Race-Ethnic Differences of ST-Elevation Myocardial Infarction: Findings from a New York Health System Registry

Background

Race and ethnicity are major considerations in the incidence, management, and long-term outcome of ST-elevation myocardial infarction (STEMI) in the United States, but there is limited existing comparative data.

Methods

We assembled a registry in a health system serving Bronx, NY of STEMI patients from 2008-2014 and analyzed differences in presentation, treatment and mortality between Hispanic/Latino (H/L), non-Hispanic Black (NHB) and non-Hispanic White (NHW). Upon discharge post-treatment for STEMI, all patients were followed for a median of 4.4 years (interquartile range 2.5, 6.0). Out of 966 STEMI patients, mean age was 61 years, 46% were H/L and 65% were male. H/Ls and NHBs had a higher prevalence of hypertension and diabetes mellitus than their NHW counterparts, coinciding with a lower socioeconomic status (SES).

Results

The number of critically diseased vessels found at cardiac catheterization and mean troponin levels did not vary by race-ethnicity; neither did the adjusted hazard ratios (HR) for death. However, age-sex adjusted rates of general hospital readmission were higher in NHBs vs NHWs (HR 1.30, P=.03). Age-sex adjusted cardiovascular readmissions rates were higher in H/Ls than NHWs (HR 1.42, P=.03). Age-sex adjusted heart failure readmissions were increased for both H/Ls (HR 2.14, P=.01) and NHBs (HR 2.12, P=.02) over NHWs.

Conclusions

Among STEMI patients, a higher prevalence of modifiable cardiovascular risk factors and a lower SES was seen among NHBs and H/Ls compared to NHWs. Despite similar coronary disease severity and in-hospital death, NHBs and H/Ls had a greater risk of general, cardiovascular and heart failure readmissions post-STEMI compared to NHWs.

The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies

BACKGROUND

Low back pain (LBP) causes 2.6 million visits to U.S. emergency departments (EDs) annually. These patients are often treated with skeletal muscle relaxants (SMRs).

OBJECTIVES

The goal of this study was to determine whether efficacy of SMRs is associated with age, sex, or baseline LBP severity.

METHODS

This was a planned analysis of data from 4 randomized studies of patients with acute nonradicular LBP. Patients were enrolled during an ED visit and followed-up 1 week later. The primary outcome was improvement in the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and the 1-week follow-up. We compared the change in RMDQ among 8 groups: placebo, baclofen, metaxalone, tizanidine, diazepam, orphenadrine, methocarbamol, and cyclobenzaprine. All patients also received a nonsteroidal anti-inflammatory drug. We performed analysis of variance to determine statistically significant differences between medications and linear regression to determine the association of age, sex, and baseline severity with the primary outcome.

RESULTS

The mean improvement in RMDQ per group was placebo 10.5 (95% confidence interval [CI] 9.5-11.5), baclofen 10.6 (95% CI 8.6-12.7), metaxalone 10.3 (95% CI 8.1-12.4), tizanidine 11.5 (95% CI 9.5-13.4), diazepam 11.1 (95% CI 9-13.2), orphenadrine 9.5 (95% CI 7.4-11.5), methocarbamol 8.1 (95% CI 6.1-10.1), and cyclobenzaprine 10.1 (95% CI 8.3-12). The between-group differences were not statistically significantly different. Results were similar regardless of age, sex, and baseline severity. Higher baseline RMDQ was associated with greater clinical improvement (B coefficient 5.7, p < 0.01). Adverse medication effects were more common with cyclobenzaprine than with placebo (p < 0.01).

CONCLUSIONS

Among patients in the ED with acute LBP treated with a nonsteroidal anti-inflammatory drug, SMRs do not improve outcomes more than placebo. Neither age, sex, nor baseline impairment impacts these results.

Pharmacological and interventional management of pulmonary embolism: where do we stand?

As the third most common cardiovascular disease, pulmonary embolism (PE) has an uptrending incidence and mortality, resulting in significant healthcare expenditure. Risk stratification of acute PE guides management. Although anticoagulation remains the cornerstone management, systemic fibrinolysis and targeted therapeutic approaches, catheter-directed thrombolysis and catheter-based embolectomy are available for high-risk patients. Life-threatening bleeding complications associated with systemic fibrinolysis have restricted its widespread implementation. Catheter-based techniques for intermediate high-risk categories were devised to reduce bleeding complications and improve outcomes. Catheter-directed thrombolysis helps minimize bleeding by way of direct drug delivery. Catheter-based embolectomy mechanically retrieves thrombi without using fibrinolytics. This focused review of medical and interventional management of acute PE provides a highlight of ongoing trials expected to add value to current practice.

