Lack of efficacy of atenolol for the prevention of neurally mediated syncope in a highly symptomatic population: a prospective, double-blind, randomized and placebo-controlled study

OBJECTIVES

This study was designed to evaluate the efficacy of atenolol for the long-term management of patients with vasovagal syncope. The primary hypothesis was that atenolol is not superior to placebo for the treatment of vasovagal syncope.

BACKGROUND

There is no definitive well-controlled analysis of the efficacy of beta-adrenergic blocking agents in patients with recurrent vasovagal syncope.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled study. Fifty patients with recurrent vasovagal syncope were included (at least two episodes in the last year). A baseline tilt test was performed. Twenty patients (40%) had a positive tilt test. Intravenous atenolol prevented a second positive tilt in five patients. The patients were randomized to receive either atenolol or a placebo (26 patients atenolol 50 mg/day, 24 patients placebo). The follow-up procedure lasted one year. The primary end point of the study was the time to first recurrence of syncope.

RESULTS

In the intention-to-treat analysis, the group treated with atenolol had a similar number of patients with recurrent syncopal episodes as the placebo group. The Kaplan-Meier actuarial estimates of time to first syncopal recurrence showed that the probability of remaining free of syncope drops similarly in both groups and that there was no statistical difference between both curves (patients treated with atenolol vs. the placebo) with a log-rank test p value of 0.4517.

CONCLUSIONS

The recurrence of neurocardiogenic syncope in highly symptomatic patients treated with atenolol is similar to that of patients treated with placebo.

Sonographic findings in brucellar hepatic abscess

Brucellar hepatic abscesses are rare; to our knowledge, only 41 cases have been described in the literature. We report the case of a 29-year-old Spanish woman who was hospitalized because of fever, weakness, and weight loss. Abdominal sonography showed a hypoechoic lesion with central calcification. Brucella spp. were not isolated from an aspirate of the liver or blood cultures. The diagnosis was based on the association of characteristic sonographic features (central calcification and peripheral necrotic areas) and positive Brucella agglutination tests. The patient improved rapidly with antibiotic treatment.

[Yield of transthoracic echocardiography with high frequency transducer in the study of the anterior descending coronary artery]

INTRODUCTION AND OBJECTIVES

This study was performed to evaluate the feasibility and utility of a transthoracic high frequency transducer to detect and measure the left anterior descending coronary artery flow in patients with lesions in this artery or anterior myocardial infarction.

MATERIALS AND METHODS

We studied 11 subjects with lesions greater than 75% and another 10 with anterior myocardial infarction. We compared the results with a control group of 18 subjects. An ATL HDI 5000 ultrasound unit with a 5-8 MHz transducer was used to identify the left anterior descending in the anterior interventricular sulcus from an apical four chamber window. We considered that left anterior descending was detected when a diastolic predominant flow pattern was obtained with pulse Doppler.

RESULTS

Left anterior descending was detected in 37/39 of cases (94.4%). Patients with coronary lesions showed a decrease in the limit of significance in the diastolic/systolic peak velocity ratios: 2.5 (SD 0.7) vs 1.8 (SD 0.3) with a p = 0.024. Patients with anterior myocardial infarction obtained lower diastolic/systolic peak velocity ratios than controls: 2.5 (SD 0.7) vs 1.4 (SD 0.3) with a p = 0.001.

CONCLUSIONS

Left anterior descending coronary artery flow can be assessed by transthoracic high frequency echocardiography in greater than 90% of the cases. Patients with coronary lesions and those with anterior myocardial infarction have a decreased diastolic/systolic peak velocity ratio.

Second-harmonic generation studies in the B2 and B4 phases of a banana-shaped liquid crystal

Second-harmonic generation (SHG) measurements have been performed in the B2 phase of the achiral banana-shaped molecule with n=12 alkoxy end chains (P-12-O-PIMB). A quantitative value of the nonlinear efficiency has been obtained from SHG curves at oblique incidences, taking into account that the signal is generated by a random orientation of different domains. In the B4 phase, circular dichroism, optical absorption and SHG studies have been carried out. It has been found that there are no simple helical arrangements giving rise to selective reflection in the visible region of the spectrum. In addition, some unusual features of the SHG behavior are pointed out. It is concluded that the phase is intrinsically inactive for the SHG process. The detected signal is due to the presence of some birefringent inclusions that are created at the B2 to B4 transition and slowly disappear while the sample is maintained within the B4 phase. A structural model for these inclusions is presented.

Visualization of substrate binding and translocation by the ATP-dependent protease, ClpXP

Binding and internalization of a protein substrate by E. coli ClpXP was investigated by electron microscopy. In sideviews of ATP gamma S-stabilized ClpXP complexes, a narrow axial channel was visible in ClpX, surrounded by protrusions on its distal surface. When substrate lambda O protein was added, extra density attached to this surface. Upon addition of ATP, this density disappeared as lambda O was degraded. When ATP was added to proteolytically inactive ClpXP-lambda O complexes, the extra density transferred to the center of ClpP and remained inside ClpP after separation from ClpX. We propose that substrates of ATP-dependent proteases bind to specific sites on the distal surface of the ATPase, and are subsequently unfolded and translocated into the internal chamber of the protease.

