Prosthetic rehabilitation of maxillary lateral incisors agenesis using dental mini-implants: a multicenter 10-year follow-up

Objectives

Implants are used to replace congenitally missing lateral incisors but often the space across the alveolar crest is too narrow to permit their use. This multicenter study (Dental Clinic of the University of Foggia, Odontostomatology Clinic of the University of L’Aquila) evaluated the efficacy of mini-implants in cases of maxillary lateral incisor agenesis with severe osseous atrophy in 10-year follow-up.

Materials and methods

Forty-seven mini-implants have been inserted in 35 patients affected by lateral incisors agenesis (23 single and 12 bilateral ageneses). All patients underwent orthodontic opening of the space of the upper lateral incisors. After the insertion of the implants, the immediate, non-functional loading, positioning of crowns, presence of pain during percussion and mini-implant function, horizontal and vertical movement when a force of 5 N was applied, ridge loss, and plaque index have been evaluated 1 month after loading, 1 year after loading, and then every 5 years in the following 10 years. Little’s test was used to evaluate the assumption that data of loss to follow-up implants are missing completely at random (MCAR) and that a complete-case scenario could be adopted. Wilcoxon test was carried out to look statistically significant differences between the various parameters resulting in the complete-case scenario and those assumed for the worst scenario. The software R (v. 3.6.1, 2019) was employed to perform the statistical analysis.

Results

The results obtained over 10 years range from 89% of success rate in a worst-case scenario to the 100% using a complete-case analysis with satisfactory values of marginal bone resorption and good conditions of the peri-implant tissue. Ten-year follow-up using complete-case analysis shows survival rates of 100% for implants with no signs of peri-implantitis, stability of the marginal bone levels and soft tissue around the dental implants.

Conclusions

The data collected show very good implant stability, absence of progressive peri-implantitis, and satisfactory aesthetical results in time (no signs of infraocclusion).

Clinical relevance

Mini-implants can be considered a valid and stable over time solution in the restorative treatment of maxillary lateral incisors agenesis.

Sella turcica and craniofacial morphology in patients with palatally displaced canines: a retrospective study

BACKGROUND

The aim of the study was to evaluate the sella and craniofacial morphological features in growing patients with palatally displaced canines compared to controls.

MATERIALS AND METHODS

Twenty-two subjects with palatally displaced canines were retrospectively selected and compared to 22 controls matched for age and gender. Lateral cephalograms were collected and sagittal and vertical cephalometric variables were measured, together with sella interclinoid distance, sella depth, and sella diameter. The independent samples T-test or Mann-Whitney U-test were used to compare all the variables between the two groups. A Pearson correlation was computed for the craniofacial and sella variables that differed significantly (p < 0.05) between the groups.

RESULTS

Patients with palatally displaced canines showed a smaller interclinoid distance and a greater SNA angle than control subjects. The interclinoid distance and the SNA angle were negatively correlated (-0.52, p = 0.017) in the experimental group.

CONCLUSIONS

Growing patients with palatally displaced canines had smaller sella interclinoid distances and a greater SNA angle than control subjects.

Modification of growth, immunologic and feeding parameters in children with OSAS after adenotonsillectomy

SUMMARY

Obstructive sleep apnoea syndrome can cause growth delay in children. Adeno-tonsillectomy can resolve the syndrome in most cases. The aim of our study is to examine modifications in clinical and laboratory growth and immunological parameters and food intake changes in OSAS children after surgery. Twenty-eight children with severe OSAS associated with adeno-tonsillar hypertrophy were submitted to paediatric evaluation to calculate auxologic parameters (weight, height, BMI and standard deviation scores), a blood draw to evaluate growth (GH; IGF-1) and immunological parameters (IgG; IgA; IgM) and a dietitian evaluation to calculate caloric intake before and after 3 months following adeno-tonsillectomy. Mean height and weight values in the study group were slightly inferior to same-age children mean according to the percentile values. After surgery, both height and BMI increased significantly at 3-months follow-up: mean height increased 2.93 cm (p = 0.0001); BMI values greatly increased by 0.72 kg/m² (p = 0.009). Standard deviation scores increased significantly for height (p = 0.03), weight (p = 0.001) and BMI (p = 0.001). These values significantly increased, despite almost unchanged caloric intake between the pre- and post-surgery period (90 ± 24 vs 91 ± 27 kcal/kg/day; p > 0.05). In all children, age-related GH values were normal and did not show any significant increase, while IGF-1 values significantly increased during the study period (p = 0.01). Regarding immunological parameters, only IgA levels decreased after surgery and maintained a value that was higher than normal (> 70 mg/dL). In conclusion, children affected by adenotonsillar hypertrophy and OSAS do not show significant growth delay, but they do experience a slowdown in growth rate. After adeno-tonsillectomy, the speed of growth soon increases, as weight and growth increase notwithstanding an unchanged food intake. Moreover, surgery does not cause reduction in the efficiency of the immune system.

