Prophylactic bypassing agent use before and during immune tolerance induction in patients with haemophilia A and inhibitors to FVIII.

The development of high-titre inhibitory antibodies (inhibitors) against factor VIII (FVIII) remains a challenge in the management of patients with haemophilia A (HA). Patients with high-titre inhibitors are more likely to experience uncontrolled bleeding, physical disability from chronic arthropathy and premature death compared with those without this complication. Immune tolerance induction (ITI), utilizing repeated infusions of FVIII, is an effective therapeutic approach to eliminating inhibitory antibodies. This strategy can eradicate FVIII inhibitors, so that FVIII-specific tolerance is induced. However, patients undergoing ITI are still vulnerable to the development of serious and/or repeated bleeding events. The efficacy of bypassing agents in preventing bleeding episodes has been widely proven in patients with HA and inhibitors to FVIII. Evidence suggests that reducing bleeding during ITI can also shorten the time to tolerance. There are concerns with the use of bypassing agents, including the cost of treatment, short half-life, management of non-responders and the risk of thrombosis. Despite these concerns, and the still limited evidence from prospective studies and consensus reports, the use of prophylaxis with bypassing agents during ITI has been gaining support. This review presents a rationale and current data supporting the use of prophylactic bypassing agents as effective and safe therapies to reduce the incidence of joint bleeding due to inhibitors and improve quality of life in patients with HA undergoing ITI.

Radionuclide synovectomy/synoviorthesis (RS) in patients with bleeding disorders: A review of patient and procedure demographics and functional outcomes in the ATHNdataset.

INTRODUCTION: Radionuclide synovectomy/synoviorthesis (RS) to manage proliferative synovitis in persons with bleeding disorders has been utilized for decades; however, aggregate US results are limited. AIM: To determine the prevalence of RS utilization, patient and procedure related demographics and functional outcomes in United States haemophilia treatment centres (HTCs). The ATHNdataset includes US patients with bleeding disorders who have authorized the sharing of their demographic and clinical information for research. METHODS: We performed a multi-institutional, observational cohort study utilizing this dataset through 2010. Cases treated with RS procedure were compared to controls within the dataset. Standard template for data collection included patient and procedure related demographics as well as functional outcomes including range of motion (ROM) of the affected joint. Normative age- and sex-matched control ROM was obtained from published data. RESULTS: In the ATHNdataset there were 19 539 control-patients and 196 case-patients treated with RS. Patients with severe haemophilia were more likely to have had RS compared to those with mild/moderate haemophilia, although the proportion of RS performed was similar between severe HA and HB. Inhibitory antibodies, HIV and hepatitis C infection were significantly more common in cases. There were 362 RS procedures captured with 94 cases having >1 RS procedures. CONCLUSIONS: Right-sided joint procedures were more prevalent than left-sided procedures. Overall, case-patients had worse joint ROM compared to control-patients and published normative values. Geographically, there was regional variation in RS utilization, as the Southeast region had the largest percent of case-patients.

Hepatitis B vaccination is effective by subcutaneous route in children with bleeding disorders: a universal data collection database analysis.

Subcutaneous (SQ) vs. intramuscular (IM) vaccination may cause fewer injection site complications in children with bleeding disorders, but little is known about comparative immunogenicity. To compare immunogenicity of hepatitis B virus (HBV) vaccination administered SQ or IM to individuals <2 years old with bleeding disorders, we performed a retrospective analysis of HBV surface antibody titres among patients enrolled in the universal data collection database who had received three doses of HBV vaccine solely by one route (SQ or IM). Data reviewed were from an initial visit before 24 months of age, until time of hepatitis antibody titre testing. The SQ and IM study groups did not differ in demographics, haemophilia type or severity or bleeding history. The mean age at the time of HBV surface antibody (anti-HBs) testing was 56.9 ± 20.3 months. Eighty-five of 92 subjects (92.4%) who received vaccine SQ developed a positive antibody titre (>12 IU/L), compared to 101/114 (88.6%) who received IM (P = 0.30). There was no statistically significant difference in distribution of titre values. The average age of the subjects at time of testing was 53 ± 20 months in the SQ group vs. 60 ± 20 months in the IM group (P = 0.02). The average time between the last dose of vaccine and anti-HBs testing was 47.6 ± 18.5 months among SQ vaccinated subjects vs. 51.6 ± 20.5 months in the IM group (P = 0.2). Immunogenicity to hepatitis B vaccination by the SQ and IM routes is similar.

