Managing hematological cancer patients during the COVID-19 pandemic: an ESMO-EHA Interdisciplinary Expert Consensus

BACKGROUND

The COVID-19 pandemic has created enormous challenges for the clinical management of patients with hematological malignancies (HMs), raising questions about the optimal care of this patient group.

METHODS

This consensus manuscript aims at discussing clinical evidence and providing expert advice on statements related to the management of HMs in the COVID-19 pandemic. For this purpose, an international consortium was established including a steering committee, which prepared six working packages addressing significant clinical questions from the COVID-19 diagnosis, treatment, and mitigation strategies to specific HMs management in the pandemic. During a virtual consensus meeting, including global experts and lead by the European Society for Medical Oncology and the European Hematology Association, statements were discussed and voted upon. When a consensus could not be reached, the panel revised statements to develop consensual clinical guidance.

RESULTS AND CONCLUSION

The expert panel agreed on 33 statements, reflecting a consensus, which will guide clinical decision making for patients with hematological neoplasms during the COVID-19 pandemic.

Feasibility of a prehabilitation program before major abdominal surgery

Objective

Prehabilitation programs claim to improve exercise capacity and postoperative outcomes. The study aim was to assess the feasibility of a prehabilitation program and its effects on fitness and clinical outcomes after major abdominal surgery.

Methods

In this prospective pilot study, patients were assigned to high-intensity physical exercise training with 3 training sessions per week for 3 weeks preoperatively. Feasibility of this intervention was assessed based on recruitment and adherence to the training program. Impact on fitness (VO2 AT) was evaluated and correlated with complications and length of stay (LOS).

Results

Of 980 eligible patients, 87 patients (8.9%) were approached for inclusion. Main obstacles to not approach patients were insufficient time (< 3 weeks) prior to scheduled surgery (n = 276, 28.2%) or screening failure (n = 312, 31.8%). Out of these 87 patients, 24 (28%) declined to participate, 43 (49%) met exclusion criteria and 20 (23%) were included. Six patients (30%) could not complete the prehabilitation program due to contra-indication for exercise training evidenced during the test (n = 3), lack of motivation (n = 2) and modification of the planned operating date (n = 1). VO2 AT increased from 9.8 to 11.5 ml/min/kg (p = 0.050). There were no correlations between the change in VO2 AT and postoperative complications (r = -0.133, p = 0.649) and LOS (r = -0.94, p = 0.750).

Conclusion

Prehabilitation programs are difficult to implement and many patients are either not eligible or not motivated. Future efforts should concentrate on those patients who are most likely to benefit from these time- and cost-intensive interventions.

[Contribution of a hospital pharmacy team to critical care of patients infected with SARS-CoV-2]

Le circuit du médicament hospitalier le plus sûr est la dispensation journalière individuelle nominative automatisée assurée par la pharmacie. Depuis plusieurs années nous essayons de convaincre les décideurs hospitaliers de l’implanter dans notre établissement. En attendant, pour pallier les risques d’erreurs médicamenteuses encourus par les patients et les soignants, nous avons constitué plusieurs équipes de travail au sein des unités de soins. Ces équipes sont constituées d’un pharmacien et d’un ou deux préparateurs en pharmacie hospitalière qui assurent notamment la gestion des armoires à pharmacie des unités de soins. La collaboration étroite avec médecins et personnel infirmier développée au fil des années a été un élément favorable déterminant lorsqu’il a fallu doter en médicaments et en dispositifs médicaux stériles (DMS) les nouvelles unités de soins critiques face à l’afflux de patients contaminés par le SARS-CoV2. Le suivi quotidien des médicaments consommés par patient, particulièrement les curares, et des DMS en rupture d’approvisionnement a été un élément clé de la gestion des stocks et des changements de principes actifs, de conditionnements et/ou de références de matériel. Les faits relatés donnent du poids au rapport Claris qui souligne les effets positifs en termes de qualité et de sécurité de prise en charge des patients du travail des PPH et pharmaciens dans les unités de soins. Ils soulignent par ailleurs les dangers auxquels sont exposés patients et soignants samedi, dimanche et jours fériés quand la pharmacie est fermée. Ils légitiment la question de l’extension de l’ouverture de la pharmacie en équipe complète 365 jours par an.

Prognosis of Lymphoma in Patients With Known Inflammatory Bowel Disease: A French Multicentre Cohort Study

BACKGROUND AND AIMS

The prognosis of lymphoma that occurs in patients with inflammatory bowel disease [IBD] is poorly known.

METHODS

A multicentre retrospective cohort analysis was done in seven French tertiary centres from 1999 to 2019. Only lymphoma occurring in patients with previous established diagnosis of IBD were analysed. The primary outcome was progression-free survival at 3 years.

