Report of an international working group to standardize response criteria for myelodysplastic syndromes

Standardized criteria for assessing response are essential to ensure comparability among clinical trials for patients with myelodysplastic syndromes (MDS). An international working group of experienced clinicians involved in the management of patients with MDS reviewed currently used response definitions and developed a uniform set of guidelines for future clinical trials in MDS. The MDS differ from many other hematologic malignancies in their chronicity and the morbidity and mortality caused by chronic cytopenias, often without disease progression to acute myeloid leukemia. Whereas response rates may be an important endpoint for phase 2 studies of new agents and may assist regulatory agencies in their evaluation and approval processes, an important goal of clinical trials in MDS should be to prolong patient survival. Therefore, these response criteria reflected 2 sets of goals in MDS: altering the natural history of the disease and alleviating disease-related complications with improved quality of life. It is anticipated that the recommendations presented will require modification as more is learned about the molecular biology and genetics of these disorders. Until then, it is hoped these guidelines will serve to improve communication among investigators and to ensure comparability among clinical trials. (Blood. 2000;96:3671-3674)

Pharmacological modulation, preclinical studies, and new clinical features of myocardial ischemic preconditioning

The term "ischemic preconditioning (PC)" was first applied to canine myocardium subjected to brief episodes of ischemia and reperfusion that tolerated a more prolonged episode of ischemia better than myocardium not previously exposed to ischemia. Protective effect of myocardial ischemic PC was demonstrated in several animal species, resulting in the strongest endogenous form of protection against myocardial injury, jeopardized myocardium, infarct size, and arrhythmias other than early reperfusion. New onset angina before acute myocardial infarction, episodes of myocardial ischemia during coronary angioplasty or bypass surgery, and the "warm-up" phenomenon may represent clinical counterparts of the PC phenomenon in humans. Here, we have attempted to summarize pharmacological modulation, preclinical studies, and new clinical features of ischemic PC. To date, the pathophysiological basis of the "chemical PC" is still not well established, and "putting PC in a bottle" for clinical applications still remains a new pharmacological venture.

[Surgery in the cirrhotic patient. Prognosis and risk factors]

Patients with cirrhosis have reduced life expectancy. Surgery is often associated with clinical decompensation in this group of patients. The purpose of this paper is to study the surgical risk in cirrhotic patients undergoing nonderivative operations. Unfortunately, most of the studies in the literature about this problem are retrospective reviews with limitations. The conditions increasing surgical risk in cirrhotic patients are analysed. These include changes in the pharmacokinetics and pharmacodynamics of various drugs, altered hemostasis, poor resistance to infections, water retention, suture line insufficiency, chronic renal failure and congestive heart failure. Assessment of the disease stage in cirrhosis is very important, because the severity of hepatic abnormalities influences the prognosis. The Child-Pugh classification has been used extensively to risk-stratify patients with cirrhosis. However, the disregard for cardiorespiratory, renal, electrolyte balance and acid-base status limits its predictive accuracy. Recently a new scoring system, the Acute Physiology and Chronic Health Evaluation (APACHE III), has been introduced and seems to be superior to Child-Pugh for prognosticating short term survival of cirrhotic patients. In conclusion, surgery can be done safely only in cirrhotic patients with a good hepatic function. On the contrary, in patients with advanced cirrhosis, surgery causes a very high mortality. Finally, the patients with moderate hepatic failure can be operated only after a careful study of the disease and an adequate correction of the reversible risk factors.

Leaching and degradation of corn and soybean pesticides in an Oxisol of the Brazilian Cerrados