A quantitative study of fault tolerance, noise immunity, and generalization ability of MLPs

An analysis of the influence of weight and input perturbations in a multilayer perceptron (MLP) is made in this article. Quantitative measurements of fault tolerance, noise immunity, and generalization ability are provided. From the expressions obtained, it is possible to justify some previously reported conjectures and experimentally obtained results (e.g., the influence of weight magnitudes, the relation between training with noise and the generalization ability, the relation between fault tolerance and the generalization ability). The measurements introduced here are explicitly related to the mean squared error degradation in the presence of perturbations, thus constituting a selection criterion between different alternatives of weight configurations. Moreover, they allow us to predict the degradation of the learning performance of an MLP when its weights or inputs are deviated from their nominal values and thus, the behavior of a physical implementation can be evaluated before the weights are mapped on it according to its accuracy.

Epidemiology of paragonimiasis in Colombia

Five newly discovered endemic foci for paragonimiasis in Colombia are described for the first time. The disease was diagnosed in 24 people from the Embera Indian communities located at the Colombian Pacific Coast and investigated in 1993-98. We also describe the clinical, epidemiological and treatment response aspects. In these foci an Aroapyrgus sp. snail different from A. colombiensis was found to be the first intermediate host, and the crab Hypolobocera emberarum nsp. the second intermediate host.

[Left ventricular pseudoaneurysm with a fistula to right ventricle following previous repair of septal defect after acute myocardial infarction]

A case of left ventricular pseudoaneurysm with a fistula to right ventricle is presented. It appeared following the repair of a ventricular septal defect after acute myocardial infarction. The left ventricular pseudoaneurysm is associated, in most cases, with acute myocardial infarction. However, we should not forget surgery as aetiology of this pathology. The most frequent post-surgery pseudoaneurysms appear after aneurysmectomy and after mitral valve replacement. They tend to develop fistulas which differ from post acute myocardial infarction pseudoaneurysms. Few cases have been described following the repair of septal defect and none of them complicated with a fistula to right ventricle, as in our case.

Statement of current majority practices in graft-versus-host disease prophylaxis and treatment in children

Great variations exist in the prophylaxis and treatment of GVHD in children undergoing allogeneic stem cell transplantation (SCT). The EBMT Working Party Paediatric Diseases (EBMT-WP PD) and the International BFM Study Group--Subcommittee Bone Marrow Transplantation (IBFM-SG), aimed at evaluating current local standards in the prevention and treatment of GVHD and steps which can be taken to achieve a uniform policy for the individual methods. Several conferences with their members assessed practices which are mainly applied or under investigation in children and identified where additional information is needed. For prevention of GVHD, the majority of the paediatric centres prefer CsA +/- MTX. Addition of folinic acid to MTX was considered for reduction of side-effects. During treatment of acute GVHD most centres administer prednisolone and whole blood level-adjusted CsA as medications of first choice. In cases of poor or no response to this therapy, additional immunosuppressive agents such as ATG, mycophenolate-mofetile and tacrolimus are being increasingly used. The treatment of chronic GVHD usually consists of various combinations of prednisolone and CsA. In severe cases, extracorporeal photopheresis, psoralene-UVA (PUVA) and thalidomide are administered.

Comparison between the switching dynamics of homeotropic and planar cells of chiral smectic-C liquid crystals

The molecular dynamics during the switching of homeotropic and planar cells of chiral smectic-C liquid crystals has been investigated using electrooptic measurements and second-harmonic-generation interferometry. Two ferroelectric liquid crystals with great differences in their molecular structures have been studied. It has been found that the molecular motion is rather different depending on the type of cell used. For planar cells, the azimuthal rotation of the molecules is limited within half the smectic cone and the molecules rotate in opposite directions in the two halves of the chevron structure. In contrast, for homeotropic cells there is no chevron structure and a uniform macroscopic optical indicatrix can be defined all over the sample during the whole switching process. However, the molecular reorientation takes place within numerous microdomains of size smaller than the optical wavelength. There are two types of microdomains that occur with different probabilities depending on the material. Within each domain the molecules rotate in opposite directions, and the molecules describe a complete cone during a whole switching period.

Sustained but not transient phytochrome A signaling targets a region of an Lhcb1*2 promoter not necessary for phytochrome B action

Current evidence is inconclusive regarding the point of signaling convergence downstream from different members of the phytochrome family. In transgenic Arabidopsis, the activity of a reporter enzyme under the control of the -453 to +67 fragment of an Lhcb1*2 promoter shows very low fluence responses (VLFRs) and high-irradiance responses (HIRs) mediated by phytochrome A and low-fluence responses (LFRs) mediated by phytochrome B. A 5' deletion of the promoter to -134 abolished the HIR without affecting VLFR or LFR. In transgenic tobacco, VLFR and LFR were observed for the -176 to -31 or -134 to -31 fragments of Lhcb1*2 fused to 35S cauliflower mosaic virus minimal promoters, but only the largest fragment showed HIR. We propose that sustained activation of phytochrome A with far-red light initiates a signaling cascade that deviates from phytochrome B signaling and transient phytochrome A signaling and that this divergence extends as far as the Lhcb1*2 promoter.

