Haploidentical related-donor hematopoietic cell transplantation in children using megadoses of CliniMACs-selected CD34(+) cells and a fixed CD3(+) dose.

We conducted a prospective phase II trial utilizing the CliniMACs system to perform CD34(+)-cell selection of PBSCs from haploidentical donors to evaluate engraftment and hematoimmunological reconstitution. In total, 21 children with hematological malignancies or nonmalignant conditions underwent conditioning with 1200 cGy TBI, thiotepa, fludarabine and Thymoglobulin. Patients received megadoses of CD34(+) cells (median: 22 × 10(6)/kg) with a fixed dose of 3 × 10(4)/kg CD3(+) cells/kg, and engraftment occurred in 90% with prompt recovery of neutrophils and platelets. Grade II acute GVHD (aGVHD) was seen in 32% (95% confidence interval (CI), 15-54%) of evaluable patients, there was no grade III-IV aGVHD, and chronic extensive GVHD was seen in 35% (95% CI, 17-59%) of patients. The estimated 2-year EFS was 62% (95% CI, 48-83%) with a median survivor follow-up of 49 months (range: 18-119 months). Patients with nonmalignant diseases had an estimated 2-year EFS of 100% (95% CI, 56-100%) and patients with malignancies in remission had an estimated 2-year EFS of 56% (95% CI, 22-89%). Megadose CD34(+) cells with a fixed CD3(+) cell dose from haploidentical related donors resulted in good outcomes for pediatric patients with nonmalignant diseases and those with malignant diseases transplanted in remission.

Clinical and immunologic outcomes following haplocompatible donor lymphocyte infusions.

We retrospectively analyzed the characteristics of 16 consecutive pediatric patients who received one or more G-CSF-mobilized donor lymphocyte infusions (DLI) following a T-cell-depleted haplocompatible hematopoietic SCT (HSCT) to enhance immune recovery and/or treat an infection. The median time from HSCT to administration of first DLI was 12 weeks and the median dose of DLI administered was 3 x 10(4)/kg (range, 2.5-6 x 10(4)/kg). The incidence of Grade I-II acute GVHD was 19% (95% confidence interval (CI), 6-44%), and there were no cases of Grade III-IV acute GVHD. Chronic GVHD developed in 13% (95% CI, 2-37%) of patients. In surviving patients who did not undergo a second stem cell infusion, T-cell numbers and function increased to a protective level in a median of 3 months (range, 2-12.5 months) following the first DLI administration. In patients given DLI for treatment of an infection, 75% (95% CI, 46-92%) cleared their infection after a median of 9 weeks (range, 1-27 weeks). In patients with CMV infection, the development of CMV-specific T cells was observed following DLI. The 1-year overall survival following haplocompatible DLI was 71% (95% CI, 59-83%), with a median follow-up of 16 months from the first DLI.

Fetal glucocorticoid exposure and hypothalamo-pituitary-adrenal (HPA) function after birth.

The fetus may be exposed to increased endogenous glucocorticoid or synthetic glucocorticoid in late gestation. Indeed, 7-10% of pregnant women in Europe and North America are treated with synthetic glucocorticoid to promote lung maturation in fetuses at risk of preterm delivery. Such therapy is effective in reducing respiratory complications. However, very little is known about the mechanisms by which synthetic glucocorticoid or prenatal stress influence neurodevelopment in the human, or whether specific time windows of increased sensitivity exist. Glucocorticoids are essential for many aspects of normal brain development. However, there is growing evidence that exposure of the fetal brain to excess glucocorticoid can have lifelong effects on neuroendocrine function and behavior. We have shown that both endogenous glucocorticoid and synthetic glucocorticoid exposure has a number of rapid effects in the fetal brain in late gestation, including modification of neurotransmitter systems and transcriptional machinery. Such fetal exposure permanently alters hypothalamo-pituitary-adrenal (HPA) function in prepubertal, postpubertal, and aging offspring, in a sex-dependent manner. These effects are linked to changes in central glucocorticoid feedback machinery after birth. Prenatal glucocorticoid manipulation also leads to modification of HPA-associated behaviors, brain and organ morphology, as well as altered regulation of other endocrine systems. Permanent changes in endocrine function will have a long-term impact on health, since elevated cumulative exposure to endogenous glucocorticoid is linked to the premature onset of pathologies associated with aging.

