AB0554 CONCORDANCE IN THE CLASSIFICATION CRITERIA IN A PATIENT COHORT WITH IDIOPATHIC INFLAMMATORY MYOPATHIES (IIM)

Background:

Differents classifications criteria for IIM exist. New classification criteria are superior to previous in capturing different subgroups of IIM.

Objectives:

To compare the concordance and disparity of Bohan and Peter and EULAR/ACR 2017 classification criteria at the level of diagnostic certainty, in a group of chilean patients with IIM.

Methods:

40 adults patients with IIM (27 Dermatomyositis (DM) and 13 Polimyositis (PM)), according Bohan and Peter criteria were analized. The patients were reclassified with EULAR/ACR criteria. The level of diagnostic certainty (definitive, probable and possible) was registered for both Classification Criteria. The concordance and disparity between criteria was evaluated. Concordance and disparity analysis were made considering the strict agreement between level of certainty of both criteria, using Cohen´s Kappa coefficient. The analysis was done for the complete cohort and for separated groups.

Patients with discordance belonging to the same subgroup were evaluated using contingency tables. The direction of the change (gain or lost of certainty) and the relation with diagnostic subgroup was also analized. Descriptive statistics is expressed as diagnostic categories, number of patients and rates.

Results:

For the complete cohort and for DM and PM groups the concordance was low. For 27 patients with DM, the observed concordance rate was 63% (16 definitives, 1 probable). The observed disparity rate was 37%. The direction of the change was gain of one level of certainty in 14.5% and two levels in 22.2% of patients applying EULAR/ACR criteria compared to Bohan y Peter criteria. For 13 pacients with PM, the observed concordance rate was 46% (3 definitives and 3 probables). The observed disparity rate was 54%. The direction of the change was loss of certainty. The loss of certainty was one level in 85,7% (one patient change from probable to posible). Only one patiente had gain of certainty of one level (14.3%).

Conclusion:

The strict concordance between both classification criteria was low. The observed concordances were better in patients with DM that PM. The disparities involved gain of level of diagnostic certainty in DM patients, while in PM patients there was mostly lost of level of certainty.

References:

[1]Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). NEJM 1975;292:344-7.

[2]Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). NEJM 1975;292:403-7.

[3]2017 European League Against Rheumatism/American Colllege of Rheumatology Classification Criteria for Adult and Juvenile Idiopathic Inflammatory Myopathies and Their major Subgroups. Arthritis Rheum 2017;0:1-12.

Disclosure of Interests: :

None declared

Incorporating posttransplant cyclophosphamide-based prophylaxis as standard-of-care outside the haploidentical setting: challenges and review of the literature

Posttransplant high-dose cyclophosphamide (PTCy) effectively prevents GvHD after haploidentical SCT. However, its use in HLA-matched SCT has been less explored. Fifty-six consecutive patients who underwent allo-SCT for hematological malignancies have been included in this prospective single-center protocol. Donors have been HLA-identical siblings, fully-matched unrelated or 1-allele-mismatched unrelated donors in 30%, 32%, and 37% of cases, respectively. Nine patients have received a TBI-containing MAC regimen, while the remaining (84%) received RIC platforms based on Fludarabine plus Busulfan/Melphalan. Due to the high graft failure (GF) rate (21%) in a preliminary analysis in the allo-RIC cohort (n = 29), protocol amendments have been implemented, with no further cases of GF after the introduction of mini-thiotepa (0/18). The overall incidence of grade II-IV acute GvHD is 24% (95% CI: 17-31%) with four steroid-refractory cases. Severe chronic GvHD has occurred in only 1 of 43 evaluable cases. The 1-year NRM and relapse are 18% (95% CI: 12-26%) and 30% (18-42%) and the OS and DFS are 78% and 64%, respectively. These outcomes support the feasibility of using PTCy as a SOC outside the haplo-setting, albeit mini-thiotepa (3 mg/kg) was incorporated in the standard allo-RIC platforms to prevent GF. Despite the limitations of a single-center experience and the short follow-up, these protocols show promising results with particular benefit in reducing the occurrence of moderate-to-severe GvHD.

Severe infections after single umbilical cord blood transplantation in adults with or without the co-infusion of CD34+ cells from a third-party donor: results of a multicenter study from the Grupo Español de Trasplante Hematopoyético (GETH)

BACKGROUND

Umbilical cord blood transplantation (CBT) is an established alternative source of stem cells in the setting of unrelated transplantation. When compared with other sources, single-unit CBT (sCBT) is associated with a delayed hematologic recovery, which may lead to a higher infection-related mortality (IRM). Co-infusion with the sCBT of CD34+ peripheral blood stem cells from a third-party donor (TPD) (sCBT + TPDCD34+) has been shown to markedly accelerate leukocyte recovery, potentially reducing the IRM. However, to our knowledge, no comparative studies have focused on severe infections and IRM with these 2 sCBT strategies.

METHODS

A total of 148 consecutive sCBT (2000-2010, median follow-up 4.5 years) were included in a multicenter retrospective study to analyze the incidence and risk factors of IRM and severe viral and invasive fungal infections (IFIs). Neutrophil engraftment occurred in 90% of sCBT (n = 77) and 94% sCBT + TPDCD34+ (n = 71) recipients at a median of 23 and 12 days post transplantation, respectively (P < 0.01).

