High T cell colony numbers do not reflect immune competence

The number of T cell colonies growing from ficoll separated PHA-stimulated peripheral blood cells was compared to 3H-thymidine uptake in 133 normal donors of all ages. Unexpectedly, the two parameters did not correlate: The tendency of growing cells to aggregate during the incubation period resulted in few, but large spherical colonies in persons who by young age and high counts for thymidine uptake were judged to have good T cell function. This clustering effect was less pronounced in old persons and those with a low PHA response; it was virtually absent in 17 of 18 patients with undoubted cellular immune deficiency early after allogeneic bone marrow transplantation. This resulted in a growth pattern consisting of a high number of small scattered colonies. The capacity of growing cells to aggregate was sensitive to sublethal irradiation. We conclude that the number of T cell colonies growing from a given cell suspension not only depends on the number of lymphocytes responding to the mitogen. It is negatively determined by the drive of growing cells to cluster. This phenomenon deserves further study, since it appears to be a parameter of cellular immune competence which is not readily recognized with 3H thymidine incorporation.

Treatment of severe aplastic anaemia with antilymphocyte globulin or bone-marrow transplantation

Fifty-three patients with severe aplastic anaemia were admitted to this hospital between January 1976 and June 1980, of whom three arrived in terminal condition and died before treatment for their basic disease could be given. Thus 50 patients were treated and evaluated in a prospective study according to one protocol. Eighteen patients with an HLA-identical sibling underwent bone-marrow transplantation with the aim of achieving haematopoietic chimerism. Thirty-two patients without an HLA-identical sibling were given antilymphocyte globulin with or without an infusion of HLA-haplotype-identical marrow. All these 32 patients received low-dose androgens after the procedure. In the first group eight patients (44%) survived. In the two other groups, 22 patients survived (69%), of whom 20 were completely self-sustaining (63%). Engraftment and graft-versus-host disease did not occur in the group who received antilymphocyte globulin and haploidentical marrow, and the haematopoietic reconstitutions in these patients were all autologous. These results confirm the efficacy of antilymphocyte globulin in the treatment of severe aplastic anaemia and show that such treatment is at least as good as bone-marrow transplantation. Its mechanism of action remains unknown, but most patients with aplastic anaemia have a pool of haematopoietic stem cells able to repopulate the marrow after this type of treatment.

Naloxone-like actions of MIF-1 do not require the presence of the pituitary

The actions of peripherally administered MIF-1 (Pro-Leu-Gly-NH2) and naloxone in blocking the effects of morphine in the tail-flick test were measured across a wide range of five doses in hypophysectomized and intact mice. The presence of the pituitary gland failed to influence the response to MIF-1 or naloxone. Both hypophysectomized and intact mice were significantly affected by these two compounds at doses of 0.01, 0.1, 1.0, and 10.0 mg/kg IP. The greatest effect of MIF-1 occurred at 100 mg/kg, but naloxone was lethal at this dose. Preliminary experiments with other tests showed that at 10 mg/kg, naloxone, but not MIF-1, was effective in preventing the Straub-tail reflex and in precipitating withdrawal-jumping in mice implanted with morphine pellets. Only minimal activity was shown by MIF-1 in preventing blockade of electrically induced contractions of the guinea pig ileum by morphine. Neither compound was active in the frog-righting test. In summary, the results emphasize the differential actions of MIF-1 as an opiate antagonist and demonstrate that the pituitary is not required for their mediation.

[Experience with intensive plasma exchange]

Experience with a total of 49 plasma exchanges in 14 patients is reported. All exchanges were performed with the Aminco cellseparator in an attempt to remove documented or suspected antibodies completely. Indications were ABO-barrier before bone marrow-transplantation (6), acute rejection following renal transplantation (3), autoimmune diseases (3), Moschowitz disease, antithrombocytic antibodies and hepatic coma (1 each). The technique was modified to make it possible routinely to exchange 121 of plasma in 4 hours with no major untoward side effects even in anuric or thrombopenic patients. Complete removal of circulating antibodies was possible and often followed by impressive clinical benefit.

