Long-Term Liver Expression of an Apolipoprotein A-I Mimetic Peptide Attenuates Interferon-Alpha-Induced Inflammation and Promotes Antiviral Activity.

Apolipoprotein A-I mimetic peptides are amphipathic alpha-helix peptides that display similar functions to apolipoprotein A-I. Preclinical and clinical studies have demonstrated the safety and efficacy of apolipoprotein A-I mimetic peptides in multiple indications associated with inflammatory processes. In this study, we evaluated the effect of the long-term expression of L37pA in the liver by an adeno-associated virus (AAV-L37pA) on the expression of an adeno-associated virus encoding interferon-alpha (AAV-IFNα). Long-term IFNα expression in the liver leads to lethal hematological toxicity one month after AAV administration. Concomitant administration of AAV-L37pA prevented the lethal toxicity since the IFNα expression was reduced one month after AAV administration. To identify the mechanism of action of L37pA, a genomic and proteomic analysis was performed 15 days after AAV administration when a similar level of IFNα and interferon-stimulated genes were observed in mice treated with AAV-IFNα alone and in mice treated with AAV-IFNα and AAV-L37pA. The coexpression of the apolipoprotein A-I mimetic peptide L37pA with IFNα modulated the gene expression program of IFNα, inducing a significant reduction in inflammatory pathways affecting pathogen-associated molecular patterns receptor, dendritic cells, NK cells and Th1 immune response. The proteomic analysis confirmed the impact of the L37pA activity on several inflammatory pathways and indicated an activation of LXR/RXR and PPPARα/γ nuclear receptors. Thus, long-term expression of L37pA induces an anti-inflammatory effect in the liver that allows silencing of IFNα expression mediated by an adeno-associated virus.

Hematologic Manifestations of Nutritional Deficiencies: Early Recognition is Essential to Prevent Serious Complications.

Nutritional deficiencies, including deficiencies of vitamin B12, copper, and vitamin C, may result in cytopenias and hematologic symptoms. Early recognition of these deficiencies is imperative for prompt treatment and improvement in hematologic and other manifestations. We describe 5 cases which illustrate the hematologic manifestations of nutritional deficiencies and challenges to initial diagnosis and management. Supplementation of the deficient vitamin or micronutrient in all of these cases resulted in rapid resolution of cytopenias, hemorrhage, and other associated hematologic symptoms. We also review other nutritional deficiencies that manifest with hematologic symptoms and compile recommendations on treatment and expected time to response.

Clinical observation of Shuanghuang Shengbai Granule () on prevention and treatment of myelosuppression caused by chemotherapy in cancer patients.

OBJECTIVE: To study the efficacy and safety of Shuanghuang Shengbai Granule (, SSG), a traditional Chinese herbal medicine, on myelosuppression of cancer patients caused by chemotherapy. METHODS: A total of 330 patients were randomly assigned to the treatment group (220 cases, analysed 209 cases) and the control group (110 cases, analysed 102 cases) with a 2:1 ratio by envelope method. The patients in the treatment group at the first day of chemotherapy started to take SSG for 14 days, while the patients in the control group took Leucogon Tablets. The changes of the blood routine, clinical symptoms and immune function in both groups were observed for safety and efficacy evaluation. RESULTS: At the 7th day of chemotherapy, the white blood cells (WBCs) level in the treatment group was significantly higher than that in the control group (P<0.05). After treatment, the WBCs rate in the normal range accounted for 50.2% in the treatment group, the myelosuppression of WBCs and neutrophil were mainly grade I, while 8.1% and 5.7% of patients emerged grade III and grade IV myelosuppression, respectively. The incidence of myelosuppression of the treatment group was significantly lower than that of the control group (P<0.05). The total effective rate of Chinese medicine syndrome in the treatment group was significantly higher than that in the control group (84.2% vs. 72.5%, P<0.05). The immune cell levels in both groups were maintained in the normal range. Compared with that before treatment, the levels of CD3+ and CD4+ cells were significantly increased in the treatment group after treatment (P<0.05). The discrepancy of CD3+ and CD4+ cell activity before and after treatment in both groups were significantly different (P<0.05). No obvious adverse event occurred in both groups. CONCLUSION: SSG had a protection effect on bone marrow suppression, and alleviated the clinical symptoms together with clinical safety.

Complications of Reduced Intensity Conditioning HSCT for XIAP Deficiency (Alloimmune Cytopenias and HLH) Successfully Managed With Donor Lymphocyte Infusion.

