Plasma cell depletion with bortezomib in the treatment of refractory N-methyl-d-aspartate (NMDA) receptor antibody encephalitis. Rational developments in neuroimmunological treatment.

BACKGROUND AND PURPOSE: The aim was to assess the therapeutic potential of bortezomib in the treatment of refractory N-methyl-d-aspartate receptor (NMDAR) antibody encephalitis and its potential in other immune-mediated, B-cell-driven neurological diseases. METHODS: Two cases of severe NMDAR antibody encephalitis, resistant to first and second line therapy with steroids, intravenous immunoglobulins, plasma exchange, cyclophosphamide and rituximab, were treated with four and five cycles of 1.3 mg/m2 bortezomib at 350 and 330 days following initial presentation. RESULTS: Both patients showed significant clinical improvement with reductions of NMDAR antibody titres following bortezomib treatment. This is the first case in the literature where the NMDAR antibody level was undetectable following treatment with bortezomib. CONCLUSION: Bortezomib's unique ability to target long-lived autoreactive plasma cells appears to be a useful adjunct to standard second line immunosuppressive therapy in treatment-refractory NMDAR antibody encephalitis. The drug's pharmacodynamics, cell targeting and mechanism of action are reviewed, and it is postulated that bortezomib may be useful in a host of B-cell-driven neuroimmunological diseases.

A new enzyme-linked immunosorbent assay to measure anti-endothelial antibodies after cardiac transplantation demonstrates greater inhibition of antibody formation by tacrolimus compared with cyclosporine.

BACKGROUND: Chronic rejection or transplant-associated coronary artery disease (TxCAD) is the most serious complication after human cardiac transplantation. Previous studies, using Western blotting, have shown formation of antibodies against endothelial antigens of 56 and 58 kDa, which are associated with early TxCAD. These antigens were later identified as being vimentin and its breakdown products. The aims of the present study were to devise a robust assay for detection of anti-vimentin antibodies and to compare antibody formation in patients taking different immunosuppressive drugs. METHODS: 106 sequential serum samples from 19 patients taking tacrolimus and 68 sera from 12 patients taking cyclosporine were examined by enzyme-linked immunosorbent assay (ELISA) for anti-vimentin antibodies and Western blotting for reactivity against bands at 56/58 kDa. Serum samples were taken before transplantation and at 1, 3, 6, 9, and 12 months. RESULTS: The vimentin ELISA produced significantly higher numbers of positive episodes per patient (3.92+/-1.08) compared with use of Western blotting (2.54+/-0.52). Serum from patients taking tacrolimus contained significantly less antibodies measured by ELISA (15.8%) or Western blotting (6.5%) than sera from patients taking cyclosporine (46.8% for ELISA; P=0.001 and 21% by Western blotting, P=0.01). Intravascular ultrasound performed on six patients at 12 months showed a correlation between anti-vimentin antibody formation and detection of early coronary disease. CONCLUSIONS: The results demonstrate first, that differences in antibody profiles produced by different immunosuppressive drugs, and second, that detection of anti-vimentin antibodies may be a noninvasive method of detecting disease activity in transplanted vessels.

Antibodies to endothelial cells identify myocardial damage and predict development of coronary artery disease in patients with transplanted hearts.

BACKGROUND: Transplant-induced coronary artery disease is a leading cause of graft failure in cardiac allograft recipients after the first year of transplantation, but there presently is no test to identify patients at high risk for developing the disease. Our research is focused on development of a predictive test to identify patients at high risk of developing the disease. METHODS: Sixty-eight cardiac allograft recipients transplanted and followed at Methodist Hospital between 1982 and 1996 were studied. Serial annual angiograms were used to diagnose coronary artery disease, and serial endomyocardial biopsies were used to detect cellular infiltrates and microvascular disease. Biopsy-matched serum samples were used for cardiac troponin-T determinations as measures of myocardial damage, and serum antibodies to endothelial cells were determined by using flow cytometry, enzyme-linked immunosorbent assay and immunoblotting techniques. The endothelial antibody data were evaluated statistically for associations with angiographic changes, biopsy findings and biochemical evidence of myocardial damage. FINDINGS: Antibodies to endothelial cells were identified by all three techniques, and significant associations were found for the amount of antibody identified by Western immunoblotting with histological rejection grades in biopsies, which were confirmed immunocytochemically as macrophages (p<0.01) and T lymphocytes (P = 0.03). These antibodies also associated significantly with vascular antithrombin depletion (p = 0.02), biochemical evidence of myocardial damage (p = 0.005) and subsequent development of coronary artery disease (p = 0.03). INTERPRETATION: The significant association of anti-endothelial antibodies with cellular infiltrates, depletion of vascular antithrombin and myocardial damage suggests a role for antibody in the development of transplant-induced arteriopathy. The significant association of antiendothelial antibodies with the future development of coronary artery disease further suggests that assessment of these antibodies may provide a non-invasive test to predict the development of transplant-induced coronary artery disease.

