Two new DR52-associated alleles, DRB1*1111 and *1312, identified by PCR/SSOP and confirmed by DNA sequencing.
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Alleles↗
Biomedical subjects
J A Hansen
Publications and source records attributed to J A Hansen.
Role of the mixed lymphocyte culture (MLC) reaction in marrow donor selection: matching for transplants from related haploidentical donors.
The utility of the MLC assay as a test of HLA-D region matching and predictor of acute graft-versus-host disease (GvHD) was evaluated in 157 patients receiving marrow grafts from HLA-A, B identical related haploidentical donors. All donors and recipients were tested by HLA-DR serology, by Dw phenotyping with homozygous typing cells (HTC) and by standard MLC. Ninety-nine of the donor-recipient pairs were mismatched for a serologically defined HLA-DR antigen while 109 pairs were mismatched for the HLA-DR region by HTC typing. Donor antirecipient relative responses (RR) in MLC, corresponding to the GvHD vector in marrow transplantation, ranged from -4% to 100%, with a median of 25%. A comparison of reactivity in MLC with presence or absence of matching by Dw phenotyping, however, showed a significant overlap in the distribution of RRs from HLA-Dw matched versus Dw mismatched pairs, suggesting that the MLC was not a reliable predictor of HLA-Dw matching. Using an optimally-defined cutoff of 3% RR, the MLC was correlated with risk of developing clinically significant grades II-IV acute GvHD (p = 0.03) but not with risk of developing severe grades III-IV GvHD (p = 0.18). In contrast, matching by Dw phenotype was a significant predictor of GvHD, with Dw-compatible transplant recipients less likely to develop either grades II-IV (p = 0.004) or III-IV (p = 0.036) GvHD than Dw-incompatible transplant recipients. Overall, these results underscore the difficulty in using the MLC to measure HLA-D region compatibility and predict the risk of severe graft-versus-host disease among patients receiving related haploidentical marrow grafts. HLA-D (HTC) typing results correlate primarily with DRB compatibility, and with the advent of DRB1 allele matching by sequence-specific oligonucleotide probes (SSOP) or by direct sequencing, the precision in donor matching achievable with these methods is far greater than with either HLA-D typing or direct MLC testing.
Adolescent↗
Molecular diversity of the HLA-C locus in unrelated marrow transplantation.
The diversity of HLA-C exon-2 alleles in 56 HLA-A, B, DRB and DQB1-matched patient-unrelated marrow donor pairs was examined by non-cloning polymerase chain reaction-based sequencing of genomic DNA. This method allows simultaneous analysis of both alleles in heterozygous samples. All Cw5-positive individuals encoded a sequence which differed from the published Cw*0501 sequence at position 61. Among 82 samples assigned a single antigen by serologic testing, 64 (78%) were heterozygous for two distinct alleles when tested by sequencing. Cw*1202, 1601 and 15 were identified in samples for which no phenotype could be assigned (C "blank"). Finally, 7 of the 56 HLA-A, B, DRB, DQB1-matched pairs (12.5%) were mismatched for one or both HLA-C alleles. We conclude that sequence-based methods constitute the optimal strategies for typing HLA-C alleles in the unrelated marrow transplant population.
Alleles↗
Analysis of HLA-B*44 alleles encoded on extended HLA haplotypes by direct automated sequencing.
