Replicated Adsorption Technique used to Resolve ALX148 Interference in the Immunohematology Reference Laboratory

Introduction/Objective

Increased expression of CD47 by cancer cells inhibits macrophages' phagocytic activity through CD47-SIRPα interactions, allowing evasion of the innate immune system. Several drugs on the market have been developed to target this interaction, including monoclonal therapeutics and fusion proteins. ALX148 is a genetically engineered SIRPα fusion protein with an inactivated Fc portion. CD47 is expressed highly on red blood cells (RBC), resulting in strong interference in pre-transfusion compatibility testing of patients receiving ALX148. Consequently, trial patients are at increased risk of transfusion-related adverse events or delay of needed transfusion. Few resolutions of ALX148 interference to assess underlying alloantibody development have been reported. One such examiniation demonstrated x6 linear papain-treated RBC adsorptions removed ALX148 interference. This study aimed to replicate these findings.

Methods/Case Report

Three patients receiving combination ALX148 (dose 6.57-20mg/mL) and Azacitidine therapy with broad-reactive RBC antibody reactivity were selected. High volume alloadsorptions (8:1 RBC:plasma) were performed with papain-treated rr (ccdee) RBCs. Adsorptions were incubated at 37C for 10 minutes. Polyethylene glycol (PEG) was utilized in test tube indirect antiglobulin testing (IAT).

Results (if a Case Study enter NA)

Initial reactivity strength was 3-4+ at PEG-IAT and saline-IAT with a three-cell screening RBC reagent. Alloadsorbed plasma was non-reactive at IAT with a three-cell screening RBC reagent enhanced by PEG. Drug interference was removed following three times high volume papain-treated alloadsorption.

Conclusion

Cancer immunotherapies have transformed the standard of care in oncology. Despite the evident clinical success, the medical laboratory has been challenged with adapting to cancer drug therapies capable of causing interference in routine laboratory testing. Clinical trials of ALX148 are associated with interference in pre-transfusion compatibility testing. The use of extended phenotype matching for RBC transfusion can be utilized but incurs additional time and resources. These results suggest high volume linear papain RBC alloadsorptions may be incorporated into antibody resolution for patients receiving ALX148.

Feline panleukopenia virus DNA shedding following modified live virus vaccination in a shelter setting

This study assessed the frequency and timing of feline panleukopenia virus (FPV) shedding in feces following administration of a modified live FPV vaccine. Feces were collected from 37 shelter cats that did not meet clinical criteria for panleukopenia on the day of vaccination or on days 3, 7, 14, and 21 post-vaccination (NCL group). A commercial quantitative PCR (qPCR) fecal pathogen panel and a canine parvovirus point-of-care antigen test were performed. FPV DNA copy numbers from a concurrent study of 39 cats with panleukopenia (CL group) were compared with the NCL group. Of the 165 samples from the NCL group, one had a weak positive antigen test result on day 7, while nine samples (5.5%) from eight cats (21.6%) produced positive FPV qPCR test results, one on day 3 and eight on day 7. There were no day 21-positive qPCR results in the 11 cats that were revaccinated on day 14. There was no association between the number of additional fecal pathogens identified and a positive FPV qPCR result. Of the cats with positive results, FPV DNA copy numbers differed between NCL group and CL group (median 1.13 × 10⁷ and 5.01 × 10⁸ copies/g feces, respectively; P < 0.001). The FPV qPCR cannot differentiate subclinical infection from vaccine virus shedding. To avoid unnecessary isolation and euthanasia, shelters should therefore limit FPV PCR testing to cats with a high index of suspicion of panleukopenia. The timing of recent vaccination should also be considered when interpreting test results.

Low-carbohydrate diet and the risk of metabolic syndrome in Korean adults

BACKGROUND & AIMS

The association of low-carbohydrate diet with weight loss and the risk of cardiovascular diseases has recently been the focus of increasing research attention. However, studies on low-carbohydrate diet in the Asian population are limited. The present study was aimed to examine the association between low-carbohydrate diet and metabolic syndrome among Korean adults.

