Long-term treatment of invasive sinus, tracheobroncheal, pulmonary and intracerebral aspergillosis in acute lymphoblastic leukaemia

A 59-year-old male with acute lymphoblastic leukemia developed sinus, tracheobroncheal, pulmonary, and intracerebral aspergillosis. All lesions except the intracerebral aspergillosis healed after combination antifungal treatment. Long-term voriconazole--but not posaconazole--therapy induced partial regression of the cerebral manifestations. At the time of writing, 3.5 years after the initial diagnosis, the patient is working half-time and suffers from a possible voriconazole-induced polyneuropathy.

Effects of chronic iron deficiency anaemia on myoglobin content, enzyme activity, and capillary density in the human skeletal muscle

The influence of chronic iron deficiency anaemia on myoglobin content, maximal enzyme activities and capillarization in the human skeletal muscle was investigated. Muscle samples from musculus vastus lateralis were screened in an Indonesian population. The causes of iron deficiency were chronic intestinal bleeding or repeated pregnancy combined with low iron intake. The maximal activities of iron-dependent and non-iron-dependent glycolytic and oxidative enzymes as well as myoglobin showed similar values in the iron-deficient group and the matched control group. The activities of the oxidative enzymes in both the iron-deficient group and the controls were lower, however, compared even to untrained Swedish subjects. The capillary density was essentially within a normal range in both groups. It is concluded that chronic iron deficiency anaemia of a moderate or severe degree, with Hb concentrations of about 80-100 g.1(-1), does not cause an impaired biochemical function of the human skeletal muscle.

Upregulation of bfl-1 is a potential mechanism of chemoresistance in B-cell chronic lymphocytic leukaemia

B-cell chronic lymphocytic leukaemia (B-CLL) is characterised by the progressive accumulation of monoclonal CD5(+) B cells. In a previous study, we have analysed the expression profile of apoptosis-regulating genes using a cDNA-based microarray and found overexpression of the antiapoptotic bcl-2 family member, bfl-1, in B-CLL cells with an apoptosis-resistant phenotype. In this study, bfl-1 mRNA levels have been determined by competitive PCR in an extended population of B-CLL patients to characterise its role in disease progression and development of chemoresistance. bfl-1 levels were significantly higher in patients with no response (NR) to last chemotherapy than in patients responding (partial response (PR)) to last chemotherapy (P<0.05) and in patients who had not required treatment (P<0.05). We found no correlation between bfl-1 mRNA levels and disease progression, IGHV mutational status or other clinical parameters. In addition, bfl-1 mRNA levels were inversely correlated with apoptotic response to in vitro fludarabine treatment of B-CLL cells. Specific downregulation of bfl-1 using siRNA induced apoptosis in resistant cells. Our data suggest that bfl-1 contributes to chemoresistance and might be a therapeutic target in B-CLL.

Treatment of severe refractory autoimmune hemolytic anemia in B-cell chronic lymphocytic leukemia with alemtuzumab (humanized CD52 monoclonal antibody)

Progressive B-cell chronic lymphocytic leukemia (B-CLL) is often complicated by autoimmune hemolytic anemia (AIHA), which in some cases may be refractory to conventional therapy such as corticosteroids, rituximab and splenectomy. We report here on 5 patients (median age 66 years, range 59-69) with advanced B-CLL, all of whom developed severe transfusion-dependent AIHA resistant to conventional therapy and received subcutaneous (SC) or intravenous (IV) alemtuzumab, a humanized monoclonal antibody that targets the CD52 antigen as salvage treatment for AIHA. Alemtuzumab was well tolerated with only minor 'first dose' reactions. All 5 patients responded with a >or=2.0 g/dl rise in hemoglobin (Hb) concentration, in the absence of further transfusions, after a median time of 5 weeks (range 4-7), and the mean Hb increased from 7.2 g/dl at baseline to 11.9 g/dl at end of treatment. All patients remained stable, without further AIHA episodes, after a median follow-up time of 12 months with a mean Hb of 12.5 g/dl (range 12.2-12.9). For patients with severe, refractory CLL-related AIHA, who have not previously responded to conventional therapy, alemtuzumab is an effective agent.

Expression and transcriptional regulation of functionally distinct Bmf isoforms in B-chronic lymphocytic leukemia cells

Bmf is a BH3-only Bcl-2 family member that is normally sequestered to myosin V motors by binding to the dynein light chain 2 (DLC2). Certain damage signals release Bmf, which then binds prosurvival Bcl-2 proteins and triggers apoptosis. Here, two novel isoforms of human Bmf, Bmf-II and Bmf-III, were identified and cloned from cDNA derived from B-chronic lymphocytic leukemia (B-CLL) cells. Bmf-II and Bmf-III were characterized as two splice variants, lacking the BH3 domain but retaining the DLC2 binding domain. Bmf (here called Bmf-I) expression in HeLa cells induced apoptosis and reduced colony formation in contrast to Bmf-II and Bmf-III, which had no effect on apoptosis and instead increased colony formation. While bmf-I mRNA was expressed in many cell types, expression was higher in B lymphoid cells and bmf-II and bmf-III were mainly detected in B-CLL and normal B cells. bmf-I mRNA was upregulated in normal and leukemic B cells, while bmf-III mRNA was downregulated only in B-CLL cells by serum deprivation. We show that Bmf is regulated by transcriptional activation and alternative splicing and conclude that the relative levels of Bmf isoforms may have a role in regulating growth and survival in B cells and leukemic B-CLL cells.

