Pegylated asparaginase in combination with high-dose methotrexate for consolidation in adult acute lymphoblastic leukaemia in first remission: a pilot study

The German Multicentre acute lymphoblastic leukaemia (ALL) study group (GMALL) performed a pilot study using pegylated asparaginase (PEG-ASP) in combination with high-dose methotrexate as consolidation therapy in the 05/93 protocol. The aim of the study was an intra-individual comparison of two different doses of PEG-ASP in 26 patients, with regard to the depletion of asparagine in serum and toxicity. 'Pharmacokinetic' monitoring was performed to evaluate the effect of an intra-individual dose escalation of PEG-ASP from 500 to 1000 U/m2 intravenously in successive doses. Serum asparaginase activity was targeted at > or =100 U/l for 1 week and > or =50 U/l for 10 d. The second course of PEG-ASP was administered to 23 patients. Due to hypersensitivity reactions in five patients, only 18 patients were evaluable for pharmacokinetic monitoring. With respect to the PEG-ASP activity, an effective depletion of asparagine could be postulated in the majority of patients during 10 d after the first administration. The effect of an intraindividual dose escalation form 500 to 1000 U/m2 was evaluable in 17 of 22 patients. An increment in peak PEG-ASP activity >70% was observed in 65% of the patients. PEG-ASP was well tolerated. Despite the long half-life of PEG-ASP, neither pancreatic nor central nervous toxicities occurred among the 26 adult patients treated in this pilot study.

Using a pericentromeric interspersed repeat to recapitulate the phylogeny and expansion of human centromeric segmental duplications

Despite considerable advances in sequencing of the human genome over the past few years, the organization and evolution of human pericentromeric regions have been difficult to resolve. This is due, in part, to the presence of large, complex blocks of duplicated genomic sequence at the boundary between centromeric satellite and unique euchromatic DNA. Here, we report the identification and characterization of an approximately 49-kb repeat sequence that exists in more than 40 copies within the human genome. This repeat is specific to highly duplicated pericentromeric regions with multiple copies distributed in an interspersed fashion among a subset of human chromosomes. Using this interspersed repeat (termed PIR4) as a marker of pericentromeric DNA, we recovered and sequence-tagged 3 Mb of pericentromeric DNA from a variety of human chromosomes as well as nonhuman primate genomes. A global evolutionary reconstruction of the dispersal of PIR4 sequence and analysis of flanking sequence supports a model in which pericentromeric duplications initiated before the separation of the great ape species (>12 MYA). Further, analyses of this duplication and associated flanking duplications narrow the major burst of pericentromeric duplication activity to a time just before the divergence of the African great ape and human species (5 to 7 MYA). These recent duplication exchange events substantially restructured the pericentromeric regions of hominoid chromosomes and created an architecture where large blocks of sequence are shared among nonhomologous chromosomes. This report provides the first global view of the series of historical events that have reshaped human pericentromeric regions over recent evolutionary time.

Stress relaxation tests in polypropylene monofilament meshes used in the repair of abdominal walls

The objective of this work has been to characterize stress relaxation in the polymer material on applying different levels of constant strain. The meshes were strained at values of 5.2%, 5.4% and 5.6% which are the values at which the mesh is strained in clinical use for the repair of abdominal walls. Laws have been obtained to model the viscoelastic behavior at different strains for this material. Finally, fracture studies were carried out by environmental scanning electron microscopy to determine the fracture mechanisms of these meshes. Besides, the implantation of the meshes was practised in two different layers of abdominal wall: the superficial or preaponeurotic layer and deep or preperitoneal layer, showing the neoformation of connective tissue on the mesh, which tended to be organized differently in each layer studied; more roughly and densely in the superficial layer than in the deep one.

Comparative analyses of multi-species sequences from targeted genomic regions

The systematic comparison of genomic sequences from different organisms represents a central focus of contemporary genome analysis. Comparative analyses of vertebrate sequences can identify coding and conserved non-coding regions, including regulatory elements, and provide insight into the forces that have rendered modern-day genomes. As a complement to whole-genome sequencing efforts, we are sequencing and comparing targeted genomic regions in multiple, evolutionarily diverse vertebrates. Here we report the generation and analysis of over 12 megabases (Mb) of sequence from 12 species, all derived from the genomic region orthologous to a segment of about 1.8 Mb on human chromosome 7 containing ten genes, including the gene mutated in cystic fibrosis. These sequences show conservation reflecting both functional constraints and the neutral mutational events that shaped this genomic region. In particular, we identify substantial numbers of conserved non-coding segments beyond those previously identified experimentally, most of which are not detectable by pair-wise sequence comparisons alone. Analysis of transposable element insertions highlights the variation in genome dynamics among these species and confirms the placement of rodents as a sister group to the primates.