METHODS AND RESULTS

A total of 16,349 participants aged 30 years or older who participated in a 24-h dietary recall survey of the fifth and sixth Korea National Health and Nutrition Examination Survey were included in this study. Low-carbohydrate diet was evaluated using the low-carbohydrate-diet score, which was calculated based on the percentage of energy from carbohydrate, protein, and fat by sex. The association between the low-carbohydrate-diet score and metabolic syndrome was analyzed using multiple logistic regression analysis. A low-carbohydrate diet was not associated with metabolic syndrome and its components such as waist circumference, blood pressure, and triglyceride levels. However, women in the highest decile of the animal- or plant-based low-carbohydrate-diet score showed a decreased risk of reduced high-density lipoprotein (HDL)-cholesterol levels, and men in the highest decile of the animal-based low-carbohydrate-diet score showed a decreased risk of reduced HDL-cholesterol levels than those in the lowest decile of the low-carbohydrate-diet score.

CONCLUSION

These findings indicate that, in Korea, a low-carbohydrate diet did not increase the risk of metabolic syndrome among adults who typically consume a high-carbohydrate low-fat diet. However, it may moderately decrease the risk of reduced HDL-cholesterol levels.

NT-PGC-1α deficiency decreases mitochondrial FA oxidation in brown adipose tissue and alters substrate utilization in vivo

Transcriptional coactivator PPAR γ coactivator (PGC)-1α and its splice variant N-terminal (NT)-PGC-1α mediate transcriptional regulation of brown adipose tissue (BAT) thermogenesis in response to changes in ambient temperature. PGC-1α is dispensable for cold-induced BAT thermogenesis as long as NT-PGC-1α is present. However, the functional significance of NT-PGC-1α in BAT has not been determined. In the present study, we generated NT-PGC-1α^-/- mice to investigate the effect of NT-PGC-1α deficiency on adaptive BAT thermogenesis. At thermoneutrality, NT-PGC-1α^-/- mice exhibited abnormal BAT phenotype with increased accumulation of large lipid droplets concomitant with marked downregulation of FA oxidation (FAO)-related genes. Consistent with transcriptional changes, mitochondrial FAO was significantly diminished in NT-PGC-1α^-/- BAT. This alteration, in turn, enhanced glucose utilization within the NT-PGC-1α^-/- BAT mitochondria. In line with this, NT-PGC-1α^-/- mice had higher reliance on carbohydrates. In response to cold or β₃-adrenergic receptor agonist, NT-PGC-1α^-/- mice transiently exhibited lower thermogenesis but reached similar thermogenic capacities as their WT littermates. Collectively, these findings demonstrate that NT-PGC-1α is an important contributor to the maintenance of FAO capacity in BAT at thermoneutrality and provide deeper insights into the relative contributions of PGC-1α and NT-PGC-1α to temperature-regulated BAT remodeling.

Conservation of the behavioral and transcriptional response to social experience among Drosophilids

While social experience has been shown to significantly alter behaviors in a wide range of species, comparative studies that uniformly measure the impact of a single experience across multiple species have been lacking, limiting our understanding of how plastic traits evolve. To address this, we quantified variations in social feeding behaviors across 10 species of Drosophilids, tested the effect of altering rearing context on these behaviors (reared in groups or in isolation) and correlated observed behavioral shifts to accompanying transcriptional changes in the heads of these flies. We observed significant variability in the extent of aggressiveness, the utilization of social cues during food search, and social space preferences across species. The sensitivity of these behaviors to rearing experience also varied: socially naive flies were more aggressive than their socialized conspecifics in some species, and more reserved or identical in others. Despite these differences, the mechanism of socialization appeared to be conserved within the melanogaster subgroup as species could cross‐socialize each other, and the transcriptional response to social exposure was significantly conserved. The expression levels of chemosensory‐perception genes often varied between species and rearing conditions, supporting a growing body of evidence that behavioral evolution is driven by the differential regulation of this class of genes. The clear differences in behavioral responses to socialization observed in Drosophilids make this an ideal system for continued studies on the genetic basis and evolution of socialization and behavioral plasticity.