Pesticide pollution of ground and surface water is of growing concern in tropical countries. The objective of this pilot study was to evaluate the leaching potential of eight pesticides in a Brazilian Oxisol. In a field experiment near Cuiabá, Mato Grosso, atrazine, chlorpyrifos, lambda-cyhalothrin, endosulfane alpha, metolachlor, monocrotofos, simazine, and trifluraline were applied onto a Typic Haplustox. Dissipation in the topsoil, mobility within the soil profile and leaching of pesticides were studied for a period of 28 days after application. The dissipation half-life of pesticides in the topsoil ranged from 0.9 to 14 d for trifluraline and metolachlor, respectively. Dissipation curves were described by exponential functions for polar pesticides (atrazine, metolachlor, monocrotofos, simazine) and bi-exponential ones for apolar substances (chlorpyrifos, lambda-cyhalothrin, endosulfane alpha, trifluraline). Atrazine, simazine and metolachlor were moderately leached beyond 15 cm soil depth, whereas all other compounds remained within the top 15 cm of the soil. In lysimeter percolates (at 35 cm soil depth), 0.8-2.0% of the applied amounts of atrazine, simazine, and metolachlor were measured within 28 days after application. Of the other compounds less than 0.03% of the applied amounts was detected in the soil water percolates. The relative contamination potentials of pesticides, according to the lysimeter study, were ranked as follows: metolachlor > atrazine = simazine >> monocrotofos > endsulfane alpha > chlorpyrifos > trifluraline > lambda-cyhalothrin. This order of the pesticides was also achieved by ranking them according to their effective sorption coefficient Ke, which is the ratio of Koc to field-dissipation half-life.

Effect of long-term losartan administration on renal haemodynamics and function in hypertensive patients

In this study the efficacy and safety of long-term losartan administration on renal haemodynamics were evaluated in mild to moderate hypertension. After a run-in period with placebo, 18 hypertensives without renal or cardiovascular disease were allocated to losartan (50 mg/die for one year) treatment. Renal haemodynamic measurements included renal plasma flow (ERPF) and glomerular filtration rate (GFR) by standardized radioisotope study. Effective renal blood flow (ERBF), filtration fraction (FF), and renal vascular resistance (RVR) were also calculated. Blood pressure was evaluated monthly, whereas renal haemodynamics and function were detected at baseline and after 6 and 12 months of losartan administration. Losartan induced a significant (p < 0.001) decrease in SBP, DBP, and MBP versus baseline values both at 6 months and at 12 months. In addition a significant decrease in RVR (p < 0.001) and in FF (p < 0.05) was also seen. In addition RVR values at 1 year of treatment were higher than their values at 6 months, but this difference was not significant. Our data indicated that long-term control in blood pressure induced by losartan administration was associated with a maintained renal function after 6 months of treatment, but these favourable effects were attenuated after 1 year of treatment.

Decreased expression of the INK4 family of cyclin-dependent kinase inhibitors in Wilms tumor

Cyclin-dependent kinase (CDK) inhibitors represented by the INK4 family (including p16(INK4a, CDKN2A), p15(INK4b, CDKN2B), p18(INK4c, CDKN2C), and p19(INK4d, CDKN2D)) are regulators of the cell cycle shown to be aberrant in many types of human cancer. We tested the hypothesis that these CDK inhibitors are a target for altered gene expression in Wilms tumor. Using RT-PCR, gene expression of the INK4 family was found to be decreased in 9 of 38 Wilms tumor samples obtained from the National Wilms Tumor Study Group (NWTSG) tissue bank. All the affected tumor samples were of favorable histology. Methylation-specific PCR revealed that methylation in the p16 promoter region may be responsible for altered expression. The incidence of loss of p16 expression may increase with increasing tumor stage, i.e., 1/10 (10%) with stage I/II FH Wilms tumor, 2/10 (20%) with stage III FH Wilms tumor, and 4/10 (40%) with stage IV FH Wilms tumor. Thus, determining the expression status of the INK4 family may have potential prognostic value in the management of Wilms tumor.

Limited collateralization of neurons in the rat prefrontal cortex that project to the nucleus accumbens

The specificity and selectiveness of a neuronal message depends in part on the number of recipient neurons that simultaneously receive this message. Hence, projections involved in higher order cognitive processes might be expected to exhibit a lower degree of collateralization than projections that mediate more basic brain functions. This study sought to determine the degree to which neurons projecting from the prefrontal cortex to the nucleus accumbens collateralize to major cortical and subcortical regions: the contralateral prefrontal cortex, the basolateral amygdala or the ventral tegmental area. Fluoro-Gold and cholera toxin-b were used to label prefrontal cortex neurons that project to these targets, and the proportion of neurons singly and dually labeled by immunofluorescence for these tracers was determined. The prefrontal cortex neurons projecting to these regions exhibited a partially complementary laminar distribution. Furthermore, of the neurons projecting to the nucleus accumbens, 13% sent a collateralized projection to the contralateral prefrontal cortex, 7% collateralized to the basolateral amygdala, and 3% sent a branched projection to the ventral tegmental area. No differences were observed in the degree of collateralization of neurons in superficial versus deep layers.Thus, the degree of collateralization of corticoaccumbens neurons was overall limited, but significantly greater to a cortical target than to subcortical regions. These branching patterns provide anatomical substrates for temporal and spatial coordination of activity in limbic circuits.

