Middle-age abolishes cardioprotection conferred by thioredoxin-1 in mice

Thioredoxin-1 (Trx1) has cardioprotective effects on ischemia/reperfusion (I/R) injury, although its role in ischemic postconditioning (PostC) in middle-aged mice is not understood. This study aimed to evaluate if combining two cardioprotective strategies, such as Trx1 overexpression and PostC, could exert a synergistic effect in reducing infarct size in middle-aged mice. Young or middle-aged wild-type mice (Wt), transgenic mice overexpressing Trx1, and dominant negative (DN-Trx1) mutant of Trx1 mice were used. Mice hearts were subjected to I/R or PostC protocol. Infarct size, hydrogen peroxide (H2O2) production, protein nitration, Trx1 activity, mitochondrial function, and Trx1, pAkt and pGSK3β expression were measured. PostC could not reduce infarct size even in the presence of Trx1 overexpression in middle-aged mice. This finding was accompanied by a lack of Akt and GSK3β phosphorylation, and Trx1 expression (in Wt group). Trx1 activity was diminished and H2O2 production and protein nitration were increased in middle-age. The respiratory control rate dropped after I/R in Wt-Young and PostC restored this value, but not in middle-aged groups. Our results showed that Trx1 plays a key role in the PostC protection mechanism in young but not middle-aged mice, even in the presence of Trx1 overexpression.

The Role of Steroids in the Preservation of Hearing and Vestibular Function in Cochlear Implantation

OBJECTIVE

Cochlear implant surgery is guided by principles of atraumatic insertion as to protect the inner ear. Previous studies suggest the potential benefit of steroids in patients undergoing cochlear implantation (CI), although the optimal route of administration has yet to be determined. We aim to systematically review the human studies of hearing and vestibular function preservation in patients undergoing CI receiving perioperative steroids and to discuss their role.

DATA SOURCES

Search performed in PubMed, EMBASE, and CENTRAL databases in December 2023.

REVIEW METHODS

Studies comparing several methods of steroid delivery and conventional management for patients undergoing CI were identified. Primary outcomes included hearing and vestibular function preservation. Secondary outcomes included reported adverse events, routes of steroid administration, and the presence of a control group without steroid administration.

RESULTS

A total of 15 studies (N = 659) met inclusion criteria. Methodology, doses, route of steroid administration, and follow-up duration differed between most studies. Audiometric, vestibular, and hearing preservation (HP) results were inconsistent. In 12 studies, perioperative steroids were associated with either increased HP or vestibular function preservation. Only two studies reported adverse events related to oral corticosteroid therapy.

CONCLUSIONS

There is a tendency for perioperative steroids to have a positive impact, at least in the short term, on hearing and vestibular function preservation in CI. Topical corticosteroid therapy appears to have a superior risk-benefit profile. There is a need for future carefully designed randomized controlled trials to determine the ideal route of steroid administration and its real impact in the long term. Laryngoscope, 2024.

The efficacy of paclitaxel drug-eluting balloon angioplasty versus standard balloon angioplasty in stenosis of native hemodialysis arteriovenous fistulas

Background

End stage renal disease is on increasing trend and haemodialysis is the main dialysis modality among these patients. Thus, a functioning dialysis vascular access is critical to the delivery of life-saving haemodialysis treatment to these patients. Conventional angioplasty is the first line of treatment; with a 50% of permeability rate (6 months). For this reason, new alternatives are necessary to maintain the access permeability.Hypothesis: Paclitaxel coated balloon is superior to conventional plain balloon angioplasty with decreased re-stenosis of target lesion, improved access circuit and target lesion patency, and decreased number of interventions needed to maintain patency.

Methods

A total of 39 patients were randomized to receive a paclitaxel-coated balloon (n=15) or plain angioplasty balloon (n=24) after satisfactory angioplasty with a high-pressure balloon. The inclusion criteria were clinical signs of vascular dysfunction confirmed by Doppler Ultrasound and/or angiography. The primary endpoint was target lesion patency defined as time elapsed between the completion of effective and the appearance of restenosis at 3, 6 and 12 months after angioplasty. Secondary endpoints included the relationship between the location of the stenosis, previous angioplasty, demographic variables and survival.

Results

We recruited 39 patients with dysfunctional vascular accesses; 24 were assigned to the conventional balloon angioplasty group and 15 drug-eluting balloon angioplasty (paclitaxel). With demographic characteristics in Table I. In group A, all were autologous acces. Group B 16% (4) of the accesses were prosthetic and 84% (20) autologous. In relation to the type and length of stenosis, group A was more frequent at the level and longer, whereas in group B it predominated in the central type and less than 20 mm.In our study, we also observed a high rate of total occlusions, frequently in central vessels in group B, while in group A, where peripheral vessels were predominant, total occlusion was less frequent. Table II. We had no complications in either group, and dialysis was immediate at the end of the procedure. Group A did not present restenosis. Table III. Table III shows DEB group (15p) with 100% of permeability according to follow-up and only one (1/15) of patients died due to myocardial infarction and cerebrovascular accident and this patient kept lasted 9 months without restenosis In Table IV. Group B had 2 (8%) patients with restenosis so it was necessary to reoperate using a drug eluting balloon and until now there is no restenosis. From this group we do not have mortality. One patient 1 (24%) had a recovered infarction.

Conclusions

Paclitaxel-coated balloon angioplasty resulted in superior survival of dysfunctional peripheral vascular access at 12 meses. Both arms show equivalent complications and similar mortality

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Enrique Garcés Hospital

Single-sided deafness: Bone conduction devices or cochlear implantation? A systematic review with meta-analysis

OBJECTIVES

To perform a systematic review with meta-analysis of the studies published on the efficacy of bone conduction devices and cochlear implantation in single-sided deafness, through the evaluation of speech discrimination in noise, sound localization and tinnitus suppression. As a secondary outcome, patient satisfaction is also assessed.

