Regenerative medicine strategies for chronic complete spinal cord injury

Spinal cord injury is a condition in which the parenchyma of the spinal cord is damaged by trauma or various diseases. While rapid progress has been made in regenerative medicine for spinal cord injury that was previously untreatable, most research in this field has focused on the early phase of incomplete injury. However, the majority of patients have chronic severe injuries; therefore, treatments for these situations are of fundamental importance. The reason why the treatment of complete spinal cord injury has not been studied is that, unlike in the early stage of incomplete spinal cord injury, there are various inhibitors of neural regeneration. Thus, we assumed that it is difficult to address all conditions with a single treatment in chronic complete spinal cord injury and that a combination of several treatments is essential to target severe pathologies. First, we established a combination therapy of cell transplantation and drug-releasing scaffolds, which contributes to functional recovery after chronic complete transection spinal cord injury, but we found that functional recovery was limited and still needs further investigation. Here, for the further development of the treatment of chronic complete spinal cord injury, we review the necessary approaches to the different pathologies based on our findings and the many studies that have been accumulated to date and discuss, with reference to the literature, which combination of treatments is most effective in achieving functional recovery.

Stem cell allografting for chronic Myeloid leukemia in the tyrosine kinase era - forgotten but not gone

Due to the remarkable success of tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML), allogeneic stem cell transplantation (alloSCT) is not first-line treatment for delivering durable, long-term survival. Consequently, alloSCT is reserved for patients with TKI-resistant or TKI-intolerant chronic phase CML (CP-CML) and advanced phase CML (AP-CML). Advances in transplant technology, such as high-resolution HLA typing, introduction of reduced intensity conditioning and increased alternative donor availability, coupled with improved supportive care, have significantly reduced transplant-related mortality and expanded the pool of transplant-eligible patients. Refinement of conditioning regimens, innovative use of post-transplant cellular and pharmacological therapies, and judicious post-transplant monitoring are important strategies for reducing risk of relapse. Given its potential to cure, alloSCT will invariably remain a key part of the treatment algorithm. This article reviews the data underpinning the role and outcomes of alloSCT and provides an update on current recommendations.

Aleukemic Chronic Myeloid Leukemia Without Neutrophilia and Thrombocytosis: A Report From the BCR::ABL1 Pathology Group

Chronic myeloid leukemia (CML) is characterized by leukocytosis with left-shifted neutrophilia, basophilia, eosinophilia, and variable thrombocytosis. However, extremely rare cases of patients with CML without significant leukocytosis and thrombocytosis (aleukemic phase [ALP] CML, or CML-ALP) have been reported. Due to its rarity and limited awareness, there remains a significant knowledge gap concerning the pathologic diagnosis, disease progression, and optimal patient management and outcomes. In this multi-institutional study, we investigated 31 patients with CML-ALP. Over half (54.8%) of patients had a history of or concurrent hematopoietic or nonhematopoietic malignancies. At time of diagnosis of CML-ALP, approximately 26.7% of patients exhibited neutrophilia, 56.7% had basophilia, and 13.3% showed eosinophilia. The median number of metaphases positive for t(9;22)(q34;q11.2) was 15, with a median of 38.5% of interphase nuclei positive for BCR::ABL1 by fluorescence in situ hybridization. The median BCR::ABL1 level was 26.14%. Remarkably, 14 (45.2%) patients were initially misdiagnosed or not diagnosed before karyotype or fluorescence in situ hybridization information for BCR::ABL1 became available. Twenty-five patients received tyrosine kinase inhibitors (TKIs). One patient developed blast crisis while on TKI treatment 8 months after initial diagnosis. With a median follow-up time of 46.1 months, 20 of 22 patients who received TKI therapy and had detailed follow-up information achieved complete cytogenetic remission or deeper, 15 achieved major molecular remission or deeper, and 10 achieved molecularly undetectable leukemia. In conclusion, given the frequent occurrence of prior or concurrent malignancies, aleukemic presentation, and low level of t(9;22)(q34;q11.2)/BCR::ABL1, misdiagnosis or delayed diagnosis is common among these patients. While these patients generally respond well to TKIs, rare patients may develop blastic transformation. It is therefore important for pathologists and hematologists to be aware of this highly unusual presentation of CML to ensure timely diagnosis and appropriate management.

[Headache attributed to ischaemic stroke. An update on its semiology and diagnosis]

INTRODUCTION

Headache is a common symptom in acute ischemic stroke which is often overlooked and undertreated because of focus in neurologic function, communication difficulties in stroke patients and the current diagnostic criteria of this type of headache. The present study aimed to determine the prevalence of Acute and Persistent Headache Attributed to Ischemic Stroke and to analyze the fulfillment of the criteria of the International Classification of Headaches (ICHD-IID).

PATIENTS AND METHODS

Prospective observational analytical cohort study. The study population consisted of patients with acute ischemic stroke admitted to the Stroke Unit of a tertiary care hospital over a period of 12 months.

RESULTS

Two hundred and forty-four patients with acute ischemic stroke (59.8% males, mean age 71+12.8 years) were included. Headache at onset or at the first 72 hours was present in 23.2% and 12.5% of them presented persistent headache attributed to ischemic stroke. Only 62.5% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-III.

CONCLUSION

Headache after ischemic stroke is a common symptom. It was associated with female sex, posterior circulation stroke and low scores on the National Institutes of Health Stroke Scale (NIHSS). The current diagnostic criteria should be reviewed.

Plantar Plate Repair using Suture Anchors for Chronic Plantar Plate Rupture of the first Interphalangeal Joint in a Pediatric Patient: A Case Report

Introduction

Injuries of the great toe are common sports-related injuries; however, isolated traumatic plantar plate tears at the interphalangeal (IP) joint are relatively rare. Here, we present a pediatric case of a chronic plantar plate tear of the IP joint of the great toe that was difficult to diagnose definitively, which delayed surgical treatment.

Case Report

An 11-year-old girl was injured when she collided with her right great toe while using a jump box during gymnastics. She felt pain in her great toe that progressively worsened despite conservative treatment at an initial clinic, and she experienced hyperextension of the IP joint. She was referred to our outpatient clinic because of diagnostic difficulty and increased symptoms, such as pain and swelling of the plantar side of her right great toe. Physical examination revealed swelling and tenderness on the plantar aspect of the IP joint and the impossibility of active flexion of the IP joint. The passive range of motion was 35° during extension. Ultrasonography revealed a low-echoic area on the plantar plate on the phalangeal side. Thus, we diagnosed the patient with a chronic plantar plate tear of the IP joint of the right great toe and performed surgical treatment 8 months after its onset. The plantar plate ruptured at the insertion of the proximal phalanx; however, the insertion of the distal phalanx remained intact. The plantar plate was repaired using suture anchors, and excellent short-term postoperative results were obtained at the 1-year follow-up.

Conclusion

Isolated plantar plate rupture is difficult to diagnose definitively in the acute phase because of the lack of specific findings on physical and radiographic examinations. Plantar plate rupture should be suspected as a differential diagnosis in patients with great toe injuries due to axial load and hyperextension forces. Plantar plate repair using suture anchors may be a useful option for treating plantar plate tears of the IP joint of the great toe when its insertion into the distal phalanx is preserved, even during the chronic phase.

Participation in the Chronic Phase after Traumatic Brain Injury: Variations and Key Predictors

Participation is of major importance for individuals with traumatic brain injury (TBI). This study evaluates participation over a period of one year among persons with TBI in the chronic phase and explores sociodemographic, psychological, and environmental predictors of levels and trajectories of participation. One hundred and twenty home-living survivors of TBI with persistent injury-related consequences at least two years post-injury who participated in a goal-oriented randomized trial were assessed at baseline and after four and twelve months. Linear mixed-effects model analysis was applied to evaluate height, trajectory slope, and predictors of the Participation Assessment with the Recombined Tools-Objective (PART-O) total score and the subscales Productivity, Social Relations, and Being Out and About. Being married, having a higher education, and having good global functioning predicted more frequent participation. Education, executive- and global functions predicted Productivity, while age and being married predicted Social Relations. Participating in the study during the COVID-19 pandemic had a negative impact on Productivity. Participation was relatively stable over 12 months, with a slight decline, but may be influenced by demographic factors and functional consequences. Rehabilitation services should particularly focus on people with TBI living alone with lower levels of global and executive function.

Incidence and Risk Factors for Pneumonia in the Chronic Phase of Cervical Spinal Cord Injury with Complete Motor Paralysis

Introduction

Pneumonia is one of the leading causes of acute- and chronic-phase mortality in patients with cervical spinal cord injury (CSCI) with quadriplegia. The risk factors for chronic-phase pneumonia recurrence in CSCI are still unknown. This study aimed to investigate the incidence of pneumonia in the chronic phase after injury and to identify its risk factors.

Methods

This retrospective clinical observational study included patients with CSCI with American Spinal Injury Association Impairment Scale grades of A or B admitted to our center within 72 h of CSCI injury who started treatment and were available for follow-up for at least 90 days. The patients were assessed for incidences of pneumonia and its associations with clinical characteristics, including risk factors at the time of injury. Patients in whom pneumonia developed within 30 days postadmission and those after 30 days of hospitalization were comparatively examined using univariate and multivariate analyses.