Expression of the human homologue of rat NG2 in adult acute lymphoblastic leukemia: close association with MLL rearrangement and a CD10(-)/CD24(-)/CD65s(+)/CD15(+) B-cell phenotype

The expression of the chondroitin sulfate proteoglycan neuron-glial antigen 2 (NG2) has been demonstrated in association with rearrangement of the mixed lineage leukemia (MLL) gene in acute leukemia, but the frequency of NG2 expression in adult acute lymphoblastic leukemia (ALL) is yet unknown. We evaluated NG2 expression in 313 adult ALL patients by flow cytometry and simultaneously determined MLL rearrangement in 120 adult patients out of them with B-precursor ALL by reverse transcription-polymerase chain reaction and fluorescence in situ hybridization. A total of 57% of pro-B ALL, 2% of common ALL and 20% of pre-B ALL were NG2 positive, but NG2 was absent in T-ALL and mature B-ALL. In B-precursor ALL, NG2 expression was significantly associated with a CD10(-)/CD34(-)/CD24(-)/CD65s(+)/CD15(+)/CD13(-)/CD33(-) phenotype and showed a sensitivity, specificity and positive predictive value of 0.89, 0.89, and 0.93 for MLL rearrangement, respectively. NG2 was positive in three patients without detectable MLL rearrangement and negative in eight patients with MLL-AF4 transcripts. However, NG2 predicted with a 100% accuracy MLL rearrangement among patients disclosing a CD65s(+) and/or CD15(+) immunophenotype. In summary, NG2 adds to a more precise identification of high-risk adult ALL and should therefore be included into diagnostic marker panels. As NG2 is negative in non-malignant hematopoietic cells, this novel antigen might also serve in future studies as a powerful marker in monitoring minimal residual disease.

AA2500 testosterone gel normalizes androgen levels in aging males with improvements in body composition and sexual function

Testosterone replacement in hypogonadal men improves body composition, mood, and sexual functioning. In this 90-d study, we compared the pharmacokinetics and treatment effectiveness of a topical testosterone gel (AA2500) at two concentrations, 50 mg/d and 100 mg/d, to a testosterone patch and placebo gel in 406 hypogonadal men. Pharmacokinetic profiles were obtained, body composition was measured, and mood and sexual function were monitored. AA2500 treatments resulted in dose-dependent improvements in all pharmacokinetic parameters, compared with testosterone patch and placebo. Mean average concentrations at d 90 T were 13.8, 17.1, 11.9, and 7.3 nmol/liter for 50 mg/d AA2500, 100 mg/d AA2500, testosterone patch, and placebo, respectively. At d 90, the 100 mg/d AA2500 treatment improved lean body mass by 1.7 kg and percentage of body fat by 1.2% to a significantly greater degree than either control treatment. Significant improvements in spontaneous erections, sexual desire, and sexual motivation were also evidenced with the 100 mg/d AA2500 dose in comparison with placebo. Testosterone gel was well tolerated; however, the testosterone patch resulted in a high rate of application site reactions. Overall, AA2500 is an effective, well tolerated treatment for hypogonadism.

Prevalence of antigliadin antibodies in ataxia patients

We determined antigliadin antibodies in 95 ataxia patients and 73 controls. Antibodies were positive in 8% of the controls, 19% of patients with sporadic ataxia, 8% of patients with recessive ataxia, and 15% of patients with dominant ataxia. Statistical comparison using chi(2) statistics did not reveal significant differences between the groups. Although we found a trend toward a higher prevalence of antigliadin antibodies in patients with sporadic ataxia and dominant ataxia, our data do not support an association of ataxia with antigliadin antibodies.

