Long term outcome of patients with hairy cell leukemia treated with pentostatin

BACKGROUND

With the introduction of new drugs such as interferon-alpha (IFN) and purine analogs, the management of hairy cell leukemia (HCL) patients has changed. However, pentostatin has been found to produce higher complete remission rates than IFN. The current study was undertaken to investigate response and long term follow-up in HCL patients treated with pentostatin.

METHODS

Between March 1989 and October 1996, 49 patients with HCL and 1 patient with a HCL variant were treated with pentostatin. Eighteen patients had received no prior therapy, 31 patients had received prior treatment with IFN, and 1 patient had received prior treatment with 2'-chlorodeoxyadenosine (2'CdA) and IFN. All patients except 1 were treated with a dose of 4 mg/m2 every 2 weeks. The median number of cycles was 12.

RESULTS

The overall response rate was 96% (48 of 50 patients); 22 patients (44%) achieved a complete response, 18 patients (36%) achieved a good partial response (defined as residual bone marrow infiltration < 5%), 8 patients (16%) achieved a partial response, and 2 patients died. For a median follow-up of 33 months off therapy, there were 5 recurrences between 12-66 months; 3 of these patients were treated further with and responded to 2'CdA and 2 died of disease progression at 12 and 40 months, respectively. In addition, 3 patients died of unrelated causes (1 of very early infection, 1 of toxic death and another of cardiac arrest) comprising an overall death rate of 14% (7 of 50 patients). The overall survival rate was 86% for a median follow-up of 38 months (range, 8-105 months). Major side effects were febrile episodes, herpes zoster, nausea/emesis, and pancytopenia.

CONCLUSIONS

This analysis confirms both the high remission rate and durable responses that may be achieved with pentostatin treatment in HCL patients. Although pentostatin is active, the risk of cytopenia and immunosuppression must be evaluated carefully.

CD40 regulation of death domains containing receptors and their ligands on lymphoma B cells

Within the tumour necrosis factor (TNF) family the induction of apoptosis is restricted to some ligand-receptors pairs, including TNF-TNF receptor type I (TNFRI/p55), FasL-Fas, TNF-related apoptosis-inducing ligand (TRAIL) and its death-receptors (DR)-4 and -5. The pair CD40L-CD40 belongs to the same family but rescues B cells from apoptosis. To investigate how these opposing actions are cross-linked, purified follicular lymphoma (FL) cells were activated upon a human CD40L-transfected murine fibroblastic layer, then RNA messengers for the above molecules were analysed using RT-PCR. The observed down-modulation of TRAIL and up-regulation of TNF and Fas transcripts might account for CD40-CD40L-mediated FL cell survival.

Cloning and characterization of a novel form of tyrosine hydroxylase from the human parasite, Schistosoma mansoni

Catecholamines such as dopamine and noradrenaline play important roles as neuromuscular transmitters and modulators in all parasitic helminths, including the human parasite, Schistosoma mansoni. We have cloned a novel S. mansoni tyrosine hydroxylase (SmTH) cDNA that shows high homology to mammalian tyrosine hydroxylase, the enzyme that catalyzes the first and rate-limiting step in the biosynthesis of catecholamines. Two subsets of SmTH transcripts were identified, one of which carries the S. mansoni spliced-leader (SL) sequence at its 5' end, whereas the other does not appear to be trans-spliced to the S. mansoni SL. The two types of SmTH transcripts encode the same protein of 465 amino acids and a predicted size of 54 kDa. Expression of SmTH as an N-terminal histidine fusion protein in Escherichia coli produced an active enzyme that was purified approximately 52-fold to apparent homogeneity and had a final specific activity of 0.78 micromol/min/mg. The purified enzyme was found to have the same absolute requirement for a tetrahydrobiopterin cofactor and the same sensitivity to inhibition by high concentrations of the substrate, tyrosine, as the mammalian enzyme. Purified SmTH also showed characteristic inhibition by catecholamine products, although the sensitivity to product inhibition was lower than that of the mammalian enzyme. This evidence indicates that SmTH encodes a functional tyrosine hydroxylase that has catalytic properties similar to those of the mammalian host's enzyme but may differ in its properties of regulation. This first demonstration of tyrosine hydroxylase in a parasitic helminth further suggests that the parasites have the enzymatic capacity to synthesize catecholamines endogenously.