No benefit from adding GM-CSF to induction chemotherapy in transforming myelodysplastic syndromes: better outcome in patients with less proliferative disease

In this prospective randomized multicenter trial 93 patients, median age 72 years, with RAEB-t (n=25) and myelodysplastic syndrome (MDS)-AML (n=68) were allocated to a standard induction chemotherapy regimen (TAD 2+7) with or without addition of granulocyte-macrophage-CSF (GM-CSF). The overall complete remission (CR) rate was 43% with no difference between the arms. Median survival times for all patients, CR patients, and non-CR patients were 280, 550, and 100 days, respectively, with no difference between the arms. Response rates were significantly better in patients with serum lactate dehydrogenase (S-LDH) levels </=9.5 microkat/l, bone marrow cellularity </=70%, and WBC counts <4.0 x 10(9)/l, but S-LDH was the only variable independently associated with response by logistic regression analysis. Cox's regression analysis identified four significant prognostic factors for survival: bone marrow cellularity, S-LDH, cytogenetic risk group (International Prognostic Scoring System), and age. Only bone marrow cellularity (P=0.01) and S-LDH (P=0.0003) retained statistical significance in the log-rank test. Severe adverse events were significantly more common in the GM-TAD arm (P=0.01). Thus, addition of GM-CSF to chemotherapy showed no clinical benefit in terms of response but carried an increased risk for side effects. We present a clinically useful tool to predict response to chemotherapy and survival in elderly patients with transforming MDS, favoring patients with features of less proliferative disease.

Patterns of clinical presentation, treatment, and outcome in patients with Waldenstrom's macroglobulinemia: a two-institution study

Waldenstrom's macroglobulinemia (WM) is in the World Health Organization (WHO) classification considered to be a clinical syndrome rather than a specific pathologic diagnosis. The clinical manifestations associated with WM relate to direct tumor infiltration, hyperviscosity, and deposition of IgM in various tissues. The indications for and choice of treatment vary considerably and no generally accepted prognostic models exist. The clinical features, treatment, and prognosis of 72 patients with WM seen at one British (n = 36) and one Swedish (n = 36) academic center were therefore compared. Significantly more patients presented with a low albumin concentration (< v > 40 g/L, P <.001), anemia (hemoglobin < v > 120 g/L; P <.001), thrombocytopenia (< v > 150 x 10(9)/L; P <.05), hepatomegaly (P <.001), splenomegaly (P <.01), and lymphadenopathy (P <.01), at St Bartholomew's Hospital (SBH) in comparison to the Karolinska Hospital (KH). Fifty-six percent of SBH patients received chemotherapy immediately following diagnosis as compared to 14% at KH. The median overall survival of all patients was 6.3 years; 4.2 years and 11.0 years at SBH and KH, respectively (P <.001). In univariate analysis, anemia (hemoglobin < 120 g/L) and albumin < 35 g/L (but not <40 g/L) at diagnosis predicted a worse overall survival. The presence of hepatomegaly and/or splenomegaly and/or lymphadenopathy was significantly associated with anemia (P <.001) and hypoalbuminaemia (P <.001). The mean Morel score (including age, albumin, and cytopenias) of patients treated at SBH (2.6) was significantly higher than that of KH patients (1.6; P <.001). These findings illustrate the clinical heterogeneity of WM, most probably explained by differences in referral patterns, and in addition, indicate the need for establishing standard criteria for diagnosis, response to treatment, and prognostic features.

Nitric oxide induces apoptosis in NALM-6, a leukaemia cell line with low cyclin E protein levels

Intracellular nitric oxide levels may differ in resting and stimulated cells and contribute to the regulation of cell survival and proliferation through a variety of mechanisms and effects. We exposed two B-cell lines to a range of S-nitroso-N-acetyl-D,L-penicillamine (SNAP) concentrations in order to examine their susceptibility to exogenous nitric oxide and the participation of nitric oxide as modulator of cell proliferation. Although both FLEB and NALM-6 decreased their levels of thymidine incorporation, only NALM-6 cells were induced to undergo G1 arrest, phosphatidyl serine exposure and DNA fragmentation when cultured in the presence of 250 microm SNAP. This higher sensitivity of NALM-6 coincided with initially low cyclin E protein levels which were increased 7.8-fold after culture for 24 h with 250 microm SNAP. In contrast, there was no difference in cyclins A and D3, Bcl-2 and actin levels, neither at the beginning nor at the end of the 24 h culture. Our study reveals that FLEB and NALM-6 exhibit different response to the same concentration of nitric oxide, that nitric oxide can simultaneously induce cell cycle alterations and apoptosis, and further suggests an association between these two processes, with the involvement of cell cycle regulatory molecules.

