Radiomorphologische Arbeiten zur Hämochromatose-Arthropathie am Handskelett bei Patienten mit einer phänotypischen Hämochromatose

Hintergrund und Fragestellung: Die Arthropathie ist eine erst spät entdeckte Komplikation der hereditären Hämochromatose. Die Erstbeschreibung erfolgte durch Schumacher 1964. Sie ist eine der häufigsten Frühsymptome bei Hämochromatose-Patienten, weiterhin beeinflusst die Arthropathie von allen Hämochromatose-assoziierten Erkrankungen die Lebensqualität der Patienten am stärksten. Eine radiologisch dokumentierte Langzeituntersuchung findet sich in der Literatur nicht. Ziel der als retrospektiv angelegten Untersuchung war es, bei einem großen, einheitlich definierten Kollektiv den Einfluss demographischer Daten, des HFE-Genotyps, des Ausmaßes der Eisenüberladung sowie der mechanischen Belastung auf das Auftreten sowie die Ausprägung einer Arthropathie des Handskelettes zu untersuchen. An den vorhandenen radiologisch dokumentierten Langzeitverläufen sollte die Progression der radiologischen Veränderungen unter einer Aderlass- Therapie beurteilt werden. Des weiteren sollte anhand der erhobenen Daten und unter Würdigung der vorhandenen Literatur, die Theorien zur Genese der Hämochromatose- Arthropathie diskutiert, sowie eine einheitliche Definition der Arthropathie und ein Diagnose-Algorithmus erarbeitet werden. Patienten und Methodik: Es wurden 143 Patienten (98 Männer, 45 Frauen) mit nachgewiesener Eisenüberladung und erfolgter HFE- Genotypisierung auf das Vorliegen einer Hämochromatose- assoziierten Erkrankung, insbesondere einer Arthropathie untersucht. Dokumentiert und verglichen wurden demographische Daten, maximal gemessene Eisenstoffwechselparameter (Ferritin und Transferrinsättigung), der HFE- Genotyp, Angaben über die (berufliche) mechanische Belastung der Gelenke sowie Aderlassbehandlungen. Als Vergleichsgruppe sollten die Patienten mit nachgewiesener Eisenüberladung, aber ohne den Nachweis einer Arthropathie dienen. Bei Patienten mit radiologisch nachgewiesener Hämochromatose- Arthropathie wurden die vorliegenden Röntgenbilder des Handskelettes auf radiomorphologische Veränderungen sowie auf das Vorliegen eines möglichen Gelenktropismus hin untersucht und ausgewertet. Bei 16 Patienten mit radiologisch dokumentierten Langzeitverläufen wurden diese gesondert auf eine radiologische Progression hin untersucht. Ergebnisse: Bei 64 (44,8%) Patienten (52 Männer, 12 Frauen) wurde die Diagnose einer Hämochromatose- Arthropathie gestellt. Im Vergleich zu den 79 Patienten (46 Männer, 33 Frauen) ohne die Diagnose einer Arthropathie ergaben sich signifikante Unterschiede insbesonders im maximal gemessenen Ferritin, der Transferrinsättigung sowie dem Alter. In der Gruppe mit diagnostizierter Hämochromatose- Arthropathie und verfügbaren Röntgenbildern des Handskelettes (51 Patienten) konnte der in der Literatur beschriebene Gelenktropismus bezüglich des zweiten und dritten Metacarpophalangealgelenkes bestätigt werden. Es ergab sich weiterhin eine positive Korrelation zwischen der Höhe der Eisenüberladung und der Ausprägung der Arthropathie. Ein Zusammenhang zwischen mechanischer Beanspruchung und Schwere der Arthropathie konnte im Rahmen der Untersuchung, trotz wegweisender Befunde, nicht belegt werden. In den radiologisch dokumentierten Langzeitverläufen (16 Patienten) konnte unter einer bestehenden Aderlass- Therapie nur ein geringer radiologischer Progress und in keinem Fall eine neue Alteration der Metacarpophalangealgelenke dokumentiert werden. Es wurde weiterhin aufgrund der erhobenen Ergebnisse und unter Würdigung der vorhandene Literatur der Entwurf für eine einheitliche Definition der Hämochromatose- Arthropathie und ein Diagnose-Algorithmus erarbeitet. Fazit: Die Bedeutung der Eisenüberladung für die Entstehung sowie die Ausprägung der Hämochromatose- Arthropathie konnte nachgewiesen werden. Des weiteren konnte ein nur geringem Progress der radiologischen Veränderungen im