Treatment of aGVHD with OKT3: clinical outcome and side-effects associated with release of TNF alpha.

Monoclonal antibodies are increasingly used for treatment of acute graft-versus-host disease (aGVHD) in bone marrow transplantation. We treated seven patients with steroid resistant aGVHD with the monoclonal anti-T cell antibody OKT3. Though five patients showed improvement of aGVHD, only two became long-term survivors. OKT3 treatment was accompanied by deterioration of microangiopathy and prolonged increase of tumor-necrosis-factor alpha serum levels indicating activation of monocytes/macrophages in vivo, as this was not observed in a control group of patients receiving anti-T cell globulin. These findings may be related to immunostimulatory activity reported for OKT3 in vitro. Strategies interfering with cytokine release should improve clinical results of OKT3 treatment.

Is acute cholecystitis a contraindication for laparoscopic cholecystectomy?

Two-hundred and ninety-four patients underwent laparoscopic cholecystectomy between May 1993 and April 1997 in the Clinical and Surgical Gastrointestinal Unit at Santa Casa Hospital of Porto Alegre. Of all, 47 were operated on for acute cholecystitis (AC). The mean age was 47.1 years, 70.2% were females and 29.8% were males. The mean operative time was 142.8 minutes. Routine intraoperative cholangiography was successfully done in 38 (80.8%) and conversion was necessary in 3 (6.4%). All patients received prophylactic antibiotics for 24 hours. No intraoperative or postoperative complications were detected. The results in this series showed that laparoscopic cholecystectomy is a possible and safe technique for the treatment of the AC.

A clinical interview assessing cancer patients' spiritual needs and preferences.

We conducted a phase-I study to test the practicability and usefulness of a short (15-30 min) clinical interview for the assessment of cancer patients' spiritual needs and preferences. Physicians assessed the spirituality of their patients using the semi-structured interview SPIR. The interview focuses on the meaning and effect of spirituality in the patient's life and coping system. Visual Analogue Scales (VAS) and Questionnaires were completed following the interview for rating whether SPIR had been helpful or distressing, and to what extent spirituality seemed important in the patient's life and in coping with cancer disease. Thirty oncological outpatients who all agreed to participate were included. The majority wanted their doctor to be interested in their spiritual orientation. Patients and interviewing physicians evaluated the SPIR interview as helpful (patients mean 6.76 +/- 2.5, physicians 7.31 +/- 1.9, scale from 0 to 10) and non-distressing (patients 1.29 +/- 2.5, physicians 1.15 +/- 1.3, scale from 0 to 10). Following the interview, doctors were able to correctly gauge the importance of spirituality for their patients. Patients who considered the interview as very helpful (VAS > 7) were more often female (P = 0.002). There were no differences between patients who evaluated the SPIR as very helpful and those who did not, as far as diagnosis, educational level or belonging to a religious community were concerned. The present study shows that a short clinical assessment of cancer patients' spirituality is well received by both patients and physicians. The SPIR interview may be a helpful tool for addressing the spiritual domain, planning referrals and ultimately strengthening the patient-physician relationship.

[Psychosocial distress as a concomitant symptom in cancer patients]. / Psycho-sozialer Distress als Begleitsymptom der Krebserkrankung.

According to the lay mind the psyche is somehow responsible for the cancer growth, at least to name one reason for the verdict of guilty. Scientifically this issue has no evidence, as well as there is no evidence that the psyche has an influence on neither survival time nor healing rates. Merely undisputed is the effect of the psychosocial stress of a life-threatening medical illness onto the quality of life of the patients and family members. This kind of stress is called "distress"in the American-speaking countries. The translation into German terms is still poorly defined and mainly concentrated to the psychiatric disorders (ICD-10) like depressions and anxiety disorders. Psycho-oncological research is currently interested besides others issues in the question of a suitable screening-method to identify patients in regard to their distress level, who would profit by a specific psycho-oncological intervention.