DESIGN

A systematic search in PubMed, Embase and CENTRAL was conducted, including all articles written in English and published in the last 10 years. The outcomes selected were speech perception in noise, sound localization, tinnitus intensity and, secondarily, quality of life assessment. Studies that met prospectively defined criteria were subjected to random effects meta-analyses. The review protocol is registered on PROSPERO with number CRD42019121444.

RESULTS

Nineteen articles reporting a total of 210 patients (95 patients with bone conduction devices and 115 in the cochlear implantation group) were included. The meta-analysis identifies statistically significant benefits in cochlear implantation for sound localization, tinnitus suppression, in global quality of life assessment and in 2 of the 3 subscales of quality of life assessment (ease of communication and reverberation). Bone conduction devices are better regarding speech discrimination in noise and background noise quality of life assessment.

CONCLUSION

Cochlear implants effectively offer better results in 2 of the 3 evaluated parameters, being a very valid option. Bone conduction devices should continue to be considered in the treatment of these patients because, in addition to allowing better discrimination in noise, patient satisfaction is greater in environments with background noise.

Production and properties of a bioemulsifier obtained from a lactic acid bacterium

In the present work, the production of bioemulsifier (BE) by a lactic acid bacterium (LAB) grown at 25 °C in lactic whey-based media for 24 h was evaluated. Maximum production was detected in a medium containing yeast extract, peptone and lactic whey (LAP_LW medium), with a yield of 270 mg L^-1. The BE proved to be more innocuous for Caco-2 cells, used as a toxicological indicator, than the non-ionic surfactant Triton X-100. In addition, the microbial product presented higher stability to changes in temperature (37 °C to 100 °C), pH (2-10), and salt concentration (5% and 20%, w/v) than the synthetic surfactant. Regarding emulsifying capacity tested against different hydrophobic substrates (kerosene, motor oil, diesel, sunflower oil, and grape oil), the BE displayed E₂₄ values similar to or even better than those of Triton X-100. Finally, Triton X-100 caused irreversible modifications on the giant unilamellar vesicles (used as model membrane system), promoting the solubilization of the lipid bilayers. Nevertheless, BE induced temporary modifications of the membrane, which is associated with incorporation of the bioproduct in the outer layer. These results demonstrate the role of BE in biological processes, including reversible changes in microbial membranes to enhance the access to hydrophobic substrates.

Nitinol versus non-Nitinol prostheses in otosclerosis surgery: a meta-analysis

The aim of this study is to perform a systematic review and meta-analysis of observational studies in which hearing outcomes after primary stapes surgery have been reported. After the surgical procedure, the effectiveness of stapes surgery using nickel titanium (Nitinol) or other prostheses were systematically compared and evaluated using a meta-analytic method. A systematic search for articles before January 2017 in Embase, Medline and Cochrane Library databases was conducted. Only articles in English were included. Inclusion criteria for qualitative synthesis consisted of a population of otosclerosis patients, intervention with primary stapes surgery using the Nitinol heat-crimping prosthesis compared with other type of stapes stapedotomy prostheses, and hearing outcome. Inclusion criteria for quantitative analysis consisted of application of audiometry guidelines of the American Academy of Otolaryngology Head and Neck Surgery Committee on Hearing and Equilibrium for evaluation of conductive hearing loss. A postoperative air-bone gap (ABG) ≤ 10 dB was considered effective. A bias assessment tool was developed according to Cochrane guidelines. To evaluate the mean age of the samples we used the chi-square test. Of the 4926 papers identified through the electronic database search (3695 in Pubmed/Cochrane and 1231 in Embase), 540 studies matched the selection criteria (436 in Pubmed/Cochrane and 104 in Embase) after application of filters and elimination of duplicate articles. After analysis of the title and abstract, 459 were excluded (396 in Pubmed/Cochrane and 63 in Embase). Of the remaining 81 papers, 74 were excluded according to the study selection criteria. A total of seven eligible studies with 1385 subjects, consisting of 637 in the Nitinol group and 748 in the non-Nitinol group, were included in our study. There were statistically significant differences in the effectiveness of stapes surgery between the Nitinol and non-Nitinol prostheses; the data showed a combined odds ratio (OR) of 2.56 (95% CI 1.38-4.76, p = 0.003). There were no statistically significant differences in the mean pre-operative age between Nitinol and non-Nitinol prostheses (p = 0.931). Our results suggest that the effectiveness of Nitinol was higher than non-Nitinol prostheses, with superiority of the number of patients with ABG ≤ 10 dB.

[Stages for Undertaking a Systematic Review]

There has been an increase in the use of systematic review as a research methodology to compile and analyze large datasets of existing studies. With this increase, the recommendations to conduct this type of research also increased. The aim of this article is to provide a guide for understanding and/or undertaking a systematic review for publication across all stages of the review process. When doing a systematic review of the literature the authors become knowledgeable of the subject and, although time-consuming, they can develop a set of skills including literature research and scientific writing. A systematic review, compared to primary research, requires relatively few resources, allowing clinicians not normally involved in research to produce clinically relevant, high-quality articles.

Radiofrequency for Treatment of Refractory Epistaxis in Hereditary Hemorrhagic Telangiectasia

Hereditary hemorrhagic telangiectasia is a rare multi-systemic autosomal dominant disorder characterized by dysplasia of the vascular connective tissue and recurrent bleeding tendency. Epistaxis is the most common and earliest symptom. It is usually mild to moderate, however, in some patients it can be severe with significant interference in quality of life. We report a case of a patient with hereditary hemorrhagic telangiectasia, in which an episode of refractory epistaxis was treated with radiofrequency and fibrin sealant. Control of acute bleeding and elimination of telangiectasia was possible with this technique. After six months follow-up, there was no epistaxis recurrence. Various treatments for epistaxis in this disease have been described in the literature, but there is no consensus about the gold-standard procedure. Radiofrequency ablation of telangiectasia is a recent technique that has shown to be safe, effective and well tolerated, even in patients who underwent other previous treatments.

