Haploidentical allogeneic hematopoietic cell transplantation in adults using CD3/CD19 depletion and reduced intensity conditioning: an update

Haploidentical hematopoietic cell transplantation (HHCT) after high dose conditioning with CD34-selected stem cells has been complicated by high regimen related toxicities, slow engraftment and delayed immune reconstitution leading to increased treatment related mortality (TRM). A new regimen using reduced intensity conditioning (RIC) and graft CD3/CD19 depletion with anti-CD3 and anti-CD19 coated microbeads on a CliniMACS device may allow HHCT with lower toxicity and faster engraftment. CD3/CD19 depleted grafts not only contain CD34+ stem cells but also CD34 negative progenitors, natural killer, graft facilitating and dendritic cells. RIC was performed with fludarabine (150-200 mg/m(2)), thiotepa (10 mg/kg), melphalan (120 mg/m(2)) and OKT-3 (5 mg/day, day -5 to +14) and no posttransplant immunosuppression. Twenty nine patients (median age=42 (range, 21-59) years) have been transplanted with this regimen. Diagnosis were AML (n=16), ALL (n=7), NHL (n=3), MM (n=2) and CML (n=1). Patients were "high risk" with refractory disease or relapse after preceding HCT. The CD3/CD19 depleted haploidentical grafts contained a median of 7.6x10(6) (range, 3.4-17x10(6)) CD34+ cells/kg, 4.4x10(4) (range, 0.006-44x10(4)) CD3+ T cells/kg and 7.2x10(7) (range, 0.02-37.3x10(7)) CD56+ cells/kg. Donor-recipient KIR-ligand-mismatch was found in 19 of 29 patients. The regimen was well tolerated with maximum acute toxicity being grade 2-3 mucositis. Because of severe neurotoxicity in 4 patients treated with 200 mg/m(2) fludarabine, the dose was reduced to 150 mg/m(2). Engraftment was rapid with a median time to >500 granulocytes/microL of 12 (range, 10-21) days, >20,000 platelets/microL of 11 (range, 7-38) days and full donor chimerism after 2-4 weeks in all patients. Incidence of grade II-IV degrees GVHD was 48% with grade II degrees =10, III degrees =2 and IV degrees =2. One patient, who received the highest T-cell dose, developed lethal grade IV GVHD. TRM in the first 100 days was 6/29 (20%) with deaths due to idiopathic pneumonia syndrome (n=1), mucormycosis (n=1), pneumonia (n=3) or GVHD (n=1). Overall survival is 9/29 patients (31%) with deaths due to infections (n=7), GVHD (n=1) and relapse (n=12) with a median follow-up of 241 days (range, 112-1271). In conclusion, this regimen is promising in high risk patients lacking a suitable donor, and a prospective phase I/II study is ongoing.     

Coxiella burnetii and coinfections in Ixodes ricinus ticks in Central Germany

A total of 1000 Ixodes ricinus ticks were collected in 2006 and 2007 in a forest region of Central Germany and investigated for Coxiella burnetii. The transposase element IS1111 and isocitrate dehydrogenase gene were targets of the real-time polymerase chain reaction. The pathogen was detected in 19 ticks (1.9%), and interestingly, in 10 of these samples, coinfections with Borrelia spp., spotted fever group rickettsiae, or Babesia spp. were present. Our study reports on C. burnetii infections in I. ricinus ticks in an area where cases of Q fever occur regularly and Dermacentor marginatus is not present. The broad spectrum of copathogens indicates interactions in transmission cycles and the possibility of coinfections in humans in areas where people are in close contact with infected ticks and domestic animals.     

Delivering quality of care while managing the interests of all stakeholders

National healthcare systems worldwide face growing challenges to reconcile interests of patients for high-quality medical care and of payers for sustainable and affordable funding. Advances in the provision of renal replacement therapy can only be made by developing and implementing appropriate sophisticated and state-of-the-art business models that include reimbursement schemes for comprehensive care packages. Such business models must succeed in integrating and reconciling the interests of all stakeholders. NephroCare as dialysis provider has adopted and tailored recognized management techniques, i.e. Balanced Scorecard and Kaizen, to achieve these goals. Success of the complete business model package is tangible - strategies initiated to improve treatment quality even at the cost of providers have been translated into win-win scenarios for the complete stakeholder community. Room for improvement exists: the possibility to extend the portfolio of service offerings within the comprehensive care frame, as well as the challenge for achieving a balance between the stability of targets while keeping these up to date concerning new insights.     