A truncated PPAR gamma 2 localizes to mitochondria and regulates mitochondrial respiration in brown adipocytes

Peroxisome proliferator-activated receptor gamma (PPARγ) is a key regulator of brown adipocyte differentiation and thermogenesis. The PPARγ gene produces two isoforms, PPARγ1 and PPARγ2. PPARγ2 is identical to PPARγ1 except for additional 30 amino acids present in the N-terminus of PPARγ2. Here we report that the C-terminally truncated form of PPARγ2 is predominantly present in the mitochondrial matrix of brown adipocytes and that it binds to the D-loop region of mitochondrial DNA (mtDNA), which contains the promoter for mitochondrial electron transport chain (ETC) genes. Expression of mitochondrially targeted MLS-PPARγ2 in brown adipocytes increases mtDNA-encoded ETC gene expression concomitant with enhanced mitochondrial respiration. These results suggest that direct regulation of mitochondrially encoded ETC gene expression by mitochondrial PPARγ2, in part, underlies the isoform-specific role for PPARγ2 in brown adipocytes.

An unexpected role for the transcriptional coactivator isoform NT-PGC-1α in the regulation of mitochondrial respiration in brown adipocytes

Brown adipose tissue dissipates energy as heat, a process that relies on a high abundance of mitochondria and high levels of electron transport chain (ETC) complexes within these mitochondria. Two regulators of mitochondrial respiration and heat production in brown adipocytes are the transcriptional coactivator PGC-1α and its splicing isoform NT-PGC-1α, which control mitochondrial gene expression in the nucleus. Surprisingly, we found that, in brown adipocytes, some NT-PGC-1α localizes to mitochondria, whereas PGC-1α resides in the nucleus. Here we sought to investigate the role of NT-PGC-1α in brown adipocyte mitochondria. Immunocytochemistry, immunotransmission electron microscopy, and biochemical analyses indicated that NT-PGC-1α was located in the mitochondrial matrix in brown adipocytes. NT-PGC-1α was specifically enriched at the D-loop region of the mtDNA, which contains the promoters for several essential ETC complex genes, and was associated with LRP130, an activator of mitochondrial transcription. Selective expression of NT-PGC-1α and PGC-1α in PGC-1α^-/- brown adipocytes similarly induced expression of nuclear DNA-encoded mitochondrial ETC genes, including the key mitochondrial transcription factor A (TFAM). Despite having comparable levels of TFAM expression, PGC-1α^-/- brown adipocytes expressing NT-PGC-1α had higher expression of mtDNA-encoded ETC genes than PGC-1α^-/- brown adipocytes expressing PGC-1α, suggesting a direct effect of NT-PGC-1α on mtDNA transcription. Moreover, this increase in mtDNA-encoded ETC gene expression was associated with enhanced respiration in NT-PGC-1α-expressing PGC-1α^-/- brown adipocytes. Our findings reveal a previously unappreciated and isoform-specific role for NT-PGC-1α in the regulation of mitochondrial transcription in brown adipocytes and provide new insight into the transcriptional control of mitochondrial respiration.

Mathematical Model-Based Accelerated Development of Extended-release Metformin Hydrochloride Tablet Formulation