Effect of spironolactone and its metabolites on contractile property of isolated rat aorta rings

Spironolactone and its active metabolites canrenone and potassium canrenoate are normally used as antihypertensive drugs. Although they are classified as antagonists of aldosterone, their mechanism of action cannot be ascribed solely to the regulation of ion transport in the distal tubule of nephrons. Here we have evaluated the effects of spironolactone, canrenone, and potassium canrenoate on contractile properties of isolated rat aorta rings. Spironolactone (1-300 microM), canrenone (1-300 microM), and potassium canrenoate (0.01-10 mM), in a concentration-dependent manner, relaxed rat aorta rings precontracted with phenylephrine (1 microM) or KCl (40 mM). These relaxant effects were not affected by prior treatment with either aldosterone (100 microM), glibenclamide (10 microM), or tetraethylammonium (10 mM), excluding the possibility that these drugs can be involved in either the nongenomic effect of aldosterone or on activation of potassium channels. Spironolactone and canrenone at concentrations of 30 and 100 microM, but not at 10 microM, and potassium canrenoate at concentrations of 0.3 and 1 mM, but not at 0.1 mM, significantly inhibited the phenylephrine (0.001-3 microM) concentration-response curve. Conversely, all tested concentrations of spironolactone (10, 30, and 100 microM), canrenone (10, 30, and 100 microM), and potassium canrenoate (0.1, 0.3, and 1 mM) significantly inhibited the concentration-response curve induced by cumulative concentrations of KCI (10-80 mM). Because both phenylephrine- and KCl-induced contractions imply an intracellular Ca2+ influx, we suggest that these drugs could act through an inhibition of voltage-dependent Ca2+ channels.

Severe Kawasaki disease in infants: two fatal cases

Kawasaki disease is a systemic vasculitis that manifests itself in many ways. Infants may present as atypical cases and commonly experience severe inflammatory changes. The two cases that are presented here highlight unusual severity and pathology. Patient 1 was a three-month-old infant with atypical Kawasaki disease who developed gangrenous lesions, and coronary and extracoronary artery aneurysms. Multiorgan failure ensued with diffuse cardiac and extracardiac aneurysms and thromboses at autopsy. Patient 2 was a five-month-old infant with Kawasaki disease, cholangitis and peripheral gangrene. Severe coronary artery aneurysms developed and he died following a myocardial infarction, despite multiple doses of intravenous immunoglobulin, acetylsalicylic acid (ASA) and corticosteroids. There is a higher occurrence of atypical disease and more severe vasculitis in infants with Kawasaki disease. Pathological changes are described, including coronary and extracardiac lesions. Patient 1 shows extensive peripheral gangrene and widespread aneurysms, and patient 2 illustrates severe cardiac complications with diffuse organ inflammation. Therapies including intravenous immunoglobulin, ASA, corticosteroids and antithrombotics are reviewed.

In vitro and in vivo effects of 2'-deoxycoformycin (Pentostatin) on tumour cells from human gammadelta+ T-cell malignancies