Tobacco Use Prevalence and Transitions From 2013 to 2018 Among Adults With a History of Cardiovascular Disease

Background Although tobacco product use and transitions have been characterized in the general population, few studies have focused on individuals with established cardiovascular disease (CVD) in a population-based sample. Methods and Results We examined tobacco use prevalence and longitudinal patterns of tobacco product transitions in adults (≥18 years) of the nationally representative PATH (Population Assessment of Tobacco and Health) study, from 2013 to 2014 (Wave 1) through 2016 to 2018 (Wave 4). Prevalent CVD was classified through self-report of having had a heart attack, heart failure, stroke, or other heart condition. Factors associated with tobacco product use and transitions were investigated using survey logistic regression. We examined 2615 participants with self-reported CVD at Wave 1. Overall, 28.9% reported current tobacco use, equating to ≈6.2 million adults in the United States with prevalent CVD and current tobacco use. Among adults with CVD who are current tobacco users, the most commonly used product was cigarettes (82.8%), followed by any type of cigar (23.7%), and e-cigarette use (23.3%). E-cigarette use without concurrent cigarette use among participants with prevalent CVD was uncommon (1.1%). Factors associated with tobacco use were younger age, male sex, had lower education level, and lack of knowledge about the association between smoking and CVD. Men with prevalent CVD were less likely to use e-cigarettes compared with women (odds ratio [OR], 0.7; 95% CI, 0.5-0.9). Among cigarette users with CVD, transition rates between Waves 1 and 4 demonstrated <5% decrease in cigarette, with a 0.5% increase in e-cigarette use. Only ≈10% were in formal tobacco cessation programs. Conclusions Despite known harmful cardiovascular effects, over one fourth of adults with prevalent CVD use tobacco products and few quit smoking over the 4 waves of the PATH data set.

Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study

AIMS

Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation.

METHODS AND RESULTS

We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24).

CONCLUSION

In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.

Engorgement of Deep Medullary Veins in Neurosarcoidosis: A Common-Yet-Underrecognized Cerebrovascular Finding on SWI

We describe the prevalence and potential significance of deep medullary vein engorgement on SWI in patients with neurosarcoidosis, a finding that has not been described previously. Engorgement was evaluated for possible associations with meningeal or perivascular disease, intracranial hemorrhage, and venous thrombosis, as well as with modified Rankin Scale scores at the time of MR imaging and at follow-up. Deep medullary vein engorgement was seen in 7 of 21 patients and was more common in men. Patients with venous engorgement had a significantly increased incidence of microhemorrhages, perivascular disease, and hydrocephalus. There was no association with the degree of leptomeningeal disease, venous dural sinus thrombosis, or modified Rankin Scale scores. In conclusion, deep medullary vein engorgement was common in our patients with neurosarcoidosis. Although its pathophysiology remains uncertain, it could be related to venous or perivenous abnormalities and may represent a useful secondary finding of cerebrovascular disease.

Cavitary Plaques in Otospongiosis: CT Findings and Clinical Implications

BACKGROUND AND PURPOSE

Cavitary plaques have been reported as a manifestation of otospongiosis. They have been related to third window manifestations, complications during cochlear implantation, and sensorineural hearing loss. However, their etiology and clinical implications are not entirely understood. Our purpose was to determine the prevalence, imaging findings, and clinical implications of cavitary plaques in otospongiosis.

MATERIALS AND METHODS

We identified patients with otospongiosis at a tertiary care academic medical center from January 2012 to April 2017. Cross-sectional CT images and clinical records of 47 patients (89 temporal bones) were evaluated for the presence, location, and imaging features of cavitary and noncavitary otospongiotic plaques, as well as clinical symptoms and complications in those who underwent cochlear implantation.

RESULTS

Noncavitary otospongiotic plaques were present in 86 (97%) temporal bones and cavitary plaques in 30 (35%). Cavitary plaques predominated with increasing age (mean age, 59 years; P = .058), mostly involving the anteroinferior wall of the internal auditory canal (P = .003), and their presence was not associated with a higher grade of otospongiosis by imaging (P = .664) or with a specific type of hearing loss (P = .365). No patients with cavitary plaques had third window manifestations, and those with a history of cochlear implantation (n = 6) did not have complications during the procedure.

CONCLUSIONS

Cavitary plaques occurred in one-third of patients with otospongiosis. Typically, they occurred in the anteroinferior wall of the internal auditory canal. There was no correlation with the degree of otospongiosis, type of hearing loss, or surgical complications. Cavitary plaques tended to present in older patients.