RESULTS

The 4-year IRM was 24% and 20%, respectively (P = 0.7), with no differences at day +30 (5% and 4%, respectively) and day +100 (10% and 8%, respectively). In multivariate analysis early status of the underlying malignancy, cytomegalovirus (CMV)-seronegative recipient and high CD34+ cell content in the cord blood unit before cryostorage (≥1.4 × 10(5) /kg) were protective of IRM. Among the causes of IRM, bacterial infections and IFIs were more common in sCBT (15% vs. 4%), while CMV disease and parasitic infections were more common in the sCBT + TPDCD34+ cohort (5% vs. 16%).

CONCLUSION

These data show that sCBT supported with TPDCD34(+) cells results in much shorter periods of post-transplant leukopenia, but the short- and long-term rates of IRM were comparable to those of sCBT, presumably because immune recovery is equally delayed in both graft types.

Clinical and economic impact of various strategies for varicella immunity screening and vaccination of health care personnel

BACKGROUND

Exposure to patients with varicella or herpes zoster causes considerable disruption to a health care facility's operations and has a significant health and economic impact. However, practices related to screening for immunity and immunization of health care personnel (HCP) for varicella vary widely.

METHODS

A decision tree model was built to evaluate the cost-effectiveness of 8 different strategies of screening and vaccinating HCP for varicella. The outcomes are presented as probability of acquiring varicella, economic impact of varicella per employee per year, and cost to prevent additional cases of varicella. Monte Carlo simulations and 1-way sensitivity analyses were performed to address the uncertainties inherent to the model. Alternative epidemiologic and technologic scenarios were also analyzed.

RESULTS

Performing a clinical screening followed by serologic testing of HCP with negative history diminished the cost impact of varicella by >99% compared with not having a program. Vaccinating HCP with negative screen cost approximately $50,000 per case of varicella prevented at the current level of U.S. population immunity, but was projected to be cost-saving at 92% or lower immunity prevalence. Improving vaccine acceptance rates and using highly sensitive assays also optimize cost-effectiveness.

CONCLUSION

Strategies relying on screening and vaccinating HCP for varicella on employment were shown to be cost-effective for health care facilities and are consistent with current national guidelines for varicella prevention.

A survey of recent introduction events, spread and mitigation efforts of mynas (Acridotheres sp.) in Spain and Portugal

The common myna Acridotheres tristis is listed among the world’s 100 worst invasive alien species. We combined previous records with a field survey to update the extent and fate of myna introductions in Spain and Portugal. Results suggest that there have been at least 22 independent accidental introductions of three myna species throughout the Iberian peninsula and three archipelagos since the early 1990s. While bank mynas (A. ginginianus) did not become established elsewhere, common mynas reached breeding populations on four islands. Eradication efforts allowed the extirpation of these breeding island populations, but common mynas continue to breed in the Tagus Estuary (continental Portugal). In this region, there is also a breeding population of crested mynas (A. cristatellus), which was undergone an exponential population growth in the last decade. To avoid further accidental introductions, eradication campaigns should be combined with preventive actions aiming to stop the trade of these species in Europe.

Coagulation profiles of unexpected DCDD donors do not indicate a role for exogenous fibrinolysis

It has been suggested that vascular stasis during cardio-circulatory arrest leads to the formation of microvascular thrombi and the viability of organs arising from donation after circulatory determination of death (DCDD) donors may be improved through the application of fibrinolytic therapy. Our aim was to comprehensively study the coagulation profiles of Maastricht category II DCDD donors in order to determine the presence of coagulation abnormalities that could benefit from fibrinolytic therapy. Whole blood from potential DCDD donors suffering out-of-hospital cardiac arrest was sampled after declaration of death in the emergency department, and rotational thromboelastomeric analysis was performed. Between July 2012 and December 2013, samples from 33 potential DCDD donors were analyzed. All patients demonstrated hyperfibrinolysis (HF), as reflected by maximum clot lysis of 98-100% in all cases, indicating that there is no role for additional fibrinolytic therapy in this setting. As well, we observed correlations between thromboelastomeric lysis parameters and maximum hepatic transaminase levels measured in potential donors and renal artery flows measured during ex situ hypothermic oxygenated machine perfusion, indicating that further studies on the utility of thromboelastometry to evaluate organ injury and perhaps even viability in unexpected DCDD may be warranted.

Impact of Epstein Barr virus-related complications after high-risk allo-SCT in the era of pre-emptive rituximab

We monitored 133 high-risk allo-SCT recipients for 6 months after transplant for EBV reactivation by quantitative real-time PCR. Rituximab was given as pre-emptive therapy for viremia >1000 copies/mL. The 1-year cumulative incidence of EBV reactivation was 29.4% (95% confidence interval (CI): 18-40) in patients monitored due to initial high-risk characteristics (n=93) and 31.8% (95% CI: 19.7-44) in those followed because of the development of refractory GVHD (n=40). Overall response rate to Rituximab was 83%. Nine patients (9.6%) developed post-transplant lymphoproliferative disorder (PTLD) at a median of +62 days after SCT. Eight of them showed a concomitant CMV reactivation. Second SCT was the only risk factor associated with EBV infection and PTLD in multivariate analysis (hazard ratio (HR) 2.6 (95% CI: 1.1-6.4; P=0.04) and HR 6.4 (95%CI: 1.3-32; P=0.02)). The development of EBV reactivation was not associated with non-relapse mortality or OS (P=0.97 and P=0.84, respectively).

