Survival with dacarbazine and fotemustine in newly diagnosed glioblastoma multiforme

A total of 55 patients with histologically proven glioblastoma multiforme (total gross resection: n=24, subtotal resection: n=20, stereotactic biopsy: n=11) were treated with the combination of dacarbazine (D) (200 mg m(-2)) and fotemustine (F) (100 mg m(-2)) and concomitant radiotherapy (2 Gy day(-1), 5 days per week using limited fields up to 60 Gy) to assess efficacy and toxicity of this regimen. Survival (median survival, 12-, 18- and 24-month survival rates) and time to progression (median time to progression (TTP), 6-month progression-free survival) were analysed by Kaplan-Meier's method. A total of 268 (range 1-8, median: 5) cycles were administered. Median survival is 14.5+ (range: 0.5-40+) months, and the 12-, 18- and 24-month survival rates are 58, 29 and 23%, respectively. Median TTP from the start of D/F therapy is 9.5+ (range: 0.5-33+) months. The 6-month progression-free survival is 54%. Partial remissions were observed in 3.6%. Main toxicity was thrombocytopenia. Five patients were excluded from further D/F application, four patients because of prolonged thrombocytopenia NCI-CTC grades 3 and 4 and one patient because of whole body erythrodermia. One patient died because of septic fever during thrombocytopenia and leukopenia NCI-CTC grade 4 after the first cycle. No other toxicities of NCI-CTC grade 3 or 4 occurred. The treatment is feasible in a complete outpatient setting and the results of the D/F regimen justify further investigations with these compounds.

The new hematology analyzer Sysmex XE-2100: performance evaluation of a novel white blood cell differential technology

CONTEXT

The new hematology analyzer Sysmex XE-2100 (TOA Medical Electronics, Kobe, Japan) has a novel, combined, white blood cell differential technology and a special reagent system to enumerate nucleated red blood cells.

DESIGN

Performance evaluation of both technologies of the Sysmex XE-2100 according to the H20-A protocol of the National Committee for Clinical and Laboratory Standards and comparison of the results with those for the hematology analyzer Sysmex NE-8000 (TOA Medical Electronics).

SPECIMENS

Five hundred forty-four blood samples randomly chosen from various inpatient and outpatient departments of the Vienna University hospital.

RESULTS

Five-part white blood cell differential counts on the XE-2100 revealed excellent correlation with the manual reference method for neutrophils, lymphocytes, and eosinophils (r =.925,.922, and.877, respectively) and good correlation for monocytes and basophils (r =.756 and.763, respectively). The efficiency rates of flagging for the presence of >/=1% abnormal white blood cells were 83% (XE-2100) and 66% (NE-8000). The correlation of automated and microscopic nucleated red blood cell counts was excellent (r =.97).

CONCLUSIONS

From the present evaluation and our former experience with other types of Sysmex analyzers, we conclude that the new white blood cell differential technology of the XE-2100 represents a further development toward more efficient flagging of abnormal white blood cells.

Role of immunological lymphocyte subset typing as a screening method for lymphoid malignancies in daily routine practice

BACKGROUND

The major diagnostic role of peripheral lymphocyte subset typing is to distinguish between malignant and reactive conditions.

METHODS

The present study evaluates the screening efficacy of flow cytometric lymphocyte subset typing for the presence of a lymphoid malignancy. Four hundred samples were analyzed with a combination of anti-T-, B-, and natural killer (NK)-cell monoclonal antibodies.

RESULTS

Two hundred and twenty (55%) samples showed a normal distribution of lymphocyte subsets, 73 (18%) samples exhibited unspecific alterations of lymphocyte subsets, 19 (5%) samples exhibited a reactive phenotype typical of Epstein-Barr virus/cytomegalovirus (EBV/CMV) infection, and 88 (22%) samples expressed a phenotype suggestive of lymphoma. The most predictive independent factor of a lymphoma-specific phenotype was the absolute lymphocyte count (P = 0.0001, odds ratio 73.225). Seventy-eight percent of samples containing >/=4 x 10(9)/l lymphocytes and 2% of samples with lymphocyte counts <4 x 10(9)/l exhibited a lymphoma-specific phenotype. The specificity of the referring clinical comment was the second best predictor of a lymphoma-specific typing outcome (P = 0.0001, odds ratio 19.589). The independent predictive values of lymphocyte morphology and of relative lymphocyte counts were of borderline significance.