Imaging Manifestations of Pseudoprogression in Metastatic Melanoma Nodes Injected with Talimogene Laherparepvec: Initial Experience

Talimogene laherparepvec is an oncolytic virus recently approved for targeted treatment of advanced melanoma. Because of an inflammatory reaction, treated lesions may increase in size and develop infiltrative margins that can be construed as disease progression or extracapsular spread. In this report, we describe our initial experience imaging the response of metastatic nodes injected with talimogene laherparepvec. Six of 12 nodes (50%) showed growth from baseline followed by decreased size, 5 of 12 nodes (42%) showed a downward size trend, and 1 node showed continued increase in size. Seven of 9 nodes (78%) developed infiltrative margins at a median of 79 days, and 6 of 9 (67%) nodes became necrotic at a median of 76 days after injection, all showing decreased size at final follow-up. An increase in the size of nodes injected with talimogene laherparepvec does not necessarily indicate progression. Infiltrative margins are also frequently seen and may be confused with extracapsular disease.

A first-in-human study of DS-1040, an inhibitor of the activated form of thrombin-activatable fibrinolysis inhibitor, in healthy subjects

Essentials DS-1040 inhibits the activated form of thrombin-activatable fibrinolysis inhibitor (TAFIa). Infusion of DS-1040 was safe and well tolerated in healthy young and elderly subjects. DS-1040 substantially decreased TAFIa activity but had no impact on bleeding time. DS-1040 may provide an option of safer thrombolytic therapy.

SUMMARY

Background Current treatments for acute ischemic stroke and venous thromboembolism, such as recombinant tissue-type plasminogen activator and thrombectomy, are limited by a narrow time window and the risk of bleeding. DS-1040 is a novel low molecular weight compound that inhibits the activated form of thrombin-activatable fibrinolysis inhibitor (TAFIa), and was developed as a fibrinolysis enhancer for the treatment of thromboembolic diseases. Objectives This first-in-human, randomized, placebo-controlled, three-part, phase 1 study was conducted to evaluate the safety, pharmacokinetics and pharmacodynamics of DS-1040 in healthy subjects. Subjects/Methods Young (18-45 years) or elderly (65-75 years) subjects (N = 103) were randomized to receive single ascending doses of DS-1040 ranging from 0.1 mg to 40 mg, or placebo, administered either as a 0.5-h intravenous infusion or as a 24-h continuous infusion. Results All doses of DS-1040 were tolerated, and no serious adverse events (AEs) or discontinuations resulting from AEs occurred during the study. Bleeding time remained within the normal range for all doses tested in all subjects. Plasma exposure of DS-1040 increased proportionally with increase in dose. Elderly subjects had higher exposures to DS-1040 and prolonged elimination times, probably because of decreased renal clearance. DS-1040 caused a substantial dose-dependent and time-dependent decrease in TAFIa activity and in 50% clot lysis time. The levels of D-dimer, indicative of endogenous fibrinolysis, increased in some individuals following DS-1040 treatment. No effects of DS-1040 on coagulation parameters or platelet aggregation were observed. Conclusions The novel fibrinolysis-enhancing agent DS-1040 has favorable pharmacokinetic/pharmacodynamic properties and a favorable safety profile, warranting further clinical development.

IL-6 blockade reverses the abnormal STAT activation of peripheral blood leukocytes from rheumatoid arthritis patients

Considering the interplay of multiple STATs in response to cytokines, we investigated how IL-6 and its blocking affect STAT signaling in rheumatoid arthritis (RA). Leukocytes obtained from RA patients before and after tocilizumab treatment and healthy donors (HDs) were cytokine-stimulated and STAT phosphorylation was analyzed by cytometry. RA patients had significantly fewer pSTAT1+, pSTAT3+, and pSTAT6+ monocytes and pSTAT5+ lymphocytes than HDs. After 24weeks of treatment, percentages of IFNγ-induced pSTAT1+ and IL-10-induced pSTAT3+ monocytes in RA patients increased, reaching levels comparable to HDs. pSTAT1+ and pSTAT3+ cells correlated inversely with RA disease activity index and levels of pSTAT+ cells at baseline were higher in patients with good EULAR response to tocilizumab. IFNγ-induced pSTAT1+ cells correlated inversely with memory T cells and anti-CCP levels. IL-10-induced pSTAT3+ cells correlated with Treg/Teff ratio. Our findings suggest that IL-6 blocking reduces the inflammatory mechanisms through the correction of STAT1 and STAT3 activation status.

PP131. Regulation of heme oxygenase/carbon monoxide (ho/co) and l-arginine/nitric oxide (no) pathways by human chorionic gonadotropin (hcg) in human fetal endothelium

INTRODUCTION

HO/CO and l-arginine/NO pathways are critical regulators of vascular function in early human pregnancy. HO is the rate-limiting enzyme in heme catabolism leading to the formation of biliverdin, which is subsequently reduced to bilirubin by biliverdin reductase, carbon monoxide, and free iron. HO-1, the inducible isoform of the enzyme, is essential to promote placental function and fetal development (1). HO-1 is also required to maintain nitric oxide synthesis (2). Human chorionic gonadotropin (hCG) is the first blastocyst-derived hormonal signal playing a significant role in implantation and placentation (3). We hypothesized that hCG upregulates HO-1 and thus positively regulates early vascular events in human pregnancy.

