Diffuse Alveolar Hemorrhage Secondary to Human Metapneumovirus Pulmonary Infection

A 67-year-old man presented with a week of flu-like symptoms, hypoxia, and fever. Respiratory viral panel was positive for human metapneumovirus. Initial chest imaging showed left lower lobe opacification, suggesting a bacterial superimposed on viral pneumonia. Despite antibiotics, the patient became tachycardic and increasingly hypoxic, requiring 40 L high-flow nasal cannula. Repeat imaging demonstrated worsening of a left lower lobe process. Elective bronchoscopy with bronchoalveolar lavage revealed hemorrhage. Subsequent autoimmune, bacterial, and fungal workup was negative. The patient was diagnosed with diffuse alveolar hemorrhage (DAH) secondary to human metapneumovirus pneumonia. DAH is defined as bleeding into the alveolar spaces of the lungs, a process which carries high rates of morbidity and mortality.1 While dramatic in name and often associated with hemoptysis, DAH may only present with clinically subtle and nonspecific features with a variety of alternative etiologies to consider. We present this case of DAH secondary to human metapneumovirus (hMPV) to promote discussion of etiologies of DAH aside from systemic vasculitis.

A Review of the Literature of Mirtazapine in Co-Occurring Depression and an Alcohol Use Disorder

BACKGROUND

Prior medication studies involving individuals with major depression in combination with an alcohol use disorder (MDD/AUD) have mainly focused on SSRI and tricyclic antidepressants, with generally ineffective results. Consequently, effective treatments for that common comorbid condition remain elusive. Mirtazapine is an antidepressant medicine with a unique pharmacological profile, whose effectiveness for treating non-comorbid depression reportedly may exceed that of SSRIs.

OBJECTIVE/METHODS

We now review the published literature regarding the tolerability and efficacy of mirtazapine for the treatment of the depression and the pathological alcohol ingestion of individuals with co-occurring MDD/AUD, including a review of four of our own small studies and two studies conducted outside the United States.

RESULTS/CONCLUSIONS

The findings of these studies suggest that mirtazapine is well tolerated among persons with comorbid MDD/AUD. Results also provide some evidence of efficacy for mirtazapine for decreasing the level of depression of persons with co-occurring MDD/AUD, and suggest that decreases in depression may occur relatively quickly after starting treatment, but provide no evidence of effectiveness for decreasing the level of alcohol ingestion. Large-scale double-blind, placebo-controlled studies are warranted to further clarify the tolerability and efficacy of mirtazapine among individuals with MDD/AUD.

Abstract B08: New Abelson interactor-1(Abi-1)-driven mechanism of acquired drug resistance

In hematological malignancies, quiescent leukemic stem cells are responsible for persistence of minimal residual disease and relapse. We have recently identified a new signaling pathway that is significantly dysregulated in imatinib mesylate (IM) resistant leukemic cells (Chorzalska et all, Leukemia in press). A key player in this pathway is Abelson interactor-1 (Abi-1). Abi-1 was originally identified as Abl kinase associating protein that was later confirmed to be one of the Bcr-Abl interactors. Abi-1 was recently shown to interact directly with α4 integrin, which controls lodging of hematopoietic and leukemic stem cells (HSCs/LSCs) in the bone marrow microenvironment. We have recently obtained evidence that Abi-1 plays a role in signaling cross-talk between Bcr-Abl and α4 integrin. We have found that loss of Abi-1 leads to increased adhesion and quiescence, resulting in increased chemoresistance of leukemic CD34+ progenitor cells. Comparison of Abi-1 (ABI-1) and α4 integrin (ITGA4) gene expression in relapsing Bcr-Abl positive CD34+ progenitor cells demonstrated a reduction in Abi-1 and an increase in α4 integrin mRNA in the absence of Bcr-Abl mutations. This inverse correlation between Abi-1 and α4 integrin expression, as well as linkage to elevated phospho-Akt and phospho-Erk signaling, was confirmed in imatinib mesylate (IM) resistant leukemic cells. These results indicate that the α4-Abi-1 signaling pathway may mediate acquisition of the drug resistant phenotype of leukemic cells. Based on our findings, we hypothesize that chemoresistance arises as a consequence of dysregulation of a pathway involving α4 integrin and Abi-1, and is mediated through a previously unknown mechanism that is independent of oncogene activity.

Citation Format: Anna Chorzalska, Ibrahem Salloum, Philip Marjon, Diana Treaba, Christoph Schorl, Morgan John, Christine R. Bryke, John Reagan, Eric Winer, Adam J. Olszewski, Patrycja M. Dubielecka. New Abelson interactor-1(Abi-1)-driven mechanism of acquired drug resistance. [abstract]. In: Proceedings of the AACR Precision Medicine Series: Drug Sensitivity and Resistance: Improving Cancer Therapy; Jun 18-21, 2014; Orlando, FL. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(4 Suppl): Abstract nr B08.