Results

Pneumonia occurred in 36% of the 69 enrolled patients throughout the study period and in 20% of all patients after 30 days of hospitalization. Multivariate analysis of risk factors for pneumonia showed that atelectasis (adjusted OR [aOR], 95% confidence interval [CI]: 4.9, 1.2-20.0), enteral feeding (aOR [95% CI]: 13.3 [3.0-58.9]), mechanical ventilation (aOR [95% CI]: 4.0 [1.0-15.0]), and tracheotomy (aOR [95% CI]: 14.6 [2.3-94.6]) within 30 days of admission were significantly associated with the occurrence of pneumonia even after 30 days of hospitalization.

Conclusions

The risk factors for developing pneumonia in the chronic phase were atelectasis, enteral feeding, mechanical ventilation, and tracheotomy within 30 days of hospitalization. This study suggests that treatment of atelectasis, long-term respiratory muscle rehabilitation, and training to improve swallowing function are essential to prevent the recurrence of pneumonia after 30 days of hospitalization.

Bleeding Diathesis as the Initial Presentation of Chronic Myeloid Leukemia: A Case Series

Chronic myelogenous leukemia, or CML, is another name for chronic myeloid leukemia (CML), a cancer type that starts in certain bone marrow blood-forming cells. The primary initiator of granulocytic proliferation in CML, a myeloproliferative malignancy, is the BCR-ABL1 fusion protein or Philadelphia chromosome. CML is classified into three stages: chronic, accelerated, and blast. It has been widely recognized that the likelihood of developing CML varies by gender, geography, and age. In the chronic phase of CML (CML-CP), bleeding is a rare sign since the thrombocyte and coagulation functions are still adequate. Uncertainties exist regarding the CML bleeding mechanism. We report four cases of CML-CP in adult patients. The majority of these patients had CML and had idiopathic spontaneous bleeding in multiple locations.

Stem Cell Factor and Granulocyte Colony-Stimulating Factor Promote Remyelination in the Chronic Phase of Severe Traumatic Brain Injury

Severe traumatic brain injury (TBI) causes long-term disability and death in young adults. White matter is vulnerable to TBI damage. Demyelination is a major pathological change of white matter injury after TBI. Demyelination, which is characterized by myelin sheath disruption and oligodendrocyte cell death, leads to long-term neurological function deficits. Stem cell factor (SCF) and granulocyte colony-stimulating factor (G-CSF) treatments have shown neuroprotective and neurorestorative effects in the subacute and chronic phases of experimental TBI. Our previous study has revealed that combined SCF and G-CSF treatment (SCF + G-CSF) enhances myelin repair in the chronic phase of TBI. However, the long-term effect and mechanism of SCF + G-CSF-enhanced myelin repair remain unclear. In this study, we uncovered persistent and progressive myelin loss in the chronic phase of severe TBI. SCF + G-CSF treatment in the chronic phase of severe TBI enhanced remyelination in the ipsilateral external capsule and striatum. The SCF + G-CSF-enhanced myelin repair is positively correlated with the proliferation of oligodendrocyte progenitor cells in the subventricular zone. These findings reveal the therapeutic potential of SCF + G-CSF in myelin repair in the chronic phase of severe TBI and shed light on the mechanism underlying SCF + G-CSF-enhanced remyelination in chronic TBI.

Asciminib (Scemblix): A third-line treatment option for chronic myeloid leukemia in chronic phase with or without T315I mutation

PURPOSE

To review the pharmacology, efficacy, safety, dosing and administration, and place in therapy of asciminib, an oral tyrosine kinase inhibitor (TKI) used as a third-line treatment option for Philadelphia chromosome-positive chronic myeloid leukemia (CML) in chronic phase.

SUMMARY

CML is a rare cancer caused by a chromosomal translocation that forms a fusion of the BCR and ABL1 genes on chromosomes 22 and 9. Until recently, patients for whom first-line treatment options failed were treated with TKIs that bind to the adenosine triphosphate-binding site on BCR-ABL1. However, because of similar mechanisms of action, there continues to be an unmet need in patients for whom at least 2 TKIs have failed or those with a T315I mutation unable to tolerate ponatinib. In October 2021, the Food and Drug Administration approved asciminib (Scemblix), the first TKI specifically targeting the ABL1 myristoyl pocket (STAMP) via allosteric binding, as a third-line option for patients with chronic-phase (CP)-CML. Asciminib received accelerated approval due to meeting its primary endpoint at week 24, demonstrating a major molecular response rate of 25.5% for patients on asciminib compared to 13.2% for those receiving bosutinib. In addition, patients on asciminib achieved a higher rate of complete cytogenetic response at 40.8% compared to a rate of 24.2% for bosutinib. Clinicians prescribing asciminib should monitor for increased levels of pancreatic enzymes, hypertension, cardiovascular toxicity including ischemic and thromboembolic conditions, and decreased numbers of neutrophils and platelets, as these may require treatment interruption, dose reduction, or treatment discontinuation.

CONCLUSION

Asciminib is a unique targeted TKI that provides clinicians with an additional third-line and beyond treatment option for adults with CP-CML regardless of mutation status as well as a second TKI treatment option for patients harboring a T315I mutation.

Comparable Outcomes of Pre- Versus Post-Tyrosine Kinase Inhibitor Era Treatment in Chronic Myeloid Leukemia: A Retrospective Cohort Study With Long-term Follow-up

Imatinib, a selective BCR-ABL tyrosine kinase inhibitor (TKI), was introduced after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with chronic myeloid leukemia (CML). However, the long-term effects of allo-HSCT in chronic phase CML patients are mostly unknown. We retrospectively analyzed the outcomes of 204 patients with sibling donors who received peripheral stem cells and underwent allo-HSCT of chronic phase I (CP1) in the pre- and post-TKI era at Shariati Hospital in Tehran, Iran, from 1998 to 2017 and followed up till the end of 2021. The median follow-up time for all patients was 8.7 (SD = 0.54) years. Fifteen-year overall survival (OS), disease-free survival (DFS), graft-versus-host disease-free relapse-free survival (GRFS), relapse, and non-relapse mortality (NRM) incidence were 65.70%, 57.83%, 17.56%, 13.17%, and 28.98%, respectively. Using multivariable analyses, the only risk factor increasing the hazard of death was the time between diagnosis to allo-HSCT greater than 1 year compared to this time less than 1 year by 74% [hazard ratio (HR) = 1.74, P = 0.039]. Also, age is a significant risk factor for DFS (HR = 1.03, P = 0.031). Our findings suggested that allo-HSCT is still an important treatment option for CP1 patients, especially those resistant to TKI treatment. TKI consumption can have a desirable effect on NRM after allo-HSCT for CP1 CML.

Asciminib monotherapy for newly diagnosed chronic myeloid leukemia in chronic phase: the ASC4FIRST phase III trial

Asciminib is the first BCR::ABL1 inhibitor that works by Specifically Targeting the ABL Myristoyl Pocket (STAMP). Asciminib has shown favorable efficacy and safety in patients with chronic myeloid leukemia in chronic phase without the T315I mutation who have received ≥2 prior tyrosine kinase inhibitors (TKIs) in phase I and III clinical trials and in patients with the T315I mutation who have received ≥1 prior TKI in phase I. ASC4FIRST (NCT04971226) is a phase III, multicenter, open-label, randomized study of asciminib versus investigator-selected TKI in patients with newly diagnosed chronic myeloid leukemia in chronic phase. The primary end point is major molecular response at week 48. Secondary end points include responses at and by scheduled time points, safety, pharmacokinetics and patient-reported outcomes. Clinical Trial Registration: NCT04971226 (ClinicalTrials.gov).

Chronic Myeloid Leukemia: Chronic Phase Presenting as Extramedullary Presentation

Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by immature granulocytes in the peripheral blood and bone marrow. In 95% of cases, it is always associated with the presence of the Philadelphia chromosome, which is characterized by the presence of reciprocal translocation between chromosomes 9 and 22. However, 3.1-9.1% of patients also have an extramedullary proliferation of skin, lymph nodes, bone, or central nervous system (CNS), which could be either myeloid, lymphocytic, or mixed lineage in origin. An extramedullary myelogenous neoplasm termed myeloid sarcoma (MS) can originate from myeloblasts or immature myeloid cells. Due to the green, gross appearance caused by the myeloperoxidase enzyme in immature myeloid cells, it is also known as chloroma. According to WHO guidelines, it is a tumor composed of myeloid blasts, mature or immature. Here we report an old female patient with CML - chronic phase who came for imatinib therapy and presented as MS in the right parotid gland.

