The outcomes and prognostic factors of patients with hepatocellular carcinoma and Child-Turcotte-Pugh class B

BACKGROUND

The Child-Turcotte-Pugh (CTP) score is widely used for assessing the liver's functional reserve in patients with advanced chronic liver disease (ACLD) and hepatocellular carcinoma (HCC). This study aims to explore the outcomes of patients with HCC and CTP class B and to investigate the prognostic accuracy of prediction models for ACLD in these patients.

METHODS

We retrospectively enrolled 1143 patients with HCC and CTP class B between 2007 and 2022. We divided the patients into three subgroups based on their CTP scores: CTP-B7, CTP-B8, and CTP-B9. We compared the corrected Akaike information criterion among each mortality prediction model, including the CTP score, albumin-bilirubin (ALBI) score, modified ALBI score, the model for end-stage liver disease (MELD), and MELD 3.0.

RESULTS

Among the enrolled patients, 576 (50.3%) were in the CTP-B7 group, 363 (31.8%) were in the CTP-B8 group, and 204 (17.9%) were in the CTP-B9 group. After a median follow-up of 4.6 months (interquartile range IQR 1.8-17.2 months), 963 patients died, and the 5-year overall survival (OS) rate was 11.4%. The 5-year OS rates were 11.6%, 13.6%, and 8.3% in the CTP-B7, CTP-B8, and CTP-B9 groups, respectively. Patients in the CTP-B7 group and CTP-B8 group had comparable OS ( p = 0.089), both of which were better than those in the CTP-B9 group ( p < 0.001). Furthermore, the MELD 3.0 score had the lowest corrected akaike information criteria value and provided a more accurate mortality prediction than the MELD score, ALBI grade, modified ALBI grade, and CTP score.

CONCLUSION

Patients in the CTP-B7 and CTP-B8 groups had comparable OS, both of which were better than those in the CTP-B9 group. Moreover, MELD 3.0 provided the most accurate mortality prediction in patients with HCC and CTP class B.

The outcomes and prognostic factors of patients with hepatocellular carcinoma and normal serum alpha fetoprotein levels

BACKGROUND

Alpha fetoprotein (AFP) is the most widely used tumor marker for hepatocellular carcinoma (HCC). Nevertheless, few studies have investigated the prognostic factors of HCC patients with normal serum AFP levels.

METHODS

We retrospectively enrolled 2198 patients with HCC and normal serum AFP levels (<20 ng/mL) from 2007 to 2020. Overall survival (OS) rates were calculated by the Kaplan-Meier method, and analyses of the prognostic factors were performed using a Cox proportional hazard model.

RESULTS

Among the enrolled patients, 1385 (63%) patients were in the low-normal AFP group (serum AFP levels ≤7 ng/mL), and 813 (37%) patients were in the high-normal AFP group (serum AFP levels between 7 and 20 ng/mL). The high-normal AFP group had poorer liver functional reserve, more multiple tumors, and smaller tumor size compared to those in the low-normal AFP group. After a median follow-up of 32.4 months, 942 patients died, and the 5-year OS rate was 54.4%. The 5-year OS rates were 57.4% and 49.8% in the low-normal AFP group and high-normal AFP group, respectively (p = 0.001). A multivariate analysis showed the independent prognostic factors of poor OS were no anti-viral therapy, advanced albumin-bilirubin grades, the presence of vascular invasion, tumor size ≥5 cm, and non-curative treatment modalities. Serum AFP levels were not associated with OS according to the multivariate analysis.

CONCLUSION

Liver functional reserve, anti-viral therapy, tumor size, vascular invasion, and treatment modalities, determined the outcomes of HCC patients with normal serum AFP levels, but serum AFP levels did not.

[Efficacy and safety of VRD regimen of autologous hematopoietic stem cell transplantation in patients with newly diagnosed multiple myeloma]

Objective: To explore the stem cell collection rate and efficacy and safety of patients aged 70 and below with newly diagnosed multiple myeloma (MM) treated with the VRD (bortezomib, lenalidomide and dexamethasone) regimen followed by autologous stem cell transplantation (ASCT). Methods: Retrospective case series study. The clinical data of 123 patients with newly diagnosed MM from August 1, 2018, to June 30, 2020, at the First Affiliated Hospital of Soochow University and Suzhou Hopes Hematology Hospital, who were eligible for VRD regimen sequential ASCT, were collected. The clinical characteristics, efficacy after induction therapy, mobilization regimen of autologous stem cells, autologous stem cell collection rate, and side effects and efficacy of ASCT were retrospectively analyzed. Results: Of the 123 patients, 67 were males. The median patient age was 56 (range: 31-70) years. Patients with IgG, IgA, IgD, and light-chain types accounted for 47.2% (58/123), 23.6% (29/123), 3.2% (4/123), and 26.0% (32/123) of patients, respectively. In addition, 25.2% (31/123) of patients had renal insufficiency (creatinine clearance rate<40 ml/min). Patients with Revised-International Staging System (R-ISS) Ⅲ accounted for 18.2% (22/121) of patients. After induction therapy, the rates of partial response and above, very-good partial response (VGPR) and above, and complete response (CR)+stringent CR were 82.1% (101/123), 75.6% (93/123), and 45.5% (56/123), respectively. Overall, 90.3% (84/93) of patients were mobilized with cyclophosphamide+granulocyte colony-stimulating factor (G-CSF) and 8 patients with G-CSF or G-CSF+plerixafor due to creatinine clearance rate<30 ml/min and one of them was mobilized with DECP (cisplatin, etoposide, cyclophosphamide and dexamethasone)+G-CSF for progressive disease. The rate of autologous stem cell collection (CD34⁺cells≥2×10⁶/kg) after four courses of VRD regimen was 89.1% (82/92), and the rate of collection (CD34⁺cells≥5×10⁶/kg) was 56.5% (52/92). Seventy-seven patients treated with the VRD regimen sequential ASCT. All patients had grade 4 neutropenia and thrombocytopenia. Among the nonhematologic adverse events during ASCT, the highest incidence was observed for gastrointestinal reactions (76.6%, 59/77), followed by oral mucositis (46.8%, 36/77), elevated aminotransferases (44.2%, 34/77), fever (37.7%, 29/77), infection (16.9%, 13/77) and heart-related adverse events (11.7%, 9/77). Among the adverse events, grade 3 adverse events included nausea (6.5%, 5/77), oral mucositis (5.2%, 4/77), vomiting (3.9%, 3/77), infection (2.6%, 2/77), elevated blood pressure after infusion (2.6%, 2/77), elevated alanine transaminase (1.3%, 1/77), and perianal mucositis (1.3%, 1/77); there were no grade 4 or above nonhematologic adverse events. The proportion of patients who achieved VGPR and above after VRD sequential ASCT was 100% (75/75), and the proportion of patients who were minimal residual disease-negative (<10^-4 level) was 82.7% (62/75). Conclusion: In patients aged 70 and below with newly diagnosed MM treated with VRD induction therapy, the collection rate of autologous stem cells was good, and good efficacy and tolerability were noted after follow-up ASCT.

