Successful salvage of RAEB/AML relapsing early post allograft with FLAG-Ida conditioned mini-allograft: a report of two cases

Management options are often limited for patients with AML or high grade myelodysplasia (MDS) relapsing within a year of allogeneic transplantation. We report, in two such patients, the use of re-induction with FLAG-Ida chemotherapy, followed by the infusion of GCSF-mobilized blood stem cells from the same HLA-matched donor. Both patients achieved durable complete remissions with good quality of life and longer disease-free survival than after the first myeloablative allografts. This mini-allograft approach offers a practical, well-tolerated salvage and a potentially curative treatment for relapsed AML/high grade MDS patients failing a first conventional myeloablative allogeneic transplants.

A novel gene conserved from yeast to humans is involved in sterol biosynthesis

The ERG28 gene was originally identified by microarray expression profiling as possibly involved in the Saccharomyces cerevisiae sterol pathway. Microarray analyses suggested that the transcription pattern of ERG28 closely followed that of genes involved in sterol synthesis. ERG28 was also found in Schizosaccharomyces pombe and Arabidopsis as well as humans, and in the latter was shown to be highly expressed in adult testis tissue. All four proteins contain potential transmembrane domain(s). Gas chromatography-mass spectrometry analysis of an ERG28-deleted S. cerevisiae strain (which is slow growing but not auxotrophic for ergosterol) indicates a lesion in sterol C-4 demethylation. Sterol profiles indicate accumulation of 3-keto and carboxylic acid sterol intermediates, which are involved in removing the two C-4 methyl groups from the sterol A ring. Similar intermediates have previously been demonstrated to accumulate in erg26 (sterol dehydrogenase/decarboxylase) and erg27 (3-ketoreductase) mutants in yeast. We speculate that the role of the Erg28 protein (Erg28p) may be either to tether Erg26p and Erg27p to the endoplasmic reticulum or to facilitate interaction between these proteins.-Gachotte, D., J. Eckstein, R. Barbuch, T. Hughes, C. Roberts, and M. Bard. A novel gene conserved from yeast to humans is involved in sterol biosynthesis. J. Lipid Res. 2001. 42: 150;-154.

Short Report: Engraftment of T-cell-depleted allogeneic haematopoietic stem cells using a reduced intensity conditioning regimen

Graft-versus-host disease (GVHD) remains a significant complication in patients undergoing allogeneic stem cell transplantation (SCT) using a reduced intensity conditioning regimen. Although T-cell depletion (TCD) reduces the risk of GVHD after a myeloablative conditioning regimen, it is associated with an increased risk of graft failure. We have therefore examined whether TCD compromises engraftment using a fludarabine-based conditioning regimen. Fifteen patients have been transplanted using such a regimen of whom 13 underwent ex vivo TCD. All but one patient demonstrated durable engraftment and no patient receiving a TCD product developed severe GVHD. Thus, TCD may play a role in GvHD prophylaxis using such regimens.

Genetic analysis of deciduous tooth size in Australian twins

Investigations of permanent dental crown size in twins and family groups indicate a high degree of transmissible control, but little is known about the relative contributions of genetic and environmental factors to variation in size of the deciduous (primary) teeth. Here, maximum mesiodistal and buccolingual crown dimensions of maxillary and mandibular primary teeth were measured from dental models of 602 individuals, including 99 monozygous (MZ) twin pairs, 81 dizygous (DZ) same-sex pairs, 41 DZ opposite-sex pairs, and 160 singletons. Data were subjected to univariate genetic analysis with the structural-equation-modelling package, Mx using the normal assumptions of the twin model. A model incorporating additive genetic (A) and unique environmental (E) variation was found to be the most parsimonious for all tooth-size variables. Estimates of heritability for deciduous crown size ranged from 0.62 to 0.91. This study shows that variation in deciduous crown size has a strong genetic component, similar to that observed in the permanent dentition. Further studies are required to determine whether the underlying genetic mechanisms are the same for both deciduous and permanent teeth.