We developed a PCR-based approach to sequence exons 2 and 3 of HLA-B44 alleles from genomic DNA. We applied this method to determine the B44 alleles encoded on extended HLA-A, B, DRB1, DQB1 haplotypes and the degree of mismatching for B44 alleles among marrow transplant patients and their unrelated donors (URD). A total of 81 samples was studied and included 38 patients, 42 donors and the cell "FMB"; the 80 clinical samples were comprised of 8 unpaired patients, 12 unpaired donors, and 30 URD-recipient pairs. Three alleles encoding B44 were identified, B*4402 (N = 51), 4403 (N = 32) and a new allele designated B*44KB and named B*4405 (N = 4). Of the 27 patients for whom family study was available, there were 13 different B*4402, 7 different B*4403 and 2 new B*4405 haplotypes. HLA-A2, Cw*0501, B*4402, DRB1*0401, DQB1*0301 (n = 2); A2, Cw*0501, B*4402, DRB1*1501, DRB5*0101, DQB1*0602 (n = 2); and HLA-A29, Cw*1601, B*4403, DRB1*0701, DQB1*0201 (n = 5) comprised the most common patient haplotypes. Of 30 URD-recipient transplant pairs studied, 27 were HLA-A, B serologically matched and DRB1, DRB3, DRB5, DQB1 allele matched, and 3 pairs were DRB1-mismatched. All B44 allele mismatching (N = 3) occurred among the 27 matched pairs. The novel B*4402-variant sequence, HLA-B*4405, was identified in 4 individuals, and in each case was associated with an HLA-B44, Cw*02022, DRB1*0101, DQB1*0501 haplotype. HLA-B*4405 and B*4402 are identical in exon 2; in exon 3 however, B*4405 encodes T instead of G at nucleotide position 75 which translates to a substitution of tyrosine for aspartic acid at codon 116.(ABSTRACT TRUNCATED AT 250 WORDS)
Alleles↗
DRB1*1504 (DR2Dai): a new DR2 allele identified in the Dai minority population of southwest China.
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Alleles↗
High-dose fractionated total-body irradiation, etoposide, and cyclophosphamide followed by autologous stem-cell support in patients with malignant lymphoma.
PURPOSE: To evaluate a high-dose treatment regimen of fractionated total-body irradiation (TBI), etoposide, and cyclophosphamide (Cy) followed by autologous stem-cell transplantation (ASCT) in patients with malignant lymphoma. PATIENTS AND METHODS: Fifty-three patients with non-Hodgkin's lymphoma (NHL; n = 43) or Hodgkin's disease (HD; n = 10) received 12.0 Gy of fractionated TBI, etoposide 60 mg/kg, and Cy 100 mg/kg followed by infusion of autologous hematopoietic stem cells. RESULTS: Thirty-one of 53 patients are alive a median of 643 (range, 177 to 1,144) days after transplant. The 2 year Kaplan-Meier (K-M) estimates of survival, event-free survival (EFS), and relapse for all 53 patients were 54%, 45%, and 43%, respectively. Sixteen of 24 patients with less advanced disease and 10 of 29 patients with more advanced disease survive free of disease for K-M estimates of EFS of 61% and 31%, respectively (P = .006). The K-M estimates of relapse were 34% for patients with less advanced disease and 53% (P = .05) for patients with more advanced disease. The K-M estimates of dying from causes other than relapse were 8% in patients with less versus 25% in patients with more advanced disease (P = .09). CONCLUSION: These data indicate that approximately 60% of patients transplanted early after failure of initial therapy for malignant lymphoma are projected to be disease-free more than 2 years after treatment with fractionated TBI, etoposide, and Cy and infusion of autologous hematopoietic stem cells. The transplant-related mortality rate is low and relapse is the main cause of treatment failure in patients with less advanced disease. For patients with more advanced disease, the K-M estimates of both transplant-related deaths (25%) and relapse (53%) remain major problems.
Adolescent↗
The effects of spray-dried blood meal on growth performance of the early-weaned pig.
A total of 1,956 weanling pigs were used in five experiments to evaluate spray-dried blood meal (SDBM) in starter pig diets. In Exp. 1, 432 weanling pigs (initially 6.9 kg BW and 21 d of age) were used to evaluate different protein sources in the d 7 to 28 postweaning diet. Pigs were fed a control diet containing 5% select menhaden fish meal or diets with 3.88% spray-dried porcine plasma, 2.49% SDBM (porcine), 5.74% soy protein concentrate, 5.74% moist extruded soy protein concentrate, or L-lysine.HCl and DL-methionine replacing select menhaden fish meal on an ideal protein basis. Pigs fed diets containing the spray-dried blood products had higher (P < .06) mean ADG than pigs fed the other protein sources. In Exp. 2, 744 weanling pigs (initially 5.8 kg BW and 21 d of age) were used to determine the effects of 0, 1, 2, 3, 4, or 5% SDBM (bovine) in the d 7 to 28 postweaning diet. Pigs fed increasing SDBM had greater (quadratic, P < .01) ADG and improved gain:feed ratio (G/F). Inflection point analysis projected optimum ADG and G/F at 1.9% SDBM. In Exp. 3, 216 weanling pigs (initially 10.9 kg BW and 42 d of age) were used to determine the effects of 0, .5, 1, 1.5, 2, and 2.5% SDBM (bovine) in the d 21 to 42 postweaning diet. Pigs fed increasing SDBM had decreased (linear, P < .05) ADG and G/F. In Exp. 4 and 5, 144 and 180 weanling pigs (initially 5.3 and 6.2 kg BW and 24 and 21 d of age, respectively) were used to evaluate either 2.5% spray-dried porcine, spray-dried bovine, or flash-dried bovine blood meal (Exp. 4) or 2.5% spray-dried bovine or spray-dried avian blood meal (Exp. 5). Pigs fed diets containing the spray-dried blood meals had improved ADG and G/F (P < .01) compared with pigs fed flash-dried blood meal. However, no differences (P > .10) were observed among treatments when pigs were fed spray-dried blood meals from different species. We conclude that spray-dried bovine, porcine, and avian blood meal are effective protein sources in starter pig diets (d 7 to 28 postweaning). However, SDBM is not necessary in the diets of older pigs (d 21 to 42 postweaning) for maximum growth performance.