The role of transboundary air pollution over Galicia and North Portugal area

In summer, high levels of ozone (O3) are frequently measured at both Galicia and Northern Portugal air quality monitoring stations, even exceeding the limit values imposed by legislation. This work aims to investigate the origin of these high O3 concentrations by the application of a chemical transport modelling system over the northwestern area of the Iberian Peninsula. The WRF-CHIMERE modelling system was applied with high resolution to simulate the selected air pollution episodes that occurred simultaneously in Galicia and North Portugal and in order to study both the contribution of local emission sources and the influence of transboundary pollution. Emission inputs have been prepared based on the development of the Portuguese and Galician emission inventories. The obtained results for O3 have been evaluated and validated against observations. Modelling results show possible contribution of the transboundary transport over the border of two neighbour regions/countries, indicating that the O3 episode starts over the urban and industrialised area of North coast of Portugal, reaching the maximum peaks over this region; at the same time, O3 levels increased over Galicia region, where lower concentrations, but still high, were observed. These results pointed out that air quality management should not be driven by political boundaries and highlight the importance of joining efforts between neighbouring countries.

Synoptic patterns and air mass transport during ozone episodes in northwestern Iberia

High levels of ozone are frequently measured at the Galicia (NW Iberian Peninsula) air quality monitoring stations from March to October. However, there have been very few studies on surface ozone in the northwestern Iberian Peninsula, most likely because the climate of this region is not favourable to photochemical ozone generation. The occurrence of these episodes may be related to either local-scale photochemical pollution or regional-scale transport from other polluted regions. In addition, high ozone episodes usually are developed under specific synoptic conditions. The main purposes of this study are to characterise the atmospheric conditions that lead to the ozone episodes in this region and to identify possible advection paths of ozone and precursors. A surface hourly ozone dataset (2002-2007) measured at rural sites in Galicia was analysed to identify high ozone episodes together with their associated synoptic patterns using a subjective classification with 23 different synoptic types. The synoptic weather patterns revealed that most of the episodes occur with high surface pressures centred over the British Isles and/or Central Europe while a high-altitude anticyclonic ridge crosses the Peninsula from North Africa, causing easterly or southeasterly winds. This analysis was completed with 3-day backward air mass trajectories obtained with HYSPLIT to assess the contribution of long-range transport, resulting in the following main routes: Mediterranean-Peninsular, South Atlantic-Portuguese, local and French-Cantabric.

Trends of rural tropospheric ozone at the northwest of the Iberian Peninsula

Tropospheric ozone levels around urban and suburban areas at Europe and North America had increased during 80's–90's, until the application of NO_x reduction strategies. However, as it was expected, this ozone depletion was not proportional to the emissions reduction. On the other hand, rural ozone levels show different trends, with peaks reduction and average increments; this different evolution could be explained by either emission changes or climate variability in a region. In this work, trends of tropospheric ozone episodes at rural sites in the northwest of the Iberian Peninsula were analyzed and compared to others observed in different regions of the Atlantic European coast. Special interest was focused on the air quality sites characterization, in order to guarantee their rural character in terms of air quality. Both episodic local meteorological and air quality measurements along five years were considered, in order to study possible meteorological influences in ozone levels, different to other European Atlantic regions.

Investigating a high ozone episode in a rural mountain site

A very high ozone episode with observed hourly values above 350 μg m(-3) occurred in July 2005 at the Lamas d'Olo air quality monitoring station, located in a mountainous area in the north of Portugal. Aiming to identify the origin and formation of this ozone-rich episode, a statistical analysis and a modelling approach were applied. A cross-spectrum analysis in the frequency domain and a synoptic analysis of the meteorological and air quality time series were performed. In order to go further in this analysis, a numerical modelling approach was applied. The results indicate that the transport of ozone and its precursors is the main responsible for the high ozone concentrations. Together with the local mountain breeze and subsidence conditions, the sea-breeze circulation transporting pollutants from the coastal urban and industrialized areas that reach the site during late afternoon turn out to be the driving forces for the ozone peaks.

Extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening: a pilot study

BACKGROUND

Caecal intubation can be achieved by extended flexible sigmoidoscopy in 32% of patients.

AIM

To assess the feasibility of extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening.

METHODS

We enrolled 41 patients referred for screening flexible sigmoidoscopy. After purging, examination was performed with a colonoscope. All patients completed sigmoidoscopy (success in meeting referral goal); 93% and 71% had examination to the transverse or ascending colon, and caecum, respectively. Overall yield and right-sided polyps was 56% and 27%, respectively. Caecal intubation and complete examination with polypectomy took 6.0 +/- 2.5 and 18.3 +/- 5.1 min, respectively; with no complications. Twelve patients requested colonoscope withdrawal because of discomfort. Although 46% reported moderate to severe discomfort, 39% and 36%, respectively, were definitely or probably willing to repeat flexible sigmoidoscopy.

RESULTS

Unsedated colonoscopy introduced as extended flexible sigmoidoscopy emphasizes the benefits of added yield rather than the negative image of withholding of discomfort relief. The patient can choose to accept the equivalent of an unsedated colonoscopy or reject the option based on perceived discomfort during extended flexible sigmoidoscopy performed by the colonoscopist.

CONCLUSION

Extended flexible sigmoidoscopy is a feasible option in carefully selected patients, fully prepared and by an experienced colonoscopist.