Langzeitverlauf und ein Fehlen einer neuen Alterationen der Metacarpophalangealgelenke unter fortlaufender Eisendepletion nachgewiesen werden. Die in der Literatur dargestellte therapeutische Ineffektivität einer Aderlass-Therapie auf den Progress einer Hämochromatose-Arthropathie konnte somit nicht bestätigt werden. Die frühzeitige und konsequente Aderlass-Therapie stellt die Quintessenz der oben dargestellten Ergebnisse bezüglich einer Therapieoption zur Verhinderung oder Konsolidierung einer Hämochromatose-Arthropathie dar.Arthropathy is a recently discovered complication of hereditary hemochromatosis. It was first described by Schumacher in 1964 and is one of the most frequent early symptoms in hemochromatosis patients. Of all hemochromatosis-associated symptoms, arthropathy has the highest negative impact on a patient's quality of life. The aim of this retrospective study was to show possible correlations between demographic factors, the HFE-genotype, the level of iron-overload as well as the mechanic burden of manual labor on the manifestation and extent of an arthropathy of the hand skeleton. Based on long-term radiologic data, the progression of radiologic change in the hand skeleton of patients receiving phlebotomy treatment was to be determined. Theories on the pathogenesis of hemochromatosis-arthropathy were to be reviewed and a standard definition of hemochromatosis-arthropathy including a diagnostic algorithm were to be developed. Material and methods: 143 HFE-genotyped patients (98 male, 45 female) with a proven iron-overload were screened for hemochromatosis-associated diseases, especially arthropathy. Demographic data, the maximum ferritin- and transferrin-saturation, the HFE-genotype, administered phlebotomies and details of the mechanical burden on the joints were documented and compared. Patients with a proven iron-overload but without manifestations of an arthropathy served as a reference group. In patients with a proven hemochromatosis-arthropathy, X-rays of the hand skeleton were screened for radiomorphologic changes as well as possible joint tropism. 16 patients with long-term radiologic documentation were selectively screened for radiologic progression. Results: 64 (44,8% ) patients (52 male, 12 female) were diagnosed as having a hemochromatosisarthropathy. When compared to the 79 patients (46 male, 33 female) without an arthropathy, there were significant differences in the maximum measured ferritin, transferrin-saturation and age. In the group of patients with a proven hemochromatosis-arthropathy and available Xrays of the hand skeleton (51 patients), the joint tropism of the second and third metacarpophalangeal joint described in the literature was confirmed. Furthermore, there was a positive correlation between the level of iron-overload and the extent of the arthropathy. There was no correlation between the mechanical burden on the joints and the extent of the arthropathy. The 16 patients with long-term radiologic documentation (undergoing phlebotomy therapy) showed only slow radiologic progression, and in no case could recent changes in the metacarpophalangeal joint be found. With the help of the results of this study and the literature, a standard definition of hemochromatosis-arthropathy and a diagnostic algorithm were developed. Discussion: In this study, the importance of iron-overload in the manifestation and extent of hemochromatosis-arthropathy was shown. Furthermore, in patients undergoing phlebotomy therapy, only a slow progression of radiologic changes in the long term and no recent changes in the metacarpophalangeal joints were found. So the therapeutic ineffectiveness of phlebotomy therapy in slowing the progression of a hemochromatosis-arthropathy, as postulated in the literature, could not be confirmed. Early onset and consistent implementation of phlebotomy therapy represents a viable option to prevent or stop the progression of hemochromatosis-arthropathy

