Revisiting the Syndrome of "Obsessional Slowness"

Background

Obsessional slowness (OS) denotes a rare condition of disablingly slow motor performance. It was originally described in patients with obsessive-compulsive disorder as a "primary" condition; however, subsequent reports have included heterogeneous clinical populations. We wished to reassess patients with this diagnosis at our own institution and also revisit the literature to provide an overview of this condition.

Methods

Clinical documentation and videos of 3 patients diagnosed with OS in the National Hospital for Neurology and Neurosurgery (London, UK) were reviewed. One of the patients was clinically reappraised. A systematic review of published articles with sufficient clinical patient information was also conducted.

Results

Our 3 cases were male with symptom onset in adolescence or early adulthood. Motor slowness with poverty of movement and a history of obsessive-compulsive symptoms were characteristic. Poor speech production, bizarre postures, mannerisms, echophenomena, and oculogyric tics were also noted. Dopaminergic imaging was normal in 2 cases. One case had autistic features. Systematic literature review identified 77 further cases. Male preponderance with symptom onset mainly during the second decade and presence of obsessive-compulsive symptoms were noted. Additional motor and neuropsychiatric features were often present.

Conclusion

The existence of OS as a "primary" condition is doubtful. This diagnosis has been given to characterize different clinical presentations ranging from obsessive-compulsive disorder with motor slowness resulting from covert obsessive-compulsive symptoms to catatonia. Clinicians should be aware of this syndrome to separate it from juvenile parkinsonism and other causes of motor slowness given that diagnostic approaches and treatment strategies differ.

Enhanced International Prognostic Index (NCCN-IPI), Charlson Comorbidity Index and absolute lymphocyte count as predictors for survival of elderly patients with diffuse large B cell lymphoma treated by immunochemotherapy

Diffuse large B cell lymphoma (DLBCL) affects more commonly patients over 60 years. These patients have vast number of comorbidities which can modify survival as well as other clinical parameters. The aim of this study was to evaluate prognostic significance of the National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI), absolute lymphocyte count (ALC), absolute monocyte count (AMC), lymphocyte-to-monocyte ratio (LMR) and comorbidities expressed with Charlson Comorbidity Index (CCI). A total of 182 DLBCL patients 60 years old and older were included, focusing on whole group and patients older than 70. All patients were treated with immunochemotherapy.Overall treatment response was achieved in 84.6% of patients. The NCCN-IPI was of highly prognostic value in the analyzed group (p<0.0001). Survival analysis showed that ALC>1.1x109/L, AMC≤0.59x109/L, and LMR>2.8 were associated with more favorable outcome (p=0.029, p=0.019, p=0.028, respectively). The patients with CCI≥2 had poorer outcome (p=0.008) compared to the patients with CCI 0-1. Multivariate analysis showed that among ALC, AMC, LMR, NCCN-IPI and CCI, the NCCN-IPI was the critical parameter that significantly affected survival (p<0.0001). Furthermore, comorbidities were also valuable independent factors which influenced survival (p=0.031) as well as the ALC (p=0.024). In elderly DLBCL patients, NCCN-IPI and ALC proved their prognostic validity, while poorer outcome could be expected in older patients with high CCI (≥2). Furthermore, mentioned prognostic parameters retained their prognostic value in the group of patients older than 70.

Stiff Limb Syndrome Mimicking Corticobasal Syndrome

Stiff limb syndrome (SLS) is a focal variant of the spectrum of stiff person syndrome. Its presentation with stiffness, limb posturing, and freezing-of-gait (FOG)-like episodes, together with the relative rareness of the disorder, make it conceivable that SLS might be misdiagnosed as atypical parkinsonism, in particular, corticobasal syndrome (CBS). To illustrate this, we present two cases of established SLS resembling CBS and discuss the distinguishing features that may alert the clinician to the correct diagnosis, with its obvious therapeutic and prognostic implications.

Glycine receptor antibodies in PERM and related syndromes: characteristics, clinical features and outcomes

See Martinez-Martinez et al. (doi:10.1093/brain/awu153) for a scientific commentary on this article.

Carvajal-González et al. describe the first prospective cohort of patients with glycine receptor antibodies. The majority have progressive encephalomyelitis with rigidity and myoclonus. The antibodies bind to extracellular determinants on glycine receptor-α1 and to glycine receptors on spinal cord and brainstem neurons. The patients make a good recovery with immunotherapies.