Early infections in adult patients undergoing unrelated donor cord blood transplantation

Early transplant-related mortality after cord blood transplantation from unrelated donors (UD-CBT) is close to 50%, mainly due to infectious complications. We have studied the incidence and characteristics of early infections (before day 100) in a series of 27 adult patients (median age 30 years, range 16-46) undergoing UD-CBT at a single institution. All 27 patients experienced at least one infectious episode and 18 (66%) suffered a severe infection. Bacteremia occurred in 55% of patients (13 with Gram-positive and 11 with Gram-negative microorganisms). Eleven of 19 CMV-seropositive patients (58%) developed CMV antigenemia and one patient had CMV disease. Fungal infections were documented in three patients (11%), comprising invasive fungal infections in two cases and a localized esophagitis in one. Ten patients (37%) died before day 100 after transplantation. Infection was considered the primary cause of death in four patients (sepsis by Acinetobacter spp. bacteremia in three cases) and contributed to death in another four. The most striking findings in this series were the high incidence of, and mortality due to multiresistant Acinetobacter spp. and the low incidence of and lack of mortality due to CMV disease. This report confirms that infection is a major complication in adults undergoing UD-CBT.

Infectious complications in patients undergoing unrelated donor bone marrow transplantation: experience from a single institution

OBJECTIVE

To analyze the incidence and characteristics of documented infections in patients with hematologic malignancies undergoing unrelated donor bone marrow transplantation (UD-BMT).

METHODS

We studied the occurrence of infections in 22 patients with hematologic malignancies or severe aplastic anemia who underwent UD-BMT from April 1990 to December 2000. The median age was 26 years (range 13-46). Acyclovir-ganciclovir, co-trimoxazole, fluconazole-nystatin and ciprofloxacin were administered for anti-infectious prophylaxis.

RESULTS

We registered 61 infectious episodes. During the early post-transplant period, there were eight clinically documented infections (CDIs), four cases of fever of unknown origin (FUO), seven cases of bacteremia, two cases of cytomegalovirus (CMV) antigenemia, and one case of CMV disease. In the intermediate period (days 30-100 after BMT), there were nine cases of CMV antigenemia, three bacterial infections, two fungal infections, one case of disseminated toxoplasmosis, and one case of FUO. In the late period (day 100 and later), we documented 13 viral infections, eight bacterial infections, one CDI, and one case of invasive aspergillosis. Infections contributed to death in 10 of 17 patients. Citrobacter bacteremia and sepsis of unknown origin were the main causes of infectious mortality in the early period. Infection was the main cause of death in six of seven patients in the late period.

CONCLUSION

A high incidence of life-threatening infections and infection-related mortality was observed. A high rate of CMV infection in the early period, and death caused by multiresistant Gram-negative microorganisms in the late period, were the main findings in this series.

Characteristics of nitric oxide-induced apoptosis and its target cells in mitogen-stimulated peripheral blood mononuclear cells from HIV+ subjects

The phenomenon of apoptosis observed in lymphoid cells from HIV+ subjects is an important factor contributing to their massive depletion. Several studies have identified nitric oxide (NO) as one of the molecules involved in the apoptosis phenomenon observed during HIV infection. It has been shown that HIV-derived gp120 enhances NO synthesis in cultured cells from HIV+ individuals. Therefore, we tested the potential of two nitric oxide synthase (NOS) inhibitors with different mechanisms of action as preventive agents of in vitro apoptosis, in peripheral blood mononuclear cells (PBMC) from HIV+ subjects. PBMC isolated from these patients always showed higher apoptosis levels than normal subjects, a fact that correlated with overproduction of NO and with reduction of mitochondrial transmembrane potential in these cells. We identified the CD8+ T lymphocyte sub-population as the major apoptosis target in PBMC cultures. Treatment with NO inhibitors N(G)-monomethyl-L-arginine (L-NMMA) and dexamethasone (DEX) inhibited spontaneous and mitogen-induced apoptosis, while reducing mitochondrial alterations in PBMC from both normal (30%) and HIV+ (70%) subjects. The development of apoptosis in target cells correlated with their mitochondrial transmembrane potential impairment and with increased expression of Fas (CD95) molecules. These results offer additional alternatives for the manipulation of cellular depletion in HIV disease.

Standardized, unrelated donor cord blood transplantation in adults with hematologic malignancies

The potential role of unrelated donor cord blood transplantation (UD-CBT) in adults remains unclear. This study reports the results of UD-CBT in 22 adults with hematologic malignancies following conditioning with thiotepa, busulfan, cyclophosphamide, and antithymocyte globulin in 21, with thiotepa, fludarabine, and antithymocyte globulin in 1, and graft-versus-host disease (GVHD) prophylaxis with cyclosporine and prednisone. Median age was 29 years (range, 18-46 years), and median weight was 69.5 kg (range, 41-85 kg). HLA match was 6 of 6 in 1 case, 5 of 6 in 13 cases, and 4 of 6 in 8 cases. Median number of nucleated cells infused was 1.71 x 10(7)/kg (range, 1.01 x 10(7)/kg to 4.96 x 10(7)/kg). All 20 patients surviving more than 30 days had myeloid engraftment, and only 1, who received the lowest cell dose, developed secondary graft failure. Median time to reach an absolute neutrophil count of at least 0.5 x 10(9)/L was 22 days (range, 13-52 days). Median time to platelets numbered at least 20 x 10(9)/L was 69 days (range, 49-153 days). Seven patients (32%) developed acute GVHD above grade II, and 9 of 10 patients at risk developed chronic GVHD, which became extensive in 4 patients. Twelve patients remained alive and disease-free 3 to 45 months after transplantation. Disease-free survival (DFS) at 1 year was 53%. Age strongly influenced DFS (P =.01). For patients aged 30 years or younger, the DFS at 1 year was 73%. These preliminary results suggest that UD-CBT should be considered a reasonable alternative in young adults with hematologic malignancy and no appropriate bone marrow donor.