Experimenter Expectancy Bias Does Not Explain Eurasian Jays' (Garrulus glandarius) Performance in a Desire-State Attribution Task

Male Eurasian jays have been found to adjust the type of food they share with their female partner after seeing her eat one type of food to satiety. One interpretation of this behavior is that the male encoded the female’s decreased desire for the food she was sated on, and adjusted his behavior accordingly. However, in these studies, the male’s actions were scored by experimenters who knew on which food the female was sated. Thus, it is possible that the experimenters’ expectations (sub-consciously) affected their behavior during tests that, in turn, inadvertently could have influenced the males’ actions. Here, we repeated the original test with an experimenter who was blind to the food on which the female was sated. This procedure yielded the same results as the original studies: the male shared food with the female that was in line with her current desire. Thus, our results rule out the possibility that the Eurasian jay males’ actions in the food sharing task could be explained by the effects of an experimenter expectancy bias

Allogeneic stem cell transplantation benefits for patients >= 60 years with acute myeloid leukemia and FLT3 internal tandem duplication : a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation

Intermediate-risk cytogenetic acute myeloid leukemia with an internal tandem duplication of FLT3 (FLT3-ITD) is associated with a high risk of relapse, and is now a standard indication for allogeneic stem cell transplantation. Nevertheless, most studies supporting this strategy have been performed in young patients. To address the benefit of allogeneic transplantation in the elderly, we made a selection from the European Society for Blood and Marrow Transplantation registry of de novo intermediate-risk cytogenetic acute myeloid leukemia harboring FLT3-ITD in patients aged 60 or over and transplanted from a related or unrelated donor between January 2000 and December 2015. Two hundred and ninety-one patients were identified. Most patients received a reduced-intensity conditioning (82%), while donors consisted of an unrelated donor in 161 (55%) patients. Two hundred and twelve patients received their transplantation in first remission, 37 in second remission and 42 in a more advanced stage of the disease. The 2-year leukemia-free survival rate was 56% in patients in first remission, 22% in those in second remission and 10% in patients with active disease, respectively (P= 60 with FLT3-ITD acute myeloid leukemia in first remission, similarly to current treatment recommendations for younger patients.Peer reviewe

Long-term results and GvHD after prophylactic and preemptive donor lymphocyte infusion after allogeneic stem cell transplantation for acute leukemia

We report on 318 patients with acute leukemia, receiving donor lymphocyte infusion (DLI) in complete hematologic remission (CHR) after allogeneic stem cell transplantation (alloSCT). DLI were applied preemptively (preDLI) for minimal residual disease (MRD, n = 23) or mixed chimerism (MC, n = 169), or as prophylaxis in high-risk patients with complete chimerism and molecular remission (proDLI, n = 126). Median interval from alloSCT to DLI1 was 176 days, median follow-up was 7.0 years. Five-year cumulative relapse incidence (CRI), non-relapse mortality (NRM), leukemia-free and overall survival (LFS/OS) of the entire cohort were 29.1%, 12.7%, 58.2%, and 64.3%. Cumulative incidences of acute graft-versus-host disease (aGvHD) grade II–IV°/chronic GvHD were 11.9%/31%. Nineteen patients (6%) died from DLI-induced GvHD. Age ≥60 years (p = 0.046), advanced stage at transplantation (p = 0.003), shorter interval from transplantation (p = 0.018), and prior aGvHD ≥II° (p = 0.036) were risk factors for DLI-induced GvHD. GvHD did not influence CRI, but was associated with NRM and lower LFS/OS. Efficacy of preDLI was demonstrated by decreasing MRD/increasing blood counts in 71%, and increasing chimerism in 70%. Five-year OS after preDLI for MRD/MC was 51%/68% among responders, and 37% among non-responders. The study describes response and outcome of DLI in CHR and helps to identify candidates without increased risk of severe GvHD

A large-scale species level dated angiosperm phylogeny for evolutionary and ecological analyses.

