Complement C3 and marginal zone B cells promote IgG-mediated enhancement of RBC alloimmunization in mice.

Administration of anti-RhD immunoglobulin (Ig) to decrease maternal alloimmunization (antibody-mediated immune suppression [AMIS]) was a landmark clinical development. However, IgG has potent immune-stimulatory effects in other settings (antibody-mediated immune enhancement [AMIE]). The dominant thinking has been that IgG causes AMIS for antigens on RBCs but AMIE for soluble antigens. However, we have recently reported that IgG against RBC antigens can cause either AMIS or AMIE as a function of an IgG subclass. Recent advances in mechanistic understanding have demonstrated that RBC alloimmunization requires the IFN-α/-ß receptor (IFNAR) and is inhibited by the complement C3 protein. Here, we demonstrate the opposite for AMIE of an RBC alloantigen (IFNAR is not required and C3 enhances). RBC clearance, C3 deposition, and antigen modulation all preceded AMIE, and both CD4+ T cells and marginal zone B cells were required. We detected no significant increase in antigen-specific germinal center B cells, consistent with other studies of RBC alloimmunization that show extrafollicular-like responses. To the best of our knowledge, these findings provide the first evidence of an RBC alloimmunization pathway which is IFNAR independent and C3 dependent, thus further advancing our understanding of RBCs as an immunogen and AMIE as a phenomenon.

Key Performance Indicators and Metrics for the Implementation of an Oral Chemotherapy Adherence Program.

BACKGROUND: Oral anticancer agents (OAAs) transformed cancer care for patients, extending survival and delaying progression in certain cases. There are multiple pharmacy-driven models to improve patient knowledge and adherence to OAAs. However, a lack of measurable key performance indicators (KPIs) has limited the adoption, implementation, and maintenance of these models. The objective of this study was to identify a set of KPIs, their metrics, and the target values that indicated improved patient care through an OAA adherence program. METHODS: A literature review was conducted to identify an initial list of defined KPIs, metrics of the KPIs, and targets for success. We assembled an advisory panel of clinicians (n=9), administrators (n=7), and patients (n=2) from across an academic and affiliated community cancer center to gauge agreement on identified KPIs for use within a structured adherence intervention. We used a Qualtrics survey consisting of questions measured using a 5-point Likert scale response that ranged from 1 (strongly disagree) to 5 (strongly agree) and a subsequent consensus-building discussion with the advisory panel to identify agreeability with the definitions, metrics, and targets of identified KPIs. RESULTS: Eleven KPIs were identified: (1) time to intended OAA initiation; (2) adherence rate during active treatment; (3) adverse events; (4) medication-related financial toxicity; (5) patient satisfaction; (6) treatment-related emergency department visits; (7) treatment-related hospital admissions; (8) proportion of patients with adherence, toxicity, and financial barriers assessed; (9) proportion of patients referred to social work; (10) time spent by patient in each phase of care as defined by the intervention's standard operating procedure; and (11) revenue generated by billing for service. CONCLUSIONS: This study identified 11 KPIs that can be used in evaluating the success of an OAA adherence program. Use of these KPIs will be piloted after formal implementation of the program in both academic and community cancer centers.

Evaluation of real-world versus clinical trial outcomes of tyrosine kinase inhibitor therapy for chronic myeloid leukemia.

Tyrosine kinase inhibitors (TKIs) are the mainstay of treatment for chronic myeloid leukemia (CML). Patients enrolled in clinical trials investigating the safety and efficacy of TKIs in CML are generally younger, have fewer comorbidities, and are monitored differently than patients treated in the real world. This narrative literature review summarizes efficacy outcomes (complete cytogenetic response, major molecular response, and disease progression) and safety outcomes (duration of TKI therapy, TKI discontinuation rates, dosage changes, and frequently reported adverse events) from landmark clinical trials as well as real-world studies. Patients with CML treated with TKIs in a real-world setting may achieve different rates of specific response milestones than those treated on clinical trials. While real-world studies reported similar overall incidences of adverse events as clinical trials, real-world patients with CML were more likely to discontinue TKIs due to adverse events.