Left ventricular hypertrophy does not prevent heart failure in experimental hypertension

BACKGROUND

Left ventricular hypertrophy (LVH) secondary to hypertension has been accepted to prevent heart failure (HF) while paradoxically increasing cardiovascular morbi-mortality.

OBJECTIVES

To evaluate whether antihypertensive treatment inhibits LVH, restores beta-adrenergic response and affects myocardial oxidative metabolism.

METHODS

Ninety spontaneously hypertensive rats (SHR) were distributed into groups and treated (mg/kg, p.o.) with: losartan 30 (L), hydralazine 11 (H), rosuvastatin 10 (R), carvedilol 20 (C). Hypertension control group comprised 18 normotensive rats (Wistar-Kyoto, WKY). Following euthanasia at 16months, contractility was measured in 50% of rats (Langendorff system) before and after isoproterenol (Iso) 10^-9M, 10^-7M and 10^-5M stimulation. Left ventricular weight (LVW) was measured in the remaining hearts, and normalized by BW. Expression of thioredoxin 1 (Trx-1), peroxyredoxin 2 (Prx-2), glutaredoxin 3 (Grx-3), caspase-3 and brain natriuretic peptide (BNP) was determined.

RESULTS

Systolic blood pressure (mmHg): 154±3 (L), 137±1 (H), 190±3 (R)*, 206±3 (SHR)*, 183±1 (C)**, and 141±1 (WKY) (*p<0.05 vs. L, H, WKY, **p<0.05 vs. L, H, WKY, SHR). LVW/BW was higher in SHR and R (p<0.05). Groups SHR, R and C evidenced baseline contractile depression. Response to Iso 10^-5M was similar in WKY and L. Expression of Trx-1, Prx-2 and Grx-3 increased in C, H, R and L (p<0.01).

CONCLUSIONS

Present findings argue against the traditional idea and support that LVH might not be required to prevent HF. Increased expression of thioredoxins by antihypertensive treatment might be involved in protection from HF.

[Translation, Cultural Adaptation and Validation of the Satisfaction with Amplification in Daily Life Scale for European Portuguese]

INTRODUCTION

The scale Satisfaction with Amplification in Daily Life uses a simple and easily administered questionnaire to evaluate the adaptation of individuals to their hearing aids. The objective of this study is to validate the scale for European Portuguese speakers, by means of translation and cultural adaptation of the questionnaire. The study includes an evaluation of reproducibility and a description of the results of the administration of the questionnaire to patients fitted with hearing aids.

MATERIAL AND METHODS

We invited 147 individuals fitted with hearing aids (uni- or bilateral) to participate in the study. Participants had used a hearing aid for at least six weeks and were patients of the Department of Otolaryngology at the Egas Moniz Hospital (Lisbon). The consent as well the guidelines for translation from and into the English language were obtained from the author of the scale, and the translation from and into, and cultural adaptation were carried out, along with an evaluation of reproducibility and internal consistency.

RESULTS

The participants were 54% male and 46% female, aged between 16 and 93 (66.09 ± 17.41 years). The results of the study showed an overall level of satisfaction of 5.4 among hearing aids users. The sub-scale satisfaction levels were: positive effects 5.88, service and cost 5.25, negative effects 4.24, and self-image 5.57. The Cronbach α score was 0.75 which indicates good internal consistency. Furthermore, the questionnaire's overall and sub-scale average scores did not differ significantly from the results obtained under the American scale. The inter-examiner reproducibility was also good.

DISCUSSION

This study provides reliable results of the scale for the Portuguese of Portugal and adequate internal consistency, with significant age variability in the sample.

CONCLUSION

This adaptation of the Satisfaction with Amplification in Daily Life questionnaire for European Portuguese speakers should be considered a good tool for evaluation of the level of satisfaction of hearing aid users, and until now, is the only available scale for speakers of European Portuguese.

Does Type of Substratum Affects Chironomid Larvae Assemblage Composition? A Study in a River Catchment in Northern Patagonia, Argentina

Chironomid larvae assemblages were investigated at seven sampling stations in relation to stream habitat type in the Challhuaco-Ñireco river system located in the Nahuel Huapi National Park, in the North-Western part of Rio Negro Province, Argentina. A total of 2229 individuals were sampled and 43 Chironomidae taxa were recorded with Orthocladiinae (29) being the best represented subfamily, followed by Diamesinae (5), Tanypodinae (3), Podonominae (3) and Chironominae (3). Stictocladius spF, Cricotopus (Paratrichocladius) sp6, Cricotopus sp2, Cricotopus sp3 and Parapsectrocladius sp2 were the most abundant taxa. Sites near the source of the river system were dominated by Podonomus sp., Limnophyes sp., Parapsectrocladius sp. and Stictocladius spF, whereas sites close to the river mouth were dominated by Diamesinae sp5 and Cricotopus sp. Rank/abundance plots show that all the analysed sites displayed dominance of some species. Stictocladius spF, Cricotopus sp2, Cricotopus sp3, Cricotopus (Paratrichocladius) sp6, Parapsectrocladius sp. and Limnophyes sp. resulted as dominant species, or being part of a group of dominant species, at least in one sample. Eleven taxa were associated with habitats related with riffle areas and stable substrates with filamentous algae. Species-environment relationships were examined using ordination analysis. Elevation was the most significant environmental variable that explained 22% of the total variability of the chironomid assemblages, showing stronger relationships among sites within an altitudinal gradient than among habitat type. Abundance of chironomids increased from headwaters to the outflow in Nahuel Huapi Lake responding to an altitude gradient as well as some environmental factors such as coarse matter and nutrient concentrations.

Allogeneic stem-cell transplantation in patients with cutaneous lymphoma: updated results from a single institution

BACKGROUND

Cutaneous T-cell lymphomas (CTCLs) and its common variants mycosis fungoides (MF) and leukemic Sézary syndrome (SS) are rare extranodal non-Hodgkin's lymphomas. Patients who present with advanced disease and large-cell transformation (LCT) are incurable with standard treatments. In this article, we report the largest single-center experience with allogeneic stem-cell transplantation (SCT) for advanced CTCL.

