Examining the immune response in sentinel lymph nodes of mice and men

Recently, it was recognized that an immune response develops along one of two major pathways. One leads to a destructive immune response (type 1), while the alternative leads to a nondestructive immune response (type 2). Our studies in animal models suggest that therapeutic vaccines induce a tumor-specific type 1 immune response while ineffective vaccines induce a type 2 response. These results have led us to examine the immune response in sentinel lymph nodes draining tumor vaccines of patients entered onto clinical trials for melanoma, breast and renal cell cancer.

Vaccination with BV8S2 protein amplifies TCR-specific regulation and protection against experimental autoimmune encephalomyelitis in TCR BV8S2 transgenic mice

TCR determinants overexpressed by autopathogenic Th1 cells can naturally induce a second set of TCR-specific regulatory T cells. We addressed the question of whether immune regulation could be induced naturally in a genetically restricted model in which a major portion of TCR-specific regulatory T cells expressed the same target TCR BV8S2 chain as the pathogenic T cells specific for myelin basic protein (MBP). We found vigorous T cell responses to BV8S2 determinants in naive mice that could be further potentiated by vaccination with heterologous BV8S2 proteins, resulting in the selective inhibition of MBP-specific Th1 cells and protection against experimental encephalomyelitis. Moreover, coculture with BV8S2-specific T cells or their supernatants reduced proliferation, IFN-gamma secretion, and encephalitogenic activity of MBP-specific T cells. These results suggest that immune regulation occurs through a nondeletional cytokine-driven suppressive mechanism.

Presence of a p53 gene deletion in patients with multiple myeloma predicts for short survival after conventional-dose chemotherapy

In multiple myeloma (MM), previous studies showed that mutations of the p53 gene are rare events in patients with newly diagnosed disease, but it is not known whether deletions of p53 are of any significance in MM. To address this question, we used interphase fluorescence in situ hybridization (FISH) with a DNA probe specific for the p53 locus at 17p13 and investigated bone marrow plasma cells from 72 patients with MM (59 patients = 81.9% before therapy). By FISH, deletions of p53, which were found to be predominantly monoallelic, were detected in 32.8% and 54.5% of patients with newly diagnosed and relapsed MM, respectively. Karyotypes from six of the patients with a p53 deletion by FISH showed a structural abnormality of 17p in only one of them. Additional FISH studies including a distal-17p probe (specific for the D17S34 locus) provided evidence for an interstitial deletion on 17p resulting in loss of p53 hybridization signals in myeloma cells. Among all 59 patients with newly diagnosed MM, presence of a p53 deletion was associated with stage III (P = .054), but not with other laboratory and clinical parameters. Patients with a p53 deletion had significantly shorter survival time compared with those without a deletion, both from the time of diagnosis (median 13.9 v 38.7 months; P < .0001) and from the time of initiation of induction treatment consisting of conventional dose chemotherapy (median 15.9 months v median not reached at 38 months; P < .0002). On stepwise multivariate regression analysis, presence of a p53 deletion was the most significant independent parameter predicting for shortened survival (P = .002). We conclude that a p53 gene deletion, which can be identified by interphase FISH in almost a third of patients with newly diagnosed MM, is a novel prognostic factor predicting for short survival of MM patients treated with conventional-dose chemotherapy.

Bone resorption in multiple myeloma and in monoclonal gammopathy of undetermined significance: quantification by urinary pyridinium cross-links of collagen

To quantify osseous breakdown in multiple myeloma (MM), monoclonal gammopathy of undetermined significance (MGUS), and benign osteoporosis, we measured urinary levels of pyridinium cross-links of collagen in 50 patients with newly diagnosed and untreated MM, 40 patients with MGUS, 40 untreated patients with osteoporotic vertebral fractures, and 64 healthy adults. Ion-paired, reverse-phase high-performance liquid chromatography (HPLC) was used to measure total urinary excretion of pyridinoline (h-PYD) and deoxypyridinoline (h-DPD). Urinary excretion of free immunoreactive deoxypyridinoline (i-DPD) was determined with an enzyme immunoassay. MM patients had significantly (P < .0001) higher levels of h-PYD, h-DPD, and i-DPD than the healthy adults, patients with MGUS, or patients with osteoporosis. The MGUS and osteoporosis groups presented with elevated (P < .05) levels of urinary pyridinium cross-links when compared with healthy controls. In 20 MM patients who subsequently received chemotherapy, the percent changes in i-DPD did not correlate with the changes in the monoclonal protein. In one of three patients experiencing a transition of initial MGUS into stage I MM, i-DPD increased above the upper limit of the normal range. In 13 patients with stable MGUS, i-DPD remained normal in repeated measurements. Based on the upper limits of the normal range, the sensitivity of urinary pyridinium cross-links in stage I and II MM was low (<50%), but it was between 78% (h-DPD) and 93% (i-DPD) in stage III MM. Specificity in patients with MGUS was between 87% (h-PYD) and 97% (h-DPD). In conclusion, determining the urinary excretion of pyridinium cross-links seems to be a promising noninvasive and thus easily repeatable method for evaluating the actual degree of osseous breakdown. Although measurement of pyridinium cross-link levels is not useful in discriminating patients with MGUS from early-stage myeloma patients, determination of i-DPD levels may contribute importantly to clinical guidance, since increased i-DPD levels seem to identify patients who are particularly likely to benefit from osteoclast-inhibiting drugs such as bisphosphonates. The fact that in a number of patients paraprotein concentrations and i-DPD levels did not change in parallel but instead diverged strongly after chemotherapy might explain the observation that bone lesions sometimes progress even in patients who achieve complete remission.