OBJECTIVES

In this study we used human umbilical vein endothelial cells (HUVECs) to demonstrate that hCG up-regulates mRNA and protein abundance of HO-1. The effect of hCG on l-arginine transport and the expression of hCAT1, the main cationic amino acid transporter involved in endothelial nitric oxide synthesis were evaluated.

METHODS

HUVEC were isolated from normal pregnancies (approval from the Institutional Review Board) by collagenase digestion and grown (37°C, 5% CO2) in medium 199 supplemented with 20% newborn and fetal calf sera. Cells were treated with hCG (0.5-100IU/mL, 0-24hours and CoCl2 (150μM, 6hours) as positive control. Total proteins were separated by SDS-PAGE electrophoresis, transferred to nitrocellulose membranes and incubated with monoclonal anti human HO-1 or anti β-actin and respective secondary antibody conjugated with horseradish peroxidase. Protein bands were detected by enhanced chemiluminiscence. Total RNA was isolated and cDNA was obtained by reverse transcription. PCR assays were performed in a reaction mix containing 0.5μM primers, dNTPs, Taq DNA polymerase, 2 mM MgCl2. Relative abundance of HO-1, hCAT-1 and 28S were determined. l-[(3)H]Arginine transport (100μM, 2 μCi ml(-1), 37°C, 1min) were determined in HUVECs exposed (30min) to hCG (0.5-100IU/mL) and CORM-2 (CO donor).

RESULTS

The highest level of HO-1 protein were obtained at 5IU/mL of hCG and declined at higher concentrations. hCG increased HO-1 protein abundance and maximal response was observed at 6 hours (4-fold), decreasing at 24hours exposure. These effects of hCG on HO-1 protein abundance are well correlated with changes in HO-1 mRNA regarding time of exposure and concentration of hCG. L-arginine transport and hCAT-1 mRNA were also increased (2.8-fold and 4.5-fold, respectively) by hCG.

CONCLUSION

Upregulation of HO-1 as well as the increase in l-arginine transport and hCAT-1 mRNA in HUVECs are novel effects of hCG, which occur at physiological plasma concentrations of the hormone, as those found in the first weeks of pregnancy. These changes could be relevant for the maintenance of the NO synthesis in fetal and maternal vasculature, ensuring the predominance of the vasodilator tone. These effects could be also critical for vascular remodelling of uterine circulation and placental vascular development in early stages of pregnancy, the lack of which could result in abnormal placentation as described in preeclampsia and fetal growth restriction.

Retreatment with interferon and ribavirin vs interferon alone according to viraemia in interferon responder-relapser hepatitis C patients: a prospective multicentre randomized controlled study

Low pretreatment viral load has consistently been shown to be an independent predictor of sustained response (SR) in patients with chronic hepatitis C infection. We assessed the efficacy of interferon (IFN) plus ribavirin vs IFN alone in low viraemic patients (<2 millions copies/mL) who had relapsed to a previous course of IFN and the efficacy of 24 vs 48 week combination therapy in high viraemic patients. Two hundred and ninety-seven patients were randomly assigned to one of the four regimens after stratification on pretreatment viral load. All patients received IFN-alpha2b (6 million units thrice weekly for 24 weeks and 3 million units thrice weekly for 24 weeks). Patients with low viraemia received either IFN-alpha2b alone for 48 weeks (R1: 42 patients) or IFN-alpha2b plus ribavirin (600 mg/day) for 24 weeks and IFN-alpha2b alone for the next 24 weeks (R2: 48 patients). Patients with high viral load received either IFN-alpha2b plus ribavirin for 24 weeks and then IFN-alpha2b alone for the next 24 weeks (R3: 104 patients) or IFN-alpha2b plus ribavirin for 48 weeks (R4: 103 patients). In low viraemic patients the rate of SR was 37.7% in group R1 and 59.6% in group R2 (P < 0.05). In high viraemic patients, the rate of SR was 44.7% in group R3 and 51.4% in group R4 (P: NS). Thirty-one patients discontinued treatment (10.4%) without difference regarding treatment regimen. In the regimen using ribavirin we found no difference in terms of SR between patients receiving a dose of ribavirin below 10.6 mg/kg/day (55%) or over 10.6 mg/kg/day (58%). Histological improvement occurred in 70.2% of patients regardless of the regimen. Logistic regression showed that genotype 2 and 3, Knodell score <6 and alanine aminotransferase pretreatment level >3 x upper limit of normal were significantly and independently correlated with SR. In low viraemic patients who relapsed to a previous IFN treatment, combination therapy using high-dose IFN and low-dose ribavirin is better than high-dose IFN alone. In high viraemic patients there was no benefit in increasing the duration of combination therapy from 24 to 48 weeks. In this study, it was found that low dose of ribavirin can be used safely and there is no effect of ribavirin dose on SR.

