Role of miRNAs and alternative mRNA 3'-end cleavage and polyadenylation of their mRNA targets in cardiomyocyte hypertrophy.

miRNAs play critical roles in heart disease. In addition to differential miRNA expression, miRNA-mediated control is also affected by variable miRNA processing or alternative 3'-end cleavage and polyadenylation (APA) of their mRNA targets. To what extent these phenomena play a role in the heart remains unclear. We sought to explore miRNA processing and mRNA APA in cardiomyocytes, and whether these change during cardiac hypertrophy. Thoracic aortic constriction (TAC) was performed to induce hypertrophy in C57BL/6J mice. RNA extracted from cardiomyocytes of sham-treated, pre-hypertrophic (2 days post-TAC), and hypertrophic (7 days post-TAC) mice was subjected to small RNA- and poly(A)-test sequencing (PAT-Seq). Differential expression analysis matched expectations; nevertheless we identified ~400 mRNAs and hundreds of noncoding RNA loci as altered with hypertrophy for the first time. Although multiple processing variants were observed for many miRNAs, there was little change in their relative proportions during hypertrophy. PAT-Seq mapped ~48,000 mRNA 3'-ends, identifying novel 3' untranslated regions (3'UTRs) for over 7000 genes. Importantly, hypertrophy was associated with marked changes in APA with a net shift from distal to more proximal mRNA 3'-ends, which is predicted to decrease overall miRNA repression strength. We independently validated several examples of 3'UTR proportion change and showed that alternative 3'UTRs associate with differences in mRNA translation. Our work suggests that APA contributes to altered gene expression with the development of cardiomyocyte hypertrophy and provides a rich resource for a systems-level understanding of miRNA-mediated regulation in physiological and pathological states of the heart.

APOE*E2 allele delays age of onset in PSEN1 E280A Alzheimer's disease.

Alzheimer's disease (AD) age of onset (ADAOO) varies greatly between individuals, with unique causal mutations suggesting the role of modifying genetic and environmental interactions. We analyzed ~50 000 common and rare functional genomic variants from 71 individuals of the 'Paisa' pedigree, the world's largest pedigree segregating a severe form of early-onset AD, who were affected carriers of the fully penetrant E280A mutation in the presenilin-1 (PSEN1) gene. Affected carriers with ages at the extremes of the ADAOO distribution (30s-70s age range), and linear mixed-effects models were used to build single-locus regression models outlining the ADAOO. We identified the rs7412 (APOE*E2 allele) as a whole exome-wide ADAOO modifier that delays ADAOO by ~12 years (ß=11.74, 95% confidence interval (CI): 8.07-15.41, P=6.31 × 10(-8), PFDR=2.48 × 10(-3)). Subsequently, to evaluate comprehensively the APOE (apolipoprotein E) haplotype variants (E1/E2/E3/E4), the markers rs7412 and rs429358 were genotyped in 93 AD affected carriers of the E280A mutation. We found that the APOE*E2 allele, and not APOE*E4, modifies ADAOO in carriers of the E280A mutation (ß=8.24, 95% CI: 4.45-12.01, P=3.84 × 10(-5)). Exploratory linear mixed-effects multilocus analysis suggested that other functional variants harbored in genes involved in cell proliferation, protein degradation, apoptotic and immune dysregulation processes (i.e., GPR20, TRIM22, FCRL5, AOAH, PINLYP, IFI16, RC3H1 and DFNA5) might interact with the APOE*E2 allele. Interestingly, suggestive evidence as an ADAOO modifier was found for one of these variants (GPR20) in a set of patients with sporadic AD from the Paisa genetic isolate. This is the first study demonstrating that the APOE*E2 allele modifies the natural history of AD typified by the age of onset in E280A mutation carriers. To the best of our knowledge, this is the largest analyzed sample of patients with a unique mutation sharing uniform environment. Formal replication of our results in other populations and in other forms of AD will be crucial for prediction, follow-up and presumably developing new therapeutic strategies for patients either at risk or affected by AD.