Hepatosplenic gammadelta+ T-cell lymphoma represents a rare neoplasm of post-thymic phenotype, characterized by an aggressive clinical course and a poor response to conventional chemotherapy. In the present study, we have examined the cytotoxic effects of the purine analogue 2'-deoxycoformycin (dCF) on cultured mononuclear cells and purified gammadelta+ tumour cells from bone marrow or peripheral blood of four patients with hepatosplenic gammadelta+ T-cell lymphoma. At a concentration of 10 microM, dCF, in the presence of 2'-deoxyadenosine (dAdo), displayed an early and selective cytotoxic effect on gammadelta+ tumour T cells. After 48 h of in vitro exposure to dCF, the absolute number of viable CD3+/gammadelta+ tumour T cells was reduced by more than 90% in all samples with respect to control cultures, with absolute counts of viable CD3+/alphabeta+ lymphocytes being reduced only by 6-40% of the initial cell input. Analysis of cultures after 5 d of exposure to dCF plus dAdo revealed the persistence of normal CD3+/alphabeta+ T cells, which accounted, however, for only 20-25% of the initial cell input. Accordingly, the combination of dCF (10-100 microM) plus dAdo was able to induce a dose-dependent inhibition of clonogenic growth and [3H]-thymidine incorporation in purified CD3+/CD4-/CD8- gammadelta+ tumour cells. We also report that one patient with hepatosplenic gammadelta+ T-cell lymphoma in terminal leukaemic phase showed a striking haematological response to single-agent dCF given as fourth-line treatment. In particular, the selective clearance of gammadelta+ tumour T cells in peripheral blood and bone marrow was observed starting after the second course of treatment. Our results suggest that dCF may represent a potentially active drug for the management of this aggressive form of T-cell lymphoma.

[Spiral computed tomography in the assessment of vascular lesions of the pelvis due to blunt trauma]

PURPOSE

We investigated the role of Helical Computed Tomography (CT) in the evaluation of low or high flow vascular injuries in patients with blunt pelvic trauma.

MATERIAL AND METHODS

From May 1998 to December 1999, forty-nine patients (32 men and 17 women, ranging in age 14-59 years) with acute symptoms from blunt pelvic trauma were submitted to Computed Tomography (CT). A conventional radiography of the pelvis had been performed in all cases. CT was performed with a helical unit (thickness 8 mm, reconstruction interval 8 mm, pitch 1.5) after intravenous contrast agent (150-180 mL) rapid infusion (4-5 mL/s, 60 s acquisition delay from bolus starting) and using a power injector. A second spiral acquisition was performed in all cases from the iliac roofs to the inferior border of the pubic symphysis. Vascular hemorrhage was considered as low flow when the hematoma appeared as a focal homogeneous density area and as high flow when associated with contrast agent extravasation. Moreover, traumatic assessment included evaluation of the hematoma, of the leakage site and of the involved vessel.

RESULTS

Radiologic examination of the pelvis revealed fractures in 35/49 patients (71.4%). Helical CT allowed us to identify low flow hemorrhage in 37 patients, affected with hematomas from fracture of the iliac wing or of the sacrum (14 cases), tear of the pelvic (3 cases) or extrapelvic (4 cases) muscular structures, or injury of the venous plexus (20 cases). In four patients two vascular injuries were detected. High flow hemorrhage was seen in 12 patients, who had Helical CT findings of contrast agent extravasation along the common iliac vein (3 cases), external iliac artery (3 cases), internal iliac artery (4 cases), internal pudendal artery (1 case), obturator artery (1 case), inferior epigastric artery (2 cases), superior gluteal artery (2 cases), inferior gluteal artery (1 case), cremasteric artery (1 case). In 6 patients with high flow hemorrhage, two vascular injuries were shown. In all these patients, an extraperitoneal hematoma was associated with the contrast agent extravasation.

DISCUSSION AND CONCLUSIONS

Fractures of the pelvic ring generally result from severe trauma. Management of these injuries must include not only treatment of the skeletal trauma but also of the associated shock and complications. Major blood loss usually occurs as a result of bleeding from the branches of the internal iliac artery. With respect to pelvic plain radiography, CT provides superior detailing of fractures, position of fracture fragments and extent of diastasis of the sacroiliac joints and pubic symphysis. Moreover CT provides diagnostic information regarding the presence or absence of pelvic bleeding and can identify the site of bleeding. In our experience, Helical CT allows us to distinguish high flow hemorrhage, where vascular injuries must be treated first, from low flow hemorrhage which can be managed differently.