X-linked inhibitor of apoptosis protein deficiency is a rare illness and although stem cell transplant is curative, full intensity conditioning is associated with high mortality rates. We describe a child with unusual complications associated with residual host lymphocytes following reduced intensity stem cell transplant. Recipient derived, donor directed, antigranulocyte antibodies led to life-threatening and prolonged neutropenia and residual recipient lymphocytes reestablished hemophagocytic lymphohistiocytosis after withdrawal of immune suppression despite high levels of whole blood chimerism. Hemophagocytic lymphohistiocytosis was abolished following specific improvement in donor T-cell chimerism after donor lymphocyte infusions, and alloimmune cytopenias were no longer evident.

Calf-level factors associated with bovine neonatal pancytopenia--a multi-country case-control study.

Bovine neonatal pancytopenia (BNP), a high fatality condition causing haemorrhages in calves aged less than 4 weeks, was first reported in 2007 in Germany and subsequently observed at low incidence in other European countries and New Zealand. A multi-country matched case-control study was conducted in 2011 to identify calf-level risk factors for BNP. 405 BNP cases were recruited from 330 farms in Belgium, France, Germany and the Netherlands by laboratory confirmation of farmer-reported cases. Up to four calves of similar age from the same farm were selected as controls (1154 calves). Risk factor data were collected by questionnaire. Multivariable modelling using conditional logistic regression indicated that PregSure®BVD (PregSure, Pfizer Animal Health) vaccination of the dam was strongly associated with BNP cases (adjusted matched Odds Ratio - amOR 17.8 first lactation dams; 95% confidence interval - ci 2.4, 134.4; p = 0.005), and second or more lactation PregSure-vaccinated dams were more likely to have a case than first lactation vaccinated dams (amOR 2.2 second lactation; ci 1.1, 4.3; p = 0.024; amOR 5.3 third or more lactation; ci 2.9, 9.8; p = <0.001). Feeding colostrum from other cows was strongly associated with BNP if the dam was not PregSure-vaccinated (amOR 30.5; ci 2.1, 440.5; p = 0.012), but the effect was less if the dam was PregSure-vaccinated (amOR 2.1; ci 1.1, 4.0; p = 0.024). Feeding exclusively dam's milk was a higher risk than other types of milk (amOR 3.4; ci 1.6, 7.5; p = 0.002). The population attributable fractions were 0.84 (ci 0.68, 0.92) for PregSure vaccination, 0.13 (ci 0.06, 0.19) for feeding other cows' colostrum, and 0.15 (ci 0.08, 0.22) for feeding dam's milk. No other calf-level factors were identified, suggesting that there are other important factors that are outside the scope of this study, such as genetics, which explain why BNP develops in some PregSure-colostrum-exposed calves but not in others.

A colostrum substitute prevents bovine neonatal pancytopenia (BNP) in a herd with previously BNP-affected calves.

The objective of this study was to demonstrate that bovine neonatal pancytopenia (BNP) can be prevented when intake of maternal colostrum is prevented in a dairy farm with verified BNP cases. A group of 30 female calves was fed with a colostrum substitute instead of maternal colostrum (group A) whereas the control group of 30 female calves was fed with the colostrum of their own mothers (group B). The female calves were randomly assigned to groups A or B. All 60 calves were daily blood sampled in the first eleven days of life, afterwards up to the age of three weeks one blood sample was taken every other day. All blood samples were analyzed for thrombocyte and leucocyte counts. In addition, 113 calves of both sexes, which were born during the trial period, were blood sampled once at 6-10 days old. In group A, no BNP positive calf was verified. In group B, eight calves with a significant decrease of thrombocyte and leucocyte counts were observed. Only one of these eight calves had clinical signs consistent with BNP and the other seven calves were classified as subclinical BNP cases. Of the other 113 contemporary calves, eleven animals had clinical signs of BNP accompanied by a decrease of thrombocyte and leucocyte counts and four of these eleven calves died due to BNP. Our results revealed that replacement of maternal colostrum can prevent subclinical and clinical cases of BNP as well as losses due to BNP in a dairy herd with verified BNP-cases and in addition, that colostrum from these cows was the major risk factor for BNP in this dairy herd.

Effect of the vaccination scheme on PregSure® BVD induced alloreactivity and the incidence of Bovine Neonatal Pancytopenia.