Inlay osmotic pump tablets containing metformin and glipizide.

The goal of diabetes therapy today is to achieve and maintain as near normal glycemia as possible to prevent the long-term microvascular and macrovascular complications of an elevated blood glucose. A newly developed inlay osmotic pump tablet (IOPT) can deliver glipizide (GLZ) and metformin HCl (MET) gradually in controlled manner. The aim of present investigation was to prepare the IOPT that can deliver >75% of GLZ in 2 h, whereas MET released after 2 h and sustained up to 12 h. In the present work, HP-ß-CD was used to modify the solubility of GLZ before incorporating in the osmotic system and MET was spray-dried with HPMC A15C to modify its release profile, flow property, and compressibility. Various parameters mainly G(75%) (75% GLZ release), t(LMET) (lag time of MET release from device), Q(10 h) (percent of MET released within 10 h), and RSQ(ZERO) (R(2) of release data fitted to zero-order equation) were used to compare different formulations. The effects of different formulation variables, that is, osmagents, concentration of hydrophilic polymer, diameter of drug releasing orifice, and coating composition on the drug release profile were investigated. The release rate of GLZ could be effectively modified by the addition of sodium carbonate and sodium chloride, whereas the release rate of MET was adjusted by dual-coating system and by addition of hydrophilic polymer. The developed inlay osmotic system could be effective in the multidrug therapy of diabetes by delivering both drugs in a controlled manner.

Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the "Trifecta and Pentafecta".

Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if "Trifecta" and "Pentafecta" outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008-2019) was analysed. "Pentafecta" was defined as achievement of "Trifecta" (negative surgical margin, no postoperative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Binary logistic regression analysis was conducted to predict factors which may prevent achieving a Trifecta/Pentafecta. Median tumour size was 3 cm and mean WIT was 15 min. Positive surgical margins (PSM) occurred in 2 cases. Overall, the intra-operative complication rate was 7%. One recurrence conferred 5-year cancer-free survival of 97%. Trifecta outcome was achieved in 169 (67%) and Pentafecta in 141 (56%) of cases. At logistic regression analysis, intraoperative blood loss was the only factor to affect Trifecta achievement (p = 0.018). Advanced patient age negatively impacted Pentafecta achievement (p = 0.010). The Trifecta and Pentafecta outcomes are easily applicable to PN data, and offer an internationally comparable PN outcome, quality measure. We recommend applying this standardization to national data collection to improve the quality of reporting and ease of interpretation of surgeon/centres' outcomes.

The first cytogenetic map of the tuatara, Sphenodon punctatus.

Tuatara, Sphenodon punctatus, is the last survivor of the distinctive reptilian order Rhynchocephalia and is a species of extraordinary zoological interest, yet only recently have genomic analyses been undertaken. The karyotype consists of 28 macrochromosomes and 8 microchromosomes. A Bacterial Artificial Chromosome (BAC) library constructed for this species has allowed the first characterization of the tuatara genome. Sequence analysis of 11 fully sequenced BAC clones (approximately 0.03% coverage) increased the estimate of genome wide GC composition to 47.8%, the highest reported for any vertebrate. Our physical mapping data demonstrate discrete accumulation of repetitive elements in large blocks on some chromosomes, particularly the microchromosomes. We suggest that the large size of the genome (5.0 pg/haploid) is due to the accumulation of repetitive sequences. The microchromosomes of tuatara are rich in repetitive sequences, and the observation of one animal that lacked a microchromosome pair suggests that at least this microchromosome is unnecessary for survival. We used BACs bearing orthologues of known genes to construct a low-coverage cytogenetic map containing 21 markers. We identified a region on chromosome 4 of tuatara that shares homology with 7 Mb of chicken chromosome 2, and therefore the orthologous region of the snake Z chromosome. We identified a region on tuatara chromosome 3 that is orthologous to the chicken Z, and a region on chromosome 9 orthologous to the mammalian X. Since the tuatara determines sex by temperature and has no sex chromosomes, this implies that different tuatara autosome regions are homologous with the sex chromosomes of mammals, birds and snakes. We have identified anchor BAC clones that can be used to reliably mark chromosomes 3-7, 10 and 13, some of which are difficult to distinguish based on morphology alone. Fluorescence in situ hybridization mapping of 18S rDNA confirms the presence of a single NOR located on the long arm of chromosome 7, as previously identified by silver staining. Further work to construct a dense physical map will lead to a better understanding of the dynamics of genome evolution and organization in this isolated species.