[Efficacy and safefy of Polymyxin B treatment for neutropenic patients suffering from refractory Gram-negative bacterial bloodstream infection]

Objective: To assess the efficacy and safety of polymyxin B in neutropenic patients with hematologic disorders who had refractory gram-negative bacterial bloodstream infection. Methods: From August 2021 to July 2022, we retrospectively analyzed neutropenic patients with refractory gram-negative bacterial bloodstream infection who were treated with polymyxin B in the Department of Hematology of the First Affiliated Hospital of the Soochow University between August 2021 to July 2022. The cumulative response rate was then computed. Results: The study included 27 neutropenic patients with refractory gram-negative bacterial bloodstream infections. Polymyxin B therapy was effective in 22 of 27 patients. The median time between the onset of fever and the delivery of polymyxin B was 3 days [interquartile range (IQR) : 2-5]. The median duration of polymyxin B treatment was 7 days (IQR: 5-11). Polymyxin B therapy had a median antipyretic time of 37 h (IQR: 32-70). The incidence of acute renal dysfunction was 14.8% (four out of 27 cases), all classified as "injury" according to RIFLE criteria. The incidence of hyperpigmentation was 59.3%. Conclusion: Polymyxin B is a viable treatment option for granulocytopenia patients with refractory gram-negative bacterial bloodstream infections.

[The expression level of secretory mature B cell surface antigen in primary diagnosed multiple myeloma and its clinical significance]

Objective: To explorer Secretory mature B cell surface antigen (sBCMA) expression level, changes during treatment and clinical significance in newly diagnosed MM patients. Methods: Clinical data of 158 MM patients admitted to the Department of Hematology, the First Affiliated Hospital of Soochow University from August 2018 to September 2020 were analyzed retrospectively. The concentration of sBCMA in the patients was determined by BCMA ELISA and compared with the normal range. The results were compared with clinical efficacy, age, type, R-ISS stage, renal impairment, and humoral immune function. Results: The median age of the patients was 57 (31-73 years old), 86 (54.5%) males and 72 (45.5%) females, mainly IgG type, 81 patients(51.2%). SBCMA value M(Q₁,Q₃) was 76.50 (55.50, 94.40) μg/L, 100% higher than the upper limit of normal value. According to the efficacy evaluation, the patients were divided into complete remission(CR) group, very good partial remission(VGPR) group, partial remission(PR) group and ineffiecacy group, the results showed the level of sBCMA in CR group[80.10 (58.05, 96.90) vs 15.70 (9.85, 28.65) μg/L] and VGPR group[74.60 (52.20, 93.00) vs 17.20 (13.30, 38.80) μg/L]was significantly higher than that before treatment(all P<0.001), and there was no significant difference in PR group and ineffective group before and after treatment (all P>0.05).The amount of serum intact protein M protein was positively correlated with the level of sBCMA expression in newly diagnosed patients (r=0.22, P=0.040), and there was no correlation between the proportion of bone marrow plasma cells and sBCMA expression (r=0.07, P=0.449).The correlation between sBCMA levels at initial diagnosis and MM type[IgG type, IgA type vs light chain type:(78.6±3.5), (72.4±5.4) vs (83.8±6.9)μg/L], age[≥65 vs<65 years: (73.6±5.5)vs (79.3±3.1)μg/L], R-ISS stage[stage Ⅰ, Ⅱ vs Ⅲ:(80.2±3.1) vs (69.4±6.1)μg/L], renal impairment [Creatinine clearance rate (Ccr) ≤30 vs>30 ml/min:(81.6±4.8) vs (76.5±3.4)μg/L], and high-risk karyotype[high-risk vs standard-risk:(73.6±5.7) vs (80.2±3.2)μg/L] were not associated (all P>0.05). Expression levels of sBCMA were negatively correlated with IgM levels in MM patients (r=-0.39, P=0.002) and after treatment (r=-0.25, P=0.015). Conclusions: The expression of sBCMA in MM patients is a reliable indicator of the clinical efficacy of MM and is related to the occurrence of MM immune deficiency and recovery after treatment. sBCMA can be used as a new independent marker for monitoring and predicting the efficacy of MM patients.

[Efficacy of total oral regimens containing ixazomib in patients with relapsed and refractory multiple myeloma]

To investigate the efficacy and safety of total oral regimen containing ixazomib in multidrug-resistant relapsed and refractory multiple myeloma(RRMM). A total of 38 patients were retrospectively analyzed from August 2018 to January 2020 in the First Affiliated Hospital of Soochow University. The overall response rate (ORR)was 36.8%. Among them, the very good partial response (VGPR) or better rate was 23.7%, and the complete response (CR) rate was 5.3%. The ORR was 41.7% in patients receiving ixazomib-lenalidomide-dexamethasone (IRD) regimen. Median PFS was 5 months and median OS was 7.5 months. The ORR was 50% after second-line therapy, 40% after third-line therapy and 12.5% after forth-line therapy or more. The ORR was 29.0% in bortezomib-refractory patients, 38.0% in lenalidomide-refractory patients, 21.4% in bortezmoib & lenalidomide dual refractory patients. Grade 3-4 hematological adverse events (AEs) were reported in 21% patients. Common hematological AEs included lymphopenia, neutropenia, thrombocytopenia. Other usual AEs were fatigue and diarrhea. No grade 3-4 peripheral neuropathy was recorded. In the treatment of relapsed/refractory multiple myeloma patients with multidrug resistance, the total oral regimens containing ixazomib demonstrate reliable efficacy and safety. Early administration of ixazomib at first or second relapse is suggested for more favorable clinical outcome.