PATIENTS AND METHODS

This is a prospective case series of 47 CTCL patients who underwent allogeneic SCT after failure of standard therapy between July 2001 and September 2013. The Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS) curves. The method of Fine and Gray was used to fit regression models to the same covariates for these cumulative incidence data.

RESULTS

The Kaplan-Meier estimates of OS and PFS at 4 years were 51% and 26%, respectively. There was no statistical difference in the OS in patients who had MF alone, SS, MF with LCT, or SS with LCT. PFS at 4 years was superior in patients who had SS versus those who did not (52.4% versus 9.9%; P = 0.02). The cumulative incidences of grade 2-4 acute graft-versus-host disease (GVHD) and chronic GVHD were 40% and 28%, respectively. The cumulative nonrelapse mortality rate was 16.7% at 2 years.

CONCLUSION

Allogeneic SCT may result in long-term remissions in a subset of patients with advanced CTCL. Although post-SCT relapse rates are high, many patients respond to immunomodulation and achieve durable remissions.

CLINICALTRIALSGOV

NCT00506129.

Muscle fibers inside a fat tumor: a non-specific imaging finding of benignancy

INTRODUCTION

The differential diagnosis between benign and low-grade well-differentiated malignant lipomatous tumors might be very difficult for both the radiologist and the pathologist, although it has practical consequences. Among the criteria, muscular fibers detected inside the lesion are considered radiologically and histologically as a reliable sign of a benign intramuscular lipoma. New genetic criteria are now available. We report two cases of fat tumors containing muscular fibers both radiologically and histologically, but which are definitely malignant, considering genetic criteria.

MATERIAL AND METHODS

Two cases of soft tissue fat tumors, containing muscular fibers on imaging examinations as well as histologically, had an aggressive behaviour, suggesting malignancy. Genetic criteria were therefore used to confirm the clinical impression.

RESULTS

MDM2 and CDK4 confirmed the malignancy in the two cases.

CONCLUSION

Intra lesional muscular fibers detected on imaging or histological examinations should not be considered as a completely reliable sign of a benign intramuscular lipoma. In case of atypical clinical behaviour, genetic criteria should be used to prove the aggressiveness of the tumor.

Frequency and clinical features of Lewy body dementia in Italian memory clinics

BACKGROUND

The latest developments in Lewy Body Dementia (DLB) raise some controversies on clinical features, neuroimaging and therapy. The aim of our study is to determine clinical, neuropsychological, neuroimaging and EEG profile of DLB through retrospective and prospective data of 102 patients.

METHODS

data were collected with an analytical form that was developed by an expertise of neurologists.

RESULTS

DLB represented 4.8% of the dementia population, with no sex difference. Family history of dementia was common (24.5%), while familiarity for parkinsonism was rare (4.9%). Cognitive disturbances were the predominant clinical presentation at onset (49%), followed by behavioral symptoms (29.4%) and parkinsonism (21.6%). Clinical features at consultation were: memory disturbances (almost all cases), symmetrical (68.6%) or asymmetrical (18.6%) parkinsonism, cognitive fluctuations (49%), visuospatial deficits (53.9%), and visual hallucinations (44.1%). Autonomic signs were present in a third of the cases, while sleep disorders were present in 44.1%. Some clinical response to antiparkinsonian drugs was evident in half of the cases. MRI, SPET, EEG and Neuropsychiatric Inventory data were available in a subgroup of patients.

CONCLUSIONS

Most of our data were in accordance with the previous literature. However, some data underline the relationship between DLB, Alzheimer's and Parkinson's disease.

A pilot study CD34 selected haploidentical transplant using a chemotherapy-only preparative regimen and intensive antibiotic prophylaxis for treatment of advanced leukemia

7097

Background: We present preliminary data of haploidentical transplant for 13 patients (pts) with acute leukemia. Methods: Phase II Study Results: We present preliminary data of haploidentical transplant for 13 patients (pts) with acute leukemia using a chemotherapy-only preparative regimen of Melphalan 140 mg/m2 on day −8; Thiotepa 10 mg/kg on day −7; Fludarabine 40 mg/m2 on days −6, −5, −4, −3; 1.5 mg/kg of rabbit ATG/day days −6, −5, −4, −3. The transplant was administered on day 0 using positive selection of CD34 positive cells by the CliniMACS device as a means of T-cell depletion. All products had <1 × 104 CD3+ T-cells/kg recipient body weight and needed a minimum of 5 × 106 CD34+ cells/kg but preferably >1 × 107 CD34+ cells/kg recipient body weight. Age ranged 23–50 years/median 37 years, four patients were in advanced remission and nine were in refractory relapse. Patients received intensive PCP prophylaxis with sulfamethoxazole-trimethoprim and pentamidine prior to transplant and during pancytopenia; CMV prophylaxis with valganciclovir during the BMT prep and foscarnet while pancytopenic; and with liposomal amphotericin or cancidas for fungal prophylaxis. Two patients had primary graft failure-one survived disease free and one relapsed. One patient died of multiple organ failure prior to engraftment. Median time to engraftment was 15 days (range, 9–26) to 500 neutrophils and 14 days to platelets 20,000 (range, 13–25). Seven patients died of relapse at a median of 10 months (range 2–13 months), and one patient died of a viral infection. Two of 10 patients who engrafted developed grade one acute graft-versus-host (GVHD) and four patients had chronic GVHD (3 limited, 1 extensive). Four patients survive beyond 2 years, without recurrent disease. Conclusions: This report for haploidentical transplant demonstrates that a chemotherapy only preparative regimen can achieve a high rate of engraftment. Infectious complications were minimal with aggressive prophylaxis. Long-term remission are achievable with little risk of severe GVHD with t-cell depletion with use of CliniMACS in haploidentical stem cell transplant.

No significant financial relationships to disclose.