Robotic laparoscopic surgery: cost and training.

The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.

Trans-obturator tape: a single centre experience.

AIM: To assess the clinical outcome of TOT tape for stress and mixed urinary incontinence in a single centre. METHODS: From March 2002 to October 2006, 82 patients completed the study, all were evaluated at 3 and 12 months by physical examination and validated questionnaires. Seventy nine patients had the procedure under epidural anaesthesia and all women received antibiotics starting before surgery. RESULTS: TOT was mostly performed as a day case surgery with short operative time of 22 minute (range 15-38 minute). A total of 62 (70.4%) patients were discharged from the hospital within a few hours (4.3 +/- 1.7 hours). CONCLUSION: The TOT tape can safely be performed as a day-case procedure, which has a continence cure rate of approximately 80%. This figure is comparable with the more established TVT, however the TOT tape has a significantly lower morbidity in our experience.

Does stigma curvature promote delayed selfing? An experimental investigation in Triodanis perfoliata (Campanulaceae).

Self-fertilisation that is delayed until after opportunities for outcrossing have ceased has been argued to provide both the reproductive assurance benefits of selfing and the genetic advantages of outcrossing. In the Campanulaceae, presentation of pollen on stylar hairs and progressive stigma curvature have been hypothesised to facilitate delayed selfing, but experimental tests are lacking. Stigma curvature is common in Campanula, a genus largely characterised by self-incompatibility, and therefore is unlikely to have initially evolved to promote self-fertilisation. In derived self-compatible species, however, stigma curvature might serve the secondary function of delayed selfing. We investigated delayed selfing in Triodanis perfoliata, a self-compatible relative of Campanula. Using floral manipulation experiments and pollen tube observations, we quantified the extent and timing of self-pollination. Further, we hypothesised that, if stigma curvature provides the benefit of delayed selfing in Triodanis, selection should have favoured retention of self-pollen through the loss of a stylar hair retraction mechanism. Results of a stigma removal experiment indicated that autonomous selfing produces partial seed set, but only some selfing was delayed. Pollen tube observations and a flower senescence assay also supported the finding of partial delayed selfing. Scanning electron microscopy revealed that pollen-collecting hairs retract during anthesis, which may limit the extent of delayed selfing. Delayed selfing appeared to be only partially effective in T. perfoliata. The stylar hair retraction in this species would seem to contradict selection for selfing. We suggest that caution and rigour are needed in interpreting floral traits as adaptive mechanisms for delayed selfing.

Nonmyeloablative allogeneic stem-cell transplantation for metastatic renal cell cancer: a review and update.

Metastatic renal cell carcinoma (RCC) is resistant to conventional chemotherapy and radiotherapy. However, immunotherapy appears to be effective in 15-20% of cases, with interleukin-2 becoming the standard therapy for this disease. As a consequence of the immune susceptibility of RCC, other avenues of immunotherapy are being explored, such as nonmyeloablative allogeneic stem cell transplantation (NST). A number of trials have shown NST to be effective in varying degrees, causing partial or complete regression. Although nonmyeloablative conditioning is safer than myeloablative conditioning, its role has yet to be clearly proven as many studies have shown variable effect. Alongside this limitation, transplant-related toxicity also forms obstacles. Regardless of the limitation of NST, further refinement of the technique, with appropriate patient selection, may lead to this being an effective therapeutic choice for a significant number of individuals.