Sensitization to TRAIL-induced apoptosis and modulation of FLICE-inhibitory protein in B chronic lymphocytic leukemia by actinomycin D

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a potent activator of the cell death pathway and exerts tumoricidal activity in vivo with minimal toxicity. In order to investigate the therapeutic potential of TRAIL in B chronic lymphocytic leukemia (B-CLL) we have analyzed the expression of TRAIL receptors (TRAIL-Rs) in leukemic cells from B-CLL patients and their in vitro sensitivity to apoptosis induced by recombinant human TRAIL. We have found TRAIL-R1 and -R2 death receptor, and TRAIL-R3 and -R4 decoy receptor mRNA expression in most of the 57 B-CLL patients studied (R1 82%, R2 100%, R3 96% and R4 82%). TRAIL-R1 and R2 proteins were expressed on the surface and within the cells, whereas R3 and R4 decoy receptors were almost exclusively expressed in the cytoplasm. Despite TRAIL death receptor expression, B-CLL cells were relatively resistant to induction of apoptosis by recombinant human TRAIL (300 ng/ml). However, the susceptibility to TRAIL-induced apoptosis was increased by treatment of B-CLL cells with actinomycin D (Act D). Western blot analysis showed higher constitutive expression of the long form of FLICE-inhibitory protein (FLIP(L)) in B-CLL as compared to normal tonsillar B cells. Act D treatment down-regulated both long and short FLIP expression, which was correlated with the increase in B-CLL sensitivity to TRAIL. Although the surface TRAIL death receptor expression was up-regulated both by cell culture and by Act D treatment, the changes were not correlated with a gain in susceptibility to TRAIL. In addition, neither decoy receptors nor Bcl-2 expression were affected by Act D. Our findings suggest the possible involvement of FLIP in regulating TRAIL-mediated apoptosis in B-CLL.

Liposomal amphotericin B and surgery in the successful treatment of invasive pulmonary mucormycosis in a patient with acute T-lymphoblastic leukemia

Pulmonary mucormycosis is a usually fatal opportunistic infection in immunocompromised patients. We describe the first case of an adult patient with hematological malignancy and profound neutropenia to survive a disseminated pulmonary Rhizomucor pusillus infection. Early diagnostic procedures combined with high doses of liposomal amphotericin B and surgical resection may have contributed to the successful outcome.

Caesarean section in previously untreated acute promyelocytic leukaemia. Report of two patients

Acute promyelocytic leukaemia (APL) is characterised by a life-threatening hemorrhagic diathesis which is attributed to a DIC-like coagulopathy. This report describes the problems of childbirth in two patients with untreated APL. It is concluded that caesarean section can be performed without major complications. A prerequisite is an active treatment of the coagulopathy and a close collaboration between the obstetrician and the haematologist.

Frequent good partial remissions from thalidomide including best response ever in patients with advanced refractory and relapsed myeloma

Twenty-three patients with advanced and heavily pretreated myeloma were treated with thalidomide. Starting dose was 200 mg/d, and 20 patients had dose escalations up to 400 (n = 5), 600 (n = 12) or 800 mg/d (n = 3), usually in divided doses. Nineteen patients were refractory to recent chemotherapy, and four had untreated relapse after prior intensive therapy. Ten out of 23 patients (43%) achieved partial response (PR; nine with refractory and one with relapsed disease), six patients had minor response or stabilization of the disease and four had disease progression. Another three patients died early from advanced myeloma at less than 3 weeks of thalidomide therapy. Of the 10 patients with PR, seven had a better response than after any prior therapy, despite vincristine-doxorubicin-dexamethasone (VAD)-based treatment in all but one and high-dose melphalan with autologous stem cell support in four. Time to achieve PR was rapid in patients receiving thalidomide in divided doses (median 31 d). Responses also included reduced bone marrow plasma cell infiltration and improved general status. Normalized polyclonal gammaglobulin levels were seen in four cases. Six out of 10 patients with PR remained in remission with a median time on treatment of 23 weeks (range 15-50 weeks). Sedation was common but usually tolerable, and some patients continued full- or part-time work. Four patients had skin problems, three patients had pneumonia, one hypothyrosis, one sinus bradycardia and one minor sensory neuropathy. Thalidomide may induce good partial remissions in advanced refractory myeloma with tolerable toxicity, and should be evaluated in other settings for myeloma patients. Divided thalidomide doses seem to reduce time to achieve remission and may improve response rate.

