Seizures exacerbate excitatory: inhibitory imbalance in Alzheimer's disease and 5XFAD mice

Approximately 22% of Alzheimer's disease (AD) patients suffer from seizures, and the co-occurrence of seizures and epileptiform activity exacerbates AD pathology and related cognitive deficits, suggesting that seizures may be a targetable component of AD progression. Given that alterations in neuronal excitatory:inhibitory (E:I) balance occur in epilepsy, we hypothesized that decreased markers of inhibition relative to those of excitation would be present in AD patients. We similarly hypothesized that in five times familial AD (5XFAD) mice, the E:I imbalance would progress from an early stage (prodromal) to later symptomatic stages, and be further exacerbated by pentylenetetrazol (PTZ) kindling. Post-mortem AD temporal cortical tissue from patients with or without seizure history were examined for changes in several markers of E:I balance, including levels of the inhibitory GABAA receptor, the sodium potassium chloride cotransporter 1 (NKCC1) and potassium chloride cotransporter 2 (KCC2), and the excitatory NMDA and AMPA type glutamate receptors. We performed patch clamp electrophysiological recordings from CA1 neurons in hippocampal slices and examined the same markers of E:I balance in prodromal 5XFAD mice. We next examined 5XFAD mice at chronic stages, after PTZ or control protocols, and in response to chronic mTORC1 inhibitor rapamycin, administered following kindled seizures, for markers of E:I balance. We found that AD patients with comorbid seizures had worsened cognitive and functional scores and had decreased GABAA receptor subunit expression, and increased NKCC1/KCC2 ratios, indicative of depolarizing GABA responses. Patch clamp recordings of prodromal 5XFAD CA1 neurons showed increased intrinsic excitability, along with decreased GABAergic inhibitory transmission and altered glutamatergic neurotransmission, indicating that E:I imbalance may occur in early disease stages. Furthermore, seizure induction in prodromal 5XFAD mice led to later dysregulation of NKCC1/KCC2 and a reduction in GluA2 AMPA glutamate receptor subunit expression, indicative of depolarizing GABA receptors and calcium permeable AMPA receptors. Finally, we found that chronic treatment with the mTORC1 inhibitor, rapamycin, at doses we have previously shown to attenuate seizure-induced β-amyloid pathology and cognitive deficits, could also reverse elevations to NKCC1/KCC2 ratio in these mice. Our data demonstrate novel mechanisms of interaction between AD and epilepsy and indicate that targeting E:I balance, potentially with FDA-approved mTOR inhibitors, hold therapeutic promise for AD patients with a seizure history.

The role of mTORC1 activation in seizure-induced exacerbation of Alzheimer's disease

The risk of seizures is 10-fold higher in patients with Alzheimer's disease than the general population, yet the mechanisms underlying this susceptibility and the effects of these seizures are poorly understood. To elucidate the proposed bidirectional relationship between Alzheimer's disease and seizures, we studied human brain samples (n = 34) from patients with Alzheimer's disease and found that those with a history of seizures (n = 14) had increased amyloid-β and tau pathology, with upregulation of the mechanistic target of rapamycin (mTOR) pathway, compared with patients without a known history of seizures (n = 20). To establish whether seizures accelerate the progression of Alzheimer's disease, we induced chronic hyperexcitability in the five times familial Alzheimer's disease mouse model by kindling with the chemoconvulsant pentylenetetrazol and observed that the mouse model exhibited more severe seizures than the wild-type. Furthermore, kindled seizures exacerbated later cognitive impairment, Alzheimer's disease neuropathology and mTOR complex 1 activation. Finally, we demonstrated that the administration of the mTOR inhibitor rapamycin following kindled seizures rescued enhanced remote and long-term memory deficits associated with earlier kindling and prevented seizure-induced increases in Alzheimer's disease neuropathology. These data demonstrated an important link between chronic hyperexcitability and progressive Alzheimer's disease pathology and suggest a mechanism whereby rapamycin may serve as an adjunct therapy to attenuate progression of the disease.

Weekend Admissions for Somatic Symptom and Related Disorders and Length of Stay

OBJECTIVES

To evaluate whether admission on weekends affects the length of stay (LOS) for patients hospitalized with somatic symptom and related disorders (SSRDs).

METHODS

Data from 2012-2018 was obtained for all patients aged 4 to 21 years (N = 5459) with a primary discharge diagnosis of SSRDs from 52 tertiary care pediatric hospitals in the United States. We obtained patient demographics, admission date and/or time, LOS, procedure count, and comorbid conditions. We defined a weekend as 3 pm Friday to 3 pm Sunday. The Wilcoxon rank test was used for unadjusted analysis. Multiple logistic regression was used to estimate the odds of having LOS >1 day, >2 days, >3 days, and >4 days in weekend versus weekday groups.

RESULTS

Weekend admission significantly correlated with increased LOS (P < .001). Compared with weekdays, a weekend admission was associated with increased odds of having LOS >1, >2, and >3 days. This remained statistically significant while adjusting for the number of chronic conditions, procedures, and individuals with Black or Hispanic ethnicity compared with White ethnicity. LOS was not associated with sex or age of the patients.

CONCLUSIONS

Patients with SSRDs admitted on the weekend have an increased LOS compared with those admitted on a weekday. This may be due to a decrease in multidisciplinary care available during weekends. In future studies, researchers should aim to better understand the specific factors that contribute to this disparity and test interventions that may close the gap in care, including expanding to 7-day services, increasing mental health resources, and working to decrease the need for inpatient admissions.

The Medial Metaphyseal Periosteal Artery (MMPA): An Alternate Pedicle for the Medial Femoral Trochlea Flap

We report a case of medial femoral trochlea flap used for scaphoid proximal pole reconstruction, in which the transverse branch of the descending genicular artery was vestigial. The medial metaphyseal periosteal artery was clearly the dominant pedicle supplying the trochlear region. The flap was safely raised on the medial metaphyseal periosteal artery pedicle. The incidence of this uncommon presentation remains unknown and this anatomical variant is newly described.

New thinking for filth fly control: residual, non-chemical wall spray from volcanic glass

Filth flies are of medical and veterinary importance because of the transfer of disease organisms to animals and humans. The traditional control methods include the use of chemical insecticides. A novel mechanical insecticide made from volcanic glass and originally developed to control mosquitoes (Imergard™ WP; ImG) was investigated for control of adult grey flesh flies, Sarcophaga bullata (Parker), secondary screwworms, Cochliomyia macellaria (F.), and house flies, Musca domestica L. In a modified WHO cone test device, the time to 50% mortality (LT₅₀ ) when applied at 5 g/m² (tested at 30 °C and 50% relative humidity (rH)) was 7.1, 4.3 and 3.2 h, respectively. When knockdown was included, the LT₅₀ s were 5.5, 1.5 and 2.8 h, respectively. Application rates of 1.25 and greater g/m² had the shortest LT₅₀ s. The time to the LT₅₀ increased for M. domestica as rH increased, but ImG was still active at the highest rH tested of 70%. Scanning electron micrographs showed ImG was present on all body parts, unlike that for mosquitoes where it was found mostly on the lower legs. These first studies on the use of Imergard WP against flies suggest this could be an alternative method for filth fly control.

