Gemcitabine as single agent therapy in advanced non small cell lung cancer and quality of life in the elderly

BACKGROUND

The aim of this study is to test the efficacy of gemcitabine as single agent therapy in advanced non-small cell lung cancer in the elderly by the evaluation of the clinical response, the survival increase and the quality of life.

METHODS

Nineteen patients (age >65 years) with a PS >2, bearing an advanced non-small cell lung cancer (IIIb-IV) not treated with chemotherapy before, were charged between December 1996 and December 1998. Sixteen patients were treated with gemcitabine at the dose of 1000 mg/mq 1-8-15 every 28 days. CT scan, X-rays and skeletal scintigraphy were used in the evaluation of the therapeutic response. The toxicity was estimated by following WHO indexes. The quality of life and the modification of the specific symptoms were estimated by particular tests (Spitzer Index, IADL, EORTC-LC13).

RESULTS

One complete response (6%), 4 partial responses (25%), 7 cases of illness stabilization (43%), 4 cases of illness progression, were shown. One year of survival was found in 43% of cases with a 14 week of therapeutic response and a global survival ratio of 12.4 weeks. Only 2 cases (12.5) of medium grade G3-leucopenia were found. All patients improved their quality of life (IADL and Spitzer indexes) with reduction of symptoms, (EORTC-LC13) and increase of self-agin and relationships.

CONCLUSIONS

The effectiveness of gemcitabine as single agent therapy as not yet been tested due to the scanty number of patients, nevertheless it must be considered in relation to the improvement of the patient s quality of life.

Role of human FcepsilonRI+ cells in HIV-1 infection

Enhanced serum IgE levels in adults and children with HIV-1 infection could be a marker of poor prognosis. HIV-1 infection is believed to involve a switch toward a "TH2-like" cytokine pattern. HIV-1 gp120 from different clades is a potent stimulus for histamine release from human basophils and mast cells. Gp120 also induces IL-4 and IL-13 synthesis from basophils. It functions as a viral superantigen by interacting with the VH3 region of IgE to induce mediator release from human FcepsilonRI+ cells. The chemokine receptor CCR3, which binds the chemokines eotaxin and RANTES, is expressed by basophils and lung mast cells. By interacting with the CCR3 receptor on FcepsilonRI+ cells, HIV-1 Tat protein is a potent chemoattractant for basophils and lung mast cells. Tat protein also induces IL-4 and IL-13 release from basophils. Incubation of basophils with Tat protein upregulates the surface expression of the CCR3 receptor, a co-receptor of HIV-1 infection. Extracellular Tat affects the directional migration of human FcepsilonRI+ cells, CCR3 expression and TH2 cytokines release. We have shown that HIV-1 proteins gp120 and Tat trigger the release of cytokines critical for TH2 polarization from FcepsilonRI+ cells through two distinct mechanisms. In addition, Tat upregulates the beta-chemokine receptor CCR3, making FcepsilonRI+ cells more susceptible to infection with CCR3 tropic HIV-1 isolates.

Cellular contamination of plasma collected with various apheresis systems

Efforts to improve the purity of blood products have mainly focused on reducing white blood cell (WBC) levels in cellular blood products. Relatively little attention has been given to the cellular purity of plasma. We evaluated plasma units collected on six apheresis systems: Dideco Excel, Haemonetics-MCS+, Fresenius-AS-Tech 204, Baxter-Amicus, Gambro BCT COBE Spectra and Gambro BCT-Trima. Collected plasma volumes averaged 300-350 ml for the various systems. Plasma samples were analyzed for platelet (PLT) content (Technicon H3, Bayer) and residual WBC (Imagn 2000). Results are given below. Platelet levels were consistently low for MCS+, COBE Spectra and Trima (all <50 x 10(3) microl(-1)), and were highest with AS204. Residual WBC levels were relatively low in all systems except MCS+. Extremely low levels were observed in Trima plasma. All of the Trima and Spectra units contained <1 x 10(6) WBC per product. With Excel, AS-Tech 204 and Amicus, 1 to 2 units were found to have >1 x 10(6) WBC, while almost all units from MCS+ exceeded this limit. Different levels of plasma purity were obtained with different apheresis systems. The Gambro BCT COBE Spectra and Trima systems were found to achieve consistently low levels of both platelets and WBC.

Evaluation of dosed red blood cell units collected with Gambro BCT--TRIMA

The increasing need of collecting high quality blood components and of improving the overall productivity of a blood centre requires the utilisation of a new innovative process that combines high speed collection with an automated process and blood component tailoring to fit individual patient requirements. We collected dosed Red Blood Cell (dRBC) units on 64 donors, eligible as regular donors on the Gambro BCT TRIMA using the dRBC collection protocol. The collection target was set to 180 ml packed Red Blood Cells (pRBCs) in 225 ml total collection volume (n = 7), or 300 ml pRBCs in 375 ml total collection volume (n = 33) or 360 ml in 450 ml (n = 24), depending on donor's hematological profile and blood volemia. Saline was infused as the replacement fluid at a 120%) collection:infusion ratio. Donor per cent hematocrit was (mean +/- S.D.) 43.7 +/- 4.0% and TBV = 4.99 +/- 0.69 1. The procedures yielded 100 +/- 6% of predicted yield, with a hematocrit of 78.2 +/- 6.6% in 29 +/- 3 min. Hb content was 99.9 +/- 21.8 in all procedures, or 61.5-94.4-118.6 g in the three groups, respectively. After the addition of the SAG-M storage solution, the hematocrit was 56.3 +/- 6.2%. No adverse reactions have been reported by the donors and all pPRBC units were transfused to patients without any transfusion reaction being reported by clinicians. The dRBC protocol is well tolerated by donors without any side effects, other than normal effects of regular blood donation. Higher pRBC productivity can be reached with a safe and automated process in conjunction with a high and consistent product quality easily matching the donor collection criteria and pRBC unit standards. Tailoring of pRBC units can result in an improved patient transfusion support.