The AERX aerosol delivery system

PURPOSE

We describe the AERX aerosol delivery system, a new, bolus inhalation device that is actuated at preprogrammed values of inspiratory flow rate and inhaled volume. We report on its in vitro characterization using a particular set of conditions used in pharmacokinetic and scintigraphic studies.

METHODS

Multiple doses of aerosol were delivered from single use collapsible plastic containers containing liquid formulation. The aerosol was generated by forcing the formulation under pressure through an array of 2.5 micron holes. Air was drawn through the device at 70 LPM, and the aerosol was collected onto a filter or Andersen cascade impactor. The emitted dose was quantified from the filter collection data, and the particle size distribution was obtained from the best fit log-normal distribution to the impactor data.

RESULTS

57.0 +/- 5.9% of the dose of drug placed as an aqueous solution in the 45 microL collapsible container was delivered as an aerosol (n = 40). The best fit size distribution had an MMAD = (2.95 +/- 0.06) microns and a geometric standard deviation sigma g = 1.24 +/- 0.01 (n = 6).

CONCLUSIONS

The AERX aerosol delivery system generates a nearly monodisperse aerosol with the properties required for efficient and repeatable drug delivery to the lung.

Interphase fluorescence in situ hybridization identifies chromosomal abnormalities in plasma cells from patients with monoclonal gammopathy of undetermined significance

Karyotypic studies in patients with monoclonal gammopathy of undetermined significance (MGUS) have been hampered by a low percentage of bone marrow plasma cells (BMPC), which are predominantly nonproliferating. By combining cytomorphology and interphase fluorescence in situ hybridization (FISH) we investigated whether or not chromosomal abnormalities occur in BMPC from patients with MGUS. Studying chromosomes 3, 7, 11, and 18, which we found to be frequently aneuploid by FISH in multiple myeloma (MM), we observed three hybridization signals for one of these chromosomes 3 were most common, occurring in 38.9% of patients, followed by gains of chromosomes 11 (25%), 7 (16.7%), and 18 (5.6%) Among BMPC, the frequency of aneuploid cells was 18.9% +/- 13.9% (mean +/- SD) for chromosome 3, 22.3% +/- 9.2% for chromosome 11, 23.2% +/- 22.0% for chromosome 7, and 6.1% +/- 2.3% for chromosome 18. In five patients, chromosomal abnormalities were shown to be restricted to BMPC expressing cytoplasmic immunoglobulins corresponding to the serum paraprotein. No gain of hybridization signals was observed in normal and reactive plasma cells. In one patient with MGUS, metaphase cytogenetics revealed one abnormal metaphase with 47, XY, +4, and trisomy 4 was also demonstrated in a subpopulation of BMPC by interphase FISH. FISH results from patients with MGUS and newly diagnosed MM at stage IA (n = 14) indicated that aberrations involving > or = 2 chromosomes occurred significantly more often in early stage MM (P < .01). With respect to clinical and laboratory features, MGUS patients with and without chromosomal abnormalities were indistinguishable. Our results indicate that MGUS already has the chromosomal characteristics of a plasma cell malignancy.

Multiple myeloma: high incidence of chromosomal aneuploidy as detected by interphase fluorescence in situ hybridization