New Mosquitocide Derived From Volcanic Rock

Malaria, dengue, yellow fever, and the Zika and West Nile Viruses are major vector-borne diseases of humans transmitted by mosquitoes. According to the World Health Organization, over 80% of the world's population is at risk of contacting these diseases. Insecticides are critical for mosquito control and disease prevention, and insect insecticide resistance is on the increase; new alternatives with potentially different modes of action from current chemistry are needed. During laboratory screening of industrial minerals for insecticide activity against Anopheles gambiae (Giles) (Diptera: Culicidae) we discovered a novel mechanical insecticide derived from volcanic rock (MIVR) with potential use as a residual spray. In modified WHO cone tests, the time to 50% mortality was 5 h under high-humidity conditions. MIVR treated surfaces demonstrated no mosquito repellency. In field studies where the mechanical insecticide was applied to wood using standard spray equipment and then placed under stilt homes in New Orleans, LA, the residual activity was >80% after 9 wk against Aedes aegypti (L.) (Diptera: Culicidae), Aedes albopictus (Skuse) (Diptera: Culicidae) and Culex quinquefasciatus (Say) (Diptera: Culicidae) (with similar efficacy to a positive chemical insecticide control). In scanning electron microcopy studies, the MIVR was transferred as particles mostly to the legs of the mosquito. This wettable powder made from volcanic rock is a mechanical insecticide representing a potential new mode of action different from current chemistry for mosquito control and is in commercial development under the trade name Imergard™WP as an indoor and outdoor residual spray.

Bio-Efficacy of Diatomaceous Earth, Household Soaps, and Neem Oil against Spodoptera frugiperda (Lepidoptera: Noctuidae) Larvae in Benin

Spodoptera frugiperda was first reported in Africa in 2016 and has since become a serious threat to maize/cereal production on the continent. Current control of the pest relies on synthetic chemical insecticides, which can negatively impact the environment and promote the development of resistance when used indiscriminately. Therefore, great attention is being paid to the development of safer alternatives. In this study, several biorational products and a semi-synthetic insecticide were evaluated. Two household soaps ("Palmida" and "Koto") and a detergent ("So Klin") were first tested for their efficacy against the larvae under laboratory conditions. Then, the efficacy of the most effective soap was evaluated in field conditions, along with PlantNeem (neem oil), Dezone (diatomaceous earth), and Emacot 19 EC (emamectin benzoate), in two districts, N'Dali and Adjohoun, located, respectively, in northern and southern Benin. The soaps and the detergent were highly toxic t second-instar larvae with 24 h lethal concentrations (LC50) of 0.46%, 0.44%, and 0.37% for So Klin, Koto, and Palmida, respectively. In field conditions, the biorational insecticides produced similar or better control than Emacot 19 EC. However, the highest maize grain yields of 7387 and 5308 kg/ha were recorded, respectively, with Dezone (N'Dali) and Emacot 19 EC (Adjohoun). A cost-benefit analysis showed that, compared to an untreated control, profits increased by up to 90% with the biorational insecticides and 166% with Emacot 19 EC. Therefore, the use of Palmida soap at 0.5% concentration, neem oil at 4.5 L/ha, and Dezone at 7.5 kg/ha could provide an effective, environmentally friendly, and sustainable management of S. frugiperda in maize.

Implementing Resident Team Assistant Programs at Academic Medical Centers: Lessons Learned

BACKGROUND

Excessive inpatient administrative tasks can lead to adverse consequences for residents and their patients. Furthermore, this burden has been linked to depersonalization, a major component of physician burnout.

OBJECTIVE

To describe the development, implementation, feasibility, acceptability, and early outcomes of Resident Team Assistant (RTA) programs.

METHODS

Three large academic medical centers created RTA programs in which administrative assistants are incorporated into inpatient medical teams. First steps included a needs assessment and driver diagram creation to identify key issues and to solidify goals. Program directors were assigned, and RTAs were hired, trained, and incorporated into inpatient teams at each institution (2003, 2016, 2018). Program leadership and institutional stakeholders met regularly to discuss development and quality assurance. Surveys and direct interviews were performed to evaluate impact and acceptability. Institutional goals in accordance to RTAs tasks were also investigated.

RESULTS

Resident surveys and interviews have shown acceptability with RTAs completing a large percentage of resident administrative tasks while promoting time spent in direct clinical care and job satisfaction. Hospital-specific improvements have included increase in referring physician communication rate and decrease in work hour violations. The programs have maintained high feasibility and sustainability with a relatively low time commitment from leadership and cost for the institutions.

CONCLUSIONS

The RTA programs at the 3 institutions have continued to be sustained over time with perceived improvements in administrative task burden and job satisfaction for the residents. They have maintained high acceptability and feasibility in terms of effort and costs for the hospitals.

Vertebral osteomyelitis due to Salmonella Poona in a healthy adolescent female

We present a case of vertebral osteomyelitis in a previously healthy, adolescent Caucasian female athlete. After months of lower back pain, spinal imaging demonstrated phlegmon and suspected osteomyelitis of the L4 vertebral body. A bone biopsy was obtained, and microbiologic cultures yielded pure growth of Salmonella enterica subsp. enterica serovar Poona (S. Poona), a member of the nontyphoid Salmonella group associated with food-borne gastroenteritis in the United States. This case represents the first reported association of S. Poona with osteomyelitis and is interesting in that the infection developed in a patient without traditional risk factors for invasive Salmonella disease (i.e. sickle cell disease). This case highlights the importance of keeping a broad differential diagnosis for lower back pain and emphasizes the value of obtaining specimens for microbiologic culture to aid in diagnosing non-traditional and potentially emerging bacterial pathogens.

