Allogeneic Mesenchymal Stromal Cells (MSCs) are of Comparable Efficacy to Syngeneic MSCs for Therapeutic Revascularization in C57BKSdb/db Mice Despite the Induction of Alloantibody.

Intramuscular administration of mesenchymal stromal cells (MSCs) represents a therapeutic option for diabetic critical limb ischemia. Autologous or allogeneic approaches may be used but disease-induced cell dysfunction may limit therapeutic efficacy in the former. Our aim was to compare the efficacy of allogeneic and autologous MSC transplantation in a model of hindlimb ischemia in diabetes mellitus and to determine whether allogeneic transplantation would result in the activation of an immune response. MSCs were isolated from C57BL/6 (B6) and diabetic obese C57BKSdb/db mice. Phosphate-buffered saline (control group), and MSCs (1 × 106) from B6 (allogeneic group) or C57BKSdb/db (syngeneic group) were administered intramuscularly into the ischemic thigh of C57BKSdb/db mice following the induction of hindlimb ischemia. MSCs derived from both mouse strains secrete several angiogenic factors, suggesting that the potential therapeutic effect is due to paracrine signaling. Administration of allogeneic MSCs significantly improved blood perfusion as compared with the control group on week 2 and 3, post-operatively. In comparison with the control group, syngeneic MSCs significantly improved blood perfusion at week 2 only. There was no statistical difference in blood perfusion between allogeneic and syngeneic MSC groups at any stages. There was no statistical difference in ambulatory and necrosis score among the three groups. Amputation of toes was only observed in the control group (one out of seven animals). Alloantibody was detected in three out of the eight mice that received allogeneic MSCs but was not observed in the other groups. In summary, we demonstrated comparable efficacy after transplantation of autologous and allogeneic MSCs in a diabetic animal model despite generation of an immune response.

Can 'Hot Spotting' Prove to be a Useful Tool to Identify Disproportionate ED Use in the Rural General Hospital Setting?

'Hot spotting' allows the identification of areas with disproportionate use of Emergency Department (ED) services. To date, 'hot spotting' has focused on large urban centres. The aim of this study was to determine if there are geographic hotspots for ED use in the rural general hospital. ED attendances were logged between 1st July 2013 and 30th June 2014. Frequent users and super users were isolated. Addresses were cross referenced against national census data to determine number of users per 500 population in geographically distinct regions. The number of frequent users ranged from 1.00/500 population to 4.88/500 population. Four out of nineteen areas had > or equals; 4 frequent users per 500 population. There was no correlation between number of users and distance from MGH (p=0.44). 77% of frequent users presented with mixed aetiologies. Nineteen percent of frequent attenders presented via GP referral only, 13% attended via self-referral only and 88% attended via GP and self-referral routes.

Hepatitis B core antibody-positive donors in cardiac transplantation: a single-center experience.

Hepatitis B virus (HBV) core antibody (HBcAb)-positive donors are increasingly utilized in solid organ transplantation. We report a single center's experience in cardiac transplantation with 18 HBcAb-positive donors. Available follow-up on recipients of cardiac allografts from HBcAb-positive donors, including 2 donors with low-level serum HBV DNA at the time of transplantation, demonstrated no documented donor-derived HBV transmission.

Renal transplantation using belatacept without maintenance steroids or calcineurin inhibitors.

Kidney transplantation remains limited by toxicities of calcineurin inhibitors (CNIs) and steroids. Belatacept is a less toxic CNI alternative, but existing regimens rely on steroids and have higher rejection rates. Experimentally, donor bone marrow and sirolimus promote belatacept's efficacy. To investigate a belatacept-based regimen without CNIs or steroids, we transplanted recipients of live donor kidneys using alemtuzumab induction, monthly belatacept and daily sirolimus. Patients were randomized 1:1 to receive unfractionated donor bone marrow. After 1 year, patients were allowed to wean from sirolimus. Patients were followed clinically and with surveillance biopsies. Twenty patients were transplanted, all successfully. Mean creatinine (estimated GFR) was 1.10 ± 0.07 mg/dL (89 ± 3.56 mL/min) and 1.13 ± 0.07 mg/dL (and 88 ± 3.48 mL/min) at 12 and 36 months, respectively. Excellent results were achieved irrespective of bone marrow infusion. Ten patients elected oral immunosuppressant weaning, seven of whom were maintained rejection-free on monotherapy belatacept. Those failing to wean were successfully maintained on belatacept-based regimens supplemented by oral immunosuppression. Seven patients declined immunosuppressant weaning and three patients were denied weaning for associated medical conditions; all remained rejection-free. Belatacept and sirolimus effectively prevent kidney allograft rejection without CNIs or steroids when used following alemtuzumab induction. Selected, immunologically low-risk patients can be maintained solely on once monthly intravenous belatacept.