RESULTS

A total of 52 patients [male 65%, Crohn's disease 79%, median age 48.3 years, median duration of IBD 10.1 years] were included, of whom 37 had been previously exposed to immunosuppressants and/or biologics for at least 3 months and 20 had primary intestinal lymphomas. The lymphoma histological types were: diffuse large B cell lymphomas [N = 17], Hodgkin lymphomas [N = 17], indolent B cell lymphomas [N = 12], and others including T cell lymphomas, mantle cell lymphomas, and unclassifiable B cell lymphoma [N = 6]. The median follow-up after lymphoma was 5.1 years (interquartile range [IQR] 4-7.8). Progression-free survival at 3 years was 85% in the overall population (95% confidence interval [CI] 75%-96%) with no significant difference between the exposed and unexposed group, 79% for patients exposed to immunosuppressants and/or biologics [95% CI 67%-94%], and 83% for patients diagnosed with primary intestinal lymphoma [95% CI 67%-100%]. No relapse of IBD has been observed during chemotherapy. The IBD relapse rate at the end of the last chemotherapy cycle was 23% at 3 years [95% CI 11%-39%] in the overall population.

CONCLUSIONS

In this large cohort, the prognosis for lymphomas occurring in IBD appears to be good and similar to what is expected, irrespective of the exposure to biologics and/or immunosuppressants.

Onboard wake vortex localization with a coherent 1.5 µm Doppler LIDAR for aircraft in formation flight configuration

An onboard LIght Detection And Ranging (LIDAR) sensor designed to track wake vortex created by aircraft in formation flight is presented. It uses short pulses (75 ns) to obtain a spatial resolution of ∼22.5 m required to resolve small-scale structures of vortices and a blind zone of 17.5 m to locate vortices next to the wing tip. Monte Carlo simulations show that vortex centers could be located within ±0.5 m. Flight tests were performed with two aircraft in formation flight configuration. The LIDAR, installed in the following aircraft, was able to measure, in real time (every 6 s), the air flow velocities induced by the vortices created by the leading aircraft. The software was used to determine the vortex centers. These measurements were coupled to global positioning system (GPS) measurements of the two aircraft positions to determine the falling velocity of the vortices and infer their circulations.

Characterisation of Small-Scale Atmospheric Wind-Field Structures Using Coherent Wind Lidar With Short Pulses

A lidar design has been developed at ONERA that uses short square pulses (75 ns) to have a small spatial resolution (22.5 m) and be able to measure small-scale atmospheric wind-field structures. Results show that the system is able to resolve the small-scale structures of vortices and to measure wind field structures of a turbulent wind field down to ~20 m.

P14.125 Retrospective analysis of long-term response to bevacizumab in combination with irinotecan for recurrent glioblastoma: identification of prognostic factors

BACKGROUND

In absence of standard treatment for recurrent glioblastoma (rGBM), numerous prospective and retrospective studies have evaluated the off-label combination of bevacizumab (BEV) with irinotecan (IRI) in patients with rGBM. We report here our single center experience with this combination and we investigated prognostic factors for long-term response.

MATERIAL AND METHODS

We performed a retrospective analysis of consecutive patients treated initially by Stupp protocol and with BEV-IRI for a rGBM between 2007 and 2017. Times to progression and overall survival, as well as toxicities, were investigated and analysed. Patients without progression at least 12 month after the first administration of BEV-IRI were considered as long-term responders. The primary end-point was overall survival post-BEV-IRI (OS-BEV-IRI).

RESULTS

One-hundred eleven patients were eligible for the analysis. Median age at the diagnosis was 57 years and the value of WHO Performance Status (PS) at the recurrence was 0 to 1 for 67,5% of patients. Kaplan-Meier median progression-free survival (PFS-BEV-IRI) and overall survival (OS-BEV-IRI) at recurrence estimates (calculated from start of BEV-IRI) were 6.51 and 10.41 months, respectively. The median OS (calculated from diagnosis) was 22,4 months. Twenty-Three patients (20,7%) were long-term responders to BEV-IRI regimen. This subgroup was not significantly different than the short-term responders according to age or PS distribution, but the relative proportion of biopsy in comparison to other surgery modalities was significantly increased in long-term responders (p<0,0001). Univariate analysis showed that PS 0–1 (p=0,007), biopsy (p=0,0022) are significantly associated with a better prognosis, but not age. Eighty three patients (75%) had toxicities, mainly grade 1 and 2 (92%), such as hypertension, proteinuria, haemorrhage, thrombosis, nausea, diarrhoea, fatigue or neutropenia. Most of the grade 3 and grade 4 toxicities were related to BEV treatment. Adverse events were significantly more frequent in long-term responders (p=0,0096).

CONCLUSION

BEV-IRI Combination is well tolerated and may offer some clinical benefits in recurrent GBM patients, more particularly if only biopsy was performed instead of surgery. Our results strengthened the role of these agents for the treatment of recurrent GBM.

From hepatitis C virus infection to B-cell lymphoma

In addition to liver disorders, hepatitis C virus (HCV) is also associated with extrahepatic immune manifestations and B-cell non-Hodgkin lymphoma (NHL), especially marginal zone lymphoma, de novo or transformed diffuse large B-cell lymphoma and to a lesser extent, follicular lymphoma. Epidemiological data and clinical observations argue for an association between HCV and lymphoproliferative disorders. The causative role of HCV in NHL has been further supported by the response to antiviral therapy. Pathophysiological processes at stake leading from HCV infection to overt lymphoma still need to be further elucidated. Based on reported biological studies, several mechanisms of transformation seem however to emerge. A strong body of evidence supports the hypothesis of an indirect transformation mechanism by which sustained antigenic stimulation leads from oligoclonal to monoclonal expansion and sometimes to frank lymphoma, mostly of marginal zone subtype. By infecting lymphocytes, HCV could play a direct role in cellular transformation, particularly in de novo large B-cell lymphoma. Finally, HCV is associated with follicular lymphoma in a subset of patients. In this setting, it may be hypothesized that inflammatory cytokines stimulate proliferation and transformation of IgH-BCL2 clones that are increased during chronic HCV infection. Unraveling the pathogenesis of HCV-related B-cell lymphoproliferation is of prime importance to optimize therapeutic strategies, especially with the recent development of new direct-acting antiviral drugs.