ImergardTMWP: A Non-Chemical Alternative for an Indoor Residual Spray, Effective against Pyrethroid-Resistant Anopheles gambiae (s.l.) in Africa

Malaria is the deadliest mosquito-borne disease and kills predominantly people in sub-Saharan Africa (SSA). The now widespread mosquito resistance to pyrethroids, with rapidly growing resistance to other insecticide classes recommended by the World Health Organization (WHO), may overturn the successes gained in mosquito control in recent years. It is of utmost importance to search for new, inexpensive, and safe alternatives, with new modes of action, that might improve the efficacy of current insecticides. The efficacy of a novel mechanical insecticidal mineral derived from volcanic rock, ImergardTMWP, was investigated to determine its efficacy as a stand-alone residual wall spray and as a mixture with deltamethrin (K-Othrine® Polyzone) in experimental huts in Cove, Benin. The evaluation was conducted with susceptible (Kisumu) and wild-type Anopheles gambiae (s.l.). Deltamethrin applied alone demonstrated 40-45% mortality (at 72 h post-exposure) during the first four months, which declined to 25% at six months for wild An. gambiae from Cove. ImergardTMWP alone and mixed with deltamethrin, under the same assay conditions, produced 79-82% and 73-81% mortality, respectively, during the same six-month period. ImergardTMWP met the 80% WHO bio-efficacy threshold for residual activity for the first five months with 78% residual activity at six months. ImergardTMWP can be used as a mixture with chemical insecticides or as a stand-alone pesticide for mosquito control in Africa.

Surgical Treatment and Outcomes of Syndactyly: A Systematic Review

Background: Different techniques are used to release simple and complex congenital syndactyly in order to create an adequate web space, and to separate the fingers to allow independent function.

Methods: This article is a systematic review of the literature, aiming to evaluate the evidence for the different techniques and outcome measures utilised.

Results: The studies consisted mainly of retrospective, non-controlled descriptive series and a few retrospective cohort studies. The level of evidence is predominantly poor.

Conclusions: Although recommendations in favour of any particular surgical technique cannot be given based on evidence, a number of conclusions can be drawn out of the existing literature with regards to the design of the incisions for finger separation, use of pulp flaps and grafts.

Cadaveric Dissection of the Axillary Nerve: An Investigation of Extra-Muscular and Intra-Muscular Branching Patterns

BACKGROUND

Variations in the axillary nerve branching patterns have been reported. The aim of the study is to investigate the extra- and intra-muscular course of the axillary nerve and quantify the regional innervation of the deltoid.

METHODS

In fresh frozen specimens, the origin of the axillary nerve from the posterior cord of the brachial plexus and its extra- and intra-muscular course were identified. Muscle dimensions, branching patterns and the distance from the axillary nerve origin to major branches were measured. The weights of muscle segments supplied by major branches of the axillary nerve were recorded.

RESULTS

Twenty-three cadaveric dissections were completed. The axillary nerve bifurcated within the quadrangular space in all cases. The mean distance from the origin to bifurcation of the axillary nerve was 39 ± 13 mm; from axillary nerve bifurcation to the teres minor branch was 13 ± 6 mm; and from axillary nerve bifurcation to the middle branch of anterior division was 26 ± 11 mm. The nerve to teres minor and superior lateral brachial cutaneous nerve originated from the posterior division or common trunk in all cases. No fibrous raphe were identified separating anterior, middle and posterior deltoid segments. The anterior division of axillary nerve supplied 85 ± 4% of the deltoid muscle (by weight). The posterior division supplied 15 ± 4% of the deltoid muscle (by weight). The posterior deltoid was supplied by both anterior and posterior divisions in 91.3% of cases.

CONCLUSIONS

This study demonstrates a consistent branching pattern of the axillary nerve. The anterior division of the axillary nerve innervates all three deltoid segments in most instances (85% of the deltoid by weight). This study supports the concept of re-innervation of the anterior division alone in isolated axillary nerve injuries.

Cost Comparison of Collagenase Clostridium Histolyticum and Fasciectomy for Treatment of Dupuytren's Contracture in the Australian Health System

BACKGROUND

Dupuytren's disease results in contracted cords in the hand that lead to deformity and disability. Current treatment options include fasciectomy and an injectable, collagenase clostridium histolyticum. No cost comparison studies have been published within the Australian health care environment.

METHODS

A retrospective review of all patients treated for Dupuytren's disease in a major teaching hospital was undertaken to compare the costs of treatment by fasciectomy or collagenase injection.

RESULTS

Eighteen patients underwent fasciectomy and 21 collagenase clostridium histolyticum injections were performed during the study period and were eligible for inclusion under the review criteria. Of the 39 patients, 36 were male and 3 were female with an average age 66.4 years (50-85). Twenty-five digits were treated by fasciectomy in 18 patients, and 23 digits were treated by collagenase in 21 patients. The fasciectomy group attended an average 9.2 visits (5-22), incurring an average costing of US$5738.12 per patient ($3181.18-$9618.10). The collagenase group attended an average 3.8 visits (3-8), incurring an average costing of US$2076.83 per patient ($1842.24-$3929.57).

CONCLUSIONS

Collagenase treatment of Dupuytren's contracture represents a significant reduction in cost relative to fasciectomy, with 64% savings, length of follow up and number of visits. This is a similar finding to studies in other countries.

Evaluation of subcutaneous rituximab administration on Canadian systemic therapy suites

Background

Non-Hodgkin lymphoma (nhl) is the most common hematologic malignancy. Diffuse large B-cell lymphoma (dlbcl) and follicular lymphoma (fl) constitute 55% of new nhl cases and are initially treated with rituximab-based chemoimmunotherapy. Relative to intravenous (IV) rituximab, a subcutaneous (sc) formulation approved in 2016 has comparable pharmacokinetics, efficacy, and safety, and a greatly reduced administration time; it is also preferred by patients. The objective of the present study was to estimate the effect (on systemic therapy suite time and on the costs of drug acquisition and administration) of implementing sc rituximab in the initial chemoimmunotherapy for fl and dlbcl over 3 years in the Canadian market.

Methods

An Excel (Microsoft Corporation, Redmond, WA, U.S.A.)-based model was created with a population size based on epidemiologic data and current rituximab use, duration of use considering initial therapy, time savings for sc rituximab administration from published studies, costs from standard Canadian sources, and assumed uptake in implementing provinces of 65%, 75%, and 80% over 3 years. Key parameters and sensitivity analysis values were validated by clinical experts located in various Canadian jurisdictions. Costs are reported in 2017 Canadian dollars from the perspective of the health care system.

Results

More than 3 years after implementation of sc rituximab, we estimated that 5762 Canadians would be receiving sc rituximab, resulting in savings of 128,715 hours in systemic therapy suite time and approximately $40 million in drug and administration costs. Sensitivity analyses suggest that the model is most sensitive to sc market uptake, number of induction therapy cycles, and eligible patients.

Conclusions

Subcutaneous administration of rituximab can significantly reduce systemic therapy suite time and achieve substantial savings in drug and administration costs.