Quantitative cytochemical detection of malignant and potentially malignant cells in the colon.

It was found to be possible to distinguish malignant cells from normal cells by using an oxygen-sensitive tetrazolium salt (neotetrazolium) for the histochemical demonstration of glucose-6-phosphate dehydrogenase activity in cryostat sections of human colon. We have studied 12 cases of established adenocarcinoma of the colon in addition to 4 of ulcerative colitis and 4 of adenomatous polyposis (polyposis coli). In a nitrogen atmosphere the activities of malignant and normal cells were similar. However, after incubation in an atmosphere of pure oxygen, only malignant cells gave a positive reaction after 5 min. Three of the four cases of adenomatous polyposis gave a positive reaction for glucose-6-phosphate dehydrogenase activity in oxygen in a manner similar to that of specimens with severe dysplasia. In general, positive foci were histologically indistinguishable from the neighboring tubuli. However, foci of severely dysplastic epithelium usually showed a positive reaction. All three patients eventually developed clear-cut severe dysplasia. The other patient, who showed a negative reaction in oxygen, was diagnosed after 3 years as not suffering from dysplasia. All cases of ulcerative colitis gave a reaction in oxygen comparable with that of normal cells. Therefore, the areas with a positive reaction are considered to be either in the process of malignant transformation or malignant. An explanation for the oxygen insensitivity of cancer cells appeared to be a decrease in the activity of superoxide dismutase (EC 1.15.1.1), as addition of exogenous superoxide dismutase to malignant cells caused a normal reaction. We wish to suggest that this test in combination with the routine histology may be exploited for the diagnosis of polyps in premalignant conditions.

Estimation of loss and analysis of nicotine, reducing sugar and chloride in bidi tobacco due to reniform nematode under pot conditions.

Estimation of avoidable loss in yield of bidi tobacco due to reniform nematode under pot conditions revealed that variety A 119 suffered heavily than ABT 10 due to reniform nematode. Inoculation of reniform nematode @ 2000 J4 per plant significantly reduced the plant growth characters and increased nematode multiplication preferring A 119 variety. Estimation of avoidable loss in cured shoot yield of bidi tobacco due to infection of reniform nematode in individual variety ABT 10 and A 119 has been estimated to the tune of 30.5 and 34.2 per cent with overall loss 31.9 per cent in both the variety 60 DAI. Simply growing of ABT 10 variety irrespective of infection of reniform nematode avoided 29.5 per cent loss in cured shoot yield. ABT 10 recorded significantly high nicotine, reducing sugar and chloride than A 119; inoculation of reniform nematode significantly increased nicotine, reducing sugar and chloride compared to no inoculation. Interaction indicated that inoculation of 2000 J4 of reniform nematode significantly increased nicotine, reducing sugar and chloride in A 119 compared to no inoculation; while significantly reduced reducing sugar and increased chloride in ABT 10. There was no significant impact of infection of reniform nematode on nicotine in ABT 10.

Comparative pathogenicity of reniform nematode on root-knot resistant and susceptible bidi tobacco.

Comparative pathogenicity of reniform nematode on root-knot resistant ABT 10 and susceptible bidi tobacco A119 revealed that ABT 10 was found significantly superior to A119 with respect to plant growth characters and as good as A119 with respect to multiplication of reniform nematode. Initial inoculum of 1,000 J4 of the nematode found damaging to both ABT 10 and A119 varieties of bidi tobacco.

DNA-binding phosphoproteins induced after T cell activation: effects of cyclosporin A.