Bone marrow participates in the biosynthesis of human transcobalamin II

Studies concerning the site of synthesis of the vitamin B12 binding serum protein, transcobalamin II, have been done in various mammalian animals. The actual site of biosynthesis in man has not yet been defined. The finding that bone marrow derived cells release apo-transcobalamin II in the mouse led us to examine the genetic patterns of transcobalamin II in man, both before and after marrow transplantation. A gradual but incomplete transformation of the recipient's transcobalamin II type into donor's type, corresponding to 75% or less of the total activity, was registered in 4 cases. Surprisingly, persistent host-type TC II, in spite of different donor type, was observed in 4 further marrow recipients. We conclude that hematopoietic cells transferred with the transplanted marrow participate in the biosynthesis of human transcobalamin II.

[Progress in bone marrow transplantation in acute leukemia and aplastic anemia]

Experience with 17 allogeneic bone marrow transplantation (BMT) patients with refractory acute leukemia is reported. The authors show that it is extremely difficult to cure patients with end stage disease by this procedure. Based on experience that, if performed early, BMT can bring about over 50% potential cures, it is postulated that marrow grafts should be performed much earlier than is done at present. From the results in 45 patients with severe aplastic anemia it is concluded that the majority do not have a defect at the pluripotent stem cell itself. There is disturbed maturation to functional end cells which can be corrected in most instances by ALG, infusion of allogeneic marrow and low dose androgens. BMT between HLA-identical siblings need not cause major problems, but it involves a considerable risk of fatal complications such as irreversible marrow rejection and GvH.

Additional evidence that small amounts of a peptide can cross the blood-brain barrier

It was determined that an antiserum against delta-sleep inducing peptide (DSIP) required eight of the nine constituent amino acids for antigenic activity. Measurement by this radioimmunoassay (RIA) or DSIP-like material in the rat brain, therefore, would necessarily involve almost the entire molecule present in essentially intact form. Injection of 200 microgram DSIP into the carotid artery of rats resulted in a doubling of brain levels of peptide as measured shortly afterwards by RIA. The brain tissue to plasma ratio of radioactivity in rats injected with labeled DSIP was much higher than that in rats injected with labeled inulin; this suggests that the increased amount of material measured by RIA was not merely trapped in the blood vessels. Thus, the results indicate that a small amount of essentially intact peptide can cross the blood-brain barrier. This could represent one of the mechanisms by which central effects of peripherally injected peptides can be exerted.

[Immunosuppression, bone marrow infusion and low dose androgens, successful therapy of severe aplastic anemia]

18 patients with severe aplastic anemia (SAA) but without an HLA-identical sibling were treated by antilymphocyte globulin (ALG) followed by infusion of marrow cells from a semi-compatible family donor. 13 of these received low dose androgens after ALG: 11 (85%) achieved stable remission without transfusion requirement. One patient relapsed after 4 months, one patient with only partial remission died from infection. None of the 4 patients who did not receive androgens after ALG achieved remission. ALG, marrow and low-dose androgens represent a promising therapy for SAA and can be favorably compared with allogeneic bone marrow transplantation.

Pathological cell aggregates in bone marrow cultures from patients with various hematological diseases

Non-clonal growth of macroscopic cell aggregates in methylcellulose cultures of abnormal marrow is described. They were seen in all patients with Graft-versus-Host Disease, graft rejection, and autoimmune disease presumably directed against hemopoietic cells, we found them in 35% of patients with primary hematological neoplasias and rarely in patients with solid tumors. They were never encountered in 80 healthy controls. The aggregates originated from small cell clumps which sedimented with the "buffy coat" in contrast to normal bone marrow particles. They contained tumor cells, grafted myeloid cells, or target cells of autoimmune disease in association with a widely varying amount of macrophages. Preliminary results suggest that the frequency of macrophages within the aggregates correlates inversely with the aggressiveness of the clinical condition. We propose that appearance of such aggregates in an indicator of immune activation; we expect that further quantitation of the phenomenon will reveal important clinical correlations and provide a model for the study of host defense to "foreign" cells.