Cloning and sequence analysis of a lysophospholipase homologue from Schistosoma mansoni

A novel cDNA encoding a lysophospholipase (SmLPLH) homologue has been cloned from the human parasite, Schistosoma mansoni. The predicted primary structure of SmLPLH shares high sequence homology with mammalian lysophospholipases (62%) and also contains aconsensus signature peptide (GXSXG), which is present in all lipases. Two splice variants of SmLPLH that differ by 32 N-terminal amino acids were identified. The shorter truncated species carries a conserved S. mansoni spliced leader (SL) sequence at its 5' end and is believed to be formed by trans-splicing of the SL to an internal exon splice site. The functional significance of these two isoforms of SmLPLH is currently unknown.

[Scleredema, acanthosis nigricans and IgA/Kappa multiple myeloma]

BACKGROUND

Scleredema is an uncommon disease of unknown origin. Characteristic thick skin with symmetrical diffuse induration develops. The infiltration begins on the face and neck then extends to the root of the upper limbs and trunk. There are three clinical types of scleredema. The first is preceded by an upper airway infection and progresses rapidly before regressing spontaneously within a few months. The second type is associated with chronic diabetes. The third type is associated with monoclonal gammapathy, rarely of myelomatous type, and develops insidiously. Acanthosis nigricans can be a paraneoplastic syndrome, often associated with a gastrointestinal cancer. Few cases associating scleredema and acanathosis nigricans have been reported.

CASE REPORT

A 56-year old woman had developed scleredema over the last 6 years when acanthosis nigricans appeared together with IgA kappa multiple myeloma. Treatment with melphalan and prednisolone was effective against the myeloma as well as the scleredema and acanthosis nigricans.

DISCUSSION

Only five cases of associated scleredema and multiple myeloma have been reported, four with kappa IgG myeloma and one with IgA myeloma. An association between acanthosis nigricans and sclerederma could be coincidental although the fact that the different manifestations regressed together after the myeloma treatment would suggest some relationship between these three diseases.

[Leisure and recreation in a clinical unit: what the participating patients think and feel about it]

This paper is a report of experience, accomplished with intern patients at two units of a University Hospital (H.U.), whose main objective was identifying how the intern patients perceived leisure activities and recreation during their hospitalisation, and what was these activities effect on the patients involved.

Plasma levels of tumour necrosis factor and its soluble receptors correlate with clinical features and outcome of Hodgkin's disease patients

A prospective study was performed to assess the use of plasma measurement of tumour necrosis factor (TNF), lymphotoxin alpha (LT alpha) and their soluble receptors (p55 and p75) for prognostic risk assignment in 61 patients with Hodgkin's disease. Plasma levels of TNF, p55 and p75, but not of LT alpha, were higher in Hodgkin's disease patients than in healthy controls. Plasma levels of TNF, p55 and p75 were associated with several prognostic factors for Hodgkin's disease, including those related to the host (age, performance status) and to the tumour (disease stage, extranodal site involvement, bulky tumour, serum levels of LDH and beta2-microglobulin, histology). Elevated plasma levels of TNF, p55 and p75 were also associated with several parameters reflecting an immune activation, including the presence of B symptoms, elevated serum levels of gammaglobulins, alkaline phosphatase and fibrinogen, as well as peripheral monocytosis, anaemia and low serum albumin levels. Finally, elevated TNF ligand receptor plasma markers were associated with a lower incidence of complete response to therapy and predicted shorter free-from-progression survival and overall survival of the patients. These results indicate that the plasma levels of TNF and its soluble receptors correlate with clinical features and outcome of patients with Hodgkin's disease.

Genetic polymorphisms in the tumor necrosis factor locus influence non-Hodgkin's lymphoma outcome