Origin of the optical activity of silver thiogallate

Using a high-accuracy universal polarimeter, the birefringence and optical activity of AgGaS2have been determined between 300 and 500 K. The optical rotation has been found to be 94° mm−1at room temperature for a wavelength of 632.8 nm. This value is unexpectedly small if compared with values close to 1000° mm−1at 485 nm reported previously. The present optical data are well explained using a point-dipole model for the calculation of the refractive indices and optical activity. The main contributors to the optical rotation are the S atoms. However, these atoms are not at positions especially suitable to promote extremely large gyrations. Consequently, the size of the optical rotation reported before in the blue part of the spectrum is presumably due to the existence of a circular dichroism band close to that region. Using an optical system based on a photoelastic modulator, a strong linear dichroism peak has been measured in the range 450–500 nm. This fact has prevented reliable measurement of the circular dichroism.

The replication activity of influenza virus polymerase is linked to the capacity of the PA subunit to induce proteolysis

The PA subunit of the influenza virus polymerase complex is a phosphorylated protein that induces a proteolytic process that decreases its own accumulation levels and those of coexpressed proteins. The amino-terminal third of the protein is responsible for the induction of proteolysis. We mutated five potential casein kinase II phosphorylation sites located in the amino-terminal third of the protein. Mutations affecting position 157 almost completely abrogated proteolysis induction, whereas a mutation at position 162 produced a moderate decrease and mutations at positions 151, 200, and 224 did not affect proteolysis induction. Reconstitution of the influenza virus polymerase in vivo with viral model RNA containing the chloramphenicol acetyltransferase (CAT) gene indicated that the CAT activity obtained correlated with the capacity of each PA mutant to induce proteolysis. RNA protection assays of the products obtained with viral polymerase, reconstituted in vivo with model RNAs, indicated that mutations at position 157 led to a selective loss of the ability to synthesize cRNA from the viral RNA template but not to transcribe viral RNA, while a mutation affecting position 162 showed an intermediate phenotype. Collectively, these data provide a link between PA-mediated induction of proteolysis and the replication activity of the polymerase.

Ultrastructural and functional analyses of recombinant influenza virus ribonucleoproteins suggest dimerization of nucleoprotein during virus amplification

Influenza virus ribonucleoproteins (RNPs) were reconstituted in vivo from cloned cDNAs expressing the three polymerase subunits, the nucleoprotein (NP), and short template RNAs. The structure of purified RNPs was studied by electron microscopy and image processing. Circular and elliptic structures were obtained in which the NP and the polymerase complex could be defined. Comparison of the structure of RNPs of various lengths indicated that each NP monomer interacts with approximately 24 nucleotides. The analysis of the amplification of RNPs with different lengths showed that those with the highest replication efficiency contained an even number of NP monomers, suggesting that the NP is incorporated as dimers into newly synthesized RNPs.

A new measurement of noise immunity and generalization ability for MLPs

This paper shows a quantitative relation between the regularization techniques, the generalization ability, and the sensitivity of the Multilayer Perceptron (MLP) to input noise. Although many studies about these topics have been presented, in most cases only one of the problems is addressed, and only experimentally obtained evidence is provided to illustrate some kind of correlation between generalization, noise immunity and the use of regularization techniques to obtain a set of weights after training that provides the corresponding MLP with generalization ability and noise immunity. Here, a new measurement of noise immunity for a MLP is presented. This measurement, which is termed Mean Squared Sensitivity (MSS), explicitly evaluates the Mean Squared Error (MSE) degradation of a MLP when it is perturbed by input noise, and can be computed from the statistical sensitivities (previously proposed) of the output neurons. The MSS provides an accurate evaluation of the MLP performance loss when its inputs are perturbed by noise and can also be considered a measurement of the smoothness of the error surface with respect to the inputs. Thus, as the MSS can be used to evaluate the noise immunity or the generalization ability, it gives a criterion to select among different weight configurations that present a similar MSE after training.