The Basel experience with total body irradiation for conditioning patients with acute leukemia for allogeneic bone marrow transplantation

We are reporting our experience with 13 patients suffering from end stage acute leukemia that were prepared for allogeneic bone marrow transplantation by combined chemotherapy followed by high dose cyclophosphamide (Cy) and total body irradiation (TBI). Only one patient became a long term survivor. Of the evaluable 12 patients, 6 died of interstitial pneumonia, 4 of GvH and 1 of recurrent leukemia. We conclude that adding combined chemotherapy to the standard conditioning program with Cy and TBI probably increases the risk of developing fatal interstitial pneumonia without eliminating the risk of recurrent leukemia. We suggest that allogenic marrow grafts should be performed earlier in the course of refractory acute leukemias, because in patients with end stage disease its chances of being curative are small.

[Bone marrow transplantation in severe aplastic anemia and acute leukemia]

Much progress has been made in allogeneic bone marrow transplantation for severe aplastic anemia (SAA) and acute leukemia (AL). In SAA it was shown that hemopoietic chimerism and apparently permanent cures can be achieved in the majority of patients by conditioning with cyclophosphamide followed by bone marrow transplantation (BMT) from an HLA-identical sibling. The previous transfusion history is crucial for failure or success: untransfused patients do very well while graft rejection is an enormous problem in most polytransfused ones. We have shown that most patients without HLA-identical sibling donors can be adequately helped as well. After conditioning with ALG followed by transfusion of haploidentical marrow and low dose androgens there is partial to complete autologous hemopoietic reconstitution in virtually all patients. This points to the fact that most of these patients have pluripotent hemopoietic stem cells that are intact, but apparently unable to differentiate to mature cells, because they are inhibited by autoimmune mechanisms. The results of BMT in patients with endstage leukemia are modest. New pilotstudies with early marrow grafts, i.e. for ANLL in first remission and for ALL in second remission indicate that with this type of approach potentially over 50% of all patients with HLA-identical siblings can be cured. We recommend that HLA-typing should be performed early in families with SAA and AL and that the possibility of a marrow graft should be seriously considered before the patients have endstage disease. Marrow grafts are technically simple but they may pose enormous problems such as graft versus host reaction (GvH), interstitial pneumonia, graft rejection and leukemic recurrence. Therefore, the procedure should only be performed in highly specialized centers with much knowledge and experience in the immunobiology of bone marrow transplantation.

Radioimmunoassay of DSIP-like material in rat brain

Antibodies generated in a rabbit by immunization with synthetic delta-sleep inducing peptide (DSIP) showed no cross-reactivity with 19 naturally-occurring peptides or analogues and were used to establish a radioimmunoassay. Since DSIP is not readily iodinated by conventional methods, N-Tyr-DSIP was synthesized to prepare the tracer; the dose-response curve for N-Tyr-DSIP was exactly parallel to that for DSIP. With this assay, DSIP-like immunoreactivity was detected in the brain of rats. The highest brain values were found in the thalamus (11.9 +/- 1.3 pg/mg). The widespread presence of DSIP-like material throughout the body as well as the shared amino acid sequences of DSIP with other proteins suggest caution in defining the material being measured by this new assay. Nevertheless, the demonstration of DSIP-like activity in brain tissue and elsewhere warrants consideration of functions in addition to a possible role in sleep.

[Differential diagnosis of primary and secondary erythrocytosis by means of in vitro culture of hematopoietic stem cells]

Peripheral blood precursor cells from all of 12 patients with polycythaemia vera (PV) formed hemoglobinized colonies in vitro without addition os was strictly epo-dependent in 30 normals and 8 patients with erythrocytosis of other origin. By addition of 1 U epo/ml to the cultures, colony formation was increased up to 5-fold in PV. Untreated patients with a short history had the highest numbers of such epo-responsive precursor cells. In 3 patients with concomitant myelofibrosis, erythroid in vitro growth was abundant, but scattered, single colonies could hardly be identified and their hemoglobinization was poor. This picture did not change with addition of epo, and hemoglobinization did not improve. In vitro grown colonies in PV had morphological abnormalities as compared to colonies grown from normal precursor cells: all stages of erythroid differentiation and up to 50% necrotic cells were found within single colonies. Scattered colonies contained an excess of large, immature, vacuolated erythroblasts. It is concluded that these functionaland morphological abnormalities of in-vitro erythropoiesis are a reliable indicator of PV. Further, transition to myelofibrosis is recognized by a characteristic growth pattern with decreased epo-responsiveness.