Bovine Neonatal Pancytopenia (BNP) is a new neonate-maternal incompatibility phenomenon caused by vaccine-induced, maternal alloantibodies. The syndrome affects newborn calves at the approximate age of ten days and is characterized by spontaneous bleeding, severe anemia with an almost complete destruction of the red bone marrow. During the past two years the causal role of bioprocess impurities in PregSure(®)BVD, a strongly adjuvanted, inactivated vaccine against Bovine Virus Diarrhoea (BVD), in the induction of BNP causing alloantibodies has clearly been established. Despite intensive research efforts that have elucidated the basic principles of the BNP immunopathology still a number of questions remain open. In the current manuscript we address the puzzling observation that BNP incidences vary widely between different regions: as an example we compare the BNP incidences in the German Federal States of Bavaria and Lower Saxony. In Bavaria the BNP-incidence reaches 100 cases per 100,000 doses PregSure(®)BVD, while in Lower Saxony the incidence is as low as 6 cases per 100,000 doses. In Bavaria the vaccine has always been used according to the instructions for use. By contrast, in Lower Saxony BVD-immunization was performed according to a two-step vaccination protocol including a first immunization with an inactivated BVD-vaccine followed by booster immunizations with a live-attenuated BVD-vaccine. As a consequence, those cattle that received PregSure(®)BVD received in general more than two doses in Bavaria, while in Lower Saxony cows received at maximum one dose. By experimental immunization we can show that the two-step regimen including PregSure(®)BVD as a priming vaccine results in significantly lower alloantibody titers as compared to repetitive immunizations with the inactivated vaccine. The lower alloantibody titer after two-step vaccination explains the lower BNP-incidence in Lower Saxony and - generally speaking - indicates that variations in the vaccination regimen have a great influence on the induction of adverse reactions through bioprocess impurities.

CBLB613: a TLR 2/6 agonist, natural lipopeptide of Mycoplasma arginini , as a novel radiation countermeasure.

To date, there are no safe and effective drugs available for protection against ionizing radiation damage. Therefore, a great need exists to identify and develop non-toxic agents that will be useful as radioprotectors or postirradiation therapies under a variety of operational scenarios. We have developed a new pharmacological agent, CBLB613 (a naturally occurring Mycoplasma-derived lipopeptide ligand for Toll-like receptor 2/6), as a novel radiation countermeasure. Using CD2F1 mice, we investigated CBLB613 for toxicity, immunogenicity, radioprotection, radiomitigation and pharmacokinetics. We also evaluated CBLB613 for its effects on cytokine induction and radiation-induced cytopenia in unirradiated and irradiated mice. The no-observable-adverse-effect level of CBLB613 was 1.79 mg/kg and 1 mg/kg for single and repeated doses, respectively. CBLB613 significantly protected mice against a lethal dose of (60)Co γ radiation. The dose reduction factor of CBLB613 as a radioprotector was 1.25. CBLB613 also mitigated the effects of (60)Co γ radiation on survival in mice. In both irradiated and unirradiated mice, the drug stimulated induction of interleukin-1ß (IL-1ß), IL-6, IL-10, IL-12, keratinocyte-derived chemokine, granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor-1α. CBLB613 also reduced radiation-induced cytopenia and increased bone marrow cellularity in irradiated mice. Our immunogenicity study demonstrated that CBLB613 is not immunogenic in mice, indicating that it could be developed as a radioprotector and radiomitigator for humans against the potentially lethal effects of radiation exposure.

Could antioxidants be the "magic pill" for cirrhosis-related complications? A pathophysiological appraisal.

Patients with liver cirrhosis are prone to serious complications by almost all systems, leading to high morbidity rates and even death. Although the functional and structural derangement of diverse vital organs developed in the course of advanced liver disease is the result of one entity (cirrhosis) there are various treatment modalities for each system's complications, which are often ineffective. Identification of the link which connects the complications of cirrhosis from diverse systems might lead to a global, simple and more effective treatment approach for patients with cirrhosis. Accumulating evidence from experimental and clinical studies suggests that intestinal barrier dysfunction and subsequent gut-derived endotoxemia represent an important common pathogenetic mechanism in the development of diverse complications of cirrhosis. Intestinal oxidative stress seems to be a pivotal factor of gut barrier dysfunction in cirrhosis through promotion of enterocyte apoptosis, modulation of intestinal tight junctions and impairment of intestinal brush border function. In parallel, oxidative stress plays a fundamental role in the aggravation of liver injury and in the structural and/or functional derangements of diverse organs complicating the course of cirrhosis. Our hypothesis is that antioxidant treatments could prevent in a global way virtually all cirrhosis-related complications acting in two crucial levels in the pathophysiological cascade of events: (a) in a primary level, which is the gut-liver axis by ameliorating gut-derived endotoxemia, through prevention of intestinal oxidative stress and its associated gut barrier dysfunction, concurrently conferring direct antioxidant protection in the liver tissue and (b) in a secondary level, which refers to the diverse organs whose function is affected by liver cirrhosis, by preventing their oxidant-related structural and functional derangements.

Transfusion-associated graft-versus-host disease.