Systemic release of tumor necrosis factor (TNF) and lymphotoxin-alpha (LTalpha) has been found to contribute to the severity of non-Hodgkin's lymphoma (NHL). We investigated whether genetic polymorphisms in the TNF locus, previously shown to influence TNF and LTalpha genes expression, might contribute to these cytokines production and to the clinical course of NHL. Genomic DNA from 273 lymphoma patients was typed for TNF (-308) polymorphism using an allele-specific polymerase chain reaction (PCR) and for LTalpha (+252) polymorphism with a PCR-based restriction fragment length polymorphism. The presence of the TNF allele involved in increased TNF gene transcription was associated with higher plasma levels of this cytokine at the time of lymphoma diagnosis (chi2 test, P = .013). An extended haplotype analysis showed that the presence of at least two TNF or LTalpha high-producer alleles constituted a risk factor for first-line treatment failure (chi2 test, P = .021), shorter progression-free survival (log-rank test, P = .0007), and overall survival (log-rank test, P = .012). In the subgroup of 126 patients with diffuse large-cell lymphoma, the presence of two or more TNF/LTalpha high producing alleles contributed significantly to a higher rate of relapse and progression (log-rank test, P = .045 and P = .027). In multivariate Cox regression models including the variables of the International Prognostic Index, the TNF/LTalpha haplotype status was found to be an independent risk factor for progression-free survival (relative risk 2.33, 95% confidence interval [1.17 to 4.64], P = . 0053) and overall survival (relative risk 1.92, 95% confidence interval [0.63 to 5.80], P = .081) of large-cell lymphoma patients. These results indicate that genetic polymorphism leading to increased TNF production influences the outcome of NHL and suggest a pathophysiological role for the genetic control of the immune response in lymphoid malignancies.

Granulocyte-macrophage colony-stimulating factor in post-remission therapy of acute myeloid leukemia

The impact on occult leukemia of GM-CSF as a sensitizing agent has not been studied. We treated 41 adult patients with de novo acute myeloid leukemia, 25 of whom achieved complete remission and were given 1 to 3 post-remission courses, each course including GM-CSF begun 4 days prior to chemotherapy and given until day 3. After a median follow-up of 32 months, the probability of remaining in continuous complete remission was 17% at 46 months. GM-CSF in this setting was not associated with an improved outcome, arguing against a priming effect.

Ivermectin resistance in nematodes may be caused by alteration of P-glycoprotein homolog

Resistance to ivermectin and related drugs is an increasing problem for parasite control. The mechanism of ivermectin resistance in nematode parasites is currently unknown. Some P-glycoproteins and multidrug resistance proteins have been found to act as membrane transporters which pump drugs from the cell. A disruption of the mdrla gene, which encodes a P-glycoprotein in mice, results in hypersensitivity to ivermectin. Genes encoding members of the P-glycoprotein family are known to exist in nematodes but the involvement of P-glycoprotein in nematode ivermectin-resistance has not been described. Our data suggest that a P-glycoprotein may play a role in ivermectin resistance in the sheep nematode parasite Haemonchus contortus. A full length P-glycoprotein cDNA from H. contortus has been cloned and sequenced. Analysis of the sequence showed 61-65% homology to other P-glycoprotein/multidrug resistant protein sequences, such as mice, human and Caenorhabditis elegans. Expression of P-glycoprotein mRNA was higher in ivermectin-selected than unselected strains of H. contortus. An alteration in the restriction pattern was also found for the genomic locus of P-glycoprotein derived from ivermectin-selected strains of H. contortus compared with unselected strains. P-glycoprotein gene structure and/or its transcription are altered in ivermectin-selected H. contortus. The multidrug resistance reversing agent, verapamil, increased the efficacy of ivermectin and moxidectin against a moxidectin-selected strain of this nematode in jirds (Meriones unguiculatus). These data indicate that a P-glycoprotein may be involved in resistance to ivermectin and other macrocyclic lactones in H. contortus.

A new death receptor 3 isoform: expression in human lymphoid cell lines and non-Hodgkin's lymphomas

Two isoforms encoding the full-length transmembrane death receptor 3 (DR3) were isolated from mRNAs of a panel of human cell lines and tumor tissues obtained from patients with follicular non-Hodgkin's lymphoma. A new DR3 variant (DR3 beta) was characterized by 2 insertions of respectively 20- and 7-base pairs (bp) which result in a predictive translated polypeptide differing from the described DR3 molecule by a 28 amino-acid stretch in the extracellular domain. DR3 was shown to be expressed in all cell lines and lymphoma samples tested, whereas DR3 beta expression was restricted to lymphoid T-cell and immature B-cell lines and to selected cases with follicular lymphoma. These data provide new insight into the molecular heterogeneity of DR3, suggesting the presence of several receptor isoforms that can participate in lymphoid cell homeostasis.

