Importância da avaliação hematológica e sorológica (dot-blot ELISA) no diagnóstico de erliquiose em cães

This study compared the hematological and serological analysis of diagnosis of canine ehrlichiosis. The survey of Ehrlichia canis was performed through the evaluation of blood smears from 150 dogs. The serological test was performed on 12 samples selected by the platelet count (less than 170,000 platelets / uL). Serologic testing was performed with the Imunocomb kit - Dot-blot-ELISA. No cytoplasmatic inclusion characteristic of morula of E. canis was found in blood smears. In serologic testing, eight samples were positive for Ehrlichia canis, concluding that thrombocytopenia is an important hematological finding of ehrlichiosis diagnosis and the detection of Ehrlichia canis morulae is uncommon. The serological evaluation Dot-blot ELISA is an accurate and brief diagnosis method of canine ehrlichiosis, been the most appropriate to be used in veterinary practice routine.

Hemofilia A em cão: relato de caso

Hemophilia A is an X-linked inherited disorder characterized by a Factor VIII (FVIII) deficiency, being therefore transmitted by female dogs to their offspring. Since it is a secondary hemostatic defect, the main clinical signs are hematomas and deep hemorrhage in body cavities, muscles and joints. A four-month-old male Boxer was presented to the Veterinary Hospital at the School of Veterinary Medicine and Animal Science in Botucatu with excessive bleeding due to an incision made three days prior by another veterinarian to drain a local hematoma. Laboratory results showed platelet count within the reference range, as well as prolonged whole blood clotting and activated partial thromboplastin times. FVIII activity was 0,96%, which characterizes the most severe degree of hemophilia A.

Deregulation of apoptosis-related genes is associated with PRV1 overexpression and JAK2 V617F allele burden in Essential Thrombocythemia and Myelofibrosis

Background: Essential Thrombocythemia (ET) and Primary Myelofibrosis (PMF) are Chronic Myeloproliferative Neoplasms (MPN) characterized by clonal myeloproliferation/myeloaccumulation without cell maturation impairment. The JAK2 V617F mutation and PRV1 gene overexpression may contribute to MPN physiopathology. We hypothesized that deregulation of the apoptotic machinery may also play a role in the pathogenesis of ET and PMF. In this study we evaluated the apoptosis-related gene and protein expression of BCL2 family members in bone marrow CD34(+) hematopoietic stem cells (HSC) and peripheral blood leukocytes from ET and PMF patients. We also tested whether the gene expression results were correlated with JAK2 V617F allele burden percentage, PRV1 overexpression, and clinical and laboratory parameters. Results: By real time PCR assay, we observed that A1, MCL1, BIK and BID, as well as A1, BCLW and BAK gene expression were increased in ET and PMF CD34(+) cells respectively, while pro-apoptotic BAX and anti-apoptotic BCL2 mRNA levels were found to be lower in ET and PMF CD34(+) cells respectively, in relation to controls. In patients' leukocytes, we detected an upregulation of anti-apoptotic genes A1, BCL2, BCL-XL and BCLW. In contrast, pro-apoptotic BID and BIMEL expression were downregulated in ET leukocytes. Increased BCL-XL protein expression in PMF leukocytes and decreased BID protein expression in ET leukocytes were observed by Western Blot. In ET leukocytes, we found a correlation between JAK2 V617F allele burden and BAX, BIK and BAD gene expression and between A1, BAX and BIK and PRV1 gene expression. A negative correlation between PRV1 gene expression and platelet count was observed, as well as a positive correlation between PRV1 gene expression and splenomegaly. Conclusions: Our results suggest the participation of intrinsic apoptosis pathway in the MPN physiopathology. In addition, PRV1 and JAK2 V617F allele burden were linked to deregulation of the apoptotic machinery.