Indicators Predicting Inpatient Mortality in Post-Stroke Patients Admitted to a Chronic Care Hospital: A Retrospective Pilot Study

Evidence concerning the mortality of post-stroke patients admitted to a chronic-phase hospital seems to be lacking. This pilot study aimed to identify mortality-related clinical variables in the admission of post-stroke patients from a retrospective perspective. A group of 38 non-survival stroke patients and another group of 46 survival stroke patients in a chronic-phase ward of the single center were recruited. Clinical variables including age, sex, stroke type, and Barthel index (BI) score were collected. The difference in the age and BI scores on admission were statistically significant between the two groups (p < 0.01). Polytomous logistic regression analysis revealed that age (odds ratio = 1.09, p = 0.03, and 95% confidence interval: 1.01−1.07), male sex (odds ratio = 5.04, p = 0.01, and 95% confidence interval: 1.39−18.27), and BI scores on admission (odds ratio = 0.90, p = 0.01, and 95% confidence interval: 0.83−0.97) could be prognostic variables. The percentage of correct classification was 83.3%. Age, male sex, and BI scores on admission may be prognostic indicators. The result of this study could lay the groundwork for palliative care for such a clinical population.

Two-Month Individually Supervised Exercise Therapy Improves Walking Speed, Step Length, and Temporal Gait Symmetry in Chronic Stroke Patients: A before-after Trial

Gait asymmetry is common after stroke and is a major risk factor for falls. In particular, temporal gait asymmetry often remains in the chronic stage of stroke. However, health insurance does not cover rehabilitation for patients with chronic stroke in many countries. Accordingly, it is undetermined whether individually supervised exercise therapy has beneficial effects on chronic hemiparetic gait. Patients with stroke (n = 25) more than 6 months after onset performed 70 min of individually supervised exercise twice weekly for 2 months in 16 sessions with qualified personnel. The intervention significantly reduced the pre-swing phase on the paretic side (mean = 91.8%, 95%CI, 84.8−98.8). In addition, there was a significant improvement in pre-swing phase symmetry in those with great asymmetry prior to the intervention (p = 0.022). Step length significantly increased after the intervention on both sides (non-paretic, p = 0.029; paretic, p = 0.0055). Walking time at both comfortable and maximum speeds was significantly shortened (comfortable, p = 0.0041; maximum, p < 0.0001). Our findings suggest that there remains scope to improve gait ability with individually supervised exercise therapy in patients with chronic stroke, whose functional recovery is often considered unlikely. This type of intervention may be a simple and effective option to improve gait parameters, including temporal asymmetry, even in patients with chronic stroke.

TNF-TNFR1 Signaling Enhances the Protection Against Neospora caninum Infection

Neospora caninum is a protozoan associated with abortions in ruminants and neuromuscular disease in dogs. Classically, the immune response against apicomplexan parasites is characterized by the production of proinflammatory cytokines, such as IL-12, IFN-γ and TNF. TNF is mainly produced during the acute phases of the infections and binds to TNF receptor 1 (CD120a, p55, TNFR1) activating a variety of cells, hence playing an important role in the induction of the inflammatory process against diverse pathogens. Thus, in this study, we aimed to evaluate the role of TNF in cellular and humoral immune responses during N. caninum infection. For this purpose, we used a mouse model of infection based on wildtype (WT) and genetically deficient C57BL/6 mice in TNFR1 (Tnfr1 ^-/-). We observed that Tnfr1 ^-/- mice presented higher mortality associated with inflammatory lesions and increased parasite burden in the brain after the infection with N. caninum tachyzoites. Moreover, Tnfr1 ^-/- mice showed a reduction in nitric oxide (NO) levels in vivo. We also observed that Tnfr1 ^-/- mice showed enhanced serum concentration of antigen-specific IgG2 subclass, while IgG1 production was significantly reduced compared to WT mice, suggesting that TNFR1 is required for regular IgG subclass production and antigen recognition. Based on our results, we conclude that the TNF-TNFR1 complex is crucial for mediating host resistance during the infection by N. caninum.

Transitional and Long-Term Care System in Japan and Current Challenges for Stroke Patient Rehabilitation

In Japan, the national medical insurance system and long-term care insurance (LTCI) system cover rehabilitation therapy for patients with acute, convalescent, and chronic stroke. Medical insurance covers early and multidisciplinary rehabilitation therapy during acute phase hospitalizations. Patients requiring assistance in their activities of daily living (ADL) after hospitalization are transferred to kaifukuki (convalescent) rehabilitation wards (KRW), which the medical insurance system has also covered. In these wards, patients can receive intensive and multidisciplinary rehabilitation therapy to improve their ADL and transition to a smooth home discharge. After discharge from these hospitals, elderly patients with stroke can receive outpatient (day-care) rehabilitation and home-based rehabilitation using the LTCI system. The Japanese government has proposed building a community-based integrated care system by 2025 to provide comprehensive medical services, long-term care, preventive care, housing, and livelihood support for patients. This policy aims to promote smooth coordination between medical insurance services and LTCI providers. Accordingly, the medical insurance system allows hospitals to receive additional fees by providing patient information to rehabilitation service providers in the LTCI system. A comprehensive database on acute, convalescent, and chronic phase stroke patients and seamless cooperation between the medical care system and LTCI system is expected to be established in the future. There are only 2,613 board-certified physiatrists in Japan, and many medical schools lack a department for rehabilitation medicine; establishing such a department at each school is encouraged to teach students efficient medical care procedures, to conduct research, and to facilitate the training of personnel in comprehensive stroke rehabilitation.

Comparative Gene Expression Analysis Reveals Similarities and Differences of Chronic Myeloid Leukemia Phases

Chronic myeloid leukemia (CML) is a slowly progressing blood cancer that primarily affects elderly people. Without successful treatment, CML progressively develops from the chronic phase through the accelerated phase to the blast crisis, and ultimately to death. Nowadays, the availability of targeted tyrosine kinase inhibitor (TKI) therapies has led to long-term disease control for the vast majority of patients. Nevertheless, there are still patients that do not respond well enough to TKI therapies and available targeted therapies are also less efficient for patients in accelerated phase or blast crises. Thus, a more detailed characterization of molecular alterations that distinguish the different CML phases is still very important. We performed an in-depth bioinformatics analysis of publicly available gene expression profiles of the three CML phases. Pairwise comparisons revealed many differentially expressed genes that formed a characteristic gene expression signature, which clearly distinguished the three CML phases. Signaling pathway expression patterns were very similar between the three phases but differed strongly in the number of affected genes, which increased with the phase. Still, significant alterations of MAPK, VEGF, PI3K-Akt, adherens junction and cytokine receptor interaction signaling distinguished specific phases. Our study also suggests that one can consider the phase-wise CML development as a three rather than a two-step process. This is in accordance with the phase-specific expression behavior of 24 potential major regulators that we predicted by a network-based approach. Several of these genes are known to be involved in the accumulation of additional mutations, alterations of immune responses, deregulation of signaling pathways or may have an impact on treatment response and survival. Importantly, some of these genes have already been reported in relation to CML (e.g., AURKB, AZU1, HLA-B, HLA-DMB, PF4) and others have been found to play important roles in different leukemias (e.g., CDCA3, RPL18A, PRG3, TLX3). In addition, increased expression of BCL2 in the accelerated and blast phase indicates that venetoclax could be a potential treatment option. Moreover, a characteristic signaling pathway signature with increased expression of cytokine and ECM receptor interaction pathway genes distinguished imatinib-resistant patients from each individual CML phase. Overall, our comparative analysis contributes to an in-depth molecular characterization of similarities and differences of the CML phases and provides hints for the identification of patients that may not profit from an imatinib therapy, which could support the development of additional treatment strategies.

Pre-stroke Disability and Long-Term Functional Limitations in Stroke Survivors: Findings From More of 12 Years of Follow-Up Across Three International Surveys of Aging

Background

Almost 50% of the post-stroke disabled population already have a premorbid disability before stroke. These patients may be offered a different care pathway in the acute and subacute phase than those without pre-morbid disability. Therefore, the aim of this study was to assess the association of the severity of premorbid disability with change of limitations in basic and instrumental activities of daily living (ADL/IADL) 1 year after stroke and over the following decade.

Methods

Among 3,432 participants from HRS, SHARE and ELSA cohorts with a first stroke, ADL/IADL limitations were measured at 1-2 years prior to stroke, at 1 year post-stroke, and during the chronic phase. Modified Ranking Scale (P-mRS) was used to categorize the participants by level of premorbid disability (1-2 years pre-stroke). Change in ADL/IADL limitations by P-mRS level (0-1, 2-3, and 4-5) was assessed using a piecewise linear mixed model with a breakpoint set at 1 year post-stroke, stratified by median age groups.

Results

Increase in ADL limitations at 1 year post-stroke was less pronounced in P-mRS ≥2 (p < 0.005). After years of relative stability, limitations of ADL increased for all P-mRS levels (p = 0.003). In those aged ≥75 years at stroke event, the increase was similar irrespective of P-mRS (p = 0.090). There were no significant differences in IADL trajectories between P-mRS levels (p ≥ 0.127).

Conclusion

These results suggest similar trajectories of functional limitations between P-mRS levels up to 9 years post-stroke, highlighting the possible benefit of including patients with pre-morbid disability to certain treatments during the acute phase.

Analysis of Clinical Manifestations of Acute and Chronic Brucellosis in Patients Admitted to a Public General Hospital in Northern China

Objective

To analyze the clinical features of patients with acute and chronic brucellosis in order to further improve the understanding of the disease.