Normalizing complementary DNA by quantitative reverse transcriptase-polymerase chain reaction of beta2-microglobulin: molecular monitoring of minimal residual disease in acute promyelocytic leukemia

Reverse transcription (RT)-polymerase chain reaction (PCR) raises unique methodological matters that may hamper the reliability of the procedure, especially when results should direct therapeutic decisions. One of these matters is represented by the RT step. The present study shows that differences in complementary DNA (cDNA) preparations purposely containing increasing amounts of retrotranscribed RNA were not disclosed by nonquantitative RT-PCR by two different housekeeping genes, leading to fictitious results when the expression of a given gene was quantitatively assessed. To overcome this problem, the following are proposed: 1) to evaluate the efficiency of RT step through the quantification, by competitive RT-PCR, of the expression levels of the housekeeping gene beta2-microglobulin (beta2M); 2) to normalize each cDNA preparation to be comprised within 1 standard deviation of the mean value of beta2M absolute level (3.14 +/- 1.14 attomoles/microg RNA) found by analyzing 33 cell lines of hematopoietic origin. To validate this strategy in a clinical setting, serial cDNA samples from patients were checked by conventional and quantitative RT-PCR for beta2M. Again, only a quantitative evaluation of beta2M levels was allowed to unveil significant differences, otherwise undetected, in the efficiency of RT reactions among these cDNA samples. Normalization of samples to obtain cDNA preparations containing comparable beta2M levels, eventually led to an increased sensitivity in the detection of PML-RARalpha fusion transcripts. This approach seems of great value for the monitoring of minimal residual disease in serial patient samples when a tumor-specific marker is available.

Leiomyoma of the esophagus associated with bronchial obstruction owing to inflammatory pseudotumor in a child

Although relatively common in adults, leiomyoma of the esophagus is a rare disorder in children. A single case report describes the coexistence of both esophageal and bronchial leiomyoma in a child. The authors describe the diagnostic and treatment challenges encountered in a 2-year-old boy with coexisting inflammatory pseudotumor and esophageal leiomyoma presenting as massive atelectasis.

Prevalence of antibodies to Leptospira serovars in sheep and goats in Alto Adige-South Tyrol

Serum samples from 313 sheep and 95 goats were collected during November 1993 in 26 localities in Alto Adige-South Tyrol and tested by microscopic agglutination test for antibodies to 28 serovars of the genus Leptospira. At the time of blood collection all the animals appeared healthy with no clinical sign suggestive of leptospirosis. The observed seroprevalence in sheep was 6.1%, whereas the seropositivity rate for goat serum samples was 2.1%. The highest serological prevalence in sheep was recorded for serovar castellonis, followed by poi, sejroe, hardjo subtype hardjobovis, copenhageni, and cynopteri. Titres to poi were the only ones found in goats. These findings, which are proof of Leptospira infection in Alto Adige-South Tyrol, indicate that foci of several serovars exist in this region.

Delayed presentation of traumatic left-sided diaphragmatic avulsion. A case report

We describe the case of a 35-year-old man who had suffered a severe multitrauma with blunt thoracic injury, left scapula and humerus fractures 5 years earlier. At the time of the trauma, a diaphragmatic lesion went unnoticed. Five years later, the patient had a 24-h history of increasingly severe abdominal pain with repeated vomiting. Helical CT showed a portion of the left hemidiaphragm avulsed from its insertions on the ribs with large-bowel loop obstruction herniated in the left hemithorax. The preoperative CT diagnosis was confirmed by surgery: reduction of the hernia and reinsertion of the hemidiaphragm to the lumbocostal arch were performed.

Antiproliferative triterpene saponins from Trevesia palmata

During the course of a study of plants of the family Araliaceae, antiproliferative activity was demonstrated by the crude saponin fraction of Trevesia palmata. After chromatographic purification, six new bisdesmosidic saponins (1-6), along with two known triterpenoid saponins, (7 and 8), were isolated. The structures of 1-6 were determined by (1)H-(1)H correlation spectroscopy (COSY-DQF, 1D TOCSY, 2D HOHAHA, 1D ROESY) and (1)H-(13)C (HSQC, HMBC) spectroscopy. The antiproliferative activity of compounds 1-8 and of their prosapogenins (2a-7a) prepared by alkaline hydrolysis, was evaluated using three continuous culture cell lines.