Magnetic resonance imaging of lipoma and liposarcoma: potential of short tau inversion recovery as a technique of fat suppression

The present limited retrospective study was performed to assess MR imaging of lipomatous tumours of the musculoskeletal system and to evaluate the potential of the T2 short tau inversion-recovery (STIR) technique for differentiating lipomas from liposarcomas. Magnetic resonance imaging of 12 patients with lipomatous tumours of the musculoskeletal system (eight benign lipomas, three well-differentiated liposarcomas and one myxoid liposarcoma) were reviewed. Benign lipomas were usually superficial and showed homogeneity on T1- and T2-weighted spin echo sequences. Full suppression at T2 STIR was readily demonstrated. In contrast, the liposarcomas in the present series were all deep-seated. Two well-differentiated liposaromas showed homogeneity at long and short relaxation time (TR) but failed to show complete suppression at T2 STIR. One case of well-differentiated liposarcoma (dedifferentiated liposarcoma) and one of myxoid liposarcoma showed mild and moderate heterogeneity at T1 and T2, respectively, and posed no difficulty in being diagnosed correctly. In conclusion, short and long TR in combination with T2 STIR show promise in differentiating benign from malignant lipomatous tumours of the musculoskeletal system, when taken in combination with the position of the tumour.

Brain stem stroke causing baroreflex failure and paroxysmal hypertension

BACKGROUND

Paroxysmal neurogenic hypertension has been associated with a variety of diseases affecting the brain stem but has only rarely been reported after brain stem stroke. The mechanism is thought to involve increased sympathetic activity and baroreflex dysfunction. We undertook microneurographic recordings of muscle sympathetic nerve activity (MNSA) during beat-to-beat blood pressure (BP) monitoring to investigate this hypothesis.

CASE DESCRIPTION

We investigated a 75-year-old woman who developed paroxysmal hypertension (BP 220/110 mm Hg) after a large left-sided medullary infarct. The paroxysms were triggered by changes in posture and were accompanied by tachycardia, diaphoresis, and headache. Serum catecholamines were substantially increased (norepinephrine level, 23.9 nmol/L 9 days after stroke; normal level, <3.8 nmol/L), and heart rate variability, measured by spectral analysis, was decreased in both low- and high-frequency domains (0.04 and 0.06 ms(2), respectively; normal level, 0.14+/-0.02 ms(2)). MNSA was increased in frequency (61 bursts per minute; normal level, 34+/-18 bursts per minute), and the burst amplitude was not inversely related to diastolic BP. BP and MNSA responses to cold pressor and isometric handgrip stimuli were intact.

CONCLUSIONS

Extensive unilateral infarction of the brain stem in the region of the nucleus tractus solitarius may result in partial baroreflex dysfunction, increased sympathetic activity, and neurogenic paroxysmal hypertension.

Pulmonary edema in patients after liver transplantation

The aim of this study is to determine the incidence of radiological pulmonary edema in elective liver transplant recipients and its relationship to perioperative factors and postoperative course. We reviewed 102 chest radiographs from 34 patients who had undergone orthotopic liver transplantation (OLT). Films were assessed by 2 trained radiologists for evidence of pulmonary edema using a standardized system. Clinical and outcome data from the 34 patients were also recorded. There was a high incidence (47%) of postoperative radiological pulmonary edema that was associated with deterioration in gaseous exchange, elevated pulmonary artery pressure, and increased duration of ventilator dependence and intensive care stay. Eighteen percent of the patients developed edema immediately after surgery, which was associated with greater pulmonary artery pressure and transfusion requirements during surgery. An additional 29% developed edema during the next 16 to 20 hours, but there was no association with fluid replacement. We conclude that pulmonary edema is common after OLT and will influence postoperative recovery in a substantial proportion of transplant recipients. Excess perioperative fluid replacement is unlikely to be the sole mechanism of edema in these patients.

Inappropriate antidiuretic hormone secretion, abdominal pain and disseminated varicella-zoster virus infection: an unusual triad in a patient 6 months post mini-allogeneic peripheral stem cell transplant for chronic myeloid leukemia

Severe abdominal pain followed by inappropriate antidiuretic hormone secretion (SIADH) preceding by several days the skin manifestation of varicella-zoster virus (VZV) infection in an immunocompromised patient is described. This is a rare presentation of a severe infection described previously only once in a chronic myeloid leukemia (CML) patient 5 months post allo-BMT during immunosuppressive treatment with cyclosporin A. This is the first case described in the setting of non-myeloablative preparation with fludarabine and melphalan and followed by donor leukocyte infusion (DLI) 2 and 4 months post allo-BMT. The influence of these factors on development of VZV virus infection is discussed. We also highlight the high incidence and high mortality in VZV infection in immunocompromised patients as well as the frequent atypical presentation.

Localised enamel hypoplasia of human deciduous canines: genotype or environment?