Fenbendazole resistance in Heterakis gallinarum, the vector of Histomonas meleagridis, on a broiler breeder farm in South Carolina.

Parasites are highly prevalent in poultry; thus, the management of parasites is a key component in the profitable production of poultry. The most common nematode parasite of poultry, Heterakis gallinarum, typically causes no direct pathology but is the vector of Histomonas meleagridis, a highly pathogenic protozoan parasite that causes blackhead disease. There are no approved treatments for H. meleagridis, making control reliant on controlling the helminth vector. In the United States, the benzimidazole anthelmintic fenbendazole (FBZ) is the only approved treatment for H. gallinarum. We were contacted by an industry veterinarian regarding clinical problems with histomoniasis despite frequent anthelmintic treatments. Given that we had recently diagnosed FBZ resistance in the closely related parasite Ascaridia dissimilis, we were interested to determine if H. gallinarum had also evolved resistance. An initial on-farm pilot study using 20 birds suggested that FBZ was poorly effective, therefore a larger controlled study was initiated. Heterakis gallinarum eggs were isolated from litter at the farm and used to infect 118 chicks. Treatment groups included a non-treated control, a label-, and a 2×-label dose of FBZ, with 36 birds per group divided into two replicates of 18 birds. Three weeks post-hatch, birds were infected with 150 embryonated eggs. Two weeks post-infection treated birds were administered either a label- or 2× label-dose of FBZ in water for five days (SafeGuard® Aquasol, 1 mg/kg BW). To increase the likelihood that all birds consumed the full intended dose, the dosage was calculated using 1.25 times the average body weight. One-week post-treatment, birds were euthanized, and parasites enumerated. There were no significant differences in worm numbers recovered from any of the three groups (p-value = 0.3426), indicating that both dosages of FBZ failed to provide the expected levels of efficacy. These data provide strong evidence that H. gallinarum has developed resistance to FBZ on this farm. Consequently, on this farm, or any farm with FBZ-resistant H. gallinarum, H. meleagridis will continue to cycle in an unrestricted manner despite administration of anthelmintic treatments. Given recent evidence of increasing problems with histomoniasis, and the fact that resistance was documented on the first farm we investigated, further investigations are needed to determine the prevalence of resistance in H. gallinarum on poultry farms. These data, when viewed together with our recent findings of FBZ resistance in A. dissimilis on multiple farms, suggest that drug resistance in ascarid nematodes may be an emerging problem in the US poultry industry.

Impact of fenbendazole resistance in Ascaridia dissimilis on the economics of production in turkeys.

Feed conversion efficiency is among the most important factors affecting profitable production of poultry.Infections with parasitic nematodes can decrease efficiency of production, making parasite control through the use of anthelmintics an important component of health management. In ruminants and horses, anthelmintic resistance is highly prevalent in many of the most important nematode species, which greatly impacts their control. Recently, we identified resistance to fenbendazole in an isolate of Ascaridia dissimilis, the most common intestinal helminth of turkeys. Using this drug-resistant isolate, we investigated the impact that failure to control infections has on weight gain and feed conversion in growing turkeys. Birds were infected on D 0 with either a fenbendazole-susceptible or -resistant isolate, and then half were treated with fenbendazole (SafeGuard Aquasol) at 4- and 8-wk postinfection. Feed intake and bird weight were measured for each pen weekly throughout the study, and feed conversion rate was calculated. Necropsy was performed on birds from each treatment group to assess worm burdens at wk 7 and 9 postinfection. In the birds infected with the susceptible isolate, fenbendazole-treated groups had significantly better feed conversion as compared to untreated groups. In contrast, there were no significant differences in feed conversion between the fenbendazole-treated and untreated groups in the birds infected with the resistant isolate. At both wk 7 and 9, worm burdens were significantly different between the treated and untreated birds infected with the drug-susceptible isolate, but not in the birds infected with the drug-resistant isolate. These significant effects on feed conversion were seen despite having a rather low worm establishment in the birds. Overall, these data indicate that A. dissimilis can produce significant reductions in feed conversion, and that failure of treatment due to the presence of fenbendazole-resistant worms can have a significant economic impact on turkey production. Furthermore, given the low worm burdens and an abbreviated grow out period of this study, the levels of production loss we measured may be an underestimate of the true impact that fenbendazole-resistant worms may have on a commercial operation.

