Venetoclax ramp-up strategies for chronic lymphocytic leukaemia in the United Kingdom: a real world multicentre retrospective study

This retrospective, observational study evaluated patterns of inpatient versus outpatient tumour lysis syndrome (TLS) monitoring during venetoclax ramp-up in 170 patients with chronic lymphocytic leukaemia. The primary outcome was clinical/biochemical TLS. Two clinical and four biochemical TLS occurred (4.1%). Five of the six events occurred in high-risk patients, four occurred at 20 mg dose and three at the 6-h time-point. Inpatient versus outpatient TLS rates within the high-risk subgroup were 15% and 8%. Risk category was the only predictor of TLS events in multivariate analysis. Outpatient escalation did not associate with clinically meaningful TLS events, suggesting outpatient escalation has manageable associated TLS risks, including in high-risk cohorts. These observations require confirmation in larger studies.

Age, menopausal status and homocysteine levels in women around menopause

OBJECTIVE

To obtain data on the relation between age, menopause and homocysteine levels in women around menopause, we collected data for a sample of about 500 women attending a menopause clinic in Milan, Italy.

STUDY DESIGN

Eligible for the study were all women aged 45-75 years, never HRT users consecutively observed for the first time at the Menopause Center of the 1st Obstetric Gynecological Clinic of the University of Milan. Fasting blood samples for total homocysteine plasma levels were collected during the visit. Of the 490 study subjects, 107 were pre-menopausal and 383 post-menopausal.

RESULTS

In the total series, the mean homocysteine level was 8.3 micromol/L (S.D. 3.7, range 3.2-48.8). The values increased from 7.8 micromol/L in women aged <47 years to 9.0 micromol/L in those aged >59. Among pre-menopausal women the mean homocysteine level was 7.7 micromol/L compared to 8.3 micromol/L in post-menopausal women: this difference disappeared on the adjusted values. In post-menopausal women only, no clear relationship emerged between years since menopause and homocysteine levels.

CONCLUSION

In our population, age, and not menopausal status, was the main determinant of homocysteine levels in women around menopause.

Effect of oral or transdermal hormone replacement therapy on homocysteine levels: a randomized clinical trial

OBJECTIVE

Aim of this randomized trial was evaluate the effect on homocysteine plasma levels of two different hormone replacement therapy (HRT) formulations in a group of late postmenopausal women.

METHODS

Eligible for this study were women: in postmenopause since 5 years or more (confirmed from FSH level > or = 40 mIU/l); with body mass index (BMI) < or = 35; without endocrine, hepatic or renal diseases; not current users of vitamin B or folic acid supplements; not users of any lipid-lowering drugs and sex steroids in the 6 months before trial entry. Group A: oral estradiol valerate 2 mg per day per oral normegestrol acetate 2.5 mg per day (n = 98) for 12 months; Group B: a weekly patch releasing estradiol (50 microg per day) per oral normegestrol acetate 2.5 mg per day (n = 101) for 12 months.

RESULTS

The mean values of the homocysteine levels in the group A and B at baseline, 3, 6 and 12 months were 7.9 and 9.1, 8.7 and 8.9, 9.3 and 10.2, 9.6 and 10.2, respectively, the differences between the two treatments were not statistically significant (time by treatment interaction, P = 0.32). Otherwise, the changes of homocysteine level at the four visits was statistically significant (P = 0.0001) in both groups. In particular, in the oral treatment group homocysteine levels increased from baseline of 10.5% at 3 months, of 17.2% after 6 months of therapy and of 21.9% at the end of the study; in the transdermal group, after a little decrease at 3 months (1.5%), the increases were of 12.1 and 12.9%, respectively.

CONCLUSIONS

This study does not show any different effect of oral and transdermal treatment with estradiol plus normegestrol acetate on homocysteine levels. Further it does not support previous suggestion of a lowering effect of HRT on plasma homocysteine.

CMV gB genotypes and outcome of vertical transmission: study on dried blood spots of congenitally infected babies

BACKGROUND

The role of the virulence of the infecting cytomegalovirus (CMV) strain in the transmission of the virus from mother to fetus and the outcome of the fetal infection has not received much attention yet. Molecular analysis of the gene coding for the surface glycoprotein B (gB) has been used to investigate the relationship between genotype and virulence in groups of immunosuppressed patients.