Animal Feed↗
Interactive effects among porcine somatotropin, the beta-adrenergic agonist salbutamol, and dietary lysine on growth performance and nitrogen balance of finishing swine.
An experiment was conducted to evaluate the interactive effects among porcine somatotropin (pST), salbutamol, and dietary lysine on growth performance, nitrogen balance, and carcass characteristics of finishing barrows (n = 32; 62.8 kg initially). Two replicate 32-d studies were set up in a split-plot design to evaluate singular and combined use of pST (0 or 4 mg/d) and salbutamol (0 or 2.75 ppm of the diet) as whole-plot treatments and diets containing .8, 1.2, 1.6, or 2.0% lysine as subplot treatments. Dietary lysine levels were administered within subplots in a 4 x 4 Latin square with pigs allowed 4 d of adjustment to diets followed by 4 d of urine and feces collection for determination of N retention and apparent digestibility of DM and N. Interactions between lysine and salbutamol were not found (P > .16). A pST x lysine interaction (P < .05) resulted in ADG being maximized at 1.2% lysine for pST-treated pigs (lysine quadratic, P < .02) but decreased linearly (P < .02) with increasing lysine for pigs receiving buffer. Pigs injected with 4 mg/d of pST had improved gain:feed (G:F) up to 1.2% lysine (lysine quadratic, P < .05), but no further increase to 2% lysine, whereas pigs injected with buffer showed no benefit from increased lysine (pST x lysine, P < .06). Pigs receiving buffer had greater increases in plasma urea N (PUN) as lysine increased than those receiving pST (pST x lysine, P < .002), but PUN was reduced by pST (P < .001) regardless of lysine level.(ABSTRACT TRUNCATED AT 250 WORDS)
Adipose Tissue↗
The effect of spray-dried porcine plasma on growth performance in the early-weaned pig.
A total of 904 weanling pigs were used to investigate the effects of 1) spray-dried porcine plasma (SDPP), 2) blends of SDPP and spray-dried blood meal (SDBM), and 3) added dietary methionine in a SDPP-based diet on starter pig performance. In Exp. 1, 534 weanling pigs (initially 6.4 kg and 21 +/- 2 d of age) were used to determine the effects of either 0, 2, 4, 6, 8, or 10% SDPP and lactose as a replacement for dried skim milk in the Phase I diet (d 0 to 14 postweaning). All pigs were fed the same diet from d 14 to 28 postweaning. Average daily gain from d 0 to 14 increased (linear, P < .01) with increasing SDPP. From d 14 to 28, ADG decreased (linear, P < .03) as level of SDPP fed during Phase I increased. However, for d 0 to 28, ADG was increased (linear, P < .01) with increasing SDPP in the Phase I diet. Feed intake increased with increasing SDPP from d 0 to 14 and d 0 to 28 (quadratic, P < .04 and P < .08, respectively); however, gain/feed (G/F) was not affected. In Exp 2, 298 weanling pigs (initially 5.5 kg and 19 +/- 2 d of age) were used to determine the effects of replacing SDPP with SDBM in the Phase I diet. Pigs were fed either a diet containing 10% SDPP or diets with SDBM replacing 25, 50, 75, or 100% of the lysine provided by the SDPP.(ABSTRACT TRUNCATED AT 250 WORDS)
Animal Feed↗
T-cell receptor polymorphisms in Tlingit Indians with rheumatoid arthritis.
