A phase I trial evaluating the safety and biological activity of iboctadekin (rhIL-18) in combination with rituximab in patients with CD20+ B-cell non-Hodgkin's lymphoma

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Background: Iboctadekin (rhIL-18) is an immunostimulatory cytokine that has demonstrated anti-tumor activity in several preclinical models. When administered as monotherapy in phase I clinical studies, rhIL-18 was safe, well tolerated and induced potent biological responses (e.g. Th1 cytokine production and expression of activation markers on NK, CD8+ and CD4+ cells). These data affirm the endogenous role of IL-18 as a co-stimulatory cytokine and suggest that its optimal use would be in a combination with other immune modulators such as rituximab. Methods: Patients with CD20+ B cell non-Hodgkin's lymphoma are being given rituximab (375 mg/m2) IV weekly for 4 consecutive weeks in combination with ascending doses of intravenous rhIL-18 (1 to 100 mcg/kg in 6 cohorts of 3 patients each) IV weekly for 12 weeks to identify a dose that is safe and tolerable and gives a maximum biological effect. Eligible patients must have disease which progressed after standard therapy or for which there is no effective standard treatment. Assessments include safety/tolerability, pharmacokinetics, pharmacodynamics (serum cytokines, peripheral blood phenotypic markers and tumor biomarkers), immunogenicity and anti-tumor activity. Results: To date, thirteen subjects have been enrolled in the first four cohorts (1, 3, 10 and 20 mcg /kg of rhIL-18). The combination is well tolerated with a safety profile similar to that observed with rituximab or rhIL-18 monotherapy. The pharmacodynamic response is as expected with a dose-dependent decrease in circulating activated (CD69+) NK cells within 4 hours after completing the rhIL-18 infusion which rebound to pre-dose levels within 2–4 days. Using the International Working Group response criteria for lymphoma, two subjects had complete responses at 10 and 20 mcg/kg, one subject had a partial response at 10 mcg/kg and three subjects had stable disease at 1, 3 and 3 mcg/kg. Conclusions: These data show that the combination of rhIL-18 and rituximab is safe, well tolerated and induces potent biological activity. This study will define the dose level to be used in a future phase II trial evaluating this combination in patients with relapsed or refractory follicular lymphoma.

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Increased Prevalence of Factor V Leiden Mutation in Premature but Not in Full-Term Infants with Grade I Intracranial Haemorrhage

OBJECTIVES

In the current prospective study our aim was to analyse the distribution of the factor V Leiden (G1691A) mutation in preterm and full-term neonates with grade I intraventricular haemorrhage and in control neonates.

STUDY METHOD

A group of 125 individually selected neonates with grade I intraventricular haemorrhage and 128 controls were investigated.

RESULTS

The allele frequency was 7.2% in the total population of affected infants while it was 3.9% in the controls (p < 0.05); the latter corresponds to an average European allele frequency in healthy populations. When the infants were grouped as premature (<2,500 g and < or =36 weeks of gestational age) and appropriate for gestational age full-term infants the statistical analysis revealed an increased prevalence of the mutation in the premature group (10% allele frequency vs. 4.8% in the controls, p < 0.05), and a normal prevalence in the mature group (4.6 vs. 3.1%, respectively); therefore, the overall increase was due to the increase of incidence rate in preterm neonates.

CONCLUSIONS

These data confirm our previous results and suggest that as the preterm and term infants differ from each other in haemorrhage susceptibility in many clinical particulars, carrying of the mutation has probably also a different impact in premature and in full-term infants with respect to the intraventricular haemorrhage.

Association of wilms tumor with spinal dysraphism

Previous data suggested an association of vertebral anomalies with Wilms tumor. At the same time, vertebral midline fusion defects are often indicated by dermal anomalies over the spine. In the present study the prevalence of both occult spina bifida and cutaneous signs of spinal dysraphism was significantly higher in 50 Wilms patients than in 180 control children (18.0 versus 4.4%, p <.01, and 35.9 versus 17.5%, p <.02, respectively). Family investigations are needed to answer the question whether signs of spinal dysraphism in parents and sibs of patients may be regarded as indicators of an increased risk of Wilms tumor in the family.