Increased prevalence of inhibitors in Hispanic patients with severe haemophilia A enrolled in the Universal Data Collection database.

Neutralizing inhibitors develop in 20-30% of patients with severe factor VIII (FVIII) deficiency. It is well established that Blacks have a higher prevalence of inhibitors than Whites. This is the first study to definitively demonstrate increased inhibitor prevalence in the Hispanic population. We compared inhibitor prevalence among various racial and ethnic groups in a cross-sectional analysis of 5651 males with severe haemophilia A that participated in the Universal Data Collection project sponsored by the Centers for Disease Control and Prevention. We used logistic regression analysis to control for potential confounding variables. We assigned as Hispanic those participants who were white and labelled themselves Hispanic. The prevalence of high-titre inhibitors in the Hispanic participants was 24.5% compared to 16.4% for White non-Hispanic patients (OR 1.4, 95% CI 1.1, 1.7). Possibilities as to the underlying cause of increased inhibitor prevalence in minority ethnic populations include polymorphisms in the FVIII molecule, HLA subtypes and differing inflammatory responses. A better understanding may lead to tailored treatment programmes, or other therapies, to decrease or prevent inhibitor development.

Alpha2-antiplasmin and its deficiency: fibrinolysis out of balance.

Fibrinolysis serves an important role in the process of coagulation, ensuring that clots that are formed in response to injury resolve after the injured tissue is repaired. Fibrinolysis occurs because the protein plasminogen is converted to the active serine protease plasmin by its activating molecules (primarily tissue plasminogen activator). One of the inhibitors of fibrinolysis is alpha(2)-antiplasmin, which acts as the primary inhibitor of plasmin(ogen). Congenital deficiency of alpha(2)-antiplasmin causes a rare bleeding disorder because of increased fibrinolysis. Despite the rare nature of this disorder, understanding of the actions of alpha(2)-antiplasmin and the results of its deficiency has provided the opportunity for better understanding of the fibrinolytic system in both how it affects the risk of bleeding and its impact on other bodily systems. Here, we review the history of the discovery of alpha(2)-antiplasmin, our understanding of its genetics and function, and our current knowledge of its congenital deficiency. We also discuss some of the current avenues of investigation into its impact on other diseases and physiological states.

Misuse of veterinary phenylbutazone.

Phenylbutazone is a nonsteroidal anti-inflammatory drug that was commonly prescribed for the treatment of arthritic conditions; it is no longer available for use in humans because of its numerous side effects, including aplastic anemia. We describe a horse trainer who developed gastric ulcers and renal insufficiency as a result of taking veterinary phenylbutazone. A review of the literature reveals a pattern of abuse by those who work with and around animals. When appropriate, patients who work around animals should be questioned about illicit phenylbutazone consumption.

Inhibitor recurrence after immune tolerance induction: a multicenter retrospective cohort study.

BACKGROUND: Immune tolerance induction (ITI) in patients with congenital hemophilia A is successful in up to 70%. Although there is growing understanding of predictors of response to ITI, the probability and predictors of inhibitor recurrence after successful ITI are not well understood. OBJECTIVES: To determine the association of clinical characteristics, particularly adherence to factor VIII (FVIII) prophylaxis after ITI, with inhibitor recurrence in patients with hemophilia A who were considered tolerant after ITI. METHODS: In this multicenter retrospective cohort study, 64 subjects with FVIII level < 2% who were considered successfully tolerant after ITI were analyzed to estimate the cumulative probability of inhibitor recurrence using the Kaplan-Meier method. The association of clinical characteristics with inhibitor recurrence was assessed using logistic regression. RESULTS: A recurrent inhibitor titer ≥ 0.6 BU mL(-1) occurred at least once in 19 (29.7%) and more than once in 12 (18.8%). The probability of any recurrent inhibitor at 1 and 5 years was 12.8% and 32.5%, respectively. Having a recurrent inhibitor was associated with having received immune modulation during ITI (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2-22.4) and FVIII recovery of < 85% at the end of ITI (OR 2.6, 95% CI 1.3-5.9) but was not associated with adherence to post-ITI prophylactic FVIII infusion (OR 0.5, 95% CI 0.06-4.3). CONCLUSIONS: The use of immune modulation therapy during ITI and lower FVIII recovery at the end of ITI appear to be associated with an increased risk of inhibitor recurrence after successful ITI. Adherence to post-ITI prophylactic FVIII infusions is not a major determinant of recurrence.