Autologous bone marrow transplantation for high risk acute lymphoblastic leukemia: clinical relevance of ex vivo bone marrow purging with monoclonal antibodies and complement

Herein we describe our experience with 75 consecutive autologous BM transplants for patients with high-risk ALL, with special attention to the clinical impact of BM purging. Fifty-two patients received purged BM using monoclonal antibody (MoAb) cocktails and complement, and 23 patients received untreated BM. The distribution of prognostic factors was similar in both groups. Hemopoietic reconstitution was adequate and did not differ in the two groups. Transplant-related mortality was 9.6% and 13% in 'purged' and 'unpurged' groups. Median follow up was 11 months (2-71) and overall actuarial probability of disease-free survival (DFS) at 5 years was 40% (53% relapse probability). We found a beneficial effect of purging in patients over 15 years of age and in patients needing more than 1 month to reach CR1. Patients in CR1 receiving purged marrow had a longer DFS and a lower relapse probability (52% vs 12%, P = 0.02 and 35% vs 86%, P = 0.005, respectively) which were related to the efficacy of the purging procedure (more or less than one log of depletion). In further CR, no advantage of purging has been found. Our data strongly suggest the clinical relevance of BM purging in autologous BMT in high-risk ALL patients and support the need for prospective randomized studies.

[Status epilepticus in children. Experience with intravenous valproate. Update of treatment guidelines]

INTRODUCTION

The treatment in the acute phase of seizures and status epilepticus is a neurological emergency situation. Aggressive treatment and resuscitation maneuvers against the seizure may be required to avoid progression towards status epilepticus, with the high risk for the patients outcome this involves.

DEVELOPMENT

The use of rectal diazepam has supposed a great advance in the management of acute seizures. Intravenous sodium valproate has become available in these last years to control seizures and status epilepticus. Given at 20 mg/kg as single dose and with maintenance rate of 1 mg/kg/hour by intravenous infusion in 19 paediatric patients (1 day-7 years) status epilepticus was controlled in 58%, with reduction of status in 26%. Tolerance was good and there was no evidence of important adverse effects.

CONCLUSION

In view of our experience, we present a new protocol for the treatment of seizures and status epilepticus in childhood.

[Fibrous craniofacial dysplasia]

A case report of fibrous dysplasia affecting only the craniofacial right side, in a 56-year-old woman, seen in our outpatients Department suffering from fronto-orbital headache and subjective hypoacusis of the right side, besides a syndrome of dizziness of 6 years development.

Effect of zinc supplementation on incidence of infections and hospital admissions in sickle cell disease (SCD)

Zinc deficiency is a common nutritional problem in adult sickle-cell disease (SCD) patients. Hyperzincuria and increased requirement of zinc due to continued hemolysis in SCD are probable bases for zinc deficiency in these patients. Zinc deficiency affects adversely T-helper1 (TH1) functions and cell mediated immunity and interleukin (IL)-2 production is decreased in zinc deficient subjects. We hypothesized that zinc supplementation will improve T-helper1 function and decrease incidence of infections in patients with SCD. We tested this hypothesis in 32 SCD subjects who were divided in three groups (Grs A, B, and C). Grs A (n = 11) and B (n = 10) were zinc deficient based on cellular zinc criteria and Gr C (n = 11) were zinc sufficient. Gr A subjects were observed for 1 year (baseline), following which they received zinc acetate (50 to 75 mg of elemental zinc orally daily) for 3 years. Gr B subjects were observed for 1 year (baseline), following which they received placebo for 1 year and then switched to zinc supplementation (50 to 75 mg of elemental zinc orally daily) for 2 years. Gr C subjects did not receive any intervention inasmuch as they were zinc sufficient. Prolonged zinc supplementation resulted in an increase in lymphocyte and granulocyte zinc (P = 0.0001), and an increase in interleukin-2 production (P = 0.0001), decreased incidence of documented bacteriologically positive infections (P = 0.0026), decreased number of hospitalizations and decreased number of vaso-occlusive pain crisis (P = 0.0001). The predominant pathogens isolated were staphylococci and streptococci involving the respiratory tract and aerobic gram-negative bacteria, particularly Escherichia coli, involving the urinary tract. Further confirmation of our observations will require prospective studies of zinc supplementation in a larger number of SCD patients.

Factors associated with outcome after cord blood transplantation in children with acute leukemia. Eurocord-Cord Blood Transplant Group

We have analyzed factors influencing the outcome of 102 children with acute leukemia given a cord blood transplantation (CBT) and reported to the Eurocord Registry. Seventy patients with acute lymphoblastic and 32 with acute myeloid leukemia were given either a related (n = 42) or an unrelated (n = 60) CBT. Children given CBT during first or second complete remission were considered as belonging to the good-risk group (n = 66), whereas those who received a transplant in a more advanced stage of disease were assigned to the poor-risk group (n = 36). In the related group (RCBT), 12 of 42 patients received transplantation from an HLA-disparate donor, whereas in the unrelated group (UCBT) 54 of 60 received an HLA mismatched CBT. Kaplan-Meier estimates for neutrophil recovery at day 60 were 84% +/- 7% in RCBT and 79 +/- 6% in UCBT (P =.16). In multivariate analysis, the most important factor influencing neutrophil engraftment in UCBT was a nucleated cell dose infused greater than 3.7 x 10(7)/kg (P =.05, relative risk [RR] of 1.85, 95% confidence interval [CI]: 0.98-3.4). The incidence of grade II through IV acute graft-versus-host disease was 41% +/- 8% in the RCBT group and 37% +/- 6% in the UCBT group (P =.59). Kaplan-Meier estimates of 2-year event-free survival (EFS) after RCBT or UCBT were 39% +/- 8% and 30% +/- 7%, respectively (P =.19). In multivariate analysis, the most important factor influencing EFS was disease status at time of transplantation: good-risk patients had a 2-year EFS of 49% +/- 7% as compared to 8% +/- 5% in patients with more advanced disease (P =.0003, RR: 0.40, 95% CI: 0.24 to 0. 65). This was a consequence of both an increased 1-year transplant related mortality and a higher 2-year relapse rate in the poor-risk group (65% +/- 9% and 77% +/- 14%, respectively), as compared with good risk patients (34% +/- 6% and 31% +/- 9%, respectively). These data confirm that allogeneic CBT from either a related or an unrelated donor is a feasible procedure able to cure a significant proportion of children with acute leukemia, especially if transplanted in a favorable phase of disease.