A computational fluid dynamic (CFD) model was developed to predict metformin release from a hydroxypropylmethylcellulose (HPMC) matrix-based extended-release formulation that took into consideration the physical and chemical properties of the drug substance, composition, as well as size and shape of the tablet. New high dose strength (1000 mg) tablet geometry was selected based on the surface area/volume (SA/V) approach advocated by Lapidus/Lordi/Reynold to obtain the desired equivalent metformin release kinetics. Maintaining a similar SA/V ratio across all extended-release metformin hydrochloride (Met XR) tablet strengths that had different geometries provided similar simulations of dissolution behavior. Experimental dissolution profiles of three lots of high-strength tablets agreed with the simulated release kinetics. Additionally, a pharmacokinetic absorption model was developed using GastroPlus™ software and known physicochemical, pharmacokinetic, and in vitro dissolution properties of metformin to predict the clinical exposure of the new high strength (1000 mg) tablet prior to conducting a human clinical bioequivalence study. In vitro metformin release kinetics were utilized in the absorption model to predict exposures in humans for new 1000-mg Met XR tablets, and the absorption model correctly projected equivalent in vivo exposure across all dose strengths. A clinical bioequivalence study was pursued based on the combined modeling results and demonstrated equivalent exposure as predicted by the simulations.

Islet amyloid inhibitors improve glucose homeostasis in a transgenic mouse model of type 2 diabetes

Increasing evidence points to the cytotoxicity of islet amyloid polypeptide (IAPP) aggregates as a major contributor to the loss of β-cell mass in type 2 diabetes. Prevention of IAPP formation represents a potential treatment to increase β-cell survival and function. The IAPP inhibitory peptide, D-ANFLVH, has been previously shown to prevent islet amyloid accumulation in cultured human islets. To assess its activity in vivo, D-ANFLVH was administered by intraperitoneal injection into a human IAPP transgenic mouse model, which replicates type 2 diabetes islet amyloid pathology. The peptide was a potent inhibitor of islet amyloid deposition, resulting in reduced islet cell apoptosis and preservation of β-cell area leading to improved glucose tolerance. These findings provide support for a key role of islet amyloid in β-cell survival and validate the application of anti-amyloid compounds as therapeutic strategies to maintain normal insulin secretion in patients with type 2 diabetes.

Staging systems in bipolar disorder: an International Society for Bipolar Disorders Task Force Report

OBJECTIVE

We discuss the rationale behind staging systems described specifically for bipolar disorders. Current applications, future directions and research gaps in clinical staging models for bipolar disorders are outlined.

METHOD

We reviewed the literature pertaining to bipolar disorders, focusing on the first episode onwards. We systematically searched data on staging models for bipolar disorders and allied studies that could inform the concept of staging.

RESULTS

We report on several dimensions that are relevant to staging concepts in bipolar disorder. We consider whether staging offers a refinement to current diagnoses by reviewing clinical studies of treatment and functioning and the potential utility of neurocognitive, neuroimaging and peripheral biomarkers.

CONCLUSION

Most studies to date indicate that globally defined late-stage patients have a worse overall prognosis and poorer response to standard treatment, consistent with patterns for end-stage medical disorders. We believe it is possible at this juncture to speak broadly of 'early'- and 'late'-stage bipolar disorder. Next steps require further collaborative efforts to consider the details of preillness onset and intermediary stages, and how many additional stages are optimal.

Predominant recurrence polarity among 928 adult international bipolar I disorder patients

OBJECTIVE

To test the hypothesis that patients with bipolar disorder (BPD) differ demographically and clinically within subgroups based on the predominant-polarity of major recurrences.

METHOD

We tested factors for association with predominantly (≥2 : 1) depressive vs. mania-like episodes with 928 DSM-IV type-I BPD subjects from five international sites.

RESULTS

Factors preliminarily associated with predominant-depression included: electroconvulsive treatment, longer latency-to-BPD diagnosis, first episode depressive or mixed, more suicide attempts, more Axis-II comorbidity, ever having mixed-states, ever married, and female sex. Predominant-mania was associated with: initial manic or psychotic episodes, more drug abuse, more education, and more family psychiatric history. Of the 47.3% of subjects without polarity-predominance, risks for all factors considered were intermediate. Expanding the definition of polarity-predominance to ≥51% added little, but shifting mixed-states to 'predominant-depression' increased risk of suicidal acts from 2.4- to 4.5-fold excess over predominant-mania-hypomania, and suicidal risk was associated continuously with increasing proportions of depressive or mixed episodes.