Methods

The clinical data of 144 patients with brucellosis who were admitted to our hospital were selected for retrospective analysis and were divided into two groups: the acute phase group (n = 86) and the chronic phase group (n = 58), and the clinical characteristics of the acute and chronic phases of the disease were analyzed. The χ² test was used for countable data comparisons between the two groups.

Results

Brucella melitensis was found as the contact organism in 61 patients (70.93%) in the acute phase group and in 12 patients (20.69%) in the chronic phase group (p < 0.01). Brucella abortus was found as the contact organism in 14 patients (16.28%) in the acute phase group and in 38 patients (65.52%) in the chronic phase group (p < 0.01). The results showed that the respective prevalence of fever, excessive sweating, splenomegaly, and lymph node enlargement were higher in the acute phase group than in the chronic phase group (p < 0.01). The respective prevalence of testicular swelling and pain were higher in the acute phase group than in the chronic phase group (p < 0.05), while the prevalence of joint and muscle pain was higher in the chronic phase group than in the acute phase group (p < 0.01).

Conclusion

In Harbin, two types of clinical brucellosis, acute and chronic phase, infected sheep and cattle, respectively, are endemic at the same time, which complicates diagnosis. Besides, the clinical manifestations of brucellosis are complex and diverse, and they are often misdiagnosed and mistreated, leading to serious health injuries. Therefore, it is important to improve the understanding of disease characteristics in patients with acute and chronic brucellosis.

Treatment-Free Remission in Chronic Myeloid Leukemia: Can We Identify Prognostic Factors?

Simple Summary

Chronic myeloid leukemia (CML) is a blood cancer. Unlike other cancers CML treatment is lifelong and many patients experience side effects. For those patients who respond well to treatment and achieve deep molecular remission, quality of life is impacted because of continuous treatment. In this review, we look at emerging clinical trials which aim to investigate which patients can safely stop treatment. Treatment-free remission is the ultimate goal for CML patients, but there is still a gap in our knowledge as to why some patients can achieve treatment-free remission, while others relapse when treatment is stopped. Here we discuss if there are any prognostic factors that can predict the best candidates who qualify for treatment discontinuation, with a view to keeping them in remission.

Abstract

Following the development of tyrosine kinase inhibitors (TKI), the survival of patients with chronic myeloid leukaemia (CML) drastically improved. With the introduction of these agents, CML is now considered a chronic disease for some patients. Taking into consideration the side effects, toxicity, and high cost, discontinuing TKI became a goal for patients with chronic phase CML. Patients who achieved deep molecular response (DMR) and discontinued TKI, remained in treatment-free remission (TFR). Currently, the data from the published literature demonstrate that 40–60% of patients achieve TFR, with relapses occurring within the first six months. In addition, almost all patients who relapsed regained a molecular response upon retreatment, indicating TKI discontinuation is safe. However, there is still a gap in understanding the mechanisms behind TFR, and whether there are prognostic factors that can predict the best candidates who qualify for TKI discontinuation with a view to keeping them in TFR. Furthermore, the information about a second TFR attempt and the role of gradual de-escalation of TKI before complete cessation is limited. This review highlights the factors predicting success or failure of TFR. In addition, it examines the feasibility of a second TFR attempt after the failure of the first one, and the current guidelines concerning TFR in clinical practice.

Quantitative Mass Spectrometry Imaging of Metabolomes and Lipidomes for Tracking Changes and Therapeutic Response in Traumatic Brain Injury Surrounding Injured Area at Chronic Phase

Traumatic brain injury (TBI) is a complex disease process that may contribute to temporary or permanent disability. Tracking spatial changes of lipids and metabolites in the brain helps unveil the underlying mechanisms of the disease procession and therapeutic response. Here, the liquid microjunction surface sampling technique was used for mass spectrometry imaging of both lipids and metabolites in rat models of controlled cortical impact with and without XueFu ZhuYu decoction treatment, and the work was focused on the diffuse changes outside the injured area at chronic phase (14 days after injury). Quantitative information was provided for phosphotidylcholines and cerebrosides by adding internal standards in the sampling solvent. With principal component analysis for the imaging data, the midbrain was found to be the region with the largest diffuse changes following TBI outside the injured area. In detail, several phosphatidylcholines, phosphatidylethanolamines, phosphatidic acids, and diacylglycerols were found to be significantly up-regulated particularly in midbrain and thalamus after TBI and XFZY treatment. It is associated with the reported "self-repair" mechanisms at the chronic phase of TBI activated by neuroinflammation. Several glycosphingolipids were found to be increased in most of brain regions after TBI, which was inferred to be associated with neuroinflammation and oxidative stress triggered by TBI. Moreover, different classes of small matabolites were significantly changed after TBI, including fatty acids, amino acids, and purines. All these compounds were involved in 10 metabolic pathway networks, and 6 target proteins of XFZY were found related to the impacted pathways. These results shed light on the molecular mechanisms of TBI pathologic processes and therapeutic response.

Higher Red Blood Cell Distribution Width is a Poor Prognostic Factor for Patients with Chronic Myeloid Leukemia

Purpose

Red blood cell distribution width (RDW) has been considered as a potential indicator of the effects of treatment or as a prognostic indicator for various malignancies. Most chronic myeloid leukemia (CML) patients are in the chronic phase, but some have transformed to accelerated phase or blast phase (blast crisis). However, the clinical significance of RDW in CML remains limited.

Patients and Methods

In the present study, detailed clinical information and the RDW of 168 healthy people and 153 CML patients (106 patients for the training cohort and 47 patients for the validation cohort) were retrospectively assessed.

Results

Multivariate analysis demonstrated that patient age (OR, 1.081; 95CI% 1.039~1.125; p < 0.001), platelet counts (OR, 0.997; 95CI% 0.994~0.999; p = 0.001) and RDW at admission (OR,1.469; 95CI% 1.121~1.925; p = 0.005) were significantly associated with the patients with advanced phase. Among CML patients in the chronic phase, higher RDW was significantly associated with overall survival (OS; p = 0.0008) and the event-free survival (EFS; p = 0.0221) among CML patients with chronic phase, but not with Transformation-free survival (TFS; p = 0.0821). Furthermore, higher RDW was associated with higher mortality compared to patients with low RDW (CML-associated deaths; p < 0.0001). In addition, a decline in RDW is associated with the treatment of CML patients with tyrosine kinase inhibitors, especially at 6 and 12 months after the start of treatment.

Conclusion

Higher RDW is a potential prognostic biomarker for chronic CML patients.

Physical Activity and Sport for Acquired Brain Injury (PASABI): A Non-Randomized Controlled Trial

Background and objectives: Acquired brain injury (ABI) is the first cause of disability and physical activity (PA) is a key element in functional recovery and health-related quality of life (HRQoL) during the subacute and chronic phases. However, it is necessary to develop PA programs that respond to the heterogeneity and needs of this population. The aim of this study was to assess the effectiveness of a PA program on the HRQoL in this population. Materials and Methods: With regard to recruitment, after baseline evaluations, participants were assigned to either the intervention group (IG, n = 38) or the control group (CG, n = 35). Functional capacity, mood, quality of life and depression were measured pre- and post-intervention. The IG underwent the “Physical Activity and Sport for Acquired Brain Injury” (PASABI) program, which was designed to improve HRQoL (1-h sessions, two to four sessions/week for 18 weeks). The CG underwent a standard rehabilitation program without PA. Results: Results for the IG indicated significant differences and large effect sizes for the physical and mental dimensions of quality of life, as well as mood and functional capacity, indicating an increase in HRQoL. No significant differences were found for the CG across any variables. Conclusions: The PASABI program was feasible and beneficial for improving physiological and functionality variables in the IG. The wide range of the activities of the PASABI program allow its application to a large number of people with ABI, promoting health through PA, especially in the chronic phase.

Impact of anemia on the outcomes of chronic phase chronic myeloid leukemia in TKI era

Objectives: It is common of chronic phase chronic myeloid leukemia (CML-CP) patients coexisting anemia at diagnosis, but the role of anemia on the prognosis is not clear. This study aims to explore impact of anemia on outcomes of CML-CP patients in TKI era.Methods: In the retrospective study, 258 newly diagnosed CML patients treated with TKIs were enrolled. Patients with moderate anemia (Hb ≤ 90 g/L) and non-moderate anemia (Hb > 90 g/L) were compared.Results: The incidence of moderate anemia at the time of CML diagnosis was 34.8%. Compared with patients with non-moderate anemia, patients with moderate anemia had higher proportion of intermediate-high Sokal risks and more aggressive characteristics such as higher WBC counts, higher percent of myeloblasts and basophils. However, there were no statistical differences in terms of optimal response rates, 5-year PFS and OS between the two groups.Conclusion: Moderate anemia is a common concomitant symptom in CML-CP patients and is associated with high-risk CML, but its occurrence does not affect the survival of CML-CP patients in TKI era.