Allogeneic hematopoietic stem cell transplantation for cutaneous T-cell lymphoma (CTCL)

7540

Background: Patients (pts.) with advanced CTCL have a poor prognosis. There has been limited experience with the use of allogeneic hematopoietic stem cell transplantation (HSCT) in these pts. We report the results of 11 pts. with advanced CTCL/Sezary syndrome who underwent allogeneic HSCT at our institution. Patients and Methods: All pts. signed informed consent. Median age at the time of HSCT was 50.5 years (range, 22–63). There were 8 F/3M. All were diagnosed with stage IV disease. The median number of prior treatment regimens was 5.5 (range, 3–11). Treatment regimens included PUVA, TSEB, ECP, topical therapy, retinoids, bexarotene, denileukin diftitox, and multiagent chemotherapy. Seven pts. had a PR to treatment administered prior to transplantation, 2 pts. were in CRu and 2 pts. had SD. The conditioning regimen was fludarabine (125 mg/m2), melphalan 140 mg/m2 in 8 pts., fludarabine (125 mg/m2), cyclophosphamide (3 g/m2) ± rituximab in 2 pts., and fludarabine (120 mg/m2), busulfan (11.2 mg/m2) in 1 pt. Patients who received unrelated or mismatched related stem cells also received ATG. GVHD prophylaxis was with tacrolimus/methotrexate in all patients. Results: Ten of 11 pts. engrafted with a median time to ANC >500 mm3 of 12 days (range, 8–14). One pt. died at 17 days post transplant without engraftment due to sepsis. One pt. developed autologous reconstitution and underwent a 2nd allogeneic HSCT procedure and remains in CR at 3 years post transplant. Of the remaining 9 pts., 7 achieved full donor chimerism and 2 pts. were mixed chimera. At the time of this report 4 of 11 pts. have died. Cause of death was sepsis in 2, fungal pneumonia in 1, and PD in 1 pt. Three pts. relapsed post transplant, all 3 were induced back in to a CR by tapering of immunosuppression (2) or DLI (1). Overall 7 pts. continue to be alive and remission with a median follow up of 2.9 years (range, 3 months to 4.4 years). Four of 7 pts. have cGVHD requiring treatment (Table). Conclusions: Allogeneic HSCT is an effective therapy for refractory CTCL/SS and merits further evaluation.

[Table: see text]

No significant financial relationships to disclose.

Sirolimus in combination with tacrolimus and corticosteroids for the treatment of resistant chronic graft-versus-host disease

Chronic graft-versus-host disease (cGVHD) remains a major cause of morbidity and mortality in haematopoietic transplant recipients. Sirolimus is a macrocyclic triene antibiotic with immunosuppressive, antifungal and antitumour properties, that has activity in the prevention and treatment of acute GVHD. We conducted a phase II trial of sirolimus combined with tacrolimus and methylprednisolone in patients with steroid-resistant cGVHD. Thirty-five patients who developed GVHD after day 100 post-transplant were studied. Six patients had a complete response and 16 a partial response with an overall response rate of 63%. Major adverse events related to the combination of tacrolimus and sirolimus were hyperlipidaemia, renal dysfunction and cytopenias. Four patients had thrombotic microangiopathy (TMA) and 27 (77%) had infectious complications. The median survival for the whole group was 15 months. A significantly better outcome was observed in patients with a platelet count > or = 100 x 10(9)/l, as well as in those with true chronic manifestations of GVHD compared to those with acute GVHD beyond day 100. Controlled trials comparing this approach with alternative strategies to determine which can best achieve the goal of GVHD-free survival are warranted.

Reduced-intensity allogeneic stem cell transplantation in relapsed and refractory Hodgkin's disease: low transplant-related mortality and impact of intensity of conditioning regimen

A total of 40 patients with relapsed/refractory Hodgkin's disease (HD) underwent reduced-intensity conditioning (RIC) allogeneic stem cell transplantation (allo-SCT) from an HLA-identical sibling (n=20) or a matched unrelated donor (n=20). The median age was 31 years (range 18-58). Disease status at allo-SCT was refractory relapse (n=14) or sensitive relapse (n=26). The conditioning regimens were fludarabine-cyclophosphamide+/-antithymocyte globulin (n=14), a less intensive regimen, and fludarabine-melphalan (FM) (n=26), a more intensive one. The two groups had similar prognostic factors. The median time to neutrophil recovery (ie absolute neutrophil count >/=500/microl) was 12 days (range 10-24). The median time to platelet recovery (ie platelet count >/=20 000/microl) was 17 days (range 7-132). Day 100 and cumulative (18-month) transplant-related mortalities (TRMs) were 5 and 22%. Twenty-four patients (60%) are alive (14 in complete remission or complete remission, unconfirmed/uncertain) with a median follow-up of 13 months (4-78). In all, 16 patients expired (TRM n=8, disease progression n=8). FM patients had better overall survival (73 vs 39% at 18 months; P=0.03), and a trend towards better progression-free survival (37 vs 21% at 18 months; P=0.2). RIC allo-SCT is feasible in relapsed/refractory HD patients with a low TRM. The intensity of the preparative regimen affects survival.

Outcomes of autologous stem cell transplantation in patients with multiple myeloma who received dexamethasone-based nonmyelosuppressive induction therapy

High-dose chemotherapy (HDC) followed by autologous stem cell transplantation (ASCT) improves survival in myeloma (MM). The role of induction therapy on outcomes of ASCT in MM has not been systematically studied. Nonmyelosuppressive (NMS) steroid-based induction can be used in MM, with the potential of reducing neutropenias and other toxic effects prior to ASCT. NMS induction however could be associated with poorer outcomes if disease control or stem cell collection were inadequate. We studied outcomes of 136 MM patients who underwent HDC and ASCT as part of their initial therapy between March 1998 and December 2000. Of these, 46 received HDC and ASCT without any exposure to myelosuppressive agents, 39 received myelosuppressive therapy for disease control and/or stem cell collection, and 51 received alkylating agent-based initial treatment. We compared OS and EFS rates, stem cell collectability, and contamination of the grafts with monoclonal plasma cells. After a median of 33 months, response rates, EFS and OS rates were comparable in the three groups of patients. Adequacy of stem cell collection and plasma cell contamination were similar. Our data support the hypothesis that NMS induction for patients with MM is safe and effective and does not compromise the results of HDC.

