Stereoselectivity in metabolism of ifosfamide by CYP3A4 and CYP2B6

The aim was to identify the hepatic cytochromes P450 (CYPs) responsible for the enantioselective metabolism of ifosfamide (IFA). The 4-hydroxylation, N2- and N3-dechloroethylation of IFA enantiomers were monitored simultaneously in the same metabolic systems using GC/MS and pseudoracemate techniques. In human and rat liver microsomes, (R)-IFA was preferentially metabolized via 4-hydroxylation, whereas its antipode was biotransformed in favour of N-dechloroethylation. CYP3A4 was the major enzyme responsible for metabolism of IFA enantiomers in human liver. The study also revealed that CYP3A (human CYP3A4/5 and rat CYP3A1/2) and CYP2B (human CYP2B6 and rat CYP2B1/2) enantioselectively mediated the 4-hydroxylation, N2- and N3-dechloroethylation of IFA. CYP3A preferentially supported the formation of (R)-4-hydroxyIFA (HOIF), (R)-N2-dechloroethylIFA (N2D) and (R)-N3-dechloroethylIFA (N3D), whereas CYP2B preferentially mediated the generation of (S)-HOIF, (S)-N2D and (S)-N3D. The enantioselective metabolism of IFA by CYP3A4 and CYP2B1 was confirmed in cDNA transfected V79 cells.

Enantiomer–enantiomer interaction of ifosfamide in the rat

The objective of this study was to study the enantiomer-enantiomer interaction of ifosfamide (IFA) in a rat model. Following intravenous administration of individual IFA enantiomers or pseudo-racemates to male Sprague-Dawley rats, two enantiomers and their metabolites, 4-hydroxyIF (HOIF), N2-dechloroethylIF (N2D), N3-dechloroethylIF (N3D), and isophosphoramide (IPM), were quantified using gas chromatography/mass spectrometry (GC/MS) and isotope dilution techniques. In addition, the mutual inhibition in the metabolism between two stereoisomers was also investigated in vitro using rat liver microsomes. Pharmacokinetic parameters were similar between (R)-IFA and (S)-IFA when individual enantiomers were intravenously administered to rats separately. However, in the rats administered with the IFA racemate, half-life, mean residence time (MRT), and area under the concentration-time curve (AUC) values of (S)-IFA were significantly increased with total body clearance (CLT) being decreased. No significant difference in volumes of distribution (Vss), and renal clearance (CLr) and blood cell partition was observed between two enantiomers regardless of (R)-IFA and (S)-IFA being administered separately or in combination as a racemate. The results from the in vitro metabolism and inhibition experiment suggested that each IFA enantiomer inhibited the metabolism of its antipode in a competitive manner. It is concluded that the enantiomeric interaction of IFA mainly occurred in the process of metabolism with (S)-IFA being affected to a larger extent.

Natural history of pelvic lymphocysts as observed by ultrasonography after bilateral pelvic lymphadenectomy

OBJECTIVES

To determine, in patients who have undergone bilateral pelvic lymphadenectomy for gynecological cancer, the incidence of lymphocyst formation, their change in size with time, risk factors and correlation with symptoms.

METHODS

This was a prospective observational study of 108 patients undergoing bilateral pelvic lymphadenectomy for gynecological cancer in our unit. We performed serial three-dimensional (3D) ultrasound assessment at 2 and 6 weeks and 3, 6, 9 and 12 months after surgery. Before each ultrasound assessment, symptoms were recorded and a physical examination was performed.

RESULTS

Forty-eight (44.4%) patients had unilateral or bilateral lymphocysts detected during the follow-up period; 26 were on the left side, 16 were on the right side and six were bilateral. In 39 (81.2%) of the patients, the lymphocysts were first noted 2 weeks after the operation. In nine (18.8%) the lymphocysts persisted until 12 months after surgery. There was no association between lymphocyst formation and diagnosis, type of operation performed, surgeon, operative blood loss, adjuvant radiotherapy and number of lymph nodes removed. Four lymphocysts were detected by physical examination before the ultrasound diagnosis. There was no association between lymphocyst and symptoms, including pain over the abdomen, pelvis, thigh, legs or back, lymphedema, fever or symptoms of cystitis. Only one patient developed an infection of the lymphocyst, which required surgical intervention.