Assessment of faithful interleukin-3 production by novel bicistronic interleukin-3 reporter mice.

Interleukin-3 (IL-3) is an important hematopoietic growth factor and immunregulatory cytokine. Although activated T helper cells represent a main source of IL-3, other cell types have been reported to express this cytokine. However, precise identification and quantification of the cells that produce IL-3 in vivo have not been performed. Therefore, we used a CRISPR/Cas approach to engineer mice containing a bicistronic mRNA linking a readily identifiable reporter, enhanced green fluorescent protein (ZsGreen1), to IL-3 expression. To characterize these novel reporter mice, we first examined ZsGreen1 expression by CD4 T cells subsets primed and activated in vitro. We found that activated Th1 cells expressed ∼4-fold higher levels of ZsGreen1 as compared to Th0 and Th2 cells. Endogenous IL-3 expression remained intact although reporter Th1 cells secreted ∼33 % less IL-3 than similarly activated wild-type cells. To characterize the ability of reporter mice to accurately mark IL-3-producing cells in vivo, we infected mice with Nippostrongylus brasiliensis. Low but significant numbers of ZsGreen1+ CD4 T cells were detected in the mesenteric lymph nodes and lung following both primary and secondary infection. No difference in basophil and intestinal mast cell numbers were observed between infected reporter and wild-type mice indicating that reporter mice secreted IL-3 levels in vivo that results in IL-3-driven biological activities which are indistinguishable from those observed in corresponding wild-type mice. These IL-3 reporter mice will be a valuable resource to investigate IL-3-dependent immune responses in vivo.

Resistance to fenbendazole in Ascaridia dissimilis, an important nematode parasite of turkeys.

An important factor in efficient production of poultry is management of parasites. Ascaridia dissimilis is the most prevalent small intestinal nematode parasite of turkeys with up to 100% of flocks infected. High worm burdens can cause necrotic enteritis leading to high mortality in flocks. Recently, we were made aware of multiple cases where high burdens were seen at slaughter despite the administration of anthelmintics at frequent intervals, suggesting that resistance may have evolved in A. dissimilis. To address this issue, we obtained eggs of A. dissimilis from 4 commercial turkey farms and performed controlled efficacy tests to determine if fenbendazole resistance was present. Three farms had histories of frequent use of fenbendazole and worms found at slaughter, suggesting they may have resistance, and one was an organic farm where we had no additional history other than the farm had transitioned to organic production a few years earlier. For each worm isolate there were 2 treated and 2 untreated groups containing 9 birds each, with all groups being replicated in 2 separate rooms. Birds were infected with approximately 200 infective eggs, and treated groups received fenbendazole in the water (SafeGuard Aquasol, 1 mg/kg) for 5 consecutive days starting on day 24 post-infection. One week after the last treatment birds were necropsied, intestinal contents were collected and worms enumerated. Three of the four isolates demonstrated greater than 99% efficacy, indicating they were fully susceptible to fenbendazole. However, the fourth isolate demonstrated a significantly reduced efficacy of 63.89%, indicating the presence of resistance. Interestingly, this was the organic farm, whereas the 3 farms with "suspected" resistance all turned out to be fully susceptible. Given that 1 randomly acquired isolate of A. dissimilis, out of 4 tested, demonstrated resistance in this study, fenbendazole resistance may be a much larger problem on turkey farms than is currently recognized. Additional studies are needed to determine the prevalence of resistance, as well as the economic impact that resistant A. dissimilis have on turkey production.