The clinical associations of glycine receptor antibodies have not yet been described fully. We identified prospectively 52 antibody-positive patients and collated their clinical features, investigations and immunotherapy responses. Serum glycine receptor antibody endpoint titres ranged from 1:20 to 1:60 000. In 11 paired samples, serum levels were higher than (n = 10) or equal to (n = 1) cerebrospinal fluid levels; there was intrathecal synthesis of glycine receptor antibodies in each of the six pairs available for detailed study. Four patients also had high glutamic acid decarboxylase antibodies (>1000 U/ml), and one had high voltage-gated potassium channel-complex antibody (2442 pM). Seven patients with very low titres (<1:50) and unknown or alternative diagnoses were excluded from further study. Three of the remaining 45 patients had newly-identified thymomas and one had a lymphoma. Thirty-three patients were classified as progressive encephalomyelitis with rigidity and myoclonus, and two as stiff person syndrome; five had a limbic encephalitis or epileptic encephalopathy, two had brainstem features mainly, two had demyelinating optic neuropathies and one had an unclear diagnosis. Four patients (9%) died during the acute disease, but most showed marked improvement with immunotherapies. At most recent follow-up, (2–7 years, median 3 years, since first antibody detection), the median modified Rankin scale scores (excluding the four deaths) decreased from 5 at maximal severity to 1 (P < 0.0001), but relapses have occurred in five patients and a proportion are on reducing steroids or other maintenance immunotherapies as well as symptomatic treatments. The glycine receptor antibodies activated complement on glycine receptor-transfected human embryonic kidney cells at room temperature, and caused internalization and lysosomal degradation of the glycine receptors at 37°C. Immunoglobulin G antibodies bound to rodent spinal cord and brainstem co-localizing with monoclonal antibodies to glycine receptor-α1. Ten glycine receptor antibody positive samples were also identified in a retrospective cohort of 56 patients with stiff person syndrome and related syndromes. Glycine receptor antibodies are strongly associated with spinal and brainstem disorders, and the majority of patients have progressive encephalomyelitis with rigidity and myoclonus. The antibodies demonstrate in vitro evidence of pathogenicity and the patients respond well to immunotherapies, contrasting with earlier studies of this syndrome, which indicated a poor prognosis. The presence of glycine receptor antibodies should help to identify a disease that responds to immunotherapies, but these treatments may need to be sustained, relapses can occur and maintenance immunosuppression may be required.

Psychogenic Movement Disorders: Gait Is a Give-Away!

The aim of this article is to point out that an incongruity of gait disorder (either in relation to the presenting movement disorder or incongruity with any type of organic gait disorder) is a useful clue in diagnosing psychogenic movement disorders. To illustrate this, we present a case series of patients with various types of psychogenic movement disorders (rest tremor, myoclonus, dystonia, and chorea). Incongruity of the walking pattern with the presenting movement disorder was a revealing diagnostic clue in all cases. "Incongruity" is currently a main plank in the diagnosis of psychogenic conditions. Our series emphasizes that incongruity of the gait pattern may be the most important sign in a patient where it is otherwise difficult to establish whether the movement disorder is congruous or incongruous with an organic disorder.

Facial tremor in dystonia

BACKGROUND

Tremor of the upper/middle part of the face, including the perinasal region and the forehead has been very rarely described in some patients with Parkinson's disease or Essential Tremor. It has not yet been reported in patients with idiopathic dystonia.

METHODS

We describe here a series of 8 patients with common forms of idiopathic focal/segmental dystonia with tremor involving the upper/middle part of the face, along with demonstrative videos and electrophysiological recordings.

RESULTS

The distribution of the tremor was confined to the face in two patients, whereas in six patients tremor was also evident either in the head/lower part of the face or in their upper limbs. Electrophysiological recordings disclosed a slightly irregular tremor with a frequency at about 3-5 Hz.

CONCLUSIONS

A number of patients with classical forms of dystonia can show a tremor involving the upper/middle part of the face.

Identification of a ZEB2-MITF-ZEB1 transcriptional network that controls melanogenesis and melanoma progression

Deregulation of signaling pathways that control differentiation, expansion and migration of neural crest-derived melanoblasts during normal development contributes also to melanoma progression and metastasis. Although several epithelial-to-mesenchymal (EMT) transcription factors, such as zinc finger E-box binding protein 1 (ZEB1) and ZEB2, have been implicated in neural crest cell biology, little is known about their role in melanocyte homeostasis and melanoma. Here we show that mice lacking Zeb2 in the melanocyte lineage exhibit a melanoblast migration defect and, unexpectedly, a severe melanocyte differentiation defect. Loss of Zeb2 in the melanocyte lineage results in a downregulation of the Microphthalmia-associated transcription factor (Mitf) and melanocyte differentiation markers concomitant with an upregulation of Zeb1. We identify a transcriptional signaling network in which the EMT transcription factor ZEB2 regulates MITF levels to control melanocyte differentiation. Moreover, our data are also relevant for human melanomagenesis as loss of ZEB2 expression is associated with reduced patient survival.

T-cell homeostasis in pediatric multiple sclerosis: old cells in young patients

OBJECTIVE

To assess pediatric patients with multiple sclerosis (MS) for early signs of homeostatic and functional abnormalities in conventional (Tcon) and regulatory T cells (Treg).