CONCLUSION

Subtyping by predominant-polarity yielded predictive associations, including the polarity of first episodes and risk of suicide attempts. Such subtyping may contribute to improve planning of clinical care and to biological studies of BPD.

Crystal structure of aquachloro[N,N′-bis(3-ethoxysalicylidene)ethylenediiminato] manganese(III) dihydrate, [Mn(C20H22N2O4)Cl(H2O)] · 2H2O

C20H28ClMnN2O7, monoclinic, P121/n1 (no. 14), a = 11.863(1) Å, b = 13.960(2) Å, c = 14.005(2) Å, β = 103.990(2)°, V = 2250.4 Å3, Z = 4, Rgt(F) = 0.061, wRref(F2) = 0.170, T = 293 K.

Crystal structure of N-benzoyl-4,4-dimethyl-2-methylamino-2-thiazoline, C13H16N2OS

C13H16N2OS, monoclinic, C12/c1 (no. 15), a = 21.908(2) Å, b = 13.932(2) Å, c = 8.7971(9) Å, β = 101.952(2)°, V = 2626.9 Å3, Z = 8, Rgt(F) = 0.041, wRref(F2) = 0.113, T = 293 K.

Crystal structure of aquachloro[N,N′-bis(3-ethoxysalicylidene)propylenediiminato] manganese(III) dihydrate, [Mn(C21H24N2O4)Cl(H2O)] · 2H2O

C21H30ClMnN2O7, triclinic, P1̅ (no. 2), a = 10.029(2) Å, b = 11.561(2) Å, c = 11.689(2) Å, α = 106.331(3)°, β = 107.874(3)°, γ = 99.092(3)°, V = 1192.8 Å3, Z = 2, Rgt(F) = 0.071, wRref(F2) = 0.238, T = 293 K.

Dipstick urine protein, as a predictor of cardiovascular mortality in Korean men: Korea Medical Insurance Corporation study

OBJECTIVES

This study was to investigate if the dipstick proteinuria can predict cardiovascular mortality in a population of Korean men.

METHODS

We measured urine protein and other cardiovascular risk factors in 100,059 Korean men, aged between 35-59 years in 1990 and 1992. Levels of proteinuria measured by dipstick method were trace or less, 1+, 2+, and 3+ or greater. The primary outcomes were deaths from all causes, cardiovascular disease, cancer, and others in a 12 year follow-up from 1993 to 2004.

RESULTS

The multivariate-adjusted relative risks (95% CI) for cardiovascular death according to the level of proteinuria (1+, 2+, 3+ and more) in 1990 examination were 2.18 (1.36-3.48), 2.55 (1.37-4.78), and 4.57 (2.16-9.66) respectively. The corresponding relative risks according to the level of proteinuria in 1992 examination were 2.49 (1.71-3.64), 2.64 (1.53-4.58), and 2.78 (1.15-6.73). The relative risks for cardiovascular death of men with proteinuria (1+ or greater) once and twice among the examinations were 2.18 (1.63-2.92) and 3.75 (2.27-6.18), compared with men without proteinuria in 1990 and 1992 examinations.

CONCLUSIONS

Our results showed that dipstick proteinuria is associated with cardiovascular mortality in Korean men. Dipstick proteinuria could be a predictor for cardiovascular mortality.

Inducible azole resistance associated with a heterogeneous phenotype in Candida albicans