A discrete area of defective enamel formation that appears on the labial surface of the crowns of deciduous canine teeth has been described in both recent and prehistoric human populations, with reported frequencies varying from 1 to 45 per cent. Suggestions about the aetiology of this localized hypoplasia range from genotypic factors to environmental conditions and systemic effects. The major aims of this study were to describe the frequency of occurrence and pattern of expression of the lesion in Australian Aboriginal and Caucasian ethnic groups, and to clarify the role of genetic factors by examining a sample of twins. The study sample consisted of dental casts of 181 pairs of Australian Caucasian twins, 215 Aborigines and 122 Caucasian singletons, together with 253 extracted deciduous canines. Examination of dental casts and extracted teeth was undertaken under 2x magnification with emphasis being placed upon location and expression of the lesion. The defect was observed in 49 per cent of twins and 44 per cent of Aborigines, but only 36 per cent of singletons. The percentages of affected teeth in each group were: 18 per cent in twins, 17 per cent in Aborigines and 13 per cent in Caucasians. A significant proportion of the defects occurred on the mesial aspect of the labial surface, in the middle area incisocervically, with the majority in the lower jaw. A number of significant differences in frequency were observed between groups, sexes, arches and sides. The results confirm some of the findings of previous studies, but also suggest that none of environmental, genetic or systemic factors can be ruled out as being involved in aetiology of the defect. The higher incidence of the lesion occurring on the mesial aspect of the labial surface is suggestive of physical trauma. Also, the vulnerability of the prominent developing mandibular canine, with its thin or missing labial covering of bone, would be expected to lead to higher prevalence of the lesion in the lower jaw. Although not definitive, the results of concordance analyses in twins were suggestive of a possible genetic predisposition in the formation of the lesion. Further research with a greater clinical orientation and emphasis on determining specific aetiological factors within any given environment in different ethnic groups may provide better insight into the ambiguous aetiology of the hypoplastic enamel defect.

Factors affecting the outcome of allogeneic bone marrow transplantation for adult patients with refractory or relapsed acute leukaemia

We evaluated the outcome of allogeneic bone marrow transplantation (BMT) for advanced acute myeloid leukaemia (AML) and acute lymphoblastic leukaemia (ALL) in 383 adult patients in nine Australian adult BMT centres between 1981 and 1997. The median overall survival for the group was 4.8 months, with an estimated 5-year survival of 18%. 28% of patients died of transplant-related toxicities within the first 100 d. Progressive disease was responsible for 48% of deaths. Multi-factor analysis demonstrated that AML (v ALL), disease status (second complete remission [CR2] v others), age (< 40 years) and duration of prior first complete remission (CR1) (> 6 months) were pre-transplant variables significantly associated with improved survival. Acute graft-versus-host disease (GVHD) of any grade reduced the rate of relapse in both AML and ALL, but only grades I-II were associated with improved survival. Both limited and extensive chronic GVHD were associated with increased survival. Only patients with AML in untreated first relapse or CR2, with a duration of CR1 > 6 months, or patients with T ALL, had a 5-year survival > 20%. Transplants for AML in induction failure or pre-B ALL in untreated first relapse or CR2 had an intermediate outcome, with 5-year survival of 10-20%. A 5-year survival of < 10% was observed for patients transplanted for ALL in induction failure or for pre-B ALL or AML in refractory first relapse or beyond CR2. These results suggest that for most adult patients with advanced acute leukaemia an allograft offers only a small chance of cure.

The prediction of parasuicide repetition in a high-risk group

OBJECTIVES

This study explores whether the specificity of risk assessment for parasuicide repetition can be improved by measurement of two psychological variables (over-generality of autobiographical memory and future fluency for positive events) in the immediate aftermath of the index parasuicide.

DESIGN

In a longitudinal study, parasuicide patients deemed to be at high risk of repetition on the basis of sociodemographic factors (Kreitman & Foster, 1991) were followed-up over a 12-month period.

METHOD

As soon as practicable after taking a deliberate drug overdose, patients completed the Autobiographical Memory Test, the Personal Future Test and the Beck Hopelessness Scale. The relative power of each of these measures, together with the number of sociodemographic risk factors, in predicting parasuicide repetition was investigated using a forward step-wise logistic regression analysis.

RESULTS

The most potent short-term predictor of parasuicide repetition was found to be scores on the Beck Hopelessness Scale, whereas in the longer term the number of previous para-suicides was the major predictor.