Family therapy for identical twins with anorexia nervosa

The rarity of identical twins with anorexia nervosa (AN) makes formulating an effective treatment approach for this subset of individuals quite difficult Clinicians may be applying treatment strategies that have been designed for individuals with an eating disorder. However, these approaches might have to be modified for the treatment of identical twins. The few available case studies have not discussed the challenges a clinician faces when treating identical twins with AN. In this report we describe the presentation of the case of adolescent monozygotic twins who were simultaneously concordant for AN. We discuss their unique presentation and our approach to their treatment.

German multicenter study group for adult ALL (GMALL): recruitment in comparison to ALL incidence and its impact on study results

Due to eligibility criteria not all patients with the disease under investigation can be recruited for therapeutic studies. Thus, the external validity of study results cannot per se be taken for granted. The representativity of the admitted patients is the most relevant determinant for external validity and has to be assessed. As an example we examined the representativity of the patients recruited for the German multicenter study group for adult acute lymphoblastic leukemia (ALL) (GMALL). Lacking nationwide ALL incidence figures available in Germany, a methodology was developed to estimate incidence figures, too. All relevant study groups, hospitals, and diagnostic labs were asked to provide data about patients with ALL newly diagnosed between 1997 and 1998. A matching procedure was developed, as heterogeneous databases had to be pooled and checked for duplicates. Age- and sex-specific incidences of ALL were estimated and compared with the number of patients recruited for the GMALL in the same time period. The purpose was to develop a methodology for estimating incidence figures and evaluating the representativity of patients of the GMALL. The combination of various data sources allowed estimation of reliable incidence data for ALL in Germany. Comparisons with the incidence figures for ALL in other countries and crosschecks within Germany confirm our results. Sixty-two percent of all ALL patients in Germany were admitted to the GMALL study. The recruitment rate of more than 60% of the annual incidence of ALL to the GMALL suggests a high external validity as well as an impact of the study on the patterns of treatment and referral of ALL in adults in Germany. There is no selection bias of patients admitted to the GMALL compared to those patients not included in the study.

Butyrate induced Caco-2 cell apoptosis is mediated via the mitochondrial pathway

BACKGROUND

During the process of tumorigenesis most colon cancer cells acquire resistance to apoptosis. The short chain fatty acid butyrate is well established as an antitumour agent which selectively induces apoptosis in colon cancer cells but not in normal intestinal epithelial cells.

AIMS

To analyse the signalling pathway of butyrate induced apoptosis.

METHODS

Using Caco-2 cells we focused on the bcl family of proteins, mitochondrial pathway, and caspase signalling cascade involved in butyrate induced apoptosis. Techniques employed included western blots, immunofluorescence, as well as experiments with peptide inhibitors of specific caspases.

RESULTS

Butyrate induced a clear shift of the mitochondrial bcl rheostat towards a proapoptotic constellation, as demonstrated by upregulation of proapoptotic bak accompanied by reduced antiapoptotic bcl-x(L) levels. This was associated with translocation of cytochrome-c from the mitochondria to the cytosol, resulting in activation of the caspase cascade via caspase-9. Key executioner enzymes were caspases-3 and -1. No effect of butyrate on regulatory proteins of the inhibitor of apoptosis family was observed.

CONCLUSIONS

Butyrate induced Caco-2 cell apoptosis via the mitochondrial pathway. Upregulation of bak and translocation of cytochrome-c were upstream of the caspase cascade. Subsequently, this cascade was activated via the formation of an apoptosome.

CNS-aspergillosis: are there new treatment options?

Invasive aspergillosis is an increasing cause of morbidity and mortality in immunocompromised patients. Extension of invasive aspergillosis to the central nervous system (CNS) is associated with an exceeding high mortality which approaches 100%. One major factor contributing to this devastating outcome is a poor penetration into the CNS of frequently used antifungal drugs, such as amphotericin B or itraconazole. Voriconazole, a new triazole with broad activity against various fungi, including Aspergillus species, shows superior activity in invasive aspergillosis compared to treatment with conventional amphotericin B. Voriconazole readily penetrates the blood-brain barrier yielding fungicidal drug concentrations within the CNS. A growing number of patients with CNS aspergillosis has been successfully treated with voriconazole in recent years. The pharmacological properties, the broad antifungal activity and the promising clinical data suggest that the use of voriconazole in CNS aspergillosis might improve the outcome in this otherwise devastating clinical condition. However, additional clinical data are needed to determine more precisely the role of voriconazole in CNS aspergillosis. In this review, we have compiled the available pharmacological and clinical data on CNS aspergillosis.