METHODS

We studied the composition of the peripheral T-cell compartment and Treg function in a cross-sectional study with 30 pediatric MS (pMS) patients by multicolor flow cytometry and proliferation assays. Data were compared to those obtained from adult patients (n = 26) and age-matched control donors (n = 67).

RESULTS

Proportions of naive T cells were 10%-20% higher in children than in adults, reflecting the age-related decline. pMS patients, however, had clearly lower numbers of naive T cells, among them recent thymic emigrants (RTE), whereas percentages of memory T cells were increased. In the Treg compartment, reduced RTE numbers coincided with markedly dampened suppressive capacities of total Treg. These homeostatic changes in circulating T cells precisely paralleled the pattern seen in adult MS. As in adults, treatment with immunomodulatory drugs attenuated these alterations.

CONCLUSION

The homeostatic changes detected in the T-cell compartment in pMS are similar to those in adult-onset disease. With ratios between naive and memory T-cell subsets matching those of 20- to 30-years-older controls, signs of early thymic involution are already found in pMS, suggesting that an intrinsic compromise in thymic-dependent T-cell neogenesis might contribute to MS pathogenesis.

B cells undergo unique compartmentalized redistribution in multiple sclerosis

Increasing evidence fosters the role of B cells (BC) in multiple sclerosis (MS). The compartmentalized distribution of BC in blood and cerebrospinal fluid (CSF) is incompletely understood. In this study, we analyzed BC-patterns and BC-immunoreactivity at these sites during active and during stable disease and the impact of disease modifying drugs (DMD) on peripheral BC-homeostasis. For this purpose we assessed BC-subsets in blood and CSF from patients with clinically isolated syndrome (CIS), relapsing remitting MS (RRMS), rheumatoid arthritis (RA), and healthy controls (HC) by flow cytometric detection of whole (W-BC), naïve, transitional (TN-BC), class-switched memory (CSM-BC), unswitched memory (USM-BC), double-negative memory (DNM-BC) BC-phenotypes, plasma blasts (PB), and plasma cells (PC). FACS-data were correlated with BC-specific chemotactic activities in CSF, intrathecal CXCL13-levels, and immunoreactivity of peripheral W-BC. Our study revealed that frequencies of systemic CSM-BC/USM-BC became contracted in active CIS/MS while proportions of naive BC, TN-BC and DNM-BC were reciprocally expanded. Moreover, the shifted BC-composition promoted reduced immunoreactivity of W-BC and resolved during remission. Cross-over changes in CSF included privileged accumulation of CSM-BC linked to intrathecal CXCL13-concentrations and expansion of PB/PC. Treatment with interferon-beta and natalizumab evoked distinct though differing redistribution of circulating BC-subsets. We conclude that symptomatic CIS and MS are accompanied by distinctive changes in peripheral and CSF BC-homeostasis. The privileged reciprocal distribution between naïve versus CSM-phenotypes in both compartments together with the marked chemotactic driving force towards BC prompted by CSF supernatants renders it likely that CSF BC are mainly recruited from peripheral blood during active CIS/MS, whereas constantly low percentages of circulating PB/PC and their failure to respond to migratory stimuli favors intrathecal generation of antibody secreting cells. Notably, BC-redistribution closely resembles alterations detectable in systemic autoimmunity associated with active RA and impacts BC-function Together with unique effects of DMDs on BC-homeostasis these findings underline the important role of BC in MS.

The interleukin-7 receptor α chain contributes to altered homeostasis of regulatory T cells in multiple sclerosis

Treg homeostasis is disturbed in multiple sclerosis (MS). Frequencies of recent thymic emigrant (RTE)-Treg are reduced and the disparity between RTE-Treg and long-lived memory Treg coincides with the MS-associated Treg defect, as shown previously. Recent studies demonstrate that IL-7 and thymic stromal lymphopoietin (TSLP) are critical for Treg maturation. Therefore, altered signaling through their receptors (IL-7R, TSLP receptor (TSLPR)), sharing the IL-7Rα-chain (IL-7Rα), might contribute to impaired Treg development. Using blood samples from 56 patients with MS and 33 healthy controls, we assessed IL-7Rα-expression on conventional T cells; frequencies, phenotypes and suppressive activities of Treg, plasma levels of IL-7 and soluble IL-7Rα; and screened for MS-associated IL-7RA gene polymorphism rs6897932. Moreover, we determined Treg expressing two different TCR Vα-chains designating thymus-originated cells. As TSLP/TSLPR signaling in thymic myeloid dendritic cells (MDCs) promotes Treg differentiation, we measured TSLPR expression on peripheral MDCs to indirectly test whether altered TSLPR expression might add to compromised Treg neogenesis. We found reduced IL-7Rα expression on conventional T cells and upregulated IL-7 plasma levels together with reduction of RTE-Treg frequencies and Treg function in MS, without clear genetic influence. Decreased IL-7Rα expression in MS correlated with declined dual-receptor-Treg and reduced MDC TSLPR expression, indicating contracted thymic Treg output. We suggest that altered IL-7R/TSLPR signaling contributes to impaired Treg neogenesis in MS, which is compensated by expanded memory-Treg and finally results in dysfunctional Treg.