Serial kinematic analysis of the canine hindlimb joints after deafferentation and anterior cruciate ligament transection.

OBJECTIVE AND DESIGN: Transection of the anterior cruciate ligament 2 weeks after ipsilateral hindlimb deafferentation leads to osteoarthritis of the knee joint within 3 weeks. We analyzed the gait of six dogs that underwent this procedure in order to identify kinematic changes that could account for this rapid joint degeneration. All animals were video taped, 1, 3, 6, 9 and 13 weeks after surgery while they trotted on a treadmill. RESULTS: In each dog, extension of the hip, knee and ankle joints of the unstable limb was increased, and the yield phase of the unstable knee was delayed or attenuated. When killed, five of six dogs showed a large full-thickness cartilage ulcer on the distal and/or anterior surface of the medial femoral condyle of the unstable knee; in the sixth dog, a smaller ulcer was observed. However, the severity of pathology in each individual was not obviously related to difference among the dogs in postoperative joint kinematics. CONCLUSIONS: These data, and results of prior studies in humans and dogs, suggest that knee hyperextension resulting from limb deafferentation, and knee instability resulting from anterior cruciate ligament transection, operate in concert to create a mechanical environment (i.e., increased tibiofemoral separation and changes in the loading of articular surfaces) that results in rapid joint breakdown.

Utilization of the Denny-Brown collection: differential recovery of forelimb and hind limb stepping after extensive unilateral cerebral lesions.

The Denny-Brown collection of primate lesion material was used to test the hypothesis that there is a difference in the rate of forelimb and hind limb recovery of locomotor movements after major unilateral cerebral ablation (pre/postcentral gyrus, decortication or hemispherectomy). The results indicate that, following major cerebral injury, hind limb recovery precedes that of the forelimb in adolescent and adult primates, but not in infants. This suggests that there is an underlying physiological basis to the widely-held belief that, in humans, lower limb recovery after stroke is generally more complete than that of the upper limb.

Serial kinematic analysis of canine hind limb joints after unilateral L4-S1 dorsal root ganglionectomy: Insights into locomotor control mechanisms.

Following unilateral L4-S1 dorsal root ganglionectomy to deafferent the hind limb, each of six dogs showed increased extension of the ipsilateral hip, knee and ankle joints during most of the gait cycle throughout a 26-week period of observation. The contralateral hind limb joints initially exhibited increased flexion during gait (which presumably compensated for the increased extension of the deafferented limb), but over time contralateral joint extension gradually increased, i.e. the movement of the joints of the contralateral limb progressively began to resemble that of the ipsilateral joints. We suggest that the long-term kinematic changes in both limbs (increased extension) occurred because of neurological changes in spinal cord structure, associated with death of sensory neurons and an associated increase in the influence of descending systems (e.g. vestibulospinal) on motoneurons. These results emphasize the importance of long-term observation of kinematic patterns after experimental induction of neural lesions and indicate that the contralateral limb should not, a priori, be considered a valid control in such studies.

Serial kinematic analysis of the canine knee after L4-S1 dorsal root ganglionectomy: implications for the cruciate deficiency model of osteoarthritis.