Clinical and genetic heterogeneity in frontometaphyseal dysplasia: severe progressive scoliosis in two families

Frontometaphyseal dysplasia is a rare genetic syndrome affecting the skeletal system and connective tissue. It is believed to be inherited as an X-linked trait. Features of frontometaphyseal dysplasia overlap with other skeletal dysplasias. Prominent supraorbital ridges, radiologic evidence of cranial hyperostosis, and flared metaphyses are characteristic. Scoliosis, a rare associated finding, is usually mild, and familial progressive scoliosis has not been reported so far. The skeletal dysplasia and the associated clinical findings show significant intra- and interfamilial variability. The syndrome has been suggested to be an allelic variant of the Melnick-Needles osteodysplasty, an X-linked (dominant) entity. We present two families with frontometaphyseal dysplasia, in which both males and females showed the facial and skeletal features of the syndrome in association with progressive scoliosis. Some of the affected members also had hearing loss and urogenital anomalies, supporting the existence of the recently suggested entity "fronto-otopalatodigital-osteodysplasty syndome".

Cleidocranial dysplasia with decreased bone density and biochemical findings of hypophosphatasia

Cleidocranial dysplasia (CCD; MIM 119600) is an autosomal dominant skeletal dysplasia characterised by hypoplastic clavicles, patent fontanelles, short stature, tooth anomalies and other variable skeletal changes. Different mutations of the RUNX2/CBFA1 gene (MIM 600211) have been detected in patients with CCD. We investigated a mother and daughter with features of CCD presenting with reduced plasma alkaline phosphatase activity, increased urinary phosphoethanolamine excretion and decreased bone density. The latter findings were suggestive of hypophophatasia but mutation analysis showed no mutation in the tissue-nonspecific alkaline phosphatase gene (TNSALP; MIM 171760). However, a heterozygous mutation (Arg169Pro caused by nucleotide change 506G > C) was detected in the RUNX2 gene. Metabolic alterations gradually improved in both mother and daughter but bone-specific alkaline phosphatase remained low (less than 30% of normal) and mild phosphoethanolaminuria persisted. Recent studies in the Cbfa1 knock-out mouse showed decreased expression of alkaline phosphatase in differentiating bone.

CONCLUSION

we suggest that the observed metabolic alterations are secondary to the RUNX2 gene mutation affecting early bone maturation and turnover. This is the first description of biochemical findings of hypophosphatasia in patients with cleidocranial dysplasia.

[Ultrasound-guided hydrostatic reduction of intussusception]

In our country, the hydrostatic reduction is performed in three different ways. 1. A method with negative contrast material (gas enema) and fluoroscopy is performed only in one hospital. 2. A second method is performed with the use of Gastrographin and guided with ultrasound examination, and finally controlled with x-ray, this method is used in the most places. 3. Sonographically guided enema using physiological saline solution which has been performed by the authors for five years is only used in the Transdanubian region and is getting more and more popular in the resent years. The case history of 34 patients with intussusception was analysed retrospectively and the results of hydrostatic reduction with ultrasound guidance were reviewed. In 22 of 34 patients vomiting was noticed, blood in the stool was found in approximately one-third of all cases, the abdominal pain as the most important sign was presented by all patients. In 24 of 34 patients with intussusception, a single hydrostatic reduction was completely successful, but 10 patients were operated on. With the use of author's method, the following advantages were noticed: control X-ray examination was not needed, and in cases of multiple intussusception of the small intestines all of the lesions were detected.

[Combination, transition and degrees of severity of various syndromes]

Nowadays it is difficult to recognise and separate the various syndromes. The geneticists and the morphologists often change the classification of syndromes. The problem may be caused by a new case of a known syndrome, when new symptoms are described among the known ones. Then it is not sure, if a new syndrome discovered or it is a more complicated variation of an already known syndrome. To emphasise and exemplify the difficulties of syndrome identification 5 patients are presented and analysed: on with anadysplasia, two with cleidocranial dysplasia and a sibling pair with Larsen syndrome. It is concluded that no new syndrome could be described, and in a similar context, the definition of several new syndromes is not justified. The classification of syndromes based on bone disorders must be modified in order to fit the Genetic Classification easier and more clearly.

[Normal percentiles of kidney size in children as measured by ultrasonography]

The most anomaly of kidney development and urinary tract diseases have an effect on the size of the kidneys. Kidney size (renal length and parenchymal thickness) is readily measurable by ultrasonography, but the evaluation remains subjective without the use of appropriate standards. The aim of authors was, to produce a centile chart for normal kidney size based on US measurement in healthy Hungarian children. Renal length and renal parenchymal thickness (upper pole, middle part and lower pole) as well body weight and height were measured in 330 children. Normograms (centile charts) with 10th, 50th and 90th centiles were produced for body weight/height and renal length/parenchymal thickness. Renal length correlated strongly with both body weight (r = 0.93, p < 0.001) and height (r = 0.93, p < 0.001). The centile chart for renal size enables the objective evaluation of abnormal kidney size; it can help in the early recognition and follow up of urinary diseases.