Glatiramer acetate improves regulatory T-cell function by expansion of naive CD4(+)CD25(+)FOXP3(+)CD31(+) T-cells in patients with multiple sclerosis

Naturally occurring regulatory T-cells (Treg) exhibit impaired function in patients with relapsing-remitting multiple sclerosis (RRMS) resulting from an age-inappropriate disproportion between prevalences of newly generated CD31-coexpressing naive Treg and long-lived memory Treg in the periphery. Recent evidence suggests that the immunomodulatory action of glatiramer acetate (GA) includes effects on Treg function and frequencies. We prospectively assessed suppressive activities and frequencies of Treg and Treg subsets in 15 patients with RRMS undergoing long-term therapy with GA. Treatment for up to six months reconstituted naive Treg and increased total Treg numbers with concomitant reversion of the Treg defect.

Interferon beta-induced restoration of regulatory T-cell function in multiple sclerosis is prompted by an increase in newly generated naive regulatory T cells

BACKGROUND

Naturally occurring regulatory T (T(reg)) cells are functionally impaired in patients with relapsing-remitting multiple sclerosis. We recently showed that prevalences of newly generated CD31-coexpressing naive T(reg) cells (recent thymic emigrant-T(reg) cells) are critical for suppressive function of circulating T(reg) cells, and a shift in the homeostatic composition of T(reg)-cell subsets related to a reduced de novo generation of recent thymic emigrant-T(reg) cells may contribute to the multiple sclerosis (MS)-related T(reg)-cell dysfunction. Interferon beta, an immunomodulatory agent with established efficacy in MS, lowers relapse rates and slows disease progression. Emerging evidence suggests that T(reg)-cell suppressive capacity may increase in patients with MS undergoing treatment with interferon beta, although the mechanisms mediating this effect are uncertain.

OBJECTIVE

To evaluate the effect of interferon beta treatment on the suppressive activity and the homeostasis of circulating T(reg) cells in patients with MS.

PARTICIPANTS

Twenty patients with relapsing-remitting MS and 18 healthy control subjects.

INTERVENTIONS

Administration of interferon beta.

MAIN OUTCOME MEASURES

Effect of interferon beta on T(reg)-cell homeostasis and suppressive capacity.

RESULTS

Suppressive capacities of T(reg) cells were consistently upregulated at 3 and 6 months after treatment with interferon beta. The restoration of T(reg)-cell function was paralleled by increased naive recent thymic emigrant-T(reg) cells and a coincidental reduction in memory T(reg) cells.

CONCLUSION

The increase in T(reg)-cell inhibitory capacity mediated by interferon beta treatment can be explained by its effect on the homeostatic balance within the T(reg) cell compartment.

Collection strategies and cryopreservation of umbilical cord blood

The aim of this study was to compare (a) two different umbilical cord blood (UCB) collection methods while the placenta is still in the uterus (in utero), and (b) to evaluate the efficacy of four cryopreservation protocols based on UCB haematopoiestic stem cell (HSC) recovery. We analysed UCB samples collected with our original collection system designed for active Syringe/Flush/Syringe method or by standard in utero method. For comparing different cryopreservation procedures, dimethyl sulphoxide (DMSO) at final concentration of 5 and 10% was used and combined with our own controlled-rate or uncontrolled-rate cryopreservation. A total of 99 samples were collected. A significantly higher UCB volume, total nucleated cell and mononuclear cell were seen following the first collection strategy (n= 49; mean +/- SD, 103 +/- 35.4 mL; 12.34 +/- 5.27 x 10(8); 595 +/- 3.47 x 10(6)) vs. the second strategy (n= 50; 86 +/- 29.3 mL; 9.87 +/- 4.47; 424 +/- 2.82 x 10(6)) respectively (P < 0.01). The discard rate was 14% for the first and 36% for the second collection strategy (P < 0.01). It was shown that the most efficient procedure was the controlled-rate protocol combined with lower (5%) DMSO concentration. Using active Syringe/Flush/Syringe method, we collected UCB with greater volumes and with lower discard rate compared to the standard by gravity technique. The data presented also showed much better recovery of UCB cells when controlled-rate freezing procedure and 5% DMSO were combined.