Recent improvements in outcome for elderly patients with de novo acute myeloblastic leukemia

A retrospective analysis was performed on 263 consecutive patients aged over 60 with de novo acute myeloid leukemia (AML) diagnosed in a single institution between 1979 and 1998. Eighty-nine patients (33%) received only palliative treatment, while 174 patients (67%) were treated with different intensive chemotherapy regimens. The 5- and 10-year overall survival (OS) for the whole series was 7.7+/-1.2 and 4.3+/-1.6%, respectively. For patients receiving chemotherapy, OS was 10.5+/-2.5 and 7+/-2.6%, while for those patients receiving supportive treatment it was 1.1+/-1.1 and 0%, respectively (P=0.002). Within the group of patients receiving chemotherapy, the complete remission (CR) rate was 46%; treatment failure rate was 54% (36% due to treatment-related mortality and 18% due to resistant disease). Variables influencing CR rate were FAB subtype, CD7 positivity, chemotherapy regimen, creatinine level, hepatomegaly, and period of diagnosis. Median disease-free survival (DFS) duration was 8.4 months with a probability of being disease-free at 10 years of 10+/-5%. There were no significant differences in DFS according to age. According to the period of diagnosis (1979-1986 vs. 1987-1998), improvements in the CR rate (27 vs. 56%, P=0.0002), and OS (10.9 vs. 15.7 months, P=0.0007) were observed. This large single-center study of unselected de novo AML elderly patients substantiates the progressive improvement achieved in the management of elderly patients with AML, probably due to an improvement in supportive care and the administration of conventional induction chemotherapy.

Unrelated donor cord blood transplantation in adults with chronic myelogenous leukemia: results in nine patients from a single institution

The potential role of unrelated donor cord blood transplantation (UD-CBT) in adults is not well established. We report the results of UD-CBT in nine adult patients with chronic myeloid leukemia (CML). The median age was 27 years (range, 19-41 years), and the median weight was 62 kg (range, 45-78 kg). At transplant, six patients were in chronic phase (five in first, and one in second), two in blast crisis, and one in accelerated phase. Eight had received intensive chemotherapy, and three had undergone autologous peripheral blood hematopoietic stem cell transplantation. Four had received interferon with no cytogenetic response, and only three underwent UD-CBT within 1 year of diagnosis. After serological typing for class I antigens, and high-resolution DNA typing for DRB1, the degree of HLA match between patients and cord blood (CB) units was 4/6 in six cases and 5/6 in three cases. The median number of nucleated cells infused was 1.7 x 10(7)/kg (range, 1.2 to 4.9 x 10(7)/kg), and was above 2 x 10(7)/kg in only two cases. All patients received thiotepa, busulfan, cyclophosphamide and anti-thymocyte globulin as conditioning; cyclosporine and prednisone for graft-versus-host disease (GVHD) prophylaxis; and G-CSF from day +7 until engraftment. All seven evaluable cases engrafted. The median time to reach an absolute neutrophil count > or =0.5 x 10(9)/l and > or =1 x 10(9)/l was 22 days (range, 19-52 days) and 28 days (range, 23-64 days), respectively. In the four patients evaluable for platelet recovery time to levels of > or =20 x 10(9) platelets/l, > or =50 x 10(9) platelets/l, and > or =100 x 10(9) platelets/l, these ranged from 50 to 128 days, 60 to 139 days, and 105 to 167 days, respectively. Three patients developed acute GVHD above grade II, and three of the five patients at risk developed extensive chronic GVHD. Four patients, all transplanted in chronic phase, remain alive in molecular remission more than 18, 19, 24 and 42 months after transplantation. These preliminary results suggest that UD-CBT may be considered a reasonable alternative in adults with CML who lack an appropriate bone marrow donor.

Marked reduction in the incidence of hepatic veno-occlusive disease after allogeneic hematopoietic stem cell transplantation with CD34(+) positive selection

Veno-occlusive disease of the liver (VOD) is a common and severe complication of allogeneic hematopoietic stem cell transplantation (HSCT). To determine the incidence of, and the risk factors for the development of VOD, we performed a retrospective analysis of a series of 178 patients, who underwent allogeneic HSCT at our institution between 1990 and 1999. Busulfan and cyclophosphamide constituted the conditioning regimen most frequently administered. Bone marrow was the source of stem cells in 129 patients (73%), and peripheral blood (PBSC) in 49 patients (27%). Thirty-one patients of the PBSC group received CD34(+) positively selected grafts. Most patients were given cyclosporin A and methotrexate (MTX) as graft-versus-host disease (GVHD) prophylaxis. Overall, 30 patients (17%) developed VOD. In univariate analyses, the incidence of VOD was significantly higher in recipients of unmanipulated grafts (20% vs 0%; P = 0.01), in patients with active malignant disease at transplantation (24% vs 9%; P = 0.03), in recipients of marrow from unrelated donors (33% vs 15%; P = 0.03), in patients grafted with bone marrow (21% vs 6%; P = 0.03), and in those receiving MTX as GVHD prophylaxis (21% vs 6%; P = 0.05). Under multivariate analysis, only CD34(+) positive selection (P = 0.0004) and the status of the disease at transplant (P = 0.03) were statistically significant variables for the development of VOD. We conclude that CD34(+) positively selected PBSC transplantation could result in a marked reduction in the incidence of VOD after allogeneic HSCT.