Rheumatoid arthritis (RA) develops as a result of the interaction of both genetic and environmental factors. Among the genes in humans that have been suggested as candidate susceptibility genes in RA are those encoding the T cell receptor for antigen (TCR). A high prevalence and early age of onset of RA has previously been reported in Alaskan Tlingit Indians. In this study, the frequency of seven different restriction fragment length polymorphisms (RFLPs) in the TCR alpha and beta gene complexes were measured in a population of Alaskan Tlingit Indians. No statistically significant differences were noted when the frequencies of these RFLPs were compared between Tlingits with RA and healthy controls (p > 0.05). These results do not support the hypothesis of an RA-susceptibility allele in the vicinity of these TCR alpha or beta genes. Since TCR RFLPs have not been extensively studied in native American populations, TCR polymorphism frequencies in the Tlingits were also compared to the frequencies observed in a second control group of healthy Caucasians. Statistically significant differences were observed in these comparisons implying a different distribution of individuals in these populations with different TCR repertoires.
Alleles↗
Rheumatoid arthritis in Tlingit Indians: clinical characterization and HLA associations.
OBJECTIVE: To characterize the features of rheumatoid arthritis (RA) in Tlingit Indians, to identify the HLA-DR alleles associated with RA in the Tlingit, and to determine whether disease severity or specific clinical manifestations correlate with the presence of specific HLA antigens. METHOD: Thirty-seven Tlingit patients with RA and 75 controls were evaluated clinically; comparative HLA studies were carried out in 33 patients and 62 controls. RESULTS: The results of this clinical study of RA in the Tlingit confirms that the disease found in them is classical RA, characterized by an early age of onset, a high frequency of nodules, serum rheumatoid factor (RF) and antinuclear antibodies (ANA); an often severe clinical course, with a high frequency of erosive disease and frequent need for surgical joint repair, and an often positive family history. In Tlingit volunteers who did not have RA we also found an increased prevalence of RF and ANA. Neither HLA-DR1 nor DR4 was found to be associated with RA in the Tlingit. The commonest DR antigen in patients with RA was DR14. The most frequent DRB1 allele was DRB1*1402 (Dw16). CONCLUSION: The Tlingit population had a very high frequency of the DRB1*1402 allele, which shares key sequence homology with DRB1*0401 (Dw4) and DRB1*0101 (Dw1), associated with RA in other racial groups. No correlations were found between specific HLA-DRB1 alleles or combinations of alleles and specific disease features or severity.
Adult↗
Effect of graft-versus-host disease prophylaxis on relapse in patients transplanted for acute myeloid leukemia.
Between November 1978 and September 1988, 184 patients with acute myeloid leukemia in first remission received marrow transplants from HLA-identical siblings after conditioning with 120 mg/kg of cyclophosphamide and 12.0 Gy fractionated total body irradiation. Patients received either cyclosporine (CYA, n = 59), methotrexate (MTX, n = 82), or MTX + CYA (n = 43 as graft-versus-host disease (GVHD) prophylaxis. The probabilities of grades II-IV acute GVHD after CYA, MTX or MTX+CYA were 0.43, 0.48 and 0.28, respectively (p = 0.06). The probability of non-relapse mortality was 0.53, 0.50 and 0.42 at 4 years in patients treated with CYA, MTX, or MTX + CYA, respectively. The probability of relapse was 0.24 in patients receiving CYA, 0.24 in patients receiving MTX and 0.44 in patients receiving MTX + CYA (p = 0.02). The probability of survival at 4 years was 0.54 with CYA, 0.51 with MTX and 0.45 with MTX + CYA. A multivariate analysis of risk factors for relapse examined age, WBC at diagnosis, blast count at diagnosis, percentage of marrow blasts, FAB subtype, the number of remission induction courses to achieve a remission, maintenance therapy, consolidation therapy, marrow cell dose, donor-recipient sex, GVHD prophylaxis regimen and isolation and decontamination in laminar airflow rooms. GVHD prophylaxis with MTX + CYA was independently significantly associated with an increased risk of relapse (relative risk 2.25, p = 0.01). Acute GVHD was associated with increased non-relapse mortality (RR = 3.58, p < 0.0001). The administration of MTX + CYA did not adversely affect survival because patients receiving this regimen experienced less mortality from causes other than relapse when compared with patients receiving either CYA or MTX alone.