[Interleukin-8 serum levels in patients with various types of open heart surgical procedures performed under extracorporeal circulation]

Serum concentrations of proinflammatory cytokine interleukin-8 (IL-8) in 15 patients with surgically revascularized myocardium by triple venous cardiopulmonary bypass (CPB x 3) and in 10 patients with implanted artificial aortic valves (AV) were measured. Average IL-8 concentrations in (CPB x 3) patients and in those with artificial aortic valve were 7.3 +/- 11.6 pg/mL 24 hours before surgery, i.e. 3.3 +/- 3.4 pg/mL; six hours after surgical procedure 32.7 +/- 71.4 pg/mL, i.e. 8.9 +/- 9.9 pg/mL; and 24 hours after surgery 10.9 +/- 9.7 pg/mL, i.e. 8.3 +/- 4.6 pg/mL. Extracorporeal circulation (ECC) caused significant increase of IL-8 serum concentration in both investigated groups six hours after surgery. Comparing preoperative values of the both groups, as well as those of 6 and 24 hours after surgery, no significant values of IL-8 were found. Various types of open heart surgical procedures had no influence on the extent of the production and secretion of proinflammatory IL-8 cytokine measured in patients during 24 hours after surgery.

[A severe form of falciparum malaria associated with staphylococcal endocarditis]

A case is presented of a patient, aged 56 years, with severe form of imported malaria caused by Plasmodia falciparum. Hyperparasitemia of erythrocytes > 30% was registered, and during the course of the disease CNS dysfunction, severe anemia, acute renal failure, disseminated intravenous coagulation with manifest hemorrhagic syndrome, icterus, enterocolitis, pneumonia and staphylococcal endocarditis were developed Due to hyperparasitemia and numerous complications, antimalarial drugs such as quinidine (1,200 mg/day) and artemether (160 mg/day) were administered parenterally. Infected erythrocytes were exchanged with 2.5 litres of healthy erythrocytes suspension. Hemodialysis was also performed as well as nine-week antistaphylococcal therapy. During the treatment preparation of deplasmated blood, concentrated thrombocytes, fresh frozen plasma, cryoprecipitates, human albumins and immunoglobulins were applied, along with the correction of electrolytic dysbalance, administration of diuretic, cardiotonic, antiarrhythmic, anxiolytic, antipsychotic and antidepressive drugs. Two months after the admission the patient was released from the Clinic in good condition, with normal clinical-laboratory findings.

Increased nitric oxide metabolites in exhaled breath condensate after exposure to tobacco smoke

BACKGROUND

Cigarette smoking reduces the level of exhaled nitric oxide (NO) in healthy subjects, although the mechanism is unclear. NO is a highly reactive molecule which can be oxidised or complexed with other biomolecules, depending on the microenvironment. The stable oxidation end products of NO metabolism are nitrite and nitrate. This study investigated the effect of smoking on NO metabolites in exhaled breath condensate.

METHODS

Fifteen healthy current smokers were recruited together with 14 healthy non-smokers. Measurement of exhaled NO, lung function, and collection of exhaled breath condensate were performed. Nitrite, nitrite + nitrate, S-nitrosothiols, and nitrotyrosine levels were measured. The effect of inhaling two cigarettes in smokers was also evaluated. The mean level of exhaled NO in smokers was significantly lower than in non-smokers (4.3 (0.3) ppb v 5.5 (0.5) ppb, p<0.05).

RESULTS

There was no difference in the levels of nitrite, nitrite + nitrate, S-nitrosothiols, and nitrotyrosine in the exhaled breath condensate at the baseline visit between smokers and non-smokers. After smoking, nitrite + nitrate levels were significantly but transiently increased (from 20.2 (2.8) microM to 29.8 (3.4) microM, p<0.05). There was no significant change in the levels of exhaled NO, nitrite, S-nitrosothiols, or nitrotyrosine 30 and 90 minutes after smoking.

CONCLUSIONS

These findings suggest that acute smoking can increase the level of nitrate, but not nitrite, S-nitrosothiols, or nitrotyrosine in breath condensate. The deleterious effect of oxidant radicals induced by smoking may contribute to the epithelial damage of airways seen in smokers.

Increased nitrotyrosine in exhaled breath condensate in cystic fibrosis

Exhaled nitric oxide (ENO), a marker of inflammation in airway diseases is decreased in cystic fibrosis (CF) patients, perhaps because nitric oxide (NO) is metabolized to oxidative end-products. A stable product, 3-nitrotyrosine, may indicate local formation of reactive nitrogen species. Whether NO metabolites in exhaled breath condensate may be increased in CF patients was investigated. The fractional concentration of ENO (Feno), nitrotyrosine and oxides of nitrogen in exhaled breath condensate from 36 stable CF patients were compared to 14 normal subjects using an enzyme immunoassay and fluorescence assay. Nitrotyrosine levels in breath condensate were increased significantly in stable CF patients, compared with normal subjects (25.3 +/- 1.5 versus 6.3 +/- 0.8 ng x mL(-1), p<0.0001). There was an inverse correlation between the levels of nitrotyrosine and the severity of lung disease. Feno levels were significantly lower in CF patients than in normal subjects (4.4 +/- 0.3 versus 5.6 +/- 0.4 (parts per billion), p<0.05). No correlation was found between nitrotyrosine and Feno levels in CF. There was no significant difference in the levels of nitrite and nitrate between CF patients and normals. The elevation in nitrotyrosine may reflect increased formation of reactive nitrogen species such as peroxynitrite or direct nitration by granulocyte peroxidases, indicating increased oxidative stress in airways of cystic fibrosis patients.