Long-Term follow-up of recipients of CD8-depleted donor lymphocyte infusions for the treatment of chronic myelogenous leukemia relapsing after allogeneic progenitor cell transplantation

Donor lymphocyte infusions (DLIs) are an effective treatment for relapsed Chronic myeloid leukemia (CML) after allogeneic transplantation but are limited by the occurrence of GVHD. CD8+ T lymphocytes are involved in the pathogenesis of GVHD but may not be essential for the graft-versus-leukemia (GVL) effect in CML. We have treated 26 CML patients with posttransplantation relapse with CD8-depleted DLI. Thirteen of 15 patients (87%) who relapsed in early-phase CML achieved complete cytogenetic response, but only 1 of 11 who relapsed in advanced-phase disease achieved complete response. Acute GVHD occurred in 2 patients (8%), and extensive chronic GVHD occurred in 2 patients (11%). Treatment-related mortality was 11.5%. Responses were durable; with a median follow-up of 4.2 years (1-7.5 years), only 1 responding patient relapsed (7%). CD8-depleted DLI was equally effective and safe after unrelated donor transplants and sibling transplants. Cytogenetic clonal evolution at the time of DLI was not predictive of treatment failure unless associated with hematologic criteria for disease acceleration. CD8 depletion is an effective method to separate GVL from GVHD for posttransplantation relapsed CML. This strategy is associated with durable complete remissions and a low rate of complications and therefore merits further investigation in larger-scale comparative trials.

Extracorporeal photopheresis therapy in the management of steroid-refractory or steroid-dependent cutaneous chronic graft-versus-host disease after allogeneic stem cell transplantation: feasibility and results

We conducted a retrospective analysis of all allogeneic stem cell transplantation (ASCT) patients started on extracorporeal photopheresis (ECP) for the management of steroid-dependent (SD) or steroid-refractory (SR) cutaneous chronic graft-versus-host disease (cGVHD) following ASCT during a 36-month period (9/98-8/01). Only SD or SR patients who were treated by ECP after day 100 and who received at least 4 weeks of ECP were considered evaluable for this analysis. Out of 64 ASCT patients reviewed, 32 patients met the inclusion criteria. All 32 patients had been previously treated with systemic corticosteroids with 11 (34%) being SR and 21 (66%) SD. Cutaneous cGVHD was extensive in 28 patients (88%) and was accompanied by visceral (hepatic, gastrointestinal) cGVHD in 23 patients (72%). The 32 evaluated patients had received a median of three prior therapies before ECP, most commonly systemic corticosteroids, tacrolimus, and mycophenolate mofetil. Patients received a median of 36 ECP sessions (range 12-98) over a median of 5.3 months (range 1-28), with a median of six sessions per month. The complete response (CR) rate was 22% (n=7) and the partial response rate was 34% (n=11). In all, 28 patients were on systemic corticosteroid therapy at ECP initiation and 18 patients achieved 50% dose reduction while on ECP, yielding a 64% steroid-sparing response rate. Of seven CRs, five are ongoing. A total of 11 (34%) patients have died after ECP, with all cases due to visceral cGVHD or cGVHD-related infectious complications. All 21 surviving patients remain on at least some immunosuppressive cGVHD therapy (including ECP in eight). Overall, ECP displays a substantial response rate and, in particular, steroid-sparing activity in SR/SD extensive cutaneous cGVHD. However, most patients continue to require at least some chronic therapy and cGVHD-related morbidity and mortality remain high.

Fludarabine/melphalan conditioning for allogeneic transplantation in patients with multiple myeloma

The purpose of the study was to determine the feasibility and efficacy of a reduced intensity conditioning regimen of fludarabine and melphalan for allogeneic transplantation in patients with multiple myeloma. From August 1996 to December 2000, 22 patients received a reduced intensity conditioning regimen with fludarabine and melphalan. Median age was 51 years (range, 45-64), median time from initial therapy to transplant was 36 months (range, 3-135 months). Disease phase prior to transplant was primary refractory in two patients, refractory relapse in 11 patients, sensitive relapse in eight patients and initial remission consolidation in one patient. The median number of prior therapies was five (range, 1-7), and median beta 2 microglobulin prior to transplant was 3.0 mg/l (range, 1.0-7.3). All patients received unmanipulated grafts from either HLA matched sibling donors (n = 13) or matched unrelated donors (n = 9). Eighteen patients received fludarabine 30 mg/m(2) for 4 days with melphalan 140 mg/m(2) as a single dose and four patients received fludarabine 25 mg/m(2) for 5 days with melphalan 90 mg/m(2) daily for 2 days. All 21 patients evaluable for engraftment achieved a neutrophil count of >0.5 x 10(9)/l after a median of 12 days (range, 9-24), 18 patients achieved platelet transfusion independence after a median of 14 days (range, 8-47). All engrafting patients had 100% donor cell engraftment. Seven patients achieved a complete remission. Six patients are currently alive with a median follow-up of 15 months (range, 10-47 months). The actuarial survival and progression-free survival is 30 +/- 11% and 19 +/- 9% at 2 years. Non-relapse mortality at 100 days was 19 +/- 10% and 40 +/- 10% at 1 year. Fludarabine/melphalan combinations are feasible and allow consistent engraftment of allogeneic progenitor cells from both related and unrelated donors in patients with multiple myeloma and should be explored in patients with less advanced disease.