Low expression of Abelson interactor-1 is linked to acquired drug resistance in Bcr-Abl-induced leukemia

The basis for persistence of leukemic stem cells in the bone marrow microenvironment (BMME) remains poorly understood. We present evidence that signaling crosstalk between α4 integrin and Abelson interactor-1 (Abi-1) is involved in acquisition of an anchorage-dependent phenotype and drug resistance in Bcr-Abl positive leukemia cells. Comparison of Abi-1 (ABI-1) and α4 integrin (ITGA4) gene expression in relapsing Bcr-Abl positive CD34+ progenitor cells demonstrated a reduction in Abi-1 and an increase in α4 integrin mRNA in the absence of Bcr-Abl mutations. This inverse correlation between Abi-1 and α4 integrin expression, as well as linkage to elevated phospho-Akt and phospho-Erk signaling, was confirmed in imatinib mesylate (IM) resistant leukemic cells. These results indicate that the α4-Abi-1 signaling pathway may mediate acquisition of the drug resistant phenotype of leukemic cells.

Abstract LB-350: Abelson interactor-1 (Abi1) expression levels as a prognostic and drug resistance marker in Bcr-Abl positive leukemias

In hematological malignancies, quiescent leukemic stem cells are responsible for persistence of minimal residual disease and relapse. Emerging evidence points to the involvement of the bone marrow microenvironment in survival and systemic retention of leukemic stem/progenitor cells. Integrins, particularly α4β1, which controls hematopoietic stem cell trafficking, were shown to be required for leukemic stem cells lodging to the bone marrow niche, and were shown to be crucial for the persistence of minimal residual disease. The molecular mechanism governing these processes is not known. We have just recently obtained evidence that newly identified α4 integrin-Abelson interactor 1 (Abi1) signaling cross-talk is involved in acquired drug resistance in Bcr-Abl positive leukemic cells. Our data also indicated that Abi1 and α4 integrin may be useful as prognostic markers of treatment outcome in patients with relapsing Bcr-Abl positive leukemia. Comparison of mRNA levels of Abi1 and α4 integrin in Bcr-Abl positive CD34+ progenitor cells isolated from blood or bone marrow of CML (chronic myelogenous leukemia) patients at diagnosis and at relapse revealed significant decrease in mRNA levels of Abi1 and increase in mRNA levels of α4 integrin in relapsing CD34+ progenitor cells. Subsequent analyses performed on various imatinib mesylate (IM) resistant cell lines including K562, LAMA-84 or Bcr-Abl supplemented Ba/F3 cells, confirmed abnormal expression of Abi1 and α4 integrin, both mRNA and protein levels. IM resistant cells also exhibited acquired anchorage-dependent phenotype and enhanced adhesive properties. Further detailed analyses of α4 integrin-dependent pathways revealed significant de-regulation of integrin α4 downstream signaling being due to the abnormal expression of Abi1, what resulted in elevated levels of phospho-Akt (Ser472), phospho-Erk (Thr202/Tyr204) and abnormal JNK/SAPK and p38MAPK phosphorylation signals. In summary, our results not only indicate that Abi1 and α4 integrin may serve as potentially useful prognostic markers of treatment outcome in patients with relapsing Bcr-Abl positive leukemia, but also suggest that newly identified α4 integrin-Abi1-Bcr-Abl cross-talk may play a significant role in the interactions between leukemic progenitor cells and the bone marrow microenvironment, and alterations in this signaling mediate acquisition of the drug resistant phenotype of leukemic cells and contribute to the mechanisms of acquired drug resistance.

Citation Format: Anna D. Chorzalska, Ibrahem Salloum, Hammad Shafqat, Saad Khan, Philip Marjon, Vincent Falanga, Ting Zhao, John Reagan, Eric Winer, Samer Al-Homsi, Nicola Kouttab, Patrycja M. Dubielecka. Abelson interactor-1 (Abi1) expression levels as a prognostic and drug resistance marker in Bcr-Abl positive leukemias. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-350. doi:10.1158/1538-7445.AM2013-LB-350

The prevalence of phenotypic subgroups in Greek women with polycystic ovarian syndrome

BACKGROUND

Since 2003, when the American Society for Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE) sponsored consensus established criteria for polycystic ovarian syndrome (PCOS) diagnosis, the phenotypic spectrum of the syndrome has been significantly broadened.

PURPOSE OF THE STUDY

This survey makes an effort to distinguish PCOS according to phenotypic expression and to estimate its prevalence in a Greek population.

MATERIALS AND METHODS

Greek women from 18 to 35 years of age, who visited the outpatient department, claiming either irregular menstruation (oligo- or anovulation, OA) or clinical manifestations of hyperandrogenemia (HA) were recruited. They gave full disease history and underwent clinical examination, including transvaginal ultrasound (TVUS) scan to identify PCO morphology. Blood samples were collected to perform hormonal and metabolic analyses. Acute or chronic disorders were excluded. Finally, 266 PCOS women constituted the study population.

CONCLUSIONS

The full-blown phenotype (HA+OA+PCO) is the predominant phenotype in this Greek population.

Computerized analysis of fetal heart rate variability using the matching pursuit technique as an indicator of fetal hypoxia during labor

OBJECTIVE

To determine whether the computerized analysis of fetal heart rate variability with the new matching pursuit technique can indicate fetal distress during labor.