Addition of etoposide to CHOP chemotherapy in untreated patients with high-grade non-Hodgkin's lymphoma

BACKGROUND

Second- and third-generation chemotherapy protocols for the treatment of aggressive non-Hodgkin's lymphomas (NHL) have considerable, and age-related, toxic effects. In addition, they do not seem to prolong overall survival in comparison to standard CHOP chemotherapy. In this phase II study we investigated the feasibility and efficacy of the addition of etoposide to the conventional CHOP regimen.

PATIENTS AND METHODS

Toxicity and clinical efficacy were determined in 132 patients with previously untreated high-grade NHL. There were 51 patients in clinical stage I and II and 81 patients in stage III and IV, with a median age of 54 years (range 17-85). Patients received standard-dose CHOP plus etoposide 100 mg/m2 i.v. on day 1 and 200 mg/m2 p.o. on days 2-3.

RESULTS

The overall response rate was 84%, with 70% complete and 14% partial responses. The predicted three- and five-year survivals for the group as a whole were 60% and 53%, respectively, and the corresponding disease-free survivals for patients achieving complete remissions were 65% and 56%, respectively. Outcome was not different from that of CHOP-treated patients in a recently completed Nordic study performed during the same time period. Myelosuppression (WHO grade 3-4), observed in 87% of patients and infectious complications (WHO grade 3-4) in 33%, dominated the toxicity profile of this regimen. Fifty-seven of 92 complete responders (62%) received 6-8 CHOP-E cycles with no reductions in planned dose intensity. LDH level higher than normal, extranodal sites = 2, stage III-IV at diagnosis were all indicators of a poor survival.

CONCLUSIONS

We conclude that CHOP-E treatment is effective in high-grade NHL. However, mainly due to severe myelosuppression frequent schedule modifications were required and the results are not obviously superior to those of conventional CHOP.

Accumulation of FDG in axillary sweat glands in hyperhidrosis: a pitfall in whole-body PET examination

A diabetic male with severe autonomic neuropathy and recently discovered Hodgkin's disease demonstrated bilateral uptake of [2-18F]-2-fluoro-2-deoxy-d-glucose (FDG) in the axillary sweat glands during profuse sweating caused by hypoglycaemia at positron emission tomography examination. It is not yet clear whether the sweating interfered with the distribution of the radiopharmaceutical. Regardless of the cause or mechanism for the uptake, the finding is clinically relevant. A bilateral symmetrical accumulation of FDG in the axillae of a tumour patient does not necessarily indicate malignant involvement of the lymph nodes.

Histamine and interleukin-2 in acute myelogenous leukemia

Interleukin-2 (IL-2) activates natural killer (NK)-cells to destroy leukemic blasts from patients with acute myelogenous leukemia (AML), but even aggressive regimens of IL-2 fail to prevent relapse or prolong remission time in AML. Results obtained in studies of NK-cell-mediated killing of AML blasts show that monocytes inhibit IL-2-induced lysis of AML blasts in vitro. Histamine, a biogenic amine, prevents the monocyte-derived, inhibitory signal; thereby, histamine and IL-2 synergize to induce killing of AML blasts. Here we present updated results of a post-consolidation trial in which histamine (0.5-0.7 mg s.c. bid) has been administered together with IL-2 (1 micro/kg s.c. bid) to 22 AML patients (aged 29-79, mean 59) in repeated courses of three weeks, continued until relapse or until a disease-free remission of 24 months. Low-dose therapy with cytarabine and thioguanine was given between the initial courses of histamine/IL-2. In 13 patients, treatment according to this protocol was started in first complete remission (CR1). The mean remission time in CR1 patients is 19 (median 14) months, and 9/13 remain in CR. Nine patients have entered the protocol in CR2 (n=6), CR3 (n=2), or CR4 (n=1). The mean remission time in CR2-4 is 19 (median 21) months, and 6/9 patients remain in CR. Seven out of seven evaluable patients have achieved a duration of CR which exceeds that of the foregoing remission. Histamine has been well tolerated, and 21/22 CR patients have treated themselves at home throughout the trial. We conclude that the putative benefit of histamine treatment in AML should be the focus of a randomized trial.

