes in the first 100 days. With a median follow-up of 52 months, seven of 22 ALL, five of six AML, and one of one lymphoma patients are alive and in remission. The regimen of TBI, fludarabine, and melphalan allows the engraftment of allogeneic hematopoietic stem cells (including mismatched CB). It was fairly well tolerated in pediatric patients, even for second transplants. Its efficacy requires further evaluation.

Seroprevalence of Encephalitozoon cuniculi in wild rodents, foxes and domestic cats in three sites in the United Kingdom

Encephalitozoon cuniculi is an obligate intracellular microsporidian that is the causal agent of encephalitozoonosis, an important and emerging disease in both humans and animals. Little is known about its occurrence in wildlife. In this study, serum samples from 793 wild rodents [178 bank voles (BV), 312 field voles (FV) and 303 wood mice (WM)], 96 foxes and 27 domestic cats from three study areas in the UK were tested for the presence of antibodies to E. cuniculi using a direct agglutination test (DAT). Seroprevalence in the wild rodents ranged from 1.00% to 10.67% depending on species (overall 5.31%) and was significantly higher in foxes [49.50% (50/96)]. None of the 27 cats sampled were found to be seropositive. This is the first report of seroprevalence to E. cuniculi in BV, FV, WM, foxes and cats in the UK and provides some evidence that foxes could act as sentinels for the presence of E. cuniculi in rodents. The study demonstrates that wildlife species could be significant reservoirs of infection for both domestic animals and humans.

Periosteal pedicle graft for the treatment of gingival recession defects: a novel technique

BACKGROUND

The periosteum is a highly cellular connective tissue with rich vascularity and regenerative potential. These qualities make it a suitable autogenous graft. A technique utilizing autogenous periosteal pedicle graft (PPG) for the treatment of gingival recession defects is described.

METHODS

Four patients with Miller Class I and II recessions > or = 3 mm were treated utilizing PPG.

RESULTS

At the end of one year, all defects were completely covered.

CONCLUSIONS

The PPG technique can be used for the treatment of gingival recession defects successfully.

Response to dietary phosphorus deficiency is affected by genetic background in growing pigs

Concern over the environmental effect of P excretion from pig production has led to reduced dietary P supplementation. To examine how genetics influence P utilization, 94 gilts sired by 2 genetic lines (PIC337 and PIC280) were housed individually and fed either a P-adequate diet (PA) or a 20% P-deficient diet (PD) for 14 wk. Initially and monthly, blood samples were collected and BW recorded after an overnight fast. Growth performance and plasma indicators of P status were determined monthly. At the end of the trial, carcass traits, meat quality, bone strength, and ash percentage were determined. Pigs fed the PD diet had decreased (P < 0.05) plasma P concentrations and poorer G:F (P < 0.05) over the length of the trial. After 4 wk on trial, pigs fed the PD diet had increased (P < 0.05) plasma 1,25(OH)(2)D(3) and decreased (P < 0.05) plasma parathyroid hormone compared with those fed the PA diet. At the end of the trial, pigs fed the PD diet had decreased (P < 0.05) BW, HCW, and percentage fat-free lean and tended to have decreased LM area (P = 0.06) and marbling (P = 0.09) and greater (P = 0.12) 10th-rib backfat than pigs fed the PA diet. Additionally, animals fed the PD diet had weaker bones and also decreased (P < 0.05) ash percentage and increased (P < 0.05) concentrations of 1alpha-hydroxylase and parathyroid hormone receptor mRNA in kidney tissue. Regardless of dietary treatment, PIC337-sired pigs consumed more feed and gained more BW than their PIC280-sired counterparts (P < 0.05) during the study. The PIC337-sired pigs also had greater (P < 0.05) HCW, larger (P < 0.01) LM area, and tended to have (P = 0.07) greater dressing percentage. Meat from the PIC337-sired pigs also tended to have greater (P = 0.12) concentrations of lactate but decreased (P = 0.07) concentrations of total glucose units 24 h postslaughter. Although plasma 1,25(OH)(2)D(3) concentrations were elevated (P < 0.05) in all the animals fed the PD diet, this elevation due to P deficiency tended (P = 0.09) to be greater in the PIC337-sired pigs after 12 wk on the treatment. The PIC337-sired pigs had stronger (P < 0.01) bones with greater ash percentage than the PIC280-sired pigs. The difference in the strength of the radii between the PIC337-sired pigs fed the PA and PD diets was greater than their PIC280-sired counterparts, which resulted in sire line x treatment interactions (P < 0.05). These data indicate differing mechanisms of P utilization between these genetic lines. Elucidating these mechanisms may lead to strategies to increase efficiency of growth in a more environmentally friendly manner.

Bacteriophages as pathogens and immune modulators?

While Shiga toxins (Stx) are key determinants of enterohemorrhagic Escherichia coli (EHEC) pathophysiology in humans, their dissemination to target organs following gastrointestinal EHEC infection is still poorly understood. Most types of Stx target cells with globotriaosylceramide (Gb3) receptors, which are expressed on endothelial cells. According to current theory, Stx is trafficked on the surface of peripheral blood cells, and transfer of toxin from these trafficking cells to endothelial cells results in microvascular damage to target organs, including the kidneys and brain. Inside the cell, Stx inhibits protein synthesis, resulting in cell death. Host "repair" responses can lead to microthrombus formation, erythrocyte damage, and reduced oxygen supply, potentially resulting in organ failure. A recent study [L. V. Bentancor et al., mBio 4(5):e00501-13, 2013, doi:10.1128/mBio.00501-13] indicates that another mechanism for Stx "dissemination" needs to be considered. Bentancor et al. demonstrated that high-pressure injection of a plasmid encoding the "prokaryotic" Stx2 sequence into mice can lead to mortality, with pathology indicative of Stx activity and antibody responses to Stx. While the plasmid levels and injection methodology were extreme, the study indicates that these sequences are potentially taken up into eukaryotic cells, transcribed, and translated, producing active Stx. Stx genes are present on integrated bacteriophage genomes in EHEC, and Stx-encoding phages are released following bacterial lysis in the gastrointestinal tract. We therefore need to consider whether bacteriophage sequences can be expressed in eukaryotic cells, what the wider implications are for our understanding of many "bacterial" diseases, and the possibility of developing novel interventions that target bacteriophages.