Report of a Case of Discoid Lupus Erythematosus Localised to the Oral Cavity: Immunofluorescence Findings

Discoid Lupus Erythematosus (DLE) is a chronic disease with a typical cutaneous involvement. This pathology rarely involves mucosa: oral cavity is interested in 20% of DLE patients. We describe a case of oral DLE in a 50-year-old woman with an anamnesis for autoimmune disorders. This study shows the helpful role of immunofluorescence in the diagnosis of autoimmune diseases. The first diagnostic step was the clinical observation of the oral mucosa: the lesion area was erythematous, athrophic and hyperkeratotic. The patient then underwent laboratory examination. We utilized human epithelial cells (Hep-2010) for Indirect Immuno-Fluorescence (IIF). Moreover, the biopsy site for Direct Immuno-Fluorescence (DIF) and histopathological analysis was the untreated oral lesion. IIF detected an increase of Anti-Nuclear Antibody (ANA) and positivity for SSA-RO. By DIF, we observed IgG/IgA/fibrinogen along basal layer. Multiple biopsies reported signs of chronic basal damage. Steroid systemic therapy induced a considerable lesion regression. We suggest the use of immunofluorescence with the integration of further data to improve diagnosis of rare diseases and to establish a suitable therapy.

Sinus Lift Augmentation by Using Calcium Sulphate. A Retrospective 12 Months Radiographic Evaluation Over 25 Treated Italian Patients

Purpose:

The aim of this investigation was to assess bone healing of sinus lift procedure in which the augmentation has been performed by using calcium sulphate like bone substitutes. The methods of this investigation how the use of Cone Beam Computed Tomography (CBCT) may be a valid instrument to support reconstructive surgery of the jaws.

Patients and Methodology:

25 Patients presented large bone defects after tooth extractions located in the upper jaw posterior area. Vertical bone volume was assessed by CBCT examinations before and about six months after sinus lift surgery.

Results:

Examined defects treated with sinus lift surgery and evaluated by CBCT showed a strong increasing on the bone volume at 6 months follow up control.

Conclusion:

Calcium sulphate application in sinus lift surgery represent a safe and predictable option in the place of autologous bone. Therefore the application of CBCT investigation may give the clinicians the opportunity of evaluating with high precision value, the consistence of the bone defects before the surgery.

Breathing pattern and head posture: changes in craniocervical angles

AIM

The aim of this study was to observe the influence of oral breathing on head posture and to establish possible postural changes observing the variation of craniocervical angles NSL/OPT and NSL/CVT between oral breathing subjects and physiological breathing subjects.

METHODS

A cross-sectional study was conducted. The sample included 115 subject, 56 boys and 59 girls, 5-22-year-old. Among these, 80 were classified as oral breathers and 35 as physiological breathers. The diagnosis of oral breathing was carried out thanks to characteristic signs and symptoms evaluated on clinical examination, the analysis of characteristic X-ray images, ENT examination with active anterior rhinomanometric (AAR) test. The structural and postural analysis was carried out, calculating the craniofacial angles NSL/OPT and NSL/CVT.

RESULTS

Both NSL/OPT and NSL/CVT appear to be significantly greater to those observed in physiological breathing patients. This means that patients who tend to breathe through the mouth rather than exclusively through the nose show a reduction of cervical lordosis and a proinclination of the head.

CONCLUSION

Our study confirms that the oral breathing modifies head position. The significant increase of the craniocervical angles NSL/OPT and NSL/CVT in patients with this altered breathing pattern suggests an elevation of the head and a greater extension of the head compared with the cervical spine. So, to correct the breathing pattern early, either during childhood or during adolescence, can lead to a progressive normalization of craniofacial morphology and head posture.

Unilateral posterior crossbite in adolescents: surface electromyographic evaluation

AIM

Unilateral posterior crossbite (UPCB) is characterised by an inverse relationship of the upper and lower buccal dental cusps and may involve one or several teeth. The aim of this study was to compare the electromyographic outcomes of patients with UPCB and those of healthy controls.

MATERIALS AND METHODS

Fifteen patients (mean age 11.5 years) with UPCB and fifteen healthy controls (mean age 12 years) were examined at the Department of Orthodontics, Second University of Naples. Surface electromyography was performed on patients and controls.

RESULTS AND CONCLUSION

Patients with UPCB had less muscle activation than healthy subjects (p<0.0001) and an asymmetric muscle activation with 89.23% muscle balancing for temporals and 83.21% for masseters. The control group showed a 99.32% of muscle balancing for temporals and 97.77% for masseters. These findings suggest that asymmetric muscle activation may influence maxillary and mandibular growth in adolescents with UPCB.

Effect of the Enveloppe Linguale Nocturne on atypical swallowing: surface electromyography and computerised postural test evaluation

AIM

Swallowing is a neuromuscular mechanism regulated by many nervous reflex arcs. Persistence of child swallowing at the end of dental eruption is called atypical swallowing (AS). This condition is related to a dysfunction of vertical maxillary growth called open bite. The authors treated this malocclusion with the Enveloppe Linguale Nocturne (ELN), or tongue positioner, created by Dr. Bonnet. The aim of this work is to evaluate the effect of ELN on swallowing and the postural variation obtained by its use.