Portal hypertension: a comparison between portal-venous pressure measurement and ARFI measurement of liver and spleen stiffness

PURPOSE. Portal pressure is measured invasively as Hepatic Venous Pressure Gradient (HVPG) in the angiography room. Liver stiffness measured by Fibroscan was shown to correlate with HVPG values below 12 mmHg. This is not surprising, since in cirrhosis the increase of portal pressure is not directly linked with liver fibrosis and consequently to liver stiffness. We hypothesized that, given the spleen’s privileged location upstream to the whole portal system, splenic stiffness could provide relevant information about portal pressure. Aim of the study was to assess the relationship between liver and spleen stiffness measured by Virtual Touch™ (ARFI) and HVPG in cirrhotic patients. METHODS. 40 consecutive patients (30 males, mean age 62y, mean BMI=26, mean Child-Pugh A6, mean platelet count=92.000/mmc, 19 HCV+, 7 with ascites) underwent to ARFI stiffness measurement (10 valid measurements in right liver lobe both surface and centre, left lobe and 20 in the spleen) and HPVG, blindly to each other. Median ARFI values of 10 samplings on every liver area and of 20 samplings on spleen were calculated. RESULTS. Stiffness could be easily measured in all patients with ARFI, resulting a mean of 2,61±0,76, 2,5±0,62 and 2,55±0,66 m/sec in the liver areas and 3.3±0,5 m/s in the spleen. Median HPVG was 14 mmHg (range 5-27); 28 patients showed values ≥10 mmHg. A positive significant correlation was found between spleen stiffness and HPVG values (r=0.744, p<0.001). No significant correlation was found between all liver stiffness and HVPG (p>0,05). AUROC was calculated to test spleen stiffness ability in discriminating patients with HVPG ≥10. AUROC = 0.911 was obtained, with sensitivity of 69% and specificity of 91% at a cut-off of 3.26 m/s. CONCLUSION. Spleen stiffness measurement with ARFI correlates with HVPG in patients with cirrhosis, with a potential of identifying patients with clinically significant portal hypertension.

Untersuchungen zum Einfluss des HMG-CoA-Reduktase-Inhibitors Lovastatin auf die Toxizität ionisierender Strahlung sowie des Anthrazyklinderivats Doxorubicin im Mausmodell