Abstract 5211: Dual E-selectin and CXCR4 inhibition reduces tumor growth and metastatic progression in an orthotopic model of osteosarcoma

Osteosarcoma is the most common bone cancer in children and young adults and has a strong propensity to develop lung metastases. E-selectin is known to be involved in the focal adhesion of tumor cells to cytokine exposed endothelial cells and we postulated may play a central role in osteosarcoma progression. Previously we identified that SDF-1, the main ligand for CXCR4, was upregulated in the pre-metastatic niche (Kaplan et al Nature 2005). Many tumor cells express CXCR4 and may use this signaling pathway to direct disseminated tumor cells to pre- and early metastatic sites in the lung. Based on these findings we examined human osteosarcoma cell lines and primary patient derived xenografts (PDXs) for the expression of CXCR4 and E-selectin ligands by flow cytometry. We found robust expression of these ligands in the majority of both the human osteosarcoma cell lines and PDXs examined. We therefore, investigated the impact of targeting these two axes on metastatic progression of orthotopic osteosarcoma using a small molecule, glycomimetic compound with dual inhibitory activity against E-selectin and CXCR4, GMI-1359. Five days post paratibial injection the HOS cell line, female NMRI-nu mice (n=12/group) were treated with saline; GMI-1359 alone (40 mg/kg IP BID x 25 days); doxorubicin (DOX) alone (5 mg/kg IV days 5, 15 and 25), or the combination of GMI-1359 and DOX. All treatments were well tolerated. The % tumor volume in treatment/control on day 27 of mice treated with GMI-1359, DOX or the combination was 35.5, 36.7 and 32.5, respectively. At study conclusion the incidence of lung metastases was approximately 60% and 50% in mice treated with saline or DOX and 15% in mice treated with GMI-1369 alone or in combination with DOX. Moreover, the extent of ectopic bone formation and/or osteolytic lesions was lower in mice treated with GMI-1359 compared to saline and DOX. These results indicate that the E-selectin and CXCR4 axes are important for the progression of osteosarcoma, and further, that inhibition of these two pro-tumor growth components by GMI-1359 has a therapeutic advantage over chemotherapy alone. Furthermore, studies in the adjuvant setting can provide proof of concept of utility of targeting CXCR4 and E- selectin ligands in the metastatic niche as a therapeutic strategy to limit metastatic progression in high risk patients.

Citation Format: Wei Ju, Choh L. Yeung, Arnulfo Mendoza, Meera Murgai, Sabina Kaczanowska, Jennifer Zhu, Shil Patel, David A. Stewart, William E. Fogler, John L. Magnani, Rosandra N. Kaplan. Dual E-selectin and CXCR4 inhibition reduces tumor growth and metastatic progression in an orthotopic model of osteosarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5211.

Neutrophilic Dermatosis of the Hands: A Review of 17 Cases

PURPOSE

Neutrophilic dermatosis of the hands is an inflammatory skin condition related to Sweet syndrome that responds to corticosteroids. It commonly affects the dorsum of the hand and often mimics infection, with violaceous inflammatory papules and plaques that may ulcerate. The aim of this study was to review the clinical presentation of neutrophilic dermatosis of the hands.

METHODS

A retrospective review was undertaken of all cases of neutrophilic dermatosis of the hands seen at a tertiary hospital in New South Wales, Australia, over a 5-year period.

RESULTS

Seventeen cases were identified. The mean time to diagnosis was 9 days after lesion onset. Most cases were older adults (mean age, 71 years). The most common referral diagnoses were infection or a nonhealing wound and 65% of cases reported a history of trauma. The dorsal index finger was the site of involvement in 41% of cases. One case involved the palm. Histopathology reports were available for skin punch biopsy for 14 of 17 cases, which showed dermal neutrophilic infiltrate (93%) and epidermal involvement with necrosis, ulceration, or pustulation (64%). Six cases were treated surgically prior to the correct diagnosis and management being introduced.

CONCLUSIONS

Neutrophilic dermatosis of the hands was often misdiagnosed as infection. A history of trauma is common and may be misleading. Dermatological consultation and skin punch biopsy are useful in confirming the diagnosis, ideally prior to surgical management.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

House Staff Participation in Patient Safety Reporting: Identification of Predominant Barriers and Implementation of a Pilot Program

OBJECTIVES

Patient safety event (PSE) reporting is a critical element for healthcare organizations that are striving for continuous quality improvement. Although resident physicians routinely provide the majority of direct patient care, the level of their participation in PSE reporting historically has been low. In addition, as part of the Accreditation Council for Graduate Medical Education's Next Accreditation System, the Clinical Learning Environment Review site visit assesses residents' engagement in PSE reporting at each accredited academic institution. The objective of this study was to understand the common barriers to PSE reporting and design an intervention to increase the number of PSE reports by resident physicians.

METHODS

We surveyed 304 residents and fellows to assess attitudes toward the PSE reporting system and identify barriers to submitting online PSE reports. Based on this analysis of barriers, we piloted interventions with the internal medicine residency program and measured their effect on resident PSE reporting.

RESULTS

Of the survey respondents, 58% had never submitted a PSE report. The most commonly identified barriers were too much time required to submit a report (38% of all respondents), lack of education on how or what to report (37%), lack of feedback or change after reporting (19%), and concern for repercussions or lack of anonymity (13%). Based on this analysis of barriers, we piloted interventions with the internal medicine residency program to educate residents about PSE reporting through a reminder message in their orientation e-mail, informational slides at the end of conferences that described what and how to report, a pocket card with reporting instructions, and leadership encouragement during walk rounds by chief medical residents and the program director. Compared with the 10 weeks before the start of the intervention, the number of PSE reports submitted by internal medicine residents more than doubled, from 16 to 37 reports (P < 0.01). This increase in resident PSE reporting was sustained for 20 weeks despite the interventions lasting only 8 weeks.

CONCLUSIONS

A resident-driven intervention that fostered a culture of encouragement for PSE reporting through leadership support and targeted education increased the number of PSE reports submitted by internal medicine residents at our health system. Hospitals and health systems should seek to understand the common barriers to PSE reporting from this important group of direct patient care providers and administer structured educational programs to encourage their participation.

Improving Interdisciplinary Provider Communication Through a Unified Paging System

OBJECTIVES

Interdisciplinary communication at a Veterans Affairs (VA) academic teaching hospital is largely dependent on alphanumeric paging, which has limitations as a result of one-way communication and lack of reliable physician identification. Adverse patient outcomes related to difficulty contacting the correct consulting provider in a timely manner have been reported.