MATERIALS AND METHODS

Seven patients affected by AS were evaluated. Surface Electromyography (sEMG) testing was performed on each patient with different tongue positions, and swallowing was evaluated with and without the ELN. A surface Electromyograph (Biopack) with 8 channels was used (4 channels for the right muscles and 4 for the left) on 4 groups of muscles: temporals, masseters (MM), submental (SUB) and sternocleidmastoids. On each patient a postural test using a computerised Postural test (Lizard) was also performed. Statistical analysis was done using the Graph pad Instat 3 both for sEMG activity and for computerised postural analysis.

RESULTS

All seven subjects had different results in the sEMG and footrest tests. The sEMG test results indicated that muscle activation and swallowing duration varied greatly with the use of ELN, with a reduction of time of swallow act (p = 0.002) and variation in contraction of muscles. Mean MM activation was higher without ELN than in tests performed with the appliance (p = 0.002). Mean SUB activation was higher with than without ELN (p = 0.0033). ELN has a therapeutic effect on posture too. Computerised postural test without device showed in all patients an alteration of barycentre as well as an elevated oscillatory record (A mmq; V mms). With ELN footrest kilogram difference (p = 0.0110), Oscillatory Area (P = 0.0102) and velocity of oscillation (P = 0.0102) presented a great reduction in respect to patients record without ELN.

CONCLUSION

With ELN the tongue reaches the physiologic position during the swallowing and it is possible to have a low dental contact without tongue interference. ELN has no dental retention or contact. For this reason sEMG swallowing test shows that ELN induces a Mm activation reduction compared to swallowing test without ELN (P = 0.002) and an increase of SUB activation (P = 0.0033). In the same way with ELN there is a significant reduction of time of swallowing (c.f. oral phase) (P = 0.002). Patients with ELN changed their posture with a complete modification of barycentre (Footrest unbalancing kg P = 0.0110), oscillatory movement area (Footrest Area difference P = 0.0102), and oscillatory Velocity (Footrest Velocity oscillation difference P = 0.0102). These data suggest that this appliance has a function in the rehabilitation of atypical swallowing. ELN produces a physiologic neuromuscular mechanism that induces the correction of tongue position.

Clinical and computerized evaluation in study of temporo-mandibular joint intracapsular disease

AIM

In this work authors show a diagnostic criteria in study of TMID: neuro occlusal clinical evaluation (NOE), T-Scan 2 system and surface electromyography (sEMG).

METHODS

Nine patients 25-30 years old with TMID problem and 9 healthy group control have been selected and examined. On each patients it has been performed NOE, T-Scan and sEMG test. NOE has been calculated on each patient photos lateral mandibular excursion angle called: masticatory functional angle (AFM). T-Scan System is a computerized occlusal analyzer that provide in-depth understanding of the overall balance of the occlusion. At the same time of T-Scan record sEMG tests, in resting position and in maximum clench, have been performed.

RESULTS

In healthy control there were no AFM difference. In no healthy group there were difference between the two AFM greater than 6 degrees. T-Scan COF showed how in healthy group control there was never a difference of COF greater than 5%. In no healthy group the difference were greater than 5% P<0.05. T-scan showed difference of time force in maximum intercuspidation (MIFT) in healthy respect TMID patients. In healthy patients MIFT was higher than TMID patients P<0.05. sEMG test showed in non healthy group a great asymmetrical activation of masseter (MM). MM activation were greater on side affected by joint sound than the balance side P<0.001. sEMG show how in TMID patients maximum masseter activation is always lower than maximum masseter activation of healthy subjects P<0.001.

CONCLUSION

Neuro occlusal clinical evaluation (NOE) in TMID patients is supported by instrumental evaluation.

[Primary and secondary prevention procedures of temporo-mandibular joint disease in the evolutive age]

In the last years prevention of temporomandiboular joint (TMJ) disease had acquired great importance. According to the neuro-occlusal rehabilitation (RNO) it is possible to say that TMJ disease starts since first years of life. So it is important both for dentist and for pediatric know what are the conditions and the atypical functions which predispose to this pathology. The aim of this work was to show how it is possible to intercept since primary teeth and the correct norms of primary and secondary prevention.

Oral squamous cell carcinoma and biological markers: an update on the molecules mainly involved in oral carcinogenesis

Squamous cell carcinoma (SCC) is one of the most common malignant cancer of the oral cavity encompassing at least 92.8% of all oral malignancies. Despite improved diagnostic and therapeutic methods over the 20 last years, this tumour is still characterized by a high rate of mortality. The latest advances of molecular biological methods have contributed to better understand the mechanisms involved in the oral carcinogenetic process. Deregulation of cell cycle, apoptosis and cell-cell/cell-matrix adhesions are considered the pathways mainly influencing this multistage event and scientific researches over the last decade have been performed in order to investigate the biological diagnostic and prognostic parameters related to these events (i.e. tumour growth markers, markers of tumour suppression and anti-tumour response, angiogenesis markers, markers of tumour invasion and metastatic potential, cell surface markers, intracellular markers, markers derived from arachidonic acid, and enzymatic markers). The aim of the present review was to outline the current knowledge on the role of some of these tumour biological markers in carcinogenesis of oral SCC.