Role of tissue factor and protease-activated receptors in a mouse model of endotoxemia

Sepsis is associated with a systemic activation of coagulation and an excessive inflammatory response. Anticoagulants have been shown to inhibit both coagulation and inflammation in sepsis. In this study, we used both genetic and pharmacologic approaches to analyze the role of tissue factor and protease-activated receptors in coagulation and inflammation in a mouse endotoxemia model. We used mice expressing low levels of the procoagulant molecule, tissue factor (TF), to analyze the effects of TF deficiency either in all tissues or selectively in hematopoietic cells. Low TF mice had reduced coagulation, inflammation, and mortality compared with control mice. Similarly, a deficiency of TF expression by hematopoietic cells reduced lipopolysaccharide (LPS)-induced coagulation, inflammation, and mortality. Inhibition of the down-stream coagulation protease, thrombin, reduced fibrin deposition and prolonged survival without affecting inflammation. Deficiency of either protease activated receptor-1 (PAR-1) or protease activated receptor-2 (PAR-2) alone did not affect inflammation or survival. However, a combination of thrombin inhibition and PAR-2 deficiency reduced inflammation and mortality. These data demonstrate that hematopoietic cells are the major pathologic site of TF expression during endotoxemia and suggest that multiple protease-activated receptors mediate crosstalk between coagulation and inflammation.     

Comparison of magnetic resonance imaging and computed tomography of 8 aortic stent-graft models.

PURPOSE: To report the systematic comparison of magnetic resonance imaging (MRI) with contrast-enhanced computed tomography (CT) for evaluating 8 different aortic stent-graft models. METHODS: MR angiography (MRA) was performed using a 1.5-T whole body system within 2 days of a CT examination (4 detector row scanner) on 8 patients with one of these stent-graft models: AneuRx, Endofit, PowerLink, Excluder, LifePath, Talent, Vanguard, or Zenith. Using a 4-point scale (maximum score 112 points), 4 independent readers (1 vascular surgeon and 3 radiologists) rated the impact of stent-related artifacts on the diagnostic quality of each imaging method for 28 parameters: length, diameter, collateral aortic side branches, stent-graft prostheses, and contrast. Each examiner also scored his personal diagnostic confidence with each stent-graft model. RESULTS: The scores for diagnostic confidence in the CT imaging were 4 points for each stent-graft, with the exception of the LifePath (3 points). The diagnostic confidence in the MR images was mainly poor, with a median score of only 1; however, 3 stent-grafts (AneuRx, Excluder, and Vanguard) received > or =3 points. The total scores for comparative assessment were significantly different (p<0.05) between CT imaging (111.5) and MR (58.5). CT studies of all stent-grafts received >101 points, while only 3 devices acquired >80 points (AneuRx, Excluder, and Vanguard). Bland-Altman analysis showed that the reliability of the 4 readers was higher using the CT method. The total assessment scores of the stent-graft systems were related only on the different imaging methods (p<0.0001) and not to the different readers (p=0.983). CONCLUSIONS: CT and MRI are fast, reliable means of providing all relevant information for stent-graft surveillance. Of 8 different stent-graft models, only 3 could be adequately assessed by MRA. Therefore, the potential advantages of the MR technique (e.g., use of minimally nephrotoxic contrast media, lack of ionizing radiation) are available only to a small proportion of patients.     

Sudden hearing loss in patients with chronic hepatitis C treated with pegylated interferon/ribavirin

BACKGROUND: Sudden hearing loss has been reported on standard interferon (IFN)-alpha2 therapy. This is the first report on the occurrence of sudden hearing loss in six cases of chronic hepatitis C in temporal relation to treatment with pegylated (PEG)-IFN alfa2a or b/ribavirin combination therapy. Three patients were treated in an ongoing randomized placebo-controlled trial comparing the addition of 200 mg amantadine or placebo to the combination of 180 microg PEG-IFN alpha2a (PEGASYS, Roche, Basel, CH)/wk and 1-1.2 g ribavirin/d (COPEGUS, Roche, Nutley, USA) in de novo patients infected with HCV genotype 1. Sudden hearing loss and tinnitus developed on day 1 and after 4, 23, 25, 36, and 40 wk of treatment, respectively. CONCLUSIONS: Sudden hearing loss may occur in about 1% of patients on PEG-IFN/ribavirin combination therapy. This rate was not different to that observed in an untreated population. Possible mechanisms involved include direct ototoxicity of IFN, autoimmunity, and hematological changes. In contrast to published cases on auditory disability due to standard IFN, hearing loss did not fully resolve after discontinuation of therapy with PEG-IFN. On the other hand, symptoms did not worsen on continued treatment. Therefore, the decision whether to continue or to stop the treatment when signs of ototoxicity appear is based on the clinical judgment of the treating physician.     