Intraductal papillary or mucinous tumors (IPMT) of the pancreas: report of a case series and review of the literature

OBJECTIVE

Despite a better understanding of these conditions, intraductal papillary or mucinous tumors (IPMT) of the pancreas still present difficulty relating to the predictive factors of malignancy and the risk of relapse after surgical resection. The aim of this study was to report on our experience and to compare it to previously published cases.

METHODS

We studied retrospectively 26 patients (mean age 60.3 yr) presenting with IPMT. Of the 26 patients, 19 had surgical resection and seven did not. The main clinical feature was acute pancreatitis occurring in 38% of the patients. Segmental pancreatectomy was performed in all the cases. At pathological assessment of resection margins, tumor resection was considered as complete in 17 cases. Margins exhibited benign mucinous involvement, and resection was considered to be incomplete in one multifocal case and in one case with diffuse spread of the tumor.

RESULTS

A total of 11 tumors were benign and five were malignant. Carcinomas were invasive in four cases (two invading the pancreatic parenchyma, one the duodenum, and one the peripancreatic nodes) and in situ in one case. Malignancy was not diagnosed preoperatively except when invasion was evident (duodenal spread). Although main pancreatic duct type and obstructive jaundice appeared as suggestive features for the risk of malignancy, no reliable preoperative predictive factors for malignancy could be identified as regarding to clinical parameters, biological examinations, carcinoembryonic antigen or CA19-9 levels in serum or in pure pancreatic juice, imaging, and cytological methods. Within 40.8 months mean follow-up after surgery (range 2-96 months), three patients (16%), two with malignant and one with benign tumor, had tumor relapse after respectively 7, 27, and 14 months. Margins were positive without malignant features in the two malignant cases and negative in the other case. Tumor relapse was malignant with diffuse spreading in the three cases, and the patients died within 34 months after surgical resection.

CONCLUSIONS

Our series and the review of the literature indicate that preoperative indicators of malignancy in IPMT are still lacking. Concerning resection margins, complete tumor resection is usually possible by segmental pancreatectomy. Malignant relapses are not exceptional. Incomplete resection and diffuse or multifocal tumor represent poor prognostic factors. Total pancreatectomy should be considered in such cases.

Donor age-related differences in PBPC mobilization with rHuG-CSF

BACKGROUND

Data on the administration of rHuG-CSF to normal donors <18 years old are very limited.

STUDY DESIGN AND METHODS

The results of rHuG-CSF administration to 61 donors <18 years old (Group A) were retrospectively evaluated and compared with results from 353 donors > or = 18 years old (Group B) who are included in the Spanish National Donor Registry. The mean age (range) in Group A and B was 14 (1-17) and 38 (18-71) years, respectively (p<0.001). The mean dose of rHuG-CSF was 10 microg per kg per day (range, 9-16) during a mean of 5 days (range, 4-6). Central venous access was placed more frequently in younger donors (25% vs. 6%; p<0.001).

RESULTS

The mean number of CD34+ cells collected was 7.6 and 6.9 x 10(6) per kg of donor's body weight in Group A and B, respectively. Fifty-six percent of Group A donors needed only one apheresis to achieve > or = 4 x 10(6) CD34+ cells per kg versus 39 percent of Group B donors (p = 0.01). Side effects were more common in Group B (71% vs. 41%; p<0.001).

CONCLUSION

The administration of rHuG-CSF to donors <18 years old leads to CD34+ cell mobilization in a pattern similar to that observed in adults. Greater age was associated with a more frequent requirement for more than one apheresis to achieve a similar number of CD34+ cells.

[Pancreatic intubation ifn pancreas divisum]

AIM

Long-term results of endoscopic pancreatic stenting in pancreas divisum is still debated. The aim of this retrospective study was to evaluate the efficacy of dorsal duct stenting in patients presenting with acute recurrent pancreatitis.

PATIENTS AND METHODS

Between 1980 and 1998, among 34 patients presenting with recurrent acute pancreatitis associated with pancreas divisum, 21 were treated by pancreatic stenting during a mean time of 11 months. There were 13 men and eight women (mean age: 50 years).