[Treatment of Hodgkin's disease with high-dose chemotherapy and autologous stem cell transplantation]

High dose chemotherapy (HDC) with autologous stem cell transplantation (SCT) was applied for the treatment of 13 patients (pts) with Hodgkin's disease (HD) (10 with relapsed form and 3 with conventional chemotherapy resistant form) in the Clinic for Hematology, Military Medical Academy, from May 1997 to October 1999. After the initial treatment for the reduction of tumor, burden stem cells were mobilized by cyclophosphamide 2.5-7.0 g/m2 with G-CSF 5-12 micrograms/kg body mass (BM). The average number of colected mobilized mononuclear cells (MNC) was 2.99 (1.66-5.9) x 10(8)/kg BM by the apheresis large volume from peripheral blood. All patients received BEAM (BCNU, etoposide, Cyto-Ara, and melfalan) conditioning regimen with adequate supportive therapy. Good engraftment (100%) was observed at postransplantation period: number of polymorphonuclear cells was > 0.5 x 10(9)/l, on day 13th (10-21) and number of platelets > 20 x 10(9)/l, on day 17th (11-28). One patient (7.6%) died due to infective complications at day 98th after transplantation, 9 (69.2%) patients achieved complete and 3 (23.1%) patients partial remission of the disease. Out of three patients with partial remission, one relapsed, seven months after autologous SCT, with conventional chemotherapy resistant form and two, after the applied conventional locoregional radiotherapy reached remission. One patient (7.6%) developed secondary malignancy of acute myeloid leukemia form with threelinage displasy 27 months after autologous SCT. HDC with autologous SCT contributes to more successful treatment of early relapsed and standard chemotherapy resistant forms of HD and gives the opportunity for successful quality of living for those patients.

[Second allogenic bone marrow transplantation after late graft rejection in a patient with severe aplastic anemia]

Allogeneic bone marrow transplantation (BMT) is the treatment of choice in young patients (pts) with severe aplastic anemia (SAA) who have an HLA identical sibling donor. Late graft rejection to following allogeneic BMT for SAA is a significant clinical problem and is associated with a high risk of mortality. The optimal treatment strategy for patients with late graft rejection after first BMT is still an open question. We report 12-year-old patient with acquired SAA who underwent BMT from his HLA identical sister. BMT was first-line treatment within 3 months of diagnosis. Preparative therapy was Cyclophosphamide (Cy) 200 mg/kg body mass (BM) during 4 days. Graft versus host disease (GVHD) was prevented with Methotrexate (MTX), Methylprednisolone (MPDN) and Cyclosporin A (CsA). After 17 months, during which patient was with normal blood counts and full donor chimaerism, graft rejection occurred. The patient was re-engrafted from the same donor after conditioning with Cy 200 mg/kg BM plus horse antithymocyte globulin (ATG)--2 vials (á 25 mg)/10 kg BM over 4 days. Before the collection, donor's bone marrow was activated with low dose rhGM-CSF (3 micrograms/kg one day). Following a secondary BMT engraftment has sustained. The patient is alive with full donor chimaerism 26 months from secondary transplantation, without acute or chronic GVHD.

Plasma exchange in myasthenia gravis and multiple sclerosis

During the last twenty-year period therapeutic plasma exchange (TPE) was used in the treatment of 68 patients with myasthenia gravis and 61 patients with multiple sclerosis. The therapeutic effects were evaluated on the basis of neurologic deficit changes, electrophysiological findings, necessary laboratory analyses and patient's general conditions. It was shown that the therapeutic effects mosty depended on the nature and stage of the basic disease, adequate selection of the patients and timely applied therapeutic procedure. Significant positive effects of the TPE treatment applied with the anti-inflammatory and immunosuppressive therapy were observed in patients with myasthenia gravis and multiple sclerosis upon clinical findings and some paraclinical tests.