Myelodysplastic and myeloproliferative disorders of childhood: a study of 167 patients

Myelodysplastic syndromes (MDS) and myeloproliferative syndromes (MPS) of childhood are a heterogeneous group of clonal disorders of hematopoiesis with overlapping clinical features and inconsistent nomenclature. Although a number of genetic conditions have been associated with MDS and MPS, the overall contribution of inherited predispositions is uncertain. We report a retrospective study examining clinical features, genetic associations, and outcomes in 167 children with MDS and MPS. Of these patients, 48 had an associated constitutional disorder. One hundred one patients had adult-type myelodysplastic syndrome (A-MDS), 60 had juvenile myelomonocytic leukemia (JMML), and 6 infants with Down syndrome had a transient myeloproliferative syndrome (TMS). JMML was characterized by young age at onset and prominent hepatosplenomegaly, whereas patients with A-MDS were older and had little or no organomegaly. The most common cytogenetic abnormalities were monosomy 7 or del(7q) (53 cases); this was common both in patients with JMML and those with A-MDS. Leukemic transformation was observed in 32% of patients, usually within 2 years of diagnosis. Survival was 25% at 16 years. Favorable prognostic features at diagnosis included age less than 2 years and a hemoglobin F level of less than 10%. Older patients tended to present with an adult-type MDS that is accommodated within the French-American-British system. In contrast, infants and young children typically developed unique disorders with overlapping features of MDS and MPS. Although the type and intensity of therapy varied markedly in this study, the overall outcome was poor except in patients with TMS.

Recommendations on the use of colony-stimulating factors in children: conclusions of a European panel

During 1996 and 1997 a panel of European haematologists, oncologists, and neonatologists developed specific paediatric guidelines for the use of colony stimulating factors based on published literature and the clinical experience of these specialists within each of 13 countries. Well established indications for use comprise intervention in patients with life-threatening infection, adjunctive therapy post autologous bone marrow transplantation (BMT), mobilization of peripheral blood progenitor cells for autologous BMT, patients with acquired aplastic anaemia on anti-lymphocyte globulin and cyclosporin regimen, and severe congenital neutropenia. Less clear indications include primary prophylaxis to support dose intensification in children with high risk/advanced malignancies, secondary prophylaxis to prevent neutropenia in patients with a history of severe neutropenia, support therapy in cases of poor marrow function following BMT and for deteriorating marrow function following successful BMT, in neonatal sepsis and non infectious neonatal neutropenia, in drug induced neutropenia and in HIV-positive patients. Treatment is generally well tolerated and granulocyte colony stimulating factor appears better tolerated than granulocyte and macrophage colony stimulating factor. Economically colony stimulating factors have not been shown to induce excessive costs for a given patient.

CONCLUSION

In general the adult guidelines are applicable to children but additional considerations (aggressive or very progressive childhood neoplasms, specific indications, neonatal use, congenital disorders) must be taken into account.

Biochemical markers and cardiac troponin I release after radiofrequency catheter ablation: approach to size of necrosis

BACKGROUND

We designed this study to determine the value of serum levels of several cardiac markers in patients who underwent radiofrequency ablation and to establish the utility of cardiac troponin I (cTnI). After radiofrequency ablation there is always a small localized endomyocardial necrosis. The volume of the necrosis may be estimated by the rise of several biochemical marker levels, classically creatinine kinase (CK) and CK-MB. cTnI is a newly available biochemical marker with a high cardiac specificity.

METHODS AND RESULTS

We analyzed the data from 51 patients who underwent radiofrequency ablation and from 16 control patients who underwent an electrophysiologic study without ablation. The levels of CK, CK-MB mass, cTnI, and myoglobin were compared with clinical findings, ST-T wave abnormalities, and the presence of arrhythmias. The study shows that there is a higher release of cTnI compared with the standard markers CK, CK-MB, and myoglobin. A pathologic value of cTnI was found in 92% of the patients of the ablation group. CK-MB had a lower sensitivity (63%). The area under the receiver operating characteristic curve for cTnI was 0.9375, significantly superior to the other biochemical markers (P <.05). We found a moderate level of correlation between the number of radiofrequency pulses and cardiac cTnI release (r = 0.69, P <.0001).