CONCLUSION

Lymphocyst formation is common following bilateral pelvic lymphadenectomy. Most patients with lymphocysts are asymptomatic and the development of major complications is rare.

An eight-year-old girl with probable Lyme disease in Hong Kong

An eight-year-old girl presented with acute cerebellar syndrome and meningitis. Lumbar puncture showed elevated pressure. Examination of the cerebrospinal fluid showed lymphocytosis, raised protein and decreased glucose. She was initially treated with acyclovir and antituberculosis drugs with partial response. Subsequently, the antibody assay for Borrelia burgdorferi was positive and the antimicrobial regime was changed to ceftriaxone. She made a full recovery with no neurological deficit. A probable diagnosis of Lyme disease was made and the diagnostic approach to Lyme disease is discussed.

Selective cytotoxic activity against leukemic cell lines from mosquitocidal Bacillus thuringiensis parasporal inclusions

The discovery of parasporin has triggered an interest in examining various Bacillus thuringiensis (Bt) isolates for specific anti-cancer activity. The aim of this study was to determine the potency and specificity of parasporal inclusions from Malaysian mosquitocidal Bt isolates against a leukemic cell line (CEM-SS). The Bt isolates used in this study were identified as having weak to potent larvicidal activity against Aedes aegypti and varying hemolytic activity. The 12 mosquitocidal Bt isolates examined in this study showed low to moderate cytotoxicity when tested against CEM-SS and HeLa. Interestingly the parasporal inclusions of Bt 18 (non-hemolytic isolate), showed therapeutic potential demonstrating specificity for CEM-SS compared to HeLa, whilst being non-cytotoxic to normal T lymphocytes. The mode of cell death by Bt 18 was shown to be initially apoptotic. SDS-PAGE analysis and N-terminal sequencing of the upper and lower bands of Bt 18 showed similarity between Bt 18 parasporal inclusions with Cry 24Aa and 25Aa of Bacillus thuringiensis subsp jegathesan and Cry 15Aa of Bacillus thuringiensis subsp israelensis. Although the BLAST analysis did not show sequence similarity between Bt 18 and Parasporin, we propose that the Bt 18 parasporal inclusions share similar characteristics to Parasporin since Bt 18 is not hemolytic but discriminately cytotoxic towards leukemic cell lines.

Work rehabilitation for migrant workers with work injury--the magic of Chinese paper cutting

As China has gradually transformed from agricultural economy into industrial economy since 1978, occupational injuries and diseases become a serious social problem in China. For occupational rehabilitation professionals, helping workers with occupational injuries and diseases, return to work and re-integrate to community are the ultimate goals of occupational rehabilitation. This article reports a new indigenous initiative with cultural notions in occupational rehabilitation piloted by Guangdong Provincial Rehabilitation Center. Case studies reflected that by learning and practicing traditional Chinese paper cutting, workers with occupational injury and disease could regain their self confidence, identity their strengths, learn more vocational skills as well as to re-integrate into community.

Polymorphisms of glutathione S-transferase genes and functional activity in smokers with or without COPD

OBJECTIVE

To determine the role of polymorphisms of genes regulating glutathione S-transferase (GST) and its plasma GST activity in the pathogenesis of chronic obstructive pulmonary disease (COPD).

DESIGN

Case-control study.

METHODS

One hundred and sixty-three patients with stable COPD from several community or regional hospitals were matched for age and pack-years smoked with the same number of health controls from the general population. Each participant underwent an interview-based respiratory and smoking questionnaire, lung function testing and gave a blood sample. Genotyping was carried out using a polymerase chain reaction-based method for polymorphisms of glutathione S-transferase theta 1 (GSTT1), glutathione S-transferase mu 1 (GSTM1) and glutathione S-transferase P 1 (GSTP1) genes. Plasma GST activity was measured using the spectrofluorometric method.