Dysregulation of the IgE/Fc epsilon RI network in HIV-1 infection

Serum IgE levels are increased in adults and children with HIV-1 infection and could be a marker of poor prognosis. Allergic reactions and adverse reactions to drugs are also increased in HIV-1-infected individuals. An imbalance between a T(H)1-like and a T(H)2-like cytokine profile has been documented in HIV-1 infection. We have found that HIV-1 gp120 from different clades is a potent stimulus for histamine and cytokine (IL-4 and IL-13) release from basophils. Gp120 acts as a viral superantigen, interacting with the V(H)3 region of IgE to induce mediator release from human Fc epsilon RI(+) cells. Human basophils and mast cells express the chemokine receptor CCR3, which binds the chemokines eotaxin and RANTES. By interacting with the CCR3 receptor on Fc epsilon RI(+) cells, HIV-1 Tat protein is a potent chemoattractant for human basophils and lung mast cells. Tat protein also induced IL-4 and IL-13 release from basophils. Preincubation of basophils with Tat protein upregulated the surface expression of the CCR3 receptor. Extracellular Tat can influence the directional migration of human Fc epsilon RI(+) cells, the expression of chemokine receptor CCR3, and the release of T(H)2 cytokines. Because Tat protein is actively released by HIV-1-infected cells, our results indicate a novel mechanism by which Fc epsilon RI(+) cells are rendered more susceptible to infection with CCR3-tropic HIV-1 isolates; that is, two HIV-1 proteins, gp120 and Tat, trigger the release of cytokines critical for T(H)2 polarization from Fc epsilon RI(+) cells, and Tat upregulates beta-chemokine receptor CCR3 on these cells.

Thymic carcinoma, systemic lupus erythematosus, and hypertrophic pulmonary osteoarthropathy in an 11-year-old boy: a novel association

Thymic carcinoma is exceptionally rare in children and it has never previously been associated with autoimmune disorders. The authors report the case of an 11-year-old boy with thymic carcinoma, hypertrophic pulmonary osteoarthropathy, and an autoimmune disease that resembled systemic lupus erythematosus. To their knowledge, this is the first case of such complex clinical findings. The tumor was of high grade histologically and the boy died after 1 year, in spite of chemotherapy and radiotherapy. A review is presented of the available medical literature on thymic malignancy in childhood.

[Postectomy for phimosis: 5-year-experience]

Phimosis, i.e. congenital or acquired preputial stenosis, is one of the most frequent problems encountered in surgery departments. Circumcision remains the most frequently adopted surgical treatment, but, since this operation entails the sacrifice of the prepuce and frenulum, the penis loses its natural protection. The Authors describe five years of experience with postectomy, a technique which spares both the prepuce and frenulum while repairing the preputial phimosis, defining its benefits compared with circumcision.

Bacterial immunoglobulin superantigen proteins A and L activate human heart mast cells by interacting with immunoglobulin E

Human heart mast cells (HHMC) have been identified in heart tissue, perivascularly, and in the intima of coronary arteries. In vitro activation of isolated HHMC induces the release of vasoactive and proinflammatory mediators (histamine, tryptase, and cysteinyl leukotriene C(4) [LTC(4)]). We investigated the effects of several bacterial proteins on HHMC activation in vitro. HHMC released histamine, tryptase, and LTC(4) in response to Staphylococcus aureus Cowan 1 and the immunoglobulin (Ig)-binding protein A, but not to S. aureus Wood 46, which does not synthesize protein A. The effect of protein A was inhibited by preincubation with monoclonal IgM V(H)3(+). Some strains of Peptostreptococcus magnus express an Ig light chain-binding surface protein called protein L. Such bacteria and soluble protein L stimulated the release of preformed and newly synthesized mediators from HHMC. Preincubation of HHMC with either protein A or protein L resulted in complete cross-desensitization to a subsequent challenge with the heterologous stimulus or anti-IgE. Monoclonal IgE (kappa chains) blocked protein L-induced release, whereas IgE (lambda chains) had no effect. Streptococcal protein G, formyl-containing tripeptide, and pepstatin A did not activate HHMC. Bacterial products protein A and protein L and intact bacteria (S. aureus and P. magnus) activate HHMC by acting as Ig superantigens.

Acute intravascular hemolysis in two patients transfused with dry-platelet units obtained from the same ABO incompatible donor

Since 1989 we have been collecting dry-platelets on a routine basis. Dry-platelets are those collected along with 25-30 ml of contaminating plasma cell with separators such as the Amicus, AS 104 and the Excel Pro. Platelets are resuspended in non plasma media for storage and for at least 60 hours their viability and functionality are not impaired. In this article we report on two hemolytic crises determined by two O Rh D + units of single donor platelets (SPD) taken from the same donor in a double-apheresis session. The two split units were administered to two A Rh D + patients suffering from metastatic breast cancer and severe aplastic anemia (SAA) respectively. In both cases the hemolytic reaction was of the intravascular type, with a drop in hemoglobin (Hgb) level from 8.6 to 5.4 and from 8.8 down to 5.3 g/dl respectively. From the patients' RBC only alpha agglutinins were eluted and donor's indirect antiglobulin test (IAT) was negative with extended panel RBCs. In the first case the clinical course after erythroexchange (Erex) was uneventful whereas in the second one, that suffering from SAA, after Erex, acute renal failure and shock did complicate the clinical course and the patient died seven days after the incriminated platelet transfusion.

Surgical management of thrombosed popliteal artery aneurysm: two case reports

Popliteal artery aneurysm is not a rare event and is the most common type of peripheral arterial aneurysm. The Authors report on their experience with two cases. One patient had a giant popliteal aneurysm and was treated with a dacron patch, while the other had a smaller one and was treated with an inverse saphenous vein bypass. The Authors stress the importance of a thorough study of the patients in order to rule out aneurysmal disease in other sites. They conclude that early surgical intervention is the only effective therapeutic tool to avoid serious complications.

Neck hibernoma: case report and literature review

The case history of a 23 year old man with a large hibernoma of the cervical region is reported. Th tumour showed all the clinical and pathologic characteristic of these rare benign neoplasms. A review of the most recent literature supports the Authors' conclusion that local excision is curative.

Successfully managed genital necrotizing fasciitis with multiple debilitating diseases. A case report

Genital necrotizing fasciitis is a rapidly progressive bacterial infection of soft tissues with a reported average mortality of about 36%; associated debilitating diseases increase the mortality rate. The Authors report a case of successful management, due to an aggressive medical and surgical therapy, despite the presence of multiple debilitating diseases and an advanced necrosis.