Dasatinib treatment long-term results among imatinib-resistant/intolerant patients with chronic phase chronic myeloid leukemia are favorable in daily clinical practice

To evaluate long-term real-life results of dasatinib therapy among chronic phase chronic myeloid leukemia patients resistant or intolerant to imatinib, we retrospectively analyzed data of 118 patients treated in centers participating in the database INFINITY. With median follow-up of 37 months, estimated 5-year cumulative incidences of complete cytogenetic and major molecular responses were 78% and 68%, respectively. The estimated 5-year probability of overall survival (OS) and event-free survival (EFS) were 86% and 83%, respectively. Both OS and EFS were significantly improved among patients with BCR-ABL1 transcript level ≤10% at 3 months. Dasatinib toxicity was tolerable however persistent in almost half our patients, even after years of therapy. Pleural effusion occurred in 29% of patients and was responsible for 30% of dasatinib discontinuations. Our results confirmed very good efficacy and acceptable toxicity of dasatinib in second line setting and support the evidence and importance of high-quality real-life CML patient management.

Interleukin 6 and disease transformation in chronic myeloid leukemia: A Northeast Indian population study

Background

Interleukin 6 (IL6) has been suggested to be a valuable prognostic marker in chronic myeloid leukemia (CML). IL6 is a pleiotropic cytokine and plays an important role in immune response, hematopoiesis, and acute phase response. IL6 is regarded as a prominent target for clinical interventions.

Objective

The aim of the present study was to investigate the serum levels of IL6 in CML to provide greater insight to their role in disease transformation in Indian patients.

Materials and Methods

A total of 50 CML cases and 10 acute lymphocytic leukemia (ALL) cases along with 20 healthy controls were included in the study between 2015 and 2016. About 4 mL blood samples were collected from all cases in plain vial and serum was separated. Levels of IL6 were determined in all cases by enzyme-linked immunosorbent assay.

Results

The study suggests that both ALL and CML are associated with significantly elevated serum IL6 level than the healthy control group. Mean levels of serum IL6 are 223.4 ± 53.403 pg/mL in CML, 71.020 ± 29.549 pg/mL in ALL, and 5.360 ± 0.467 pg/mL in healthy control group. Serum IL6 correlated with different phases of CML. Mean IL6 levels are 50.93 ± 29.37 pg/mL in chronic phase (CP), 69.02 ± 22.60 pg/mL in accelerated phase (AP), and 652.77 ± 124.62 pg/mL in blast crisis (BC) phase of CML. In compared to CP and AP, in BC, IL-6 is significantly elevated ( P = 0.00 and 0.00, respectively); however, we did not find a significant difference in IL-6 serum levels between CP and AP ( P = 0.703).

Conclusion

Study suggests that the detection of IL6 level in newly diagnosed patient can predict the severity of the disease. There might be association of level of IL6 with the disease transformation.

Outcomes of Chronic Phase Chronic Myeloid Leukemia after Treatment with Multiple Tyrosine Kinase Inhibitors

We sought to evaluate the outcomes of chronic phase (CP) chronic myeloid leukemia (CML) in an era where five tyrosine kinase inhibitors (TKIs) are commercially available for the treatment of CML. Records of patients diagnosed with CP CML, treated with TKIs and referred to our center were reviewed. Between January 2005 and April 2016, 206 patients were followed for a median of 48.8 (1.4–190.1) months. A total of 76 (37%) patients received one TKI, 73 (35%) received two TKIs and 57 (28%) were exposed to >3 TKIs (3 TKIs, n = 33; 4 TKIs, n = 17; 5 TKIs, n = 7). Nineteen (9.2%) patients progressed to advanced phases of CML (accelerated phase, n = 6; myeloid blastic phase, n = 4; lymphoid blastic phase, n = 9). One third (n = 69) achieved complete molecular response (CMR) at first-line treatment. An additional 55 patients achieved CMR after second-line treatment. Twenty-five patients (12.1%) attempted TKI discontinuation and 14 (6.8%) stopped TKIs for a median of 6.3 months (range 1–53.4). The 10-year progression-free survival and overall survival (OS) rates were 81% and 87%, respectively. OS after 10-years, based on TKI exposure, was 100% (1 TKI), 82% (2 TKIs), 87% (3 TKIs), 75% (4 TKIs) and 55% (5 TKIs). The best OS was observed in patients tolerating and responding to first line TKI, but multiple TKIs led patients to gain treatment-free remission.

Role of Peroral Cholangioscopy in the Diagnosis of Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is characterized by idiopathic biliary stricture followed by progressive cholestasis and fibrosis. When diagnosing PSC, its differentiation from other types of sclerosing cholangitis and cholangiocarcinoma is necessary. The cholangioscopic findings of PSC have not been investigated sufficiently. PSC and IgG4-related sclerosing cholangitis are difficult to distinguish by peroral cholangioscopy (POCS), but POCS is useful for excluding cholangiocarcinoma. POCS findings vary according to the condition and stage of disease. In the active phase, findings such as mucosal erythema, ulceration, fibrinous white exudate, and an irregular surface are observed and may reflect strong inflammation in the biliary epithelium. On the other hand, findings such as scarring, pseudodiverticula, and bile duct stenosis appear in the chronic phase and may reflect fibrosis and stenosis resulting from repeated inflammation. Observation of inside the bile duct by POCS might confirm the current PSC activity. Because POCS offers not only information regarding the diagnosis of PSC and PSC-associated cholangiocarcinoma but also the current statuses of biliary inflammation and stenosis, POCS could significantly contribute to the diagnosis and treatment of PSC once the characteristic findings of PSC are confirmed by future studies.

Disease Resolution in Chikungunya-What Decides the Outcome?

Chikungunya disease (CHIKD) is a viral infection caused by an alphavirus, chikungunya virus (CHIKV), and triggers large outbreaks leading to epidemics. Despite the low mortality rate, it is a major public health concern owing to high morbidity in affected individuals. The complete spectrum of this disease can be divided into four phases based on its clinical presentation and immunopathology. When a susceptible individual is bitten by an infected mosquito, the bite triggers inflammatory responses attracting neutrophils and initiating a cascade of events, resulting in the entry of the virus into permissive cells. This phase is termed the pre-acute or the intrinsic incubation phase. The virus utilizes the cellular components of the innate immune system to enter into circulation and reach primary sites of infection such as the lymph nodes, spleen, and liver. Also, at this point, antigen-presenting cells (APCs) present the viral antigens to the T cells thereby activating and initiating adaptive immune responses. This phase is marked by the exhibition of clinical symptoms such as fever, rashes, arthralgia, and myalgia and is termed the acute phase of the disease. Viremia reaches its peak during this phase, thereby enhancing the antigen-specific host immune response. Simultaneously, T cell-mediated activation of B cells leads to the formation of CHIKV specific antibodies. Increase in titres of neutralizing IgG/IgM antibodies results in the clearance of virus from the bloodstream and marks the initiation of the post-acute phase. Immune responses mounted during this phase of the infection determine the degree of disease progression or its resolution. Some patients may progress to a chronic arthritic phase of the disease that may last from a few months to several years, owing to a compromised disease resolution. The present review discusses the immunopathology of CHIKD and the factors that dictate disease progression and its resolution.

Lychnopholide in Poly(d,l-Lactide)-Block-Polyethylene Glycol Nanocapsules Cures Infection with a Drug-Resistant Trypanosoma cruzi Strain at Acute and Chronic Phases

Chagas disease remains neglected, and current chemotherapeutics present severe limitations. Lychnopholide (LYC) at low doses loaded in polymeric poly(d,l-lactide)-block-polyethylene glycol (PLA-PEG) nanocapsules (LYC-PLA-PEG-NC) exhibits anti-Trypanosoma cruzi efficacy in mice infected with a partially drug-resistant strain. This study reports the efficacy of LYC-PLA-PEG-NC at higher doses in mice infected with a T. cruzi strain resistant to benznidazole (BZ) and nifurtimox (NF) treated at both the acute phase (AP) and the chronic phase (CP) of infection by the oral route. Mice infected with the T. cruzi VL-10 strain were treated by the oral route with free LYC (12 mg/kg of body weight/day), LYC-PLA-PEG-NC (8 or 12 mg/kg/day), or BZ at 100 mg/kg/day or were not treated (controls). Treatment efficacy was assessed by hemoculture (HC), PCR, enzyme-linked immunosorbent assay (ELISA), heart tissue quantitative PCR (qPCR), and histopathology. According to classical cure criteria, treatment with LYC-PLA-PEG-NC at 12 mg/kg/day cured 75% (AP) and 88% (CP) of the animals, while at a dose of 8 mg/kg/day, 43% (AP) and 43% (CP) were cured, showing dose-dependent efficacy. The negative qPCR results for heart tissue and the absence of inflammation/fibrosis agreed with the negative results obtained by HC and PCR. Thus, the mice treated with the highest dose could be considered 100% cured, in spite of a low ELISA reactivity in some animals. No cure was observed in animals treated with free LYC or BZ or the controls. These results are exceptional in terms of experimental Chagas disease chemotherapy and provide evidence of the outstanding contribution of nanotechnology in mice infected with a T. cruzi strain totally resistant to BZ and NF at both phases of infection. Therefore, LYC-PLA-PEG-NC has great potential as a new treatment for Chagas disease and deserves further investigations in clinical trials.

Variables associated with patient-reported symptoms in persons with chronic phase chronic myeloid leukemia receiving tyrosine kinase inhibitor therapy

PURPOSE

The aim of this study was to evaluate the variables associated with patient-reported symptoms and the impact of symptoms on health-related quality-of-life (HRQoL) in patients with chronic myeloid leukemia (CML) receiving tyrosine kinase inhibitors (TKIs).