[Clinical implication of minimal residual disease monitoring by 10-color flow cytometry in multiple myeloma]

目的

采用十色流式细胞术监测多发性骨髓瘤（MM）患者治疗后骨髓微小残留病（MRD），探讨其对MM患者预后的预测价值。

方法

回顾性分析2015年7月至2017年7月苏州大学附属第一医院收治的150例MM患者的临床资料，十色流式细胞术检测MRD水平。

结果

①诱导治疗结束后采用十色流式细胞术监测MRD的87例MM患者中，MRD阴性者34例（39.1%）。自体造血干细胞移植后1年内行十色流式细胞术监测MRD的69例患者中，MRD阴性者34例（49.3%），诱导治疗结束和移植后MRD阴性患者的无进展生存（PFS）期优于MRD阳性患者（未达到对21个月，P=0.022；未达到对18个月，P<0.001）。②根据移植前后MRD的动态改变将MM患者分为MRD持续阴性、阳性转阴性、持续阳性、阴性转阳性四组，四组的2年PFS率分别为83%、82%、44%、0（P=0.002）。③多因素分析显示诱导治疗结束后的MRD水平是影响PFS的独立预后因素[P=0.002，HR=4.808（95%CI 1.818~12.718）]。

结论

治疗后MRD转阴提示更好的临床预后，MRD水平对于MM患者的预后价值优于血清学疗效评估，可以联合R-ISS分期及细胞遗传学异常评估患者预后。

[Comparison of efficacy of first-line administration of generic dasatinib or imatinib in patients with Philadelphia chromosome positive acute lymphoblastic leukemia treated by hematopoietic stem cell transplantation]

Objective: To investigate the efficacy of first-line administration of generic dasatinib or first-generation TKI (imatinib) in patients with Philadelphia chromosome positive acute lymphoblastic leukemia (Ph(+) ALL) treated by hematopoietic stem cell transplantation (HSCT). Methods: Clinical features and prognoses of 63 newly diagnosed Ph(+) ALL patients from Jan 2014 to June 2017 treated by HSCT combined with first-line administration of generic dasatinib or imatinib were retrospective analyzed. Results: Of 63 Ph(+) ALL patients, 31 cases were administered generic dasatinib, and the other 32 ones imatinib. Complete remission (CR) rates at the fourth week of induction therapy in generic dasatinib and imatinib groups were 96.8% and 93.8% (P=1.000) , respectively. Meanwhile major molecular response (MMR; BCR-ABL/ABL reduce 3log) rates were 41.9% and 43.8% (χ(2)=0.021, P=0.884), respectively. Relapse rates before transplantation were 6.5% and 12.5% (P=0.672), respectively. MMR rates before HSCT were 83.9% and 68.8% (χ(2)=1.985, P=0.159), respectively. The 20-monthes overall survival (OS) rates of generic dasatinib and imatinib groups were 95.5% and 76.5% (χ(2)=0.990, P=0.320) respectively; 20-monthes event-free survival (EFS) rates were 93.5% and 61.4% (χ(2)=5.926, P=0.015), respectively. Statistically significant differences of EFS were reached. Multiple factors analysis showed that generic dasatinib (HR=0.201, 95% CI 0.045-0.896, P=0.035) and MMR before transplantation (HR=0.344, 95% CI 0.124-0.956, CI=0.041) could improve EFS. Conclusions: First-line administration of generic dasatinib could improve EFS for Ph(+)ALL patients treated by HSCT when compered with imatinib.

[Outcome of combination of HLA-haploidentical hematopoietic SCT with an unrelated cord blood unit for 127 patients with acquired severe aplastic anemia]

目的

评价单倍型造血干细胞移植（haplo-HSCT）联合第三方脐血干细胞移植治疗重型再生障碍性贫血（SAA）的疗效及安全性。

方法

对2011年9月至2017年4月间接受haplo-HSCT联合第三方脐血干细胞移植的127例SAA患者进行回顾性研究。

结果

全部127例SAA患者中，男74例，女53例，中位年龄23.5（3~54）岁，其中极重型再生障碍性贫血65例。诊断至移植中位时间2（0.5~180）个月。单倍型造血干细胞来源为骨髓+外周血。脐血均选用单份，HLA配型≥4/6相合。127例患者均接受改良Bu/Cy+ATG/ALG预处理方案（白消安+环磷酰胺+抗胸腺细胞球蛋白/抗淋巴细胞球蛋白）。以环孢素A、霉酚酸酯联合短程甲氨蝶呤预防GVHD。回输单倍型供者单个核细胞10.87（3.61~24.00）×10⁸/kg，CD34⁺细胞3.49（1.02~8.89）×10⁶/kg；回输脐血单个核细胞2.22（1.10~7.30）×10⁷/kg，CD34⁺细胞0.56（0.16~2.27）×10⁵/kg。127例患者中5例发生早期死亡。在可评估的122例患者中，1例发生原发植入失败，其余121例患者成功植入（均为单倍型造血干细胞植入）。中性粒细胞、血小板植入时间分别为11（9~28）d、15（9~330）d，5例患者发生血小板植入不良。移植过程中74例（58.27%）发生感染。存活患者中位随访20.5（4.0~60.0）个月，Ⅱ~Ⅳ度急性GVHD发生率为24.79%（30/121），中/重度慢性GVHD发生率为14.15%（15/106），预期4年总生存率为（78.5±4.3）%，无失败生存率为（77.4±4.3）%。