The development of azole resistance in Candida albicans is most problematic in patients with AIDS who receive long courses of drug for therapy or prevention of oral candidiasis. Recently, the rapid development of resistance was noted in other immunosuppressed patients who developed disseminated candidiasis despite fluconazole prophylaxis. One of these series of C. albicans isolates became resistant, with an associated increase in mRNA specific for a CDR ATP-binding cassette transporter efflux pump (K. A. Marr, C. N. Lyons, T. R. Rustad, R. A. Bowden, and T. C. White, Antimicrob. Agents Chemother. 42:2584-2589, 1998). Here we study this series of C. albicans isolates further and examine the mechanism of azole resistance in a second series of C. albicans isolates that caused disseminated infection in a recipient of bone marrow transplantation. The susceptible isolates in both series become resistant to fluconazole after serial growth in the presence of drug, while the resistant isolates in both series become susceptible after serial transfer in the absence of drug. Population analysis of the inducible, transiently resistant isolates reveals a heterogeneous population of fluconazole-susceptible and -resistant cells. We conclude that the rapid development of azole resistance occurs by a mechanism that involves selection of a resistant clone from a heterogeneous population of cells.

Attitude change towards mental illness during nursing education--a cross-cultural study of student nurses in Korea, Republic of China and Japan

This is an initial report of a cooperative project by colleagues in Korea, the Republic of China (Taiwan) and Japan, involving the measuring of attitudes toward mental illness. The discussion mainly revolves around the influence of mental health education in nursing on attitudes towards mental illness. The subjects' attitudes were assessed by Wig's profiles. The attitudes of freshmen who had just entered nursing schools and seniors who had already finished clinical training in psychiatry were compared to measure the attitude change during the course of nursing education, if any. Non-medical students served as a control group. As a result, a seemingly "negative and pessimistic" attitude was demonstrated in the senior student nurses. The findings are examined and discussed.

Single allelic C mu gene rearrangements in patients with T cell and undifferentiated leukemia

By using a panel of monoclonal antibodies in combination with conventional morphological and histochemical studies, seven leukemic patients were diagnosed as having T-cell lymphocytic leukemia (ALL) and three patients were classified as having acute undifferentiated leukemia (AUL). When genomic DNA from each patient was analysed by the Southern blot hybridization technique, two out of seven cases with T-cell ALL and two of three cases with AUL demonstrated immunoglobulin (Ig) mu gene rearrangements. Interestingly, the patterns of C mu gene rearrangement found in these four cases as well as in the T-cell line HSB-2 were quite similar with rearrangement of a single allele and germ line configuration retained in the other allele. Ig gene rearrangement is an essential property of cells of B-lineage, but detection of an Ig gene rearrangement by itself seems insufficient to assign commitment to B-lineage differentiation. The significance of Ig gene rearrangements in T-cell ALL is unclear, but this heterogeneity at the DNA level among T-cell ALL may reflect differences in leukemogeneis and have prognostic and therapeutic implications.

Lineage specific classification of leukaemia: results of the analysis of sixty cases of childhood leukaemia

In addition to conventional morphological, histochemical and immunological marker studies, cells from 60 children with leukaemia were further analysed using the Southern blot hybridization technique to look at differences in the organization of immunoglobulin (Ig) genes. Of the 60 patients studied by conventional means, 47 were diagnosed as acute lymphocytic leukaemia (ALL) and 13 as non-lymphocytic leukaemia. Seven patients were initially classified as T ALL and 40 as non-T, non-B ALL. Further subclassification of the 40 patients with non-T, non-B ALL indicated three pre-B ALL and 29 patients diagnosed as common ALL, expressing Ia and CALLA antigens. All 29 patients with common ALL demonstrated C mu gene rearrangements with or without light chain (kappa and lambda) genes rearrangement. Based on the developmental hierarchy of Ig gene rearrangement, it was possible to further subclassify the patients with common ALL into different stages of B cell development. Eight (of the 40) patients with non-T, non-B ALL were identified as CALLA- but further analysis indicated T-lineage origin in two patients and three patients were reclassified as acute undifferentiated leukaemia (AUL). C mu gene rearrangements were detected in two patients with T ALL, two patients with AUL and one patient with acute myelogenous leukaemia (AML). In contrast to the patients with common ALL, Ig gene rearrangement observed in these non-B-lineage cells was restricted to a single C mu gene while retaining germ-line configuration of the other allele of the C mu gene and both light chain genes.