Hintergund: HMG-CoA-Reduktase-Inhibitoren (Statine) sind klinisch etablierte Cholesterinsenker. Über die Inhibition der intrinsischen Cholesterinbiosynthese hinaus zeigen sie sogenannte pleiotrope biologische Effekte. Ein Großteil dieser Wirkungen wird auf die Inhibition kleiner Ras homologer GTPasen (Rho GTPasen) zurückgeführt. In vitro schützt das Statinderivat Lovastatin (Lova) primäre humane Endothelzellen vor der Zytotoxizität von ionisierender Strahlung (IR) und dem Krebsmedikament Doxorubicin (Doxo). Zielsetzung: Die Relevanz dieser Befunde für ein in vivo Mausmodell sollte in der vorliegenden Arbeit überprüft werden. Dafür wurden BALB/c-Mäuse mit IR oder Doxo behandelt und der Einfluss einer Kobehandlung mit Lova auf verschiedene Toxizitätsendpunkte untersucht (24 h nach einer einzelnen hohen Dosis IR (i), 14 Tage nach zwei geringen Dosen IR (ii), 48 h nach einer einzelnen hohen Dosis Doxo (iii), sowie 8 Tage nach drei niedrigen Dosen Doxo (iv)). Eine mögliche gleichzeitige Protektion von Tumorzellen durch die Statingabe wurde in einem Xenotransplantationsexperiment überprüft (v), in dem das gleiche Behandlungsschema wie bei iv angewendet wurde. Ergebnisse: Es konnte gezeigt werden, dass eine Statinbehandlung Normalgewebe vor Doxo- und IR-induzierter Toxizität schützt, ohne gleichzeitig protektiv auf transformierte Zellen zu wirken. Dieser Effekt ist wahrscheinlich von einer Inhibition der kleinen GTPasen Rac1 und RhoA abhängig und einer daraus folgenden Modifizierung der DNA-Schadensantwort. i: Die Statinvorbehandlung der Mäuse hatte keinen Einfluss auf die Bildung von initialen IR-induzierten DNA-Doppelstrangbrüchen (DSB) in der Leber. Die Lova-Behandlung wirkte sich jedoch auf IR-induzierte Stressantworten aus, was sich in einer Minderung der Expression von Inflammations- und Fibrosesurrogatmarkern in Leber und Darm widerspiegelte. ii: In der Lunge der Tiere wurde ein Anstieg von molekularen Inflammations- und Fibrosesurrogatmarkern detektiert, der bei Statinkobehandlung ausblieb. Zudem verhinderte die Kobehandlung mit Lova eine IR-induzierte Abnahme der Thrombozytenzahl, ohne sich auf die durch IR verringerte Leukozytenzahl im Blut auszuwirken. iii: Die Verabreichung einer hohen Dosis Doxo induzierte DSB-Formation in der Leber. Die Statinvorbehandlung reduzierte deren Menge um ca. 50 %. Dieser genoprotektive Effekt war unabhängig von der Entstehung reaktiver Sauerstoffspezies sowie einer Änderung des Doxo-Imports oder Exports. Die Expression von proinflammatorischen und profibrotischen Genen fiel besonders in der Leber und im Herzen durch die Lova-Kobehandlung geringer aus, als in der nur mit Doxo behandelten Gruppe. Zudem verringerte Lova die durch Doxo induzierte Hochregulation von für den AP1-Komplex kodierenden Genen sowie von Zellzykluskontrollfaktoren. Die Lova-Vorbehandlung führte darüber hinaus im Herzen zu einem reduzierten mRNA-Spiegel der Topoisomerasen II α und β. iv: Es konnten schwere Herz- und Leberschäden detektiert werden (gemessen an Gldh-, Gpt- sowie cTn-I-Serumkonzentrationen), die bei einer Kobehandlung mit dem Statin nicht auftraten. Die Lova-Kobehandlung verhinderte außerdem eine durch die Doxo-Behandlung verringerte Leukozytenzahl. Molekulare Marker für frühe fibrotische Ereignisse, sowie für Inflammation und Hypertrophie waren in der Leber und im Herzen nach der Doxo-Behandlung erhöht. Das Statin war auch hier in der Lage, diese toxischen Wirkungen des Anthrazyklins zu mindern. Auch die Doxo-induzierte Expression von Surrogatmarkern für Zellantworten auf oxidativen Stress wurde in der Leber abgeschwächt. In der Leber und im Herzen wiesen die mit Doxo behandelten Tiere höhere mRNA Spiegel von an Zellzykluskontrolle beteiligten Faktoren sowie von DNA-Reparatur und Fremdstoffmetabolismus assoziierten Genen auf. Am stärksten wurde die Expression von Topoisomerase II alpha - ein molekularer Marker für Zellproliferation und bedeutsame Zielstruktur von Doxo - in der Leber hochreguliert. Die Statin-Kobehandlung verhinderte all diese Doxo-induzierten Expressionsänderungen. Im Gegensatz zur Leber wurde die Top2a-mRNA Menge im Herzen durch die Doxo-Applikation reduziert. Auch hier bewirkte die Kobehandlung mit dem Statin, dass die Expression nahe dem Kontrollniveau blieb. v: Die Kobehandlung mit Lova führte zu keinem Schutz der Tumorzellen vor Doxo, sondern erhöhte sogar dessen antineoplastisches Potential.rnFazit: Die Erkenntnisse aus vorhergegangenen in vitro Versuchen konnten zum großen Teil auf die in vivo Situation im Mausmodell übertragen werden. Sie stehen im Einklang mit Ergebnissen anderer Gruppen, welche die Inhibition kleiner GTPasen mit einer geringeren, durch zytotoxische Substanzen induzierten, Inflammation und Fibrose korrelieren konnten. Eine Kobehandlung mit Lova während einer Krebstherapie erscheint somit als vielversprechende Möglichkeit Doxo- oder IR-induzierte Nebenwirkungen auf Normalgewebe zu mildern.