METHODS

Anonymous Chinese-language questionnaires were distributed to adults with chronic-phase CML (CML-CP) receiving TKIs therapy >3 months regarding symptoms' incidence, severity, and HRQoL. The multivariate cumulative logistic regression model was built to identify variables associated with the symptoms. General Linear Model was used to model the relationship between symptoms and HRQoL using stepwise-forward algorithm.

RESULTS

A total of 1142 respondents were included in this study. The top 10 common TKI-related symptoms were fatigue, periorbital and lower limb edema, chest distress and shortness of breath, memory deterioration, skin color change, alopecia, muscle cramp, weight gain and musculoskeletal pain, and itchy skin. One hundred forty-one (50%) females ≤50 years reported menstrual disorders. Female, married, therapy duration 1 to 3 years, and foreign generic TKIs were associated with increased symptoms' frequency and severity. In contrast, receiving nilotinib or dasatinib, and achieving a complete cytogenetic response but not complete molecular response were associated with fewer and milder symptoms. Chest distress and shortness of breath and loss of appetite were associated with both lower physical component summary (PCS) and mental component summary (MCS) scores; fatigue, musculoskeletal pain, dizziness and abdominal pain, were associated with lower PCS score; anxiety-depression, was associated with lower MCS score in multivariate analyses.

CONCLUSIONS

Demographic and social variables, type of TKI-therapy, therapy duration, and depth of response were associated with patient-reported symptoms in persons with chronic phase CML. Certain symptoms have adverse impact on HRQoL.

A prospective, randomized study to compare the combination of imatinib and cytarabine versus imatinib alone in newly diagnosed patients with chronic phase chronic myeloid leukemia

INTRODUCTION

To compare the efficacy and safety of imatinib and cytarabine (ara-c) combination versus imatinib monotherapy in newly diagnosed patients with chronic phase chronic myeloid leukemia (CML-CP).

MATERIALS AND METHODS

This prospective, randomized study included adult patients (age >18 years) with newly diagnosed CML-CP. Patients received either a single oral dose of imatinib 400 mg/day in combination with a subcutaneous injection of ara-c 20 mg/m²/day (imatinib + ara-c) or a single oral dose of imatinib 400 mg/day. Primary endpoints were hematological and molecular responses at 3 months and cytogenetic responses at 6 and 12 months. Secondary endpoints included grade 3/4 hematological and nonhematological adverse events (AEs).

RESULTS

Of 30 patients included, 14 were randomized to imatinib + ara-c and 16 to imatinib alone. Complete hematologic response (CHR) at 3 months was higher with imatinib + ara-c vs. imatinib alone (100% vs. 87.5%, P = 0.48). The median time to achieve CHR was significantly (P < 0.001) lower with imatinib + ara-c (32.07 vs. 23.43 days). Molecular response at 3 months was significantly higher (P = 0.04) with imatinib + ara-c vs. imatinib alone (100% vs. 68.75%). Complete cytogenetic response was also higher with imatinib + ara-c vs. imatinib alone (42.85% vs. 25% at 6 months and 71.4% vs. 62.5% at 12 months). Neutropenia followed by thrombocytopenia and anemia were the most common AEs. Grade 3/4 hematological and nausea events were significantly (P < 0.05) higher with imatinib + ara-c. Other nonhematological events were not significantly different between the treatments. The median follow-up duration was 20 months (range: 15-23 months).

CONCLUSION

Imatinib with low-dose ara-c can be considered as a potential first-line treatment option for CML-CP.

A unique presentation of destructive shoulder arthropathy in the chronic phase of chronic myeloid leukaemia

We present a previously unreported case of rapidly progressing, destructive shoulder arthropathy as an initial presentation of chronic phase chronic myeloid leukaemia. This patient initially presented to clinic for consideration of an arthroplasty for symptom relief; however, her loss to follow-up yielded a rapid progression of her symptoms. Bone marrow aspirate and targeted biopsy of the humeral head excluded blast cell crisis, in contrast to previously reported cases. She was treated conservatively with medical management of her underlying disease. Although leukaemic arthritis is a recognized phenomenon, chronic myeloid leukaemia is not known to cause bone destruction of this kind, particularly in the absence of blast crisis. Medical treatment with a tyrosine kinase inhibitor provided a dramatic improvement in our patient's pain, without the risk of attempted arthroplasty in unknown bone quality. We describe a unique presentation of severe bone destruction as a manifestation of chronic myeloid leukaemia in the absence of blast crisis. This should be considered as a rare differential diagnosis in joint arthropathy and may be appropriately managed initially with medical therapy, whereas future arthroplasty comprises uncharted territory in unknown bone quality.

Measuring Neurobehavioral Disabilities Among Severe Brain Injury Survivors: Reports of Survivors and Proxies in the Chronic Phase

Background: Neurobehavioral disability (NBD) has a major influence on long-term psychosocial outcome following acquired brain injury, as it affects not only the survivor of the brain injury, but the whole family.

Objectives: To investigate (1) the frequency of NBD among survivors of severe brain injury measured by the Danish version of the St Andrew's-Swansea Neurobehavioural Outcome Scale (SASNOS) rated by patients and proxies, (2) factors associated with NBD, and (3) concordance between reports of NBD completed by patients and proxies.

Methods: SASNOS was administered at an outpatient unit as a part of a follow-up assessment after discharge from intensive neurorehabilitation. SASNOS consists of five factors describing the following domains: Interpersonal Behavior, Cognition, Aggression, Inhibition and Communication, and both the patient and a proxy were asked to complete the questionnaire. Data collection was conducted over a period of 2 years, and 32 patients and 31 proxies completed the questionnaire. Mean time since injury was 19.4 months (10.0 SD). Most patients were male (68.8%), and most proxies were female (58.1%). Most of the patients had suffered a traumatic brain injury (68.8%).

Results: A fourth of this patient group reported themselves below the normal range on the major domains of Interpersonal Behavior and Cognition. Significant associations between proxies' reports and time since injury, cohabitant status, and the patient's score on the Extended Glasgow Outcome Scale were found. Furthermore, significant differences were found between patient and proxy ratings. Proxies rated patients as having fewer problems on the Interpersonal Behavior domain, and more problems in relation to Cognition. Cognition was the only domain, where patients rated themselves higher indicating fewer problems, compared with their proxies. On both the Aggression and Communication domains, proxies rated patients higher indicating fewer problems than the patients themselves.

Conclusion: Danish brain injury survivors experienced NBD as measured by SASNOS. Differences were found between patient and proxy ratings in relation to Cognition and Interpersonal Behavior. The NBDs identified can affect the survivor's ability to reintegrate and participate in activities of daily living, emphasizing how a systematic assessment is required.

Hydroxymethylnitrofurazone treatment in indeterminate form of chronic Chagas disease: Reduced intensity of tissue parasitism and inflammation-A histopathological study

Hydroxymethylnitrofurazone (NFOH) is a nitrofurazone prodrug effective in vivo during acute infections, and it has less hepatotoxicity effect than the standard drug benznidazole (BZN) which has been used during short- and long-term treatment. In the present study, we induced the indeterminate form of Chagas disease in mice with a Y strain of Trypanosoma cruzi and analysed the histopathological data about the effects of NFOH and BZN on different tissues, including the heart, skeletal muscle, liver, kidney, colon, spleen and brain. After infection, BALB/c mice were treated with NFOH (150 mg/kg) and BZN (60 mg/kg) for 60 days and then submitted to immunosuppression using dexamethasone (5 mg/kg) for 14 days. Two trained analysts, as part of a blind evaluation, examined the results using serial sections of 3 mm diameter in two different moments. The results showed reactivation of the disease only in the infected nontreated group (POS). After treatment, amastigote nests were found in the heart, colon, liver and skeletal muscle in the POS group and in the heart and liver of the BZN group. Interestingly, amastigote nests were not found in the NFOH and NEG groups. The histopathological analysis showed fewer tissue lesions and parasite infiltrates in the NFOH group when compared with the BZN and POS groups. We have not observed any increase in the levels of hepatocellular injury biomarkers (AST/ALT) in the NFOH group. These in vivo studies show the potential for NFOH as an effective and safe compound useful as an anti-T. cruzi agent.

Circulating microRNAs expression profile in newly diagnosed and imatinib treated chronic phase - chronic myeloid leukemia

Chronic myeloid leukemia (CML) is a stem cell derived malignant disorder result of translocation t(9;22)(q34;q11) called Philadelphia chromosome (Ph⁺). microRNAS (miRNAs) are involved in several biological processes, altering the progression of various pathologies, including CML. This study evaluated whether circulating miRNAs display differential expression profiles in peripheral blood of CML-Chronic Phase (CML-CP) patients newly diagnosed in comparison with CML-CP treated with imatinib. We obtained peripheral blood samples from CML-CP Ph⁺ patients divided among group 1 (untreated newly diagnosed) and group 2 (treated with imatinib). A pool of total leukocytes from healthy donors was considered as control group. Expression analyses were performed for 768 miRNAs by RT-qPCR array. Bioinformatic tools were used to identify significant pathways and interaction networks. We found 80 deregulated miRNAs between the groups and, according to bioinformatic analysis, they are involved in different pathways, including molecular mechanisms of cancer. The study allows better understanding of disease molecular behavior, and it is useful for possible monitoring CML treatment and prognostic biomarkers identification.