RESULTS

The median follow-up was 50 (range 11-105) months. The number of patients presenting with acute pancreatitis before pancreatic stenting, at the end of stenting and at the end of the follow-up was respectively 21/21 (100%), 2/19 (10%) and 2/18 (11%) (P < 0.01). The number of patients presenting with chronic pain before stenting, at the end of stenting and at the end of the follow-up was respectively 17/21 (80%), 6/19 (31%) and 5/18 (27%) (P = 0.07). The overall morbidity rate was 8/21 patients (38%) including mainly acute pancreatitis (three cases); all but one complication were managed conservatively.

CONCLUSION

In patients with pancreas divisum, dorsal duct stenting decreases the rate of recurrent acute pancreatitis but the improvement of chronic pain appears less obvious.

[Small bowel perforation and occlusion after migration of biliary and cystogastric prosthesis]

We report on two cases of intestinal complications associated with the migration of biliary and cystogastrostomy stents. In the first case, intestinal perforation occurred after migration of an Amsterdam type biliary stent. In the second case, a double pig tail endoprosthesis induced intestinal occlusion which was successfully managed without surgery. Complications after intestinal migration of biliopancreatic stents are very rare and usually involve the colon. Our observations point out the potential gravity of intestinal migration of biliopancreatic stents and, as in the second case, the possible resolution of stent related intestinal occlusion after medical management.

Autologous peripheral blood progenitor cell transplantation with <2 x 10(6) CD34(+)/kg: an analysis of variables concerning mobilisation and engraftment

INTRODUCTION

This study analyses the factors affecting mobilisation and engraftment in autologous peripheral blood progenitor cell transplantation according to the number of CD34(+) re-infused.

MATERIALS AND METHODS

A total of 190 patients underwent mobilisation with G-CSF alone (n=113) or in combination with chemotherapy (n=77). A total of 116 patients (61%) were autografted with <2 x 10(6) CD34(+) cells/kg and 74 patients were transplanted with >2 x 10(6) CD34(+) cells/kg. Rates of granulocyte and platelet recovery were estimated using the product-limit method of Kaplan-Meier and compared using a log-rank test. The Cox regression model was used for the multivariate analysis of factors influencing engraftment. Differences between cohorts were evaluated by one-way ANOVA or Mann-Whitney tests, and multivariate analysis was performed using a stepwise lineal regression.

RESULTS

Neutrophil and platelet engraftment was significantly longer with <2 x 10(6)/CD34(+)/kg (12 vs 10 days, P=0.014 and 16 vs 13 days, P=0.0001 respectively). Platelet recovery was affected by exposure to alkylating agents (P=0.04), refractory disease (P=0.02) and AML (P=0.0001), but only the last two variables remained significant in Cox regression (P<0.01). Granulocyte engraftment was longer in CML (univariate, P=0.04) and in refractory disease (multivariate, P=0.02). In patients re-infused with >2 x 10(6)/CD34(+)/kg, the Cox model did not identify prognostic factors for haematopoietic recovery.

CONCLUSION

Although mobilisation schedules and disease status influenced not only the yield of progenitor cells, but also the engraftment kinetics, the number of CD34(+) re-infused was the main predictor of haematopoietic recovery. While engraftment succeeded in most of the cases, the re-infusion of >2 x 10(6)/CD34(+)/kg resulted in significantly shorter recovery times.

Taenia solium cysticercosis: immunity in pigs induced by primary infection

The present study demonstrates that pigs experimentally infected with Taenia solium eggs develop resistance to reinfection that lasts at least five months. Thirteen 2-month-old piglets were infected with eggs of Taenia solium. After 5 months, two pigs were euthanized and five were challenged with eggs from a second tapeworm. Nine months after the first infection, six pigs were challenged with a third tapeworm. All 11 challenged pigs were euthanized 2 months after reinfection. In order to confirm the infectivity of the eggs, several piglets were inoculated with each taenia. Two of the five pigs reinfected after 5 months did not develop metacestodes, two showed few caseous non-infective forms and in the fifth pig, 14% of the metacestodes were vesicular and 86% colloidal and caseous. In the six animals challenged 9 months after the first infection, three were heavily infected with vesicular metacestodes and the other three showed only colloid and caseous forms in muscles. All parasites found in brains were vesicular. We conclude that immunity due to primary infection lasts at least 5 months. At 2 months of infection antigens of 24 and 39-42 kDa were the most frequently recognised. In those pigs with only a few caseous cysts in muscles and/or vesicular ones in brains no antibodies were detected.

Hair cell formation in cultures of dissociated cells from the vestibular sensory epithelium of the bullfrog

HYPOTHESIS

Bullfrog vestibular hair cells are capable of regenerating in vitro.