CONCLUSIONS

The serum level of cTnI detects the minor myocardial damage produced by radiofrequency ablation. This would be useful information to have in patients who might have the potential for other ischemic events. The other biochemical or ablation parameters usually reported, including the radiofrequency ablation parameters, have no good correlation with the size of the myocardial necrosis. Therefore we suggest that monitoring of cTnI is the best way to detect and quantify the size of myocardial necrosis created by radiofrequency ablation.

Cord blood transplantation for children with acute leukemia. Eurocord Transplant Group

Over the past decade, allogeneic cord blood transplantation (CBT) has been widely used for treating patients with malignant disorders. However, the reported low incidence of GVHD observed after allogeneic CBT might be a major drawback in leukemic recipients and at present it is not clear whether CBT really predisposes patients to an increased risk of leukemia relapse. In order to further elucidate the role of CBT in children with hematological malignancies, 54 patients with ALL or AML given either a related (31 cases) or an unrelated (23 cases) CBT in 25 centers participating in the Eurocord Registry were analyzed. Overall survival of related and unrelated CBT recipients was substantially similar, the most important factor influencing patients' outcome being disease state at time of transplantation. In fact, due to a markedly increased relapse rate, poor-risk children (ie patients transplanted in more advanced disease) experienced a significantly worse EFS than those given CBT in a more favorable disease phase (ie CR1 or CR2). These data confirm that allogeneic CBT from either a related or an unrelated donor is a feasible procedure able to cure a significant proportion of children with acute leukemia, especially if transplanted in a favorable phase of disease.

Dye affinity adsorbent replacement optimization

A method to determine the optimal replacement time for dye affinity adsorbents used in protein purification processes that are subjected to severe regeneration conditions has been developed. To demonstrate the utility of the method, an experimental fixed-bed decay model was employed to determine the optimum number of cycles for the adsorbent replacement. This number is a function of the column regeneration frequency and of the capital and operation costs. The implications of the results on the design and operation of dye-ligand chromatographic processes are discussed.

[Electromagnetic interference between automatic defibrillators and digital and analog cellular telephones]

BACKGROUND AND OBJECTIVES

Functional pacemaker interference by mobile telephones has been described with analogical systems and with possible greater influence, digital systems, including inhibition and inadequate pacing. The influence of both system has not been extensively studied in patients with implantable cardioverter defibrillators (ICD).

PATIENTS AND METHODS

We studied the influence of mobile phones, both digital and analogic network, on the performance of several models of defibrillators, in a standardised test set up designed to provide high sensitivity. The purpose of our study was to establish whether there are any influences on ICD functions, both in in vivo and in in vitro models. Several mobile phones, with different transmission powers, were moved towards the defibrillator and the electrode, under continuous documentation of defibrillator sensing and interrogation afterwards. The experimental model was performed with the aid of an arrhythmia simulator (Intersim) and demo-defibrillators. The tests were repeated both in and out of a solution of saline water with an impedance within normal human limits.

RESULTS

Partial loss of telemetry was found in 14 patients, 8 with analogical phones and 6 with digital phones. Fourteen patients showed alterations only on the surface electrocardiogram channel and five on the intracavitary channel. The same results were reproduced in the in vitro model. However, the in vitro test allowed us to simulate multiple ventricular arrhythmias, and demonstrate the normal sensing and functioning of the defibrillator during a "spontaneous" arrhythmia. After testing, we demonstrate that no real oversensing/undersensing was documented in any device. There was no evidence of ICD reprogramming or pacing inhibition. In particular, no inadequate therapies were delivered.

CONCLUSIONS

a) in our series, we have not demonstrated clinically significant electromagnetic interferences with mobile phones of digital or analogical networks: b) the in vitro model allowed us to conclude that even if a spontaneous arrhythmia appears, the function of the defibrillator is not altered; c) the use of mobile phones seems to be safe for defibrillator patients, and d) however, some basic rules, such as to maintain the phone at least 15 cm away from the defibrillator, are advised.

[Ellis-van Creveld syndrome: an easy early diagnosis?]

Ellis-Van Creveld syndrome is a rare chondroectodermal dysplasia. Congenital heart disease is present in more than one-half of cases. The majority are partial atrioventricular septal defects and affect the atrial septum. Although isolated cases of the syndrome are uncommon, an early diagnosis is made in most of the patients because of their cardinal manifestations. The cases of two gypsy brothers with Ellis-Van Creveld syndrome and congenital heart disease (ostium primum atrial septal defect and single atrium), diagnosed during adulthood, are presented.