In vitro cytostatic effect of adenine-arabinoside (Ara-A) and cytosine-arabinoside (Ara-C)

Adenine-arabinoside, a new antiviral drug with questionable bone marrow toxicity, inhibits colony formation by myeloid precursor cells in vitro. Compared to cytosine-arabinoside this cytotoxicity is roughly one third.

[Specific characteristics of hairy cell leukemia]

Report on a now 58-year-old female patient who presented in 1969 with the following objective findings: anemia, thrombocytopenia, lymphocytosis and hepatosplenomegaly. The first first diagnosis was lymphosarcoma, but up to 1976 nearly ten other diagnoses were established, e.g. reticulum sarcoma, leukemic lymphosarcoma, CML, ALL, CLL and Waldenström's disease. The patient did not respond to combined chemotherapy, but splenectomy brought about significant improvement in anemia and thrombocytopenia. She is now doing well without cytotoxic treatment. Hairy cell leukemia was diagnosed on the basis of electron microscopic findings in peripheral lymphocytes and histologic findings in bone marrow and spleen. The tartrate-resistant acid phosphatase was positive. Immunologic tests in the hairy cells showed surface immunoglobulins of monoclonal origina and the T-cells were shown to be decreased. The tests for phagocytosis and nonspecific esterase were negative. The hairy cells in this patient exhibited no colony stimulating activity in culture studies with bone marrow from 4 normal donors, as compared with the stimulating activity of normal monocytes in the same assay. In the light of this case report the question is discussed whether the hairy cells are mainly cells with lymphocytic (B-lymphocytes) or monocytic characteristics. On this question the findings in our patient support the hypothesis of a B-cell nature for the hairy cells.

[Allogenic bone marrow transplantation in severe aplastic anemia and refractory acute leukemia. 35 cases]

23 patients with severe aplastic anemia have been treated. 10 marrow grafts between HLA matched siblings were performed after conditioning with cyclophosphamide. 5 are still alive at over 7 months to over 2 1/2 years after grafting. 3 are hemopoietic chimeras and 2 show autologous marrow reconstitution. 13 patients were treated by ALG with or without transfusion of allogeneic marrow. 9 are still alive with partial to complete autologous hemopoietic reconstitution at over 1 month to over 4 years. It is concluded that in many instances aplastic anemia is an autoimmune disease rather than a primary failure of the hemopoietic stem cells. In acute leukemia allogeneic marrow grafts still pose enormous problems and only one of our 12 grafts has become a longterm survivor.

Blood-brain barrier, half-time disappearance, and brain distribution for labeled enkephalin and a potent analog

The natural opiate methionine-enkephalin and its D-alanine2 analog were iodinated by a method involving lactoperoxidase and purified by partition chromatography on Sephadex G-25. The half-time disappearance of radioactivity was determined in blood obtained from the jugular vein after injection of the iodinated methionine-enkephalin into the carotid artery or jugular vein and found to be less than a minute. Despite a greater potency and more prolonged activity of D-alanime2-methionine-enkephalin as compared with methionine-enkephalin, the half-time disappearance of radioactivity after injection of the iodinated analog was about the same, its distribution volume tended to be smaller, and the retention of counts in the brain was significantly less then after the iodinated parent compound. There was little statistical difference in the accumulation of radioactivity among nine brain regions 5 sec after the rapid injection of tritiated methionine-enkephalin into the carotid artery in contrast with the accumulation found after similar injection of tritiated tyrosine or tritiated water. The ratio of radioactivity in the pituitary or pineal to that in the brain parts within the blood-brain barrier was much greater after administration of the tritiated enkephalin than after the tritiated water. A modified brain-uptake index (BUI) value of 15 for the tritiated enkephalin indicates that methionine-enkephalin crosses the blood-brain barrier.

[Thrombocyte replacement with HL-A typed non-related single donors]

Thrombocytopenic patients who have become refractory to platelet transfusions from random donors will usually respond to HL-A compatible platelets with normal increments and hemostatic improvement. In our experience with unrelated HL-A typed donors, HL-A identity is unnecessary. Donors without excess antigen are compatible and even many donors with 1 excess antigen can be used, at any rate in immunosuppressed patients. Thus successful substitution of platelet becomes possible in refractory patients when family donors cannot be used.