METHODS

House officers were surveyed on the level of satisfaction with the current VA communication system and the rate of perceived adverse patient outcomes caused by potential delays within this system. Respondents were then asked to identify the ideal paging system. These results were used to develop and deploy a new Web site. A postimplementation survey was repeated 1 year later. This study was conducted as a quality improvement project.

RESULTS

House officer satisfaction with the preintervention system was 3%. The majority used more than four modalities to identify consultants, with 59% stating that word of mouth was a typical source. The preferred mode of paging was the university hospital paging system, a Web-based program that is used at the partnering academic institution. Following integration of VA consulting services within the university hospital paging system, the level of satisfaction improved to 87%. Significant decreases were seen in perceived adverse patient outcomes (from 16% to 2%), delays in patient care (from 90% to 16%), and extended hospitalizations (from 46% to 4%).

CONCLUSIONS

Our study demonstrates significant improvement in physician satisfaction with a newly implemented paging system that was associated with a decreased perceived number of adverse patient events and delays in care.

The two-minute walking test: a sensitive index of mobility in the rehabilitation of elderly patients

The usefulness of a timed walking test adapted for use as an index of mobility in elderly subjects undergoing rehabilitation was assessed. The 95% confidence interval for repeatability in 27 subjects was found to be -27% to +38%. The test was able to detect a significant improvement ( p < 0.01) in a group of subjects undergoing active rehabilitation, whereas no improvement was detected by a conventional rating scale. The two-minute walking test is a simple and sensitive index of mobility in the elderly.

Prospective Audit of the Management of Head Injuries in a Small District General Hospital

Abstract Background and Aims: In September 2000 the Scottish Intercollegiate Guidelines Network published their recommendations on the optimal early management of head injured patients. Early identification of significant intracranial pathology through CT scanning is central to these guidelines. At our small DGH, head injured patients are received and managed by general surgeons with no specific training in head trauma. In addition, there is as yet no arrangement in place for urgent CT scanning. Because of these factors, an audit was conducted to determine the extent to which we were able to comply with these guidelines. Methods.: A 2 month prospective audit of the management of head injured patients was carried out collecting data on patient demographics, clinical condition on admission, clinical course, radiological investigations (and difficulty in arranging them) and outcome. Results: Over the 2 month period 52 consecutive patients were studied. Fifteen patients met criteria for CT scanning, of which 9 were ultimately scanned. Tellingly, only one of the fifteen received their scan within the recommended four hour period. In this series, no patient had an adverse clinical event related to delay in scanning. Conclusion: Any hospital admitting head injured patients should have 24 hour access to CT scanning facilities. If such an arrangement is not in place then patients with head injuries should not be admitted to that hospital.

Successful replantation of a finger in an 8-month old child

A successful replantation of an index fingertip in an 8-month old girl is reported. A literature review of replants in very young children suggests this is one of the youngest patients ever to undergo digital replantation and possibly the youngest finger replant performed.

IL15 levels on day 7 after hematopoietic cell transplantation predict chronic GVHD

Chronic GVHD (cGVHD) is an important complication of allogeneic hematopoietic cell transplantation (HCT). As preemptive therapy might be efficacious if administered early post transplant, we set out to determine whether cGVHD can be predicted from the serum level of a biomarker on day 7 or 28. In a discovery cohort of 153 HCT recipients conditioned with BU, fludarabine and rabbit antithymocyte globulin (ATG), we determined serum levels of B-cell-activating factor, vascular endothelial growth factor, soluble TNF-α receptor 1, soluble IL2 receptor α, IL5, IL6, IL7, IL15, γ-glutamyl transpeptidase, cholinesterase, total protein, urea and ATG. Patients with low levels of IL15 (<30.6 ng/L) on day 7 had 2.7-fold higher likelihood of developing significant cGVHD (needing systemic immunosuppressive therapy) than patients with higher IL15 levels (P<0.001). This was validated in a validation cohort of 105 similarly-treated patients; those with low IL15 levels had 3.7-fold higher likelihood of developing significant cGVHD (P=0.001). Low IL15 was not associated with relapse; it trended to be associated with acute GVHD and was associated with low infection rates. In conclusion, low IL15 levels on day 7 are predictive of cGVHD, and thus could be useful in guiding preemptive therapy.

Patient management in the emergency department by advanced care paramedics

We describe an emergency department process using Advanced Care Paramedics in the management of patients identified as ambulatory and low acuity, or those able to be managed without an emergency nurse. Patients streamed in this way had shorter stays than other emergency patients, without affecting the care of the latter. The process was associated with improved patient flow indicators in spite of an increased patient burden.

Band gap and electronic structure of an epitaxial, semiconducting Cr0.80Al0.20 thin film

Cr(1-x)Al(x) exhibits semiconducting behavior for x = 0.15-0.26. This Letter uses hard x-ray photoemission spectroscopy and density functional theory to further understand the semiconducting behavior. Photoemission measurements of an epitaxial Cr(0.80)Al(0.20) thin film show several features in the valence band region, including a gap at the Fermi energy (E(F)) for which the valence band edge is 95 ± 14 meV below E(F). Theory agrees well with the valence band measurements, and shows an incomplete gap at E(F) due to the hole band at M shifting almost below E(F).

Molecular pathways and genetic aspects of Parkinson's disease: from bench to bedside

Idiopathic Parkinson's disease (PD) is a progressive neurodegenerative disease characterized by dopaminergic neuronal loss within the substantia nigra. The incidence and prevalence of PD is rising with an increasing aging population. PD is a slowly progressive condition and patients can develop debilitating motor and functional impairment. Current research has implicated oxidative stress, alpha-synucleinopathy and dysfunction of the ubiquitin-proteasome system in the pathogenesis of PD. A number of gene mutations have also been linked to the development of PD. The elucidation of these new molecular pathways has increased our knowledge of PD pathophysiology. This article reviews important molecular mechanisms and genetic causes implicated in the pathogenesis of PD, which has led to new areas of therapeutic drug research.

Biomechanical influence of the vincula tendinum on digital motion after isolated flexor tendon injury: a cadaveric study

PURPOSE

The vincula are specialized mesotendinous structures attaching to the flexor tendons of the hand. In addition to providing vascular supply to the tendons, the vincula can be mechanically important. The purpose of this study was to quantify the influence of intact vincula on digital flexion after flexor tendon laceration and to assess the ultimate strength and stiffness of the vincula.

METHODS

The index, middle, and ring fingers of 12 fresh-frozen cadaveric fingers were dissected free at the level of the metacarpophalangeal joint, preserving at least 10 cm of the flexor and extensor tendons. A 9.8-N load was applied to each flexor tendon, and using digital photography and image analysis software, the degree of flexion at the proximal and distal interphalangeal joints and excursion of tendons proximal to the metacarpophalangeal joint was recorded before and after division of the flexor digitorum profundus and flexor digitorum superficialis tendons at their insertions. Load to failure and stiffness of the vincula were measured via a uniaxial material testing apparatus. Analysis of means was performed with a paired t-test.