OBJECTIVES

(1) to assess the prevalence of different gB genotypes in babies with congenital CMV infection; (2) to investigate the possible relationship between genotype and severity of congenital CMV disease; (3) to evaluate the possibility of using dried blood on Guthrie cards (DBS) for genotyping.

STUDY DESIGN

CMV DNA was extracted from DBS and from urine/saliva samples collected in the first two weeks of life of 98 congenitally infected babies, half of which were symptomatic at birth. Genotyping was performed through RFLP analysis of the region corresponding to the cleavage site of the gB protein.

RESULTS

The most prevalent genotype was gB1 (42%) followed by gB3 (26%), gB2 (19%) and gB4 (13%). Rates of disease and CNS damages were higher among children infected by gB1 (35%, 17%) and gB3 (31%, 28%) than in those infected by gB2 and gB4 (20%, 17% and 13%, 15%, respectively). These differences however did not reach the statistical significance. The parallel typing of DBS and urine/saliva strains gave a full concordance of results.

CONCLUSIONS

All four major CMV gB genotypes (gB1-4) can cause a congenital infection but none seems to be associated to the development and the severity of disease. The possibility of using the neonatal DBS for genotyping opens a way to the examination of large numbers of cases of congenital CMV infection.

Cytomegalovirus DNA detection in Guthrie cards: a powerful tool for diagnosing congenital infection

BACKGROUND

A simple and reliable diagnosis of congenital cytomegalovirus infection is necessary both for clinical and epidemiological purposes. This could be accomplished through the demonstration of cytomegalovirus (CMV) DNA in blood spots (DBS) on Guthrie cards.

OBJECTIVES

(1) To assess the sensitivity and specificity of the method (DBS test) in diagnosing congenital CMV infection compared with viral isolation and (2) to evaluate the applications of the test to the late diagnosis of congenital CMV.

STUDY DESIGN

The method was tested on the cards of (1) 509 babies examined through viral isolation within their third week of life (72 positive cases) and (2) 191 children studied after 3 weeks of life (25 days to 5 years). Blood was eluted from Guthrie cards and heat extracted. The products of a nested polymerase chain reaction (PCR) amplifying one region in the CMV glycoprotein B (gB) gene were detected by agarose gel electrophoresis.

RESULTS

DBS test was positive in all 72 congenitally infected babies and in four of the 437 negative at cytomegalovirus isolation (sensitivity 100%, specificity 99%). Infection in 16 of the 92 infants with a late viral isolation was demonstrated to be congenital by the test, which also detected congenital infection in 18 of 83 children in whom viral culture was not performed (13 with and five without symptoms). Fifty-six additional control cases tested negative.

CONCLUSIONS

DBS test is a reliable assay for diagnosing congenital cytomegalovirus infection and could be used as an alternative to viral culture. It is able to reveal whether ascertained CMV infection is congenital or postnatal at an age when viral isolation is not able to do so. It can assess the role of risky procedures such as transfusion and it can ascertain the etiology of morbid conditions diagnosed late or of controversial origin.

Medium-chain triglyceride loading test in carnitine-acylcarnitine translocase deficiency: insights on treatment

The results of a medium-chain triglyceride loading test in a patient with severe carnitine-acylcarnitine translocase deficiency clearly demonstrated impaired in vivo utilization of medium-chain triglycerides. The loading test was performed at the ages of 7 and 36 months. The diet was adjusted accordingly. The clinical course has been favourable and the child is now in very good condition at age 4 years. We conclude that the utilization of medium-chain triglycerides is only partial in carnitine-acylcarnitine translocase deficiency and cannot reasonably be considered an optimal source of energy for these patients. Careful adjustment of dietetic treatment may help to improve prognosis.

Acute, severe cardiomyopathy as main symptom of late-onset very long-chain acyl-coenzyme A dehydrogenase deficiency

A 5-year-old boy with late-onset very long-chain acyl-CoA-dehydrogenase (VLCAD) deficiency presented with acute cardiomyopathy, myopathy, gross myoglobinuria and normoglycaemia. The clinical course after diagnosis was favourable.

CONCLUSION

late-onset VLCAD deficiency may present as acute cardiomyopathy.