[Secondary myelodysplastic syndrome after autologous transplantation of hematopoietic stem cells in a female patient with Hodgkin's disease]

Secondary acute myeloid leukemia with threelineage displasy (sAML/MDS) has been described as a complication of therapeutic approach with high-dose chemotherapy and autologous stem cell transplantation (SCT) in the patients with Hodgkin's disease (HD). It is not yet clear whether the sAML/MDS is a consequence of a standard therapeutic regimen, applied before transplantation, or a high-dose chemotherapy. In a female patient with initially resistant form of HD at III-B-b clinical stadium (bulky disease in neck and mediastinum) after the initial treatment (MOPPx4; ABVDx3; BEA-COPPx2), high-dose chemotherapy has been applied according to BEAM protocol with autologous SCT. In a period after transplantation, radiotherapy (RT) has been applied at initial region of the disease and a patient reached complete remission (CR), which lasted for a 27 months. After that period sAML/MDS has been observed. Application of more standard therapeutic cycles and characteristic cytogenetic findings are the facts that support the opinion that sAML/MDS is a consequence of standard treatment before transplantation, rather than high-dose chemotherapy. That finding implies the need for correct choice of the HD patients suitable for early SCT therapeutic approach.

[Significance of blood transfusion in the development of cytotoxic antibodies in patients on hemodialysis]

The aim was to evaluate the influence of red blood cells (RBC) transfusion on the development of cytotoxic antibodies (C-Ab) in patients subjected to hemodialyses (HD) and planned for the kidney transplantation. The group of 71 HD patients, of mean age 42 years (19-65), 48 males and 23 females, planned for the kidney information was examined. Out of 71 HD patients, only 42 (59.19%) HD patients (group I) received subcutaneously recombinant human erythropoietin--rhuEPO (Eprex--epoetin-alpha or Recormon SE--epoetin-beta in dosage of 4,000 IU during every HD; i.e. one to three times a week) and they were not treated by RBC transfusion. The other 29 (40.85%) HD patients (group II) received RBC transfusion: 18 (62.07%) HD patients received < 10 units 18 of RBC, 8 (27.59%) HD patients received 10-20 units of RBC; 3 (10.35%) HD patients received > 20 units of RBC. Testing of C-Ab was done in all patients every three months by standard lymphocytotoxicity test on the panel from 20 different lymphocyte donors with definite class I phenotype of antigen HLA. C-Ab was not found in HD patients who were not treated by RBC transfusion. Out of 18 HD patients who received < 10 units of RBC only 3 (16.67%) HD patients developed C-Ab; out of 8 HD patients who received 10-20 units of RBC, in 4 (50%) patients was proved C-Ab; and C-Ab was proved in all 3 HD patients who received > 20 units of RBC. RhuEPO administration is very important for the transfusiologic treatment of HD patients; especially those who are planned for the kidney transplantation. Development of C-Ab is in direct correlation with the number of transfunded units of RBC. HD patients who received 10 or more units of RBC were at great risk to develop C-Ab.

[Blood transfusion therapy at the Military Medicine Academy--present possibilities]

Blood component therapy refers to the transfusion of the specific part of blood that a patient needs, as opposed to the routine transfusion of whole blood (WB) in the past. This not only maintains blood resources, but also provides the optimal method of transfusing patients who require large amounts of a specific blood component. Since this concept have been accepted, the Institute of Transfusiology of Military Medical Academy (MMA) possess appropriate equipment for blood collection and processing of WB in components. Mainly, all kind (except frozen) of packed red cells (RBCs), platelet concentrates (random-donor buffy coat or apheresis donation), single-donor (apheresis) or random-donor (buffy coats) granulocytes, fresh frozen plasma (FFP), single-donor cryoprecipitate are prepared. Recently, fibrin glue (obtained by recycled cryoprecipitation from single-donor or autologous plasma), and some of new generation of blood components: hematopoietic stem and progenitor cells (fresh or cryopreserved), collected from bone marrow or harvested from peripheral blood after mobilization and donor-specific mononuclear cells for cell therapy, i.e. immunomodulation during relapse of leukemia after bone marrow transplantation, have become the routine. Analysis of blood component therapy done at the MMA during the past 11 years (1989-1999) showed that: a) participation of WB transfusion in the group of surgical clinics was permanently decreased (from 59.60% in 1989 to 0.37% in 1999); b) WB transfusion (in the last few years) practically was not used in the group of internal medicine clinics (0.82% in 1993 and 0.45% in 1999); c) overall WB transfusion in MMA is extremely rare (0.37%).

Donor leukocyte infusion--the effect of mutual reactivity of donor's and recipient's peripheral blood mononuclear cells on hematopoietic progenitor cells growth