The immunoglobulin superantigen-binding site of HIV-1 gp120 activates human basophils

OBJECTIVE

To investigate the mechanism whereby HIV-1 envelope glycoprotein gp120 from four different isolates obtained in three different countries induces proinflammatory mediator release from normal human basophils.

METHODS

Histamine, cysteinyl leukotriene C4 (LTC4) and interleukin 4 (IL-4) release into the supernatant was measured in gp120-stimulated peripheral blood basophils from HIV-1 and HIV-2 negative subjects.

RESULTS

The HIV glycoprotein was a potent stimulus for release of these mediators in basophils purified from donors negative for HIV-1 and HIV-2. There was also a correlation (r = 0.58; P < 0.01) between the maximum IL-4 release from basophils induced by gp120 and by anti-IgE. Basophils from which IgE had been dissociated by brief exposure to lactic acid no longer released histamine in response to gp120 and anti-IgE. Anti-IgE specifically desensitized basophils to a subsequent challenge with anti-IgE and gp120. Human monoclonal IgM carrying the VH3 domain, but not that carrying the VH6 domain, inhibited gp120-induced secretion of histamine from basophils in a concentration-dependent manner. Synthetic peptides identical to regions distant from the N- and C-termini of gp120MN inhibited its activating capacity.

CONCLUSIONS

gp120 acts as a viral superantigen interacting with the VH3 domain of IgE to induce the release of preformed and de novo synthesized mediators from human cells carrying the Fc fragment Fc epsilonRI receptor.

HIV-1 gp120 induces IL-4 and IL-13 release from human Fc epsilon RI+ cells through interaction with the VH3 region of IgE

HIV-1 glycoprotein (gp) 120 from different clades is a potent stimulus for IL-4 and IL-13 release from basophils purified from healthy individuals seronegative for Abs to HIV-1 and HIV-2. IL-4 mRNA, constitutively present in basophils, was increased after stimulation by gp120 and was inhibited cyclosporin A and tacrolimus. IL-4 and IL-13 secretion from basophils activated by gp120 was not correlated. There was a correlation between the maximum gp120- and anti-IgE-induced IL-4 release from basophils. The average t1/2 gp120-induced IL-4 release was lower than for IL-13 release. Basophils from which IgE had been dissociated by brief exposure to lactic acid no longer released IL-4 in response to gp120 or to anti-IgE. The response to a mAb cross-linking the alpha-chain of high-affinity receptor for IgE (Fc epsilon RI) was unaffected by this treatment. Three human VH3+ monoclonal IgM inhibited gp120-induced secretion of IL-4 from basophils. In contrast, VH6+ monoclonal IgM did not inhibit the release of IL-4 induced by gp120. Synthetic peptides distant from the NH2 and COOH termini of gp120MN inhibited the activating property of gp120MN. These results indicate that gp120, which acts as a viral superantigen, interacts with the VH3 region of IgE to induce the release of IL-4 and IL-13 from human Fc epsilon RI+ cells.

[The chance finding of gallbladder carcinoma during cholecystectomy for long-term symptomatic lithiasis. A clinical case]

The case of a patient who underwent conventional cholecystectomy for gallbladder adenocarcinoma is reported. Gallbladder carcinoma is rare, but since laparoscopic cholecystectomy has quickly emerged as a popular alternative to open cholecystectomy an increasing number of gallbladder carcinomas are discovered. Most of the time it is detected as an incidental tumor, the patient being with no or few symptoms and often the lesion too far advanced for any type of curative surgery. The most important questions related to the therapy are focused and a partial review of the literature is made.

Cascade filtration for TTP: an effective alternative to plasma exchange with cryodepleted plasma

TTP remains enigmatic both in terms of etiology and management. The most recent approach is aggressive plasma exchange (PE) employing cryopoor plasma for replacement, based on the pathogenetic relevance given to exceedingly large Von Willebrand (VWF) multimers in the determination of the syndrome with normalization during remission. PE with fresh frozen plasma (FFP) is better than FFP infusion as shown by a recent Canadian study, supporting the theory that to treat TTP an offending circulating agent needs to be removed from the patient's plasma in contrast to the hypothesis that a missing factor is to be given along with FFP. A more recent hypothesis is supported by the results of studies published by the end of 1998 [Moake J, Chintagumpala M, Turner N et al. Blood 1994;84:490-97; Moake J, McPherson PD. Am J Med 1989;87: 3-9N] which would show that TTP is mediated by auto-antibodies to VWF-cleaving protease, or is the result of deficiency of the protease ascribed to abnormalities in its production, function or survival. Plasmapheresis without plasma infusion is relatively ineffective perhaps because it does not increase the protease activity. Cascade filtration (CF) is the autologous counterpart of plasmapheresis. It has been used by our group since 1980 to remove from patients plasma macromolecules such as VWF, fibrinogen, LDL and circulatory immune complexes (CIC). After secondary filtration, the autologous plasma has a composition which is very similar to that of allogeneic plasma after cryoprecipitation, a product which used in the management of TTP. Based on this knowledge, in 1994 we began to use CF in the treatment of TTP patients. In the beginning (7 patients) CF was combined with a decreasing number of conventional PEs using allogeneic plasma for substitution. Lately only CF with some plasma supplementation has been used in the last 9 cases. From a clinical point of view our 16 patients achieved remission after a number of treatments (11 +/- 7) that compares sufficiently well with those required by our historical control group of 47 cases (14 +/- 13). Of course the patient's exposure to allogenic plasma was significantly lower for patients in the CF only group (1.4 +/- 1.2 plasma U/session) compared to the PE + CF group (4.4 +/- 2.3 plasma U/session) or for the controls treated by PE only (10.8 +/- 4.6 plasma U/session). There were no deaths in the CF or PE + CF groups and no untoward effect was observed. On the contrary there were 5 deaths (1 on the day of presentation) in the PE group, and 1 HBV and 2 HCV infections as well as 4 severe allergic reactions to plasma proteins (or passive antibody infusion). We conclude that CF is presently the best treatment to offer to patients suffering from sporadic TTP and that CF may contribute to expanding the knowledge of the pathogenetic mechanisms of this uncommon multisystem disorder.