[Polycenter evaluation of the break-point system]

Several research center have been set up to evaluate the system that deals with sensitivity to microbes under Sensititre break-point. The study has been broken down as follows: the break-point system was compared with the agar diffusion according to Bauer et al., using 1180 strains of fast-growing Gram-negative bacteria; a limited number of strains (176) have been used to compare the Sensititre break-point and the Sensititre MIC; results have been obtained testing 448 strains processed by break-point with correct inoculum and with simplified inoculum, from a colony; an investigation has been carried out on the time and cost of the break-point functioning. Having taken the Bauer system and others are compared them with the break-point, it was seen that their total agreement was 90.3% with 2% of major disagreement. The total major disagreement between Sensititre MIC and Sensititre break-point was 2.7%. The total major disagreement of the latter was largely the result of cephalotin (21%) on the Escherichia coli strains. An initial research centre has been formed to try to trow light upon the origins of such disagreements and we are now pleased to report back their initial findings. The preparation and reading of a test with the Bauer system and others takes about 18 minutes and costs 5600 Lit; a break-point test takes 10 minutes and costs 4500 Lit.

Effect of temperature on the p50 value for human blood

We investigated the effect of temperature (19, 30, 37, and 43 degrees C) on the p50 value for normal human blood at pco2 = 5.72 kPa (43 mmHg), at various pHs (range 7.0 to 7.6) and molar ratios of [2,3-diphosphoglycerate]/[Hb4] (range 0.4 to 2.4). The d(log p50)/d(pH) coefficient varied from 0.39 at 19 degrees C to 0.35 at 43 degrees C. The relationship between log p50 and 1/T (T = degrees Kelvin) was linear under the experimental conditions used, and the d(log p50)/d(1/T) coefficient varied between -2138 at pH 7.0 and -2162 at pH 7.6, independent of the concentration of 2,3-diphosphoglycerate. Assuming that the effect of pco2 on the p50 value is the same at 19, 30, and 43 degrees C as at 37 degrees C, one can use the reported coefficients to calculate the p50 value for normal human blood under conditions of temperature, pH, pco2, and 2,3-diphosphoglycerate concentrations prevailing under physiological and pathological conditions. The p50 value calculated by empirical equations, taking into account the effect of temperature, correlated well with the values for p50 determined experimentally (y = 0.9774x + 0.453; r = 0.998; n = 60), with an SD of 52 Pa (0.39 mmHg).

Effect of temperature on the p50 value for human blood

We investigated the effect of temperature (19, 30, 37, and 43 degrees C) on the p50 value for normal human blood at pco2 = 5.72 kPa (43 mmHg), at various pHs (range 7.0 to 7.6) and molar ratios of [2,3-diphosphoglycerate]/[Hb4] (range 0.4 to 2.4). The d(log p50)/d(pH) coefficient varied from 0.39 at 19 degrees C to 0.35 at 43 degrees C. The relationship between log p50 and 1/T (T = degrees Kelvin) was linear under the experimental conditions used, and the d(log p50)/d(1/T) coefficient varied between -2138 at pH 7.0 and -2162 at pH 7.6, independent of the concentration of 2,3-diphosphoglycerate. Assuming that the effect of pco2 on the p50 value is the same at 19, 30, and 43 degrees C as at 37 degrees C, one can use the reported coefficients to calculate the p50 value for normal human blood under conditions of temperature, pH, pco2, and 2,3-diphosphoglycerate concentrations prevailing under physiological and pathological conditions. The p50 value calculated by empirical equations, taking into account the effect of temperature, correlated well with the values for p50 determined experimentally (y = 0.9774x + 0.453; r = 0.998; n = 60), with an SD of 52 Pa (0.39 mmHg).

Glycosylated haemoglobins and the oxygen affinity of whole blood

The pO2 at which haemoglobin is half-saturated with oxygen (p50) was determined at fixed pCO2 (45 mmHg) and without altering the resulting pH and the level of organic phosphates in heparinized whole blood samples from 26 diabetic patients and 24 normal subjects of both sexes. Diabetic blood p50 was higher (29.79 +/- 1.68 versus 28.26 +/- 1.16 mmHg, p less than 0.001) and with a higher 2,3-diphosphoglyceric acid/haemoglobin molar ratio (1.04 +/- 0.15 versus 0.86 +/- 0.10, p less than 0.001). The pH at a pCO2 of 45 mmHg was the same in the two groups. The observed p50 values were compared with those obtained after normalization in respect to pH and the level of 2,3-diphosphoglyceric acid. We conclude that glycosylated haemoglobins, known to have an increased affinity for oxygen when purified and in diluted solutions, do not play a significant role in the oxygen affinity pattern of diabetics at the concentrations normally found in vivo.