RESULTS

There were no significant differences in the distribution of various genotypes of polymorphisms of GSTT1, GSTM1 and GSTP1 between COPD patients and healthy controls. GST activity was significantly higher in patients compared with controls, irrespective of their different genotypes, and was not different between patients with different levels of airflow obstruction.

CONCLUSION

Polymorphisms of GSTT1, GSTM1 and GSTP1 genes are unlikely to be involved in the pathogenesis of COPD in Chinese in Hong Kong and Southern China.

Testing for ovarian cancer

Ovarian cancer is responsible for more deaths per annum than cervical and endometrial cancer combined. Patients are often diagnosed at a late stage because of the non-specific symptoms of this disease. It can be difficult to differentiate between benign and malignant ovarian pathology, and a malignancy risk index has been developed to guide clinicians. The accuracy of CA125 and ultrasound scans as screening tests is being assessed in randomised controlled trials and proteomic technology shows promise for the early detection of cancers. At present, without accurate screening and early diagnostic techniques, high-risk patients often chose to have prophylactic surgery.

Suicide in Hong Kong: a case-control psychological autopsy study

BACKGROUND

The relative contribution of psychosocial and clinical risk factors to suicide among Chinese populations is an important issue. In Hong Kong, this issue requires vigorous examination in light of a 50% increase in suicide rate between 1997 and 2003.

METHOD

Using a case-control psychological autopsy method, 150 suicide deceased were compared with 150 living controls matched by age and gender. Semi-structured interviews were conducted with the next-of-kin of the subjects. Data were collected on a wide range of potential risk and protective factors, including demographic, life event, clinical and psychological variables. The relative contribution of these factors towards suicide was examined in a multiple logistic regression model.

RESULTS

Six factors were found to significantly and independently contribute to suicide: unemployment, indebtedness, being single, social support, psychiatric illness, and history of past attempts.

CONCLUSIONS

Both psychosocial and clinical factors are important in suicides in Hong Kong. They seem to have mediated suicide risk independently. In addition, socio-economic adversities seem to have played a relatively important role in the increasing suicide rate in Hong Kong.

A phase I clinical and pharmacokinetic study of fenretinide combined with paclitaxel and cisplatin for refractory solid tumors

BACKGROUND

Fenretinide is a semi-synthetic retinoid that has pro-apoptotic effects as a single agent and synergistically with chemotherapy in vitro. We performed this study to determine the toxicity of cisplatin, paclitaxel and fenretinide in patients with advanced cancer, the recommended phase II dose of these agents together, and the pharmacokinetics (PK) of fenretinide when administered with chemotherapy.

PATIENTS AND METHODS

Fourteen patients (mean age 57.3) were assessable for pharmacokinetics, toxicity and response. Fenretinide was given orally in 2 divided daily doses for 7 days, starting 24 hours prior to cisplatin and paclitaxel. Cisplatin and paclitaxel were given in standard fashion. Cycles were repeated every 3 weeks. Cycle one fenretinide PK was obtained on days 2 and 8.

RESULTS

Dose limiting toxicity (Gr 3 diarrhea and Gr 4 neutropenia) was encountered in two patients during cycle one at 80/175/1,800 mg/m(2) of cisplatin/paclitaxel/fenretinide (dose level 2), respectively. Seven patients received 2-8 cycles at the recommended level of 60/135/1,800 (dose level 1). Severe cumulative toxicities included fatigue, nausea/vomiting, neuropathy, and dehydration. Two patients had a partial response and 4 patients had stable disease for up to 8 cycles. PK analysis demonstrated a reduction in fenretinide Cmax on day 8 compared to day 2, accompanying a decrease in AUC.

CONCLUSIONS

Cisplatin/paclitaxel/fenretinide can be administered safely at 60/135/1,800 mg/m(2) respectively on an every three-week schedule. This combination may have activity in a variety of tumors, however, the number of pills required complicates oral dosing of fenretinide, and limits the applicability of this regimen.