Autoapheresis and intraoperative blood salvage in oncologic surgery

Transfusion of predeposit or salvaged autologous blood has continued to grow since the 1980s. Issues such as the indications for use and cost effectiveness as well as the safety of autologous blood salvaged during cancer surgery have emerged and should be addressed. The concern for possible contamination of autologous RBC with cancer cells responsible for metastasis has limited the use of autologous salvaged blood in cancer patients. Nevertheless, clinical experience has been gained on the use of salvaged blood in patients with colorectal, gastric, renal, hepatic, breast, bladder and lung cancer. No evidence has been reported showing an increase in metastasis or a decrease in patient survival, in spite of the obvious demonstration that salvaged blood is contaminated with viable tumor cells which are not washed out of the RBC layer during intraoperative blood salvage (IOBS). However, a number of limitations have hampered the widespread use of IOBS in these patients and the technique is not well established. Increasing knowledge of the deleterious effects of allogeneic blood transfusion both in terms of the increased number of viral or bacterial infections and the down-regulation of the patient's immune system have recalled attention to IOBS and to the techniques such as filtration, which might reduce the risk of reinfusion of cancer cells, or totally eliminate the risks such as irradiation has been proposed by Hansen's group. This paper reviews the topic with some emphasis on our personal experience with gamma and X-ray irradiation of salvaged blood in a large reference hospital, where IOBS and filtration of salvaged blood were established for use in cancer patients in 1993 and 1996.

Automatic volumetric capillary cytometry in the routine of an apheresis unit involved in multicomponent collection

In apheresis, leukodepletion by secondary filtration of the platelet components or by the primary use of special high efficiency apparatuses is widely used to meet current clinical practice. Leukodepletion of RBC is mandatory for hematooncological patients and new filters for plasma are progressively being introduced in the routine of European blood banks. However, since the monitoring of leukodepletion efficiency continues to be carried out manually using the Nageotte or the microdroplet fluorescence assay (MFA), inaccuracy and labour-intensity of counting will limit the possibility of satisfying the increasing demand for leukodepletion monitoring. Volumetric capillary cytometry (VCC) is a totally automated system that has been shown to correlate well with Nageotte, MFA and flow-cytometric countings of residual leukocytes in platelet and RBC product. In this article we describe the application of VCC in the quality control program of our hemapheresis unit in which all apheresis donations are of the multicomponent collection type.

Immunological modulation of human cardiac mast cells

Human mast cells, by elaborating various cytokines, chemokines and proinflammatory mediators play a complex role in several allergic and inflammatory disorders. Mast cells have been identified in human heart tissue in close proximity to the sarcolemma, in perivascular and adventitial locations and in the shoulder region of coronary atheroma. Human heart mast cells (HHMC) can be isolated from patients undergoing heart transplantation and can be immunologically activated in vitro to induce the release of tryptase, chymase, cysteinyl leukotriene C4 and prostaglandin D2. Several cytokines (e.g., stem cell factor and TNF-alpha) reside in secretory granules of HHMC. Mast cell density is increased in the hearts of patients with ischemic and idiopathic dilated cardiomyopathy. Cardiac mast cells might contribute to the evolution of atherosclerosis, dilated cardiomyopathy, cardiac and systemic anaphylaxis through the release of cytokines and vasoactive and proinflammatory mediators.

Multicomponent collection (MCC) with the latest hemapheresis apparatuses

BACKGROUND

Collection of multiple products including plasma, packed red blood cells (PBRC) and double units of platelets, is increasingly improving donor utilisation and decreasing blood transfusion costs. Total apheresis is the new trend in blood banking and both industry and physicians are progressively expanding their involvement in this field. During 1998, at our hemapheresis unit, we used three new apparatuses for multicomponent collection (MCC). These apparatuses vary in terms of principle, operation and specific capabilities, and thus knowledge of them is essential to match their characteristics with plateletapheresis needs.

STUDY DESIGN

We reviewed all MCCs carried out in 1998 with MCS+, Trima and Excel-Pro cell separators. These apparatuses were evaluated in terms of platelet yield, white blood cell (WBC) contamination, efficiency per minute, platelet activation, and PBRC product quality.

RESULTS

The three machines are compared in the following table [table in text].

CONCLUSIONS

MCC with the new apparatuses is well accepted by donors and personnel. There are no risks for the donors and, excluding ACD reactions and/or vaso/vagal attacks at the beginning of procedures, no severe reaction was seen. The quality and quantity of platelet products are good. When PRBC or a second platelets unit are collected, the cost of the kit is covered by this double product.

Dry platelets with the Dideco Excel apparatus

Dry platelets are required to prevent hemolytic and nonhemolytic febrile reactions after transfusion to ABO mismatched recipients, to reduce the risk of HLA immunization and to prevent allergic or anaphylactic reactions. Previously we have shown that the collection of single donor platelets almost free of plasma is possible with different cell separators. With the systems we described for the CS 3000+/Amicus and AS 104-204 apparatuses collection of dry platelets implies their resuspension in non plasma solutions after opening the circuit. With the new system developed by Dideco for the Excel apparatus this moreover is no longer required since the platelet bag can be connected to the resuspending medium through a dedicated line with an antibacterial filter. Platelets are collected cyclically and the resuspending solution is added when the procedure is over. In this study 53 collections were evaluated, 21 of which were erythrothrombocytapheresis. In 60-65 min 4.21 of anticoagulated blood (1/12) were processed with platelet collection automatically done after 6-700 ml cycles. The platelet yield averaged 4.67 +/- 0.7 x 10(11), with a platelet efficiency per minute of 7.18 +/- 0.9 x 10(9). The WBC contamination averaged 2.6 +/- 0.7 x 10(5) and contamination did not exceed 0.87 x 10(6). The quality of platelets was satisfactory as measured by aggregation, morphology score, and CD 62 membrane glycoprotein externalization. These results were comparable to those obtained with three other Excel apparatuses used in the conventional way to collect platelets resuspended in plasma or with the Amicus used to collect dry platelets using an open system.

Endogenous superallergen protein Fv interacts with the VH3 region of IgE to induce cytokine secretion from human basophils

BACKGROUND

Protein Fv is an endogenous protein, synthesized in liver and largely released in the digestive tract during acute and chronic viral hepatitis, that binds to immunoglobulin (Ig) from various mammalian and nonmammalian species.