Oral ulcers: three questions on their physiopathology

Ulcers and/or erosions can be the final common manifestation, often clinically indistinguishable, of a wide and complex spectrum of conditions including traumatic lesions, infectious, vesiculo-bullous, neoplastic and gastrointestinal diseases. Their formation represents the final outcome of a complex and finely orchestrated phenomenon involving both epithelial lining and chorion. Reduction of blood flow, cytokine production, cell death, wound repair, all participate to the dynamic process which we define as ''ulcer''. However, little is known about the mechanisms which crucially contribute in determining the phenomenology of ulcer, and some questions still remain unsolved. This paper aims to explain the pathophysiology of oral ulcers attempting to answer three questions: the mechanism of ulcer development, the site of appearance, and the factors which determine the severity and healing time of ulcerative lesions.

Incorporation of an additional viral-clearance step into a human immunoglobulin manufacturing process

BACKGROUND AND OBJECTIVES

Regulatory agencies have mandated that manufacturers of immunoglobulin products incorporate robust viral inactivation or removal steps into their purification processes. We evaluated the effectiveness of incorporating nanofiltration, a generic virus-clearance step, into an existing plasma-fractionation process for a human anti-D immunoglobulin product.

MATERIALS AND METHODS

The nanofiltration process studied utilizes a 180 000-molecular weight composite membrane with well-defined pore distribution. To examine its viral-clearance capability, diluted anti-D immunoglobulin was spiked with high concentrations of human and animal model viruses and subjected to tangential-flow nanofiltration during scaled-down validation runs. Viral clearance by the membrane was determined by calculating log removal values in accordance with guidelines provided by US and European regulatory agencies.

RESULTS

Nanofiltration removed viruses of varying sizes and physical characteristics. For the three non-enveloped viruses tested (porcine parvovirus, encephalomyocarditis virus and hepatitis A virus, sizes 18-30 nm), clearance was 3.3, 4.1 and > 5.1 log, respectively. For the three enveloped viruses (human immunodeficiency virus-1, bovine viral diarrhoea virus and pseudorabies virus, 50-200 nm), a substantial 5-log reduction was demonstrated. Product potency, purity and stability were unaffected.

CONCLUSION

Tangential-flow nanofiltration provides substantial virus-removal capabilities for immunoglobulin preparations.

Frequency of immediate adverse effects associated with therapeutic apheresis

BACKGROUND

Therapeutic apheresis was found to be reasonably safe in prior studies using instruments that are now largely obsolete. The incidence of adverse effects with current instruments and techniques has not been assessed in a large multicenter study.

STUDY DESIGN AND METHODS

A survey was conducted in 1995 using a uniform questionnaire that asked about 32 specific events but excluded transient paresthesia and mild vasovagal events. Eighteen centers returned 3429 responses concerning 125 to 500 therapeutic apheresis procedures per center.

RESULTS

Two hundred forty-two adverse events were reported in 163 procedures (4.75% of all procedures; 6.87% of first-time procedures and 4.28% of repeat procedures). The numbers (incidence) of selected specific events were transfusion reaction, 56 (51 in plasma exchange [PE] with plasma replacement) (1.6%); citrate-related nausea and/or vomiting, 41 (1.2%); systolic blood pressure <80 mmHg, 34 (1.0%); vasovagal nausea and/or vomiting, 17 (0.5%); pallor and/or diaphoresis, 16 (0.5%); pulse >120, 14 (0.4%); respiratory distress, 9 (0.3%); tetany or seizure, 9 (0.2%); and chills or rigors, 6 (0.2%). Rates for other specific events were < or =0.1 percent. Vasovagal phenomena were more frequent in procedures done in neurologic patients than in those done in hematology or oncology patients (p = 0.011) or renal or rheumatic patients (p = 0.038). Procedure-specific rates were red cell exchange, 8 (10.26%) of 78; PE (plasma), 89 (7.81 %) of 1140; PE (no plasma), 42 (3.35%) of 1255; leukapheresis, 4 (5.71%) of 70; plateletpheresis, 0 of 18; and autologous peripheral blood progenitor cell collection, 11 (1.66%) of 664. Three deaths were reported; all were attributed to primary disease.

CONCLUSION

Therapeutic apheresis procedures are relatively safe, with a 4.75-percent overall incidence of mostly reversible adverse effects. Among the most commonly performed procedures, the risk is higher for blood component exchanges, especially if allogeneic red cell or plasma transfusion occurs, and lower for peripheral blood progenitor cell collection.

Frequency of immediate adverse effects associated with apheresis donation

BACKGROUND

Apheresis donation is considered safe, but the incidence of adverse effects has not been determined in a large multicenter series of donations with modern instruments.