BACKGROUND

Recent studies have established that sensory organs in the inner ear of vertebrates continue to produce hair cells after birth. However, the mechanisms responsible for the regulation of this process are not well understood. The current study reports the development of a novel method for the culture of dispersed cells from the bullfrog inner ear.

METHODS

New hair cell formation in this in vitro preparation was shown by sequential photomicroscopy. Studies with the selective marker for mitotic activity 5-bromo-2-deoxyuridine (BrdU) were done to estimate the level of cell proliferation and to quantify postmitotic hair cell formation. Finally, confirmation of cell type was obtained by scanning electron microscopy and by the use of specific markers for hair cells.

RESULTS

Once the optimal culture conditions were established in the initial experiments, the formation of new hair cells was directly visualized in all unstained live cultures and fixed preparations without exception. Asymmetric division of progenitor cells, with subsequent differentiation of one of the daughter cells into new hair cells, also was documented by photomicroscopy. Approximately 12% of the cells were labeled with BrdU, of which 6% were hair cells, showing that new hair cell formation was subsequent to mitotic division in vitro. The identity of newly formed hair cells was verified as follows: 1) morphologically by scanning electron microscopy; 2) by positive labeling with phalloidin-rhodamine, a marker for actin; and 3) by positive calmodulin immunocytochemistry.

CONCLUSIONS

This study reports the development of an in vitro culture preparation in which undifferentiated epithelial cells proliferate to become new hair cells. Evidence is provided of division of hair cell progenitors and subsequent differentiation of the daughter cells as one of the mechanisms involved in new hair cell formation in the culture preparation. This newly developed cell culture technique provides a powerful tool for further study of the process of hair cell formation in the vestibular end organ.

[Determination of the cytokine level during storage of partially leukocyte-depleted (<0.5 x 10(9)) or totally leukocyte-depleted (<0.5 x 10(6)) platelets]

PURPOSE

To evaluate the levels of interleukin 1 beta (IL-1 beta), interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) during the storage of pools of PCs obtained after removing the buffy-coat, in comparison with the amount of leukocytes present in these components.

MATERIAL AND METHODS

Blood was collected in quadruple-bag-system containing 63 mL of CPD as anticoagulant and 100 mL of SAG-M solution as additive for the red cells. Approximately twelve hours after collection, blood separation was made automatically by Compomat (NPBI) and platelet concentrates were prepared from the buffy-coat fraction. Five or six PCs were mixed to obtain a pool (n = 28). Eight pools were WBC reduced by filtration (PXL-8, Pall España). Before storage a sample of each pool was obtained in order to count platelets and WBC as basal values. All kind of pools were stored at room temperature with continuous agitation during a period of 10 days. Volumes were measured by weight and specific gravity. Platelets and leukocytes were counted in the Coulter-counter (STKR Counter. Izasa) or in Nageotte chamber for the filtered products. On days 1, 4 and 7 interleukins were measured by ELISA (EASIA Kits, Medgenix Diagnostics, Brussels), Lecture was done at 450 nm using a spectophotometer (ANTHOS 2001). Lower limits of sensitivity were 2 pg/mL for IL-1 beta and 3 pg/mL for IL-6 and TNF-alpha according to the manufacturer. Wilcoxon test was used for statistical analysis.

RESULTS

The average volume of the pools was 460 mL and 374 for the filtered ones. The total platelet amount was 3.63 x 10(11) and 2.8 x 10(11) respectively, with a WBC contamination of 380 x 10(6) and 0.54 x 10(6) for the filtered. The yield of platelets after filtration was 84% with a loss of 99.90% of WBC (3-log). The measures of interleukins were not homogeneous, but a great variability was found shown among the different pools, not always in relationship with the amount of leukocytes. The levels of IL-1 beta were 3.58 pg/mL on day 1, 6.36 pg/mL on day 4 and 8.76 pg/mL on day 7 (p < 0.005). For the IL-6 we found 13.08 pg/mL on day 1, 15.43 pg/mL on day 4 and 19.77 on day 7 (p < 0.05). For the TNF-alpha, 13.65 pg/mL an day 1,24.33 pg/mL on day 4 and 30.10 pg/mL on day 7 (p < 0.05). In the filtered pools the detections of IL-1 beta and IL-6 were always under the sensibility threshold, but there was an increment of TNF-alpha on day 7 (16.91 pg/mL). Microbiologic cultures were always negative.

CONCLUSION

The accumulation of IL-1 beta, IL-6 and TNF-alpha is not prevented by the fact of removing the buffy-coat layer when preparing PCs, although these levels are considerably lower in comparison with those obtained by the PRP technic. Filtration of pooled PCs avoids the presence of these cytokines except TNF-alpha, where a low amount can be detected.