Life after ponatinib failure: outcomes of chronic and accelerated phase CML patients who discontinued ponatinib in the salvage setting

Ponatinib is a pan-tyrosine kinase inhibitor (TKI) with efficacy in multirefractory CML patients who have failed other TKIs. Despite excellent response rates, resistance or intolerance may develop. We conducted a retrospective review of the outcome of patients with chronic (CP) and accelerated (AP) phase CML refractory to prior TKI who discontinued ponatinib for resistance or intolerance. Nineteen CP patients, discontinued due to resistance (n = 13), toxicity (n = 5) and to pursue stem cell transplantation (n = 1). At discontinuation, 14 were still in CP, three had progressed to AP and two to blast phase (BP). Three CP patients improved their cytogenetic response (CyR) to complete CyR (CCyR), two after SCT and one on omacetaxine. None of the 12 patients, without a major cytogenetic response at ponatinib discontinuation, including all patients treated with subsequent TKIs, responded to therapy. Seventeen AP patients, stopped ponatinib due to resistance (n = 15) or intolerance (n = 2). At discontinuation, 14 were still in AP and three had progressed to BP. Four patients were treated with SCT and one achieved major molecular response. None of the 12 patients treated with non-SCT approaches responded to subsequent therapy. Median survival for all patients was 16.6 months after ponatinib discontinuation (31, 9 and 13 months for patients in CP, AP and BP, respectively). Median survival was 60 months for patients who discontinued ponatinib for toxicity and 11 months for those who discontinued for resistance. Long-term outcome of patients with ponatinib failure are poor with estimated one-year OS and EFS rates of 54% and 40%, respectively. New treatment options are required for this subset of patients.

Pregnant Women Hospitalized with Chikungunya Virus Infection, Colombia, 2015

Personnel in charge of obstetric populations should watch for cases of chikungunya virus‒induced sepsis with hypoperfusion and organ dysfunction.

In 2015 in Colombia, 60 pregnant women were hospitalized with chikungunya virus infections confirmed by reverse transcription PCR. Nine of these women required admission to the intensive care unit because of sepsis with hypoperfusion and organ dysfunction; these women met the criteria for severe acute maternal morbidity. No deaths occurred. Fifteen women delivered during acute infection; some received tocolytics to delay delivery until after the febrile episode and prevent possible vertical transmission. As recommended by a pediatric neonatologist, 12 neonates were hospitalized to rule out vertical transmission; no clinical findings suggestive of neonatal chikungunya virus infection were observed. With 36 women (60%), follow-up was performed 1 year after acute viremia; 13 patients had arthralgia in >2 joints (a relapse of infection). Despite disease severity, pregnant women with chikungunya should be treated in high-complexity obstetric units to rule out adverse outcomes. These women should also be followed up to treat potential relapses.

Monitoring tyrosine kinase inhibitor therapeutic responses with a panel of metabolic biomarkers in chronic myeloid leukemia patients

The aim of this study is to investigate the potential biomarkers associated with chronic myeloid leukemia (CML), reveal the metabolite changes related to the continuous phases of tyrosine kinase inhibitors (TKIs), and find the potential biomarkers associated with treatment effects. Fifty‐two patients with CML and 26 matched healthy people were enrolled as the discovery set. Another 194 randomly selected CML patients treated with TKI were chosen as the external validation set. Plasma samples from the patients and controls were profiled using the gas chromatography‐mass spectrometry‐based metabonomic approach. Multivariate and univariate statistical analyses were combined to select the differential metabolic features. The gas chromatography‐mass spectrometry‐based metabolomics showed a clear clustering and separation of metabolic patterns from healthy controls and pre‐ and post‐TKI treatment CML patients in the discovery set. We identified 9 metabolites that differentiated CML patients from healthy controls, including lactic acid, isoleucine, glycerol, glycine, myristic acid, d‐sorbitol, d‐galactose, d‐glucose, and myo‐inositol. Among the 9 markers, glycerol and myristic acid had the most significant association with TKI treatment effects in both discovery and external validation sets. In the receiver operating characteristic analysis, the combination of glycerol and myristic acid showed a better discrimination performance compared to a single biomarker. The results indicated that metabolic profiling has the potential for diagnosis of CML and the panel of biomarkers including myristic acid and glycerol could be useful in monitoring TKI therapeutic responses.

Psychological outcome after severe traumatic brain injury in adolescents and young adults: The chronic phase

OBJECTIVES

Young individuals surviving severe traumatic brain injury (TBI) frequently experience a wide range of cognitive, emotional and behavioural consequences. This cross-sectional follow-up study investigated psychological outcome of young survivors in the chronic phase, and whether psychological outcome was associated with improvement of functional abilities during sub-acute admission.

METHODS

Patients, who acquired a severe TBI during adolescence or early adulthood (n = 36) and received early intensive rehabilitation, were contacted for follow-up assessment concerning psychological outcome and completed the Adult Self Report 18-59 (ASR18-59). Demographic data, functional outcomes and severity measures were obtained from the local database.

RESULTS

The participants had a mean age of 24.1 years (SD = 4.1) at follow-up, and the mean time since injury was 72.1 months (SD = 44.2). Results showed significantly higher scores compared with the normative reference population in relation to the subscales withdrawal/isolation (p = 0.013), attention problems (p = 0.008) and intrusive behaviour (p = 0.046). Pearson correlation analyses showed that young survivors experiencing more functional improvement during inpatient rehabilitation had fewer psychological problems during the chronic phase in the subscales: withdrawal/isolation, rule breaking, intrusive behaviour and total problems.

CONCLUSION

Young patients reported psychological problems in several areas during the chronic phase of injury, which may hinder complete reintegration and participation in society. Larger functional improvement during sub-acute rehabilitation seemed to be associated with less psychological problems in the chronic phase.

Analysis of clinical characteristics and efficacy of chronic myeloid leukemia onset with extreme thrombocytosis in the era of tyrosine kinase inhibitors

The aim of this study was to investigate the clinical characteristics and efficacy of chronic myeloid leukemia (CML) onset with extreme thrombocytosis. A total of 121 newly diagnosed and untreated CML patients in chronic phase with complete clinical information from the First Hospital of Jilin University, from January 2010 to December 2014 were retrospectively recruited. Based on the platelet (PLT) count, 22 patients were assigned into CML with thrombocytosis (CML-T) group (PLT >1,000×10⁹/L) and 65 patients were classified into CML without extreme thrombocytosis (CML-N) group (PLT ≤1,000×10⁹/L). Fifty-four point five percent of patients in the CML-T group were female, which was higher than that in the CML-N group (27.7%) (P=0.022). Except for gender, there was no significant difference for clinical information of patients between the two groups. For Sokal and Hasford scoring systems, the percentage of patients at high risk in the CML-T group were higher than those in the CML-N group, 95.5% vs 52.3% (P=0.000) and 68.2% vs 41.5% (P=0.031), respectively; however, there was no significant difference for European Treatment and Outcome Study (EUTOS) score system between the two groups (P=0.213). In terms of major molecular response (MMR) rate, the percent of patients with MMR in CML-T group was lower than that in CML-N group at 36 months after tyrosine kinase inhibitor therapy (P=0.037). Up until December 2016, the median of event-free survival was 21 months in the CML-T group, however, that was not reached in the CML-N group (P=0.027). The majority of CML patients with extreme thrombocytosis were females, and compared to patients in the CML-N group, the percentage of high risk patients based on the Sokal and Hasford scoring systems was higher in the CML-T group, and the median event-free survival of patients was shorter.

Characterization of the Molecular Mechanisms Underlying the Chronic Phase of Stroke in a Cynomolgus Monkey Model of Induced Cerebral Ischemia

Stroke is one of the main causes of mortality and long-term disability worldwide. The pathophysiological mechanisms underlying this disease are not well understood, particularly in the chronic phase after the initial ischemic episode. In this study, a Macaca fascicularis stroke model consisting of two sample groups, as determined by MRI-quantified infarct volumes as a measure of the stroke severity 28 days after the ischemic episode, was evaluated using qualitative and quantitative proteomics analyses. By using multiple online multidimensional liquid chromatography platforms, 8790 nonredundant proteins were identified that condensed to 5223 protein groups at 1% global false discovery rate (FDR). After the application of a conservative criterion (5% local FDR), 4906 protein groups were identified from the analysis of cerebral cortex. Of the 2068 quantified proteins, differential proteomic analyses revealed that 31 and 23 were dysregulated in the elevated- and low-infarct-volume groups, respectively. Neurogenesis, synaptogenesis, and inflammation featured prominently as the cellular processes associated with these dysregulated proteins. Protein interaction network analysis revealed that the dysregulated proteins for inflammation and neurogenesis were highly connected, suggesting potential cross-talk between these processes in modulating the cytoskeletal structure and dynamics in the chronic phase poststroke. Elucidating the long-term consequences of brain tissue injuries from a cellular prospective, as well as the molecular mechanisms that are involved, would provide a basis for the development of new potentially neurorestorative therapies.

