Oral chronic Graft-versus-host disease : clinical and pathological staging

Allogenic hematopoietic cell transplantation (HCT) is a curative treatment for many patients with immune- hematopoietic disorders, mainly hematopoietic cancers as leukaemia. Chronic Graft-versus-Host Disease (cGVHD) is a major long-term complication, associated with mortality and morbidity following allogenic HCT. Oral cGVHD is common and might manifest as mucosal lichenoid manifestations (om-cGVHD) or with dysfunctional salivary glands (sg-cGVHD). Alloreactive T-cells respond to recipient tissues with pathological reactions of acute inflammation, progressing with chronic inflammation and dysregulated immunity, and subsequent aberrant fibrotic healing. This thesis aimed to investigate diagnostic criteria for oral cGVHD using histopathological, clinical, and immune cell characterisation. A retrospective cohort of 95 HCT-patients and 303 oral biopsies were analysed, including 15 healthy controls. Oral mucosal biopsies with and without minor salivary glands (MSG) were retrieved from Stockholm Medical Biobank. Associated clinical information was gathered from the clinical charts and HCT register data. We applied histological (Haematoxylin and Eosin, Periodic acid Schiff, van Gieson), and immunohistochemical (IHC) staining (CD4 T-helper cells, CD8 T-cytotoxic cells, CD68 macrophages, CD1a Langerhans cells (LCs), CD19 and CD20 B-cells, and CD5 T-/B-cells). Quantitative IHC was performed using CellProfiler image analysis software. In papers I and IV, oral mucosal-, and MSG histopathology were analysed in biopsies prior and post HCT, with and without cGVHD. We used the National Institutes of Health pathology criteria and formalised grading modules to assess pathology scores and grades (NIH cGVHD grading). The oral mucosa was observed with minimal criteria of lichenoid interface inflammation with exocytosis, liquefaction degeneration and apoptosis. Basal membrane alterations were the most specific criteria found. Features detected in the MSG were peri-ductal and acinar inflammation and exocytosis, destruction and fibrosis. We developed severity grades (G)0-IV and verified pathology diagnostics of “possible (GII)” and “likely (GIII-GIV)” cGVHD. In paper IV, we also employed the Greenspan composite MSG grading scheme, which was found with a strong correlation to the NIH cGVHD MSG grading. IHC quantification was performed following established pipelines in CellProfiler, as described in paper II. The methodology was compared to manual counting, with a perfect concordance in detection of positive stained cells, as well as for positive stained regions. The benefit of CellProfiler is to perform standardised and repeatable quantification in a time saving manner. Oral mucosal immune profiles were investigated in paper III. CD4 infiltration was associated with mild and distinctive om-cGVHD but were found with frequent stable levels over time. CD8 was elevated in clinical and pathologically severe om-cGVHD, particularly during cGVHD onset and progression. Immunolocalisation of CD68 revealed significant staining in various clinical groups, particularly at onset, but the association with severity was interesting especially during late stages of disease. CD1a LCs were significantly reduced in pathological GII at onset and during progression, but otherwise non-significant compared to healthy. CD19 and CD20 were rarely observed. In paper IV, we quantified the immune profiles in the MSG and found an altered pathology with significant increase of CD4- and CD8-cells. However, levels of B-cells and LCs were considerably low. The association between oral mucosal and MSG immunopathology, was investigated on the whole cohort and with respect to cGVHD duration. Overall, a moderate correlation was observed for pathology scores, CD4 and CD8 infiltrate. Interestingly, at the time of cGVHD onset, the correlation between the oral mucosal disease and MSG was stronger but with progression no further association was found. In conclusion, om- and sg-cGVHD are two heterogenous complications that display associated immune-pathology profiles during cGVHD onset, but progression appears to be tissue- dependent. We developed histopathological grading modules to facilitate severity diagnostics, which were significantly associated with CD4, CD8 and CD68 immunostaining. om-cGVHD clinical and pathological characterisation was found associated to changes in the immune profile. CD8 was found to drive the severe disease reaction during onset and progression but diminished over time. However, long duration of the disease correlated with elevated CD68 and persistent CD4 cells. This highlights the need for improved clinical and pathological characterisation in combination with biological disease classification