Contralateral Dorsally Based Septal Mucoperichondrial Page Flap, for Nasal Lining Reconstruction.

BACKGROUND: Although excellent techniques for reconstruction of nasal cover and support have been described, reconstruction of large nasal lining defects remains a challenge. Currently available methods have several shortcomings including limited size, airway obstruction, need for multiple procedures, and creation of septal fistulae. METHODS: We present 2 cases of nasal lining reconstruction for the lower and mid nasal vaults using a contralateral dorsally based septal mucoperichondrial page flap transposed dorsal to nasal septum and superficial to the ipsilateral upper lateral cartilage. Appropriate, uncomplicated, reconstruction of nasal lining was confirmed in both cases. DISCUSSION: In the lower vault, the flap permits a single-stage reconstruction, without obstruction of the external nasal valve or compromise of caudal septal support. In the mid-vault, the flap allows for reconstruction without creation of a septal fistula or narrowing of the internal nasal valve. In both locations, the size of the flap may be increased by extending it onto nasal floor, and support may be added by combining the flap with septal cartilage. CONCLUSION: The contralateral dorsally based septal mucoperichondrial flap is a useful option for reconstruction of lower and mid nasal vault lining defects.

Core measures: implications for plastic surgery.

BACKGROUND: Perioperative complications are a major source of morbidity, mortality, and expenditures in health care. Many of these complications are preventable with simple, cost-effective measures when implemented in a standardized manner. Surgical specialties are increasing efforts to implement standardized and easily monitored measures to reduce perioperative complications. METHODS: The recommendations provided by the U.S. Department of Health and Human Services and published by the Joint Commission on Accreditation of Healthcare Organizations were summarized as they pertain to plastic surgery. A review of recent plastic surgery literature was pursued to evaluate these recommendations as they pertain to the specialty. RESULTS: Measures exist to reduce the incidence of perioperative infection, venous thromboembolism, and mortality associated with cardiac events. These measures include type and timing of prophylactic antibiotics, maintenance of perioperative normothermia, appropriate hair removal, early discontinuation of urinary catheters, appropriate venous thromboembolism prophylaxis, and use of preoperative beta-blockers. CONCLUSIONS: As national quality measures are implemented across an increasing number of specialties, the expansions will likely affect plastic surgery. These measures are evidence based and validated across a diverse group of surgical specialties, resulting in improved measured outcomes. Plastic surgeons would benefit by actively providing leadership as these and similar measures are implemented.

Onset and duration of intradermal mixtures of bupivacaine and lidocaine with epinephrine.

BACKGROUND/OBJECTIVE: Bupivacaine and lidocaine are often used concurrently, in theory, to combine the more rapid onset of lidocaine and the longer duration of bupivacaine. The purpose of this study was to evaluate this concept. METHODS: Twenty-five subjects were enrolled in a double-blinded, randomized block design study to evaluate the onset and duration of four different mixtures of lidocaine and bupivacaine with epinephrine. The study was designed to achieve 80% power to detect an effect size of 0.37 at 5% overall significance. The four mixtures tested were: 0.25% bupivacaine with epinephrine (1:200,000); 1% lidocaine with epinephrine (1:100,000); 0.125% bupivacaine and 0.5% lidocaine with epinephrine (1:150,000); and 0.25% bupivacaine and 1% lidocaine with epinephrine (1:150,000). Four intradermal injections were made in the volar forearms of each participant. Time to effect and duration were measured by sensation of a sharp skin prick. RESULTS: Mean time to onset ranged from 12 s to 29 s without statistical significance across all tested solutions (P=0.891). Mean duration of effect ranged from 6 h 38 min to 7 h 25 min with a statistically significant difference across the tested solutions (P=0.036). CONCLUSIONS: No statistical benefit was measured when comparing lidocaine with epinephrine, bupivacaine with epinephrine, and mixtures of these local anesthetics with regard to onset of action. While a statistical difference was observed in duration of effect, the clinical benefit measured was narrow.