Clinical characteristics and prognostic factors of plasmablastic lymphoma patients: analysis of 135 patients from the LYSA group

Background

Plasmablastic lymphoma (PBL), initially described in 1997 in the oral cavity of HIV positive patients, is now recognized as a distinct aggressive and rare entity of diffuse large B-cells lymphoma by the World Health Organization (WHO) classification. Since the original description, others cases have been reported. However, these are largely derived from case reports or small series limiting any definitive conclusions on clinical characteristics and outcome.

Patients and methods

The clinical, biological, pathological features and outcome of a cohort including 135 patients with PBL, from LYSA centers in France and Belgium, were reported and analyzed.

Results

The median age was 58 years, with a male predominance. The cohort was divided into 56 HIV-positive patients, 17 post-transplant patients and 62 HIV-negative/non-transplanted patients. Within HIV-negative/non-transplanted, a relative immunosuppression was found in most cases (systemic inflammatory disease, history of cancer, increased age associated with weakened immune system). We have also described a new subtype, PBL arising in a chronic localized inflammatory site, without any sign of immunosuppression. At presentation, 19% of patients showed oral involvement. Immunophenotype showed CD138 positivity in 88% of cases and CD20 negativity in 90% of cases. Chemotherapy was administered to 80% of patients, with a complete response (CR) rate of 55%. The median overall survival (OS) was 32 months. In univariate analysis, HIV positive status showed better OS when compared with HIV negative status. In multivariate analysis, International Prognostic Index score, chemotherapy and CR were associated with survival benefit.

Conclusion(s)

This cohort, the largest reported to date, increases the spectrum of knowledge on PBL, rarely described. However, specific guidelines to clarify treatment are lacking, and may improve the poor prognosis of this rare disease.

[A pill to replace physical activity?]

A recent study has identified two molecules able to transform white adipose tissue ("bad fat", responsible for excess weight) in brown adipose tissue ("good fat", consuming energy), bringing new hope for the treatment of obesity and diabetes. But the authors' announcement (more humorous than scientific) declaring that the study is thefirst step toward a pill that can replace the treadmill is inappropriate. It underscores the importance of employing preventive methods such as physical activity, whose benefits on health are well documented and which represents the best medicine available. Different means and tools are described in this article in order to improve the amount and quality of physical activity prescription in primary care.

Controlled covalent binding of antiferromagnetic tetramanganese complexes to carbon nanotubes

Tetramanganese complexes are covalently attached to carbon nanotubes such, that the magnetic properties of the antiferromagnetic molecules are preserved.

Clinical spectrum of urine cultures positive for ESBL-producing Escherichia coli in hospitalized patients and impact on antibiotic use

OBJECTIVE

We wanted to describe the clinical features associated with urinalysis positive for ESBL-producing Escherichia coli and their impact on antibiotic use.

METHODS

We performed a prospective observational study in 13 French hospitals of the Paris area for 3 consecutive months. We included all patients with urine cultures positive for ESBL-producing E. coli.

RESULTS

One hundred and seventeen of the 218 patients (54%) presented with asymptomatic bacteriuria, 31 (14%) with cystitis, and 70 (32%) with a parenchymal infection. Nineteen patients with asymptomatic bacteriuria (16%) received antibiotics. Forty-one with parenchymal infections (59%) received a carbapenem. A carbapenem alternative could have been used in every patient treated with a carbapenem, according to antibiotic susceptibility testing results.

CONCLUSIONS

Urinary tract infections accounted for 46% of E. coli ESBL positive urinalysis. Fifty percent of parenchymal infections were treated with a carbapenem.

[Return to sport after anterior cruciate ligament reconstruction]

Despite continuous advances in techniques for anterior cruciate ligament reconstruction (ACLR), return to play (RTP) after surgery remains a challenge. More than one-third of the patients are unable to return to their preinjury sport level, for most because of a fear to sustain another injury. And when a RTP is attempted, up to 20% will tear their graft and a similar % will sustain an ACL tear on the opposite side. We believe that these failures result from an incomplete recovery. Based on a literature review and on our experience, we suggest 6 objective criteria to allow a safer RTP. They rely on laxity, strength, neuromuscular function, and psychological evaluations. Rehabilitation after ACLR should focus on the deficits identified by these tests and on they specific needs of the sport that the athlete plans to return to.