Predicting adverse events in children with fever and chemotherapy-induced neutropenia: the prospective multicenter SPOG 2003 FN study

PURPOSE To develop a score predicting the risk of adverse events (AEs) in pediatric patients with cancer who experience fever and neutropenia (FN) and to evaluate its performance. PATIENTS AND METHODS Pediatric patients with cancer presenting with FN induced by nonmyeloablative chemotherapy were observed in a prospective multicenter study. A score predicting the risk of future AEs (ie, serious medical complication, microbiologically defined infection, radiologically confirmed pneumonia) was developed from a multivariate mixed logistic regression model. Its cross-validated predictive performance was compared with that of published risk prediction rules. Results An AE was reported in 122 (29%) of 423 FN episodes. In 57 episodes (13%), the first AE was known only after reassessment after 8 to 24 hours of inpatient management. Predicting AE at reassessment was better than prediction at presentation with FN. A differential leukocyte count did not increase the predictive performance. The score predicting future AE in 358 episodes without known AE at reassessment used the following four variables: preceding chemotherapy more intensive than acute lymphoblastic leukemia maintenance (weight = 4), hemoglobin > or = 90 g/L (weight = 5), leukocyte count less than 0.3 G/L (weight = 3), and platelet count less than 50 G/L (weight = 3). A score (sum of weights) > or = 9 predicted future AEs. The cross-validated performance of this score exceeded the performance of published risk prediction rules. At an overall sensitivity of 92%, 35% of the episodes were classified as low risk, with a specificity of 45% and a negative predictive value of 93%. CONCLUSION This score, based on four routinely accessible characteristics, accurately identifies pediatric patients with cancer with FN at risk for AEs after reassessment.

HCV-related advanced fibrosis/cirrhosis: randomized controlled trial of pegylated interferon alpha-2a and ribavirin

In patients with hepatitis C virus (HCV)-related advanced fibrosis/cirrhosis, 30% of sustained HCV clearance has been reported with pegylated interferon alpha-2a (PEG-IFN) alone, but the efficacy and tolerability of the PEG-IFN/ribavirin (RBV) combination remain poorly defined. A total of 124 treatment-naïve patients with biopsy proved HCV-related advanced fibrosis/cirrhosis (Ishak score F4-F6, Child-Pugh score < or =7) were randomized to 48 weeks of PEG-IFN (180 microg sc weekly) and standard dose of RBV (1000/1200 mg po daily, STD) or PEG-IFN (180 microg sc weekly) and low-dose of RBV (600/800 mg po daily, LOW). Sustained virologic response (SVR) rates with PEG-IFN/STD RBV (52%) were higher--albeit not significantly--than that with PEG-IFN/LOW RBV (38%, P = 0.153). In multivariate analysis, genotype 2/3 and a baseline platelet count > or =150 x 10(9)/L were independently associated with SVR. The likelihood of SVR was < 7% if viraemia had not declined by > or =2 log or to undetectable levels after 12 weeks. Nine adverse events in the STD RBV and 15 in the LOW RBV group were classified as severe (including two deaths); dose reductions for intolerance were required in 78% and 57% (P = 0.013), and treatment was terminated early in 23% and 27% of patients (P = n.s.). The benefit/risk ratio of treating compensated HCV-cirrhotics with STD PEG-IFN/RBV is favourable.

A simple presurgical necrotizing enterocolitis-mortality scoring system

OBJECTIVE: To assess the relationship between early laboratory parameters, disease severity, type of management (surgical or conservative) and outcome in necrotizing enterocolitis (NEC). STUDY DESIGN: Retrospective collection and analysis of data from infants treated in a single tertiary care center (1980 to 2002). Data were collected on disease severity (Bell stage), birth weight (BW), gestational age (GA) and pre-intervention laboratory parameters (leukocyte and platelet counts, hemoglobin, lactate, C-reactive protein). RESULTS: Data from 128 infants were sufficient for analysis. Factors significantly associated with survival were Bell stage (P<0.05), lactate (P<0.05), BW and GA (P<0.01, P<0.001, respectively). From receiver operating characteristics curves, the highest predictive value resulted from a score with 0 to 8 points combining BW, Bell stage, lactate and platelet count (P<0.001). At a cutoff level of 4.5 sensitivity and specificity for predicting survival were 0.71 and 0.72, respectively. CONCLUSION: Some single parameters were associated with poor outcome in NEC. Optimal risk stratification was achieved by combining several parameters in a score.