To define novel proteins involved in the early transcriptional response during the activation of human T lymphocytes, we used a high-resolution, two-dimensional gel electrophoresis system to identify nuclear, deoxyribonucleic acid (DNA) binding proteins exhibiting rapid changes in phosphorylation following cell stimulation. We identified 18 nuclear proteins whose phosphorylation level changed more than 5-fold upon activation. Of these, 11 were found to possess DNA-binding properties. The 11 phosphoproteins with DNA-binding activity, along with 4 others, were analyzed further. Phosphoamino acid analysis revealed several sets of proteins with different phosphorylated residues Kinetic analysis of the phosphorylation of the selected proteins was performed and revealed a complex group of transient and sustained responses to cell activation. Finally, the activation-induced changes in one set of phosphoproteins were dramatically inhibited by cyclosporin A. We suggest that these phosphoproteins may be directly involved in regulating the transcriptional response to cellular activation by external stimuli.

Dipyridamole potentiates antipurine antifolate activity in the presence of hypoxanthine in tumor cells but not in normal tissues in vitro.

The cytotoxicity of the antifolate inhibitors of de novo purine biosynthesis, lometrexol (LTX) and LY309887, can be abolished by hypoxanthine (HPX) salvage. The nucleoside transport inhibitor, dipyridamole (DP) can prevent HPX rescue from LTX growth inhibition in a cell line-specific manner. The studies described here have shown that, excluding colon and hematological malignancies, DP prevents HPX rescue from LTX growth inhibition in approximately one-third of cell lines with otherwise limited tissue specificity. The clinical dose-limiting toxicities of antipurine antifolates are to the bone marrow and gastrointestinal tract. In vitro models of these normal tissues were established, and the effect of DP on HPX rescue from LY309887 treatment was studied. Growth inhibition assays are not feasible in these primary cultures; therefore, an alternative assay, cellular ATP depletion, was validated in four tumor cell lines as a marker of de novo and salvage purine synthesis. In LY309887-treated cells, DP prevented HPX-mediated maintenance of ATP levels only in cell lines in which DP inhibited HPX rescue from antifolate cytotoxicity. Hence, ATP depletion is a reliable indicator of sensitivity of HPX transport to DP when direct cell growth measurement is impractical. In primary cultures of human hematopoetic progenitor cells and mouse small intestine, coincubation with HPX prevented LY309887-mediated ATP depletion, which was not blocked by DP. These data suggest that DP would not prevent HPX rescue from antipurine antifolate growth inhibition in sensitive normal tissues, whereas activity against certain solid human tumors would be maintained.

Erythropoietin activation of AP1 (Fos/Jun).

Erythropoietin (Epo) is the principal natural inducer of erythroid differentiation. The mechanisms by which signals generated at the Epo receptor (Epo-R) are transmitted to the nucleus are being explored. We now report that Epo strongly increases the activity of the transcription factor AP1 in both transformed and normal erythroid cells. Using antibodies to Fos and Jun, we have found that the Epo-induced AP1 heterodimer is composed primarily of authentic Fos and Jun proteins. Blocking protein kinase C (PKC) activity with H7 completely prevented the increase in AP1 activity in response to Epo. Importantly, the increase in AP1 activity was not due to increased expression of either c-fos or c-jun, as evidenced by the steady-state mRNA levels of both genes. Our results suggest that Epo may induce AP1 activity via a co- or posttranslational mechanism, presumably through modification of the Fos and/or Jun proteins.

Surgical anatomy of the pudendal nerve and its branches in South Africans.