Feasibility of transradial coronary angiography and angioplasty in Chinese patients

OBJECTIVE

To assess the clinical applicability, efficacy, and safety of coronary angiography and angioplasty via a transradial approach in local Chinese patients.

DESIGN

Prospective case series.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All patients undergoing coronary angiography and coronary angioplasty between 1 January and 30 June 2004.

INTERVENTIONS

Transradial coronary angiography and coronary angioplasty.

MAIN OUTCOME MEASURES

Feasibility, success rate, and complications.

RESULTS

A total of 268 coronary angiographies (62% of all coronary angiographies) and 118 coronary angioplasties (48% of all coronary angioplasties) were performed via a transradial approach. The procedural success rate for coronary angiography was 93.7% with a mean duration of 21.8 (standard deviation, 13.5) minutes compared with 17.9 (10.0) minutes for angiography via a femoral approach. Most (99%) patients were free from any complications. Of those patients who underwent elective transradial coronary angiography in the morning, 64% were discharged on the same day. Comparison of data in the first half of the study period with those in the second half revealed a significant increase in the percentage of coronary angiographies performed via a transradial approach (from 52% to 73%, P<0.0001), and an improved procedural success rate (from 91.5% to 95.3%, P=0.1). For transradial coronary angioplasty, the procedural success rate was 98%. A total of 246 lesions (2.08 lesions per patient) were treated with no procedure-related complications.

CONCLUSIONS

Transradial coronary angiography and angioplasty are feasible in a significant proportion of local Chinese patients and achieve a high success rate and low complication rate. It tends to prolong procedural duration, but improves patients' comfort and permits earlier ambulation and discharge. The procedural success rate improves with accumulating experience.

Malaysian mosquitocidal soil bacterium (Bacillus thuringiensis) strains with selective hemolytic and lectin activity against human and rat erythrocytes

The objective of this study is to determine the role of carbohydrates on the toxic effect of parasporal inclusion proteins isolated from Malaysian mosquitocidal Bacillus thuringiensis (Bt) strains on erythrocytes (human and rat). Dose response analyses on the effect of these parasporal inclusions on human and rat erythrocytes suggest that toxin action is selective depending on bacterial strains and source of erythrocytes. Results from this study suggest Bt toxin is a lectin which recognizes specific plasma membrane glycoconjugate receptor(s) with a terminal residue of either D-mannose (Man), N-acetyl-D-galactosamine (GalNAc), N-acetyl-D-glucosamine (GlcNAc) or even a combination of these monosaccharides.

Anti-proliferative and pro-apoptotic effects of herbal medicine on hepatic stellate cell

Hepatic stellate cells (HSC) play a central role in hepatic fibrosis and compounds that promote apoptosis in HSC may have anti-fibrotic potentials. Herbal medicine has long been used in chronic liver disease but there is little scientific evidence for their actions. The present study investigated the effects of 14 commonly used herbs on cellular proliferation and apoptosis of a rat hepatic stellate cell line, HSC-T6 and the underlying mechanism of herb-induced apoptosis. HSC-T6 cell were incubated with herbal extracts and their proliferation was assessed by colorimetric assay. Apoptosis was measured and confirmed by flow cytometry, terminal transferase uridyl nick end labeling (TUNEL) assay and morphological features in hematoxylin and eosin staining. Apoptotic pathways involving Fas receptor and Bcl-2 family were investigated by Western blot. Five herbs, namely Angelica sinensis (AS), Carthamus tinctorius (CT), Ligusticum chuanxiong (LC), Salvia miltiorrhiza (SM) and Stephania tetrandra (ST) demonstrated both anti-proliferative and pro-apoptotic activities in HSC-T6. The highest potency was detected in SM and ST with 51.63 and 44.52% of HSC-T6 showing apoptotic changes, respectively. This was associated with upregulation of Fas and Bax and down-regulation of Bcl-xL in HSC. Fas ligand and Bcl2 expressions remained unchanged. The potential anti-fibrotic effect of herbal medicine warrants further evaluation.