Because metaphase cytogenetic studies in multiple myeloma (MM) are hampered by a low proliferative activity of myeloma cells in vitro, interphase cytogenetics by means of fluorescence in situ hybridization (FISH) should improve the detection of chromosomal abnormalities in MM. We therefore investigated chromosomal aneuploidy in 36 patients with MM using interphase FISH and alpha-satellite DNA probes for chromosomes 1, 3, 7, 8, 11, 12, 16, 17, 18, and X. By FISH, myeloma cells from 32 patients (88.9%) were aneuploid for at least one of the chromosomes examined. In 24 patients (66%), aberrations of > or = 3 chromosomes were observed. Aneuploidy was predominantly characterized by a gain of chromosome numbers, with involvement of chromosomes 3, 7, and 11 occurring in > 50% of patients. Loss of a centromeric signal suggesting monosomy was most frequently observed for chromosomes 17 (22.2% of patients) and X (monosomic in 42.3% of female patients, but loss of chromosome X was never observed in males, P < 0.05). Dual-color FISH studies provided evidence for marked heterogeneity of aneuploid cells in 8 patients (22.8%). Occurrence of chromosomal aneuploidy was independent of stage and pretreatment status. Gain of chromosome 3 was significantly correlated with an IgA paraprotein (P < 0.05). In 12 patients, the direct comparison of metaphase cytogenetics and FISH showed that FISH detected aneuploidy of chromosomes in 9 patients that was missed by metaphase analysis. In conclusion, interphase FISH, by which chromosomal aneuploidy was detected in almost 90% of patients with MM, represents an approach for evaluating the clinical significance of specific chromosomal abnormalities in MM.

Cost-effective inpatient care of neuropsychiatric patients

Managed care has decreased the frequency of hospitalization for psychiatric disorders, and it may have an especially strong impact on neuropsychiatric patients. The use of targeted, cost-effective interventions improves the quality of patient care and can assist with approval of funding for inpatient care by utilization review agencies.

Prediction of response to erythropoietin treatment in chronic anemia of cancer

Chronic anemia of cancer can be corrected in approximately 50% of the cases by treatment with recombinant human erythropoietin (rHuEPO). Early prediction of responsiveness would avoid the emotional and financial burden of ineffective medical intervention. Eighty patients with chronic anemia of cancer undergoing treatment with rHuEPO (150 U/kg, 3 times per week by subcutaneous injection; after 6 weeks without response, 300 U/kg) participated in this study. Response was defined as a gain of at least 2 g/dL hemoglobin (Hb) within 12 weeks. Multivariate discriminant analysis and logistic regression analysis of response were performed on routine blood tests; serum levels of EPO, iron, ferritin, transferrin, and its receptor; World Health Organization (WHO) performance status; various cytokines; neopterin; stem cell factor; C-reactive protein; and alpha 1-antitrypsin. At baseline, none of these factors showed sufficient prognostic power. The following predictive algorithm was developed: (1) If after 2 weeks of therapy both the serum EPO level is > or = 100 mU/mL and Hb concentration has not increased by at least 0.5 g/dL, unresponsiveness of the patient is very likely (predictive power, 93%); otherwise, response may be predicted with an accuracy of 80%. (2) If both the serum level of EPO is less than 100 mU/mL and Hb concentration has increased by > or = 0.5 g/dL, response is highly probable (predictive power, 95%). (3) Alternatively, a serum ferritin level of > or = 400 ng/mL after 2 weeks of rHuEPO therapy strongly indicates unresponsiveness (predictive power, 88%), whereas a level less than 400 ng/mL suggests response in 3 of 4 patients.

University of california at Santa Barbara Anisotropy Program: degree scale results from the South Pole 1990-1991

We report on the preliminary result of a search for anisotropy in the cosmic background radiation (CBR). Our receiver operates with four equally spaced channels from 25 to 35 GHz with a beam size of approximately 1.5 degrees full width at half maximum. The system operated successfully for 500 hr at the South Pole during 1990-1991 austral summer. The data from one region, representing 25 hr after editing, are presented here. A strong signal is present in the lower-frequency channels with a spectrum unlike CBR fluctuations. The highest-frequency channel has the smallest contribution from this signal and has been used to set a 95% confidence level upper limit DeltaT/T </= 1.4 10-5.

The non-random dic(9;12) translocation in acute lymphoblastic leukemia is associated with B-progenitor phenotype and an excellent prognosis

A dicentric translocation involving the short arms (p) of chromosomes 9 and 12 was identified in 15 of 2303 successfully banded cases of acute lymphoblastic leukemia (ALL) in children, consecutively entered on protocols of the Pediatric Oncology Group (1986-1990) or St Jude Children's Research Hospital (1984 and 1990). The dic(9;12)(p1?1;p1?2) was seen only in patients with a B progenitor cell immunophenotype: the frequency was 0.8% among pre-B cases (4/508) and 0.9% (11/1177) among early pre-B cases. Laboratory and clinical characteristics were similar to those of the general population of children with ALL, with the exception of a marked male preponderance (12/15 cases). Flow cytometric studies revealed a leukemic cell DNA index of 1.0 in all cases. All fifteen patients are in continuous complete remission at a median follow-up duration of 57+ months (range 9-93+ months). These findings suggest that the dic(9;12) is a recurrent chromosomal translocation in pediatric ALL, occurs exclusively in B-progenitor ALL, and unlike other non-random translocations, is associated with an excellent prognosis.