The deceased organ donor with an "open abdomen": proceed with caution.

In solid organ transplantation, the disparity between donor supply and patients awaiting transplant continues to increase. The organ shortage has led to relaxation of historic contraindications to organ donation. A large percentage of deceased organ donors have been subjected to traumatic injuries, which can often result in intervention that leads to abdominal packing and intensive care unit resuscitation. The donor with this "open abdomen" (OA) presents a situation in which the risk of organ utilization is difficult to quantify. There exists a concern for the potential of a higher risk for both bacterial and fungal infections, including multidrug-resistant (MDR) pathogens because of the prevalence of antibiotic use and critical illness in this population. No recommendations have been established for utilization of organs from these OA donors, because data are limited. Herein, we report a case of a 21-year-old donor who had sustained a gunshot wound to his abdomen, resulting in a damage-control laparotomy and abdominal packing. The donor subsequently suffered brain death, and the family consented to organ donation. A multiorgan procurement was performed with respective transplantation of the procured organs (heart, liver, and both kidneys) into 4 separate recipients. Peritoneal swab cultures performed at the time of organ recovery grew out MDR Pseudomonas aeruginosa on the day after procurement, subsequently followed by positive blood and sputum cultures as well. All 4 transplant recipients subsequently developed infections with MDR P. aeruginosa, which appeared to be donor-derived with similar resistance patterns. Appropriate antibiotic coverage was initiated in all of the patients. Although 2 of the recipients died, mortality did not appear to be clearly associated with the donor-derived infections. This case illustrates the potential infectious risk associated with organs from donors with an OA, and suggests that aggressive surveillance for occult infections should be pursued.

Safety and efficacy of targeted busulfan therapy in children undergoing myeloablative matched sibling donor BMT for sickle cell disease.

Busulfan influences engraftment and toxicities during hematopoietic stem cell transplantation (HSCT). We report our single-institution experience of targeted busulfan therapy for myeloablative, matched sibling donor (MSD) HSCT for sickle cell disease (SCD) and assess the relationships of busulfan levels to engraftment and toxicities. Twenty-seven patients with SCD underwent MSD HSCT from 1993 to 2007, 25 with busulfan measurements. The conditioning regimen was busulfan (initial dose 0.875 mg/kg for 16 doses), CY and antithymocyte globulin. Busulfan area under curve (AUC) was determined with the first dose, and dose adjustments were made to target the desired AUC range. Median AUC was 963 µmol min/L (range 780-1305 µmol min/L). Engraftment occurred in all cases: 21 (84%) full donor chimerism (> 95% donor cells), 4 (16%) partial donor chimerism. Hepatic veno-occlusive disease (VOD) occurred in 8 (32%) patients. Lower AUC was seen with partial donor chimerism (862 ± 73 µmol min/L) versus full donor chimerism (AUC 1018 ± 122 µmol min/L) (P = 0.022). VOD was not associated with busulfan AUC (P = 0.153). Of 25 patients, 24 survived with median follow-up of 4.9 years. Our experience shows that targeting busulfan AUC above the range used in previous multicenter trials appears safe and may contribute to sustained engraftment in SCD.

A study of tubular potassium secretory capacity in older patients with hyperkalaemia.

OBJECTIVES: Sustained hyperkalaemia usually indicates a defect in renal potassium (K+) excretion and can be due to severe impairment of glomerular filtration rate (GFR). The major determinants of renal K+ secretion were studied in hyperkalaemic and normokalaemic elderly subjects to probe the major determinants of hyperkalaemia in this setting. DESIGN: The transtubular potassium gradient (TTKG) provides an index of tubular K+ secretion and normally rises in patients with significant hyperkalaemia. Both GFR(glomerular filtration rate) and TTKG were assessed at baseline and repeated after 3 hours following ingestion of 0.1mg of fludrocortisone in three groups. SETTING: An acute general hospital in the West of Ireland. PARTICIPANTS: 23 subjects in total; 8 older patients with unexplained hyperkalaemia (OHK), 8 older patients with normokalaemia (ONK) and 9 young normokalaemic controls (YNK). MEASUREMENTS: The GFR was either measured by 24 hour creatinine clearance estimation or calculated using the Cockroft and Gault formula.TTKG was calculated using a specific formula. RESULTS: Mean baseline TTKG was similar in all three groups and consequently inappropriately low in hyperkalaemic subjects. Three hours post fludrocortisone, the TTKG had risen significantly from baseline levels in the young subjects only (from 7.5+/-0.09 to 11.6+/-1.1, p<0.05). No significant increase was noted in either older group at this timepoint. CONCLUSIONS: The inappropriately low baseline TTKG in the OHK group as well as the absence of a response to fludrocortisone indicate tubular insensitivity to aldosterone. GFR values in both OHK (40.06+/-2.31) and ONK (55.58+/-6.1) groups were significantly lower than those in the YNK group (101.66+/-6.9). In aggregate, these findings indicate that older hyperkalaemic patients typically have both impairment of glomerular filtration and renal tubular K+ secretion and highlights the requirement for vigilance in elderly patients when using medications which interfere with tubular function.