Antiendothelial antibodies after heart transplantation: the accelerating factor in transplant-associated coronary artery disease?

Although the precise cause of transplant-associated coronary artery disease is unknown, immune mechanisms have been implicated. Using the techniques of SDS-PAGe and Western immunoblotting, we have previously shown that a strong positive correlation exists between the development of coronary artery disease and the presence of antiendothelial antibodies reactive with a doublet of polypeptides of approximately 60 and 62 kDa. We have now extended this study to investigate the temporal pattern of antiendothelial antibody formation after transplantation and its association with cellular rejection episodes. The original study used patients in whom coronary artery disease had developed early after transplantation, that is at 1 or 2 years. Here we investigate whether antiendothelial antibodies are also made in patients in whom the disease does not develop until 5 to 10 years after heart transplantation and whether the antibodies are found in patients with severe nontransplant atherosclerosis. We confirm the 60 to 62 kDa antigens are membrane bound, and recalculation of their molecular mass makes the doublet 56 and 57.5 kDa. The results show that antibodies specific for the doublet of endothelial antigens are rarely produced by patients other than those in whom rapidly progressing coronary artery disease develops early after transplantation. The antibodies are unrelated to cellular rejection episodes. We believe their production may be an accelerating factor for the rapid development of transplant-associated coronary artery disease.

Pre-transplant anti-epithelial cell antibodies and graft failure after single lung transplantation.

Eighty-five patients undergoing single lung transplantation have been studied to determine the presence of anti-epithelial cell antibodies (AECA) prior to transplantation using the human lung carcinoma epithelial cell line A549 in a microcytotoxicity assay. In addition, 29 healthy volunteers were also assayed for the presence of AECA. Twenty-seven of the 85 recipients exhibited AECA prior to transplantation compared to none of the 29 control subjects (p = 0.0001). Actuarial graft survival at 1 year was 78% for the AECA negative group compared to 56% for AECA positive recipients (p = 0.01). No correlation was seen between the presence of AECA and graft rejection as determined by transbronchial biopsy. However, there was an association between AECA and post-transplant infection (p = NS) where 16 (64%) of the AECA positive recipients had postoperative infection episodes compared to 25 (47%) of the negative recipients. Sodium dodecylsulphate polyacrylamide gel electrophoresis and Western blotting was also performed for 68 of the recipients and antibody reactivity was detected in 22 patients compared to 26 patients exhibiting AECA detectable by microcytotoxicity. The presence of AECA demonstrable by Western blotting did not correlate with graft survival, rejection or infection. In conclusion, AECA detectable prior to single lung transplantation are associated with a decrease in graft survival and with postoperative infections.

Reactions in glass ionomer cements: V. Effect of incorporating tartaric acid in the cement liquid.

A description is give of the effect on the ASPA cement reaction of tartaric acid incorporated in the cement liquid. Tartaric acid acts as an accelerator that aids in the extraction of ions from the aluminosilicate glass and facilitates their binding to the polyanion chains. Postgelation hardening is significantly increased. Working time is unaffected possibly because cations are initially present as complexes.

Glass ionomer cements: chemistry of erosion.

A three-month study of the chemistry of the water erosion of two forms of ASPA cement has been made. The effect of varying cement consistency and cure time was investigated. The results are discussed in terms of the known chemistry and structure of the cement. The erosion behavior is compared to that of silicate, silicophosphate, and zinc polycarboxylate dental cements. The state of absorbed water and the mechanism of erosion is discussed.

Reactions in glass-ionomer cements: IV. Effect of chelating comonomers on setting behavior.