The clinical significance of focal active colitis.

Focal crypt injury by neutrophils (cryptitis/crypt abscesses), or focal active colitis (FAC), is a common isolated finding in endoscopic colorectal biopsies. Focal active colitis is often thought of as a feature of Crohn's disease, but may also be seen in ischemia, infections, partially treated ulcerative colitis, and as an isolated finding in patients undergoing endoscopy to exclude neoplasia. Clinical, endoscopic, and pathological data were retrospectively reviewed from 49 patients with focal active colitis, who had no other diagnostic findings on colorectal biopsy and no history of chronic inflammatory bowel disease. The histological findings were correlated with clinical diagnoses. Follow-up information was available for 42 of 49 focal active colitis patients. None developed inflammatory bowel disease; however, 19 patients had an acute self-limited colitis-like diarrheal illness, 11 had incidental focal active colitis (patients without diarrhea that were endoscoped to exclude colonic neoplasia and found to have asymptomatic FAC), 6 had irritable bowel syndrome, 4 had antibiotic-associated colitis, and 2 had ischemic colitis. Twenty patients were immunosuppressed, and 19 were taking nonsteroidal anti-inflammatory drugs. No histological features predicted final diagnoses. FAC did not predict the development of chronic colitis, even when mild crypt distortion or slight basal plasmacytosis was present. The preponderance of acute self-limited colitis and antibiotic-associated colitis among the FAC patients, along with the high number of immunosuppressed patients, support the conclusion that most FAC cases are infectious. The incidental detection of FAC in patients undergoing endoscopy to exclude colonic neoplasia was not clinically significant. The role of nonsteroidal anti-inflammatory drugs in FAC deserves further study.

Detection of protein binding to a glucocorticoid response element-like sequence in a chicken major histocompatibility complex class II promoter.

The glucocorticoid response element in gene promoters mediates regulation of gene expression by glucocorticoids. The major histocompatibility (MHC) class II genes, crucial for immunoresponsiveness, are among those modulated by glucocorticoids. A GRE-like sequence has been located in the promoter of a chicken MHC class II promoter. DNase footprinting revealed protein binding by the GRE-like sequence when nuclear extract from chicken T or B cell lines were used. Gel shift assays detected multiple binding activities in the lymphocyte cell lines, but little binding in the macrophage cell line. Relative band intensity differed among the lymphocyte cell lines. By using a mutant GRE oligonucleotide, most of the binding activities were demonstrated to be specific to the GRE. This study suggests a role of the GRE-like sequence in regulating chicken MHC class II genes and provides further evidence for the previously reported influence of glucocorticoids on chicken MHC class II expression which may be the molecular basis of glucocorticoid immunomodulation.

Case reports: trimethoprim-sulfamethoxazole-induced meningitis in patients with HIV infection.

Meningitis is a frequent complication of the human immunodeficiency infection. Possible causes include bacterial, fungal, mycobacterial, syphilitic, and vital pathogens (including the human immunodeficiency virus). Drugs must also be considered in the differential diagnosis. Two patients with probable trimethoprim-sulfamethoxazole-induced meningitis are described in the setting of human immunodeficiency virus infection.

Comparison of porcine reproductive and respiratory syndrome virus growth in media supplemented with fetal bovine serum or a serum replacement.

Commercially available serum replacements are often used in cell culture as a cheaper and less variable substitute for fetal bovine serum (FBS). The growth of porcine reproductive and respiratory syndrome virus (PRRSV) isolates in CRL11171 cells maintained in a medium supplemented with FBS was compared with virus propagation in the same cell line maintained in the same medium with a serum replacement. The PRRSV replicated significantly better when the cell culture medium was supplemented with FBS. The results of this study have implications for the use of serum replacement-supplemented medium for PRRSV diagnosis by virus isolation.

Cellular immune response to Marek's disease: listeriosis as a model of study.