Dissection of the pudendal nerve (PN) and its branches in 71 cadavers revealed anatomic variations not previously described. Knowledge of this variation is necessary to prevent nerve injury resulting in sexual of sensory dysfunction. Because descriptions vary, this study re-evaluated the anatomy of the PN as implicated in perineal procedures in South Africans. The course of the PN from the gluteal region into the perineum was dissected in an adult sample of both sexes and of African and European ancestry. Distances between PN and branches to applicable landmarks were measured. Basic descriptive statistics and comparisons were carried out between groups. In 5/13 African females, the inferior rectal nerve (IRN) entered the gluteal region separately and in 12/13 cases it passed medial to the ischial spine with the PN. The dorsal nerve of the clitoris or penis (DNC/DNP) was closer to the bony frame in those of European ancestry. The IRN branches were more superficial in females, but deeper in males of European ancestry. In African females, a PN block and Richter stitch should be placed more medial. Outside-in transobturator tape procedures might endanger the DNC/DNP in obese individuals. In females of European ancestry the IRN branches are compromised during ischioanal abscess drainage. In males of European ancestry, the dorsal penile nerve block might be less effective. Predictions should be verified clinically.

Increased expression of the SA gene in the kidney of the spontaneously hypertensive rat is localized to the proximal tubule.

OBJECTIVE: To identify the site of the increased expression of the SA gene in the kidney of the spontaneously hypertensive rat (SHR) compared with the Wistar-Kyoto (WKY) rat. METHODS: In situ hybridization of SHR and WKY rat kidney sections with a radioactively labelled rat SA complementary DNA probe. RESULTS: Compared with WKY rat kidney sections, the probe bound intensely to the SHR renal cortex. Binding was sensitive to pretreatment of the section with RNAase A. Microscopic examination after autoradiography showed the increased signal in the SHR to be localized over proximal tubules. Background signal was observed over glomeruli, distal tubules, interlobular arteries and afferent arterioles. CONCLUSIONS: The localization of the increased expression of the SA gene in the SHR kidney compared with the WKY rat kidney to the proximal tubule suggests that it might influence blood pressure through effects on tubular function. Several differences in proximal tubular function have already been described between the SHR and WKY rat, and the relationship of these to tubular SA gene expression now need to be investigated. However, in the absence of any known functions for the SA gene product it is also possible that it might act through entirely novel, still undefined mechanisms.

A quantitative histochemical study of D-amino acid oxidase activity in rat liver in relationship with feeding conditions.

The histochemical method for the demonstration of D-amino acid oxidase activity in rat liver, based on the use of cerium ions and the diaminobenzidine-cobalt-hydrogen peroxide procedure, was improved by the application of unfixed cryostat sections and a semipermeable membrane interposed between section and gelled incubation medium. The amount of final reaction product precipitated in a granular form was about four times higher with this technique in comparison with conventional procedures using fixed sections and aqueous incubation media. The specificity of the reaction was proven by the 70% reduction of the amount of final reaction product when incubating in the presence of substrate and D,L-beta-hydroxybutyrate, a specific inhibitor of D-amino acid oxidase activity. Cytophotometric analysis of liver sections revealed that the specific test minus control reaction was linear with incubation time and section thickness. The Km value of the enzyme of 10.3 +/- 2.7 mM, as determined in periportal areas, is about five times the value found with biochemical methods in liver cell homogenates. The enzyme activity in periportal areas is about five times the activity in pericentral areas. Fasting (24 and 48 hr) induced a significant decrease in D-amino acid activity in periportal and pericentral areas. The possible physiological role of the enzyme in liver is discussed.

Total lymphoid irradiation for refractory acute rejection in heart-lung and lung allografts.