Polyoxometalate-stabilized, water dispersible Fe₂Pt magnetic nanoparticles

Magnetic Fe2Pt core-shell nanoparticles with 2 nm cores were synthesized with a monolayer coating of silicotungstate Keggin clusters. The core-shell composition is substantiated by structural analysis performed using high-resolution scanning transmission electron microscopy (HR-STEM) and small angle X-ray scattering (SAXS) in a liquid suspension. The molecular metal oxide cluster shell introduces an enhanced dispersibility of the magnetic Fe-Pt core-shell nanoparticles in aqueous media and thereby opens up new routes to nanoparticle bio-functionalization, for example, using pre-functionalized polyoxometalates.

Intragenic rearrangements in LARGE and POMGNT1 genes in severe dystroglycanopathies

Dystroglycanopathies are a heterogeneous group of muscular dystrophies with autosomal recessive inheritance characterized by abnormal glycosylation of alpha-dystroglycan. The most severe phenotypes are Walker-Warburg Syndrome (WWS) and muscle-eye-brain disease (MEB) presenting with lissencephaly type II (LIS II) and in which muscular dystrophy is associated with mental retardation and eye abnormalities. To date, six distinct genes, POMT1, POMT2, POMGNT1, FKTN, FKRP, LARGE and recently in one case DPM3, have been shown to be involved in dystroglycanopathies. Genomic sequencing alone is still frequently used for diagnosis purpose, not allowing detection of intragenic rearrangements at the heterozygous state contrarily to RNA analysis, quantitative PCR and CGH array analysis. These latter methods enabled us to identify four new intragenic rearrangements in the LARGE gene in three fetuses with WWS, born to two unrelated families: deletion of exons 9-10 and duplication of introns 1-4 for the first family and deletion of exons 4 and 7 for the second one; and a deletion of the last six exons of the POMGNT1 gene in two unrelated MEB patients. Genomic dosage studies using emerging tools such as CGH array should be included in routine molecular analysis of dystroglycanopathies, not only for the screening of the LARGE gene in which this kind of mutation seems to be more frequent than point mutations, but also for the other involved genes, especially in severe clinical cases.

[Hospital infection control--beyond the hospital]

Health care related infections are expensive untoward events, not only in terms of morbidity and mortality, but also cost. Prevention is essential, as well as limiting dissemination. Specify measures refer usually to hospital hygiene. However, health care tend to be provided more and more outside of the acute care hospital, with increasing complexity and thus risk for health care related infections. This risk varies according to patient's characteristics as well as environmental parameters. Consequently, it is essential to adapt preventive measures to situations such as home health care or nursing homes. We describe a model of regional organization for infection control in various health care settings.

Restoration of thiamine status with white or whole wheat bread in a thiamine-depleted rat model

Long-term thiamine deficiency has been largely documented, whilst little is known about effects of short-term depletion/repletion periods on thiamine vitamers status. Rats were submitted to short-term depletion (8 days) followed by different durations of repletion (3 or 14 days) with thiamine from bread (whole wheat bread or white bread, whole B and white B respectively) or corresponding controls. Short-term depletion drastically decreased plasma thiamine (-97%) and its urinary excretion (-77%). TDP (thiamine diphosphate) was strongly affected in liver (-67%) but less affected in cerebellum (-38%) or kidneys (-45%). Short-term repletion (3 days) with whole B diet or its control restored TDP at initial values in cerebellum and kidneys. A longer repletion (14 days) was required to restore liver TDP. Comparison of the diet groups indicates that thiamine status in tissues of rat fed whole B or white B diet was comparable to that of rats fed purified thiamine. Plasma thiamine concentration could not be restored at initial values in the bread groups or respective controls. In conclusion, thiamine in whole wheat bread appears effective in preventing marginal deficiencies and plasma thiamine is a less reliable indicator of thiamine status than tissue TDP levels.

[Fibular tendon dislocations associated with calcaneal fractures: four case reports]

We report four cases of traumatic dislocation of the fibular tendons associated with calcaneal fractures. There are few reports of this type of association in the literature. We analyzed the diagnostic and therapeutic features. Two patients with a history of calcaneal fracture presented old, unrecognized, symptomatic dislocations of the fibular tendons. After CT confirmation, the tendons were repositioned surgically. During the last two years, CT scans performed systematically in patients with calcaneal fracture led to the discovery of two recent dislocations associated with calcaneal fractures. In these patients the fibular tendon dislocation was treated during the osteosynthesis procedure by relocating the tendon in the gutter and reinsertion of the retinaculum. The two older cases illustrated the serious functional consequences of neglecting displaced fibular tendons. We also detailed the characteristic CT signs observed with the two recent cases. The association of calcaneal fracture with fibular tendon displacement is rarely reported in the literature, but is not exceptional. Physical examination is limited during the acute phase. Imaging, particularly CT is required to demonstrate the tendon displacement. The objective results of surgical treatment were good. Orthopedic treatment is almost always unsuccessful. The association of fibular tendon displacement with calcaneal fracture is not exceptional. We have instituted a standardized CT protocol for all cases of calcaneal fracture in order to recognize disinsertion of the retinaculum and enable treatment at the same time as the osteosynthesis.

The bioavailability of polyphenols is highly governed by the capacity of the intestine and of the liver to secrete conjugated metabolites

BACKGROUND

After ingestion of a complex meal containing foods and beverages of plant origin, different polyphenols are likely to be simultaneously present in the intestine. However, almost nothing is known about their interactions and possible consequences on their bioavailability.