METHODS

Basophils obtained from normal subjects were purified by a double Percoll gradient and elutriation. The secretion of histamine induced by protein Fv was assayed by a fluorometric technique, the extracellular protein levels of IL-4 and IL-13 were measured by ELISA, and IL-4 mRNA levels were evaluated by RT-PCR.

RESULTS

Protein Fv concentration-dependently induced histamine and IL-4 and IL-13 release from purified basophils. IL-4 mRNA, constitutively present in basophils, was increased after stimulation by protein Fv. Histamine and IL-4 secretion from basophils, but not histamine and IL-13 release, activated by protein Fv was significantly correlated (rs = 0.70, p<0.001). Basophils from which IgE had been dissociated by brief exposure to lactic acid no longer released IL-4 in response to protein Fv and anti-IgE. Two preparations of human VH3(+) monoclonal IgM inhibited protein Fv-induced secretion of IL-4 and histamine from basophils. In contrast, VH6(+) monoclonal IgM did not inhibit the release of mediators caused by protein Fv.

CONCLUSIONS

These results indicate that protein Fv, which acts as an endogenous superallergen, interacts with the VH3 domain of IgE to induce the synthesis and release of IL-4, IL-13 and the secretion of histamine from basophils.

Engraftment of HLA-matched sibling hematopoietic stem cells after immunosuppressive conditioning regimen in patients with hematologic neoplasias

BACKGROUND AND OBJECTIVE

The main objective of this pilot study was to assess the possibility of achieving engraftment of HLA-matched sibling donor mobilized hematopoietic stem cells after immunosuppressive non-myeloablative therapy. The second objective was to verify whether high-dose therapy with autologous stem cells rescue followed by allografting conditioned by only an immunosuppressive regimen, can be combined in order to achieve the reduction of tumor burden after autografting and the control of residual disease with immune-mediated effects after allografting.

DESIGN AND METHODS

To enter the pilot study the patients had to fulfil the following criteria: advanced resistant disease, presence of an HLA matched sibling donor, no general contraindications to stem cell transplantation. Our data refers to 9 patients: Hodgkin's disease (n = 4), non-Hodgkin's lymphoma (n = 2), advanced chronic myelogenous leukemia (n = 2) (one patient with accelerated phase Ph-negative but p190 BCR-ABL gene positive by RT-PCR and one with Ph-positive blastic phase), refractory anemia with excess of blasts t(1;3) (p36;q21) (n = 1). All patients but one received the combined approach. At a median of 40 days (range 30-96), after high-dose therapy and autologous stem cell engraftment, the patients were treated with immunosuppressive therapy consisting of fludarabine and cyclophosphamide (Flu-Cy protocol) and then HLA matched donor mobilized stem cells were infused into the patients. GvHD prophylaxis consisted of cyclosporin and methotrexate.

RESULTS

To date, with a median observation period of 4 months (range, 2-10), complete chimerism (100% donor cells) has been achieved in 6 patients. Three patients did not achieve complete chimerism: one patient died of progressive Hodgkin's disease when he reached 55% of donor cells, another patient is now in increasing phase of donor cell engraftment and the last patient (blastic phase-CML) was the only case who appears to have had autologous recovery. Two of the Hodgkin's disease patients, who were in partial remission after autografting, achieved complete remission after allografting and both are disease free 2 and 6 months after. Another Hodgkin's disease patient is alive at 10 months but she has progressive disease. One of the two patients with non-Hodgkin's lymphoma, who achieved partial remission after autografting, obtained complete remission and he is disease free 2 months after allografting. The other patient maintains partial remission obtained after autografting. The accelerated phase-CML patient obtained hematologic and molecular remission; the RAEB patient achieved hematologic and cytogenetic remission. In two patients severe aGVHD (grade II-III) was the single major complication but neither patient died of it. Mild aGVHD was seen in another patient. In only one patient did the ANC decrease to below 1 x 10(9)/L and in no case did platelets decrease below 20 x 10(9)/L. No patients required a sterile room or any red cell or platelet transfusions.

INTERPRETATION AND CONCLUSIONS

Immunosuppressive therapy with a Flu-Cy protocol allowed engraftment of HLA-matched sibling donor stem cells without procedure-related deaths; moreover, we have demonstrated that this combined procedure can be pursued in safety in a serious ill population and some of these patients achieved a complete remission. This procedure is not likely to be curative, but a fascinating step along the path to curing these diseases. Of course, the follow-up is too short to document the incidence of cGvHD.

Multicomponent Collection (Mcc): An Overview

Collection of multiple products, including single and double units of platelets (SDP, DPP), plasma and RBC is progressively improving donor utilization and is leading to more cost-effective apheresis. Cell separators such as the Fresenius AS 204, the Dideco Excel version 97 and the Baxter Amicus are newcomers to the family of the last generation apparatuses used for MCC such as the AS 104, the Vivacell and the MCS 3p. The Cobe Spectra is for the moment the only apparatus unable to collect packed RBC along with platelets but Cobe too is moving in the direction of MCC. The next step is triple product apheresis.

Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: role of psychological and behavioral factors

The present study compared the adaptation of cancer pain patients and chronic non-cancer pain patients. Differences between samples of cancer pain patients with and without metastatic disease were also examined. Cancer pain patients reported comparable levels of pain severity to non-cancer chronic pain patients; however, pain due to cancer was associated with higher levels of perceived disability (t(250) = 2.97, P < 0.004) and lower degree of activity (t(286) = 2.45, P < 0.04). The patients with cancer pain, particularly those with metastatic disease, reported significantly higher levels of support and solicitous behaviors from significant others, compared to non-cancer chronic pain patients. The majority of the cancer patients, both with (81%) and without (84%) metastatic disease as well as non-cancer chronic pain patients (85%), could be classified into one of three psychosocial subgroups that had been previously identified with non-cancer chronic pain patients: 'dysfunctional' (high levels of pain, perceived interference, affective distress and low levels of perceived control and activity), 'interpersonally distressed' (high levels of affective distress, negative responses from significant others and low levels of perceived support) and 'adaptive copers' (low levels of interference and affective distress, high levels of perceived control and activity). The distribution of the profiles was significantly different across groups (chi2(4) = 12.79, P < 0.02). However, within each profile. the response patterns were highly comparable across groups. Thus, contrary to the suggestions of some authors, cancer pain and non-cancer chronic pain patients share many features in common. Furthermore, the heterogeneity of psychosocial adaptation to pain within each patient group suggests the importance of psychological assessment in determining the pain management plan.