结论

haplo-HSCT联合第三方脐血干细胞移植治疗SAA疗效确切且安全性较好，在无全相合供者情况下可作为有价值的治疗选择。

[Comparison of the efficacy of decitabine combined with micro-transplantation or priming regimen as consolidation treatment for older patients with acute myeloid leukemia]

目的

探索老年急性髓系白血病（AML）第1次完全缓解（CR₁）后采用地西他滨联合微移植巩固治疗的疗效与安全性。

方法

回顾性分析2012年11月至2015年9月诊治的37例CR₁老年（≥60岁）AML患者病例资料，比较分析地西他滨联合微移植（微移植组，19例）与地西他滨联合预激方案巩固治疗（化疗组，18例）的疗效和不良反应。

结果

两组患者起病时的年龄、WBC水平、疾病状态差异均无统计学意义（P值均>0.05）。两种巩固治疗方案的耐受性均良好，微移植组与化疗组的CTC 3~4级非血液学不良反应发生率差异无统计学意义[36.8%（7/19）对27.8%（5/18），χ²=0.347，P=0.728]。微移植组与化疗组中性粒细胞恢复的中位时间分别为12和13 d（z=1.599，P=0.110），血小板恢复的中位时间分别为14和12 d（z=−1.314，P=0.189）。微移植组患者均未发生移植物抗宿主病。微移植组与化疗组的2年无白血病生存率分别为50.7%和24.3%（P=0.047），2年总生存率分别为54.9%和30.0%（P=0.071）。

结论

对于老年AML患者，地西他滨联合微移植可能是一种安全有效的巩固方案。

[Comparison of allogeneic or autologous hematopoietic stem cell transplant for high-risk peripheral T cell lymphomas]

目的

比较自体造血干细胞移植（auto-HSCT）和异基因造血干细胞移植（allo-HSCT）治疗高危外周T细胞淋巴瘤（PTCL）疗效的差异。

方法

回顾性分析苏州大学附属第一医院60例接受HSCT治疗的高危PTCL患者临床资料。

结果

60例PTCL患者均为高危组患者（IPI评分≥3分），接受移植时中位年龄31 (12~58）岁。包括PTCL非特指型22例、ALK阴性的间变大细胞淋巴瘤22例、血管免疫母细胞淋巴瘤16例。其中接受auto-HSCT的有39例（63.5%），接受allo-HSCT的有21例（36.5%）。移植前40例完全缓解（CR），2例部分缓解（PR），18例未缓解（NR）。40例CR患者中10例接受allo-HSCT, 30例接受auto-HSCT。20例PR+NR患者中11例接受allo-HSCT, 9例接受auto-HSCT。移植后中位随访时间为39 (1~96）个月，auto-HSCT和allo-HSCT组的5年无进展生存率分别为61％和60%（P=0.724）。auto-HSCT和allo-HSCT组的5年总生存率分别为62％和61%（P=0.724）。auto-HSCT和allo-HSCT组的5年移植相关死亡率分别为22.7％和41.8%（P=0.250）。截至末次随访时间，auto-HSCT中7例患者复发，allo-HSCT组中2例复发，auto-HSCT和allo-HSCT组的5年累计复发率分别为37.2％和10.1%（P=0.298）。

结论

高危PTCL患者选择auto-HSCT或allo-HSCT治疗长期生存无明显差异，但allo-HSCT组患者移植前多为NR状态，表明对于NR患者，allo-HSCT效果可能较好。

[The clinical features of patients with lymphoplasmacytic diseases harboring MyD88 L265P mutation]

Objective: To explore the clinical features of lymphoplasmacytic diseases with MyD88 L265P mutation. Methods: To analyze the distribution of MYD88 L265P mutation in patients with lymphoplasmacytic diseases by using of ARMS PCR-CE. Results: There were 25(30.9%) MyD88 L265P mutated patients in 81 patients. The mutation was frequently observed in 14 patients with WM (77.8%, 14/18), 2 patients with lymphoplasmacytic lymphoma (66.7%, 2/3), 1 acute lymphocytic leukemia patient (50.0%, 1/2), 3 multiple myeloma patients (30.0%, 3/10), 1 patient with monoclonal gammopathy of undetermined significance (25%, 1/4), 3 patients with chronic lymphocytic leukemia (13.0%, 3/23) and 1 lymphoma patient (4.8%, 1/21). 20 (80%, 20/25) patients were identified with IgM subtype. Compared with wild-type group of 56 cases, mutated patients were older (median age: 67 years vs 55 years, P< 0.001), with lower WBC count (median count: 5.23 × 109/L vs 10.80 × 109/L, P=0.001), lower HGB level (median count: 85 g/L vs 119 g/L, P<0.001). Conclusion: MyD88 L265P mutation was mainly observed in patients with IgM subtype lymphoplasmacytic diseases, and Waldenstrom' s macroglobulinemia was the most common disease. Compared with the wild-type group, patients with MyD88 L265P mutation were older and had lower WBC count, lower level of HGB. However, further studies were needed to test the prognostic value of MyD88 L265P mutation.

[The roles of serum free light chain ratio in the diagnosis and prognosis of newly diagnosed multiple myeloma]

目的

分析血清游离轻链（sFLC）κ/λ比率（sFLCR）在初诊多发性骨髓瘤（MM）患者诊断和预后中的作用。

方法

回顾性分析2012年9月至2015年7月收治的82例初诊MM患者的临床资料，采用血清蛋白电泳（SPE）和免疫固定电泳（IFE）法检测血清单克隆蛋白（M蛋白）的表达，采用免疫比浊法检测sFLCκ、λ的表达水平，分析初诊时sFLCR在MM患者诊断和预后中的作用。