RESULTS

After division of the flexor digitorum superficialis tendon, proximal interphalangeal joint flexion secondary to the influence of the intact vincula was 93% of that compared with the uninjured digit. Distal interphalangeal joint flexion after flexor digitorum profundus transection was 69% of normal. The increased excursion of transected tendons compared with testing before division was 4 mm for flexor digitorum superficialis and 2 mm for flexor digitorum profundus. Load to failure was 27 N, and stiffness was 6 N/mm.

CONCLUSIONS

The vincula breve can facilitate digital flexion after distal tendon transection, allowing tendons to act indirectly across the interphalangeal joints. The intact vincula breve can facilitate an almost normal range of motion across the interphalangeal joints, making the diagnosis of a flexor tendon injury difficult. In the immediate postinjury period, the vincula breve can hold a divided tendon within a few millimeters of its insertion. Testing against resistance is important to avoid missing the diagnosis of a tendon injury.

Viral purging of haematological autografts: should we sneeze on the graft?

High-dose cytotoxic chemotherapy followed by autologous haematopoietic stem cell transplantation (ASCT) is extensively used for the treatment of many haematopoietic, as well as several epithelial cancers. Disease relapse may be the result of tumour contamination within autograft as evidenced by gene marking studies. The multiple purging strategies that have been described to date have not proven effective in most ASCT settings. This review addresses the possibility of using oncolytic viruses as a novel purging strategy. DNA viruses such as genetically engineered adenoviral vectors have widely been used to deliver either a prodrug-activating enzyme or express wild-type p53 selectively in tumour cells in ex vivo purging protocols. In addition, conditionally replicating adenoviruses that selectively replicate in tumour cells and herpes simplex virus type 1 are other DNA viruses that have been tested as ex vivo purging agents under laboratory conditions. Vesicular stomatitis virus (VSV) and reovirus are naturally occurring RNA viruses that appear to hold promise as purging agents under ex vivo and in vivo settings. Preclinical data demonstrate reovirus's purging potential against breast, monocytic and myeloma cell lines as well as patient-derived tumours of diffuse large B-cell lymphoma, chronic lymphocytic leukaemia, Waldenstrom macroglobulinemia and small lymphocytic lymphoma. In addition, VSV has shown effective killing of leukaemic cell lines and multiple myeloma patient specimens. Given the increasing interest in the utilization of viruses as purging agents, the following review provides a timely summary of the potential and the challenges of oncolytic viruses as purging modalities during ASCT.

Complications of 278 consecutive abdominoplasties

The case notes of 278 consecutive patients who underwent abdominoplasty, during a five-year period, in one institution under the care of four surgeons were reviewed. Patient details, early and late complications and revision procedures were noted. Seventy-five percent of patients had a 'full' abdominoplasty with undermining to costal cartilage and repositioning of the umbilicus and 23% had 'mini abdominoplasties', 2% were revision operations. Eighteen percent of patients suffered from early complications the most common of which were seroma (5%), haematoma (3%), infection (3%), skin or fat necrosis (2.5%) and delayed healing (2%). Twenty-five percent of patients had late complications which were often relatively minor. These included 'dog ears' (12%), localised fatty excess (10%) and unsatisfactory scars (8%). Twenty-four percent of patients underwent revision surgery. Most commonly further liposuction (12%), dog ear revision (10%) and scar revision (5%). Analysis failed to reveal significant risk factors. Despite an apparently high complication and revision rate the subjective impression is of a satisfied patient cohort.

Overnight storage of autologous stem cell apheresis products before cryopreservation does not adversely impact early or long-term engraftment following transplantation

To reduce costs and avoid inconvenient overtime work, our institution changed policy in September 2000 so that autologous stem cell apheresis products were stored overnight before cryopreservation rather than immediately processed. This retrospective review was conducted to evaluate the possible impact of this policy change on hematopoietic engraftment following autologous stem cell transplantation (ASCT). In total, 229 consecutive lymphoma patients who underwent a single, unpurged ASCT in Calgary between January 1995 and November 2003 were evaluated. Of these patients, 131 patients' autografts underwent immediate processing and cryopreservation before September 2000, and 98 patients' autografts underwent next-day cryopreservation after overnight storage following this date. Results of univariate and multivariate analyses demonstrated no adverse effect of overnight storage before cryopreservation on the number of days to initial engraftment of platelets or neutrophils, on the proportion of patients with low blood counts 6 months post-ASCT, or on lymphoma relapse rates or overall survival post-ASCT. These data suggest that overnight storage of the autograft before cryopreservation does not adversely affect graft viability or influence long-term disease status, and support the continued use of overnight storage of stem cells before cryopreservation as a convenient, cost reduction measure.

The unexpected sites of melanoma regional recurrences

Sentinel node biopsy is a means of identifying nodal involvement in melanoma and lymphoscintigraphy identifies unpredictable sites of melanoma sentinel nodes in up to 25% of cases. Whilst there is a dearth of recent publications in this area, it nevertheless remains an interesting observation that unpredictable sites of sentinel nodes are so common as to be accepted as normal. This study was performed to determine if this high rate of unpredictable lymphatic drainage was reflected in clinical practice, where therapeutic lymph node dissections were performed for pathologically confirmed regional disease.

METHODS

Patients undergoing regional lymph node dissections for histologically proven malignant melanoma were identified from a computer database. Patient details were analysed from case records.

RESULTS

Two hundred and forty-three case records were examined and 237 were suitable for analysis. The site of the primary was the head and neck in 50 (21%), trunk in 73 (31%), upper limb in 27 (11%) and lower limb in 87 (37%). In 15 cases (6%), the first site of regional disease was unpredictable. In these 15 cases, the site of the primary was the head and neck in two, trunk in 11, upper limb in one and lower limb in one. In 37 cases (16%), a subsequent site of nodal recurrence was unpredictable. Clinicians should be aware that patients with melanomas, particularly of the trunk, especially those in whom a therapeutic nodal dissection has been performed, may have nodal disease at unpredictable sites. However, unexpected sites of regional disease are not as common as sentinel node biopsy would suggest. Guidelines for lymph node examination in cutaneous melanoma are suggested based on these findings.