Phenotypic heterogeneity at the DNA level in childhood leukemia with a mediastinal mass

Although phenotypic heterogeneity of childhood T-cell acute lymphocytic leukemia (T-ALL) which bear receptors for sheep red blood cells (E-rosettes) and/or T-cell-associated antigens has been reported, there are certain clinical features which are shared by most patients. A mediastinal mass is one of the most characteristic presentations in this particular disorder. This report describes four children with ALL, who presented with a mediastinal mass. Three patients were E-rosette-negative and one was E-rosette-positive. Individual surface phenotypes, defined by a panel of monoclonal antibodies, were quite different. Since Ig gene organization is an essential property of cells of B-lineage, it was surprising to find that analysis of genomic DNA revealed immunoglobulin (Ig) gene rearrangements in two of them. These findings suggest that there is significant heterogeneity even among those leukemias associated with a mediastinal mass, and that a mediastinal mass may not clearly indicate origin from cells of T-lineage. This heterogeneity may reflect differences in leukemogenesis and may have prognostic and therapeutic implications.

Somatic rearrangement of T-cell antigen receptor gene in human T-cell malignancies

A cDNA clone representing the gene encoding the beta chain of the human T-cell antigen receptor has been isolated recently. By using fragments of this cDNA as hybridization probes in Southern blot analysis of restriction endonuclease-digested genomic DNA, we have now examined the structure of the gene in DNA from 26 patients with acute leukemia and from 23 normal individuals. We have found that the T-cell antigen receptor gene has undergone somatic rearrangement in 14 of 14 patients with the phenotypic diagnosis of T-cell acute lymphoblastic leukemia. In this group of patients, similar patterns of rearrangement appear to occur in different patients. This finding suggests that there is either a limited repertoire of possible rearrangements or an association between the development of leukemia and specific patterns of rearrangement. DNA from 6 patients with acute myeloblastic leukemia, 6 patients with non-B, non-T acute lymphoblastic leukemia, and 23 nonleukemic individuals showed no rearrangement or polymorphism. One case of T-cell acute lymphoblastic leukemia, however, showed rearrangement of both the T-cell receptor beta chain and the constant region of the immunoglobulin gene. Studies with mixtures of DNAs from leukemic bone marrow cells and cultured skin fibroblasts, as well as with remission and relapse marrow DNAs from the same patients, indicate that this technique can detect 1% leukemic cells in a mixed population. In addition, DNA from the marrow of a patient in relapse contains a similar rearrangement to that found in the marrow sample taken at the time of diagnosis, which suggests that the original clone of leukemic cells was responsible for relapse. Our results indicate that assessment of rearrangement of the T-cell antigen receptor gene will be valuable in the diagnosis and management of leukemia and can be used to evaluate clonality in T-cell neoplasia.

Volume regulation in lymphoid leukemia cells and assignment of cell lineage

Normal T lymphocytes readjust their volume after swelling in hypotonic medium, whereas B lymphocytes remain swollen. The difference between the two cell types appears to lie in the inability of B cells to increase their permeability to potassium in response to swelling. We have studied mononuclear cells from the bone marrow of 65 patients with lymphocytic leukemia, to determine whether the response to a hypotonic environment could be used to assign cell lineage. In contrast to leukemic cells of B-cell lineage (as in B-cell acute or chronic lymphocytic leukemia and non-T-cell, non-B-cell acute lymphocytic leukemia), T-cell-leukemia cells responded within five minutes to hypotonic swelling with an increase in potassium permeability and restoration toward isotonic volume. We conclude that the response to hypotonic shock may distinguish leukemic cells of T-cell origin from those derived from B-cell precursors and provides a simple, rapid, and reliable means for assigning cell lineage to lymphoid leukemia cells.