Pregnancy following recurrent angiosarcoma of the ovary—A case report and review of literature

BACKGROUND

Ovarian angiosarcomas are rare tumors which may to be distinguished from other unusual primary ovarian tumors such as clear cell carcinoma, yolk sac tumor and leiomyosarcoma on the basis of histological appearance and immunohistochemistry. Angiosarcomas of the ovary occur in all age groups but are more frequent in women of child bearing age (less than 40 years). Surgery and radiotherapy have been the traditional treatment modalities.

CASE

The case we present is the only reported long-term survivor of recurrent ovarian angiosarcoma. Her initial treatment was surgical, both at presentation and relapse but since she wished conservation of fertility, radical surgery and radiotherapy were avoided and she underwent further adjuvant chemotherapy with doxorubicin and ifosfamide. She remains in remission 6 years after treatment of recurrence of the primary tumor and has had a successful pregnancy following treatment.

CONCLUSION

Adjuvant chemotherapy of ovarian angiosarcoma with a combination of doxorubicin and ifosfamide appears effective and should be considered in women at risk of relapse who wish to conserve fertility.

Inhibition of cell proliferation in human breast tumor cells by antisense oligonucleotides against facilitative glucose transporter 5

In recent years, successful examples of antisense oligonucleotide (AS) therapy for genetic diseases have stimulated scientists to investigate its application on cancer diseases. AS can be used to down-regulate the mRNA and protein expression by annealing to specific region of the target mRNA which is responsible for the malignancy. Glucose transporter 5 (Glut5) is a tissue specific transporter that can be found on breast cancer tissues but not on normal breast tissues. Therefore, it is of clinical interest to investigate whether AS against Glut5 mRNA can tackle breast cancer. In this study, two cell lines, MCF-7 which is estrogen-receptor positive and MDA-MB-231 which is estrogen-receptor negative, were used to mimic breast cancer tissues at early and late stages, respectively. A 15-base sequence around the start codon of Glut5 was used. It was found that AS against Glut5 exerted anti-proliferative effect on both of these two breast tumor cell lines and seemed to exert its effect via the suppression of expression of Glut5 proteins in the cells. AS against Glut5 exhibited no effect on human hepatoma HepG2 cells which do not possess any Glut5. The results imply an alternative way in treating breast tumor as the AS against Glut5, unlike tamoxifen, takes effect on breast tumor cells via suppressing the expression of Glut5 that they specifically possess, and regardless whether the breast tumors are estrogen dependent or not.

Phe-Gly-Leu-amide allatostatin in the termite Reticulitermes flavipes: content in brain and corpus allatum and effect on juvenile hormone synthesis

In the subterranean termite Reticulitermes flavipes, allatostatins (ASTs) with the C-terminus Phe-Gly Leu-amide were localized by immunocytochemistry with antibody against a cockroach AST, Dippu AST-7. AST-immunoreactivity occurred in the corpus cardiacum and corpus allatum and in the lateral and medial neurosecretory cells of the brain that innervate these organs as well as in many other nerve cells of the brain. This was observed in workers, nymphs, soldiers and secondary reproductives. A radioimmunoassay, using anti-Dippu AST-11, demonstrated about 40 fmole equivalents of AST in brains of soldiers and secondary reproductives. The product of the corpora allata in this species was determined to be juvenile hormone III. Its synthesis by corpora allata of secondary reproductives, determined by in vitro radiochemical assay, was inhibited in a dose-dependent fashion by two cockroach allatostatins, Dippu AST-7 and Dippu AST-11. Thus, as in cockroaches and crickets, allatostatin-containing nerves innervate the corpora allata of this termite species and their production of juvenile hormone is inhibited by these neuropeptides.