结果

初诊时82例患者中SPE法检测M蛋白阳性率为85.5%，IFE法检测M蛋白阳性率为93.9%，sFLC异常以及sFLCR异常者占96.3%。初诊时高比率组（sFLCR≥100或≤0.01，42例）与低比率组（0.01 <sFLCR<100，40例）患者40个月的总生存率分别为87％和61%，差异有统计学意义（P=0.034）。与低比率组患者比较，高比率组患者初诊时血肌酐值、浆细胞数、β₂微球蛋白增高，血红蛋白降低，肾功能不全及需要透析者、DS分期Ⅲ期B组者、ISS分期Ⅲ期者、FISH检查异常者、λ轻链异常者较多，κ轻链异常者较少（P值均<0.05）。两组患者经过3~4个疗程诱导治疗后，高比率组和低比率组患者的治疗有效率（非常好的部分缓解及其以上）差异有统计学意义（45.2％对72.5%，P=0.012）。初诊肾功能不全者（肌酐≥178 µmol/L, 14例）与肾功能正常者（68例）的2年总生存率差异无统计学意义（85.7％对91.2%，P=0.894）。

结论

初诊时sFLC的检测相对于SPE和IFE法检测M蛋白对诊断MM有更高的敏感性；初诊时sFLCR明显异常的患者可能具有更高的肿瘤负荷和更强的侵袭性，可提示患者预后不良；初诊时伴有肾功能不全的MM患者经积极治疗后可获得与肾功能正常患者同样的疗效。

[Improved clinical outcome of acute myeloid leukemia with FLT3-ITD mutation treated with sorafenib]

OBJECTIVE

To analyze the efficacy of sorafenib on the treatment of patients diagnosed as acute myeloid leukemia(AML) with FLT3-ITD mutation.

METHODS

From January 2012 to February 2015, 42 cases of AML with FLT3-ITD mutation according to MICM (morphology, immunology, cytogenetics and molecular) diagnosis system in our hospital were retrospectively analyzed. Thirty-two cases were refractory to chemotherapy or relapsed, who were treated with sorafenib or combined with chemotherapy. Ten patients relapsed after allogeneic hematopoietic stem cell transplantation (allo-HSCT), who were retreated with sorafenib or combined with donor lymphocyte infusion (DLI) or chemotherapy. In the first group, 13 of 32 patients accepted allo-HSCT.

RESULTS

The overall response rate of all 42 patients was 73.8%, including 4 (9.5%) complete molecular remission (CMR), 9 (21.4%) complete remission (CR), 8 (19%) complete remission with incomplete hematologic recovery (CRi), 10 (23.8%) partial remission (PR), and 11 (26.2%) none remission (NR). The response rate of sorafenib alone for 17 patients was 70.6%, and that of sorafenib plus chemotherapy was 66.7% (P=0.555). Thirteen patients who received allo-HSCT included 6 CMR/CR/CRi, 4 PR, and 3 NR before transplant. The 2-year overall survival (OS) rate and progress free survival (PFS) rate in all patients were 36.9% and 28.7%, and the corresponding median time were 18 months and 9 months respectively. The 2-year OS rate in 23 patients who received sorafenib combined with allo-HSCT was superior to that in 19 patients not receiving allo-HSCT (45.5% vs 23.9%, P=0.041), so was PFS rate (44.0% vs 9.7%, P=0.014). Twelve cases died of disease progression, four of infection, and one of chronic graft versus host disease after transplant.

CONCLUSIONS

Sorafenib combined with chemotherapy improves response rate of AML patients with FLT3-ITD mutation. Those who are treated with sorafenib plus allo-HSCT obtain better long-term survival.

Abnormal glucose tolerance in transfusion-dependent beta-thalassemic patients

OBJECTIVE

To study the prevalence of and risk factors for abnormal glucose tolerance in transfusion-dependent beta-thalassemic patients.

RESEARCH DESIGN AND METHODS

A total of 89 transfusion-dependent beta-thalassemic patients were interviewed. Diabetes was previously diagnosed in 14 of them. In the remaining 75 patients, 68 participated in an oral glucose tolerance test. Potential risk factors were identified using the independent t test, chi2 test, and Fisher's exact test. Logistic regression analysis was used to select the independent risk factors that best predicted abnormal glucose tolerance A two-tailed P value of <0.05 was considered to be statistically significant.

RESULTS

The prevalence of impaired glucose tolerance was 8.5% (7 of 82) and that of diabetes was 19.5% (16 of 82). Presentation with diabetic ketoacidosis was 31.1% (5 of 16). The risk factors for abnormal glucose tolerance found in transfusion-dependent beta-thalassemic patients were serum ferritin concentration and hepatitis C infection.

CONCLUSIONS

The interaction of iron overload and hepatitis C infection worsened the prognosis of thalassemic patients. Aggressive iron-chelation therapy as well as prevention and treatment of hepatitis C infection should be mandatory in managing glucose homeostasis in transfusion-dependent beta-thalassemic patients in Taiwan.

Effect of U-995, a potent shark cartilage-derived angiogenesis inhibitor, on anti-angiogenesis and anti-tumor activities

BACKGROUND

A potent angiogenesis inhibitor, U-995, has been purified from the cartilage of the blue shark (Prionace glauca). U-995 is composed of two single peptides with molecular mass of 10 and 14 kDa, respectively.

MATERIALS AND METHODS

U-995 was designed to study human umbilical vein endothelial cell (HUVEC) migration and proliferation in vitro and angiogenesis induced by TNF alpha in chicken chorioallantoic membrane (CAM). Furthermore, we determined the ability of U-995 to inhibiting tumor cell growth and metastasis.

RESULTS

U-995 (15 and 30 micrograms/ml) markedly inhibited HUVEC migration and, at 15-50 micrograms/ml produced a dose-dependent decline in [3H]-thymidine incorporation. 30 and 50 micrograms/ml of U-995, when added to TNF alpha-induced angiogenesis caused discontinuous and disrupted blood vessels. Moreover, U-995 (30 micrograms/ml) markedly prevented collagenase-induced collagenolysis. In addition, when 200 micrograms U-995 was injected i.p. into mice it suppressed sarcoma-180 cell growth and B16-F10 mouse melanoma cell metastasis in vivo.

CONCLUSIONS

These results suggest that the anti-angiogenic effects of U-995 may be be due to interference with the proliferation and migration of HUVECs as well as inhibition of collagenolysis, thereby leading to inhibition of both angiogenesis and tumor cell growth.