The structure of somatosensory information for human postural control

The goal of the present study was to determine the properties of the somatosensory stimulus that alter its temporal coupling to body sway. Six standing subjects were tested while touching a metal plate positioned either directly in front of or lateral to the subject. In each condition, the plate moved 4 mm at 0.2 Hz in either the medial-lateral (ML) or anterior-posterior direction (AP). The results showed that coupling between body sway and touch plate movement was strongest when the touch plate moved in a direction along the longitudinal axis of the arm. Coupling strength was weaker when the touch plate moved perpendicular to the longitudinal axis of the arm. The results consistently show that a radial expansion stimulus was more effective than a lamellar-type stimulus at the fingertip. Moreover, somatosensory information from a surface is interpreted in terms of the orientation of the contact limb and the potential degrees of freedom available through its movement.

Tyrosine hydroxylase: mechanisms of oxygen radical formation

A new mechanism of oxygen radical formation in dopaminergic neurons is proposed, based on the oxidative mechanism of tyrosine hydroxylase. The cofactor (6R,6S)-5,6,7,8-tetrahydrobiopterin can rearrange in solution which allows an autoxidation reaction producing O2.-, H2O2 and HO.. The combination of tyrosine hydroxylase and the cofactor produces more oxygen radicals than does the autoxidation of the cofactor. This production of oxygen radicals could be damaging to dopaminergic neurons. In the presence of tyrosine, the enzyme produces less radicals than it does in the absence of tyrosine. Mechanisms are proposed for the generation of reactive oxygen species during the autoxidation of the cofactor and during enzymatic catalysis. The generation, by tyrosine hydroxylase, of very small amounts of oxygen radicals over the period of 65 years could contribute to the oxidative stress that causes Parkinson's disease.

[Tuberculosis lymphadenitis in slaughtered swine from the State of São Paulo, Brazil: microscopic histopathology and demonstration of mycobacteria]

INTRODUCTION

As the occurrence of tuberculosis lymphadenitis in swine constitutes a public health risk, especially in immunosuppressed individuals, the distribution of tuberculoid lesions and the presence of microbacteria in lymph nodes and hepatic and muscular tissue in swine for slaughter, in the State of S. Paulo, SP (Brazil), in the period from 1993 to 1994, were studied. MATERIAL E METHOD: Tuberculous lesions in 60 carcasses of swine, slaughtered at abattoirs during the period 1993-1994, were studied. When macroscopic lesions were observed, a representative sampling of lymph nodes, hepatic and muscular tissues (masseter and diaphragm) were examined using histopathological and microbacterial isolation techniques.

RESULTS

The macroscopic lesions were found predominantly in mesenteric lymph nodes. The MAI Complex (M.avium-intracellulare) was isolated mainly in the carcass group that showed lesions and was not found in the control group. Microorganisms of the MAI Complex were not isolated from hepatic and muscular tissues.

CONCLUSION

No clear relationship between the type of mycobacteria isolated and the macroscopic lesions observed during the carcass inspection was found.

Candidemia in acute leukemia patients

Fungal infections are an important cause of morbidity and mortality in patients with acute leukemia (AL). Candidemia, once rare, is now a common nosocomial infection because of the intensity of chemotherapy, prolonged neutropenia, administration of broad-spectrum antibiotics and use of central venous catheters (CVC). We retrospectively identified patients treated for AL from 6/86 to 6/95 who also had candidemia. We describe 28 patients (incidence 6.3%) with a median age of 39 years, 24 of whom were on remission induction and 4 on postremission chemotherapy. All patients had CVC and empiric antimicrobial therapy, 4 had been given prophylactic antifungal drugs, and 2 had parenteral nutrition. Neutropenia was profound (median leukocyte nadir 200/microliters, median duration 19 days). Candida was isolated in blood cultures 10 days (median) after the start of neutropenia. The clinical presentation included fever (100%), respiratory symptoms (71.4%), skin lesions (39.2%) and septic shock (17.8%). Amphotericin B was given to 17 patients and liposomal amphotericin to 5 patients. Infection resolved in 18 patients (64.2%). 10 of whom were in complete remission. Mortality from candidemia was 17.8% (5/28). In conclusion, fungal infections are responsible for death in a significant number of patients. In our series treatment success was related to its rapid onset and to the recovery of neutropenia.