Correlating gene expression with chemical scaffolds of cytotoxic agents: ellipticines as substrates and inhibitors of MDR1

To facilitate a systematic study of chemoresistance across diverse classes of anticancer drug candidates, we performed correlation analyses between cytotoxic drug potency and gene expression in 60 tumor cell lines (NCI-60; NCI-National Cancer Institute). Ellipticine analogs displayed a range of correlation coefficients (r) with MDR1 (ABCB1, encoding multidrug resistance (MDR) protein MDR1 or P-glycoprotein). To determine MDR1 interactions of five ellipticines with diverse MDR1-r values, we employed MDR1-transport and cytotoxicity assays, using MDR1 inhibitors and siRNA-mediated MDR1 downregulation, in MDR1-overexpressing cells. Ellipticines with negative correlations-indicative of MDR1-mediated resistance-were shown to be MDR1 substrates, whereas those with neutral or positive correlations served as MDR1 inhibitors, which escape MDR1-mediated chemoresistance. Correlation with additional genes in the NCI-60 confirmed topoisomerases as ellipticine targets, but suggested distinct mechanisms of action and chemoresistance among them, providing a guide for selecting optimal drug candidates.

Multidisciplinary team working: is it both holistic and effective?

Multidisciplinary team (MDT) working has been endorsed as the main mechanism to ensure truly holistic care for patients and a seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary, and tertiary care. However the effectiveness of each team needs to be continually evaluated to ensure that all the relevant disciplines are able to participate in the clinical management of patients. This article describes the work of the Cancer Services Collaborative at the Birmingham Women's hospital in the UK in promoting the development of a holistic MDT in parallel with the medical model.

Clinical profile and genetic basis of Brugada syndrome in the Chinese population

OBJECTIVE

To study the clinical profile and genetic basis of Brugada syndrome in Chinese patients.

DESIGN

Prospective observational study.

SETTING

Seven regional public hospitals, Hong Kong.

MAIN OUTCOME MEASURES

The clinical and follow-up data of 50 patients (47 men, 3 women; mean age, 53 years) were collected, and genetic data of 36 probands and eight family members of three genotyped probands were analysed.

RESULTS

Eight patients survived sudden cardiac death (group A), 12 had syncope of unknown origin but no sudden death (group B), and 30 were asymptomatic before recognition of Brugada syndrome (group C). Programmed electrical stimulation induced sustained ventricular arrhythmias in 88% (7/8), 82% (9/11), and 27% (3/11) of patients in group A, group B, and group C, respectively. New arrhythmic events occurred in 50% (4/8) of patients in group A and 17% (2/12) of patients in group B after a mean follow-up period of 30 (standard deviation, 13) months and 25 (7) months, respectively. All group C patients remained asymptomatic during a mean follow-up period of 25 (standard deviation, 11) months. Five of 36 probands and three of eight family members who underwent genetic testing were found to have a mutation in their SCN5A gene.

CONCLUSIONS

Chinese patients with Brugada syndrome who are symptomatic have a high likelihood of arrhythmia recurrence, whereas asymptomatic patients enjoy a good short-term prognosis. The prevalence of SCN5A mutation among probands is 14%. Thus, Chinese patients with Brugada syndrome share with their western counterparts similar clinical and genetic heterogeneity.

Allatostatin in ovaries, oviducts, and young embryos in the cockroach Diploptera punctata

The quantity and localization of -Phe-Gly-Leu-amide allatostatins (-F-G-L-amide AST) was determined by ELISA and immunohistochemistry in ovaries and oviducts and in pre-dorsal closure embryos. AST in the cytoplasm of basal oocytes gradually increased from 4 to 35 fmol/ovary pair from the start (day 2) to the completion of vitellogenesis (day 6), then rapidly increased to 121 fmol/ovary pair during choriogenesis. In oviducts, AST-immunoreactivity was found in nerves to the muscle layer and in epithelial cells. AST-immunoreactivity in oviduct epithelial cells increased during vitellogenesis. A marked increase in quantity of AST in oviduct tissue between completion of chorion formation and immediately after ovulation appears to result from AST released from oocytes as they travel down the oviducts because AST content of newly ovulated eggs was 40% lower than late stage chorionated oocytes, and these oocytes released AST when incubated in saline. AST in embryos, localized in yolk cells, decreased as embryos approached dorsal closure. That this material in ovaries and embryos is AST was confirmed by its ability to inhibit JH synthesis in vitro and identification by MALDI-TOF mass spectrometry of a peptide with a mass corresponding to that of a Diploptera punctata AST. These findings indicate likely novel functions for ASTs: facilitation of ovulation and utilization of yolk.