Incidence and progression of diabetic retinopathy among non-insulin-dependent diabetic subjects: a 4-year follow-up

BACKGROUND

To assess the incidence and progression of diabetic retinopathy and explore risk factors associated with them among non-insulin-dependent diabetes mellitus (NIDDM) patients.

METHODS

A total of 471 NIDDM subjects aged > or 40 were recruited from four primary health care centres of northern Taiwan in 1986 and followed up for 4 years. Their ocular fundi were clearly visible by ophthalmoscopy and the status of diabetic retinopathy could be graded. A structured questionnaire interview was conducted to collect basic data. Overnight fasting venous blood was collected every year to measure the levels of glucose, glycosylated haemoglobin (HbA1c), cholesterol and high density lipoprotein cholesterol.

RESULTS

Among the 344 subjects who had no retinopathy initially, 66 subjects developed retinopathy 4 years later giving a 4-year cumulative incidence of 19.2%. Of the 120 subjects initially with background or preproliferative retinopathy, evidence of deterioration developed in 36 subjects. The cumulative incidence of progression was 30%. Seven subjects developed proliferative retinopathy giving a cumulative incidence of progression to proliferative retinopathy of 5.8%. The univariate analysis disclosed that the development of retinopathy was correlated with mean fasting blood glucose (MFBG) and HbA1c, diabetic duration, diabetic treatment and residential area. The progression of retinopathy correlated with MFBG and proteinuria, and the progression to proliferative retinopathy correlated with MFBG. Stepwise logistic regression analysis revealed that MFBG and HbA1c were the significant risk factors related to the development of retinopathy.

CONCLUSIONS

Diabetic control assessed by MFBG or HbA1c was the significant risk factor correlated with the incidence and progression of retinopathy.

Maternal role in type 2 diabetes mellitus: indirect evidence for a mitochondrial inheritance

BACKGROUND

The role of mitochondrial inheritance in type 2 diabetes mellitus has received much attention recently. In this study, three existing datasets in Taiwan are analysed to examine this theory.

METHODS

Two of the datasets were community surveys and one a hospital case series. Subjects who had information regarding their paternal or maternal diabetic status were selected for the present study. In the first dataset, 745 subjects had information about paternal diabetic status and 765 had information about maternal diabetic status. In the second dataset, 255 and 267 subjects had the paternal and maternal information, respectively. In the third, a total of 3625 subjects had information about both their paternal and maternal diabetic status. Diabetic status of the study subjects was determined by fasting plasma glucose levels and/or oral glucose tolerance test; their parental diabetic status was collected by interview.

RESULTS

The three datasets consistently demonstrated a significantly elevated odds ratio (OR) for reporting maternal diabetes (OR = 2.64, 95% confidence interval: 1.12-5.71) in diabetic patients as compared to non-diabetic subjects. The reporting of paternal diabetes, however, was not significantly different between diabetics and non-diabetics. In addition, the OR for reporting paternal diabetes were not significantly different between groups of different age-at-onset. With respect to maternal history, the OR increased significantly when age-at-onset was younger (test-for-trend P < 0.001).

CONCLUSIONS

Our findings support mitochondrial inheritance of type 2 diabetes mellitus in the human population. The age-modifying effect was also in accordance with the mitochondrial oxidative phosphorylation paradigm for degenerative diseases.

[Retinal S-antigen and retinoblastoma--an immunohistochemical study]

A strain of monoclonal antibody, MabAgC6, which defines an epitope in S-antigen, was used to study S-antigen expression in 10 cases of retinoblastoma, where S-antigen immunoactivity was observed in different patterns: the "normal" photoreceptor elements incorporated in 3 cases of growing tumors, 3 of 4 fleurettes and E-W rosettes, and scattered tumor cells in 50% of the cases were stained positive. The results suggest that the expression of S-antigen in retinoblastoma may be used to assess the degree of tumor differentiation, as another of the tumor markers.

Development of macrovascular diseases in NIDDM patients in northern Taiwan. A 4-yr follow-up study

OBJECTIVE

To assess the development of macrovascular diseases and explore major associative factors in NIDDM.

RESEARCH DESIGN AND METHODS

A total of 479 NIDDM patients > or = 40 yr of age were recruited from four community primary care health centers of northern Taiwan in July 1986 for a cohort study with a 4-yr follow-up. No patient required insulin therapy within 1 yr of diagnosis nor had a history of diabetic ketoacidosis. All were able to participate independently in the activities of daily living. BP and ECG were measured, and a structured questionnaire was asked of each patient. Venous blood after overnight fasting was collected every year to measure cholesterol, HDL cholesterol, plasma glucose, and HbA1c.

RESULTS

The duration of diabetes was associated with the development of stroke with a relative risk of 1.063 for every 1-yr increment (P = 0.07). As for HVDs, the significant risk factors were serum cholesterol and HbA1c. For every 1-mg/dl increase in mean total cholesterol level, the relative risk of developing HVD increased 1.016-fold (P = 0.04). For every 1% increase in HbA1c, the relative risk of developing HVD increased 1.170-fold (P = 0.01). With regard to leg VDs, sex and cigarette smoking were significant risk factors. Women diabetic subjects had a higher relative risk than men. Cigarette smoking was significantly associated with leg VD with a relative risk of 6.9 for smokers compared with nonsmokers. The most significant risk factor for LVD was the total cholesterol level. For every 1-mg/dl increase in mean serum cholesterol level, the relative risk of LVD increased 1.013-fold.

CONCLUSIONS

In the prevention of macrovascular diseases, effective intervention of the nondiabetic cardiovascular risk factors may be as important as or even more important than the good control of diabetes.