[The role of spiral computed tomography in sigmoid diverticulitis and the diagnostic-therapeutic implications]

PURPOSE

Colonic diverticula are saccules made of colonic mucosa and submucosa that herniate from the colonic lumen through the muscular layer of the wall where straight vessels penetrate. Diverticula are localized in the sigmoid colon in 95% of cases. Bacteria pooling in the lumen may cause lumen erosion and eventually perforation. CT is a useful technique in this condition because it can demonstrate intra- and/or extramural inflammation. Aim of this retrospective study was to assess the capabilities of contrast-enhanced helical Computed Tomography (CT) in sigmoid diverticulitis, especially relative to selection of the appropriate treatment.

MATERIAL AND METHODS

We retrospectively reviewed the findings of 41 patients referred to our emergency department for diverticulitis. CT scans were performed 65 seconds after i.v. injection of nonionic contrast material (3 mL/s, 120 mL in all) administered by a CT-power injector. The following 7 CT findings were considered at least suggestive of acute diverticulitis: focal wall thickening, intramural abscess, inflammatory changes in the sigmoid mesentery root, pericolic fat inflammation or pericolic abscess formation, fistula, peritonitis. CT results were compared with surgical and physical findings.

RESULTS

Based on CT findings, diverticulitis was classified as mild (25 patients) or severe (15 patients). In mild diverticulitis we found: focal sigmoid wall thickening (6 patients), intramural abscess (3 patients), sigmoid mesentery root thickening (5 patients), edema fluid (8 patients) and phlegmon (3 patients). In severe diverticulitis we found: sigmoid mesentery abscess (6 patients), fistula (5 patients) and peritonitis (4 patients). CT findings were questionable in 1 case and thus we could not exclude a perforated carcinoma.

CONCLUSION

Contrast-enhanced helical CT is the imaging modality of choice in assessing mild or severe acute diverticulitis because it provides useful information for appropriate treatment planning in the emergency setting. This technique is most useful in questionable cases and in patients with suspected severe diverticulitis where a choice must be made between different treatment options.

[Personal experience in 71 consecutive patients with acute cholecystitis]

PURPOSE

Acute cholecystitis is one of the most frequent abdominal inflammatory processes. If untreated or misdiagnosed it can result in severe complications such as gallbladder rupture, abscesses, or peritonitis. We retrospectively reviewed a series of 71 consecutive patients with surgical confirmation of acute cholecystitis and now compare the results of the diagnostic techniques we used preoperatively.

MATERIAL AND METHODS

Over 16 months, 71 consecutive patients (42 women and 29 men; age range: 34-84 years, mean: 58) with acute abdominal pain were operated on for acute cholecystitis at Cardarelli Hospital, Naples. Abdominal plain film was performed in 65 of 71 cases, abdominal US in 69 and abdominal CT in 6. On abdominal plain films, we retrospectively searched the following signs: densities projected over the gallbladder, linear calcifications in gallbladder walls, gallbladder enlargement, focal gas collections within the gallbladder, and air-fluid levels in the gallbladder lumen. On US images we looked for: gallbladder wall thickening (> 3 mm), intraluminal content in the gallbladder, pericholecystic fluid, US Murphy's sign, and gallbladder distension. On CT images, we investigated: gallbladder distension, wall thickening, intraluminal content, pericholecystic fluid, and inflammatory changes in pericholecystic fat. Associated complications of cholecystitis were also searched on all images.

RESULTS

On plain abdominal films we found densities projected over the gallbladder (16.9%) and linear calcifications in the gallbladder wall (4.6%). Abdominal US demonstrated gallbladder wall thickening (56.5%), one or more gallstone(s) (85.5%), pericholecystic fluid (14.5%), gallbladder distension (46.4%), and US Murphy's sign (39.1%). Abdominal CT showed gallbladder wall thickening (83.3%), gallbladder distension (66.6%), pericholecystic fluid (66.6%), gallstones (50%), inflammatory changes in pericholecystic fat (33.3%), and increased bile density (> 20 HU) (33.3%).

CONCLUSIONS

US appears to be the most useful imaging technique in patients with suspected acute cholecystitis, for both screening and final diagnosis. CT plays a limited role in the early assessment of these patients, but can be a useful tool in diagnosing acute cholecystitis in patients with questionable physical findings or in investigating related complications.