Isolated ventricular non-compaction presenting with ventricular tachycardia

Isolated ventricular non-compaction is a rare congenital cardiomyopathy, manifested morphologically as prominent myocardial trabeculations and deep inter-trabecular recesses that communicate with the ventricular cavity. Heart failure is the most common presenting condition. Other manifestations include arrhythmia and cardioembolic events. This report is illustrative of isolated ventricular non-compaction in a 78-year-old woman. The diagnosis was made when she presented with ventricular tachycardia many years after a stroke. She subsequently underwent implantation of a cardioverter-defibrillator. This report documents an uncommon presentation of this disease entity in the oldest patient at presentation as yet reported in the literature.

Depsipeptide (FR 901228) promotes histone acetylation, gene transcription, apoptosis and its activity is enhanced by DNA methyltransferase inhibitors in AML1/ETO-positive leukemic cells

In t(8;21) acute myeloid leukemia (AML), the AML1/ETO fusion protein promotes leukemogenesis by recruiting histone deacetylase (HDAC) and silencing AML1target genes important for hematopoietic differentiation. We hypothesized that depsipeptide (FR901228), a novel HDAC inhibitor evaluated in ongoing clinical trials, restores gene transcription and cell differentiation in AML1/ETO-positive cells. A dose-dependent increase in H3 and H4 histone acetylation was noted in depsipeptide-treated AML1/ETO-positive Kasumi-1 cells and blasts from a patient with t(8;21) AML. Consistent with this biological effect, we also showed a dose-dependent increase in cytotoxicity, expression of IL-3, here used as read-out for silenced AML1-target genes, upregulation of CD11b with other morphologic changes suggestive of partial cell differentiation in Kasumi-1 cells. Some of these biologic effects were also attained in other myeloid leukemia cell lines, suggesting that depsipeptide has differentiation and cytotoxic activity in AML cells, regardless of the underlying genomic abnormality. Notably, the activity of depsipeptide was enhanced by 5-aza-2'-deoxycytidine, a DNA methyltransferase inhibitor (DNMT). These two agents in combination resulted in enhanced histone acetylation, IL-3 expression, and cytotoxicity, suggesting HDAC and DNMT activities as a potential dual target in future therapeutic strategies for AML1/ETO and other molecular subgroups of AML.

Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients

Paradoxical deterioration during antituberculosis therapy, defined as the clinical or radiological worsening of pre-existing tuberculous lesions or the development of new lesions in a patient who initially improves, remains a diagnostic dilemma. Although different clinical presentations of paradoxical response have been described, a systematic analysis of the entity in non-HIV-infected patients is lacking. Reported here are two cases of paradoxical deterioration in which sequential changes in lymphocyte counts and tuberculin skin test results are emphasized. In addition, 120 episodes of paradoxical response after antituberculosis treatment were reviewed. Of the total 122 episodes, 101 (82.8%) were associated with extrapulmonary tuberculosis. The median time from commencement of treatment to paradoxical deterioration was 60 days. The median time to onset of central nervous system manifestations (63 days) was longer than the time to onset of manifestations at other sites (56 days) ( P=0.02). Development of new lesions in anatomical sites other than those observed at initial presentation was observed in 31 (25.4%) episodes. A surge in the lymphocyte count, accompanied by an exaggerated tuberculin skin reaction, was observed in our patients during the paradoxical deterioration, analogous to the findings in HIV-positive patients. Treatment of the paradoxical response included surgical intervention (60.7%) and administration of steroids (39.3%). The use of steroids appeared to be safe in this series, as 95% of the Mycobacterium tuberculosis isolates were susceptible to first-line antituberculosis therapy.