Phylogenies are a central and indispensable tool for evolutionary and ecological research. Even though most angiosperm families are well investigated from a phylogenetic point of view, there are far less possibilities to carry out large-scale meta-analyses at order level or higher. Here, we reconstructed a large-scale dated phylogeny including nearly 1/8th of all angiosperm species, based on two plastid barcoding genes, matK (incl. trnK) and rbcL. Novel sequences were generated for several species, while the rest of the data were mined from GenBank. The resulting tree was dated using 56 angiosperm fossils as calibration points. The resulting megaphylogeny is one of the largest dated phylogenetic tree of angiosperms yet, consisting of 36,101 sampled species, representing 8,399 genera, 426 families and all orders. This novel framework will be useful for investigating different broad scale research questions in ecological and evolutionary biology

Fludarabine-treosulfan compared to thiotepa-busulfan-fludarabine or FLAMSA as conditioning regimen for patients with primary refractory or relapsed acute myeloid leukemia: a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation (EBMT)

Background: Limited data is available to guide the choice of the conditioning regimen for patients with acute myeloid leukemia (AML) undergoing transplant with persistent disease. Methods: We retrospectively compared outcome of fludarabine-treosulfan (FT), thiotepa-busulfan-fludarabine (TBF), and sequential fludarabine, intermediate dose Ara-C, amsacrine, total body irradiation/busulfan, cyclophosphamide (FLAMSA) conditioning in patients with refractory or relapsed AML. Results: Complete remission rates at day 100 were 92%, 80%, and 88% for FT, TBF, and FLAMSA, respectively (p = 0.13). Non-relapse mortality, incidence of relapse, acute (a) and chronic (c) graft-versus-host disease (GVHD) rates did not differ between the three groups. Overall survival at 2 years was 37% for FT, 24% for TBF, and 34% for FLAMSA (p = 0.10). Independent prognostic factors for survival were Karnofsky performance score and patient CMV serology (p = 0.01; p = 0.02), while survival was not affected by age at transplant. The use of anti-thymocyte globulin (ATG) was associated with reduced risk of grade III–IV aGVHD (p = 0.02) and cGVHD (p = 0.006), with no influence on relapse. Conclusions: In conclusion, FT, TBF, and FLAMSA regimens provided similar outcome in patients undergoing transplant with active AML. Survival was determined by patient characteristics as Karnofsky performance score and CMV serology, however was not affected by age at transplant. ATG appears able to reduce the incidence of acute and chronic GVHD without influencing relapse risk

Long-term outcome after allogeneic hematopoietic cell transplantation for myelofibrosis

Allogeneic hematopoietic stem cell transplant remains the only curative treatment for myelofibrosis. Most post-transplantation events Aoccur during the first two years and hence we aimed to analyze the outcome of 2-year disease-free survivors. A total of 1055 patients with myelofibrosis transplanted between 1995 and 2014 and registered in the registry of the European Society for Blood and Marrow Transplantation were included. Survival was compared to the matched general population to determine excess mortality and the risk factors that are associated. In the 2-year survivors, disease-free survival was 64% (60-68%) and overall survival was 74% (71-78%) at ten years; results were better in younger individuals and in women. Excess mortality was 14% (8-21%) in patients aged = 65 years. The main cause of death was relapse of the primary disease. Graft-versus-host disease (GvHD) before two years decreased the risk of relapse. Multivariable analysis of excess mortality showed that age, male sex recipient, secondary myelofibrosis and no GvHD disease prior to the 2-year landmark increased the risk of excess mortality. This is the largest study to date analyzing long-term outcome in patients with myelofibrosis undergoing transplant. Overall it shows a good survival in patients alive and in remission at two years. However, the occurrence of late complications, including late relapses, infectious complications and secondary malignancies, highlights the importance of screening and monitoring of long-term survivors.Peer reviewe