Posttransfusion hepatitis after induction chemotherapy in acute nonlymphoblastic leukemia: implications for long-term management and outcome

BACKGROUND

The purpose of this study was to evaluate 1) the incidence of hepatitis and its influence on the clinical management of and outcome in acute nonlymphoblastic leukemia (ANLL) patients in first complete remission and 2) the impact of routine hepatitis C virus screening on the incidence of hepatitis in these patients.

STUDY DESIGN AND METHODS

Clinical and blood bank charts were reviewed for 65 consecutive ANLL patients between 1985 and 1993 who achieved complete remission after a course of daunomycin and cytarabine (cytarabine: 200 mg/m2/day x 7 days in continuous infusion; daunomycin: 60 mg/m2/day for the first 3 days of the 7, as a bolus).

RESULTS

Only 43 percent of patients who developed hepatitis completed the scheduled therapy. Hepatitis did not decrease the probability of relapse (66 +/- 9% vs. 66 +/- 11%), but patients with changes in planned treatment, due to hepatitis or other causes, tended to have a higher relapse rate than patients without changes in consolidation therapy (56.5% vs. 40.4%; p = 0.10). This did not result in a decrease in disease-free survival, however, because of the higher number of treatment-related deaths in the patients without hepatitis (who completed the therapy). Over the period from 1985 through 1989, the 6-month actuarial probability of developing hepatitis was 42 percent. However, since 1989, when hepatitis C screening of blood donors was implemented, the incidence was reduced to 12.5 percent (p < 0.05), in spite of greater transfusion support (172 +/- 46 vs. 89 +/- 53, p < 0.01). No new cases of hepatitis were observed after the introduction of second-generation hepatitis C virus assays.

CONCLUSION

Hepatitis precludes the use of consolidation therapy in about half of ANLL patients, resulting, in the experience described here, in a trend toward a higher rate of relapse. Hepatitis C virus screening of blood components reduces the incidence of hepatitis in ANLL patients.

Circulating stem cell collection in lymphoma and myeloma after mobilization with cyclophosphamide and granulocyte colony-stimulating factor for autologous transplantation

We report the results of 72 leukapheresis procedures performed for autologous peripheral blood stem cell collection in 18 patients with lymphoma and myeloma, after combined mobilization with cyclophosphamide and granulocyte colony-stimulating factor (G-CSF). The numbers of mononuclear cells (MNCs), CD34+ cells and granulocyte-macrophage colony-forming units (CFU-GM) either in the peripheral circulation (preleukapheresis sample) or in the product obtained from leukapheresis (leukapheresis sample) were evaluated. A highly superior proportion of CD34+ cells (14-fold) and CFU-GM (5-fold) resulted from the mobilization therapy. CFU-GM and CD34+ cells were highly enriched with respect to all MNCs (relative recoveries: 2.13, range 0.3-41, and 1.08, range 0.2-8.5, respectively) due to an additional mobilization effect by the leukapheresis procedure. Also, a relatively strong linear correlation between the three different parameters was found in the leukapheresis product (CD34+:CFU-GM, r = 0.81; MNCs:CD34, r = 0.69; MNCs:CFU-GM, r = 0.75; CFU-GM:CD34+, and MNCs, r = 0.85). Our data suggest that the number of MNCs and CD34+ cells obtained after combined mobilization with cyclophosphamide and G-CSF can be used as predictor of the number of granulomonocytic progenitors.

[Isolated agenesis of the pulmonary valve in the adult. When is the proper time for surgery?]

The congenital absence of the pulmonary valves is a rare malformation that mainly affects children, frequently is associated with other cardiac malformations and very rarely is present in adults. Elective or urgent surgery is indicated in the symptomatic child; on the other hand, surgical treatment in the asymptomatic adult with this anomaly is controversial. Based on the reported experience in the literature, in the present article, the authors discuss the therapeutic approach of an asymptomatic 22-year-old male with pulmonary valvular absence with practically no hemodynamic repercussion. Although there had been few reported cases of isolated pulmonary valvular absence, the authors concluded that surgery is not a satisfactory solution and that it might be postponed to the time that patients develop congestive heart failure and or respiratory insufficiency. In order to detect that on time, we recommend a follow up based on periodic echocardiographic studies.

Response diversity of pontine and deep cerebellar nuclear neurons to air puff stimulation of the eye in the alert cat

The discharge of antidromically identified brainstem and cerebellar nuclear neurons involved in the corneal reflex was recorded in the alert cat during corneal air puffs. Eye movements were measured with the search coil technique. Recorded sensory, motor, reticular formation and cerebellar nuclear neurons showed a wide diversity in latencies and patterns of response to air puff stimulation. This diversity suggests that each part of the circuit may contribute different properties to information processing for the corneal reflex, for sustained eyelid closure and, possibly, for the classical conditioning of the nictitating membrane response.