Donor lymphocyte apheresis for adoptive immunotherapy compared with blood stem cell apheresis

Donor lymphocyte transfusion has gained considerable interest as adoptive cellular immunotherapy for prevention or treatment of relapse after allogeneic stem cell transplantation. This study was designed to compare the yield of CD3(+), CD3(+)4(+), CD3(+)8(+), CD19(+), CD3(-)56(+)16(+), and CD34(+) cells contained in apheresis products from 61 consecutive non-cytokine treated, human leukocyte antigen (HLA)-matched donors for lymphocyte collection with the corresponding apheresis-derived cell yield from 112 consecutive, HLA-matched donors for blood stem cell collection who received recombinant human granulocyte colony stimulating factor (rhG-CSF, filgrastim) 6 microg/kg every 12 hours until cell collection was completed. Apheresis was started on day 4 or 5 of rhG-CSF treatment. The yield of lymphoid subsets was significantly different in the two sample groups, rhG-CSF treated product yields exceeding untreated product yields by a median of 2.1-fold (range: 1.3-2.6). However, the CD34(+) cell yield in rhG-CSF-treated apheresis products exceeded untreated products by 26-fold. A single untreated apheresis procedure was usually sufficient to collect a target dose of 1 x 10(8)/kg CD3(+) cells. Untreated apheresis products contained a median of 0.2 x 10(6)/kg CD34(+) cells. A potential engraftment dose of > or =0.5 x 10(6) CD34(+) cells per kg of recipient body weight was contained in 16% of 57 untreated apheresis products. One single apheresis performed in a normal, untreated donor provides a sufficient amount of CD3(+) cells for adoptive immunotherapy. Compared with that of an rhG-CSF stimulated apheresis product, the CD34(+) cell count is usually, but not always, below the engraftment dose range. RhG-CSF treatment has little effect on the yield of lymphoid subsets collected by apheresis but is highly selective of the release of CD34(+) cells. This report provides baseline data for studies that will show whether other cytokines such as granulocyte macrophage colony stimulating factor (GM-CSF) and/or Flt-3 Ligand can immunomodulate allotransfusates in vivo to improve the graft-vs.-leukemia (GVL) effect after allogeneic stem cell transplantation, while lowering the incidence and severity of graft-vs.-host disease (GVHD).

Risk of therapy-related myelodysplastic syndrome/acute leukemia following high-dose therapy and autologous bone marrow transplantation for non-Hodgkin's lymphoma

BACKGROUND

Several recent reports have suggested that patients with non-Hodgkin's lymphomas (NHL) who undergo autologous stem cell transplantation (ASCT) are at increased risk of developing therapy-related myelodysplastic syndrome (tMDS) and acute myelogenous leukemia (tAML).

PATIENTS AND METHODS

We analyzed 493 patients with NHL who underwent ASCT at The University of Texas M.D. Anderson Cancer Center between January 1990 and August 1999.

RESULTS

With a median follow-up time of 21 months after HDT, 22 patients developed persistent cytopenia in at least one cell line with morphologic or cytogenetic evidence of tMDS or tAML. Univariate analysis identified prior fludarabine therapy, bone marrow involvement with lymphoma, and total body irradiation (TBI) as significant risk factors for the development of tMDS/tAML (P <0.05). Multiple logistic regression analysis showed that TBI was independently associated with an increased risk of developing tMDS/tAML (P <0.01). Further analysis of the patients who received TBI revealed that patients receiving TBI in combination with cyclophosphamide and etoposide were more likely to develop tMDS/tAML than those who received TBI with cyclophosphamide or thiotepa (P <0.01). The median survival of patients developing tMDS/tAML was 7.5 months (range 0-32 months).

CONCLUSIONS

TBI, especially when used in combination with cyclophosphamide and etoposide as the pretransplant conditioning regimen, is a significant risk factor for the development of tMDS/tAML.

[The activation of A1 adenosine receptors attenuates myocardial stunning in the rabbit]

Hearts exposed to a prolonged period of ischemia (> or = 30 minutes) present smaller infarct size when reperfused in the presence of adenosine. However, when the period of ischemia is shorter, the infarct areas are not very significant, but a postischemic ventricular dysfunction persists. The objective of this study was to determine the effect of adenosine, (administered only during reperfusion) on systolic and diastolic alterations present in postischemic ventricular dysfunction, as well as to determine whether A1 receptors participate in this effect. Isolated isovolumic rabbit hearts were subjected to 15 minutes of global ischemia followed by 30 minutes of reperfusion. Before ischemia and during reperfusion ventricular function was evaluated. In the control group, the left ventricular developed pressure (LVDP) reached 56 +/- 2% of recovery at 30 minutes of reperfusion. The administration of adenosine improved LVDP 75 +/- 3% (P < 0.05 vs. control). However, when adenosine was given in presence of an A1 receptor selective antagonist (DPCPX), LVDP reached 50 +/- 2% (P < 0.05 vs. control). In the control group, left ventricular end diastolic pressure (LVEDP) (diastolic stiffness), increased 293 +/- 4%, at 30 minutes of reperfusion. Only a 15 +/- 8% (P < 0.05 vs. control) increase in LVEDP was observed with adenosine. Reperfusion with adenosine plus DPCPX did not attenuate an increase of 493 +/- 9% (P < 0.05 vs. control) in diastolic stiffness. Adenosine administered from the beginning of reperfusion attenuated both systolic alterations and diastolic stiffness in postischemic dysfunction. This effect was abolished by DPCPX, suggesting an important role for the A1 receptors in adenosine protection.