AIM OF THE STUDY

The present study deals with the intestinal absorption and splanchnic metabolism of three polyphenols, genistein, hesperetin and ferulic acid (FA),when perfused in the small intestine alone or in combination, at different doses (15 and 120 microM).

METHODS

The fate of polyphenols in the small intestine was studied using a rat in situ intestinal perfusion model. Polyphenols were analysed in perfusate, bile and plasma by HPLC.

RESULTS

Whatever the perfused dose, the efficiency of the net transfer towards the enterocyte was similar for the three polyphenols and not significantly modified by any association between these molecules. However, FA largely differed from the two flavonoids by its low intestinal secretion of conjugates. When perfused at 15 microM, the secretion of conjugates back to the lumen represented 6.2% of the net transfer into the enterocytes for FA compared to 25.5 and 20 % for genistein and hesperetin respectively. Intestinal conjugation and secretion of conjugates back to the gut lumen varied with the dose of flavonoids: saturation of conjugation was observed for the highest dose or when a high dose of a second flavonoid was perfused simultaneously. Intensity of the biliary secretion substantially differed among tested polyphenols: 7.7% of the net transfer for FA vs 50% for genistein or hesperetin. The extent of the enterohepatic cycling of these polyphenols was proportional to the perfused dose and unaffected by the simultaneous presence of different compounds in the intestine.

CONCLUSION

Genistein and hesperetin appeared less available than FA for peripheral tissues because of a high intestinal and biliary secretion of their conjugates. Moreover, data suggest that a high polyphenol intake may improve their bioavailability due to saturation of the intestinal secretion of conjugates.

Determination of thiamine and its phosphate esters in rat tissues analyzed as thiochromes on a RP-amide C16 column

A new reversed-phase chromatographic method is described for the separation and quantification of thiamine (T), thiamine monophosphate (TMP) and diphosphate (TDP) in rat tissues. Sample extraction with perchloric acid (HClO(4)) was found more suitable than extraction with trichloroacetic acid (TCA), as regards convenience and background fluorescence. Derivatization of thiamine vitamers to thiochromes was optimized and complete separation of TDP and TMP thiochromes was obtained on a RP-amide C16 column in isocratic elution, with T thiochrome eluting in less than 10 min. The precision and the accuracy of the HPLC procedure were assessed: ranging from 0.5 to 7.7% for intra-day and from 2.0 to 9.4% for inter-day precision, a recovery average of 101% was determined (range 90-111%). Mean values of recovery for TDP, TMP or T were 91, 96 and 90% for liver extracts, respectively. Analysis of vitamers in tissues of rat submitted to 8 days thiamin deficiency, followed by a 14 days repletion, showed a significant reduction of TPP after 8 days of depletion in liver (-67%), brains (-50%), kidneys (-60%), followed by a complete recovery upon repletion.

Bioavailability of phloretin and phloridzin in rats

Phloretin is a flavonoid found exclusively in apples and in apple-derived products where it is present as the glucosidic form, namely, phloridzin (phloretin 2'-O-glucose). In the present study, we compared the changes in plasma and urine concentrations of these two compounds in rats fed a single meal containing 0.25% phloridzin or 0.157% phloretin (corresponding to the ingestion of 22 mg of phloretin equivalents). In plasma, phloretin was recovered mainly as the conjugated forms (glucuronided and/or sulfated) but some unconjugated phloretin was also detected. By contrast, no trace of intact phloridzin was detected in plasma of rats fed a phloridzin meal. These compounds presented different kinetics of absorption; phloretin appeared more rapidly in plasma when rats were fed the aglycone than when fed the glucoside. However, whatever compound was administered, no significant difference in the plasma concentrations of total phloretin were observed 10 h after food intake. At 24 h after the beginning of the meal, the plasma concentrations of phloretin were almost back to the baseline, indicating that this compound was excreted rapidly in urine. The total urinary excretion rate of phloretin was not affected by the forms administered, and was estimated to be 8.5 micromol/24 h in rats fed phloretin or phloridzin. Thus, 10.4% of the ingested dose was recovered in urine after 24 h.

Changes in AIDS-related lymphoma since the era of highly active antiretroviral therapy

HIV infection is associated with a high incidence of AIDS-related lymphomas (ARLs). Since the use of highly active antiretroviral therapy (HAART), the incidence of AIDS-defining illnesses has decreased, leading to a significant improvement in survival of HIV-infected patients. The consequences of HAART use on ARL are under debate. This study compared the incidence and the characteristics of ARL before and after the use of HAART in a large population of HIV-infected patients in the French Hospital Database on HIV (FHDH) and particularly in 3 centers including 145 patients with proven lymphoma. Within the FHDH, the incidence of systemic ARL has decreased between 1993-1994 and 1997-1998, from 86.0 per 10 000 to 42.9 per 10 000 person-years (P < 10(-30)). The incidence of primary brain lymphoma has also fallen dramatically between the periods, from 27.8 per 10 000 to 9.7 per 10 000 person-years (P < 10(-11)). The analysis of 145 cases of ARL in 3 hospitals showed that known HIV history was longer in the second period than in the first period among patients with systemic ARL (98 versus 75 months; P <.01). Patients had a higher number of CD4 cells at diagnosis during the second period (191 versus 63/microL, P = 10(-3)). Survival of patients with systemic ARL also increased between the periods (from 6 to 20 months; P =.004). Therefore, the profile of ARL has changed since the era of HAART, with a lower incidence of systemic and brain ARL. The prognosis of systemic ARL has improved.