Effect of myeloablative bone marrow transplantation on growth in children with sickle cell anaemia: results of the multicenter study of haematopoietic cell transplantation for sickle cell anaemia.

Although haematopoietic cell transplantation (HCT) is curative for sickle cell anaemia (SCA), concerns about its short- and long-term toxicities limit its application. A potential toxicity is an adverse effect on growth. To identify an HCT growth effect, serial height and weight measurements from 53 children and adolescents with SCA after receiving a transplant were compared to historical controls. Hierarchical Linear Models for longitudinal data were used for analysis. In general growth was not impaired by HCT for SCA in young children; however, diminished growth may occur if HCT is carried out near or during the adolescent growth spurt.

Proximal tibiofibular dislocation.

Proximal tibiofibular joint dislocation is an uncommon injury, which may be easily missed on plain radiography. If recognised, it can be treated in the emergency department, avoiding surgery and long term problems. The case is presented of a 22 year old male rugby player who was tackled from the left hand side while turning to the left. He heard a "pop" from his knee as he fell to the ground. Clinical examination revealed a prominence in the area of the fibular head. There was no evidence of peroneal nerve injury. Plain x rays confirmed a clinical suspicion for anterior dislocation of the proximal tibiofibular joint. Proximal tibiofibular joint dislocation typically occurs when the knee is slightly flexed and the foot is rotated and plantar flexed. Antero lateral dislocation is the most common pattern. Diagnosis is largely clinical, but the findings may be subtle. Plain films may not show any abnormality and computed tomography is the investigation of choice if there is clinical suspicion for the injury. The dislocation should be reduced in the emergency department, but controversy exists whether early mobilisation or casting is the most appropriate course of action.

Hematopoietic stem cell transplantation for multiply transfused patients with sickle cell disease and thalassemia after low-dose total body irradiation, fludarabine, and rabbit anti-thymocyte globulin.

Patients with sickle cell disease (N = 3) and thalassemia (N = 1) with high-risk features received hematopoietic stem cell transplantations (HCT) to induce stable (full or partial) donor engraftment. Patients were 9-30 years of age. Fludarabine, rabbit anti-thymocyte globulin (ATG), and 200 cGy total body irradiation were administered pre-transplant. Patients received bone marrow (N = 3) or peripheral blood stem cells (N = 1) from HLA-identical siblings, followed by mycophenolate mofetil and cyclosporine for post-grafting immunosuppression. Significant lymphopenia, but only moderate neutropenia and thrombocytopenia developed post transplant. No grade IV nonhematological toxicities or acute graft-versus-host disease (GVHD) were observed. At 3 months after transplantation, three of four patients had evidence of donor myeloid chimerism (range, 15-100%). However, after post transplant immunosuppression was discontinued, graft rejection occurred in all but one patient. This patient is now doing well 27 months post transplant with full donor engraftment. One patient died after a second transplant, and another patient experienced a stroke as her graft was being rejected. These results suggest that stable donor engraftment after nonmyeloablative HCT is difficult to achieve among immunocompetent patients with hemoglobinopathies and that new approaches will need to be developed before wider application of this transplantation method for hemoglobinopathies.

Bacillus anthracis contamination and inhalational anthrax in a mail processing and distribution center.

AIMS: Four inhalational anthrax cases occurred in a large mail processing and distribution center in Washington, DC, after envelopes containing Bacillus anthracis spores were processed. This report describes the results of sampling for B. anthracis spores during investigations conducted in October and December 2001. METHODS AND RESULTS: Wet swabs, wet wipes, vacuum sock, and air-filter samples were collected throughout the facility to characterize the extent of building contamination. The results showed widespread contamination of B. anthracis spores, particularly associated with one delivery bar code sorter (DBCS) machine that had sorted the spore-containing envelopes and an area where the envelopes were handled by postal workers. Spore concentrations decreased as distance from the DBCS machine increased, but spores were widely dispersed into surrounding areas. CONCLUSION: The spatial distribution of culture positive samples was closely related to the work areas of the inhalational anthrax cases and supported epidemiological evidence that the workers became ill from exposure to B. anthracis spores in areas where the contaminated envelopes had travelled. SIGNIFICANCE AND IMPACT OF THE STUDY: The results of this investigation were used to guide decontamination efforts and provided baseline spore concentrations for follow-up measurements after the building had been cleaned. Implementing methods to reduce aerosolization and dispersion of dust within the facility would reduce postal workers' potential exposures to bioterrorism agents.