The oscillating rheometer is a valuable instrument for studying the effects of additives on the setting behavior of a cement system. Using this instrument, it was found that certain chelating comonomers, the hydroxycarboxylic acids, could improve the setting characteristics of the glass-ionomer cement system when added to the PAA solution. The acid chelates probably assign the extraction of metal ions from the glass and also tend to hold them in solution, preventing premature ion binding of the polyanion chains. The effect is to increase the rate of hardening without reducing the working time, which may indeed by slightly increased. Tartaric acid, the most effective of the comonomers, can form a chelate bridge between aluminum atoms, and this metal complex probably acts as a flexible bridge structure linking polyanion chains. This mechanism offers some steric advantages over a simple salt bridge.

Zinc polycarboxylate cements: a chemical study of erosion and its relationship to molecular structure.

Experimental results show that the rate of elution of Zn2+ and Mg2+ ions from polycarboxylate cements decrease with the cement's age. This phenomenon is explained by the setting reaction in which these cations are liberated from the oxide powder by an exchange with protons from the polyacid and in this state are vulnerable to water leaching. Subsequently, these cations become bound to the polyanion chain and become more resistant to water leaching. Magnesium ions are more easily hydrolyzed than zinc ions because they are less strongly bound to the polyanion chain. Zinc ions are apparently more strongly bound to a polyacid which is a copolymer of acrylic and itaconic acids, than to the homopolymer of acrylic acid. The pattern of elution of ions differs between the different cements, so that measurements after 24 hours cannot be used to predict long-term durability on a comparative basis. This coupled with the slow but continuous loss of ions makes a 24-hour test of doubtful validity. Polycarboxylate cements absorb water that is present in the matrix in loosely bound and tightly bound forms. The ionization of the polyacid to a polyanion during the course of the reaction apparently creates a demand for water, and the cement where the COOH:C ratio in the polyacid is highest absorbs the most water.

Gelation of polyacrylic acid aqueous solutions and the measurement of viscosity.

A simple method is described for following changes in viscosity of concentrated aqueous solutions of polycarboxylic acids used in certain dental cements. The difference in behavior over several months between solutions of polyacrylic acid and related polyelectrolytes is discussed.

The hydration of dental cements.

A study was made of the hydration of dental cements, water being classified as "non-evaporable" and "evaporable". The ratio of these two types of water was found to vary greatly among different cement types, being lesser in zinc oxide and ionic polymer cements and greater in ion-leachable glass and phosphoric acid cements. The cement with the least "non-evaporable" water, i.e., showing least hydration (the zinc polycarboxylate cement), had the lowest strength and modulus and the greatest deformation at failure. A linear relationship was found to exist between strength and the degree of hydration of dental cements. All the cements were found to become more highly hydrated and stronger as they aged.

The quantitative measurement of the opacity of aesthetic dental filling materials.

A method is described for measuring the opacity of anesthetic dental filling materials using a goniophotometer. Procedures are given for converting measured opacity values to those referred to a 70% reflectance background (C0.7 values) as required by existing specifications. The conversion is involved, and, since most available white surfaces have reflectance of about 80%, it is recommended that in future specifications opacity be recorded as C0.8 values. Opacity values for 28 materials are reported. It was found that the opacity of dental cement decreases for several days following preparation and that powder/liquid ratio has little effect, while pigmentation has a marked effect on opacity.

Zinc oxide eugenol cements. V. Instrumental studies of the catalysis and acceleration of the setting reaction.

Zinc oxide eugenol (ZOE) cements were prepared by mixing powders of widely differing reactivity with a variety of liquid formulations. The course of the setting reaction was followed by penetrometer, rheological and electrical techniques. Small amounts of water, organic acids, and the reactivity of water, organic acids, and the reactivity of the zinc oxide all have a profound influence on the setting characteristics of cement pastes.

Infrared spectroscopic studies on the development of crystallinity in dental zinc phosphate cements.

An infrared spectroscopic study has been made of the development of crystallinity (hopeite) in dental zinc phosphate cements. Crystallization in the bulk of a cement is prevented only by the incorporation, in the liquid, of aluminum which forms complexes with phosphoric acid. The development of surface crystallinity is related to the chemical composition of the cement and the speed of the reaction. No acid phosphates are to be found in the matrix which consists solely of neutral orthophosphates.

Glass-ionomer cement formulations. II. The synthesis of novel polycarobxylic acids.

The synthesis of many polycarboxylic acids is reported. An account is given of their stability in aqueous solution and the properties of cements formed by their reaction with ion-leachable glasses. A copolymer of acrylic and itaconic acids was found to combine several favorable characteristics.