Transplant-related mortality in patients older than 60 years undergoing autologous hematopoietic stem cell transplantation

Although high-dose therapy with autologous hematopoietic stem cell transplantation (ASCT) is a widely used method of dose intensification in patients with hematological malignancies, patients aged over 60 are generally excluded. We evaluated high-dose therapy and ASCT in 29 cases involving 27 such patients (median age 63 years; range 61-68) with different malignancies. Patients were eligible if they had a good performance status, normal cardiac, respiratory, and hepatic function and a serum creatinine concentration of less than 2 mg/dl (<5 mg/dl in myeloma patients). Engraftment was assessable in 27 procedures. The median time to attain 0.5 and 1 x 10(9) PMN/l was 13 days (range 9-30) and 14 days (range 10-66), respectively. The median time taken to reach a platelet count greater than 50 x 10(9)/l was 14 days (range 8-223). Five patients (17%) died in the first 100 days after transplant, in two cases due to disease progression. The remaining three patients died as a consequence of transplant-related complications, with an overall transplant-related mortality of 10%. Five patients relapsed and died between 5 and 36 months after transplant. The remaining 17 patients are still alive without disease progression, with an actuarial overall survival of 47% at 42 months (95% CI 33-61). We consider that high-dose therapy with ASCT should be considered in those elderly patients with good performance status and without general organ impairment.

Cutaneous promyelocytic sarcoma at sites of vascular access and marrow aspiration. A characteristic localization of chloromas in acute promyelocytic leukemia?

Extramedullary disease (EMD) is a rare clinical event in acute promyelocytic leukemia (APL). Although the skin is involved in half of the reported EMD cases, the occurrence of cutaneous promyelocytic sarcoma (PS) has been described very rarely. We report here three cases of PS which have the peculiarity of appearing at sites of punctures for arterial and venous blood and marrow samples (sternal manubrium, antecubital fossa, wrist over the radial artery pulse, catheter insertion scar). At presentation, all patients had hyperleukocytosis and a morphologic diagnosis of microgranular acute promyelocytic leukemia variant confirmed at the genetic level by demonstration of the specific chromosomal translocation t(15;17). A BCR3 type PML/RARa transcript was documented in the two patients for whom diagnostic RT-PCR was available. Patients had morphologic bone marrow remission at the time the PS appeared. A predilection for the development of cutaneous PS at sites of previous vascular damage has been noted, but the pathogenesis remains largely unknown. A potential role for all-trans retinoic acid has been advocated, although one of the three patients in our series had received no ATRA. A review of the literature revealed six similar cases and hyperleukocytosis at diagnosis was a consistent finding in all of them. A careful physical examination of these particular sites in the follow-up of patients at risk, as well as cutaneous biopsy and laboratory examination of suspected lesions are strongly recommended.

On probing molecular monolayers: a spectroscopic optical waveguide approach of ultra-sensitivity

A broadband, multichannel, single-mode, planar waveguide based spectrometer was developed for probing molecular monolayers. A protein sub-monolayer (thickness h @ 3 nm, imaginary part of refractive index kl oe 0.01) immobilized on the waveguide surface was characterized by the waveguide attenuated total reflection (ATR) spectrometer. A sensitivity enhancement of 4 orders of magnitude, compared to conventional transmission measurements, has been experimentally achieved in the characterization of ultra-thin films. In addition, polarized spectroscopic measurements at the TE and TM waveguide modes were implemented to determine the average orientation angle of the adsorbed molecules. The work developed here is a new research tool for the investigation of some fundamental aspects of molecular films and a novel platform to develop new technological devices of high sensitivity and selectivity such as biosensors.

Bacillary angiomatosis: microbiology, histopathology, clinical presentation, diagnosis and management

Bacillary angiomatosis is known to be caused by a rickettsial organism; Rochalimaea henselae. This causative agent has been compared with different microorganisms and clinical conditions that appear in similar settings but that have been clearly differentiated from them; e.i. Cat-scratch disease (Afipia felis), Bartonella bacilliformis, other Rochalimaea sp., Kaposi;s sarcoma, Lobular capillary hemangioma, Angiosarcoma, and Epithelioid hemangioma. Clinically the bacillary angiomatosis (BA) skin lesions vary from a single lesion to thousands. The cutaneous lesion appears as a bright-red round papule, subcutaneous nodule, or as a cellulitic plaque. When the lesion is biopsied it tends to blanch-out, bleed, and cause pain. The patient might present with signs and symptoms of chills, headaches, fever, malaise, and anorexia with or without weight loss. The extracutaneous lesions found in BA tend to be from multiple organs affecting from the oral lesions to anal mucosal lesions to widespread visceral lesions. The sites of preferences for BA lesion manifestation tend to be the liver, spleen, lymph nodes, and bone. To diagnose bacillary angiomatosis the physician should prepare a differential diagnosis based primarily on its histopathological and clinical characteristics. To confirm the results from the stain, electron microscopy can identify the bacillus and pin-point the diagnosis of bacillary angiomatosis. The lesions presented by BA respond well to therapy with erythromycin 500mg four times daily for a duration of 2 weeks to 2 months. In case of intolerance to erythromycin the second line of drug that successfully treats the BA bacillus is doxycycline. If relapses of the BA lesion recur, then a prolonged antibiotic therapy is necessary and in AIDS patients the duration may be extended as life-long suppressive therapy.