The immune response of chickens to Listeria monocytogenes was studied as a potential model for cell-mediated immunocompetence. Chickens genetically resistant and susceptible to Marek's disease (MD) did not differ in their ability to survive Listeria, although during the early stages of infection the bacteria replicated more readily in MD-susceptible chickens. MD-susceptible chickens responded earlier than MD-resistant chickens, and with equal or increased intensity, in assays of various components of the cell-mediated reaction. These assays included T-cell activation, delayed-type hypersensitivity, and macrophage activation. These data indicate that genetic resistance or susceptibility to MD is not wholly dependent on the innate immunocompetence of the host. Co-infection with Listeria was used to measure cellular immunocompetence in MD-infected chickens. MD virus had no effect on the ability of host macrophages to control the growth of Listeria. The cell-mediated response was suppressed in MD-susceptible chickens. The occurrence of spleen cell proliferation, followed by marked suppression of the effector arm of the immune response in susceptible but not resistant chickens, indicated the possibility of an active suppressor-cell population associated with genetic susceptibility to MD.

Detection of equine infectious anemia virus in horse leukocyte cultures derived from horses in various stages of equine infectious anemia viral infection.

The enzyme-linked immunosorbent assay (ELISA) antigen-positive and agar-gel immunodiffusion test (AGID)-negative horses do not have infective equine infectious anemia (EIA) virus. The ELISA testing of horse leukocyte culture (HLC) supernatants did detect EIA virus in a HLC that was infected with the Wyoming strain of EIA virus and in HLC derived from horses in febrile, acute, or subacute stages of EIA infection. In supernatants of HLC derived from chronic and inapparent carrier horses, EIA virus was not detected with ELISA. Direct fluorescent antibody tests detected EIA virus in HLC infected with 10(6)TCID50 of the Wyoming strain of EIA virus and in 50% of the HLC from febrile acute or subacute horses. The direct fluorescent antibody testing of HLC derived from chronic and inapparent carrier horses did not detect cell-associated EIA virus. The pony inoculation test proved to be the most reliable and accurate method for detecting infective EIA virus in horses in various stages of EIA infection and accurately correlated with the AGID test.

Production and characterization of canine osteosarcoma cell lines that induce transplantable tumors in nude mice.

OBJECTIVE: To produce and characterize cell lines from canine primary appendicular osteosarcomas that induce transplantable tumors in athymic nude mice. ANIMALS: 57 six- to 8-week-old female athymic nude mice. PROCEDURE: Canine primary appendicular osteosarcoma tumors were harvested and cell lines were produced. Canine osteosarcoma (COSCA)-Toby (COSCA-T; 10 mice), COSCA-Princess (COSCA-Pr; 16) or canine osteosarcoma D-17 (ATCC CCL-183; 31) cells were injected into the proximal portion of the left tibia of nude mice to evaluate tumor production from each cell line; the right tibia served as the control. Tibial measurements were taken on alternating days to evaluate tumor growth during a 6-month period. Student's t-tests were used to determine whether size of the proximal portion of the left and right tibias differed significantly during the observation period. RESULTS: 88% of mice receiving COSCA-Pr and 50% of mice receiving COSCA-T cells developed a tumor at the injection site by 9 days after implantation. The D-17 cells induced tumors in 50% of injected tibias; however, tumors were not detected for 79 days. Tumors generated from COSCA-Pr and COSCA-T cells in nude mice were histologically similar to the canine tumor from which they were developed. CONCLUSION: New osteosarcoma cell lines that can reliably and rapidly induce transplantable tumors in nude mice were developed. CLINICAL RELEVANCE: Use of cell lines will allow evaluation of new treatments of canine primary appendicular osteosarcoma in a nude mouse model.

Functional characterization of a chicken major histocompatibility complex class II B gene promoter.

A 0.7 kilobase (kb) DNA fragment from the 5' flanking region of a chicken major histocompatibility complex (MHC) class II B gene was cloned into chloramphenicol acetyltransferase (CAT) reporter vectors and was transfected into a chicken macrophage cell line that expresses a low level of MHC class II antigens. Positive orientation-dependent promoter activity of the chicken DNA was evident in a reporter construct containing an SV40 enhancer. Deletion analysis of this 0.7 kb DNA fragment revealed a short fragment in the 3' end that was crucial for the promoter function and negative regulatory elements (NRE) located further upstream. The conserved MHC class II X and Y boxes did not have a significant effect on promoter activity. Sequence analysis of the 0.7 kb class II B gene upstream region suggests possible involvement of interferon (IFN), E twenty-six specific (ETS)-related proteins, and other factors in regulating this promoter. A chicken T-cell line culture supernatant increased surface expression of MHC class II antigens, as well as class II promoter activity, in this macrophage cell line. This first functional characterization of a chicken MHC class II B gene promoter will aid in understanding the regulatory mechanisms that control the expression of these genes.