[Arginine-vasopressin in septic and vasodilatorial shock]

Current therapy of septic/vasodilatory cardiovascular failure includes volume resuscitation and infusion of inotropic and vasopressor agents. Norepinephrine is the first-line vasoconstrictor, and can stabilize hemodynamic variables in most patients. Nonetheless, irreversible cardiovascular failure which is resistant to conventional hemodynamic therapies still is the main cause of death in patients with severe sepsis and septic shock. In such advanced, catecholamine-resistant shock states, arginine-vasopressin (AVP) has repeatedly caused an increase in mean arterial blood pressure, a decrease in toxic norepinephrine-dosages, as well as further beneficial hemodynamic, endocrinologic and renal effects. Although AVP exerted negative inotropic effects in previous clinical trials and in selected animal experiments, a continuous low-dose AVP infusion during advanced septic/vasodilatory shock caused a decrease in cardiac index only in patients with a hyperdynamic circulation. Adverse effects on gastrointestinal circulation and the systemic microcirculation can not be excluded, but have not yet been confirmed in clinical prospective trials. Negative side effects of a supplementary AVP therapy are an increase in total bilirubin concentrations, and a decrease in platelet count. A transient increase in hepatic transaminases during AVP infusion is most likely related to preceding hypotensive episodes. Important points which must be considered when using AVP as a "rescue vasopressor" in septic/vasodilatory shock states are: 1) AVP infusion only in advanced shock states that can not be adequately reversed by conventional hemodynamic therapy (e.g. norepinephrine >0,5-0,6 mug/kg/min), 2) presence of normovolemia, 3) AVP infusion only in combination with norepinephrine, 4) strict avoidance of bolus injections and dosages >4 IU/h. Effects of a supplementary AVP infusion in advanced vasodilatory shock on survival are currently examined in a large, prospective multicenter trial in North America and Australia.

Diagnostic criteria for hematopoietic stem cell transplant-associated microangiopathy: results of a consensus process by an International Working Group

BACKGROUND AND OBJECTIVES: There are no widely accepted criteria for the definition of hematopoietic stem cell transplant -associated microangiopathy (TAM). An International Working Group was formed to develop a consensus formulation of criteria for diagnosing clinically significant TAM. DESIGN AND METHODS: The participants proposed a list of candidate criteria, selected those considered necessary, and ranked those considered optional to identify a core set of criteria. Three obligatory criteria and four optional criteria that ranked highest formed a core set. In an appropriateness panel process, the participants scored the diagnosis of 16 patient profiles as appropriate or not appropriate for TAM. Using the experts' ratings on the patient profiles as a gold standard, the sensitivity and specificity of 24 candidate definitions of the disorder developed from the core set of criteria were evaluated. A nominal group technique was used to facilitate consensus formation. The definition of TAM with the highest score formed the final PROPOSAL. RESULTS: The Working Group proposes that the diagnosis of TAM requires fulfilment of all of the following criteria: (i) >4% schistocytes in blood; (ii) de novo, prolonged or progressive thrombocytopenia (platelet count <50 x 109/L or 50% or greater reduction from previous counts); (iii) sudden and persistent increase in lactate dehydrogenase concentration; (iv) decrease in hemoglobin concentration or increased transfusion requirement; and (v) decrease in serum haptoglobin. The sensitivity and specificity of this definition exceed 80%. INTERPRETATION AND CONCLUSIONS: The Working Group recommends that the presented criteria of TAM be adopted in clinical use, especially in scientific trials.