STUDY DESIGN AND METHODS

The Hemapheresis Committee of the American Association of Blood Banks devised a uniform questionnaire that asked about 32 specific adverse effects. Transient paresthesia and mild vasovagal events were excluded. A survey was conducted in 1995; 17 centers returned 19,611 responses concerning 250 to 2,000 consecutive apheresis donations per center.

RESULTS

Six hundred adverse effects were reported in 428 donations (2.18% of donations). Pain or hematoma at a venipuncture site was the most common response (1.15% of donations); only 203 donations had other (nonvenipuncture) adverse effects (1.04%). Total and nonvenipuncture rates were, respectively, 4.84 and 2.92 percent for 2,295 first donations and 1.78 and 0.77 percent for 17,303 repeat donations (p < 0.001). Rates of nonvenipuncture symptoms in first and repeat donations were, respectively, citrate-induced nausea and/or vomiting, 0.87 and 0.27 percent; tetany, 0.09 and 0.04 percent; pallor and/or diaphoresis, 1.87 and 0.32 percent; vasovagal nausea and/or vomiting, 0.87 and 0.13 percent; syncope and/or seizure, 0.39 and 0.04 percent; and chills and/or rigors, 0.31 and 0.01 percent. The overall rate of donor unconsciousness was 0.08 percent. Hemolysis was reported twice. Clotting or leakage occurred in 0.08 percent of donations, and inability to return blood occurred in 0.16 percent. No life-threatening adverse effects were reported. Procedure-specific nonvenipuncture rates were 1.05 percent of 17,584 platelet donations, 0.67 percent of 594 white cell donations, and 0.37 percent of 1,354 plasma donations. Center-specific rates varied from 0.32 to 6.81 percent of donations for total adverse effects and from 0.11 to 2.92 percent of donations for nonvenipuncture events.

CONCLUSION

Apheresis donation is a safe undertaking, suitable for voluntary blood donors, with a very low risk of serious adverse effects. The risk of unconsciousness is lower than that found in many studies of whole-blood donation.

Should hospitals collect blood components? Yes: hospitals put patients first

Stand-alone blood collection centers throughout the world have suffered in recent years from cost overruns, quality and regulatory problems of major proportion, and a subsequent deterioration of service levels to their communities. Their leaders have been probed by public interest groups, the media and governmental bodies, removed from positions of authority, and sadly, subpoenaed, vilified in public and even jailed. Patients, healthcare providers and hospitals have suffered through this period as well, and continue to search for alternatives to their largely monopoly suppliers. In most cases, the best alternative is the one they control themselves. Should hospitals collect blood components? Yes, since their mission--patient care--takes precedence over that of any non-provider healthcare organization. Patients and the public-at-large gain many things by the continued presence of hospitals in the provision of donor services: provider and patient needs are given first billing, and innovation in blood services is encouraged by the transfusion medicine physicians and allied health professionals who are closest to the patient. Service requirements are recognized and met faster and in simpler ways, and quality concerns are addressed with a minimum of bureaucracy and a maximum of common sense. Finally, when hospitals control their own donor programs, costs are more easily tracked and better controlled.

Is bone marrow purging proving to be of value?

Although the role of hematopoietic stem-cell transplantation (HSCT) in cancer treatment is rapidly expanding, decreasing the side effects of stem-cell infusion is a major challenge. Cancer cells present in the stem-cell collection can cause relapse after autologous transplantation. In allogeneic transplantation. T lymphocytes contribute to graft-versus-host disease. Various methods of purging have been used to remove these unwanted cells, and there is some evidence that such manipulations are clinically useful. Nevertheless, the inability to detect minimal disease makes it difficult to determine whether relapse is caused by incomplete disease eradication in the patient or by the infused cells. This makes it hard to justify the clinical benefit of ex vivo purging. Researchers can focus on this issue by designing studies with minimal variation in other factors that affect the success of stem-cell transplantation.

Erythropoietin response to anaemia is not altered by surgery or recombinant human erythropoietin therapy

Recombinant human erythropoietin (EPO) therapy has been shown to increase red blood cell (RBC) production and facilitate autologous blood donation before elective surgery. However, recent reports have suggested that surgery and/or EPO therapy may suppress endogenous erythropoietin secretion in response to anaemia. We therefore analysed the haemoglobin/erythropoietin relationship preoperatively and postoperatively in 71 autologous blood donors subjected to aggressive phlebotomy and six treatments with either EPO (150 U/kg, n = 16, 300 U/kg, n = 18, or 600 U/kg, n = 19) or placebo (n = 18). Using data from the three preoperative study visits, the linear relationship between log erythropoietin and haemoglobin was determined for each of the 18 placebo patients. We found no significant differences in the slopes of the relationships in this group during aggressive phlebotomy. Furthermore, there was no evidence of a significant difference in the erythropoietin level recorded postoperatively for each patient to that predicted from the patient's postoperative haemoglobin level, based on the haemoglobin/log erythropoietin relationship preoperatively. Similarly, for each of the EPO-treated groups, there was no evidence of a significant difference when comparing the recorded erythropoietin level to that predicted from each patient's postoperative haemoglobin level, based on the haemoglobin/log erythropoietin relationship preoperatively. We conclude that preoperative recombinant human erythropoietin therapy and/or surgery do not adversely affect the postoperative erythropoietin response to anaemia.