The PA influenza virus polymerase subunit is a phosphorylated protein

The induction of proteolysis by expression of the influenza virus PA polymerase subunit is the only biochemical activity ascribed to this protein. In the course of studying viral protein synthesis by two-dimensional gel electrophoresis, we observed the existence of several PA isoforms with different isoelectric points. These isoforms were also present when the PA gene was singly expressed in three different expression systems, indicating that a cellular activity is responsible for its post-translational modification. In vivo labelling with [32P]orthophosphate, followed by two-dimensional gel electrophoresis, clearly demonstrated the incorporation of phosphate into the PA molecule. Phosphoserine and phosphothreonine epitopes were present in PA, while phosphotyrosine residues were absent, as tested by immunoblotting with specific antibodies. These facts, as well as the presence of multiple consensus sites for casein kinase II (CKII) phosphorylation, prompted us to test the involvement of this kinase in PA covalent modification. PA protein purified by immunoprecipitation could be specifically labelled by the catalytic alpha subunit of human CKII, which was expressed and purified from bacteria. Collectively, these data demonstrate that the PA subunit of the influenza virus RNA polymerase is a phosphoprotein.

Outcome of cord-blood transplantation from related and unrelated donors. Eurocord Transplant Group and the European Blood and Marrow Transplantation Group

BACKGROUND

Cord-blood banks have increased the use of cord-blood transplantation in patients with hematologic disorders. We have established a registry containing information on the outcome of cord-blood transplantation.

METHODS

We sent questionnaires to 45 transplantation centers for information on patients receiving cord-blood transplants from 1988 to 1996. Reports on 143 transplantations, performed at 45 centers, were studied, and the responses were analyzed separately according to whether the donor was related or unrelated to the recipient.

RESULTS

Among 78 recipients of cord blood from related donors, the Kaplan-Meier estimate of survival at one year was 63 percent. Younger age, lower weight, transplants from HLA-identical donors, and cytomegalovirus-negative serologic results in the recipient were favorable prognostic factors. Graft-versus-host-disease of at least grade II occurred at estimated rates of 9 percent in 60 recipients of HLA-matched cord blood and 50 percent in 18 recipients of HLA-mismatched cord blood. Neutrophil engraftment was associated with an age of less than six years (P = 0.02) and a weight of less than 20 kg (P = 0.02), and it occurred in 85 percent of patients receiving 37 million or more nucleated cells per kilogram of body weight. Among 65 patients who received cord blood from unrelated donors, the Kaplan-Meier estimate of survival at one year was 29 percent. Cytomegalovirus-negative serologic status in these recipients was associated with improved survival (P = 0.03) and was the most important predictor of graft-versus-host disease (P = 0.04). Neutrophil recovery occurred in 94 percent of the patients who received 37 million or more nucleated cells per kilogram from unrelated donors.

CONCLUSIONS

Cord blood is a feasible alternative source of hematopoietic stem cells for pediatric and some adult patients with major hematologic disorders, particularly if the donor and the recipient are related.

Immunomagnetic bone marrow purging in children with acute lymphoblastic leukemia

Autologous bone marrow transplantation (ABMT) offers a therapeutic alternative for children with poor prognosis acute lymphoblastic leukemia (ALL) who lack an HLA-matched sibling donor. The most common cause of treatment failure after ABMT in these patients is leukemia relapse. We have developed an ex vivo autologous marrow purging program for children with ALL using an immunomagnetic method. BM purging has been performed in 37 children with ALL (31 B-lineage ALL and 6 T-lineage ALL) following an indirect method, using panels of mouse monoclonal antibodies (MAbs) directed against B or T cell antigens, Dynabeads M-450 (Dynal) coated with sheep antimouse (SAM) antibodies, and the MaxSep Magnetic Cell Separator (Baxter). Purging efficiency has been assessed by flow cytometry. Considering the limit of detection of target cells 0.1%, the median depletion was 2.0 log (range 0.8- > 2.8 log) for the B-lineage ALL and 2.7 (range 2.2- > 2, 9 log) for the T-lineage ALL patients. Twenty-seven patients have been autografted (6 in first complete remission, CR, 13 in second CR, and 8 in third or subsequent CR). Engraftment has been satisfactory in all of them, reaching levels of 500 neutrophils/mm3 and 20,000 platelets/mm3 after a median of 17 (range 12-39) and 30 (range 13-96) days post-ABMT, respectively. In summary, our results show that this immunomagnetic procedure achieves high levels of target cell depletion and can be safely applied to bone marrow purging in childhood ALL patients.

Expressed sequences from conidial, mycelial, and sexual stages of Neurospora crassa

In the Neurospora Genome Project at the University of New Mexico, expressed sequence tags (ESTs) corresponding to three stages of the life cycle of the filamentous fungus Neurospora crassa are being analyzed. The results of a pilot project to identify expressed genes and determine their patterns of expression are presented. 1,865 partial complementary DNA (cDNA) sequences for 1,409 clones were determined using single-pass sequencing. Contig analysis allowed the identification of 838 unique ESTs and 156 ESTs present in multiple cDNA clones. For about 34% of the sequences, highly or moderately significant matches to sequences (of known and unknown function) in the NCBI database were detected. Approximately 56% of the ESTs showed no similarity to previously identified genes. Among genes with assigned function, about 43.3% were involved in metabolism, 32.9% in protein synthesis and 8.4% in RNA synthesis. Fewer were involved in defense (6%), cell signalling (3.4%), cell structure (3.4%) and cell division (2.6%).