Safety of inferior vena cava filter retrieval in anticoagulated patients

PURPOSES: To evaluate the safety of inferior vena cava (IVC) filter retrieval in therapeutically anticoagulated patients in comparison to prophylactically or not therapeutically anticoagulated patients with respect to retrieval-related hemorrhagic complications. MATERIALS AND METHODS: This was a retrospective study of 115 consecutive attempted IVC filter retrievals in 110 patients. Filter retrievals were stratified as performed in patients who were therapeutically anticoagulated (group 1), prophylactically anticoagulated (group 2), or not therapeutically anticoagulated (group 3). The collected data included anticoagulant and antiplatelet medications (type, form and duration of administration, dosage) at the time of retrieval. Phone interviews and chart review was performed for the international normalized ratio (INR), activated partial thromboplastin time, platelet count, infusion of blood products, and retrieval-related hemorrhagic complications. RESULTS: Group 1 included 65 attempted filter retrievals in 61 therapeutically anticoagulated patients by measured INR or dosing when receiving low-molecular-weight heparin (LMWH). Four retrievals were not successful. In patients receiving oral anticoagulation, the median INR was 2.35 (range, 2 to 8). Group 2 comprised 23 successful filter retrievals in 22 patients receiving a prophylactic dose of LMWH. Group 3 included 27 attempted filter retrievals in 27 patients not receiving therapeutic anticoagulation. Six retrievals were not successful. Five patients were receiving oral anticoagulation with a subtherapeutic INR (median, 1.49; range, 1.16 to 1.69). No anticoagulation medication was administered in 22 patients. In none of the groups were hemorrhagic complications related to the retrieval procedures identified. CONCLUSIONS: These results suggest that retrieval of vena cava filters in anticoagulated patients is safe. Interruption or reversal of anticoagulation for the retrieval of vena cava filters is not indicated.

Bloodstream infections in pediatric ECLS: usefulness of daily blood culture monitoring and predictive value of biological markers. The British Columbia experience

INTRODUCTION: The incidence of bloodstream infection (BSI) in extracorporeal life support (ECLS) is reported between 0.9 and 19.5%. In January 2006, the Extracorporeal Life Support Organization (ELSO) reported an overall incidence of 8.78% distributed as follows: respiratory: 6.5% (neonatal), 20.8% (pediatric); cardiac: 8.2% (neonatal) and 12.6% (pediatric). METHOD: At BC Children's Hospital (BCCH) daily surveillance blood cultures (BC) are performed and antibiotic prophylaxis is not routinely recommended. Positive BC (BC+) were reviewed, including resistance profiles, collection time of BC+, time to positivity and mortality. White blood cell count, absolute neutrophile count, immature/total ratio, platelet count, fibrinogen and lactate were analyzed 48, 24 and 0 h prior to BSI. A univariate linear regression analysis was performed. RESULTS: From 1999 to 2005, 89 patients underwent ECLS. After exclusion, 84 patients were reviewed. The attack rate was 22.6% (19 BSI) and 13.1% after exclusion of coagulase-negative staphylococci (n = 8). BSI patients were significantly longer on ECLS (157 h) compared to the no-BSI group (127 h, 95% CI: 106-148). Six BSI patients died on ECLS (35%; 4 congenital diaphragmatic hernias, 1 hypoplastic left heart syndrome and 1 after a tetralogy repair). BCCH survival on ECLS was 71 and 58% at discharge, which is comparable to previous reports. No patient died primarily because of BSI. No BSI predictor was identified, although lactate may show a decreasing trend before BSI (P = 0.102). CONCLUSION: Compared with ELSO, the studied BSI incidence was higher with a comparable mortality. We speculate that our BSI rate is explained by underreporting of "contaminants" in the literature, the use of broad-spectrum antibiotic prophylaxis and a higher yield with daily monitoring BC. We support daily surveillance blood cultures as an alternative to antibiotic prophylaxis in the management of patients on ECLS.