Adolescent↗
Marrow transplants from HLA matched unrelated donors: an NMDP update and the Seattle experience.
It is now possible to access more than one million HLA-A, B typed volunteer individuals willing to donate marrow and a preliminary search through the NMDP registry provides access to more than 200,000 HLA-A, B, DR typed donors. Fifty-four percent of preliminary searches yield at least one potentially HLA-matched donor but the majority of these successful searches involve patients of Caucasian origin. Substantially greater recruitment must occur among different racial and ethnic groups if minority patients are to have a better chance of finding an HLA match. This can be accomplished by recruiting diverse donors within each regional registry or by expanding worldwide the existing international registry network. Molecular typing and matching for alleles in the HLA-D region improve the precision of donor selection and the timeliness of the donor search process. Although the risk of GVHD in unrelated donor transplants remains higher than in HLA-identical sibling transplant is not as good as HLA-identical sibling transplants, newer methods of supportive care and GVHD control are providing and gradual improvement in both the safety of the procedure and long-term relapse-free survival.
Adult↗
Marrow transplants from unrelated donors.
It is now possible to access more than 1 million HLA-A, B typed volunteers willing to donate marrow. A preliminary search through the U.S. NMDP provides direct computerized access to the HLA-A, B, DR phenotypes of more than 186,000 registered donors. Fifty-one percent of preliminary searches yield at least one HLA-A, B, DR match, but a disproportional number of successful searches benefit primarily patients of Caucasian origin. Substantially greater recruitment among different racial and ethnic groups must occur if non-Caucasians are to have a better chance of finding an HLA-matched donor. Improved cooperation between registries and transplant networks in different countries remains an important goal. The optimal application of URD transplants may not be possible until an efficient and reliable worldwide marrow donor program has been established. DNA typing and matching for HLA alleles improves the timeliness of the donor search process and the precision of donor selection. HLA mismatching increases the probability and severity of GVHD, but minor mismatches for one HLA-A, B, or D/DRB1 locus does not appear to decrease survival. Although the risk of GVHD in URD transplants remains high and survival currently is not as favorable as HLA identical sibling transplants, better supportive care and GVHD control are providing a gradual improvement in the long-term disease-free survival of URD transplants.
Bone Marrow Transplantation↗
The U.S. National Marrow Donor Program.
PURPOSE: The National Marrow Donor Program (NMDP) of the United States has nearly 650,000 unrelated potential marrow donors in its registry and > 1,225 marrow transplants have been performed. PATIENT AND METHODS: In 1991, 43% of patients who requested a search found at least one HLA-A-, -B-, -DR-identical donor in the files. The chance of finding a donor match is much better within one's own ethnic group. The individuals enrolled in the donor file are 67.0% white, 3.8% black, 3.0% Asian, 3.9% Hispanic, and 0.8% Native American. Therefore, patients who belong to ethnic minorities are at an obvious disadvantage in obtaining marrow donors. Because of this deficiency, the program has embarked on an aggressive campaign of recruitment of minority donors. RESULTS: Reciprocal search agreements with other countries have made another 200,000 potential donors available, but it is not likely that black patients will find help by this route. CONCLUSIONS: Several efforts are being made to speed up the search process and to ensure more accurate definition of identities. These efforts include prospective HLA-DR typing of donors in the file, storage of a sample of frozen blood from each donor to permit class II typing (HLA-DR, -DQ) by DNA techniques, and eliminating the mixed lymphocyte culture test as a requirement for designating a given donor as HLA identical.
Bone Marrow Transplantation↗
Syngeneic transplantation with peripheral blood mononuclear cells collected after the administration of recombinant human granulocyte colony-stimulating factor.