CONCLUSION

For the heterogeneous parasuicide population as a whole, psychological variables are unlikely to improve upon the Beck Hopelessness Scale, sociodemographic risk factors and clinical interview in the prediction of parasuicide repetition.

Persistent activation of nuclear factor-kappaB in cultured rat hepatic stellate cells involves the induction of potentially novel Rel-like factors and prolonged changes in the expression of IkappaB family proteins

Rat hepatic stellate cells (HSC) cultured in serum-containing medium underwent a rapid (3-hour) classical induction of p50:p65 and p65:p65 nuclear factor-kappaB (NF-kappaB) dimers. Subsequent culturing was associated with prolonged expression of active p50:p65 and persistent induction of a high-mobility NF-kappaB DNA binding complex consisting of potentially novel Rel-like protein(s). Formation of the latter complex was competed for by specific double-stranded oligonucleotides, was up-regulated by treatment of HSCs with tumor necrosis factor alpha (TNF-alpha), and was maintained at basal levels of expression by a soluble HSC-derived factor. An NF-kappaB-responsive CAT reporter gene was highly active in early cultured HSCs but was also trans-activated at a lower but significant level in longer-term cultured cells and could be completely suppressed by expression of dominant negative IkappaB-alpha. Physiological significance of the lower persistent NF-kappaB activities was also demonstrated by the ability of long-term cultured HSCs to support the activity of the NF-kappaB-dependent human intercellular adhesion molecule-1 (ICAM-1) promoter. Freshly isolated HSCs expressed high levels of IkappaB-alpha and IkappaB-beta. Culture activation was accompanied by a long-term reduction in levels of IkappaB-alpha with no detectable expression in the nuclear fraction of cells, under these conditions p50:p65 was detected in the nucleus. IkappaB-beta expression was transiently reduced and, upon replenishment, was associated with appearance of a lower-mobility IkappaB-beta antibody-reactive species. Bcl3 expression was absent in freshly isolated HSC but was induced during culturing and became a persistent feature of the activated HSC. Inhibition of NF-kappaB DNA binding activity by gliotoxin was associated with increased numbers of apoptotic cells. We suggest that activation of NF-kappaB in cultured HSC is required for expression of specific genes associated with the activated phenotype such as ICAM-1 and may be antiapoptotic for rat HSCs.

A survey of private pediatric dental practices in North Carolina

PURPOSE

In response to concerns about current and future demands for specialized pediatric dental care in North Carolina, a survey of private pediatric dental practices was conducted.

METHODS

Data were collected on the demographics and other practice variables. Information was also collected on the ages, caries activity, Medicaid status, estimated treatment needs, fluoridation status, and location of residence (urban/rural) of all new patients seen in each practice during three designated, consecutive days in November 1996.

RESULTS

The survey response rate was 76%. The data indicated that most pediatric dentists in North Carolina are quite busy. A total of 519 new patients were seen during the three-day survey period. The mean age was 4.7 years and 22% had advanced caries. Forty seven percent were caries free. Most of the disease was found in the primary dentitions of young children.

CONCLUSIONS

The findings indicate that the specialized pediatric dental care system in North Carolina is operating close to its capacity and is overtaxed in many areas of the state.

HCF-dependent nuclear import of VP16

Transactivation by VP16 requires the formation of a multicomponent complex, the TAATGAAAT recognition factor complex (TRF.C), that contains in addition to VP16, two cellular proteins, Oct-1 and HCF. HCF binds directly to VP16 and this promotes subsequent interaction of the VP16-HCF complex with the POU DNA-binding domain of Oct-1 and selective assembly onto target sites. Here we demonstrate a novel role of HCF in the intracellular compartmentalization of VP16. We show that while VP16 does not contain a consensus nuclear localization signal (NLS) and is largely cytoplasmic, co-expression with HCF resulted in VP16 nuclear accumulation. A candidate NLS within the C-terminus of HCF was identified and insertion of this motif into green fluorescent protein (GFP) promoted nuclear accumulation. Conversely, removal of this signal from HCF (HCFDeltaNLS) resulted in its cytoplasmic accumulation. Co-expression of HCFDeltaNLS with wild-type (wt) VP16, or of wt HCF with VP16 mutants lacking HCF-binding activity failed to promote the nuclear enrichment of VP16. These results indicate that in addition to its role in stabilizing TRF.C, HCF acts as a nuclear import factor for VP16.