Autologous marrow recovery following allogeneic marrow transplantation in a patient with severe aplastic anemia

A 45-year-old woman with severe idiopathic marrow failure was prepared for marrow transplantation by administration of cyclophosphamide (cy) 50 mg/kg on each of four successive days. She then received an intravenous infusion of 20 X 10(9) nucleated marrow cells from an HL-A matched and mixed lymphocyte culture (MLC) non-reactive sister. There was evidence for minimal marrow recovery in 1-2 months and a second marrow infusion was carried out 69 days after the first without additional immunosuppression. There was a continued slow recovery of peripheral blood counts with complete reconstitution of erythropoiesis, return of the white blood cell count to between 3 and 4000/mm3, with 50% granulocytes, and platelets to 60--70,000/mm3, 11 months after the initial grafting attempt. Red cell antigens and gamma globulin allotypes were of recipient type. The MLC and the indirect cell mediated lympholysis (CML) test became positive possibly indicating cellular sensitization to non HL-A antigens. This report of a patient with severe marrow failure documents autologous recovery of marrow function after receiving a large dose of cy and allogeneic marrow. The implications of this are discussed.

[Graft versus host disease, a little known complication of blood transfusion]

A case of fatal graft-versus-host disease (GvHD) following blood transfusions is reported. This relatively rare complication of blood and bloodcomponent replacement therapy may occur in recipients with decreased cellular immunity, which may be due to the underlying disease, chemotherapy or radiation therapy, or a combination of both. GvHD is a result of active proliferation of transfused immunologically competent cells which attack host organs. This complication can be prevented by irradiating transfusions with 1500 rads in vitro.

Distribution of 3H-alpha-MSH in rat brain

Radioactive synthetic alpha-MSH, prepared by selective tritiation of its dibromo-L-tyrosine-derivative, was injected into the carotid artery of intact, hypophysectomized or pinealectomized rats. More radioactivity was found in the occipital cortex, cerebellum, and pons-medulla than in most other brain parts of rats decapitated 15 sec and, to a less significant extent, 30 min after injection. Part of this radioactivity behaved like alpha-MSH in several identification procedures. After administration of 3H-tyrosine, the least radioactivity was consistently found in the pons-medulla. Large amounts of radioactivity after 3H-alpha-MSH were found in the pituitary and, particularly in the hypophysectomized rats, in the pineal. The half-time disappearance of the first component of radioactivity from the blood of each group of rats injected with tritiated-alpha-MSH was no more than 2.5 minutes, a time considerably shorter than the behavioral and EEG effects of this pituitary hormone on visual attention.

Failure of isogeneic marrow engraftment in a patient with acute leukemia

Marrow transplantation was carried out in a patient with acute myelogenous leukemia using a healthy identical twin as donor. The patient was prepared for grafting with combination chemotherapy, high dose cyclophosphamide, and 1,000 rad total body irradiation. Repopulation of marrow did not occur despite a second marrow infusion 21 days following the first attempt. The patient died 44 days after the initial marrow infusion. To our knowledge this is the first patient transplanted from an identical twin who did not achieve engraftment after high dose chemotherapy and supralethal irradiation. The survival time was well in excess of that required for evaluation of engraftment. The possible mechanisms for graft failure are discussed. The use of prophylactic interferon against viral infections is considered as the most likely cause of failure of engraftment.

[Experiences with allogeneic and isogeneic bone marrow transplantations in aplastic anemia and acute leukemia]

A report is presented on 13 clinical bone marrow transplantations (BMT). Six of 6 patients with refractory aplastic anemia are presently alive with partial to complete hemopoetic reconstitution now lasting up to 3 years and more. It is shown that after immunosuppression with ALG and cyclophosphamide, followed by BMT, the patient's own hemopoetic system can recover. Two failures occurred in patients over 50 years of age and in one who had donor transfusions before the graft. Two of 4 patients grafted for acute refractory leukemia are alive, one being in complete remission on day 140. One died from interstitial pneumonia and one had no take although the donor was an identical twin. This patient had been on a maintenance program which included active immunotherapy.