Clinical and laboratory comparison study of refrigerated and cryopreserved bone marrow for transplantation

Refrigerated storage for short-term preservation of bone marrow is an alternative to cryopreservation where chemotherapeutic regimens include drugs with short in vivo half-lives. We performed a clinical and laboratory comparison of bone marrow stored at 4 degrees C for up to 9 days to bone marrow cryopreserved at -90 degrees C for autotransplantation. After adjusting for the confounding effects of disease type or sex, no clinically meaningful variation in post-transplant course between refrigerated storage and cryopreserved was found. Therefore, the data presented in this study suggest that the clinical recovery indices following transplantation between the two storage groups are essentially equivalent. One potential advantage to refrigerated storage, however, is that it may provide an opportunity for extended exposure to growth factors and/or purging agents in vitro prior to transplantation. To prepare for an in vitro analysis of this hypothesis, we concentrated the stem cell population and compared the nucleated cell recovery, viability and colony forming potential following refrigerated storage of whole bone marrow and buffy coat to cryopreserved bone marrow stored for the same interval. While the nucleated cell recovery for cryopreserved marrow was significantly greater than for refrigerated storage, the viability and colony forming potential of the refrigerated storage was superior or equivalent, independent of prior processing.

The combined use of soybean agglutinin and immunomagnetic beads for T lymphocyte subset depletion of bone marrow allografts: a laboratory analysis

The prevention of graft-versus-host disease by T-lymphocyte depletion of allografts prior to bone marrow transplantation has resulted in an increase in graft failure/rejection and relapse of disease. Evidence for the selective roles of specific T-lymphocyte subsets in each of the engraftment, graft-versus-host disease, and disease relapse processes has been presented, but sufficient clinical verification to support any hypothesis in this regard is lacking. In this paper we describe a convenient and highly flexible clinical laboratory method for depletion of specific T-lymphocytes in controllable quantities by the use of select monoclonal antibodies. Almost 3 log10 removal of CD2+ and CD8+ cells without significant loss of hematopoietic progenitors (CFU-GM, BFU-E, and CD34+ cells) can be reproducibly achieved. This method, employing soybean agglutination and immunomagnetic beads, is potentially adaptable to depletion of any cell subset or any tumor cell for which unique cell-surface antigen characteristics have been defined. In addition, our protocol is equally suited to the positive selection of stem cells and hematopoietic progenitors bearing the CD34 surface antigen.

A phase III trial of recombinant human erythropoietin therapy in nonanemic orthopedic patients subjected to aggressive removal of blood for autologous use: dose, response, toxicity, and efficacy

BACKGROUND

Previous clinical trials have shown that the use of recombinant human erythropoietin (EPO) can facilitate autologous blood donation and reduce allogeneic blood transfusions in autologous blood donors who are anemic at first donation. However, the role of EPO therapy in nonanemic patients remains undefined. To identify this role, a randomized, controlled, multicenter dose-escalation trial was conducted in patients whose initial hematocrit was > 39 percent (0.39).

STUDY DESIGN AND METHODS

EPO (150, 300, or 600 units/kg) or placebo was administered intravenously at each of six phlebotomy visits over a 3-week study period. Sixteen (14%) of 116 patients were unable to complete the treatment protocol because of adverse events (n = 11) or for personal reasons (n = 5); 2 patients (1 EPO and 1 placebo) experienced serious adverse events.

RESULTS

In 91 evaluable patients, additional red cell production during the study period was 440 +/- 176, 621 +/- 215, 644 +/- 196, and 856 +/- 206 mL (mean +/- SD), respectively, for patients receiving placebo and EPO at 150, 300, and 600 units/kg (p < 0.05 for all EPO groups compared to placebo). However, the percentages of patients in each group who received allogeneic blood did not differ: 2 (9%) of 23 placebo patients and 6 (9%) of 68 EPO patients.

CONCLUSION

It is concluded that, while EPO therapy increased preoperative red cell production, no clinical benefit could be demonstrated in autologous blood donors who were not anemic at first blood donation.

Transfusion therapy for severe anemia

PURPOSE

We evaluated the safety and efficacy of a new transfusion regimen for children with severe anemia.

PATIENTS AND METHODS

Twenty-two consecutive patients with severe anemia (hemoglobin < 5 g/dl) of gradual onset requiring transfusion of packed red blood cells (PRBC) were studied. The transfusion regimen consisted of continuous infusion of PRBC at the rate of 2 cc/kg/h until the desired volume was given. Throughout the transfusion, the patients were closely monitored for any clinical signs of heart failure. The rise in hematocrit per 1 cc of PRBC/kg transfused was computed for each patient.