Molecular and cellular biology of mast cells and basophils

In all mammalian species investigated so far, mast cells and basophils are the only cells that synthesize histamine and express plasma membrane receptors that bind IgE with high affinity (Fc epsilonRI). Human basophils and mast cells derive from distinct precursors that originate in the bone marrow and fetal liver and probably circulate in peripheral blood. There is extensive evidence that mast cells and basophils and their mediators are primary effectors of allergic inflammation. Immunologically activated human basophils release two cytokines: IL-4 and IL-13. Expression of several cytokines has been documented in a number of experimental models of human and rodent mast cells. However, to date few studies have analyzed the mechanisms of gene expression in human Fc epsilonRI+ cells. Some of these studies imply a role for NFAT and GATA family members in the IgE-mediated activation of cytokine gene transcription in basophils and mast cells. Studies of human basophils and mast cells isolated from different anatomic sites have established the different profiles of eicosanoids released by these cells. Recently, the characterization of arachidonic acid pools and the identification of novel enzymes involved in arachidonate remodeling and mobilization clarified in part how eicosanoid productions is regulated in mast cells and basophils. In addition to histamine, human mast cell secretory granules contain the neutral proteases tryptase, chymase and carboxypeptidase that possess several biochemical properties. In particular, tryptase may play a role as a fibrogenic factor and chymase might convert angiotensin I to angiotensin II. Mast cells are present in human heart and in human coronary arteries raising the possibility that local activation of cardiac mast cells might contribute to certain cardiovascular diseases. Recent evidence also suggests that mast cells and basophils can play a role during viral and bacterial infections. It is now evident that in man these two cells not only participate in inflammation associated with allergic disease, but also in chronic and fibrotic disorders affecting several organs and in host defense against bacterial and viral infections.

Erythrothrombocytapheresis and plasmathrombocytapheresis with storage in T-sol of platelets collected by the new Amicus cell separator

The Amicus cell separator is the latest apparatus introduced into the international market for high-yield, low WBC contamination and short-procedure time thrombocytapheresis. In its original configuration the apparatus collects platelets for subsequent resuspension in plasma and no collection of PRBC can be carried out along with thrombocytapheresis. In this paper we present the results of plasma-thrombocytapheresis and erythro-thrombocytapheresis after the adaptation of the Amicus to the collection and storage of platelets in a non-plasma medium and the concurrent collection of PRBC. From our study it is concluded that PRBC collection doesn't modify the quality of the platelet product obtained from random donors (platelets pre-count 263x10e3/microliter) in terms of yield which is 4.6x10e11 platelets, WBC contamination (1.3x10e5) or procedure time (63 +/- 26 min.). The quality of the platelet products is satisfactory too, as measured by aggregation induced by collagen and ristocetin or by the substantial stability of membrane glycoproteins (CD62-63-51-36-42B). The concentrate had an average content of 58.8 g of hemoglobin per bag, a final volume of 376 +/- 13 ml, (after the addition of 100 ml of SAG-M) and a normal mechanic and osmotic fragility.

Plateletpheresis: what's new?

1995 has brought several novelties into the field of thrombocytapheresis. The most important is the presentation by Baxter of the Amicus CFC apparatus that, in a two-vein collection time of 51-53 min, collects 3.93-4.13 x 10(11) platelets contaminated by 0.2 x 10(6) white blood cells (WBC) with an efficiency of 72-74%. Similar results are obtained in 55 min, in single-needle procedures, with a collection efficiency of 70.7%, a total yield of 4.3 x 10(11) and a contamination of 0.9 x 10(6) WBC. Presently the machine cannot collect red blood cells (RBC), along with platelets, as does the DFC Haemonetics MCS3p. With this machine in mandatory single-needle procedures lasting 80-85 min, approximately 4.5 x 10(11) platelets can be collected with a WBC contamination of 3.1 x 10(6). Along with the platelet cells (PC), with the SDP PRC protocol at the end of each pass it is possible to collect aliquots of plasma red blood cells (PRBC) (10-50 mL) with a haematocrit of 65%. Depending on the number of passes and on the donor's body weight (BW), from 1 and 2 U/PRBC containing approximately 55 g of haemoglobin (Hb) each can be obtained. This method not only costs less but also immunological and viral risks for the patients are more efficiently addressed since it is possible to reduce the number of allogeneic exposures in the same transfusion event. PRBC can also be collected with the Fresenius AS104 and the Dideco Excel apparatuses. Dideco is presently using the "Genova" separation chamber, which can collect an average of 4.8 x 10(11) platelets contaminated with 0.5 x 10(6) WBC, in approximately 55 min. The ACD-A-to-blood ratio may be as low as 1/20 since the very last belts and lines are coated with non-thrombogenic substances. Therefore, there is no alteration of the quality of the platelets as evaluated with monoclonal antibodies (MoAbs) anti-CD 62, 63, 36 and 51, no extra haemorrhagic risk for the donors and citrate reactions and microaggregate formation are totally eliminated. In 1995 there has also been some rejuvenation of the older cell separators. The CS3000+ uses the TN6/PLT 30 combination of separation collection chambers. Platelets are collected in only 30 mL of plasma, and non-plasma solutions containing acetate can be used for their resuspension. The Fresenius AS204 is ready for better-quality combined platelet collection, and RBC-PC collection with Cobe Spectra is under evaluation along with the leucocyte reduction system that apparently brings leucocyte contamination down to 0.35 x 10(5). This interest in thrombocytapheresis is also the result of the challenge that thrombopoietin phase I and II trials have promoted.