Ruxolitinib for Glucocorticoid-Refractory Acute Graft-versus-Host Disease

BACKGROUND: Acute graft-versus-host disease (GVHD) remains a major limitation of allogeneic stem-cell transplantation; not all patients have a response to standard glucocorticoid treatment. In a phase 2 trial, ruxolitinib, a selective Janus kinase (JAK1 and JAK2) inhibitor, showed potential efficacy in patients with glucocorticoid-refractory acute GVHD. METHODS: We conducted a multicenter, randomized, open-label, phase 3 trial comparing the efficacy and safety of oral ruxolitinib (10 mg twice daily) with the investigator's choice of therapy from a list of nine commonly used options (control) in patients 12 years of age or older who had glucocorticoid-refractory acute GVHD after allogeneic stem-cell transplantation. The primary end point was overall response (complete response or partial response) at day 28. The key secondary end point was durable overall response at day 56. RESULTS: A total of 309 patients underwent randomization; 154 patients were assigned to the ruxolitinib group and 155 to the control group. Overall response at day 28 was higher in the ruxolitinib group than in the control group (62% [96 patients] vs. 39% [61]; odds ratio, 2.64; 95% confidence interval [CI], 1.65 to 4.22; P<0.001). Durable overall response at day 56 was higher in the ruxolitinib group than in the control group (40% [61 patients] vs. 22% [34]; odds ratio, 2.38; 95% CI, 1.43 to 3.94; P<0.001). The estimated cumulative incidence of loss of response at 6 months was 10% in the ruxolitinib group and 39% in the control group. The median failure-free survival was considerably longer with ruxolitinib than with control (5.0 months vs. 1.0 month; hazard ratio for relapse or progression of hematologic disease, non-relapse-related death, or addition of new systemic therapy for acute GVHD, 0.46; 95% CI, 0.35 to 0.60). The median overall survival was 11.1 months in the ruxolitinib group and 6.5 months in the control group (hazard ratio for death, 0.83; 95% CI, 0.60 to 1.15). The most common adverse events up to day 28 were thrombocytopenia (in 50 of 152 patients [33%] in the ruxolitinib group and 27 of 150 [18%] in the control group), anemia (in 46 [30%] and 42 [28%], respectively), and cytomegalovirus infection (in 39 [26%] and 31 [21%]). CONCLUSIONS: Ruxolitinib therapy led to significant improvements in efficacy outcomes, with a higher incidence of thrombocytopenia, the most frequent toxic effect, than that observed with control therapy

Detection of Burkholderia in the seeds of Psychotria punctata (Rubiaceae) – Microscopic evidence for vertical transmission in the leaf nodule symbiosis

Background and aims The bacterial leaf nodule symbiosis is a close interaction between endophytes and their plant hosts, mainly within the coffee family. The interaction between Rubiaceae species and Burkholderia bacteria is unique due to its obligate nature, high specificity, and predominantly vertical transmission of the endophytes to the next generation of host plants. This vertical transmission is intriguing since it is the basis for the uniqueness of the symbiosis. However, unequivocal evidence of the location of the endophytes in the seeds is lacking. The aim of this paper is therefore to demonstrate the presence of the host specific endophyte in the seeds of Psychotria punctata and confirm its precise location. In addition, the suggested location of the endophyte in other parts of the most plant is investigated. Methods To identify and locate the endophyte in Psychotria punctata, a two-level approach was adopted using both a molecular screening method and fluorescent in situ hybridisation microscopy. Key results The endophytes, molecularly identified as Candidatus Burkholderia kirkii, were detected in the leaves, vegetative and flower buds, anthers, gynoecium, embryos, and young twigs. In addition, they were in situ localised in leaves, flowers and shoot apical meristems, and, for the first time, in between the cotyledons of the embryos. Conclusions Both independent techniques detected the host specific endophyte in close proximity to the shoot apical meristem of the embryo, which confirms for the first time the exact location of the endophytes in the seeds. This study provides reliable proof that the endophytes are maintained throughout the growth and development of the host plant and are transmitted vertically to the offspring.status: Published onlin