A method of two-dimensional mapping of cortical perfusion by cylindrical transformation of HMPAO SPET data.

In order to synthesize three-dimensional information on relative regional blood flow (rCBF) from the cortical grey matter in 99Tcm-hexamethylpropyleneamine oxime (HMPAO) single photon emission tomographic (SPET) images into a single two-dimensional 'cortical peel' (CP) image, we developed a program that performs cylindrical transformation of SPET data. A sub-routine of this program performs measurements of cortex-to-cerebellum rCBF ratios for 54 cortical regions in the CP image. This program was used to establish a normative database derived from 30 young normal control subjects aged 28.7 +/- 6.9 years. The database was then used to express cortex-to-cerebellum rCBF ratios in four colour-coded ranges of normal standard deviation of the mean rCBF ratio across the cortical regions in the CP image. This CP method was implemented for 30 clinical HMPAO SPET studies in patients (n = 30, aged 71.8 +/- 4.2 years) with suspected dementia as well as several studies in aged healthy subjects (n = 8, aged 67 +/- 9.8 years). In 25/30 (83%) patients, all abnormalities seen on the tomographic display were evident on the corresponding CP image. No aged healthy subjects showed abnormalities on either the tomographic display or the corresponding CP image. An advantage of this technique is that the extent and severity of rCBF abnormalities are readily appreciated in one single image. This technique, in conjunction with the conventional multi-slice tomographic display, was a useful tool in identifying various patterns of rCBF abnormalities in the patients with clinically suspected dementia.

The medical device directives and their impact on the development and manufacturing of medical implants.

The introduction of a legal framework for the supply of medical implants is discussed with reference to the Active Implantable Medical Device Directive and the Medical Device Directive. The definitions of medical device and manufacturer are discussed. The application of the Directives to device/drug combinations is considered. All implants must meet certain essential requirements to ensure that they do not harm the patient, clinician or any third party. For most implants this will be indicated on the product or its packaging by CE; marking involving an independent organization called a Notified Body; the latter are appointed by the Competent Authority of the Member State. Devices are classified in proportion to the risk associated with them. The steps needed to be taken by manufacturers are outlined and the verification options discussed. The role of standards and the new approach to writing them in Europe is presented. After placing a product on the market, the manufacturer must set up a system of post-market surveillance, including a vigilance procedure, in order to monitor product performance. Individual Member States can exercise the safeguard clause when a product appears to have had the CE marking incorrectly applied.

Carotid atherosclerotic calcification does not result in high signal intensity in MR imaging of intraplaque hemorrhage.

BACKGROUND AND PURPOSE: Calcium can potentially shorten T1, generating high signal intensity in GREs. Because IPH appears as high signal intensity in MRIPH and the surface effects of calcium can potentially shorten T1 of surrounding water protons, the purpose of this study was to evaluate whether the high signal intensity seen on MRIPH could be attributed solely to IPH and not calcification. MATERIALS AND METHODS: Eleven patients undergoing carotid endarterectomy were imaged by using MRIPH. Calcification was assessed by scanning respective endarterectomy specimens with a tabletop MicroCT. MRIPH/MicroCT correlation used an 8-segment template. Two readers evaluated images from both modalities. Agreement between MRIPH/MicroCT was measured by calculating Cohen κ. RESULTS: High signal intensity was seen in 58.8% and 68.9% (readers 1 and 2, respectively) of MRIPH segments, whereas calcification was seen in 44.7% and 32.1% (readers 1 and 2, respectively) of MicroCT segments. High signal intensity seen by MRIPH showed very good but inverse agreement to calcification (κ = -0.90; P < .0001, 95% CI, -0.93 to -0.86, reader 1; and κ = -0.74; P < .0001; 95% CI, -0.81 to -0.69, reader 2). Most interesting, high signal intensity demonstrated excellent agreement with lack of calcification on MicroCT (κ = 0.92; P < .0001; 95% CI, 0.89-0.94, reader 1; and κ = 0.97; P < .0001; 95% CI, 0.96-0.99, reader 2). In a very small number of segments, high signal intensity was seen in MRIPH, and calcification was seen on MicroCT; however, these represented a very small proportion of segments with high signal intensity (5.9% and 1.6%, readers 1 and 2, respectively). CONCLUSIONS: High signal intensity, therefore, reliably identified IPH, known to describe complicated plaque, rather than calcification, which is increasingly recognized as identifying more stable vascular disease.