[Pulmonary transfer factor for carbon monoxide (TLco) in healthy children and in children with chronic lung diseases, measured with an improved rebreathing technique]

TLco, FRC-He and IVC were tested in 86 subjects (5-29 years). 46 children were healthy, 21 patients had cystic fibrosis, 13 bronchial asthma and 6 allergic alveolitis. The test gas included 14% helium and 0.3% CO. The wash in time was 18 s, the measuring time 20 s. All children were measured at rest and in a sitting position. The rebreathing volume was 3/4 of the VC plus 300 ml additional volume. The results showed a good reproducibility. The TLco increases with age, height, weight and body surface area, the correlation with VC, FRC and TLC was better. A differentiation between healthy children and patients suffering from lung disease is possible. The clearest results were shown in the case of patients suffering from CF.

Transoesophageal pacing for perioperative control of neonatal paroxysmal supraventricular tachycardia

The perioperative management of a 16-day-old infant with recurrent supraventricular tachycardia (SVT) is discussed. Vagal manoeuvres and medication were not adequate in controlling the SVT. Since the patient was scheduled for extensive surgery in the prone position, it was decided to use transoesophageal pacing as the method of choice for conversion of SVT. Transoesophageal pacing succeeded several times in overriding the SVT and restoring normal heart rate and haemodynamic variables. The advantages and disadvantages of various methods of treating SVT in the newborn are discussed.

The distally-based radial forearm free flap with valvulotomy of the cephalic vein; a preliminary report

The radial forearm free flap is widely used in microsurgical reconstruction where a thin, hairless flap is required. While the radial artery may be based either proximally or distally, the venous drainage is generally proximally based in order to provide normal flow through the valves. We have utilised this flap in two patients, based distally on both the radial artery and cephalic vein by removing the valves of the cephalic vein. This technique has been employed widely in peripheral vascular surgery of the lower limb and is called the "in-situ" technique. We have found it to be efficacious in taking a proximal skin paddle, which decreases donor site morbidity and allows for a long vascular pedicle. This paper reports on these two patients and describes the technique of valvulotomy of the cephalic vein.

Computation of diagnostic data from coronary sinus pressure: a comparison between two possible models

We have evaluated two mathematical models to describe the increase in coronary sinus pressure (CSP) following pressure controlled intermittent coronary sinus occlusion (PICSO). The models are evaluated and compared on the basis of human and canine data. Both models were fitted by non-linear least squares algorithms. Next, derived quantities, such as plateau, rise-time and mean integral of the coronary sinus pressure were calculated from the model parameters. Corresponding quantities for the two models were compared with regard to mean values, rate of successful calculation and specific features characterizing the human or canine case. One model was found to be superior for investigational purposes. The other model was found to be more stable in critical situations and is therefore suggested for usage in closed loop regulation of PICSO. Physiologically, the differences in mean values of the derived quantities between the two models were found to be negligible. The formal statistical significance of the differences is but a consequence of the large number of PICSO cycles analysed.

[Quantitative assessment of the clinical electroretinogram]

The clinical application of electroretinography has been limited until now by the lack of standardisation, especially of stimulus conditions. Normal values for the electroretinographic response parameters can only be used if patients are examined under the conditions which were given for the examination of healthy subjects. It is shown in this paper that the inexpensive apparatus designed by Kooijman and Damhof (1981) can be calibrated by any user simply and at justifiable expense. Normal values for the amplitudes and peak times for the a- and b-wave are presented. The normal range of the values has been defined with regard to the frequency distribution. According to the authors' results, methods of descriptive statistics in skewed distributions are mainly necessary at low stimulus intensities. The descriptive methods for normal distributions were regularly applied at higher stimulus intensities. In general, however, ERG parameters are normally distributed as shown by the distribution of the residuals between the linear regression of the parameter to the logarithm of the corneal illuminance and the measured values. The influence of age on the amplitude was calculated according to the results of Lehnert and Wünsche (1966) and the lower limits of the normal range are given for four age groups. The data presented here may be used as normal values provided that the simple calibration methods are applied. Thus electroretinography is no longer a method merely for the laboratory, but can be used in clinics and offices as well. However, a prerequisite is that the physician has sufficient experience in ophthalmological electrophysiology.

[Return to work following myocardial infarct]

The aim of this retrospective study involving 471 patients was to investigate the percentage of patients who returned to work after acute myocardial infarction. In the group of 350 patients who did not undergo subsequent aortocoronary bypass operation 70% returned to work, whereby half of these patients started work again within 6 months after infarction. A significantly higher number of patients who were enrolled in a cardiac rehabilitation programme returned to work as compared with patients not participating in such a programme (72% vs. 59%, respectively; p less than 0.04). There was, however, no difference between these 2 groups with respect to either the time point of resumption of work after myocardial infarction or the duration of employment between infarction and eventual retirement. Of the 121 patients who underwent an aortocoronary bypass operation, only 38% returned to work (p less than 0.001 vs. patients without bypass surgery).