PBSC collection from G-CSF primed donors

Peripheral blood stems cells (PBSCs) have been used in autologous transplantation as an alternative to bone marrow-derived cells. Recently, PBSCs have been collected from healthy donors after priming with G-CSF and used for allogeneic transplantation. We have a comparatively large experience with PBSC collection in autologous and allogeneic settings. The five cell separators we employ are: the CS3000 plus, AS 104, Excel, Cobe Spectra and MCS 3p. These machines appear to have different efficacies but no studies have been carried out on this topic. In a prospective study we have randomly assigned donors to different cell separators to evaluate their efficiency. Twenty-five donors underwent the procedure and 50 leukaphereses were carried out. Donors were given 5 micrograms kg-1 d-1 of recombinant human G-CSF for 3 days and 10 micrograms kg-1 d-1 for 4 days subcutaneously. Leukaphereses were performed on days 6 and 7 of G-CSF administration. The results of our study show that a total value of CD34+ cells ranging from 48.44 x 10(6) to 270.37 x 10(6) can be collected from donors with a white cell count ranging from 40.50 x 10(3) microL-1 to 51.34 x 10(3) microL-1 and mononuclear cells ranging from 16.42 to 20.37%. The Excel and the MCS 3p seem to differ from the other machines in terms of higher CD34+ cell collection efficiency. The Excel appears to be even more efficient than the MCS 3p, but this may not reflect reality because the Excel processes 12 L of blood while the MCS 3p employs an 8 L procedure. All the machines showed satisfactory results in terms of yield and quality of the harvests.

The Fresenius continuous autotransfusion system (CATS): preliminary studies and application

A new CFC apparatus for intraoperative blood salvage (CATS) has been introduced by Fresenius and submitted to preliminary evaluation at our hemapheresis unit. The volume of shed blood submitted to washing was 1714 +/- 496 with a hematocrit of 19% and the volume of PRBC ready for transfusion 297.9 ml with hematocrit of 64.3%. Elimination of contaminant activated platelets and WBC was 92% and 74% respectively. Elimination of contaminants such as protein, free hemoglobin, LDH and K ions was always over 95%. Regular application of CATS is warrented after our study.

High-dose chemo-radiotherapy followed by autologous Philadelphia chromosome-negative blood progenitor cell transplantation in patients with chronic myelogenous leukemia

Twenty-three patients with chronic myelogenous leukemia in early chronic phase (ECP) and not previously treated with alpha-interferon (IFN-alpha) (10 patients), in ECP but pretreated with IFN-alpha (<12 months) (seven patients) and in late chronic phase (LCP) pretreated with IFN-alpha (>12 months) (six patients) underwent autografting with Philadelphia (Ph) chromosome-negative blood progenitor cells (BPCs) (20 patients), or partially/totally Ph-positive BPCs (three patients), previously mobilized during the early phase of recovery after aplasia induced by intensive chemotherapy. The conditioning regimen consisted of high-dose chemotherapy alone or followed by total body irradiation (TBI). Recombinant G-CSF was given after BPCs infusion on day +8. All patients in ECP not pretreated with IFN-alpha are alive and five of them are Ph-negative in the marrow after autografting. Six of seven patients autografted with Ph-negative BPCs in the group of ECP pretreated with IFN-alpha (<12 months) are alive and two of them are still Ph-negative in the marrow. In the same group, the only patient transplanted with partially Ph-positive BPCs, died of blastic transformation 2 months after reinfusion. Three patients (two patients autografted with Ph-negative BPCs and one patient with Ph-positive BPC) in the group of LCP pretreated with IFN-alpha >12 months are alive but Ph-positive after autografting. The other three patients of the same group died of procedure-related toxicity (two patients) and blastic transformation (one patient). Seventeen patients (10/10 ECP not pretreated with IFN-alpha; 5/7 ECP pretreated with IFN-alpha and 2/6 LCP pretreated with IFN-alpha) of 23 autografted patients were treated with IFN-alpha +/- IL-2. Toxicities after autografting were mostly related to myelosuppression, particularly thrombocytopenia. All patients of the two groups pretreated with IFN-alpha developed febrile episodes during the aplastic phase following BPCs reinfusion. No patient autografted in ECP and those not pretreated with IFN-alpha developed febrile episodes. This is also probably due to the use of i.v. antibiotic and antimicotic prophylaxis when neutrophils were < or = 1 x 10(9)/l after autografting. Greater toxicity was observed in patients pretreated with IFN-alpha, being lethal in two cases in LCF. In conclusion, the "in vivo' manipulation approach employed in our institution is a safe procedure and it results in a high collection of Ph-negative cells in the blood if the cells are harvested: (1) in early chronic phase; (2) in early phase of recovery after chemotherapy-inducing aplasia; (3) in patients not extensively pretreated with IFN-alpha. The data presented here have shown encouraging trends in chronic phase of CML and offer new perspective for patients without an HLA-identical donor or for patients who do not respond to IFN-alpha.

Intraoperative blood salvage (IOBS) in cardiac and vascular surgery

The extensive application of IOBS has permitted a great reduction in the use of homoglous transfusion which presently represents the largest field of application of autologous systems. In cardiac and vascular surgery, IOBS is particularly useful to the goal of preventing the transmission of viral disorders and other adverse effects related to homologous transfusions. The apparatuses for IOBS may also be used to perform hemodilution and sequestration of a desired amount of platelet rich plasma. The appropriate usage of drugs in perioperative period and the promotion of hemostasis with IOBS are important costituents for the correct transfusional management of the patient. The feasibility and safety of IOBS is known and in expert hands it is an optimal method for the transfusional treatment of surgical patients.

Intraoperative blood salvage: a new artificial organ?

Optimal blood supply is critical to modern medical practice. Among the different possibilities of improving the quality and safety of blood, it is generally felt that autologous donation has played an important role and has contributed to changing transfusional practices, mainly since the appearance of HIV and HCV on the blood transfusion scene. At the San Martino Hospital Immunohematology Service, the autotransfusion era began in 1985. Autologous predeposit donation was the first to be introduced, followed by intentional perioperative hemodilution, intraoperative blood salvage with DFC apparatuses and lastly post-operative blood salvage. From about 200 autologous donations in 1985 we reached 5,372 in 1993 and more than 6,000 autologous donations are expected for 1994. Only 189 intraoperative blood salvages, were carried out in 1986, 593 in 1989, 1,207 in 1993 and more than 1,500 blood salvage sessions are anticipated for 1994. In the meantime, the total number of homologous RBC units employed in the Hospital dropped from 45,000 in 1985 to 18,000 in 1994, with the Onco-hematological Divisions using approximately 10,000 units of packed RBC.