Transfusion-associated graft-versus-host disease (TA-GvHD) is a rare complication of transfusion of cellular blood components producing a graft-versus-host clinical picture with concomitant bone marrow aplasia. The disease is fulminant and rapidly fatal in the majority of patients. TA-GvHD is caused by transfused blood-derived, alloreactive T lymphocytes that attack host tissue, including bone marrow with resultant bone marrow failure. Human leucocyte antigen similarity between the transfused lymphocytes and the host, often in conjunction with host immunosuppression, allows tolerance of the grafted lymphocytes to survive the host immunological response. Any blood component containing viable T lymphocytes can cause TA-GvHD, with fresher components more likely to have intact cells and, thus, able to cause disease. Treatment is generally not helpful, while prevention, usually via irradiation of blood components given to susceptible recipients, is the key to obviating TA-GvHD. Newer methods, such as pathogen inactivation, may play an important role in the future.

Reversal of linezolid-associated cytopenias, but not peripheral neuropathy, by administration of vitamin B6.

OBJECTIVES: We sought to determine if vitamin B6 therapy would reverse linezolid-associated cytopenias and/or peripheral neuropathy. PATIENTS AND METHODS: We have recently treated two patients with disseminated Mycobacterium abscessus infections with prolonged (> or =9 month) courses of linezolid. Both patients developed cytopenias related to linezolid, and one patient also developed peripheral neuropathy. Because continuing linezolid therapy was required, we administered vitamin B6 (50 mg orally once a day) in an attempt to mitigate the associated cytopenias. RESULTS: The cytopenias in both patients reversed following administration of vitamin B6, and stabilized during prolonged linezolid therapy, although the peripheral neuropathy did not. CONCLUSIONS: Vitamin B6 treatment may be useful to prevent or modify the course of linezolid-associated cytopenias. More formal and rigorous study of vitamin B6 therapy in patients receiving prolonged courses of linezolid is warranted.

Practical pharmacogenetics: the cost effectiveness of screening for thiopurine s-methyltransferase polymorphisms in patients with rheumatological conditions treated with azathioprine.

OBJECTIVE: Thiopurine S-methyltransferase (TPMT), which catalyzes the inactivation of azathioprine (AZA), exhibits genetic polymorphism that results in dose related, serious toxicities (mainly hematological cytopenias) in 10-15% of individuals treated with AZA. Polymerase chain reaction (PCR) tests provide a sensitive, specific means of prospectively identifying these patients before AZA therapy and minimizing toxicity through dosage reduction. Our objective was to model the cost effectiveness of the 2 alternative AZA treatment strategies in rheumatologic conditions: (1) utilizing PCR to determine polymorphisms leading to TPMT deficiencies prior to AZA therapy with a reduction in dose; and (2) no testing. The analysis was conducted from a third party payer perspective over one year. METHODS: A decision analytic model was applied to map the costs and outcomes of patients under both strategies. Data applied to the model included the positive and negative predictive values of the PCR, the probabilities of adverse events due to AZA, and the costs associated with their management. Sources of data included published clinical trials, diagnostic test evaluations, surveillance trials, and economic evaluations. RESULTS: Dose related toxicities resulted in AZA discontinuation rates of 10-20%. The usual dosing strategy cost $677 Cdn per patient, whereas the genotype directed dosing strategy cost $663 Cdn per patient. In the genotype dosing strategy, the number needed to treat to avoid one adverse event over 6 months was 20. Thus, the genotype based dosing strategy dominated the usual dosing strategy. One-way sensitivity analyses revealed that the estimates were robust to ranges of +/- 30% for the costs, the properties of the PCR test, and the probability of adverse events. CONCLUSION: The introduction of PCR testing to identify TPMT polymorphisms prior to AZA treatment may represent good value in certain health care settings.

Cytokine therapy for myelodysplastic syndrome.

The myelodysplastic syndromes are a heterogeneous family of hematologic disorders characterized by ineffective hematopoiesis. Because of the interpatient variability regarding prognosis and morbidity, management of myelodysplastic syndromes continues to be a challenge to clinical hematologists. Pancytopenia and defective function of neutrophils and platelets carry a high risk of infectious or hemorrhagic complications. Erythropoietin is perhaps the most commonly used therapeutic option, second only to transfusion; improvement of erythropoiesis is seen in approximately 20% of patients, mainly in those with relatively preserved erythroid function and no or low transfusion requirements. Coadministration of erythropoietin with either granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor may increase the response rate up to 50%. Although prophylactic administration of granulocyte- or granulocyte-macrophage colony-stimulating factor cannot be recommended, treatment of febrile neutropenia might benefit from administration of granulocyte- or granulocyte-macrophage colony-stimulating factor in addition to antibiotics.