RESULTS

No patient developed any signs of cardiac failure or increase in the heart rate during or after the completion of transfusion. All patients had a decrease in the heart rate by the completion of transfusion. The mean decrease in the heart rate was 28% of the pretransfusion heart rate (range 12-44%). Excluding the four patients with sickle cell anemia, the remaining 18 patients had a mean increase in the hematocrit of 1.04% per 1 cc/kg of PRBC (range 0.85-1.28).

CONCLUSION

We conclude that for children with severe anemia of gradual onset requiring transfusion therapy, continuous transfusion of PRBC at the rate of 2 cc/kg/h is a safe and effective regimen resulting in an increase in the hematocrit of approximately 1% for each 1 cc/kg of PRBC transfused in all patients, except patients with sickle cell anemia.

Effect of prestorage white cell reduction on bacterial growth in platelet concentrates

Platelet concentrates stored with and without autologous white cells were produced from units of whole blood that had been purposefully contaminated with bacteria immediately after phlebotomy. The blood was inoculated with one of five species of bacterium at either 10 or 50 colony-forming units per mL. The growth of the organisms was quantified throughout the conventional 5-day, 22 degrees C storage period of the platelet concentrates. One species, Klebsiella pneumoniae, failed to grow in any of the components. The remaining species, Staphylococcus epidermidis, S. aureus, Enterococcus faecalis, and Salmonella enteritidis, achieved log growth after 1 day of storage and reached a relative maximum concentration by Day 3. Although the concentration of bacteria immediately after inoculation was lower in the units reduced in white cells by filtration, no significant differences were observed thereafter. Data from this in vitro study support the concept that prestorage white cell reduction of platelet concentrates should not increase the likelihood of transfusion-induced septicemia.

Treatment of cancer chemotherapy-associated thrombotic thrombocytopenic purpura/hemolytic uremic syndrome by protein A immunoadsorption of plasma

BACKGROUND

Chemotherapy-associated thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (C-TTP/HUS) is a condition involving thrombocytopenia, microangiopathic hemolytic anemia, and progressive renal dysfunction that develops in 2-10% of patients with a history of malignant neoplasms treated with certain chemotherapeutic agents. Pathogenesis of the disease may depend on the following: (1) generation of endothelial lesions in the kidney microvasculature, resulting from drug toxic effects and/or generation of small soluble circulating immune complexes (CIC), and (2) generation of autoantibodies and/or CIC that trigger aggregation and deposition of platelets around the lesions.

METHODS

Extracorporeal immunoadsorption treatment of plasma (PROSORBA columns, IMRE Corporation, Seattle, WA) to remove immunoglobulin G and CIC was evaluated in 55 patients for the potential to induce significant clinical benefits (increase in platelet count, decrease in hemolysis, stabilization of renal function) and longer survival.

RESULTS

Response to therapy was achieved in 25 of 55 patients examined. Response was associated with an estimated 1-year survival rate of 61%, as compared with an estimated survival rate of only 22% in those who did not respond (P = 0.0001). Patients whose malignant neoplasms were in complete or partial remission at the time of development of C-TTP/HUS had a significantly higher estimated 1-year survival rate (74%) as compared with a historic control group of patients receiving other treatments (22%, P = 0.0161). Clinical responses were correlated with normalization of serum levels of CIC and complement components C3c and C4. There were no side effects associated with 75% of treatments. Immunoadsorption therapy was associated with generally mild to moderate manageable side effects, such as fever, chills, nausea/vomiting, respiratory symptoms, pain, hypertension, and hypotension, which were reported in 25% of procedures.

CONCLUSIONS

This multicenter study establishes protein A immunoadsorption as an effective and safe treatment for cancer chemotherapy-associated TTP/HUS, an otherwise fatal disease.

Evaluation of platelets collected by a new portable apheresis device

We studied the efficiency of platelet collection by the Mobile Collection System (MCS) using two types of experimental protocols and evaluated the effect of storage at 22 degrees C on the platelet concentrates (PC). MCS is a new blood cell separator that combines discontinuous flow features with a new computerized operating system and can be used to harvest either full units of apheresis PC (SDP protocol) or half units of PC together with one to two units of plasma (PLP protocol). On the average, 1.98 x 10(11) +/- 0.46 x 10(11) (mean +/- SD) platelets were obtained by the PLP protocol and 3.01 x 10(11) +/- 0.70 x 10(11) and 4.2 x 10(11) +/- 1.12 x 10(11) by the early and later versions of the SDP protocols, respectively. The mean number of WBC per PC ranged from 3.3 to 4.7 x 10(8). During the storage period pH stayed above 7.0. On the average, the production of one molecule of lactate corresponded to the consumption of 0.538 molecules of glucose, indicating that less than 8% of glucose was consumed by the oxidative pathway. There were only small increases in LDH and B thromboglobulin concentrations. Furthermore, the ability of platelets to recover from osmotic shock and to aggregate following exposure to dual agonists declined only slightly during storage, indicating that both viability and function of platelets collected by the MCS were preserved during storage.