Nerve-induced release of nitric oxide in the rabbit gastrointestinal tract as measured by in vivo microdialysis

1. Nitric oxide (NO) has been suggested as a gastrointestinal neurotransmitter, mediating the gastric receptive relaxation and the relaxation in the peristaltic reflex. The aim of the present study was to measure nerve-induced NO formation in vivo in the gastrointestinal tract. 2. Formation of the nitric oxide oxidation products nitrite and nitrate during vagal nerve stimulation were measured in the anaesthetized rabbit. Microdialysis probes were inserted into the wall of the stomach and proximal colon, and nitrite and nitrate in dialysate measured by capillary electrophoresis. 3. During bilateral vagal nerve stimulation there was an increase in nitrite and nitrate formation at the level of the stomach and in nitrite formation at the level of the colon. This increase was inhibited by intravenous administration of the NO synthase inhibitor N omega-nitro-L-arginine methyl ester (L-NAME 30 mg kg-1). Furthermore, L-NAME significantly increased nerve-induced gastric and colonic contractions, as well as spontaneous colonic contractions. 4. In summary, we present a new methodological procedure for quantification of small changes in nitric oxide formation in vivo. This study provides evidence that nitric oxide is released in the stomach and colonic wall during vagal nerve activity, at concentrations able to cause inhibition of smooth muscle contractions in vivo.

Successful intravenous immunoglobulin therapy for severe and persistent astrovirus gastroenteritis after fludarabine treatment in a patient with Waldenström's macroglobulinemia

A 78-year-old male with Waldenström's macroglobulinemia was after 23 years of conservative treatment given fludarabine phosphate in 1993 because of disease progression. Three weeks after the third fludarabine course he presented with a 5-day-history of watery diarrhoea, nausea and vomiting. Stool cultures were negative but a semiquantitative electron microscopy method demonstrated massive amounts of astrovirus (> 10(14) particles/ml). Symptomatic treatment was given but since his condition deteriorated, high-dose intravenous immunoglobulin (IvIg) treatment, 0.4 g/kg for four days was initiated. Within twenty-four hours all symptoms disappeared and the patient was discharged after a few days. A stool sample collected after two weeks demonstrated 10(7) particles/ml and after four weeks no astrovirus could be detected. The association between fludarabine and this opportunistic infection and the potential role of high dose IvIg treatment are discussed.

Transcutaneous oxygen pressure measurements in patients with intermittent claudication

Transcutaneous oxygen pressure (TcPO2) measurements were performed on 10 male patients with moderate-to-severe intermittent claudication. The TcPO2 electrode was attached to the dorsum of the foot. TcPO2 response to a standardized treadmill exercise test was evaluated, as was the reproducibility of TcPO2 measurements at rest and during exercise. Reproducibility was assessed using a similar exercise test within 2-5 days. Treadmill exercise induced a marked decrease in TcPO2 in all patients, from 9.3 +/- 0.9 to 2.8 +/- 2.0 kPa. Maximal walking distance was 280 +/- 127 m at the first treadmill test and 272 +/- 113 m at the second. Blood lactate and heart rates at rest and at end of exercise were also unchanged. TcPO2 at rest was highly reproducible, but considerable variation was found for measurements during and after exercise. This variation was most obvious for measurements during exercise and no direct or reproducible relation was found between ischaemic calf pain and TcPO2 values. Post-exercise measurements were slightly more reproducible and somewhat easier to assess. In contrast to standard TcPO2 measurements, total exercise-induced ischaemia expressed as area under the post-exercise TcPO2 curve was highly reproducible. In summary, our results with TcPO2 measurements in patients with intermittent claudication showed a marked exercise-induced decrease in all patients. However, the variation in TcPO2 values when the test was repeated after 2-5 days under stable clinical and circulatory conditions limits its application as a quantitative measure of lower-limb ischaemia. Thus, measurements of area under the TcPO2 curve might be preferred for this purpose.

Clinical and hemodynamic effects of stepwise lowering of hemoglobin concentration in patients with intermittent claudication

This study evaluates the effect of stepwise lowering of the hemoglobin (Hb) concentration on maximal walking distance (MWD) and hemodynamics in patients with intermittent claudication. The results in a study group (n = 6) were compared with those of a control group (n = 6) whose members were not subjected to venesections. An average decrease of Hb concentration from 151 +/- 4 to 121 +/- 3 g/L did not significantly influence MWD, the result being 282 +/- 62 meters before venesections and 255 +/- 54 meters after three to five (mean four) repeated venesections. Transcutaneous oxygen pressure was measured at the dorsum of the foot before and after exercise and did not change with a gradual decrease of the Hb concentration. Maximal heart rate, painfree walking distance, ankle pressure, and blood lactate concentration were also unchanged. An average venesection volume of about 1.4 liters whole blood within fourteen days, without isovolemic replacement, did not change the blood volume, which was 5.1 +/- 0.4 liters before and 5.0 +/- 0.5 liters after venesections. In conclusion, hemodilution accomplished by venesections did not have a clinically or physiologically beneficial effect in patients with severe intermittent claudication. However, hemodynamics and clinical symptoms were not affected by a considerable decrease in the arterial oxygen content within the normal Hb concentration range.