Survival after HLA-identical allogeneic peripheral blood stem cell and bone marrow transplantation for hematologic malignancies: meta-analysis of randomized controlled trials.

The impact of peripheral blood stem cell transplantation (PBSCT) on survival relative to bone marrow transplantation (BMT) remains poorly defined. Several randomized controlled trials (RCTs) comparing HLA-matched related PBSC- and BMT for patients with hematologic malignancies have been published, yielding differing results. We conducted a meta-analysis of published RCTs to more precisely estimate the effect of PBSCT on survival. Seven trials that assessed survival were identified and included in our analysis. Using a fixed effects model, and combining the results of all seven trials, the summary odds ratio for mortality after PBSCT was 0.81 (95% CI, 0.62-1.05) when compared to BMT. Subgroup analysis revealed no association between the median PBSCT 34+ cell dose and relative risk for morality after PBSCT. However, there was an association between the proportion of patients enrolled with advanced-stage disease and the summary odds ratio for mortality. The pooled estimate was 0.64 for studies where patients with intermediate/advanced disease comprised at least 25% of enrollment, and was 1.07 for the studies enrolling a smaller proportion. This finding substantiates results from previously published studies that have demonstrated a survival advantage with PBSCT limited to patients with advanced disease.

Marketing to America's youth: evidence from corporate documents.

OBJECTIVE: To evaluate the claim that the tobacco industry does not market its products to youth. DESIGN: The data for this study come from tobacco industry documents collected from the tobacco industry's document websites, presently linked at http://www.tobaccoarchives.com. The websites were searched using "request for production" (RFP) codes, specified keyword searches, and serendipitous terms identified in document citations found with RFP and keyword searches. RESULTS: Industry documents show that the cigarette manufacturers carefully monitored the smoking habits of teenagers over the past several decades. Candid quotes from industry executives refer to youth as a source of sales and as fundamental to the survival of the tobacco industry. The documents reveal that the features of cigarette brands (that is, use of filters, low tar, bland taste, etc), packaging (that is, size, colour and design), and advertising (that is, media placements and themes and imagery) were developed specifically to appeal to new smokers (that is, teenagers). Evidence also indicates that relevant youth oriented marketing documents may have been destroyed and that the language used in some of the more recent documents may have been sanitised to cover up efforts to market to youth. CONCLUSIONS: The tobacco industry's internal documents reveal an undeniable interest in marketing cigarettes to underage smokers. The industry's marketing approaches run counter to and predicate methods for tobacco prevention: (1) keep the price of the product high; (2) keep product placements and advertising away from schools and other areas with a high volume of youth traffic; (3) make cigarette advertising (that is, themes and visual images) unappealing to youth; (4) make product packaging unappealing to youth; and (5) design the product so it is not easy to inhale.

Tax, price and cigarette smoking: evidence from the tobacco documents and implications for tobacco company marketing strategies.

OBJECTIVE: To examine tobacco company documents to determine what the companies knew about the impact of cigarette prices on smoking among youth, young adults, and adults, and to evaluate how this understanding affected their pricing and price related marketing strategies. METHODS: Data for this study come from tobacco industry documents contained in the Youth and Marketing database created by the Roswell Park Cancer Institute and available through http:// roswell.tobaccodocuments.org, supplemented with documents obtained from http://www.tobaccodocuments.org. RESULTS: Tobacco company documents provide clear evidence on the impact of cigarette prices on cigarette smoking, describing how tax related and other price increases lead to significant reductions in smoking, particularly among young persons. This information was very important in developing the industry's pricing strategies, including the development of lower price branded generics and the pass through of cigarette excise tax increases, and in developing a variety of price related marketing efforts, including multi-pack discounts, couponing, and others. CONCLUSIONS: Pricing and price related promotions are among the most important marketing tools employed by tobacco companies. Future tobacco control efforts that aim to raise prices and limit price related marketing efforts are likely to be important in achieving reductions in tobacco use and the public health toll caused by tobacco.

The cigarette pack as image: new evidence from tobacco industry documents.