[Primary stent treatment in the acute phase of myocardial infaction]

INTRODUCTION

Although direct balloon angioplasty has emerged as an alternative to thrombolytic therapy in patients with acute myocardial infarction, reocclusion and restenosis rates are limiting factors. We postulated that these limitations could be partly overcome by primary stenting of the responsible lesion.

MATERIAL AND METHODS

Since January/94 we have studied 59 patients with acute myocardial infarction who were treated in the early phase (3.1 +/- 2 hours since the onset of symptoms) by elective Palmaz-Schatz stent implantation. No adjunctive thrombolytic therapy was associated. Two patients were in cardiogenic shock and were treated under percutaneous cardiopulmonary support. At cardiac catheterization a left ventriculography and coronary angiograms were obtained. Then, mechanical recanalization of the responsible lesion was performed. If the angiographic anatomy was considered suitable, a stent was implanted at the lesion.

RESULTS

The infarct related artery was the left anterior descending in 29 patients, the circumflex in 14 and the right coronary artery in 16. At baseline conditions, 40 patients had a totally occluded artery and 19 showed a TIMI-grande 1 antegrade flow. One patient had an early clinical recurrence 4 days later, which required an additional divided Palmaz-Schatz stent at the distal portion of the lesion, in order to seal a residual dissection. All remaining patients had a favourable clinical course without major complications. Immediately after treatment the minimal lumen diameter was 3.2 +/- 0.4 mm and no residual stenosis was detectable at the treated segment. Six-month angiographic reevaluation was performed in all 29 (49%) eligible patients. Restenosis (> 50% stenosis) was detected in 6 out of the 29 evaluated patients (21%).

CONCLUSIONS

Primary stent implantation in selected patients with an evolving myocardial infarction provides good initial and 6-month results.

Unrelated-donor bone marrow transplantation for Philadelphia chromosome-positive chronic myelogenous leukemia in children: experience of eight European Countries. The EBMT Paediatric Diseases Working Party

From September 1988 to December 1995 forty-four children (age < 17 years) with Ph1 Chronic Myelogenous Leukemia (CML) received unrelated donor marrow transplantation in 8 European Countries. Thirty-three evaluable children were typed by serological testing on HLA-A, B, and DR loci. Thirty of them were further DR subtyped by DNA techniques. Twenty-four pairs were 6 antigen matched. Seven were mismatched at 1 locus (2 pairs at A and B loci respectively and 3 at DR locus). Two out of 30 pairs evaluated by molecular biology had one antigen mismatched at DRB1 locus. Thirty-two (96%) out of 33 evaluable children reached a sustained granulocyte count higher than 0.5 x 10(9)/l at a median of 21 (range 14-88) days after transplantation. The remaining child failed to engraft. Two children developed secondary graft failure. A platelet count greater than 50 x 10(9)/l sustained for at least seven consecutive days without transfusion support was reached at a median of 25 (range: 20-144) days by 24 out of 33 evaluable children and 9 children never recovered to above 50 x 10(9)/l. Twenty-one out of 33 evaluable children developed grade I (n = 7), grade II (n = 8), grade III (n = 2) or grade IV (n = 4) acute GvHD (63%). Seven of the 30 evaluable children surviving more than 100 days developed chronic GvHD (20%) which was limited in 4 cases and extensive in 3. Relapse occurred in 3 of the 44 (7%) children at 2 to 24 months (median 14). Twenty-four month relapse rate was 14%. Seventeen out of 44 children (38%) died of transplant related mortality (TRM), 4 (9%) of secondary tumor, 4 (9%) of infections, 3 (7%) of organ failure, 1 (2%) of interstitial pneumonia, 5 (11%) of unknown causes. Actuarial TRM was 61% for children grafted before December 1991 and 33% for children grafted after January 1992 (p = .01). EFS was 49.7%; it was 65% for children receiving more than 3.5 x 10(9)/Kg MNC.

HLA antigens in Ameridian groups of two different linguistic families from Colombia

Serological HLA types (A, B, C, DR and DQ loci) were studied in five different Indian tribes (Cubeo, Tucano, Coreguaje, Embera and Noanama) belonging to two distinct linguistic families. For all the MHC loci, the range of variation among the five tribes was enormous. Two tribes, Cubeo and Tucano, showed a wide spectrum of antigenic specificities which seemed to be due to admixture from non-tribal groups, while in the other three tribes the polymorphisms of various HLA loci showed restricted distributions. The gene frequency data, when converted to a kinship matrix and a two-dimensional eigenvector plot, indicated that members of the same linguistic family tend to have greater genetic affinity.