Pulmicort® turbohaler® once daily as initial prophylactic therapy for asthma

AbstractIn a double-blind, randomized, parallel-group clinical trial, 340 asthmatic patients aged 12–70 years received budesonide 400 μg once daily in the morning, budesonide 400 μg once daily in the evening, budesonide 200 μg twice daily or placebo, for 12 weeks in addition to inhaled short-acting β2-agonists used as required (p.r.n.). Budesonide was given as Pulmicort Turbohaler.Peak expiratory flow rate (PEFR) increased by 20 to 30 1 min−1 in each of the active treatment groups, significantly more than in the placebo group (P<0·01). There were no significant differences between the active treatment groups. Symptom improvement and decreased β2-agonist use reflected the PEFR data. Incidences of adverse events in the active treatment groups were similar to those observed in the placebo group.Budesonide 400 μg given once daily morning or evening is equieffective with the same total daily dose given twice daily in the treatment of mild to moderate stable asthmatics

Perspectives on oral chronic graft-versus-host disease from immunobiology to morbid diagnoses

Chronic Graft-versus-Host Disease (cGVHD) is a major long-term complication, associated with morbidity and mortality in patients following allogenic hematopoietic cell transplantation (HCT) for immune hematopoietic disorders. The mouth is one of the most frequently affected organs after HCT (45-83%) and oral cGVHD, which may appear as the first visible sign. Manifestations present with mucosal lichenoid lesions, salivary gland dysfunction and limited oral aperture. Diagnosis of oral cGVHD severity is based on mucosal lesions with symptoms of sensitivity and pain and reduced oral intake. However, diagnostic difficulties arise due to subjective definitions and low specificity to cover the spectrum of oral cGVHD. In recent years there have been significant improvements in our understanding of the underlying oral cGVHD disease mechanisms. Drawing upon the current knowledge on the pathophysiology and biological phases of oral cGVHD, we address oral mucosa lichenoid and Sjogren’s Syndrome-like sicca syndromes. We consider the response of alloreactive T-cells and macrophages to recipient tissues to drive the pathophysiological reactions and biological phases of acute inflammation (phase 1), chronic inflammation and dysregulated immunity (phase 2), and subsequent aberrant fibrotic healing (phase 3), which in time may be associated with an increased malignant transformation rate. When formulating treatment strategies, the pathophysiological spectrum of cGVHD is patient dependent and not every patient may progress chronologically through the biological stages. As such there remains a need to address and clarify personalized diagnostics and management to improve treatment descriptions. Within this review, we highlight the current state of the art knowledge on oral cGVHD pathophysiology and biological phases. We address knowledge gaps of oral cGVHD, with a view to facilitate clinical management and improve research quality on lichenoid biology and morbid forms of oral cGVHD

Antifungal agents for preventing fungal infections in solid organ transplant recipients