Bacillary angiomatosis: microbiology, histopathology, clinical presentation, diagnosis and management

Bacillary angiomatosis is known to be caused by a rickettsial organism; Rochalimaea henselae. This causative agent has been compared with different microorganisms and clinical conditions that appear in similar settings buy have been clearly differentiated from them; e.i. Cat-scratch disease (Afipia felis), Bartonella bacilliformis, other Rochalimaea sp., Kaposi's sarcoma, Lobular capillary hemangioma, Angiosarcoma, and Epithelioid hemangioma. Clinically the bacillary angiomatosis (BA) skin lesions vary from a single lesion to thousands. The cutaneous lesion appears as a bright-red round papule, subcutaneous nodule, or as a cellulitic plaque. When the lesion is biopsied it tends to blanch-out, bleed, and cause pain. The patient might present with signs and symptoms of chills, headaches, fever, malaise, and anorexia with or without weight loss. The extracutaneous lesions found in BA tend to be from multiple organs affecting from the oral lesions to anal mucosal lesions to widespread visceral lesions. The sites of preference for BA lesion manifestation tend to be the liver, spleen, lymph nodes, and bone. To diagnose bacillary angiomatosis the physician should prepare a differential diagnosis based primarily on its histopathological and clinical characteristics. To confirm the results from the stain, electron microscopy can identify the bacillus and pin-point the diagnosis of bacillary angiomatosis. The lesions presented by BA respond well to therapy with erythromycin 500 mg four times daily for a duration of 2 weeks to 2 months. In case of intolerance to erythromycin the second line of drug that successfully treats the BA bacillus is doxycyline. If relapses of the BA lesion recur, then a prolonged antibiotic therapy is necessary and in AIDS patients the duration may be extended as life-long suppressive therapy.

Comparison of empiric aztreonam and aminoglycoside regimens in the treatment of serious gram-negative lower respiratory infections

An open-label, controlled, randomized study was performed to assess the efficacy and safety of combination regimens using either aztreonam or an aminoglycoside control regimen as empiric therapy for suspected aerobic gram-negative bacillary pneumonia or purulent bronchitis. Eighty-four patients, 42 in each arm of the study, were randomly assigned to one of two treatment regimens. The combination aztreonam regimen included aztreonam, 2 gm every 8 hours (q8h), plus either clindamycin, 600 to 900 mg q8h, or nafcillin, 1.5 gm to 2 gm every 6 hours (q6h). The control regimen was one of the following depending on the combination therapy that was designated standard at each of the three study institutions: amikacin, 5 mg/kg q8h, plus cefazolin, 1 gm q8h; amikacin, 500 mg every 12 hours plus mezlocillin, 4 gm q6h; or kinetically dosed tobramycin plus ticarcillin, 3 gm to 4 gm q4h. The two groups were well matched in terms of demographics and clinical characteristics. Among the 84 patients, organisms from the Enterobacteriaceae family accounted for the largest proportion of isolates (44%) including Escherichia coli (13%), Klebsiella species (14%), and Serratia species (9%). Other commonly identified organisms were Pseudomonas aeruginosa (19%), Haemophilus influenzae (15%), Streptococcus pneumoniae (12%), and Staphylococcus aureus (8%). Results of this trial included clinical response rates of 83% in both groups (P = 0.951) and a microbiologic cure rate of 75% in the aztreonam group and 63% in the control group (P = 0.291). In the 59 patients with documented aerobic gram-negative pneumonia, microbiologic eradication rates were 72% in the aztreonam group versus 57% in the control group (P = 0.359). Duration of treatment tended to be shorter in the aztreonam group than in the control group, with a median 10 days of therapy versus 12 days of therapy (P = 0.095), respectively. In addition, the percentage of patients requiring nonstudy antimicrobial agents tended to be lower in the aztreonam group than the control group, involving 21% of patients in the aztreonam group compared with 36% of patients in the control group (P = 0.086). All regimens were well tolerated, and no patient was withdrawn because of adverse reactions to the study medications. Two patients, both in the control group, required dose reduction, which was necessitated by possible aminoglycoside-induced nephrotoxicity. This trial shows that aztreonam is an effective agent with an excellent safety profile when used in combination regimens for the empiric treatment of pneumonia. A well-controlled trial is needed to verify the trend toward shorter hospital stays and a reduced need for additional antimicrobial agents seen with the aztreonam regimen when compared with those receiving aminoglycoside-combination regimens.