HISTORIQUE ET OBJECTIF: La bupivacaïne et la lidocaïne sont souvent utilisées conjointement, en théorie, pour associer le délai d'action plus rapide de la lidocaïne à la durée d'action plus longue de la bupivacaïne. La présente étude visait à évaluer ce concept. MÉTHODOLOGIE: Vingt-cinq sujets ont participé à une étude aléatoire par bloc à double insu conçue pour évaluer le délai et la durée d'action de quatre mélanges différents de lidocaïne et de bupivacaïne associés à l'adrénaline. L'étude était conçue pour atteindre une puissance de 80 % afin de déceler une ampleur de l'effet de 0,37, selon une signification globale de 5 %. Les quatre mélanges à l'essai étaient la bupivacaïne 0,25 % associée à l'adrénaline (1 sur 200 000); la lidocaïne 1 % associée à l'adrénaline (1 sur 100 000); la bupivacaïne 0,125 % et la lidocaïne 0,5 % associées à l'adrénaline (1 sur 150 000); et la bupivacaïne 0,25 % et la lidocaïne 1 % associées à l'adrénaline (1 sur 150 000). Chaque participant a reçu quatre injections intradermiques dans l'avant-bras palmaire. Les chercheurs ont mesuré le délai et la durée d'action au moyen de la sensation d'une piqûre épidermique. RÉSULTATS: Le délai d'action moyen variait de 12 secondes à 29 secondes, sans signification statistique entre les diverses solutions à l'essai (P=0,891). La durée d'action moyenne variait de 6 h 38 min à 7 h 25 min et s'associait à une différence statistiquement significative entre les solutions à l'essai (P=0,036). CONCLUSIONS: Les auteurs n'ont mesuré aucun avantage statistique lorsqu'ils ont comparé le délai d'action de la lidocaïne associée à l'adrénaline, de la bupivacaïne associée à l'adrénaline et des mélanges de ces anesthésiques locaux. Ils ont constaté une différence statistique quant à la durée d'action, mais l'avantage clinique mesuré était minime.

Incidence of breast hematoma after placement of breast prostheses.

BACKGROUND: Prosthetic breast implants are frequently used by plastic surgeons for reconstructive and aesthetic procedures. One known complication of the procedure is postoperative breast hematoma. However, the incidence and risk factors of this problem are not fully characterized. METHODS: A retrospective analysis was performed of a prospectively collected patient medical record database based on procedure codes to identify breast hematomas and possible risk factors over a 12-year period from November of 1996 to October of 2008. RESULTS: One thousand nine hundred thirty-six operations were performed on 3474 breasts with prosthetic implants used. Average patient follow-up was 48.9 months, with 32 hematomas identified following 32 operations. The latest hematoma identified was 21 months after the procedure. Hematomas were identified on average 37 days after the operation. CONCLUSIONS: In the authors' experience, postoperative breast hematomas after prosthetic implant placement occur in 0.92 percent of breast prostheses placed. No individual surgical approach is associated with the occurrence of breast hematomas. Hematomas are not statistically associated with any measured patient or surgically defined characteristic. Specifically, no statistical significance was shown for larger implant size, reoperation, operative indication, type of surgery, or implant type as an independent risk factor. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Composite tissue engineering on polycaprolactone nanofiber scaffolds.