Donor leukocyte infusions are an effective therapy for patients who relapse with leukemia after bone marrow transplantation. We report the case of 14-year-old boy who relapsed 34 months after sibling donor bone marrow transplant for Philadelphia-positive chronic myeloid leukemia. Subsequently, he received three infusions of donor mononuclear cells (DMNC) harvested in steady state hematopoiesis and one G-CSF mobilized-peripheral blood mononuclear cells (PBMC) infusion. Simultaneously, test named as--"Test of Mixed Progenitors" (TMP) was performed for the assessment whether the outcome of donor leukocyte infusion treatment could be predicted. Prior to DMNC infusions, the CFU-GM and BFU-E colony assays were performed for donor's and recipient's PBMC individually, as well as for the mixture of these cells at 1:1 ratio. The cells were plated either directly in the semisolid medium or after 24 h preincubation treatment. Significantly lower values for CFU-GM derived colonies were determined in TMP in comparison to the CFU-GM values obtained for the recipient's cells. The reduced number of CFU-GM was determined both in TMP performed without preincubation treatment, app. 80% and after the 24 h preincubation, app. 55%. The reduced number of BFU-E derived colonies (app. 44%) was observed only related to recipient's cells and after the preincubation treatment of the cells. The patient did not develop GVHD and currently (40 months after the first infusion). He remained well in complete hematological, cytogenetic, molecular and clinical remission, which was the most direct evidence of the GVL effect. The novel in vitro TMP test in which the specific contribution of donor's leukocytes to the growth of recipient's hematopoietic precursor cell growth was determined, correlated with the clinical outcome.

[Biochemical changes in thrombocyte concentrates stored for 5 days]

The purpose was to evaluate biochemical and functional changes in platelet concentrates prepared from buffy-coat (PC-BC), stored up to five days at temperature of 20 +/- 2 degrees C. Forty-two PC-BC units from random blood donors were examined. In order to determine the biochemical changes we studied the release of lactate dehidrogenase (LDH), changes in pH value, pCO2, pO2, glucose and lactate concentrations. In addition, the aggregation of platelets with adenosine diphosphate (ADP), and hypotonic shock response were examined. The concentration of LDH markedly increased from 138.8 IU/l (day 1st) up to 234 IU/l (day 5th). The lactate concentration increased significantly (p < 0.001) from 2.1 to 8.6 mmol/l, and consequently pH decrease was observed (from 7.31 to 7.13). The level of glucose decreased gradually from 22.8 to 19.4 mmol/l. The pCO2 decreased progressively from 36.8 mmHg to 24 mmHg during first two days of storage and after that gradually to 20 mmHg. In contrast, pO2 fluctuated between 108 and 133 mmHg during five day of storage. Recovery of hypotonic shock response was 70% on day 1st and 35.7% on day 5th, respectively (p < 0.001). Platelet aggregation using ADP showed significant increase from 6.6 sec (day 1st), to 11.2 sec (day 4th) and 14.6 sec (day 5th), too. Significant differences in biochemical parameters and platelet functions, with confirmed relationship between changes obtained during five days stored PC-BC did not affect the efficacy of applied platelets.

Evaluation of cryopreserved murine and human hematopoietic stem and progenitor cells designated for transplantation

The influence of five different cryopreservation protocols on the quality and/or quantity of frozen cells was investigated on mouse bone marrow cells and human peripheral blood mononuclear cells (MNC). The efficiency of the protocols was evaluated on the basis of the recovery of very primitive pluripotent hematopoietic stem cells (MRA), pluripotent progenitors (CFU-Sd12), committed granulocyte-monocyte progenitors (CFU-GM) of mouse cells after thawing. The recovery of MRA, CFU-Sd12 and CFU-GM varied depending on the type of freezing procedure and cryoprotector (DMSO) concentrations used. It was shown that the controlled-rate protocol was more efficient, enabling better recovery of all categories of progenitor cells in frozen samples. The most efficient was the controlled-rate protocol of the cryopreservation designed to compensate for the release of fusion heat, which enabled the best recovery of CFU-GM (73.0 +/- 8.8%) and CFU-Sd12 (90.0 +/- 15.9%) when combined with 5% DMSO concentration (protocol 4). On the contrary, a better recovery (79.8 +/- 13.5%) of very primitive stem cells (MRA) was achieved only when the higher concentration (10%) DMSO was used in combination with a five-step protocol of cryopreservation (protocol 1). These results pointed out the adequately used controlled-rate freezing to be essential for a highly efficient cryopreservation of some of the categories of hematopoietic stem and progenitor cells. At the same time, it was obvious that a higher DMSO concentration was necessary for the cryopreservation of MRA, but not for more mature progenitor cells (CFU-S, CFU-GM). These results imply the existence of a mechanism that decreases the intracellular concentration of DMSO in MRA cells, which is not the case in less primitive progenitors. For human MNC, the recovery and viability of the cells, as well as the engraftment potential of cryopreserved cells after thawing were investigated. Cryopreservation protocol 1 resulted in better MNC recovery (82.7 +/- 10.4%) than protocol 3 (49.9 +/- 15.1%). The mean recovery of MNCs (collected from patients for autologous transplantation) was 78.5 +/- 7.3% (protocol 1) and 53.1 +/- 26.2% (protocol 3). The obtained favorable recovery of thawed cells and rapid reconstitution of hematopoiesis (on the day 11th following the transplantation) in patients confirmed that the controlled-rate freezing in combination with optimal DMSO concentration was able to obtain sufficient progenitor cryoprotection.