Protein Synthesis in Simian Virus 40-Infected Monkey Cells

The proteins of purified Simian virus 40 (SV40) were examined by sodium dodecyl sulfate-acrylamide gel electrophoresis and compared with the polypeptides synthesized in SV40-infected monkey cells. Purified virions contain two major components, with molecular weights of 44,000 and 31,000. Together they make up 83% of the total virion proteins. In addition, the virus contains 12 minor polypeptides, which are believed to be cellular proteins, or peptides derived from proteolytic degradation of the 44,000 molecular weight polypeptide. Pulse-label experiments show that about 90% of the polypeptides synthesized after SV40 infection are host-cell proteins; 10% represent the two major structural components of the virion. A small fraction (about 0.5%) consists of three polypeptides (molecular weights 70,000, 60,000, and 8,000) that are neither part of the virion nor detectable in uninfected cells. They are either virus-induced cellular proteins or, more likely, proteins coded for by the SV40 genome.     

Cytokine-independent repression of rodent Ntcp in obstructive cholestasis

Cholestatic liver injury is associated not only with accumulation of bile acids but also with activation of proinflammatory cytokines. Common bile duct ligation (CBDL) induces sustained downregulation of the Na(+)/taurocholate cotransporter (Ntcp) in rodent liver. Although repression of Ntcp during endotoxemia is cytokine mediated, it is unclear whether inflammatory cytokines contribute to this downregulation in obstructive cholestasis. Cytokine inactivation in CBDL rats and mice was either performed directly with tumor necrosis factor alpha (etanercept) or interleukin 1 beta inactivation (anakinra/AMG 719) or indirectly Kupffer cell depletion via intraperitoneal administration of liposome-encapsulated dichloromethylene bisphosphonate. Protein and messenger RNA (mRNA) expression of Ntcp and short heterodimer partner (SHP) were analyzed via Western and Northern blotting. Key regulators of Ntcp (hepatocyte nuclear factor 1 alpha [HNF-1alpha], HNF-4alpha, retinoid X receptor alpha [RXRalpha]:retinoic acid receptor alpha [RARalpha]) were studied via electrophoretic mobility shift analysis and nuclear Western blot analysis. Both methods of cytokine inactivation failed to maintain Ntcp protein or mRNA expression within 3 days after CBDL in either rats or mice (20%-40% of sham controls), while SHP mRNA expression increased three- to five-fold. Decreased nuclear HNF-1alpha and HNF-4alpha protein levels (45% and 60% of sham controls, respectively) and HNF-1alpha binding activity (32% of sham controls) were not restored during cytokine inactivation after CBDL, indicating cytokine-independent mechanisms of Ntcp regulation. RXRalpha:RARalpha binding remained unchanged in all experimental conditions. In conclusion, during obstructive cholestasis accumulating bile acids per se, without major contribution of cytokines, leads to downregulation of Ntcp via repression of HNF-1alpha and HNF-4alpha.     

HER2 overexpression and activation, and tamoxifen efficacy in receptor-positive early breast cancer

Objectives  Tamoxifen is a partial ER antagonist that is highly effective in the treatment of receptor positive breast cancer. It significantly reduces recurrence and improves survival in both pre- and postmenopausal women. Unfortunately, many ER+ positive tumors progress despite tamoxifen treatment and until now, no possibility exists to prospectively identify tamoxifen-resistant tumors. It has been suggested that that in HER2 over-expressing tumors, cross-talk via activated HER2 receptors is a key mechanisms by which tumors become tamoxifen-resistant. Methods  We have therefore used immunohistochemistry to analyze the expression of HER2 and activated ptyr-1248 HER2 in 408 women of ER+, early breast cancer who had received at least 2 years of adjuvant tamoxifen. We then analyzed possible associations between HER2 and pHER2 expression, and prognostic parameters, and evaluated the effect of HER2 expression and survival. Results  With HER2 being positive in 12 of 208 (2.9%) of ER+ positive tumors, HER2 overexpression was found to be considerably less common in ER+ tumors than what has been thought previously. The majority of HER2 overexpressing tumors, however, also expressed the activated receptor form (r = 0.664; P < 0.0001). Both HER2 and pHER2 are moderately correlated with Grading (r = 0.138; P = 0.0052 and r = 0.118; P = 0.0241, respectively) and nodal involvement (r = 0.163; P = 0.0018 and r = 0.134; P = 0.016, respectively), but neither HER2 nor its activated form are significant predictors of RFS, DFS, or OS. Conclusions  Taken together, we have demonstrated that in ER+ breast cancer, the HER2 receptor is commonly activated, but its low prevalence in ER+ tumors does not render it a useful prognostic parameter in tamoxifen-treated patients.