[Experience with voriconazole in invasive aspergillosis]

Invasive aspergillosis causes a markable part of infection-associated morbidity and mortality in immunocompromised patients. For none of hitherto available antimycotic agents a significant superiority could be demonstrated which all are characterised by unsatisfactory response rates. The newly developed and approved voriconazole is characterized by broad antifungal activity against numerous yeasts and filamentous fungi, including Aspergillus species. Voriconazole is available for intravenous administration and shows excellent bioavailability with oral application. The profile of toxicity is typical for azoles with the particularity of causing obviously substance-specific transient, benign visual disturbances. In clinical studies could be shown that voriconazole is significantly superior to the previous antimycotic standard, amphotericin B, with regard to therapy response and survival. In patients with invasive aspergillosis the therapy response with voriconazole is about 45% even in otherwise therapy-resistant cases.

The aetiology of sporadic adult-onset ataxia

The nosology and aetiology of sporadic adult-onset ataxia are poorly understood. The aim of the present study was to answer the following questions: (i) How many sporadic ataxia patients have a genetic cause? (ii) How many sporadic ataxia patients suffer from multiple system atrophy (MSA)? (iii) Is there a specific association between sporadic ataxia and serum anti-glutamic acid decarboxylase (GAD) or antigliadin antibodies? and (iv) What are the clinical features of patients with unexplained sporadic ataxia? The study was performed in 112 patients who met the following inclusion criteria: (i) progressive ataxia; (ii) onset after 20 years; (iii) informative and negative family history (no similar disorders in first- and second-degree relatives; parents older than 50 years); and (iv) no established symptomatic cause. Thirty-two patients (29%) met the clinical criteria of possible (7%) or probable (22%) MSA. The Friedreich's ataxia mutation was found in five patients (4%), the spinocerebellar ataxia (SCA) 2 mutation in one (1%), the SCA3 mutation in two (2%) and the SCA6 mutation in seven (6%). The disease remained unexplained in 65 patients (58%). We did not detect anti-GAD antibodies in any of our patients. Antigliadin antibodies were present in 14 patients, 10 patients with unexplained ataxia (15%) and 4 patients with an established diagnosis (9%). Patients with unexplained sporadic ataxia had a median disease onset of 56.0 years. Decreased vibration sense (62%), decreased or absent ankle reflexes (40%), increased ankle reflexes (39%), dysphagia (38%) and extensor plantar responses and/or spasticity (34%) were the most frequent extracerebellar symptoms. Compared with MSA, disease progression was significantly slower.

Efficacy of a motilin receptor agonist (ABT-229) for the treatment of gastro-oesophageal reflux disease

BACKGROUND

ABT-229 is a potent motilin agonist without significant antibiotic activity. It has been shown to improve gastric emptying in humans and to increase lower oesophageal sphincter pressure in cats.

AIM

To assess the efficacy of four different doses of ABT-229 (1.25 mg, 2.5 mg, 5 mg, 10 mg b.d.) compared to placebo in the treatment of gastro-oesophageal reflux disease, and to determine its safety in patients with gastro-oesophageal reflux disease.

METHODS

In a double-blind, multicentre study, 324 patients with heartburn were randomized to receive four different doses of ABT-229 or placebo for 8 weeks. The efficacy was evaluated by Patient Symptom Questionnaire, daily diary, endoscopy and global evaluation of efficacy.

RESULTS

There were no statistically significant improvement scores for any of the ABT-229 treatment groups vs. the placebo group in any of the efficacy parameters. Reflux symptom scores were significantly worse after treatment in the dyspeptic group. ABT-229 appeared to be well tolerated and safe in total daily doses up to 20 mg.

CONCLUSION

ABT-229 appears to have limited, if any, clinical utility in the treatment of gastro-oesophageal reflux disease.

Bilateral human fetal striatal transplantation in Huntington's disease

BACKGROUND

Transplanted striatal cells have been demonstrated to survive, grow, establish afferent and efferent connections, and improve behavioral signs in animal models of Huntington's disease (HD).