Background: Invasive fungal infections (IFIs) are important causes of morbidity and mortality in solid organ transplant recipients. Objectives: This study aims to systematically identify and summarise the effects of antifungal prophylaxis in solid organ transplant recipients. Search strategy: The Cochrane Central Register of Controlled Trials (Issue 3, 2003), MEDLINE (1966-June 2003), and EMBASE (1980-June 2003) were searched. Reference lists, abstracts of conference proceedings and scientific meetings (1998-2003) were handsearched. Authors of included studies and pharmaceutical manufacturers were contacted. Selection criteria: Randomised controlled trials (RCTs) in all languages comparing the prophylactic use of any antifungal agent or regimen with placebo, no antifungal, or another antifungal agent or regimen. Data collection and analysis: Two reviewers independently applied selection criteria, performed quality assessment, and extracted data using an intention-to-treat approach. Differences were resolved by discussion. Data were synthesised using the random effects model and expressed as relative risk (RR) with 95% confidence intervals (95% CI). Main results: Fourteen unique trials with 1497 randomised participants were included. Antifungal prophylaxis did not reduce mortality (RR 0.90, 95% CI 0.57 to 1.44). In liver transplant recipients, a significant reduction in IFIs was demonstrated for fluconazole (RR 0.28, 95% CI 0.13 to 0.57). Although less data were available for itraconazole and liposomal amphotericin B, indirect comparisons and one direct comparative trial suggested similar efficacy. Fluconazole prophylaxis did not significantly increase invasive infections or colonisation with fluconazole-resistant fungi. In renal and cardiac transplant recipients, neither ketoconazole nor clotrimazole significantly reduced invasive infections. Overall, the strength and precision of comparisons however were limited by a paucity of data. Reviewers' conclusions: For liver transplant recipients, antifungal prophylaxis with fluconazole significantly reduces the incidence of IFIs with no definite mortality benefit. Given a 10% incidence of IFI, 14 liver transplant recipients would require fluconazole prophylaxis to prevent one infection. In transplant centres where the incidence of IFIs is high, or in situations where the individual risk is great, antifungal prophylaxis should be considered

Evidence-Based Guidelines for Empirical Therapy of Neutropenic Fever in Korea

Neutrophils play an important role in immunological function. Neutropenic patients are vulnerable to infection, and except fever is present, inflammatory reactions are scarce in many cases. Additionally, because infections can worsen rapidly, early evaluation and treatments are especially important in febrile neutropenic patients. In cases in which febrile neutropenia is anticipated due to anticancer chemotherapy, antibiotic prophylaxis can be used, based on the risk of infection. Antifungal prophylaxis may also be considered if long-term neutropenia or mucosal damage is expected. When fever is observed in patients suspected to have neutropenia, an adequate physical examination and blood and sputum cultures should be performed. Initial antibiotics should be chosen by considering the risk of complications following the infection; if the risk is low, oral antibiotics can be used. For initial intravenous antibiotics, monotherapy with a broad-spectrum antibiotic or combination therapy with two antibiotics is recommended. At 3-5 days after beginning the initial antibiotic therapy, the condition of the patient is assessed again to determine whether the fever has subsided or symptoms have worsened. If the patient's condition has improved, intravenous antibiotics can be replaced with oral antibiotics; if the condition has deteriorated, a change of antibiotics or addition of antifungal agents should be considered. If the causative microorganism is identified, initial antimicrobial or antifungal agents should be changed accordingly. When the cause is not detected, the initial agents should continue to be used until the neutrophil count recovers

Fungal infection-related mortality versus total mortality as an outcome in trials of antifungal agents

BACKGROUND: Disease specific mortality is often used as outcome rather than total mortality in clinical trials. This approach assumes that the classification of cause of death is unbiased. We explored whether use of fungal infection-related mortality as outcome rather than total mortality leads to bias in trials of antifungal agents in cancer patients. METHODS: As an estimate of bias we used relative risk of death in those patients the authors considered had not died from fungal infection. Our sample consisted of 69 trials included in four systematic reviews of prophylactic or empirical antifungal treatment in patients with cancer and neutropenia we have published previously. RESULTS: Thirty trials met the inclusion criteria. The trials comprised 6130 patients and 869 deaths, 220 (25%) of which were ascribed to fungal infection. The relative risk of death was 0.85 (95% CI 0.75–0.96) for total mortality, 0.57 (95% CI 0.44–0.74) for fungal mortality, and 0.95 (95% CI 0.82–1.09) for mortality among those who did not die from fungal infection. CONCLUSION: We could not support the hypothesis that use of disease specific mortality introduces bias in antifungal trials on cancer patients as our estimate of the relative risk for mortality in those who survived the fungal infection was not increased. We conclude that it seems to be reliable to use fungal mortality as the primary outcome in trials of antifungal agents. Data on total mortality should be reported as well, however, to guard against the possible introduction of harmful treatments