Comparison of the intestinal absorption of quercetin, phloretin and their glucosides in rats

Absorption and metabolism of quercetin and isoquercitrin (quercetin 3-O-glucose) were investigated in rats after in situ perfusion of jejunum plus ileum (15 nmol/min) for 30 min and compared with those of phloretin and phloridzin (phloretin 2'-O-glucose). After perfusion of the glucosides, the corresponding aglycone forms and conjugated derivatives appeared in the lumen. The conjugated metabolites were similar to those recovered after intestinal perfusion of the aglycone forms. Regardless of the aglycone or glucoside perfused, only conjugated forms were present in the mesenteric vein blood draining the perfused segment showing the importance of intestinal conjugation. The hydrolysis of glucosides was a prerequisite step before their conjugation by intestinal enzymes and their transport towards the mucosal and serosal sides. In contrast to phloridzin, lactase phloridzin hydrolase activity did not seem to be an essential pathway for isoquercitrin hydrolysis. The 3-O-glucosylation of quercetin improved the net absorption of the aglycone (P < 0.05), whereas phloretin absorption decreased when present as 2'-O-glucoside (P < 0.05). Whatever the perfused compound, the efficiency of the absorption seemed to be linked to the intestinal conjugation process and to the luminal secretion of metabolites.

Catechin is metabolized by both the small intestine and liver of rats

Flavan-3-ols are the most abundant flavonoids in the human diet, but little is known about their absorption and metabolism. In this study, the absorption and metabolism of the monomeric flavan-3-ol, catechin, was investigated after the in situ perfusion of the jejunum + ileum in rats. Five concentrations of catechin were studied, ranging from 1 to 100 micromol/L. The absorption of catechin was directly proportional to the concentration, and 35 +/- 2% of the perfused catechin was absorbed during the 30-min period. Effluent samples contained only native catechin, indicating that intestinal excretion of metabolites is not a mechanism of catechin elimination. Catechin was absorbed into intestinal cells and metabolized extensively because no native catechin could be detected in plasma from the mesenteric vein. Mesenteric plasma contained glucuronide conjugates of catechin and 3'-O-methyl catechin (3'OMC), indicating the intestinal origin of these conjugates. Additional methylation and sulfation occurred in the liver, and glucuronide + sulfate conjugates of 3'OMC were excreted extensively in bile. Circulating forms were mainly glucuronide conjugates of catechin and 3'OMC. The data further demonstrate the role of the rat small intestine in the glucuronidation and methylation of flavonoids as well as the role of the liver in sulfation, methylation and biliary excretion.

Incidence of hematological malignancies in Martinique, French West Indies, overrepresentation of multiple myeloma and adult T cell leukemia/lymphoma

A registry of hematological malignancies is held in the unit of cytology of the University Hospital of Martinique. Human T cell lymphotropic virus type-1 (HTLV1) is endemic in this island. We determined the incidence and epidemiological features of hematological malignancies from the 715 new cases diagnosed between 1990 and 1998 among the adult population. Incidence rates per year were steady during this period. The most frequent hematological malignancies were multiple myeloma (MM) (34%), followed by non-Hodgkin's lymphoma (NHL) (23%). Among the cases of NHL with an immunohistological study, 57% had a T cell phenotype. Among these 61% were adult T cell leukemia/lymphoma. Epidemiological data on hematological malignancies in the West Indies has not been previously reported. There are two striking differences with other population-based registries: a high incidence of MM (5/100000) and a high proportion of T cell NHL among NHL (57%). The high proportion of T cell NHL is probably due to the high incidence of ATL. A low incidence of B cell NHL might also contribute to this effect. The increased incidence of MM in West Indies had not been previously reported. A similar high incidence of MM has been reported among Afro-Americans in the USA.

Class 2 resistant starches lower plasma and liver lipids and improve mineral retention in rats

The effects of raw potato starch (RPS) and high amylose corn starch (HAS) on cecal digestion, lipid metabolism and mineral utilization (Ca and Mg) were compared in rats adapted to semipurified diets. The diets provided either 710 g wheat starch/100 g diet (control) alone or 510 g wheat starch/100 g diet plus 200 g resistant starch/100 g (RPS or HAS). Compared with rats fed the control diet, significant cecal hypertrophy (240% after 7 d of the fiber consumption) and short-chain fatty acids accumulation (especially propionic and butyric acids) occurred after both resistant starch diets. Apparent Ca, Mg, Zn, Fe and Cu absorptions were similarly enhanced by RPS and HAS (50, 50, 27, 21 and 90%, respectively). Cholesterol absorption was reduced to 14% of intake in rats fed RPS or HAS compared with 47% absorption in control rats. RPS and HAS were also effective in lowering plasma cholesterol (-31 and -27%, respectively) and triglycerides (-28 and -22%, respectively). There was no effect of the diets on cholesterol in d > 1.040 kg/L lipoproteins (HDL), whereas RPS and HAS depressed cholesterol in d < 1.040 kg/L lipoproteins (especially in triglyceride-rich lipoproteins). Moreover, there were lower concentrations of cholesterol (-50 and -40%, respectively) and triglycerides (-53 and -47%, respectively) in the livers of RPS- and HAS-fed rats. Thus, RPS and HAS have similar effects on intestinal fermentation, mineral utilization and cholesterol metabolism in rats.