Prediction of response to treatment with human recombinant erythropoietin in myelodysplastic syndromes

The effect of human recombinant erythropoietin (rhEPO) was investigated in 29 anemic patients with myelodysplastic syndromes (MDS). A rhEPO dosage of 150 U/kg was administered subcutaneously three times weekly for a minimum of 6 weeks. Seven out of 27 evaluable patients (26%) had an effective clinical response to therapy by increasing hemoglobin concentrations by more than 15 g/l (reaching at least 105 g/l) or by eliminating transfusion requirements. Six out of the seven patients responded within four weeks. Three of the responders successfully continued rhEPO treatment 15 months or more. To determine whether it may be possible to predict response to rhEPO, various clinical parameters were examined. Responders were found to be significantly different from non-responders in five aspects: They had less elevated baseline serum EPO levels (92 +/- 33 versus 515 +/- 108 U/l, mean +/- SEM; p = 0.023) and were more often transfusion-independent (71% versus 20% of non-responders; p = 0.022). Furthermore, responders were more often females (71% versus 40% in the non-responding group; p = 0.025), of subtype RA rather than RAEB (four patients and one patient, respectively, compared to seven and nine patients in the non-responding group; p = 0.025), and they predominantly displayed normal karyotypes or a 5q- aberration (86% versus 47%; p = 0.005). We conclude, that rhEPO treatment can reduce anemia in MDS and that certain pre-treatment clinical parameters may be used to predict response.

Etoposide, doxorubicin, cyclophosphamide and high-dose betamethasone (EACB) as outpatient salvage therapy for refractory multiple myeloma

Fifty-six patients with refractory multiple myeloma were treated with intermittent courses of etoposide, doxorubicin, cyclophosphamide and high-dose betamethasone (EACB) every 4th week. The overall response rate was 30%. Durable remissions exceeding 1 year were obtained in 12 of the 17 responding patients. A significant prolongation of the survival time was found for responding patients (median 13 months) compared to those patients who did not respond (median 9 months) to EACB therapy (p = 0.01). A low frequency of neutropenic fever episodes was noted compared to other salvage treatment regimens. The EACB regimen was usually well tolerated and could be administered safely on an out-patient basis. This regimen might be an alternative especially for elderly patients unresponsive to initial therapy.

Natural interferon-alpha in combination with melphalan/prednisone versus melphalan/prednisone in the treatment of multiple myeloma stages II and III: a randomized study from the Myeloma Group of Central Sweden

Three hundred thirty-five previously untreated patients with multiple myeloma in clinical stages II and III entered a randomized trial comparing intermittent oral melphalan and prednisone (MP) therapy (n = 171) with MP in combination with natural (leukocyte-derived) alpha-interferon (MP/IFN) (n = 164). The treatment groups were comparable with regard to major prognostic factors. The response frequency was 42% in the MP group and 68% in the MP/IFN group (P < .0001). Eighty-five percent of IgA myelomas and 71% of Bence-Jones myelomas responded to MP/IFN compared with 48% and 27%, respectively, to MP treatment (P = .001). There was no difference in the overall survival between the two treatment groups. However, the survival of 72 patients with IgA or Bence-Jones myeloma randomized to receive MP/IFN was significantly longer (median 32 months) than that of 71 patients treated with MP (median 17 months) (p < .05). No statistically significant difference in response frequency (60% v 46%) or survival was found for patients with IgG myeloma. Hematologic toxicity, WHO grades III and IV, was higher in the MP/IFN group (48%) than in the MP group (33%) (P < .05) during the induction treatment period. Flulike syndrome was observed in 68% of patients receiving MP/IFN. The results show that MP/IFN is a well-tolerated treatment regimen, superior to MP for remission induction, and it improves significantly the overall survival for patients with IgA and Bence-Jones myelomas.

Muscle strength in hyperthyroid patients before and after medical treatment

Ten hyperthyroid patients were assessed for muscle strength before and after a period of medical treatment that averaged 12 months. The subjects did not change their habitual level of physical activity between the two test occasions. Maximal voluntary isokinetic knee extensor muscle strength was determined during various concentric, eccentric and isometric conditions. Average increases in strength from before to termination of treatment ranged from 25 to 41% for the concentric and isometric tests (P less than 0.01, n = 10), and from 19 to 35% for the eccentric tests (P less than 0.01, n = 6). The present study demonstrates that medical treatment of hyperthyroid patients results in a marked increase in muscle strength.

Changes in plasma concentrations of aromatic and branched-chain amino acids during sustained exercise in man and their possible role in fatigue

The plasma concentrations of branched-chain and aromatic amino acids have been measured in two different types of sustained dynamic exercise. Twenty-two subjects participated in the 1986 Stockholm Marathon and eight subjects took part in an army training programme of approximately 1.5-h duration. Both types of exercise caused a significant decrease in the plasma concentration of branched-chain amino acids, while there was no change in the concentration of total (free plus bound to albumin) tryptophan. The plasma concentration of free tryptophan, which was measured in the marathon runners, was found to increase 2.4-fold during the race. This increase is probably caused by a pronounced elevation in the concentration of plasma free fatty acids during exercise, since these are known to displace tryptophan from albumin. The observed increase in plasma free tryptophan concentration, together with the decrease in plasma concentration of branched-chain amino acids, gives rise to a marked increase in the plasma concentration ratio of free tryptophan/branched-chain amino acids. This should lead to an increase in the rate of transport of tryptophan across the blood-brain barrier and hence to an increase in the rate of synthesis of 5-hydroxytryptamine (5-HT) in the brain. An elevated concentration of 5-HT in specific areas of the brain may be responsible, at least in part, for the development of physical, and/or mental fatigue during prolonged exercise.