Possibility to improve preservation of whole blood by leukocyte-depletion before storage.

In order to evaluate the influence of leukocytes in whole blood on the standard blood bank conditions for storage, we compared several parameters of red cells, leukocytes and platelets in leukocyte-rich and leukocyte-poor whole blood over a storage period of 5 weeks. The leukocyte-depleted units were prepared by filtration with a leukocyte trapping filter (Sepacell R500A). Our data indicate improved storage conditions, made evident by significantly lower cell damage: smaller increases of elastase, beta-thromboglobulin and lactate dehydrogenase in leukocyte-depleted blood. This improvement was achieved in a simple two-bag system using only filtration, without addition of rejuvenating solutions. In addition, this procedure allows greater flexibility in the use of filtrated blood for transfusions.

Preparation of white cell-depleted blood. Comparison of two bedside filter systems.

Numerous techniques have been established for preparing white cell-poor blood, such as centrifugation, sedimentation, freezing, and filtration. All of these methods have disadvantages that restrict their practical use: they are time-consuming, they require the facilities of a blood bank, and the white cell-poor units cannot be stored. Therefore tests have been performed on two filter systems that make possible the depletion of white cells directly at the bedside. Both filters have a high white cell-removal rate. The number of residual white cells in 1 unit of packed red cells was calculated as 1.08 +/- 0.53 x 10(7) in one system and 1.54 +/- 0.71 x 10(7) in the other. The filters do not affect the filtered red cells. Pressure filtration is performed without significant loss of efficiency. One of the systems can filter 2 units via one filter; however, handling the filters is tedious, and both filters are characterized by a low red cell recovery. Despite these disadvantages, the tested filter systems provide an effective device for preparing white cell-poor blood at the bedside. They are a suitable alternative to the conventional methods.

Posttraumatic splenic cysts and partial splenectomy: report of a case.

Nonparasitic splenic cysts are uncommon, with only around 800 cases described in the literature. Posttraumatic splenic pseudocysts constitute most such cases and require surgical treatment when symptomatic or voluminous. Recent studies have provided a better understanding of splenic tissue function and the consequent risks of complete resection of the spleen. Hence surgeons should make every possible effort to preserve splenic tissue. Several spleen-conserving surgical treatments have been proposed, especially for treatment of splenic posttraumatic pseudocysts. The authors report the case of a 13-year-old girl who had a posttraumatic splenic cyst with progressive growth. The diameter of the cyst at surgery was 15 cm, and partial splenectomy was performed. The most common spleen-conserving surgical techniques are briefly reviewed.

Increased serum levels of tumor necrosis factor alpha precede major complications of bone marrow transplantation.

Acute graft-versus-host disease, interstitial pneumonitis, endothelial leakage syndrome, and veno-occlusive disease are major complications of bone marrow transplantation. Though several new regimens for prophylaxis and treatment of these syndromes have been introduced, the overall incidence has been only slightly reduced over the last few years. We retrospectively analyzed tumor necrosis factor alpha (TNF alpha) serum levels between day -8 and day 100 after bone marrow transplantation in 56 patients transplanted in our unit for a variety of hematological diseases. In 34 patients with uneventful courses, mean TNF alpha levels rose to a maximum of 76 +/- 29 pg/mL. In contrast, 22 patients with major transplant related complications showed mean increases of TNF alpha of 492 +/- 235 pg/mL (P less than .0001). Increases of TNF alpha occurred before interstitial pneumonitis and severe acute graft-versus-host disease with a latency of 25 to 54 days. Early complications such as endothelial leakage syndrome and veno-occlusive disease were closely associated with increases of TNF alpha serum levels. Our study suggests two pathways of TNF alpha release: activation of host macrophages and stimulation of donor cells in the course of acute graft-versus-host disease. Cytokine monitoring should be helpful for prediction and earlier treatment of major transplant related complications.