Tissue engineering has largely focused on single tissue-type reconstruction (such as bone); however, the basic unit of healing in any clinically relevant scenario is a compound tissue type (such as bone, periosteum, and skin). Nanofibers are submicron fibrils that mimic the extracellular matrix, promoting cellular adhesion, proliferation, and migration. Stem cell manipulation on nanofiber scaffolds holds significant promise for future tissue engineering. This work represents our initial efforts to create the building blocks for composite tissue reflecting the basic unit of healing. Polycaprolactone (PCL) nanofibers were electrospun using standard techniques. Human foreskin fibroblasts, murine keratinocytes, and periosteal cells (4-mm punch biopsy) harvested from children undergoing palate repair were grown in appropriate media on PCL nanofibers. Human fat-derived mesenchymal stem cells were osteoinduced on PCL nanofibers. Cell growth was assessed with fluorescent viability staining; cocultured cells were differentiated using antibodies to fibroblast- and keratinocyte-specific surface markers. Osteoinduction was assessed with Alizarin red S. PCL nanofiber scaffolds supported robust growth of fibroblasts, keratinocytes, and periosteal cells. Cocultured periosteal cells (with fibroblasts) and keratinocytes showed improved longevity of the keratinocytes, though growth of these cell types was randomly distributed throughout the scaffold. Robust osteoinduction was noted on PCL nanofibers. Composite tissue engineering using PCL nanofiber scaffolds is possible, though the major obstacles to the trilaminar construct are maintaining an appropriate interface between the tissue types and neovascularization of the composite structure.

Nanofiber applications for burn care.

Nanotechnology is a growing field of manufactured materials with sizes less than 1 mum, and it is particularly useful in the field of medicine because these applications replicate components of a cell's in vivo environment. Nanofibers, which mimic collagen fibrils in the extracellular matrix (ECM), can be created from a host of natural and synthetic compounds and have multiple properties that may be beneficial to burn wound care. These properties include a large surface-area-to-volume ratio, high porosity, improved cell adherence, proliferation and migration, and controlled in vivo degradation rates. The large surface area of nanofiber mats allows for increased interaction with compounds and provides a mechanism for sustained release of antibiotics, analgesics, or growth factors into burn wounds; high porosity allows diffusion of nutrients and waste. Improved cell function on these scaffolds will promote healing. Controlled degradation rates of these scaffolds will promote scaffold absorption after its function is no longer required. The objective of this article is to review the current literature describing nanofibers and their potential application to burn care.

Cellular incorporation into electrospun nanofibers: retained viability, proliferation, and function in fibroblasts.

Nanofibers are an emerging scaffold for tissue engineering. To date no one has reported cell incorporation into nanofibers. Human foreskin fibroblasts and human adipose-derived adult stem cells (hADAS) were grown to confluence, resuspended in phosphate-buffered saline, and then solubilized in polyvinyl alcohol (PVA). Nanofibers were created using an electrospinning technique across an electric potential of 20 kV. Cell interaction with nanofibers was assessed with optical microscopic imaging and scanning electron microscopy. PVA nanofibers with incorporated cells were then solubilized in phosphate-buffered saline; cell viability was assessed by trypan blue exclusion. Viable cells were allowed to proliferate. Chondrogenesis in fibroblasts was induced with TGF-beta1. Both fibroblasts and hADAS survived the electrospinning process and were incorporated into PVA nanofibers. hADAS cell proliferation was negligible; however, fibroblasts proliferated and showed retained ability to undergo chondrogenesis. Cells can be incorporated into nanofibers, with maintained viability, proliferation, and function.

Translation de domicile: rethinking sedentarity and mobility in the early modern French countryside.

Was the countryside of early modern France marked fundamentally by mobility or sedentarity? Tax rolls suggest the former, high endogamy rates the latter. For the period 1660-1720, a rarely used source, the registers of translation de domicile (change of tax domicile), provide a more comprehensive answer than civil or tax records. They suggest that, first, 60,000-70,000 better-off families moved each year; second, poor migrants, such as day labourers, rarely made declarations; third, those who owned land, moved far less often; fourth, laboureurs typically moved between 10 and 40 kilometres to take on farms of greater importance; fifth, cottagers and day labourers moved to a nearby village, rarely more than 5 kilometres away and finally, men and their families moved for economic gain, whereas women moved because of economic loss, after the death of their husband. Because the laboureurs dominated the villages-for example, paying most of the taxes-their movement shook the village in fundamental ways. The translation de domicile registers indicate villages open to the outside, full of in-migrants, whose economic status often bore a close correlation to the distance of their move (high-long, low-short).