[Adult T-cell leukemia/lymphoma. Clinical aspects]

BACKGROUND DATA

Adult T-cell leukemia/lymphoma (ATL) is a malignant proliferation of activated CD4+ T lymphocytes. The disease is almost exclusively found in patients living in retrovirus HTLV-1 endemic areas.

VIROLOGY

In ATL, monoclonal HTLV-1 provirus is integrated into atypical lymphocytes, called clover-leaf lymphocytes. The pathogenic mechanism leading to HTLV-1-induced leukemogenesis remains obscure. The disease generally occurs after a long latency period.

FOUR CLINICAL SUBTYPES

The diversity of the clinical presentation has led to the classification of ATL into four subtypes: acute or prototype, lymphoma, chronic, and painless. In the acute form of ATL there is a tumor syndrome associated with paraneoplastic hypercalcemia and a high rate of opportunistic infections due to the immunodepression predominated by cellular immunity.

CLINICAL COURSE

Prognosis is poor for the acute and lymphomatous forms with a median survival of 6 and 10 months respectively. Infectious episodes are frequent, often caused by Pneumocystis carinii, and require systematic prophylaxis. Screening for anguilulosis and prophylaxis is also necessary.

[Adult T-cell leukemia/lymphoma. Therapeutic aspects]

CONVENTIONAL CHEMOTHERAPY: Complete remission of aggressive ATL (acute or lymphomatous forms) can be achieved in about 40% of the patients with conventional chemotherapy, but early relapse and infectious complications is the rule. For painless and chronic ATL, chemotherapy does not appear to be useful and can aggravate the immunodepression.

NEW THERAPEUTIC APPROACHES

Encouraging results have been obtained with a combination regimen using an antiretroviral agent (AZT) and interferon alpha. Response rate has been high with good tolerance. In responders, the survival rate is better than with conventional chemotherapy.

PERSPECTIVES

The success of a potentially antiretroviral approach for the treatment of this generally chemoresistant disease suggests that HTLV-1 virus could have a continuous effect on in vivo leukomogenesis.

Incidence and risk factors of central nervous system relapse in histologically aggressive non-Hodgkin's lymphoma uniformly treated and receiving intrathecal central nervous system prophylaxis: a GELA study on 974 patients. Groupe d'Etudes des Lymphomes de l'Adulte

BACKGROUND

Incidence of central nervous system (CNS) recurrence in patients with aggressive non-Hodgkin's lymphoma who did not receive meningeal prophylaxis is about 5%. Controversy remains regarding risk factors associated with such an event preventing a rational approach of prophylactic strategies.

PATIENTS AND METHODS

We analyzed a cohort of 974 patients with aggressive lymphoma in complete remission (CR). All the patients received a CNS prophylaxis consisting of intrathecal injections and intravenous high-dose methotrexate. The risk repartition on the basis of the international prognostic index (IPI) of these 974 CR-patients was low (L): 41%, low-intermediate (LI): 27%, high-intermediate (HI): 19%, high (H): 13%.

RESULTS

The incidence of isolated CNS relapse was 1.6%. In a first multivariate logistic regression analysis an increased LDH (P = 0.05, RR = 5) and the presence of more than one extranodal site (P = 0.05, RR = 3) were identified as independent risk factors for isolated CNS relapse. Another multivariate analysis incorporating IPI as a unique parameter showed that only IPI remained significantly associated with a higher risk of CNS relapse (L-LI: 0.6% vs. HI H: 4.1%, P = 0.002; RR = 7).

CONCLUSION

Prophylaxis notably reduces the risk of CNS recurrence in the higher risk patients. By contrast, we propose the deletion of prophylactic intrathecal injections in the lower risk patients.

Specificity of amygdalostriatal interactions in the involvement of mesencephalic dopaminergic neurons in affective perception

We have recently shown that dopaminergic responses to an attractive or an aversive stimulus were respectively increased and decreased in the core part of the nucleus accumbens and the ventromedial dorsal striatum. By contrast, increases in dopaminergic responses were obtained in the shell part of the nucleus accumbens with stimuli of both affective values. In addition, the involvement of the basolateral amygdala in affective processes has been reported by several authors. Anatomo-functional relationships between the basolateral amygdala and striatal structures have also been described. Thus, in the present work we studied the regulation by the basolateral amygdala of affective dopaminergic responses in the two parts of the nucleus accumbens (core and shell) and the ventromedial dorsal striatum. More precisely, variations in extracellular levels of dopamine induced by an attractive or an aversive olfactory stimulus were studied using in vivo voltammetry in freely moving rats. Changes in dopamine levels in the three left striatal regions were measured after functional blockade of the ipsilateral basolateral amygdala with tetrodotoxin. Changes in place attraction or aversion toward the stimulus were studied in parallel to dopamine variations. The results obtained suggest a specific regulation of affective dopaminergic responses in the two parts of the nucleus accumbens by the basolateral amygdala and a lack of influence of the basolateral amygdala on the ventromedial dorsal striatum. The results suggest that attraction or aversion toward a stimulus are correlated with dopamine variations in the core of the nucleus accumbens and that the basolateral amygdala controls affective behavioural responses. These data may provide new insights into the pathophysiology of schizophrenic psychoses.