OBJECTIVES: To gain an understanding of the role of pack design in tobacco marketing. METHODS: A search of tobacco company document sites using a list of specified search terms was undertaken during November 2000 to July 2001. RESULTS: Documents show that, especially in the context of tighter restrictions on conventional avenues for tobacco marketing, tobacco companies view cigarette packaging as an integral component of marketing strategy and a vehicle for (a) creating significant in-store presence at the point of purchase, and (b) communicating brand image. Market testing results indicate that such imagery is so strong as to influence smoker's taste ratings of the same cigarettes when packaged differently. Documents also reveal the careful balancing act that companies have employed in using pack design and colour to communicate the impression of lower tar or milder cigarettes, while preserving perceived taste and "satisfaction". Systematic and extensive research is carried out by tobacco companies to ensure that cigarette packaging appeals to selected target groups, including young adults and women. CONCLUSIONS: Cigarette pack design is an important communication device for cigarette brands and acts as an advertising medium. Many smokers are misled by pack design into thinking that cigarettes may be "safer". There is a need to consider regulation of cigarette packaging.

Tobacco Institute lobbying at the state and local levels of government in the 1990s.

OBJECTIVE: To describe variation in Tobacco Institute (TI) lobbying expenditures across states and test whether these expenditures vary in relationship to measures of tobacco control activity at the state level. INDEPENDENT VARIABLE: Data for this study came from the TI's State Activities Division (SAD) annual budgets for the years 1991-97, excluding 1993. These data include budgetary information pertaining to state and local lobbying activity and special projects reported by state. DEPENDENT VARIABLES: The following measures of state tobacco control activity during the period 1991 to 1997 were considered: (1) American Stop Smoking Intervention Study (ASSIST) funding; (2) voter initiatives to raise cigarette taxes; (3) cigarette excise tax level; (4) workplace smoking restrictions; (5) the intensification of smoke-free air laws covering private worksites, government worksites, and restaurants; (6) the intensification of strength of sales to minors laws; (7) the intensification of strength of laws that punish minors for possessing, purchasing, and/or using cigarettes; (8) state status as a major grower of tobacco; (9) partisan control of state government, 1996; and (10) an overall composite index reflecting a state's strength of tobacco control, combining cigarette prices with workplace and home smoking bans. RESULTS: The overall annual budget for the TI declined steadily during the 1990s, from $47.7 million in 1991 to $28.1 million by 1996. The proportion of the TI's budget allocated to the SAD remained relatively stable at about 30%. TI expenditures for lobbyists were highest in California where tobacco control activity has been strong for the past decade. We found significant associations between TI SAD expenditures and cigarette excise tax levels, the status of a state as a recipient of federal ASSIST funds, and changes in the strength of statewide laws that penalise minors for possessing, purchasing, and/or using cigarettes. We found little or no association between state and local lobbying budgets of the TI and changes in statewide smoke-free air laws, although we did find evidence of TI special project expenditures earmarked to specific states and localities to resist clean indoor air legislation/regulations (that is, Maryland and New York City). We found no significant correlation between TI lobbying expenditures and sales to minors' laws, status as a major producer of tobacco, or partisan control of state government. CONCLUSIONS: The findings from this study support the hypothesis that in the 1990s tobacco control activities such as raising cigarette excise taxes and participation in ASSIST attracted TI resources to undermine these efforts.

Fibrin degradation products, fibrin monomer and soluble fibrin in disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is characterized by activation of hemostasis and fibrinolysis resulting in the formation of thrombin and plasmin, and the characteristic effects of these enzymes on plasma fibrinogen can be useful in diagnosis. Thrombin cleaves fibrinopeptides from fibrinogen, forming fibrin monomer that rapidly polymerizes to form a clot. Small amounts can circulate in plasma as "soluble fibrin," which may have a complex composition and include fibrinogen and a variable amount of cross-linking. Plasmic degradation of cross-linked fibrin forms a heterogeneous group of degradation products reactive in assays for D-dimer, and their levels provide a measure of the amount of fibrin formation and lysis. Caution should be exercised in comparing quantitative results using different assays because of problems with standardization and variable reactivity with different molecular forms. Marked elevations of fibrin(ogen) degradation products are a constant finding in experimental animal models of DIC. In human models of DIC resulting from endotoxin infusion, D-dimer is elevated early and high levels persist, reflecting lysis of microvascular fibrin deposits. Elevated levels of D-dimer and soluble fibrin are very sensitive for the diagnosis of DIC, and a normal level has a high negative predictive value. Serial monitoring of soluble fibrin or D-dimer assays may be of value in evaluating the response to therapy and possibly in identifying at-risk patients.