Phenotypic and functional characterisation of follicle-associated epithelium of rectal lymphoid tissue

Lymphoid follicles cluster in the terminal rectum of various animal species and of man and hence this site may be important in the development of immune responses to pathogens. For the induction of immune responses at mucosal sites, interplay is required between various cell types performing functions ranging from antigen-sampling cells via antigen-presenting cells to antigen-specific lymphocytes. Therefore, we have characterised the cell populations and relevant functioning of follicle-associated epithelium (FAE) and associated follicles in the terminal portion of rectum in cattle as a representative mammal. Immunohistochemical studies of this region identified immune cell subsets (CD4+, CD8+, WC 1+gammadelta, CD2+, CD 21+ and CD 40+ cells) characteristic of an immune-inductive site. Examination of FAE identified a subset of cells with structural and functional features of antigen-sampling M-cells. Cells of the FAE and adjacent follicle-associated crypts expressed vimentin and a subset of these cells internalised microparticles, a further attribute of M-cells. The FAE cells were phenotypically heterogeneous and therefore the function and phenotype of these cell subsets requires further characterisation, particularly with respect to their potentially important role in the interaction of hosts with pathogens and the development of immune responses.

Comparison of periosteal pedicle graft and subepithelial connective tissue graft for the treatment of gingival recession defects

BACKGROUND

The use of periosteum as a pedicle graft in the treatment of gingival recession defects is a recent advancement. The subepithelial connective tissue graft (SCTG) is considered the gold standard for the treatment of gingival recession defects. The present randomized controlled trial was done to compare periosteal pedicle graft (PPG) with SCTG for the treatment of gingival recession defects.

METHODS

10 males and 10 females between the ages of 16 and 40 years (mean age 25.2 years) with Miller's Class I and II recessions ≥3 mm participated in this one-year clinical study. They were assigned randomly to test group (PPG) and control group (SCTG). Results were evaluated based on parameters measuring patient satisfaction and clinical outcomes associated with two treatment procedures. Significance was set at p < 0.05.

RESULTS

At the end of the study, the defect coverage was 3.1 ± 0.13 mm or 92.6% in the test group compared to the control group in which the defect coverage was 2.70 ± 0.11 mm or 88.5%. The difference between the two groups was statistically significant (p < 0.0001). The average residual defect was comparable between the two groups, i.e. 0.3 ± 0.67 and 0.5 ± 0.84 in the PPG and SCTG group respectively. The test group was rated higher in terms of overall patient satisfaction (p < 0.02) and comfort during and after the procedure (p < 0.001).

CONCLUSIONS

PPG and SCTG have comparable clinical effectiveness, but PPG is superior to SCTG in terms of patient-centred outcomes, reflecting improved patient comfort and overall patient satisfaction.

Traditional processing treatments as a promising approach To enhance the functional properties of rapeseed (Brassica campestris var. toria) and sesame seed (Sesamum indicum) meals

Different processing treatments were applied to rapeseed and sesame seed meals, and the functional properties of these products were assessed. All treatments except puffing for both meals and pressure cooking in sesame meal increased water absorption capacity (WAC). Fat absorption capacity (FAC) of rapeseed meals was enhanced significantly by all treatments. The full-fat meals of both sources showed maximum protein solubility when fermented and minimum protein solubility when pressure-cooked. Germinated and microwave-cooked meals enhanced foaming properties of rapeseed meals. Heat treatments, except microwave cooking, considerably reduced emulsifying properties of both meals. Fermentation and germination increased the specific viscosity of rapeseed meals, whereas processed sesame meals showed lower viscosity than dry sesame meals.

A formalism for independent checking of Gamma Knife dose calculations

For stereotactic radiosurgery using the Leksell Gamma Knife system, it is important to perform a pre-treatment verification of the maximum dose calculated with the Leksell GammaPlan (DLGP) stereotactic radiosurgery system. This verification can be incorporated as part of a routine quality assurance (QA) procedure to minimize the chance of a hazardous overdose. To implement this procedure, a formalism has been developed to calculate the dose DCAL(X,Y,Z,dav,t) using the following parameters: average target depth (dav), coordinates (X,Y,Z) of the maximum dose location or any other dose point(s) to be verified, 3-dimensional (3-dim) beam profiles or off-centerratios (OCR) of the four helmets, helmet size i, output factor Oi, plug factor Pi, each shot j coordinates (x,y,z)i,j, and shot treatment time (ti,j). The average depth of the target dav was obtained either from MRI/CT images or ruler measurements of the Gamma Knife Bubble Head Frame. DCAL and DLGP were then compared to evaluate the accuracy of this independent calculation. The proposed calculation for an independent check of DLGP has been demonstrated to be accurate and reliable, and thus serves as a QA tool for Gamma Knife stereotactic radiosurgery.