Thiotepa, busulfan, and cyclophosphamide as a preparative regimen for allogeneic transplantation for advanced myelodysplastic syndrome and acute myelogenous leukemia

Sixty-two adults underwent marrow or blood stem cell transplantation from an HLA-matched related donor using high-dose thiotepa, busulfan, and cyclophosphamide (TBC) as the preparative regimen for treatment of advanced myelodysplastic syndrome (MDS) (refractory anemia with excess blasts with or without transformation) or acute myelogenous leukemia (AML) past first remission. All evaluable patients engrafted and had complete donor chimerism. A grade 3-4 regimen-related toxicity occurred in eight (13%) patients, and a diagnosis of MDS was the only independent risk factor for grade 3-4 regimen-related toxicity (hazard ratio 9.25, P = 0.01). Day-100 treatment-related mortality (TRM) was 19%. Poor-prognosis cytogenetics increased the risk of day-100 TRM (hazard ratio 11.4, P = 0.003), and use of tacrolimus for graft-versus-host disease prophylaxis reduced the risk of day-100 TRM (hazard ratio 0.13, P = 0.027). For all patients, the three-year relapse rate was 43% (95% CI, 28%-58%). Refractoriness to conventional induction chemotherapy prior to transplantation was an independent risk factor for relapse (hazard ratio 10.8, P = 0.02). Three-year survival was 26% (95% CI, 14%-37%); survival rates were 29% for those transplanted for AML in second remission, 31% transplanted for AML in relapse, and 17% with MDS, and there were no independent risk factors for survival. TBC is an active preparative regimen for advanced AML. Patients with advanced MDS appeared to have a higher risk of toxicity and early mortality, and alternative preparative regimens should be considered for these patients.

Ifosfamide-based chemotherapy regimens in treatment of lymphoma: the M.D. Anderson experience

Investigators at M.D. Anderson Cancer Center in Houston first began investigations with the drug ifosfamide in the early 1970s. This alkylating agent has proven to be a valuable drug with easily manageable side effects in therapy of lymphomas. They have described prognostic factors for relapsed lymphomas using this drug in various combinations and have found it of major value in both cytoreduction and stem cell mobilization prior to transplant. The drug has subsequently become part of many established regimens for treatment of lymphoma, and newer combinations containing this drug should be further studied.

Decitabine with allogeneic peripheral blood stem cell transplantation in the therapy of leukemia relapse following a prior transplant: results of a phase I study

Relapse after allogeneic progenitor cell transplant is associated with a poor prognosis for patients with advanced leukemia, with few curative options available. Use of novel chemotherapeutic agents with limited toxicity is warranted. We investigated the role of decitabine, a pyrimidine analogue with significant anti-leukemic effect and limited toxicity, in this setting. Fourteen patients with advanced acute leukemia or transformed chronic myelogenous leukemia (CML) who had failed previous allogeneic transplant were treated. Decitabine at doses of 100 mg/m2 to 150 mg/m2 given every 12 h for 5 days was followed by infusion of stem cells from the original donor 2 to 5 days after the completion of chemotherapy. Dose of decitabine was escalated in cohorts of three patients based on the modified Fibonacci scheme. The primary study end-point was assessment of the toxicity of the regimen with secondary endpoints of response and survival. Eight patients responded with either a complete remission or partial hematological remission (absence of blasts in peripheral blood and bone marrow but with platelet count <100 x 10(9)/l). Toxicity was limited with no grade 3 or 4 toxicity directly attributable to the treatment. The median survival for all patients was 190 days (range 11 to 1215+ days). Decitabine at doses of 100 mg/m2 to 150 mg/m2 given every 12 h for 5 days, followed by stem cell infusion from the original donor was well tolerated, and was associated with acceptable myelosuppression. Current response data should encourage further study of this drug, either alone or in combination with other agents, for treatment of relapsed acute leukemia after an allogeneic transplant.

Leukapheresis reduces early mortality in patients with acute myeloid leukemia with high white cell counts but does not improve long- term survival

PURPOSE

Current published data on therapeutic leukapheresis in hyperleucocytic AML does not define the impact on survival from this procedure. Between 1992 and 1999 we saw 146 patients with newly-diagnosed AML (APL excluded) and an initial WBC count > 50 x 10(9)/L of whom 71 underwent leukapheresis at the discretion of their treating doctors. We compared outcome (early mortality, CR, and overall survival) rates in the patients who were and were not pheresed. After accounting for covariates relevant to these outcomes, including age, performance status, and cytogenetics, there was evidence (p = .006) that pheresis reduced 2-week mortality rate and a suggestion (p = .06) that this resulted in a higher CR rate. However there was no evidence that pheresis lengthened longer-term or overall survival; if anything the suggestion was the converse (p = .06). These data may reflect the fact that the patients chosen to have pheresis were prognostically unfavorable as defined by variables that were not captured in our data set, since the alternative explanation i.e. that pheresis per se shortens overall survival seems less likely. Whether the above justifies the use of pheresis in the absence of evidence from a randomized trial is doubtful, but it seems likely that any long-term benefit to be derived from this procedure must await further advances in anti-leukemia therapy.

Thiotepa, busulfan, cyclophosphamide (TBC) and autologous hematopoietic transplantation: an intensive regimen for the treatment of multiple myeloma

The study was designed to evaluate the efficacy and safety of an intensive, tri-alkylator conditioning regimen, consisting of thiotepa, busulfan and cyclophosphamide (TBC), prior to autologous hematopoietic cell transplantation in patients with multiple myeloma (MM) and to analyze factors associated with outcome. One hundred and twenty patients with MM received high-dose chemotherapy with TBC followed by autologous bone marrow (n = 24) or peripheral blood stem cell (PBSC) transplantation (n = 96). Fifty-four patients had chemosensitive disease and 66 had refractory disease at the time of transplantation. The overall response rate was 81% and the complete remission (CR) rate was 26%. Patients with chemosensitive disease had a CR rate of 52% vs 5% for patients with refractory disease. Multivariable analysis determined disease status at transplant as the factor most likely associated with long survival. Estimated median survival was 48, 35 and 9 months for patients with chemosensitive, primary refractory or disease in refractory relapse, respectively. Short interval from diagnosis to transplant among patients with primary refractory disease and younger age were also favorable prognostic factors for survival. Patients with refractory disease pre-transplant who achieved remission criteria rapidly after treatment had a worse outcome than the slow responders. Treatment-related mortality with the introduction of PBSC and better supportive care was 4.8%. In conclusion, TBC is an effective and relatively well-tolerated intensive conditioning regimen in patients with MM. A more favorable outcome was observed in patients with chemosensitive disease and with early treatment for primary refractory disease. TBC merits further study in these subgroups and comparison with alternative regimens in prospective studies is warranted.