Cholesterol-lowering effects of guar gum: changes in bile acid pools and intestinal reabsorption

Soluble fibers such as guar gum (GG) may exert cholesterol-lowering effects. It is generally accepted that bile acid (BA) reabsorption in portal blood is reduced, thus limiting the capacity of BA to down-regulate liver cholesterol 7alpha-hydroxylase, the rate-limiting enzyme of BA synthesis. In the present work, rats were adapted to fiber-free (FF) or 5% GG diets (supplemented or not with 0.25% cholesterol), to investigate various aspects of enterohepatic BA cycling. GG in the diet at a level of 5% elicited a significant lowering of plasma cholesterol during the absorptive period, in cholesterol-free (-13%) or 0.25% cholesterol (-20%) diet conditions. In rats adapted to the GG diets, the small intestinal and cecal BA pools and the ileal vein-artery difference for BA were markedly enhanced; reabsorption in the cecal vein was also enhanced in these rats. [14C]Taurocholate absorption, determined in perfused ileal segments, was not significantly different in rats adapted to the FF or GG diet, suggesting that a greater flux of BA in the ileum might support a greater ileal BA reabsorption in rats adapted to the GG diet. In contrast, capacities for [14C]cholate absorption from the cecum at pH 6.5 were higher in rats adapted to the GG diet than to the FF diet. Acidification of the bulk medium in isolated cecum (from pH 7.1 down to pH 6.5 or 5.8) or addition of 100 mM volatile fatty acids was also found to stimulate cecal [14C]cholate absorption. These factors could contribute to accelerated cecal BA absorption in rats fed the GG diet. The effects of GG on steroid fecal excretion thus appear to accompany a greater intestinal BA absorption and portal flux to the liver. These results suggest that some mechanisms invoked to explain cholesterol-lowering effect of fibers should be reconsidered.

Part of quercetin absorbed in the small intestine is conjugated and further secreted in the intestinal lumen

Rutin and quercetin absorption and metabolism were investigated in rats after in situ perfusion of jejunum plus ileum (15 nmol/min). In contrast to rutin, a high proportion of quercetin (two-thirds) disappeared during perfusion, reflecting extensive transfer into the intestinal wall. Net quercetin absorption was not complete (2.1 nmol/min), inasmuch as 52% were reexcreted in the lumen as conjugated derivatives (7.7 nmol/min). Enterohepatic recycling contribution of flavonoids was excluded by catheterization of the biliary duct before perfusion. After a 30-min perfusion period, 0.71 microM of quercetin equivalents were detected in plasma, reflecting a significant absorption from the small intestine. The differential hydrolysis of effluent samples by glucuronidase and/or sulfatase indicates that the conjugated forms released in the lumen were 1) glucuronidated derivatives of quercetin and of its methoxylated forms (64%) and 2) sulfated form of quercetin (36%). In vitro quercetin glucuronides synthetized using jejunal and ileal microsomal fractions were similar to those recovered in the effluent of perfusion. These data suggest that glucuronidation and sulfatation take place in intestinal cells, whereas no glucurono-sulfoconjugates could be detected in the effluent. The present work shows that a rapid quercetin absorption in the small intestine is very effective together with its active conjugation in intestinal cells.

Dipeptide derivative synthesis catalyzed by Pseudomonas aeruginosa elastase

Pseudomonas aeruginosa elastase was used to synthesize various N-protected dipeptide amides. The identity of the products was confirmed by FAB(+)-MS. After recrystallization, the yield of their synthesis was calculated, their purity was checked by RP-HPLC and their melting point was measured. With regard to the hydrolysis, it is well-established that the enzyme prefers hydrophobic amino acids in P'1 position and it has a wide specificity for the P1 position. This specificity was demonstrated to be quite unchanged when comparing the initial rates of peptide bond formation between different carboxyl donors (Z-aa) and nucleophiles (aa-NH2). The elastase, but not the thermolysin, was notably able to incorporate tyrosine and tryptophan in P'1 position. Furthermore, synthesis initial rates were at least 100 times faster with the elastase. To overcome the problematic condensation of some amino acids during chemical peptide synthesis, it has been previously suggested that enzymatic steps can combine with a chemical strategy. We demonstrated that the elastase readily synthesizes dipeptide derivatives containing various usual N-protecting groups. It was especially able to condense phenylalaninamide to Fmoc- and Boc-alanine. Increasing interest in peptides containing unnatural amino acids led us to try the elastase-catalyzed synthesis of Z-dipeptide amides including those amino acids in the P1 position. A synthesis was demonstrated with alphaAbu, Nle, Nva and Phg.