Coupling of fingertip somatosensory information to head and body sway

Light touch contact of a fingertip with a stationary surface can provide orientation information that enhances control of upright stance. Slight changes in contact force at the fingertip provide sensory cues about the direction of body sway, allowing attenuation of sway. In the present study, we asked to which extent somatosensory cues are part of the postural control system, that is, which sensory signal supports this coupling? We investigated postural control not only when the contact surface was stationary, but also when it was moving rhythmically (from 0.1 to 0.5 Hz). In doing so, we brought somatosensory cues from the hand into conflict with other parts of the postural control system. Our focus was the temporal relationship between body sway and the contact surface. Postural sway was highly coherent with contact surface motion. Head and body sway assumed the frequency of the moving contact surface at all test frequencies. To account for these results, a simple model was formulated by approximating the postural control system as a second-order linear dynamical system. The influence of the touch stimulus was captured as the difference between the velocity of the contact surface and the velocity of body sway, multiplied by a coupling constant. Comparison of empirical results (relative phase, coherence, and gain) with model predictions supports the hypothesis of coupling between body sway and touch cues through the velocity of the somatosensory stimulus at the fingertip. One subject, who perceived movement of the touch surface, demonstrated weaker coupling than other subjects, suggesting that cognitive mechanisms introduce flexibility into the postural control scheme.

pS2 protein expression in gastric carcinoma. An immunohistochemical and immunoradiometric study

The aim of this study was to examine the prevalence of pS2 expression in gastric carcinoma and to determine its prognostic significance. We analysed pS2 protein expression in 50 gastric carcinomas and respective adjacent mucosas by immunohistochemistry and immunoradiometric assay (IRMA). pS2 was consistently expressed in superficial and foveolar epithelium of non-neoplastic mucosa and in 66.0% of the carcinomas. pS2 immunoreactivity was significantly higher in diffuse than in intestinal carcinomas, and in those cases with nodal metastases than in those without. No correlation was found between pS2 immunostaining and gender, age, staging, depth of wall penetration, venous invasion, ploidy and S-phase fraction. The mean levels of pS2 (IRMA) were significantly lower in gastric carcinomas than in non-neoplastic mucosas, and were not correlated with any of the aforementioned clinicopathological features. The survival of patients with pS2-positive tumours was not significantly different from that of patients with pS2-negative tumours. We conclude that pS2 expression, which can be used as a marker of gastric-type differentiation, is associated with gastric carcinoma of diffuse type. The lack of correlation between pS2 expression and most features of tumor aggressiveness and patients' survival precludes its use as a prognostic tool in gastric carcinoma.

[Asialotransferrin discriminating excessive, subacute and chronic active alcohol consumption. Clinical usefulness in hepatic disease]

The determination of serum levels of carbohydrate deficient transferrin (CDT) and transferrin ratio in the persistent abusive alcohol consumer arises with promising utility in the study of alcohol related disorders. This series shows the excellent specificity (97%), though poor sensitivity (52%), for CDT. However the CDT/Tft ratio affords a higher sensitivity, reaching 74%, maintaining the high specificity. In persistent abusive consumers (> 70 g/day) this index, which is positively correlated with serum transferrin, is capable of defining these amounts of alcohol per capita with a high frequency and provides independent information since it is not significantly correlated with the levels of traditional biological markers (AST, ALT, GGT, AGV). Although with defined methodological limitations, these indexes denote, with the improvement of technical accessibility, a practical applicability in the screening of chronic abusive consumers. In the field of hepatology the behaviour of CDT and the transferrin ratio is capable of showing the involvement of ethanol in the study of the nature of a chronic hepatic disease with a high frequency. However, the degree of liver lesion show by the PGA hepatic index, has no significant influence on the serum levels of CDT and the transferrin ratio. In this series, the circumstances and conditions of alcohol consumption seem to be the independent determinant of the informative character which these indexes reveal.

Aortic coarctation with two intercostal aneurysms, appearing radiographically as a subclavian aneurysm. A case report

The authors present a case of adult aortic coarctation with two associated intercostal aneurysms and poor left ventricular function. The intercostal aneurysms appear, radiographically, as a subclavian aneurysm. The case illustrates, in aortic coarctation, the potential difficulty in defining the anatomy of the associated vascular aneurysms. The authors also demonstrate that the left ventricular function markedly improves after resection of the aortic coarctation.