Negative spin polarization and large tunneling magnetoresistance in epitaxial Co/SrTiO(3)/Co magnetic tunnel junctions

We perform an ab initio study of spin-polarized tunneling in epitaxial Co/SrTiO(3)/Co magnetic tunnel junctions with bcc Co(001) electrodes. We predict a large tunneling magnetoresistance in these junctions, originating from a mismatch in the majority- and minority-spin bands both in bulk bcc Co and at the Co/SrTiO(3)/Co interface. The intricate complex band structure of SrTiO(3) enables efficient tunneling of the minority d electrons which causes the spin polarization of the Co/SrTiO(3)/Co interface to be negative in agreement with experimental data. Our results indicate that epitaxial Co/SrTiO(3)/Co magnetic tunnel junctions with bcc Co(001) electrodes are a viable alternative for device applications.

High-dose mitoxantrone–vinblastine–cyclophosphamide and autologous stem cell transplantation for stage III breast cancer: final results of a prospective multicentre study

BACKGROUND

Stage III breast cancer patients continue to suffer high relapse and death rates despite standard chemotherapy regimens. High-dose alkylator chemotherapy does not further improve outcome. This phase II study evaluated a novel high-dose chemotherapy regimen which combined active breast cancer agents with differing mechanisms of action.

PATIENTS AND METHODS

Eligibility included at least seven involved axillary nodes (AxLNs) for tumours <5 cm, at least four AxLNs for tumours >5 cm or locally advanced breast cancer (LABC). Patients received four cycles of fluorouracil-adriamycin-cyclophosphamide (FAC) followed by one cycle of mitoxantrone 63 mg/m(2)-vinblastine 12.5 mg/m(2)-cyclophosphamide 6 g/m(2) (MVC) with autologous blood stem cell transplantation (ASCT).

RESULTS

Between April 1995 and December 1998, 92 patients aged 21-65 years (median 45 years) were enrolled, of whom 25 were treated preoperatively for LABC and 67 were treated postoperatively. Although there was no early treatment-related mortality, one late death occurred from secondary acute myeloid leukaemia. The 7-year event-free and overall survival rates were 53% (95% confidence interval 42-64%) and 62% (95% CI 52-73%), respectively, with no significant difference between pre- and postoperative groups.

CONCLUSION

FAC followed by MVC-ASCT is feasible and reasonably well tolerated, but does not result in improved survival rates compared with other conventional or high-dose regimens for stage III breast cancer.

Biological purging of breast cancer cell lines using a replication-competent oncolytic virus in human stem cell autografts

Autologous hematological stem cell transplantation (ASCT) is used for the treatment of many hematological and several solid cancers. ASCT, however, has proven disappointing as a therapeutic strategy for breast cancer. Our group and others have previously shown that breast cancer micrometastases found in patients' apheresis products (APs) predict shorter progression-free and overall survival. The implications of this finding are twofold: (i) contaminating tumor cells (CTCs) in AP reflect a higher systemic disease burden and/or (ii) reinfused CTCs contribute to relapse/progressive disease. To date, purging strategies have been disappointing. We have previously demonstrated the oncolytic properties of reovirus in in vitro, in vivo and ex vivo systems. In the present study, we tested the hypothesis that reovirus purges CTCs in a breast cancer cell line purging model. Reovirus-infected human breast cancer cell lines (HTB 133, HTB 132, SKBR3 and MCF7) exhibited cell death within days. Admixtures of AP with cells from breast tumor cell lines, which were then exposed to reovirus, showed complete purging of CTCs (assessed via flow cytometry/tumor cell outgrowth analysis) without deleterious effect on CD34+ cells. Our results provide preclinical support for the ex vivo use of reovirus as a purging modality for breast cancer during ASCT.

Autologous transplantation for primary systemic AL amyloidosis is feasible outside a major amyloidosis referral centre: the Calgary BMT Program experience

Recent reports from large amyloidosis referral centers suggest that primary systemic AL amyloidosis patients treated with high-dose melphalan (HDM) and autologous stem cell transplantation (ASCT) survive longer than historical controls treated with less intensive chemotherapy, despite high transplant-related mortality (TRM) rates of >10%. A retrospective review was conducted to determine if the outcome of ASCT for AL amyloidosis at our institution was similar to that reported at major amyloidosis referral centers. Over a 7 year period, we treated a total of 15 AL amyloidosis patients with ASCT, including four with poor prognosis cardiac or multisystem involvement. No TRM was observed. Overall, 10 patients (67%) achieved a complete hematological response and four patients (27%) achieved a complete organ response. The 4-year event-free and overall survival rates were 60% (95% CI 32-89%) and 75% (95% CI 50-100%), respectively. One patient, who presented with cardiac failure and multiorgan involvement with colonic bleeding currently remains in complete remission 62 months post-ASCT. In conclusion, ASCT for primary AL amyloidosis can safely be performed at experienced transplant centers that are not associated with major amyloidosis referral centers, and is feasible for patients who have multisystem involvement, particularly for motivated patients with good performance status.

Antitumor efficacy and tumor-selective replication with a single intravenous injection of OAS403, an oncolytic adenovirus dependent on two prevalent alterations in human cancer

A potentially promising treatment of metastatic cancer is the systemic delivery of oncolytic adenoviruses. This requires engineering viruses which selectively replicate in tumors. We have constructed such an oncolytic adenovirus, OAS403, in which two early region genes are under the control of tumor-selective promoters that play a role in two key pathways involved in tumorigenesis. The early region E1A is controlled by the promoter for the E2F-1 gene, a transcription factor that primarily upregulates genes for cell growth. The E4 region is under control of the promoter for human telomerase reverse transcriptase, a gene upregulated in most cancer cells. OAS403 was evaluated in vitro on a panel of human cells and found to elicit tumor-selective cell killing. Also, OAS403 was less toxic in human hepatocyte cultures, as well as in vivo when compared to an oncolytic virus that lacked selective E4 control. A single intravenous injection of 3 x 10(12) vp/kg in a Hep3B xenograft mouse tumor model led to significant antitumor efficacy. Additionally, systemic administration in a pre-established LNCaP prostate tumor model resulted in over 80% complete tumor regressions at a tolerable dose. Vector genome copy number was measured in tumors and livers at various times following tail vein injection and showed a selective time-dependent increase in tumors but not livers over 29 days. Furthermore, efficacy was significantly improved when OAS403 treatment was combined with doxorubicin. This virus holds promise for the treatment of a broad range of human cancers including metastatic disease.

Sports and the deaf child

The increasingly sedentary American lifestyle has resulted in a growing number of overweight and out-of-shape school-age children. Deaf children are not exempt from this trend, yet there is little evidence that public school programs for these children are doing anything to counter it. Much can be done to assist deaf students, not only in becoming more active movers but in gaining knowledge of opportunities and benefits associated with Deaf sport. The authors provide an argument for schools that expose deaf children to the role of sports in the Deaf community and for designing programs that will enable these children to become active participants in Deaf sport activities as athletes and organizers, or, later in life, when they no longer have the inclination or ability to compete, as spectators, with all the socialization benefits that form of involvement provides.