Arginine vasopressin in vasodilatory shock: effects on metabolism and beyond

PURPOSE OF REVIEW: To describe the effects of arginine vasopressin other than its vasoconstrictive and antidiuretic potential in vasodilatory shock. RECENT FINDINGS: Arginine vasopressin influences substrate metabolism by stimulation of hepatic glucose release, gluconeogenesis, ureogenesis and fatty acid esterification. Although arginine vasopressin is a secretagogue of different hormones, only prolactin increases during arginine vasopressin therapy. Plasmatic and cellular coagulation are affected by arginine vasopressin, resulting in thrombocyte aggregation. Therefore, platelet count typically decreases following arginine vasopressin infusion in critically ill patients. In addition, arginine vasopressin reduces bile flow and may increase bilirubin concentrations. Despite its potential to decrease serum sodium, no change in electrolytes was observed in critically ill patients receiving arginine vasopressin. Although arginine vasopressin is an endogenous antipyretic, body temperature is not decreased by central venous arginine vasopressin infusion. In addition, arginine vasopressin modulates immune function through V1 receptors. Compared with norepinephrine, arginine vasopressin may have protective effects on endothelial function. Net arginine vasopressin effects on gastrointestinal motility seem to be inhibitory and are dose dependent. SUMMARY: Except for its antidiuretic and vasoconstrictive actions, the effects of arginine vasopressin in patients with vasodilatory shock have so far only been partially examined. Potential influences of arginine vasopressin on metabolism and immune, liver and mitochondrial function remain to be assessed in future studies.

Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study

BACKGROUND ; AIMS: Complications and technical problems of paracentesis in cirrhotic patients are infrequent. However, the severity and the incidence of these events and their risk factors have not been assessed prospectively. METHODS: Cirrhotic patients (n = 171) undergoing paracentesis were included. Of the 515 paracenteses, 8.8% were diagnostic, and 91.2% were therapeutic. Technical features, demographic data, and adverse events during a period of 72 hours after the procedure were examined. RESULTS: Major complications occurred in 1.6% of procedures and included 5 bleedings and 3 infections, resulting in death in 2 cases. Major complications were associated with therapeutic but not diagnostic procedures and tended to be more prevalent in patients with low platelet count (<50 10(9)/L), Child-Pugh stage C, and in alcoholic cirrhosis patients. Technical problems occurred in 5.6%. The most frequent complication was a leak of ascites at the puncture site (5.0%), and in 89.5% there were no complications. CONCLUSIONS: The safety of paracentesis in cirrhotic patients might be decreased if risk factors, which depend on the characteristics of the patient and of the procedure itself, are present.

Classic and overlap chronic graft-versus-host disease (cGVHD) is associated with superior outcome after extracorporeal photopheresis (ECP)

The National Institutes of Health (NIH) classification of graft-versus-host disease (GVHD) is a significant improvement over prior classifications, and has prognostic implications. We hypothesized that the NIH classification of GVHD would predict the survival of patients with GVHD treated with extracorporeal photopheresis (ECP). Sixty-four patients with steroid refractory/dependent GVHD treated with ECP were studied. The 3-year overall survival (OS) was 36% (95% confidence interval [CI] 13-59). Progressive GVHD was seen in 39% of patients with any acute GVHD (aGVHD) (classic acute, recurrent acute, overlap) compared to 3% of patients with classic chronic GVHD (cGVHD) (P=.002). OS was superior for patients with classic cGVHD (median survival, not reached) compared to overlap GVHD (median survival, 395 days, 95% CI 101 to not reached) and aGVHD (delayed, recurrent or persistent) (median survival, 72 days, 95% CI 39-152). In univariate analyses, significant predictors of survival after ECP included GVHD subtype, bilirubin, platelet count, and steroid dose. In multivariate analyses overlap plus classic cGVHD was an independent prognostic feature predictive of superior survival (hazard ratio [HR] 0.34, 95% CI 0.14-0.8, p=.014). This study suggests that NIH classification can predict outcome after ECP for steroid refractory/dependent GVHD.