A comparative analysis of aztreonam + clindamycin versus tobramycin + clindamycin or amikacin + mezlocillin in the treatment of gram-negative lower respiratory tract infections

One hundred ten patients were randomized to receive one of the following antibiotic combinations: aztreonam + clindamycin, tobramycin + clindamycin, or amikacin + mezlocillin for the treatment of lower respiratory tract infections (LRTI) caused by gram-negative bacilli. Of the 68 patients who received aztreonam + clindamycin, 60 were clinically evaluable and 50 were bacteriologically evaluable. Of the 60 clinically evaluable patients, 54 were cured and 5 were treatment failures or died during the study period. Of the 50 bacteriologically evaluable patients, 46 were cured and 3 failed to respond to therapy. Of the 26 clinically evaluable patients in the tobramycin + clindamycin group, 22 were cured and 4 either failed to respond or died during the study period. Of 18 bacteriologically evaluable patients in this group, 16 were cured and 2 failed to respond. In the amikacin + mezlocillin group, 14 of the 15 clinically and bacteriologically evaluable patients were cured, and 1 failed to respond. The most commonly isolated pathogens were Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa. The very few adverse drug reactions that were seen were transient and comparable in all three groups except for renal function parameters, which deteriorated in 6-8% of patients receiving the aminoglycoside combination. All three antibiotic combinations were similar in effectiveness and safety.

Treatment of urinary tract infection with norfloxacin. Analysis of cost

Twenty-five patients with urinary tract infection were treated with norfloxacin, a fluoroquinolone antibacterial with a wide spectrum of activity for an oral agent. Of 22 patients who were evaluable, 20 had complicated urinary tract infection; infection was cured in 19 patients at one week after treatment. Optimal alternative treatments were also selected in norfloxacin's stead, based on each patient's characteristics and the results of susceptibility testing for each isolated pathogen. Direct costs for alternative treatment ranged from $7 to $970. The results indicated that for those patients with suspected or proven urinary tract infection caused by multiresistant bacteria, therapy with norfloxacin may represent a cost-effective choice.

Comparative, double-blind study of oral ciprofloxacin and intravenous cefotaxime in skin and skin structure infections

The effectiveness and safety of orally administered ciprofloxacin and intravenously administered cefotaxime were compared in a double-blind study of 60 men with infections of skin and soft tissue, including cellulitis, ulcers, abscesses, cellulitis with ulcers or abscesses, wound infections, and post-traumatic infections. Patients in the ciprofloxacin group received 750 mg orally every 12 hours for a mean duration of 9.6 days (six to 18 days), and those in the cefotaxime group received 2.0 g intravenously every eight hours for a mean duration of 9.3 days (five to 14 days). Infection was documented bacteriologically in 78 percent of the patients in the ciprofloxacin group and in 83 percent of the patients in the cefotaxime group. Pathogens included Staphylococcus aureus, enterococci, group B streptococci, Escherichia coli, Proteus mirabilis, and Klebsiella and Pseudomonas species. Half of the infections were mixed infections. Ninety percent (19 of 21) of the infections were bacteriologically eradicated with ciprofloxacin, and 82 percent (18 of 22) were eradicated with cefotaxime. Treatment was completely successful in 79 percent (22 of 28) of the patients in the ciprofloxacin group and in 68 percent (19 of 28) in the cefotaxime group (p greater than 0.1). The side effects in both treatment groups were comparable. This study demonstrates that orally administered ciprofloxacin is comparable in effectiveness and safety to cefotaxime administered intravenously in the treatment of infections of skin and soft tissue, and that it can offer an alternative in the treatment of such infections.

Susceptibility of aerobic gram-negative bacilli to aminoglycosides. Effects of 45 months of amikacin as first-line aminoglycoside therapy

Amikacin was instituted as the primary empiric aminoglycoside at the San Juan Veterans Administration Medical Center in January 1982; at that time, 16 percent of the strains at the hospital were gentamicin-resistant. A prospective surveillance study was designed to correlate detection of bacterial resistance with aminoglycoside use. In the current report, the baseline period, during which gentamicin was the first-line aminoglycoside, accounting for 61 percent of overall aminoglycoside use, is compared with the period from January 1982 to September 1985, during which the first-line aminoglycoside was amikacin, accounting for 85 percent of overall use. This study is ongoing. During the two periods, the patient population did not differ with regard to aminoglycoside therapy, indications, or overall aminoglycoside use (541 versus 680 patient days per month). Among the gram-negative bacilli isolated, the percent of strains resistant to amikacin was as follows: pre-baseline period/baseline period, 0.8/0.2 percent; amikacin-usage period, 3.6 percent. Resistance to gentamicin and tobramycin during the period of amikacin use decreased from 16 to 11 percent for gentamicin and from 17 to 11 percent for tobramycin. The decrease in resistance of the gram-negative bacilli to gentamicin varied among strains: the resistance of Escherichia coli decreased from 8 to 4 percent; that of Proteus mirabilis, from 12 to 5 percent; that of indole-positive Proteus, from 19 to 12 percent; that of Acinetobacter, from 57 to 23 percent; that of Citrobacter, from 15 to 7 percent; and that of Pseudomonas aeruginosa, from 24 to 16 percent. During the amikacin-usage period, amikacin resistance was unchanged for most strains, with the exception of P. aeruginosa, the resistance of which increased from 4.5 to 7.8 percent. Of the 4,795 strains isolated, 174 were resistant to amikacin; of these, 29 Pseudomonas strains were studied for all mechanisms of resistance. Changes in permeability were exhibited by 11 of the 29 strains; 14 strains exhibited the AAC(6')-I enzyme, 10 strains exhibited the APH(3')-II enzyme, and two strains exhibited ANT(2") in addition to some other unidentified mechanism. Multiple enzyme production was found in 15 of the strains. The use of amikacin as a first-line aminoglycoside is associated with a decrease in resistance to other aminoglycosides and a slight increase in overall resistance to amikacin among aerobic gram-negative bacilli. The usefulness of amikacin has not been affected at our institution.