Photocurrents in nanotube junctions

Photocurrents in nanotube p-n junctions are calculated using a nonequilibrium Green function quantum transport formalism. The short-circuit photocurrent displays band-to-band transitions and photon-assisted tunneling, and has multiple sharp peaks in the infrared, visible, and ultraviolet. The operation of such devices in the nanoscale regime leads to unusual size effects, where the photocurrent scales linearly and oscillates with device length. The oscillations can be related to the density of states in the valence band, a factor that also determines the relative magnitude of the photoresponse for different bands.

High-dose thiotepa, busulfan, cyclophosphamide and ASCT without whole-brain radiotherapy for poor prognosis primary CNS lymphoma

Treatment of primary central nervous system lymphoma (PCNSL) with combined high-dose methotrexate (HD-MTX)-based chemotherapy and whole-brain radiotherapy (WBRT) is associated with severe neurotoxicity, but high relapse rates are associated with the use of either modality alone. In an attempt to improve upon these dismal results, we treated seven PCNSL patients with HD-MTX-based induction therapy followed by thiotepa, busulfan, cyclophosphamide (TBC), and autologous stem cell transplant (ASCT), without WBRT. Six of these patients had at least one of the following poor prognostic features: Karnofsky performance status (KPS) <or=50%, age >60 years, or relapsed disease. All but one patient tolerated the treatment well and experienced improvements in neurological function and overall performance status post-transplant. No treatment-induced neurotoxicity (dementia, ataxia, and incontinence) was observed although the follow-up is short. One early treatment-related death occurred in a patient with multiple comorbid medical conditions. The other six patients achieved a complete response (CR) after TBC and ASCT. Five patients are currently alive and relapse-free at 5, 8, 24, 36, and 42 months from diagnosis. One additional patient relapsed and died 33 months after diagnosis. Two of the seven patients received TBC/ASCT as the only treatment after disease progression following their initial chemotherapy and both remain relapse-free at the time of this report, 22 and 31 months post-TBC/ASCT. In conclusion, prolonged CR can be attained after chemotherapy-only treatment of poor prognosis PCNSL. Furthermore, this small series suggests that high-dose chemotherapy for PCNSL should include drugs that penetrate the CNS such as busulfan and thiotepa rather than standard lymphoma regimens such as BEAM.

Possible benefits of high-dose chemotherapy and autologous stem cell transplantation for adults with recurrent medulloblastoma

In an attempt to improve the dismal prognosis of adults with recurrent medulloblastoma, six patients were treated with aggressive salvage therapy including high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT). At relapse, all patients underwent surgical debulking followed by HDCT/ASCT and then radiotherapy when possible. The treatment plan included two cycles of HDCT/ASCT; first with cyclophosphamide, etoposide and carboplatin (CECb) and then 2 months later with cyclophosphamide and thiotepa (CT). Three of the six patients received the planned therapy. One patient experienced severe toxicity requiring life-sustaining therapy. This patient developed multi-organ dysfunction including multiple enhancing lesions in both cerebral hemispheres that slowly resolved over several months. Two other patients did not mobilize sufficient stem cells for two ASCT procedures. They received one ASCT conditioned with cyclophosphamide, thiotepa and carboplatin (CTCb). Three of six patients had a complete response (CR); the other three had a partial response (PR). Following the first ASCT, median duration of response was 13.5 months (range 9-29 months) and median survival was 21.5 months (range 12-42 months). There was no treatment-related mortality. We conclude that HDCT/ASCT with CECb-CT or CTCb is active against recurrent medulloblastoma in adults and may be associated with prolonged remissions. Multiple enhancing cerebral lesions on brain MRI early post-HDCT/ASCT may be a consequence of the treatment rather than metastatic disease.

Successful treatment of post-transplant lymphoproliferative disorder in autologous blood stem cell transplant recipients

We report three cases of post-transplant lymphoproliferative disorder (PTLD) in the context of autologous stem cell transplantation (ASCT) for multiple myeloma (MM) and non-Hodgkin's lymphoma. The first two cases received ASCT for MM, one with a CD34-selected autograft and the other with an unmanipulated autograft. Both these cases of PTLD achieved a complete response following treatment with IVIG, gancyclovir, solumedrol and interferon (IFN). The third case received ASCT with an unmanipulated autograft for relapsed angioimmunoblastic lymphoma. He also achieved a complete response but only after rituximab was added to IVIG, gancyclovir, solumedrol and IFN. None of these patients experienced a relapse of their PTLD with follow-up ranging from 1.5 to 5 years. These cases highlight the importance of considering PTLD in the differential diagnosis of lymphadenopathy and fever post ASCT. They also demonstrate the possibility of durable complete remission of post-ASCT PTLD following antiviral and immune modulating therapy.

Psoralen-modified clamp-forming antisense oligonucleotides reduce cellular c-Myc protein expression and B16-F0 proliferation

The c-myc protooncogene plays an important role in the abnormal growth pattern of melanoma cells. In an attempt to inhibit c-Myc expression and the growth of an established murine melanoma cell line, we targeted homopurine sequences within the mouse myc mRNA with modified antisense oligonucleotides (AS ODNs). Psoralen was conjugated to the 5'-end of these clamp-forming oligonucleotides (clamp ODNs). Gel mobility shift analysis demonstrated a sequence-specific interaction between the active clamp ODNs (Myc-E2C and Myc-E3C) and the 1.4 kb c-myc mRNA, but no interaction with the control clamp ODN (SCR**). This association was further confirmed by thermal denaturation studies. In vitro translation assays demonstrated that both Myc-E2C and Myc-E3C at 5 microM inhibited c-Myc expression >99% after UV activation at 366 nm. Immunostaining of B16-F0 cells with a c-Myc monoclonal antibody revealed a significant reduction in c-Myc after clamp ODN treatment compared with the untreated or SCR** control-treated cells. This result was corroborated by western blot analysis. Utilizing the MTT assay to determine the effects of ODN-mediated c-Myc reduction on B16-F0 growth, we observed 60 and 64% reductions in growth after treatment with 5 microM Myc-E3C and Myc-E2C, respectively. We attribute the enhanced effectiveness of the clamp ODNs to psoralen activation. Our preliminary data suggest that inhibiting c-Myc overexpression results in a significant reduction in abnormal proliferation of B16-F0 melanoma cells and that the increased efficiency of clamp ODNs may provide an important advantage for their use in antisense therapies.