Persistent or recurrent acute allograft rejection (AR) refractory to high-dose steroid therapy can adversely affect long-term outcomes of heart-lung (HLT), bilateral-lung (BLT), and single-lung (SLT) transplantations. The use of total lymphoid irradiation (TLI) for the management of refractory acute AR in six transplant recipients (two men, four women; mean age, 29.8 +/- 3.8 years) is detailed. There are two HLT (primary pulmonary hypertension [PPH], cystic fibrosis [CF]), 1 BLT (pulmonary hypertension postventricular septal defect repair), and 3 SLT (sarcoid, PPH, congenital heart disease with atrial septal defect) recipients. Refractory AR is defined as persistent rejection unresponsive to high-dose steroid therapy in all cases. The BLT and SLT recipients had at least two moderate and one mild AR events per patient. The HLT recipients had at least two moderate acute heart and one severe and one mild asynchronous acute lung rejection events per patient. A total of 800 cGy of total lymphoid irradiation (TLI) was administered over a 5-week period. Mild and transient leukopenia was the only observed side effect. The patient with PPH received TLI 313 days after HLT for recurrent AR at another institution and died of ARDS 4 weeks after completing TLI. The patient with CF received TLI 707 days after HLT and died 457 days after TLI of severe obliterative bronchiolitis (OB) with multiorgan failure. The patient with BLT received TLI 176 days after transplant and died 372 days after TLI of respiratory failure related to severe rejection. One patient with SLT received TLI 78 days after transplant and died 679 days after TLI of severe acute AR. The two remaining patients with SLTs have been free from acute AR for more than 4 years. The patient with sarcoidosis received TLI 37 days after SLT following a clinical rejection event and two severe acute AR events. He is alive with normal lung function 5 years later. The patient with PPH received TLI 108 days after SLT following three moderate acute AR events and is alive with stable OB 4 years later. These limited preliminary results suggest that TLI has merit for the treatment of intractable acute AR following HLT and lung transplantation.

Actuarial survival of heart-lung and bilateral sequential lung transplant recipients with obliterative bronchiolitis.

BACKGROUND: Obliterative bronchiolitis is a progressive form of obstructive airway disease that threatens long-term survival in lung transplant recipients. Its incidence and the long-term survival of lung transplant recipients with obliterative bronchiolitis are unknown. METHODS: The results of 89 heart-lung and 13 bilateral sequential lung transplant survivors beyond 90 days of their operation were analyzed. The date of diagnosis for obliterative bronchiolitis was established histologically (presence of submucosal fibrosis) or physiologically by a persistent reduction in the forced vital capacity to less than 0.7 for greater than 6 weeks. There were 43 patients without obliterative bronchiolitis and 59 patients with obliterative bronchiolitis. RESULTS: No differences were found in the mean age and gender ratios between the two groups. The actuarial 1-, 5-, and 10-year percentage freedom from obliterative bronchiolitis was 72 +/- 4.6, 30 +/- 5.6, and 15 +/- 7.4, respectively, with a median onset of 689 days (range 55 to 3404 days). About half the patients with biopsy-proven obliterative bronchiolitis had a fall in their forced expiratory flow at 50% of forced vital capacity/forced vital capacity nearly 4 months before fulfilling the forced expiratory volume in 1 second criteria established by the Working Group on chronic lung dysfunction. The actuarial 1-, 5-, and 10-year percentage survival of obliterative bronchiolitis negative patients was 90 +/- 4.5, 74 +/- 8.4, and 66 +/- 10.6, respectively, versus 90 +/- 3.9, 49 +/- 6.9, and 27 +/- 10.0, respectively, for obliterative bronchiolitis positive patients (p = 0.38). The actuarial 1-, 3-, 5-, 8-, and 10-year percentage survival of lung transplant recipients after the diagnosis of obliterative bronchiolitis was 74 +/- 5.8, 50 +/- 7.5, 43 +/- 7.8, 23 +/- 8.7, and 11 +/- 9.1, respectively, with a median survival of 1084 days (range 0 to 3442 days). CONCLUSIONS: The forced expiratory flow at 50% of forced vital capacity/forced vital capacity is a more sensitive indicator for the early detection of obliterative bronchiolitis than the forced expiratory volume in 1 second after heart-lung or bilateral sequential lung transplantation. The obliterative bronchiolitis negative group survival tends to be better than the obliterative bronchiolitis positive group. The obliterative bronchiolitis positive lung transplant recipients have reasonable outcomes with a median survival time of nearly 3 years after the diagnosis of obliterative bronchiolitis. Earlier detection of obliterative bronchiolitis and refinements in management may further improve these results.