Roles of oxygen and photoinduced acidification in the light-dependent antiviral activity of hypocrellin A.

Hypocrellin A displays photoinduced antiviral activity, in particular against the human immunodeficiency virus (HIV), as does its counterpart, hypericin. Although hypocrellin A, like hypericin, executes an excited-state intramolecular proton transfer, it differs from hypericin in two important ways. Unlike hypericin, hypocrellin A absolutely requires oxygen for its antiviral activity. Also, whereas we have previously demonstrated that hypericin functions as a light-induced proton source, we do not observe that hypocrellin A acidifies its surrounding medium in the presence of light. These results are discussed in the context of the ground- and excited-state photophysics of hypericin and its mechanisms of photoinduced virucidal activity.

Endosonographic differentiation of benign and malignant stromal cell tumors.

BACKGROUND: Endosonography (EUS) is a valuable technique for diagnosing gastrointestinal stromal cell tumors. However, EUS features that are predictive of malignancy in these tumors have not been defined. METHODS: Videotapes and photographs of EUS examinations performed prior to surgical resection of 35 stromal cell tumors (9 malignant) were blindly reviewed by a single examiner. EUS features associated with malignancy were determined. Interobserver agreement in interpreting these features was then measured among a panel of five expert endosonographers who judged EUS videotapes of 35 resected stromal cell tumors (10 malignant). RESULTS: Stepwise logistic regression analysis demonstrated that tumor size (diameter > 4 cm), irregular extraluminal border, echogenic foci, and cystic spaces were independently associated with malignancy in stromal cell tumors (p < 0.05). Interobserver agreement for irregular extraluminal border, echogenic foci, and cystic spaces, as measured by mean kappa statistic, was 0.43, 0.39, and 0.28, respectively. For the five experts, the sensitivity for detecting malignancy ranged between 80% to 100% when at least two of the three features were judged to be present. The likelihood of finding malignancy ranged between 0% to 11% for the experts when all three features were judged absent. CONCLUSIONS: Tumor size and certain EUS features are useful for predicting malignancy in stromal cell tumors. Absence of these features indicates benign disease. Agreement among experts in interpreting these EUS features is fair to moderate.

EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms.

BACKGROUND: Computerized tomography (CT), magnetic resonance imaging (MRI), and transabdominal ultrasound frequently fail to detect ampullary lesions. Endoscopic ultrasound (EUS) is a sensitive modality for detecting and staging ampullary tumors. Accurate staging may be affected by biliary stenting, which is frequently performed in these patients with obstructive jaundice. The present study assessed the accuracy of ampullary tumor staging with multiple imaging modalities in patients with and those without endobiliary stents. METHODS: Fifty consecutive patients with ampullary neoplasms from two endosonography centers were preoperatively staged by EUS plus CT (37 patients), MRI (13 patients), or angiography (10 patients) over a 3(1/2) year period. Twenty-five of the 50 patients had a transpapillary endobiliary stent present at the time of endosonographic examination. Accuracy of EUS, CT, MRI, and angiography was assessed with the TNM classification system and compared with surgical-pathologic staging. The influence of an endobiliary stent present at the time of EUS on staging accuracy of EUS was also evaluated. RESULTS: EUS was more accurate than CT and MRI in the overall assessment of the T stage of ampullary neoplasms (EUS 78%, CT 24%, MRI 46%). No significant difference in N stage accuracy was noted between the three imaging modalities (EUS 68%, CT 59%, MRI 77%). EUS T stage accuracy was reduced from 84% to 72% in the presence of a transpapillary endobiliary stent. This was most prominent in the understaging of T2/T3 carcinomas. CONCLUSIONS: EUS is superior to CT and MRI in assessing T stage but not N stage of ampullary lesions. The presence of an endobiliary stent at EUS may result in underestimating the need for a Whipple resection because of tumor understaging.