Preparation and storage in Plasma-Lyte A of platelets collected with the cell separator CS3000 Plus equipped with the PLT30-separation and TNX6 collection chambers

The last five years have been characterized by the presentation of new cell separators the main task of which is the collection of high yield-high quality platelets. The CS3000 is an old apparatus which has undergone rejuvenation to sustain the assault of its new competitors. The CS3000 Plus Omnix system is the latest version to be offered along with a combination of TNX-6 separation/PLT30 collection chambers for optimal platelet collection. In this paper we present our results with this apparatus and configuration after its adaptation to the collection and storage of platelets in a non-plasma medium, the Baxter Plasma-Lyte A. After separation the platelet product (PC) was left in the collection chamber and resuspended with 200 ml of Plasma-Lyte A instead of being resuspended in autologous plasma as usual. Plasma was collected in a separate bag (400-450 ml) for transfusion or fractionation purposes. PC quality was assessed by evaluating the platelet yield (4.17 +/- 1.8 x 10(11), and the WBC contamination (4.8 +/- 2.6 x 10(5)). The presence of platelet aggregates (platelet count after aggregate fixation with formalin/platelet count after disaggregation in EDTA), the aggregation induced by ADP, collagen and ristocetin, the hypotonic shock response and the stability of membrane glycoproteins (CD 62 - 62 - 63 - 36- 42b - 51) were measured in the preapheresis samples and in the PC immediately after, 24 and 72 hours after collection. These results were totally satisfactory as was the post-transfusion survival measured as corrected count increment in 10 transfusions to non refractory patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased intestinal sugar permeability after challenge in children with cow's milk allergy or intolerance

The diagnosis of cow's milk allergy or intolerance (CMAI) is based on clinical improvement on exclusion diet and relapse after challenge with milk. The aim of this work was to investigate the value of the cellobiose/mannitol (C/M) sugar permeability test, performed before and after cow's milk challenge, as a tool for the diagnosis of CMAI. Thirty-two patients underwent milk challenge at a median age of 13 months (range 3-84 months). A dual sugar (C/M) permeability test with an iso-osmolar solution was performed before and 24 h after challenge. Of the 10 patients who developed symptoms after challenge, nine showed increased postchallenge C/M ratio, whereas such an increase was observed in only one of the 22 nonrelapsed subjects. The postchallenge C/M ratio increase in relapsed subjects is to be attributed to both higher cellobiose and lower mannitol urinary excretion. These results suggest the use of the sugar permeability test, in addition to clinical observation, as an aid in the evaluation of provocation tests in infants with suspected CMAI.

Single-donor platelet concentrates produced along with packed red blood cells with the Haemonetics MCS 3p: preliminary results

There has been an increasing interest in recent years over the qualitative superiority of single-donor platelets in the management of hemato-oncologic patients. The reasonable desire of both patients and physicians to limit the risks of transfusion along with the need for limiting the costs involved in this kind of therapy have led to application of multicomponent donations both in terms of double platelet concentrates and double products such as red blood cells (RBC) and platelets from the same donor. Single donor platelets and RBC have been collected in a semi-automated mode and only the very recent introduction of the Haemonetics MCS 3p with its SDP/RBC protocol provides a totally closed-system automated protocol for this combined collection. Twenty procedures have been carried out so far at our unit. In a mean of 87 minutes (6-7 passes), a mean of 3.1 x 10(11) platelets were collected along with approximately 220 mL of packed RBC. The leukocyte contamination of the platelet product was in the range of 0.4-1.1 x 10(7) (99% lymphocytes), and the quality of platelets was very satisfactory as measured by the hypotonic shock response, aggregation induced by ADP, collagen and ristocetin, morphology score, and membrane glycoproteins modifications. Equally satisfactory was the quality of the RBC concentrate, suspended in 80 mL of SAG-M, with a total hemoglobin (Hb) content approaching 55 g as compared to the normal Hb content of a standard RBC concentrate that is approximately 62 g.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma exchange: the cost/benefit ratio and the critical revision of indications

The number of conditions that can benefit from Plasma-Exchange (PE) continues to grow. We have recently added to the list the Cyclosporin-A induced hypertrygliceridemia and myoglobinuric acute renal insufficiency. Such as any therapeutic measure for PE, four evolutive phases can be recognized: the discovery and research, the confirmation of indications, the routine applications and the decline, when new more powerful tools are offered by culture or technology. We have participated in the first three phases during the last 20 years. Not necessarily all experiences were favourable. Nonetheless, we feel that, for the time being, a hemapheresis unit is an absolute necessity for a medium - sized hospital even if only therapeutic procedures are carried out. The phase four, decline of interest and applications, cannot be foreseen. Finally the ability of PE to shorten substantially the length of hospital stays along with the ease with which procedure can be performed on ambulatory patients, substantiate a favourable cost/benefit ratio for this therapeutic modality.

Donors thrombocytapheresis with last generation cell separators

An exciting, fast moving and promising field remains the use of plasma-free synthetic medium for platelet storage (10, 11), that along with the potential for getting more plasma for therapeutic needs, might also improve the quality of stored platelets. Addition of acetate to solution, may be the way to obtain these results. An astonishing fact is that citrate remains the only anticoagulant for platelet collection, and remains as well the only real cause of donor discomfort during thrombocytapheresis.

The organization of the autotransfusion-perioperative blood salvage at San Martino Hospital

Autologous transfusion is playing an important role in modern transfusion medicine. At San Martino hospital we use a combination of manual and mechanical techniques in order to improve autotransfusion procedures, control the hypertransfusion and avoid waste. Our autotransfusion program has determined a 55% reduction in the red cell concentrates used (from 42,000 in 1985 down to 19,400 in 1992). Proper training, cultural improvements and new applications on autotransfusion procedures will permit a better use of blood with less transfusion related complications, until a suitable substitute for blood will be available.

The Organization of the Autotransfusion-perioperative Blood Salvage at San Martino Hospital

Autologous transfusion is playing an important role in modern transfusion medicine. At San Martino hospital we use a combination of manual and mechanical techniques in order to improve autotransfusion procedures, control the hypertransfusion and avoid waste.

Our autotransfusion program has determined a 55% reduction in the red cell concentrates used (from 42,000 in 1985 down to 19,400 in 1992). Proper training, cultural improvements and new applications on autotransfusion procedures will permit a better use of blood with less transfusion related complications, until a suitable substitute for blood will be available.