Vertebral anomalies in Larsen's syndrome

The case of two sisters with Larsen's syndrome is presented. In addition to typical features of the syndrome, "multiple coronal cleft vertebrae" of the lumbar vertebral bodies were seen in both sibs. The extremities were conspicuously short.

[Sedation and sleep induction instead of anesthesia in infants and young children during CT and MRI examinations]

The authors recommend a simple, safe method to the CT and MR examinations of babies and young children instead of general anaesthesia. They performed 51 examinations (CT: 23, MRI: 28 cases, skul: 36, spine: 3, hip: 2, chest: 1, abdomen: 9) with this method and give an account of favourable results.

Syndrome of arachnodactyly, disturbance of cranial ossification, protruding eyes, feeding difficulties, and mental retardation

We have evaluated an infant with a striking combination of craniofacial anomalies, arachnodactyly, and severe developmental failure. She died at the age of 5 months during a recurrent apneic episode. She also had protruding eyes, downward slant of palpebral fissures, short upturned nose, midface hypoplasia, micrognathia, extreme under-development of the epiglottis, and severe feeding difficulties. The patient closely resembled four other previously reported patients. It is suggested that these five patients represent the same malformation syndrome, a well-recognizable separate entity. Our patient also had a pericentric inversion of chromosome 10; a possible association of this with the phenotype cannot be excluded.

[Acute hydrops of the gallbladder in childhood]

The authors discuss four cases of acute hydrops of the gallbladder being examined in the Department of Pediatrics, Medical University School of Pécs. Diagnosis was based on ultrasonography. In all cases right upper quadrant abdominal pain and fatigue were observed. The causes of hydrops were Kawasaki's disease, sepsis, and multiple trauma. In one case the cause was unknown. In one of the cases cholecystectomy was done, in three cases the hydrops resolved spontaneously. The authors discuss the aetiology, the symptomatology and the therapeutical possibilities of hydrops. On the basis of their results the authors suggest the importance of the serial ultrasound examinations.

[Revised evaluation of cardiomegaly in hypoglycemia in newborn infants]

Numerous data of the literature suggest that the cardiomegaly of hypoglycaemic newborns is due to low blood glucose levels. The size of the heart is usually determined by measuring the cardio-thoracic ratio (CTR). On the basis of the present retrospective study analyzing the clinical course and radiological findings of 66 newborns the authors suggest that: 1. CTR cannot reliably be used for determining the size of the heart in hypoglycaemic small for gestational age (SGA) newborns. 2. Routine look at the X-ray picture is also insufficient for the determination of the size of the heart in hypoglycaemic SGA newborns. 3. The method suggested by the authors is to measure the transverse diameter of the heart and to compare it to the normal, birthweight-related standard. In 3/4 of the hypoglycaemic SGA newborns studied thoracic transverse diameter (TTD) values were found to be smaller than the 50th percentile of the standard. Transverse diameter values of the heart, however, did not differ significantly from the normal mean values. In cases of true cardiomegaly, i.e. cardiac diameter above the 90th percentile, data indicative of asphyxia were more frequently seen.

[Developmental bone abnormalities, their variants and the delay of osteogenesis in children with leukemia]

When analyzing the Roentgen documentation of 102 leukaemic children, the prevalence of bone anomalies of the extremities, pelvis and vertebral column was studied. The frequency of the abnormal or unusual findings was compared with that of 660 control subjects. The frequency of osseous anomalies proved to be 2 to 3 times higher in leukaemic children tha in the controls. Considering the number of ossification centers and the presence nutritional canal of vertebrae, in leukaemic children the ossification seemed to be retarded.

Abdominal calcifications in infants and children

Abdominal and pelvic calcifications are usually incidental findings and require further measures to determine their origin. Most laboratory investigations are of little help. Plain anteroposterior and lateral x-rays are essential. The time of appearance and localisation of a calcification is of diagnostic importance. Amorphous, granular and irregular calcification can be an early sign of malignancy. Mobility of a calcification also helps to clarify its origin. Over the past 15 years abdominal and pelvic calcifications, excluding urological radiodensities, have been found in 63 patients up to fourteen years of age at our institute. A migrating deposit in the omentum, a spontaneously amputated calcified ovary mimicking a vesical calculus and a congenital retroperitoneal xanthofibroma caused the greatest difficulty in establishing a preoperative diagnosis.