Efficacy of combined immunosuppression with or without eltrombopag in children with newly diagnosed aplastic anemia

We compared the efficacy and safety of eltrombopag (ELTR) combined with immunosuppressive therapy (IST) and IST alone in treatment-naïve children with severe (SAA) and very severe (vSAA) aplastic anemia. Ninety-eight pediatric patients were randomized to receive horse antithymocyte globulin (hATG) and cyclosporin A (CsA) with (n = 49) or without (n = 49) ELTR. The primary endpoint was the overall response rate (ORR) at 4 months. After 4 months, nonresponders were crossed over to the alternative group. In all patients, the ORR in ELTR + IST and IST groups was similar (65% vs 53%; P = .218); however, the complete response (CR) rate was significantly higher in the ELTR + IST group (31% vs 12%; P = .027). In severity subgroups, the ORR was 89% vs 57% (P = .028) in favor of IST + ELTR in SAA, but it did not differ in patients with vSAA (52% vs 50%; P = .902). At 6 months after the crossover, 61% of initial ELTR(-) patients achieved a response compared with 17% of initial ELTR(+) patients (P = .016). No significant difference in ELTR + IST and IST groups was observed in the 3-year overall survival (OS) (89% vs 91%; P = .673) or the 3-year event-free survival (EFS) (53% vs 41%; P = .326). There was no unexpected toxicity related to ELTR. Adding ELTR to standard IST was well tolerated and increased the CR rate. The greatest benefit from ELTR combined with IST was observed in patients with SAA but not in those with vSAA. The second course of IST resulted in a high ORR in initial ELTR(-) patients who added ELTR and had limited efficacy among patients who received ELTR upfront. This trial was registered at Clinicaltrials.gov as #NCT03413306.

[Plastic surgery and fighting: Our experience during Nagorno-Karabakh war in 2020]

INTRODUCTION

This work relates the experience of three French surgical missions in the care of the war wounded during the armed conflict in Nagorno Karabakh which took place from September 27 to November 10, 2020.

MATERIALS AND METHODS

Three surgical missions were carried out in Armenia between October 2020 and January 2021. Surgeons intervened in different hospitals, at different times of the conflict and on various war wounds.

RESULTS

The presence of a plastic surgeon proved to be essential in the care of war wounded, especially in delayed emergency and secondary care. The ortho-plastic treatment offered during these missions has proven to be effective in the reconstruction of limbs. These missions made it possible to introduce the induced membrane technique of Masquelet AC in Armenia. During our visit to the Yerevan burn center, we mentioned the very probable use of white phosphorus as an etiology in several of the cases analyzed.

CONCLUSION

We relate the particular experience of civilian surgeons in the context of a modern armed conflict. The presence of a plastic surgeon proved to be indispensable in the care of war wounded and especially in their secondary reconstructions.

Control of thrombotic thrombocytopenic purpura by sirolimus in a child with juvenile myelomonocytic leukemia and somatic N-RAS mutation

We describe an infant who developed juvenile myelomonocytic leukemia (JMML) at the age of 6 months. Myeloproliferation was effectively controlled by low-dose cytosine arabinoside and 13-cis retinoic acid therapy. Two years after therapy for JMML was stopped, at the age of 5 years, the patient developed autoimmune thrombotic thrombocytopenic purpura (TTP). TTP was transiently controlled by plasma exchange, prednisolone, rituximab, and cyclophosphamide, but relapsed within a short time. Long-term control of TTP was established by sirolimus. Somatic N-RAS G38A→Gly13Asp substitution was restricted to hematopoietic cells. The somatic N-RAS mutation may link myeloproliferation and autoimmunity.

Molecular products and radicals from pyrolysis of lignin

Thermal degradation of lignin under two reaction regimes (pyrolysis in N(2) and oxidative pyrolysis in 4% O(2) in N(2)) has been investigated in a tubular, isothermal, flow-reactor over the temperature range 200-900 °C at a residence time of 0.2 s. Two experimental protocols were adopted: (1) Partial pyrolysis in which the same lignin sample was continuously pyrolyzed at each temperature and (2) conventional pyrolysis, in which new lignin samples were pyrolyzed at each pyrolysis temperature. The results identified common relationships between the two modes of experiments, as well as some differences. The majority of products from partial pyrolysis peaked between 300 and 500 °C, whereas for conventional pyrolysis reaction products peaked between 400 and 500 °C. The principal products were syringol (2,6-dimethoxy phenol), guaiacol (2-methoxy phenol), phenol, and catechol. Of the classes of compounds analyzed, the phenolic compounds were the most abundant, contributing over 40% of the total compounds detected. Benzene, styrene, and p-xylene were formed in significant amounts throughout the entire temperature range. Interestingly, six ringed polycyclic aromatic hydrocarbons were formed during partial pyrolysis. Oxidative pyrolysis did not result in large differences from pyrolysis; the main products still were syringol, guaiacol, phenol, the only significant difference being the product distribution peaked between 200 and 400 °C. For the first time, low temperature matrix isolation electron paramagnetic resonance was successfully interfaced with the pyrolysis reactor to elucidate the structures of the labile reaction intermediates. The EPR results suggested the presence of methoxyl, phenoxy, and substituted phenoxy radicals as precursors for formation of major products; syringol, guaiacol, phenols, and substituted phenols.

Molecular Modeling Studies of the Reactions of Phenoxy Radical Dimers: Pathways To Dibenzofurans

The B3LYP hybrid density functional computational technique was applied to describe the sequence of phenoxy radicals coupling reactions leading to the formation of dibenzofurans. Reaction kinetic parameters were estimated for key reactions. Aromatization of bis-keto dimers of phenoxy radicals followed by intermediate dehydration or dehydroxylation was demonstrated to be a strongly stereoselective process. While the S,S-diastereomer of the ortho-C//ortho-C keto dimer forms (o,o')-dihydroxybiphenyl, a known dibenzofuran intermediate, via inter-ring hydrogen transfer reaction, the less stable R,S-stereoisomer can easily be transformed into another 5-hydroxyl-4,5-cyclohexadiene-2,3-benzofuran intermediate that provides an energetically more favorable pathway for formation of dibenzofuran. The possible channels of radical-chain processes that convert these intermediates to dibenzofuran and polychlorinated dibenzofurans are discussed.

Development of expanded and core kinetic models for the gas phase formation of dioxins from chlorinated phenols

Expanded, 45 reaction, and core, 12 reaction, kinetic models have been developed that account for the major features in the homogeneous formation of polychlorinated dibenzo-p-dioxins (PCDD) from the oxidation of 2,4,6-trichlorophenol (P). The expanded and core schemes provide good agreement between experimental and calculated yields of PCDDs using the CHEMKIN combustion package or the React kinetic program, respectively. Steady-state approximations of the reaction kinetic models including radical-molecule and radical-radical formation pathways of PCDD, as well as oxidative destruction pathways of chlorinated phenoxyl radicals, reveal a competition between reactions of chlorinated phenoxyl radicals with chlorinated phenols, recombination reactions of chlorinated phenoxyl mesomers, and destruction/decomposition of phenoxyl radicals.