Effects of anaemia and stepwise-induced polycythaemia on maximal aerobic power in individuals with high and low haemoglobin concentrations

Increasing the haemoglobin concentration ([Hb]) improves the oxygen transport capacity but it also increases the viscosity of the blood. The influence of changes in [Hb] and viscosity on submaximal exercise capacity and maximal aerobic power was investigated in eight healthy males in varying states of training and with a normal resting [Hb] ([Hb]r), ranging from 123 to 178 g l-1. The subjects were venesected five times (450 ml per unit) and exercise tests were performed in the anaemic state. After 5-7 weeks, when [Hb] had returned to the 'normal' value, a stepwise re-transfusion of three to five units of blood was performed with exercise tests after each transfusion. The [Hb]r was 137 +/- 15 g l-1 in the anaemic state (A) and 170 +/- 16 g l-1 after the last re-transfusion (LT). The VO2max rose from 3.94 +/- 0.35 in A to 4.68 +/- 0.30 l min-1 after LT. Individual regression lines for [Hb] and VO2max revealed a mean increase in VO2max of 19 +/- 6 ml min-1 per g l-1 change in [Hb]. This value did not differ between individuals with high and low normal [Hb]. Furthermore, in intra-individual comparisons the relationship between [Hb] and VO2max in high and low individual [Hb] ranges was not found to be statistically different despite a 40% increase in the in vitro viscosity from the anaemic to the polycythaemic state.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of long-term anemia and retransfusion on central circulation during exercise

The purpose of this study was to evaluate the effect of long-term anemia and subsequent retransfusion of erythrocytes on various circulatory parameters. Anemia was induced in nine healthy male subjects by repeated venesections. The stored blood was retransfused after 9 wk (range 8-11 wk). Exercise tests were performed before venesection in the control state (C), in the anemic state (A), and 48 h after retransfusion (R). Hemoglobin concentration levels were 146 +/- 10 g/l in C, 110 +/- 7 g/l in A, and 145 +/- 9 g/l in R. Maximal O2 uptake was 4.55 +/- 0.6, 3.74 +/- 0.7, and 4.45 +/- 0.6 l/min in C, A, and R, respectively. A decrease in heart rate of 7 beats/min (P less than 0.01) and in cardiac output of 2 l/min (P less than 0.05) at maximal exercise occurred in the anemic state compared with control values. These decreases were not reversed but, rather, were further accentuated after retransfusion. The adaptive response to submaximal exercise (cycling at 150-175 W) in anemia was mediated to the amount of 50% by an increase in cardiac output (mainly an increase in heart rate) and 50% was due to increased O2 extraction in the peripheral tissue. In conclusion, long-term anemia was found to decrease the heart rate and cardiac output at maximal exercise. Furthermore the close correlation between hemoglobin concentration and maximal O2 uptake in humans is confirmed.

Evaluation of a modified acetylene rebreathing method for the determination of cardiac output

In order to evaluate a computerized modified acetylene rebreathing method for the determination of cardiac output, 15 healthy subjects were studied at different levels of their maximal oxygen uptake (VO2max). Submaximal exercise was performed on a cycle ergometer and maximal exercise on a treadmill. Oxygen uptake, heart rate, and cardiac output (acetylene method) were determined in all test situations. In seven subjects simultaneous determinations of cardiac output were made by a modified acetylene rebreathing method (QA) and a dye dilution method (QD). Furthermore, a new resting rebreathing technique was used. The methodological error for QA (means of double samples) was 0.37 litre min-1 (2.8%) in the same individual at 150 W. The corresponding values between individuals were 0.71 (rest), 0.41 (50 W), 0.69 (150 W), and 0.40 litre min-1 (VO2max). Thus the methodological error of the modified acetylene method was very low. There was a significant difference (P less than 0.01), however, between the acetylene method and the dye dilution method, which showed a lower value for QA at all levels. This was probably due to the long response time of the mass spectrometer combined with anatomical and physiological arteriovenous shunt effects in the lungs during exercise. When these factors were considered the correcting formula was: QAc = QA + 0.005 X Q2A. There was no significant difference between the corrected cardiac output values (QAc), and the corresponding QD values. In conclusion, this modified acetylene rebreathing method is a very useful non-invasive method for measuring cardiac output at rest as well as during heavy exercise.