Safety and efficacy of autologous blood donation before elective aortic valve operation

Although the use of preoperative autologous blood donations for patients undergoing elective cardiac operations has increased dramatically in recent years, patients awaiting elective aortic valve replacement have traditionally been denied access to preoperative autologous blood collection programs. We report our experience with 79 patients, each of whom donated 1 to 3 units of autologous blood before an aortic valve operation. All patients had serious aortic valve disease as evidenced by symptoms and preoperative catheterization data. The patients collectively made 129 blood donations. One patient had a syncopal episode within 2 hours of donation and recovered without difficulty. Of the patients who gave autologous blood preoperatively, 68% avoided any homologous blood donor exposure during their subsequent hospitalization for aortic valve replacement. In contrast, in a group of 298 patients who did not give autologous blood preoperatively, only 31% avoided homologous blood exposure during aortic valve replacement (p < 0.0001). Our experience suggests that preoperative autologous blood donation by patients awaiting elective aortic valve replacement is both safe and effective. Patients with aortic valve disease should not be routinely excluded from preoperative blood services.

Blood donation and transfusion practices: the 1990 American Association of Blood Banks Institutional Membership Questionnaire

Responses to the 1990 American Association of Blood Banks (AABB) Institutional Membership Questionnaire were submitted by 2126 regional blood centers, hospital-based blood banks, and transfusion facilities. Data from 2117 of these facilities were considered to be valid. The questionnaire included information on blood donor demographics, number of units collected, and collection procedures; services performed; usage of blood components; and transfusion-transmitted diseases reported during 1989. Institutional members collected 7.4 million whole blood units, of which 90.8 percent were donated for allogeneic use, 6.0 percent were donated for autologous use, and 3.2 percent were donated for directed use. Approximately 630,546 allogeneic and directed-use blood donors were deferred, most often for low hemoglobin or hematocrit values. Approximately 225,205 full allogeneic and directed-donor units were discarded, primarily for elevated alanine aminotransferase levels or the presence of hepatitis B core antibody. The 14.3 million transfused components included 56.7 percent red cell-containing components, 27.4 percent platelets, 11 percent fresh-frozen plasma, and 4.8 percent cryoprecipitate. Institutional members reported 1397 cases of transfusion-associated hepatitis. In this group, 921 patients were tested for hepatitis B surface antigen after the transfusion; 339 (36.8%) were found to be hepatitis B surface antigen positive. The AABB Institutional Questionnaire results provide recent data on blood donor and transfusion-related activities that are vital to the evaluation of current transfusion medicine practices.

The use of protein A columns in the treatment of cancer and allied diseases

The staphylococcal cell-wall protein known as protein A has been explored as a therapeutic modality in the treatment of cancer and allied diseases. Protein A binds the Fc fragment of IgG 1, 2 and 4, and preferentially binds to IgG incorporated into immune complexes. Early investigators focused on the immune-suppressive effects of immune complexes in cancer and, based on in vitro experiments, postulated that clearance of immune complexes in vivo would permit effective immune clearance of cancer cells. A large clinical trial of the perfusion of cancer patient plasma over protein A was subsequently undertaken. Results were generally disappointing, with no complete remissions and overall response rates of 22%. Response rates for Kaposi's sarcoma (39%) and breast adenocarcinoma (26%) were somewhat encouraging, and further clinical trials in these disorders are ongoing. More impressive have been the responses to protein A perfusion in immune thrombocytopenia and hemolytic-uremic syndrome. Using a protein A-silica device, Snyder et al. reported responses in 42% of immune thrombocytopenia patients, with mean increases in platelet count from 27 x 10(9)/l to 120 x 10(9)/l. On the basis of these results, the protein A-silica column was approved by the United States Food and Drug Administration for treatment of immune thrombocytopenia. Equally encouraging are reports of an overall 59% response rate in cancer chemotherapy-related hemolytic-uremic syndrome. Reported toxicities include fever, chills, hypotension, dyspnea and musculoskeletal pain. With rare exceptions, these reactions are easily treated and do not result in cessation of therapy. Unfortunately, the mechanism of action of plasma perfusion over protein A is very unclear.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemopoietic stem cell processing: comparison of progenitor cell recovery using the Cobe 2991 cell washer and the Haemonetics V50 apheresis system

Using 24 bone marrow (BM) harvests intended for cryopreservation and transplantation, we compared the use of the Cobe 2991 cell washer (2991) and the Haemonetics V50 apheresis system (HV50) for automated BM processing. Our in vitro data indicate that while the mononuclear cell (MNC) concentration of the HV50 product was significantly greater than that of the 2991, the overall MNC recovery of the two products was equivalent. In addition, although the concentration of CFU-GM and BFU-E in the products was equivalent, recovery of these progenitors in the 2991 product was significantly greater than those of the HV50 product. There was no significant difference in either the final product concentration or the overall recovery of cells bearing the primitive myeloid antigens, CD33 or CD34, between the two methods. The HV50 product volume, the red cell and the granulocyte mass were significantly lower than those of the 2991. We conclude that the advantages gained through the use of each machine should be evaluated within the context of the specific intention for the graft. Future advances in the identification and understanding of the primitive stem cell will aid in attempts to evaluate the methods used to isolate these cells.