OBJECTIVE: To characterize knee movements before and after unilateral hindlimb deafferentation in dogs with stable joints. METHODS: High speed cinematography and frame by frame analysis were used to analyze knee kinematics of 6 dogs serially for 26 weeks following L4-S1 dorsal root ganglionectomy, which was performed to deafferentate one hindlimb. RESULTS: Overall knee movements were not reduced, but knee extension increased during most of the gait cycle. Few changes occurred in knee velocity, and none at touchdown or during weight acceptance. CONCLUSION: We previously showed that unilateral hindlimb deafferentiation does not cause osteoarthritis or reduce ipsilateral peak vertical forces in dogs with stable knee joints over an observational period of 16 months. We now show that joint protection in the deafferented stable joint occurs, paradoxically, in the presence of increased knee extension. We conclude that whereas sensory nerves may limit knee extension during ambulation, the health of the joint is not dependent upon this "extension limiting" function.

Serial kinematic analysis of the unstable knee after transection of the anterior cruciate ligament: temporal and angular changes in a canine model of osteoarthritis.

Transection of the anterior cruciate ligament in the dog leads to osteoarthritis. This study defines the kinematic changes in the unstable knee after transection of the cruciate ligament (six dogs) and after a sham operation (four dogs). In the dogs that were anterior cruciate ligament-deficient (ACL-D), the duration of stance 1 week postoperatively decreased 38% from the preoperative value, but only a 4% decrease was seen at 6 weeks. The duration of double hindlimb support increased from 6 to 19% of the entire cycle 1 week after surgery but returned to the baseline value by 18 weeks. As the unstable limb contacted the treadmill belt, the initial flexion (yield) and subsequent extension (propulsive) phases were not evident or were markedly attenuated in every ACL-D dog throughout the 26-week period of observation. The angular velocity patterns were characterized by a slight extension velocity at touchdown (compared with a zero value preoperatively) and a decrease in the peak velocities (both flexion and extension) during the remainder of the stance phase. None of these changes was observed in the animals that had a sham operation. These data indicate that, in the dog, the nervous system compensates for instability of the knee by altering angular, but not temporal, parameters. The extension velocity at touchdown and the reduction in peak flexion velocity during the yield component of the stance phase may reduce the ability of the limb to absorb impact forces and lead to the development of osteoarthritis of the knee.(ABSTRACT TRUNCATED AT 250 WORDS)

Serial kinematic analysis of the trunk and limb joints after anterior cruciate ligament transection: Temporal, spatial, and angular changes in a canine model of osteoarthritis.

To help elucidate how sensation-mediated kinematics modulate the rate of development of osteoarthritis in the unstable knee, we have examined the serial kinematic changes in hind- and forelimb joints, and alterations in vertical movement of the rump, in six dogs followed for 26 weeks after unilateral anterior curciate ligament transection. Although marked changes in the temporal parameters occurred in treadmill gait acutely in all four limbs, by the sixth postoperative week the stance and swing durations had returned to within ±10% of the baseline values, where they remained until sacrifice. As the cruciate-deficient limb contacted the treadmill surface, the amount of flexion (yield) of the unstable knee and ipsilateral ankle was reduced 10-20° (P < 0.05). In contrast, flexion of the contralateral ankle and knee increased about 10° during yield (P < 0.05), which was associated with a 100% increase in the extent of vertical movement of the rump (P < 0.05). Hip extension in the unstable limb increased about 10° during stance (P < 0.05), which moved the support provided by this limb away from the dog's centre of gravity. Kinematic changes in the forelimb joints were only transient, and less extensive than those in the hind limb. Before ligament transection, the joint angles of comparable joints of the different dogs were remarkably similar at touchdown. After ligament transection, the variability of the ipsilateral hip and knee joints was initially markedly increased. However, by 26 weeks after surgery the ipsilateral hip and knee touchdown joint angles of all the cruciate-deficient dogs were again similar to one another. Thus, after a period of 'trial and error', the dogs responded similarly to unilateral cruciate deficiency. This response was probably modulated by sensory nerves and reduced the trauma to the unstable knee during locomotion. Presumably, this facilitated effective, but suboptimal locomotion, while slowing the rate of progression of osteoarthritis in the unstable joint compared to dogs with a deafferented hind limb and unstable joint.