Prevalence and risk factors of diabetic retinopathy among noninsulin-dependent diabetic subjects

In a population-based study in Taiwan, 11,478 subjects aged 40 years or older were screened for diabetes in one urban and five rural areas. Among the 715 subjects proven to have diabetes, 527 subjects underwent ophthalmoscopy. Diabetic retinopathy was present in 184 of the 527 subjects (35.0%), including background diabetic retinopathy in 157 subjects (30.0%), preproliferative diabetic retinopathy in 15 subjects (2.8%), and proliferative diabetic retinopathy in 12 subjects (2.2%). Diabetic retinopathy was correlated with the duration of diabetes and age at onset of diabetes, type of diabetes treatment, higher serum creatinine levels, and lower serum cholesterol levels. Several other factors, including gender, age, residential area, family income, educational level, control and family history of diabetes, body mass index, physical activity, exercise, cigarette smoking, stroke, ischemic heart disease, leg vessel disease, hypertension, and proteinuria, had no significant association with retinopathy. By multiple logistic regression analysis, duration of diabetes was the most important risk factor related to retinopathy. Diabetic subjects treated with insulin had a higher risk of developing retinopathy than those treated with dietary control (relative risk, 1.57; .05 < P < .10). The univariate analysis disclosed that proliferative diabetic retinopathy was related to older age at examination, older age at onset of diabetes, type of diabetes treatment, and presence of leg vessel disease. Insulin-treated diabetic subjects also had a higher risk of proliferative diabetic retinopathy than patients in whom diabetes was controlled by diet, with a relative risk of 2.51 (.05 < P < .10) in the multiple logistic regression analysis.

Motor-evoked potentials in diabetes mellitus

By using magnetic stimulation of the motor cortex and in the cervical region, conduction time in the central motor pathway was measured in 35 patients with diabetes mellitus (DM) and in 41 control subjects. Motor-evoked potentials (MEPs) were recorded from the contralateral thenar muscles. Central conduction time (CCT) was obtained by subtracting the latency of the spinal MEP from that of the scalp MEP. To compare central and peripheral nerve functions, the motor nerve conduction velocity (MCV) of the median nerve was also tested in patients with DM. In the 35 cases of DM, the mean latency of the cortical MEPs showed a significant increase, compared with normal controls; the mean CCT was also significantly prolonged in the patient group. There was a good correlation between central motor abnormalities and the duration of DM, as well as with impairment of the peripheral nervous system. Latencies of greater than two standard deviations were defined as abnormal. The abnormal rate in patients with DM was 29% for latency of the cortical MEP, 20% for latency of the cervical MEP and 37% for the CCT. In addition, there was a 35% abnormal rate for distal latency of the median MCV and a 40% abnormal rate for the median MCV. These findings support the theory that the metabolic disturbance in DM affects both the central and peripheral nervous systems in man. MEP studies provide objective measurements of central motor pathways.

Cutaneous thermal thresholds in normal subjects and diabetic patients without symptoms of peripheral neuropathy

An automated system operating on the Peltier principle and using a two-alternative forced-choice testing technique was applied to measure the heat and cold thermal thresholds (HT and CT) in 63 normal subjects and 68 diabetic patients who had no clinical symptoms of peripheral neuropathy. To compare large and small nerve fiber functions, 34 of the diabetic group were also tested for vibration perception threshold (VPT) and nerve conduction velocity (NCV). The testing algorithm of the devices selected for used, including reference temperature and number of turns, was investigated for assessment of variability and reliability. The age effect on thermal thresholds was found in the normal group (p less than 0.001). There was a significant difference between HT and CT in an individual (p less than 0.01). CT was greater than HT in 68% of the subjects. The diabetic group had significantly higher thermal thresholds than the normal group (HT, 0.30 +/- 0.32 degree C vs 0.10 +/- 0.05 degree C, p less than 0.005; CT, 0.39 +/- 0.43 degree C vs 0.15 +/- 0.09 degree C, p less than 0.005). Thermal thresholds greater than the linear regression estimate for age plus three standard errors of estimate were defined as abnormal. The abnormality rate in diabetics was 33.8% for HT and 22.1% for CT. Of the 34 patients, 91.1% had abnormal results in at least one of the three tests: 47.1% abnormal for HT or CT, 67.6% for VPT, and 26.4% for NCV. No correlation existed between the thermal threshold and VPT (p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of diabetic control status between urban and rural diabetic patients in Taiwan

Between 1985 and 1987, in two urban and five rural areas in Taiwan, a total of 16,636 subjects aged 40 or over were screened for diabetes mellitus according to the WHO criteria. Four hundred and fifty-two previously diagnosed patients and 274 newly diagnosed patients were found. All were non-insulin-dependent diabetics. The blood glucose control status was compared between the urban and rural previously diagnosed diabetics. Those living in the rural areas were found to have better control with a higher percentage under regular treatment. Stepwise multiple regression failed to discover a significant correlation between control status and any of the following factors: sex, age, body mass index (BMI), diabetic duration, treatment regularity, exercise, occupation, education, family income and the presence of hypertension or large vessel diseases. About 30% of the patients in rural areas and 40% in urban areas were poorly controlled. This indicates that our diabetic control program should be strengthened.

[Utilization and medical cost of patients with different insurance coverage among group practice centers]

In order to explore the utilization and medical cost of patients with different insurance coverage in group practice centers, we collected patient data in three centers from September 1, 1987 to February 28, 1988. We classified the payments as self-payment,partial-reimbursement and total-reimbursement. There were 42,234 visits by 8,111 patients. The average frequency of visits within 6 months was 6.1 in total-reimbursement patients, 5.2 in partial-reimbursement patients and 2.6 in self-payment patients. We found that the frequency of visits increased with age in patients with total-reimbursement and partial-reimbursement. On the other hand, the frequency decreased after the age of 65 in patients with self-payment; whether it was related to the economic problems of the elderly needs further study. The highest medical cost per visit was NT$. 343 in total reimbursement patients, followed by NT$. 281 in partial-reimbursement patients. The lowest cost was NT$. 208 in self-payment patients. Yet, the highest ratio of total drug cost by total medical cost per visit was 73.7% in partial-reimbursement patients followed by 63.6% in total-reimbursement patients. The lowest ratio was 56.7% in self-payment patients. Although the partial-reimbursement system could not decrease the ratio of total drug cost by total medical cost per visit, it would be beneficial in group practice centers to decrease the patients' visits and the medical cost per visit. Therefore, this system should be executed in the future.