OBJECTIVE

To evaluate feasibility and safety and to provide preliminary information regarding the efficacy of bilateral human fetal striatal transplantation in HD.

METHODS

Seven symptomatic patients with genetically confirmed HD underwent bilateral stereotactic transplantation of two to eight fetal striata per side in two staged procedures. Tissue was dissected from the lateral half of the lateral ventricular eminence of donors 8 to 9 weeks postconception. Subjects received cyclosporine for 6 months.

RESULTS

Three subjects developed subdural hemorrhages (SDHs) and two required surgical drainage. One subject died 18 months after surgery from probable cardiac arrhythmia secondary to severe atherosclerotic cardiac disease. Autopsy demonstrated clearly demarcated grafts of typical developing striatal morphology, with host-derived dopaminergic fibers extending into the grafts and no evidence of immune rejection. Other adverse events were generally mild and transient. Mean Unified HD Rating Scale (UHDRS) motor scores were 32.9 plus minus 6.2 at baseline and 29.7 plus minus 7.5 12 months after surgery (p = 0.24). Post-hoc analysis, excluding one subject who experienced cognitive and motor deterioration after the development of symptomatic bilateral SDHs, found that UHDRS motor scores were 33.8 plus minus 6.2 at baseline and 27.5 plus minus 5.2 at 12 months (p = 0.03).

CONCLUSIONS

Transplantation of human fetal striatal cells is feasible and survival of transplanted cells was demonstrated. Patients with moderately advanced HD are at risk for SDH after transplantation surgery.

Dutcher bodies in chronic synovitis

Dutcher bodies are periodic acid-Schiff-positive intranuclear pseudoinclusions found in plasma cells in mucosa-associated lymphoid tissue lymphoma, Waldenstrom macroglobulinemia, and myeloma. We describe the case of a 68-year-old woman with chronic synovitis containing multiple Dutcher bodies. The patient's workup for lymphoma was negative. Hematoxylin-eosin- and periodic acid-Schiff-stained sections of 7 cases of marked chronic synovitis selected from the files spanning a 10-year period at Memorial Hospital of Rhode Island (Pawtucket, RI) were examined, and none showed Dutcher bodies. This case illustrates that Dutcher bodies may rarely occur in benign reactive conditions, such as chronic synovitis.

Impact of oral appliance therapy: are oral skills and growth maintained one year after termination of therapy?

To determine the impact of intraoral appliance (ISMAR) therapy on functional feeding skills and growth, children with cerebral palsy and moderate dysphagia were followed a full year after termination of one year of ISMAR therapy. Seventeen children, 6.6-15.4 years old (mean age = 10.2 +/- 3.0 years), were divided into two groups: group A (n = 9) continued to wear the appliance and group B (n = 8) no longer wore the appliance. Generalized estimating equations (GEE) were used to test differences between the two groups over time while accounting for the dependence for the repeated within-subject measurements. No significant differences were found in the 7 domains of functional feeding. Significant time x group interactions for weight (kg and z-score 0.01 < p < 0.05) were found. However, post hoc analyses showed that there were no significant differences in weight changes between the two groups at either 18 or 24 months of followup. These results suggest that during a one-year period of followup, maturation was equally effective as ISMAR therapy.

Distinct patterns of word retrieval in right and left frontal lobe patients: a multidimensional perspective

Several studies have shown that patients with frontal lobe damage (FL) generate fewer words than control participants in verbal fluency tasks. In the current study, we were interested in assessing the quality of such verbal fluency data. Multidimensional exploratory techniques, namely, hierarchical clustering (HC) and correspondence analysis (CoA), were performed on verbal fluency data collected from 13 FL patients and 11 age-matched controls. HC of individual word-profiles distinguished between patients with left frontal lobe (LFL) and right frontal lobe (RFL) lesions. CoA revealed that LFL patients generated unusual word-profiles, as evidenced by their peripheral location on a CoA map, while RFL patients produced highly typical word-profiles. We would like to suggest that preserved functioning of the left frontal lobe might have constrained the responses of the RFL group resulting in typical word combinations, whereas preserved right frontal lobe functioning might have mediated greater diversification in the responses of the LFL group. The present study shows that HC and CoA can be applied to neuropsychological data to reveal complex relationships between cognitive performance and cerebral lesion sites.