Anemia causes a relative decrease in blood lactate concentration during exercise

The purpose of the present study was to examine to what degree a reduction in systemic oxygen transport capacity influences the absolute and relative levels (% of maximal oxygen uptake) of submaximal blood lactate accumulation. Anemia was induced by repeated venesections in eight healthy males. After 9-10 weeks of anemia, hemoglobin concentration [Hb] was restored by retransfusion of packed erythrocytes. The [Hb] values obtained were, before venesections, in control (C) = 145 +/- 10, in the anemic state (A) = 110 +/- 8, and after retransfusion (R) = 143 +/- 8 g X l-1 respectively. In all states, muscle biopsies were taken and measurements made of VO2max and VO2 at a running velocity corresponding to a blood lactate concentration of 4 mM (upsilon Hla 4.0). In the A condition Vo2max decreased by 19% as compared to C (P less than 0.01). upsilon Hla 4.0 was 14% lower in A as compared to C and R (p less than 0.01). VO2 at upsilon Hla 4.0 was 13% lower in A as compared to C (P less than 0.01). However, VO2 at upsilon Hla 4.0 expressed as a percentage of VO2max was increased (P less than 0.01) in the anemic state, the values obtained being C = 83.3%, A = 89.8% and R = 84.8%. Ventilation at upsilon Hla 4.0 was higher in A as compared to C and R (P less than 0.05). R and C values were not significantly different for any of the values presented above. The maximal activity of citrate synthase in muscle did not differ between the three different conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hyperthyroidism on fibre-type composition, fibre area, glycogen content and enzyme activity in human skeletal muscle

Seven hyperthyroid patients were studied by repeated muscle biopsies (vastus lateralis) before and after a period of medical treatment which averaged 10 months. The biopsies were analysed with regard to fibre-type composition, fibre area, capillary density, glycogen content and enzyme activities representing the glycolytic capacity (hexokinase, 6-phosphofructokinase), oxidative capacity (oxoglutarate dehydrogenase, citrate synthase) and Ca2+- and Mg2+-stimulated ATPase in muscle. In the pretreatment biopsy (hyperthyroid state), there was a significantly lower proportion of type I fibres (30% vs. 41%), a higher capillary density (23%), lower glycogen content (33%), and higher hexokinase activity (32%) compared with the post-treatment biopsy. No significant changes in the activity of the remaining enzymes were observed. The present study indicates that hyperthyroidism induces a transformation from type I to type II fibres in human skeletal muscle. The increase in hexokinase activity probably reflects a higher glucose utilization by skeletal muscle in order to compensate partially for the reduced glycogen content.

Effects of iron deficiency on endurance and muscle enzyme activity in man

The purpose of the present study was to evaluate the effects of iron deficiency on enzyme activities and endurance. Iron deficiency was induced in 9 healthy male subjects by repeated venesections. After a period of 9 wk (range, 8-11 wk) when the subjects had become iron deficient as defined by laboratory parameters, blood was retransfused to reestablish the control hemoglobin concentration. In this state it was possible to evaluate the effect of iron deficiency isolated from anemia. In samples secured by muscle biopsies, glycolytic, oxidative, and iron depending enzymes were analyzed in the control (C) and anemic (A) states and after retransfusion (R). There were no significant changes in the maximal activities of any of the enzymes studied. The capillary/fiber ratio remained unchanged between C (1.92) and R (1.94). Times to exhaustion on treadmill tests were 49 min, 11 s in C, 26 min, 33 s in A, and 52 min, 3 s in R. Vo2max was 4.55 1 X min-1 in C, 3.74 1 X min-1 in A, and 4.45 1 X min-1 in R. An artificially induced iron deficiency defined by conventional laboratory parameters did not affect endurance when transfusion of red blood cells was performed in order to exclude the influence of a low hemoglobin concentration. A 4-wk period of severely depleted or absent tissue iron stores did not affect the maximal activities of various enzymes in human skeletal muscle.

How to calculate human muscle fibre areas in biopsy samples--methodological considerations

Cross-sectional muscle fibre areas (type I, II A and II B) were determined in duplicate biopsies from the left vastus lateralis (n = 11) and in biopsies from right and left vastus lateralis (n = 8). The SD for the difference in means between duplicate biopsies was 510 microns 2 for type I, 1020 microns 2 for type II A and 860 microns 2 for type II B. Expressed as coefficient of variation (CV) these SD constituted 10, 15 and 15%, respectively. The variation in fibre size within a sample was considerably less than the variation between samples on the assumption that at least 15-20 areas of each fibre type were measured per sample. No difference in mean fibre area for type I, II A and II B fibres was obtained between the right and left muscle. Several artefacts due to the sampling and preparing procedures are discussed and a method for determining muscle fibre areas in biopsy samples is suggested.