A comparison of newly and previously diagnosed diabetics in Taiwan

Between 1985 and 1986, during a population survey of diabetes in 1 urban and 5 rural areas of Taiwan, a total of 11,478 adults aged 40 or older were screened. Capillary whole blood glucose was determined with a glucometer (Ames Co.) The diabetic criteria followed the WHO designations. From this survey, a comparison of 225 newly diagnosed and 383 previously diagnosed diabetics was conducted. Multiple regression analysis revealed a highly significant correlation for all diabetics with regard to age, body mass index, family history and hypertension, but no specific correlation to habitat. Mean fasting glucose levels in previously and newly diagnosed diabetics were 172 and 158 (males 158 vs 147 and females 184 vs 165) mg/dl, respectively, which suggest that treatment is apparently inadequate in this population. The prevalent rate (%) of retinopathy for previously and newly diagnosed diabetics was 45.2 and 28.3 (males 42.8 vs 33.3 and females 47.5 vs 24.8), respectively. The prevalence is as common as those reported in western countries. In conclusion, previously diagnosed diabetics had higher fasting glucose concentrations and prevalent rates of retinopathy than newly diagnosed diabetics, and these findings were particularly prominent in females.

Vibratory perception threshold in diabetic neuropathy

A total of 263 diabetic patients and 129 normal controls were enrolled in a study of vibratory perception threshold (VPT) using an electromagnetic vibrometer at two sites, the dorsum of the metacarpal bone of the index finger (IF) and the dorsomedial aspect of the metatarsal bone of the great toe (GT). The results showed that the mean values of VPT for both IF and GT were significantly higher in diabetics than in normal subjects. In both control and diabetic groups, the VPT values at GT only were elevated with increasing age. Furthermore, the mean VPTs at both IF and GT were related to the duration of illness and the severity of diabetes mellitus in the patient group. Eighty cases of diabetes mellitus received nerve stimulation tests including motor and sensory nerve conduction velocities of the upper and lower limbs. The results from these cases demonstrated good correlation between VPT and motor conduction velocity (MCV), but not between VPT and sensory conduction velocity (SCV). There was a negative correlation between VPT at IF and median MCV (p less than 0.0005) in the upper limbs, as well as VPT at GT and tibial MCV (p less than 0.0005) in the lower limbs. For clinical applications, VPT values seemed to be more sensitive than MCV in detecting neuropathic change in diabetic patients. Hence, impairment of vibratory perception can be taken as a subtle clinical sign of diabetic neuropathy, and measurement of VPT can be used as an index of a patient's current subclinical state.

Paraquat intoxication during pregnancy: a report of 9 cases

The details of nine patients who deliberately ingested paraquat (24% solution) while pregnant are presented. Two patients refused treatment. Paraquat levels in maternal, fetal and cord blood in 1 case shows that paraquat crosses the placenta and is concentrated to levels 4-6 times greater than the maternal blood. Amnioscopy in another case showed paraquat levels in amniotic fluid nearly twice that of maternal blood. All fetuses died, whether or not emergency cesarean operation was performed. The condition of the fetus worsened at delivery, or in utero if the gestational age was greater than 30 weeks. One of the 2 survivors has had a normal pregnancy since, with no evidence of teratogenicity from the earlier paraquat intoxication. This patient has shown a gradual return to normal spirometry values from the marked reduction that occurred at the time of paraquat intoxication.

Annular arrays for quantitative pulsed doppler ultrasonic flowmeters

A theory, based on the Fourier-Bessel series expansion, is developed to synthesize circularly symmetric field patterns by means of concentric annular arrays. The application of this theory to the formation of variable-width uniform sector beams is studied in detail and results in a canonical design procedure. Calculated beam patterns are compared to the actual measured patterns obtained from a prototype array suitable for transcutaneous investigation of the central blood-flow system and are observed to be in good agreement. The implementation of such arrays in the compensated-first-moment flowmeter is described. Methods of beam-pattern improvement are also discussed.

Near-field uniform beams for pulsed Doppler ultrasound

A mathematical model for the beam pattern of a pulsed ultrasonic transducer is introduced. Beam-pattern analysis and simulation of a circular transducer based on this model agree well with the experimental results. It is demonstrated that, in its near field, the pulsed transducer is capable of generating a good approximation to a uniform ultrasonic field which cannot be achieved with a cw transducer. Preliminary error analysis indicates that the near-field beam pattern of the pulsed transducer is suitable for quantitative blood-flow measurement, and design criteria are developed for this application. A prototype has been fabricated and tested in in-vitro experiments, and the results verify the feasibility of the quantitative blood flowmeter principle and the pulsed-transducer near-field approach to the formation of uniform beams.

Quantitative high-pressure liquid chromatographic determination of thimerosal in pharmaceutical formulations

A quantitative high-pressure liquid chromatographic method an anion-exchange resin column and an aqueous perchlorate solution as the mobile phase is employed for the determination of thimerosal in pharmaceutical formulations. With a liquid formulation containing large amounts of edetate disodium, calcium chloride is used for complexation to eliminate the interference from edetate disodium.

Quantitative high-pressure liquid chromatographic determination of epinephrine in pharmaceutical formulations

A quantitative high-pressure liquid chromatographic method, using a cationic exchange resin column and an aqueous phosphate buffer as the mobile phase, was employed for the determination of epinephrine in liquid pharmaceutical preparations. The method is stability determining and can differentiate epinephrine in the presence of oxidative and other degradation products.

Mechanism of action of retinyl compounds on wound healing IV: effect of desmethylretinoic acid and its vinylogs on granuloma formation

The effect of side-chain length of desmethylretinoic acid on granuloma formation induced by implantation of cotton pellets was studied. As in the homologous series of retinoic acid studies, compounds with side chains shorter than retinoic acid were not active while compounds with side chains as long or longer than retinoic acid were active. The compound with a chain two carbons longer than retinoic acid was the most active. The hydroxyproline and hexosamine contents of the granuloma were analyzed. The mechanisms of action of these active compounds on wound healing are discussed.