STUDY DESIGN

Eighty women were studied during the intrapartum period with external cardiotocography. In all cases, cord arterial pH and 5-min Apgar Scores were evaluated. Six cases that presented large segments of missing data were excluded from the study. The remaining 74 women were divided into two groups; 32 women with normal (Group A) and 42 women with non-reassuring FHR tracings (group B). Group B was divided in subgroup BI, including 24 women with pH > 7.20, and BII, including 18 women with pH < 7.20. In order to evaluate the FHR fluctuations, in different frequency ranges, we applied an adaptive time-frequency method, called Matching Pursuit. We estimated the power of the FHR signal in four frequency ranges.

RESULTS

The 5-min Apgar Scores were significantly lower in both subgroup BI and subgroup BII (p = 0.003 and p = 0.003 respectively). The Low Low Frequency (LLF) parameter appears to recognize better the cases with lower pH (sensitivity 78.5%, specificity 52.3%) than the cases with non-reassuring FHR (66.6%, 56.2). The sensitivity and specificity of the Very Low Frequency (VLF) parameter were 72.2% and 59% respectively in recognizing the cases with lower pH and 64.2% and 53.1% in recognizing non-reassuring FHR.

CONCLUSION

Fetal hypoxia during labor can be recognized using the MP technique for the analysis of FHR signal power in the VLF and LLF frequency ranges. Since the analysis is feasible in real-time, it can be a useful tool for the intrapartum evaluation of fetal well-being.

Evaluation of non-reassuring fetal heart rate patterns with fetal pulse oximetry combined with vibratory acoustic stimulation

OBJECTIVE

To determine the value of fetal pulse oximetry and vibratory acoustic stimulation in the presence of non-reassuring fetal heart rate patterns during labor.

DESIGN

Prospective study in women monitored by cardiotocography and fetal pulse oximetry during labor.

MATERIALS AND METHODS

During a period of 18 months, 907 consecutive parturients in labor were monitored by cardiotocography. Out of these women, 63 were selected on the basis of a non-reassuring fetal heart rate tracing during the first stage of labor. In these cases, fetal pulse oximetry was applied. Vibratory acoustic stimulation was applied in fetuses without spontaneous reactivity in order to evaluate the fetal status.

RESULTS

Our cases were classified into three groups, according to the lower fetal oxygen saturation levels, from the time of oximetry application until delivery. Group A consisted of 29 cases where fetal oxygen saturation levels were > or = 41%, group B (20 cases) with fetal oxygen saturation of 31-40% and group C (14 cases) with levels of < 30%. Spontaneous reactivity was observed in 15 fetuses of group A and seven of group B, while no case of reactivity was noted in group C. Vibratory acoustic-induced reactivity was associated with low fetal oxygen saturation levels. The mean umbilical artery pH levels were 7.29 +/- 0.051 in group A, 7.21 +/- 0.057 in group B and 7.04 +/- 0.05 in group C.

CONCLUSION

Fetal pulse oximetry should be indicated not only in fetuses without any reactivity but also in those with induced reactivity, after the application of vibratory acoustic stimulation.

Computerised intrapartum diagnosis of fetal hypoxia based on fetal heart rate monitoring and fetal pulse oximetry recordings utilising wavelet analysis and neural networks

OBJECTIVE

To develop a computerised system that will assist the early diagnosis of fetal hypoxia and to investigate the relationship between the fetal heart rate variability and the fetal pulse oximetry recordings.

DESIGN

Retrospective off-line analysis of cardiotocogram and FSpO2 recordings.

SETTING

The Maternity Unit of the 2nd Department of Obstetrics and Gynaecology, Aretaieion Hospital, University of Athens.

POPULATION

Sixty-one women of more than 37 weeks of gestation were monitored throughout labour.

METHODS

Multiresolution wavelet analysis was applied in each 10-minute period of second stage of labour focussing on long term variability changes in different frequency ranges and statistical analysis was performed in the associated 10-minute FSpO2 recordings. Self-organising map neural network was used to categorise the different 10-minute fetal heart rate patterns and the associated 10-minute FSpO2 recordings.

MAIN OUTCOME MEASURES

Umbilical artery pH of < or = 7.20 and Apgar score at 5 minutes of < or = 7 formed the inclusion criteria of the risk group.

RESULTS

After using k-means clustering algorithm, the two-dimensional output layer of the self-organising map neural network was divided into three distinct clusters. All the cases that mapped in cluster 3 belonged in the risk group except one. The sensitivity of the system was 83.3% and the specificity 97.9% for the detection of risk group cases.

CONCLUSIONS

A relationship between the fetal heart rate variability in different frequency ranges and the time in which FSpO2 is less than 30% was noticed. Fetal pulse oximetry seems to be an important additional source of information. Computerised analysis of the fetal heart rate monitoring and pulse oximetry recordings is a promising technique in objective intrapartum diagnosis of fetal hypoxia. Further evaluation of this technique is mandatory to evaluate its efficacy and reliability in interpreting fetal heart rate recordings.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

BACKGROUND

This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients.

METHODS

Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month.

RESULTS

Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed.

CONCLUSION

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.