Five syngeneic transplants were performed in four patients following myeloablative therapy using unmodified peripheral blood mononuclear cells (PBMCs) collected after the administration of recombinant human granulocyte colony stimulating factor (rhG-CSF) to normal donors. The only toxicity experienced by the four normal donors was bone pain. Four patients received two collections of PBMCs, and a second transplant was performed in one patient with one collection. The patients received a median of 20.53 x 10(8) total nucleated cells/kg (range 20 to 25.5), 11.3 x 10(8) total mononuclear cells/kg (range 6.52 to 17.2), 113.1 x 10(4)/kg CFU-GM (range 46.7 to 211.8) and 9.6 x 10(6) CD34+ cells/kg (range 1.6 to 12.6) Post-transplant growth factors were not administered. The median time to an absolute neutrophil count greater than 0.5 x 10(9)/L was 14 days (range 10 to 18). The median time to platelet transfusion independence was 11 days (range 10 to 13). Two patients had the number of CD3+ T lymphocytes determined in the pheresis product. An average of 3.04 x 10(10) CD3+ cells were collected per pheresis. This represents an approximate 1 log increase over the number of T lymphocytes in a typical bone marrow transplant. Rh-GCSF can be used to mobilize peripheral blood progenitor cells from normal donors with minimal toxicity. Studies of allogeneic transplants using PBMCs collected after rhG-CSF administration to determine permanent grafting ability and the incidence and severity of graft-versus-host disease are warranted.
Adult↗
Maternal-fetal disparity in HLA class II alloantigens and the pregnancy-induced amelioration of rheumatoid arthritis.
BACKGROUND: Rheumatoid arthritis frequently remits during pregnancy, for unknown reasons. Since an immune response to paternally inherited fetal HLA can occur during normal pregnancy and since rheumatoid arthritis is an autoimmune disorder with a known HLA class II antigen association, we tested the hypothesis that maternal-fetal disparity in HLA alloantigens might be associated with the pregnancy-induced remission of rheumatoid arthritis. METHODS: We studied 57 pregnancies of 41 women with rheumatoid arthritis, 18 prospectively and 39 retrospectively. Serologic and DNA techniques were used to study HLA class I and II antigens. For newborns, typing was performed from cord-blood samples obtained at delivery. For four young children, typing was performed from DNA extracted from hair samples. RESULTS: We found significantly more maternal-fetal disparity in HLA-DR and DQ antigens in pregnancies characterized by the remission or improvement of rheumatoid arthritis than in pregnancies characterized by active disease. Further studies using DNA-typing techniques to define allelic variants of HLA-DR and DQ antigens confirmed this observation. Maternal-fetal disparity in alleles of HLA- DRB1, DQA, and DQB occurred in 26 of 34 pregnancies characterized by remission or improvement (76 percent), as compared with 3 of 12 pregnancies characterized by active arthritis (25 percent) (odds ratio, 9.7; P = 0.003). The difference between the two groups was most marked for alleles of HLA-DQA. CONCLUSIONS: Amelioration of rheumatoid arthritis during pregnancy is associated with a disparity in HLA class II antigens between mother and fetus. These findings suggest that the maternal immune response to paternal HLA antigens may have a role in the pregnancy-induced remission of rheumatoid arthritis.
Alleles↗
The role of HLA-DPB1 disparity in the development of acute graft-versus-host disease following unrelated donor marrow transplantation.
The role of HLA-DPB1 disparity in the development of acute graft-versus-host disease (GVHD) following unrelated donor (URD) marrow transplantation is unknown. We studied 129 patients who underwent marrow transplantation from HLA-A, -B, -DRB, and -DQB matched URDs to determine whether matching for HLA-DPB1 alleles significantly decreased the risk of developing acute GVHD. HLA-DPB1 alleles were determined by sequence-specific oligonucleotide hybridization and by the number of patient DPB1 alleles not shared by the donor scored. The Kaplan-Meier probability of developing grades II to IV acute GVHD was determined for patients incompatible for zero (group A), one (group B), or two (group C) DPB1 alleles. Of the 129 pairs, there was no recipient DPB1 incompatibility in 28 (22%), one DPB1 mismatch in 72 (56%), and two DPB1 mismatches in 29 (22%). The probability of grades II to IV acute GVHD was 0.69 (0.50, 0.86) for group A, 0.83 (0.73, 0.91) for group B, and 0.72 (0.56, 0.87) for group C (P = .63). These results indicate that matching patients and unrelated donors for HLA-A, -B, -DRB, and -DQB does not predict for matching at DPB1. However, recipient incompatibility for DPB1 alleles does not detectably influence the risk of acute GVHD. Therefore, HLA-DP disparity should not be used as an exclusion criterion for donor selection in unrelated marrow transplantation.
Acute Disease↗