The prospects of regenerative medicine combined with rehabilitative approaches for chronic spinal cord injury animal models

Regenerative medicine has opened a window for functional recovery in acute-to-subacute phase spinal cord injury (SCI). By contrast, there are still only a few studies have focused on the treatment of the chronically injured spinal cord, in which cell-based regenerative medicine seems less effective. Since the majority of SCI patients are in the chronic phase, representing a major challenge for the clinical application of cell-based regenerative medicine. Although combined therapies for the treatment of chronic SCI have attracted attention of researchers and its potential importance is also widely recognized, there had been very few studies involving rehabilitative treatments to date. In a recent study, we have demonstrated for the first time that treadmill training combined with cell transplantation significantly promotes functional recovery even in chronic SCI, not only in additive but also in synergistic manner. Even though we have succeeded to outline the profiles of recovery secondary to the combination therapy, the mechanism underlying the effects remain unsolved. In this review article, we summarize the present progress and consider the prospect of the cell-based regenerative medicine particularly combined with rehabilitative approaches for chronic SCI animal models.

Cannabinoid Type-2 Receptor Drives Neurogenesis and Improves Functional Outcome After Stroke

BACKGROUND AND PURPOSE

Stroke is a leading cause of adult disability characterized by physical, cognitive, and emotional disturbances. Unfortunately, pharmacological options are scarce. The cannabinoid type-2 receptor (CB2R) is neuroprotective in acute experimental stroke by anti-inflammatory mechanisms. However, its role in chronic stroke is still unknown.

METHODS

Stroke was induced by permanent middle cerebral artery occlusion in mice; CB2R modulation was assessed by administering the CB2R agonist JWH133 ((6aR,10aR)-3-(1,1-dimethylbutyl)-6a,7,10,10a-tetrahydro-6,6,9-trimethyl-6H-dibenzo[b,d]pyran) or the CB2R antagonist SR144528 (N-[(1S)-endo-1,3,3-trimethylbicyclo-[2.2.1]-heptan-2-yl]-5-(4-chloro-3-methylphenyl)-1-(4-methylbenzyl)-pyrazole-3-carboxamide) once daily from day 3 to the end of the experiment or by CB2R genetic deletion. Analysis of immunofluorescence-labeled brain sections, 5-bromo-2´-deoxyuridine (BrdU) staining, fluorescence-activated cell sorter analysis of brain cell suspensions, and behavioral tests were performed.

RESULTS

SR144528 decreased neuroblast migration toward the boundary of the infarct area when compared with vehicle-treated mice 14 days after middle cerebral artery occlusion. Consistently, mice on this pharmacological treatment, like mice with CB2R genetic deletion, displayed a lower number of new neurons (NeuN⁺/BrdU⁺ cells) in peri-infarct cortex 28 days after stroke when compared with vehicle-treated group, an effect accompanied by a worse sensorimotor performance in behavioral tests. The CB2R agonist did not affect neurogenesis or outcome in vivo, but increased the migration of neural progenitor cells in vitro; the CB2R antagonist alone did not affect in vitro migration.

CONCLUSIONS

Our data support that CB2R is fundamental for driving neuroblast migration and suggest that an endocannabinoid tone is required for poststroke neurogenesis by promoting neuroblast migration toward the injured brain tissue, increasing the number of new cortical neurons and, conceivably, enhancing motor functional recovery after stroke.

A propensity score matching analysis of dasatinib and nilotinib as a frontline therapy for patients with chronic myeloid leukemia in chronic phase

BACKGROUND

Both dasatinib and nilotinib are approved frontline therapy for chronic myeloid leukemia in chronic phase (CML-CP) based on randomized trials compared with imatinib. However, no head-to-head comparison of dasatinib and nilotinib has been conducted in patients with newly diagnosed CML-CP.

METHODS

The authors conducted a propensity score (PS) matched comparison of patients with CML-CP who received frontline therapy with either dasatinib (N = 102) or nilotinib (N = 104) under the respective phase 2 trials conducted in parallel.

RESULTS

PS matching resulted in 87 patients from each trial being matched for pretreatment characteristics. The 3-month BCR-ABL1/ABL1 ratio <10% rate was 93% with dasatinib and 94% with nilotinib (P = .25); the rates of major molecular response at 12 months were 77% and 85%, respectively (P = .13); and the rates of molecular response with 4.5-log reduction in the ratio at 36 months were 66% and 64%, respectively (P = .96). All other clinically relevant responses were similar between the 2 treatment cohorts. The 3-year probability of event-free survival was 89% among the patients who received dasatinib and 87% among those who received nilotinib (P = .99), and the corresponding 3-year overall survival probabilities were 99% and 93%, respectively (P = .95). No statistical difference was observed between the dasatinib and nilotinib groups in any of the other survival endpoints. The treatment discontinuation rate also was similar between the 2 cohorts (dasatinib group, 18%; nilotinib group, 19%; P = .82).

CONCLUSIONS

In a PS-matched cohort of patients with newly diagnosed CML-CP, dasatinib and nilotinib offer similar response and survival outcomes. Both drugs can be considered reasonable standard-of-care options as first-line therapy for patients with CML-CP. Cancer 2016;122:3336-3343. © 2016 American Cancer Society.

Presence of Additional Cytogenetic Abnormality of t(1;15) at Diagnosis of Chronic Myelogenous Leukemia-Chronic Phase

At diagnosis, fewer than 10% of chronic myelogenous leukemia (CML) patients have additional cytogenetic abnormalities (ACAs), which are frequently found in transformation to blast crisis. We report a case of CML-chronic phase (CML-CP) that showed t(1;15) at diagnosis. A 64-year-old man presented with sustained leukocytosis and thrombocytosis. His bone marrow (BM) was hypercellular with 2.5% blasts and BCR-ABL1 rearrangement. The karyotype in the BM was 46,XY,t(1;15)(q32;p13),t(9;22)(q34;q11.2)[20], while the karyotype in the peripheral blood was 46,XY[20]. This is the first report on the presence of t(1;15) at diagnosis of CML-CP, and its clinical significance remains unclear.

F protein increases CD4+CD25+ T cell population in patients with chronic hepatitis C

HCV is a global health problem with an estimated 230 million chronically infected people worldwide. It has been reported that a 17-kd protein translated from core-encoding genomic region can contribute to immune-mediated mechanisms associated with the development of the chronic disease. Also, Treg cells can be contributed to an inadequate response against the viruses, leading to chronic infection. Here we evaluated the ability of protein F to modulate the frequency of CD4+CD25+FoxP3+T and IL-10+T cells in patients with chronic HCV infection. F gene was amplified and cloned in the expression vector. The protein was purified and used for stimulation of PBMCs in the HCV chronic patients and the control groups. The frequency of CD4+CD25+FoxP3+ T cell-like populations and IL-10-producing CD4+CD25+ T cells was assessed in the HCV-infected patients and in the healthy controls by flow cytometry, which showed an increase of both CD4+CD25+FoxP3+ T cell-like population and IL-10-producing CD4+CD25+ T cells in the HCV-infected patients positive for anti-F antibody. Our results suggest the potential involvement of F and core antigens in increasing the frequency of CD4+CD25+FoxP3+ T cell-like population and IL-10-producing CD4+CD25+ T cells which may be associated with HCV-persistent infection.

Predicting early blast transformation in chronic-phase chronic myeloid leukemia: is immunophenotyping the missing link?

BACKGROUND

Flow cytometry (FC) is a commonly requested test in the workup of leukocytosis in community practices. The role of FC in chronic-phase chronic myeloid leukemia (CP-CML) is unknown. We hypothesized that finding aberrant cells with FC in CP-CML may predict early blast-phase (BP) transformation.

METHODS

Results for FC performed at the time of diagnosis for adult and pediatric patients with CP-CML who were referred to our institution were reviewed, and they were correlated with outcomes.

RESULTS

FC was performed at the time of diagnosis for 110 of 233 patients (47%) with CP-CML. Aberrant populations, representing a median of 2% (range, 0.3%-15%), were detected with FC in 30% of patients (33 of 110): 2 of these 33 patients expressed lymphoid markers, and 31 expressed aberrant myeloid markers. Patients received imatinib (85%), dasatinib (12%), or nilotinib (3%) as their first-line treatment. With a median follow-up of 43 months (range, 2-113 months), chronic myeloid leukemia transformed to BP in 5 of the 33 patients. The 2 patients with lymphoid markers and the 3 of 31 patients with aberrant myeloid markers experienced a transformation to lymphoid BP at a median of 11 months (range, 4-72 months) after the initiation of tyrosine kinase inhibitor therapy. Although both cases with detectable lymphoid markers rapidly progressed to lymphoid BP, the positive predictive value of BP transformation by the detection of myeloid aberrant cells with FC was only 10% (3 of 31).

CONCLUSIONS

In contrast to aberrant myeloid markers, the detection of lymphoid markers by FC at the time of the diagnosis of CP-CML appears to be associated with early progression to lymphoid BP.