Immunoglobulin gene rearrangement in acute myelogenous leukemia

Twenty-one cases of newly diagnosed nonlymphocytic leukemia were subjected to analysis of immunoglobulin gene organization. Although immunoglobulin gene organization is an essential property of B-lineage cells, immunoglobulin gene rearrangement has also been observed in mouse T-cells and occasionally in cultured human T-cell leukemic cells. Here we report the first case of acute myelogenous leukemia in which mu-chain gene rearrangement is demonstrated. This finding provides a further step in our understanding of both normal and abnormal hematopoietic cell differentiation and the heterogeneity of nonlymphocytic leukemia.

A live varicella vaccine in a pediatric community

A total of 663 children with various underlying diseases were immunized with a live varicella vaccine at the vaccine clinic of Osaka University Hospital during a period of seven years from October, 1975. Clinical reactions after vaccination occurred in 32.4% (24/74) of the children with malignancies and in 0.3% (2/591) of those in other groups. Vaccine-induced immunity was detected for more than 6 years, by FAMA (fluorescent antibody to membrane antigen) and IAHA (immune adherence hemagglutination) tests, and a skin-test for varicella-zoster virus (VZV). During an observation period of more than 7 years, clinical varicella developed in 12 children, 8 of whom were in the group with malignancies. Zoster occurred in only 4 (9.1%) of 44 vaccinees with acute leukemia, this incidence being significantly less (p less than 0.05) than that (21.6%, 8/37) in un-vaccinated leukemic children.

Immunoglobulin mu-chain gene rearrangement in a patient with T cell acute lymphoblastic leukemia

A 6-yr-old girl with T cell acute lymphoblastic leukemia (ALL) is described. She had a mediastinal mass and her leukemic cells expressed T cell-associated antigens (Leu 1+, OKT3+, OKT9+, and OKT10+). When we examined genomic DNA from the leukemic cells, we detected Ig mu-chain gene rearrangement with germ-line configuration of light chain genes. As reported recently, detecting Ig gene rearrangement has become an important procedure for further classifying B cell precursor cells. This case, however, suggests that there is also heterogeneity among patients with T cell ALL, not only at the level of cell surface phenotypes, but also at the level of the Ig gene. These findings have major implications when we consider both the ontogenesis of these leukemic cells and the normal differentiation of human lymphocytes.

[Adriamycin and Ara-C infusions in the treatment of refractory leukemia]

We have treated two pediatric patients with refractory ANLL and four with relapsed high-risk ALL with Adriamycin continuous Ara-C i.v. Four out of six patients were able to enter complete remission after first or second course of the treatment. All of them developed severe bone marrow suppression, and various degree of oral mucositis, liver dysfunction and gastrointestinal toxicity, and two patients died from side effects. Recently this combination chemotherapy is becoming a best regimen for the treatment of untreated ANLL. Although our cases are small in number, this combination therapy also seems to be effective for refractory ANLL and relapsed high-risk ALL. It is needless to say that we have to pay more attention when we use this regimen.

Choriocarcinoma in infant and mother

A 2-month-old female baby was noticed to have liver tumor. A hemangioma of the right lobe was suspected from the findings by celiac angiography. Histologic findings of the surgically resected material revealed choriocarcinoma of the liver. At autopsy, multiple metastatic nodules were found in the lungs, but remnant liver, ovaries, uterus, mediastinum, and sacrococcygeal region were free of tumor. The ovary had several thecalutein cysts, and the endometrium of the uterus showed pseudodecidual change of the stroma. The mother died two months later. Although histologic materials were not available, the clinical findings including a high value of serum HCG seemed to show that she had been affected by choriocarcinoma. The most probable origin of the choriocarcinoma in the infant from the mother is discussed.

Intrapleural therapy of malignant pleurisy in patients with neuroblastoma

Three children with advanced neuroblastoma developed pleural effusion in the course of their disease. This unusual complication was successfully treated with intrapleural administration of a nonspecific "immunostimulatory" agent; cell wall skeleton of Nocardia rubra (N-cws). The side effects of this procedure were mild and well tolerated even in infants in spite of their terminal stage. Intrapleural therapy in this study seemed to be useful for the treatment of pediatric malignant pleurisy.