CONCLUSIONS

The use of flow cytometric lymphocyte subset typing as a diagnostic screening method for lymphoma should be restricted to cases of unexplained elevation of absolute lymphocyte counts with or without morphological atypias and to cases with definite clinical symptoms of lymphoma.

Pancreatic elastase 1 in stool: variations within one stool passage and individual changes from day to day

Concentration of fecal pancreatic elastase 1 has been claimed to be a highly sensitive and specific noninvasive test for exocrine pancreatic function. The aim of our study was to investigate variations in elastase concentration within one stool passage and from day to day. For the analysis of the variation of fecal elastase within one stool passage, we utilized 3 different samples collected from 8 patients. Further, we assessed the individual day to day variation of fecal elastase using stools collected on 3 consecutive days from 40 patients. For the determination of pancreatic elastase 1 in stool we used an ELISA kit. We found a relatively considerable variation of fecal elastase concentration within one stool passage (n = 8, mean CV = 22%, range 4.6-83.1%) and from day to day (n = 40; mean CV = 26%, range 2.4-61.1%). Therefore, we recommend routine analysis of more than 1 stool sample collected on different days for fecal elastase and to use a borderline area of +/- 25% of the recommended cut off of 200 micrograms/g stool for the diagnosis of pancreatic insufficiency.

Evaluation of four automated methods for determination of whole blood cyclosporine concentrations

Cyclosporine is a widely used and potent immunosuppressant drug with a narrow therapeutic index. Therefore, cyclosporine concentrations should be monitored closely. Various automated immunologic methods for cyclosporine whole blood determinations are available. Two new methods, fluorescence polarization immunoassay (FPIA) for the AxSYM by Abbott Laboratories, Chicago, IL, and the cloned enzyme donor immunoassay (CEDIA) by Boehringer Mannheim, Mannheim, Germany, have been introduced. In addition, Dade Behring improved its enzyme multiplied immunoassay (EMIT) assay. The present study evaluated all 3 new methods in comparison with high-performance liquid chromatography (HPLC) and the FPIA for the TDx analyzer. We measured whole blood cyclosporine concentrations of 179 samples obtained from 127 patients after kidney, bone marrow, heart-lung, and liver transplantation. All 4 automated immunologic methods can be used for routine measurement of cyclosporine whole blood concentrations. Disadvantages, such as higher cross-reactivity (Abbott TDx, CEDIA) or a limited linearity range (EMIT), are accompanied by advantages, such as a high precision (Abbott TDx) or an easy sample handling procedure (CEDIA). Information presented in this article should help to find the most adequate cyclosporine method for each medical laboratory.

Activation of endothelium by immunotherapy with interleukin-2 in patients with malignant disorders

Treatment with intravenous recombinant human interleukin-2 (rh IL-2) is frequently accompanied by the capillary leak syndrome and disturbances of the coagulation system. Although the exact mechanisms are still not fully understood, the involvement of the endothelium is proven. This investigation aimed to elucidate more precisely the role of the endothelium in the generation of IL-2-based side-effects. In nine tumour patients receiving intravenous rh IL-2, parameters characterizing endothelial cell activation as well as activation of the coagulation system were evaluated. A significant increase of the circulating endothelial leucocyte adhesion molecule-1 (cELAM-1) and the vasoconstrictor peptide endothelin-1 (ET-1) was observed (P<0.05), indicating activation of endothelial cells. The simultaneous increase of tissue-plasminogen activator and plasminogen activator inhibitor type-1 during therapy (P<0.05) corroborated this observation. A decrease in platelet count parallelled by an increase of fibrin degradation products, the prolongation of partial thromboplastin time, and the decrease of fibrinogen (P<0.05) suggested the development of disseminated intravascular coagulation (DIC), induced by activated endothelium and intensified by transient hepatic failure. We concluded that activation of the endothelium mediated by IL-2 was accompanied by a loss of endothelial integrity and capillary leak. The activated endothelium can trigger DIC via activation of the coagulation cascade. The increased ET-1 might act as an endogenous counter-regulator of the disadvantageous haemodynamic side-effects induced by IL-2.

Fosinopril decreases levels of soluble vascular cell adhesion molecule-1 in borderline hypertensive type II diabetic patients with microalbuminuria

Angiotensin converting enzyme inhibitors (ACE-I) are a mainstay for the treatment of heart failure, and of diabetic microalbuminuria. Recently ACE-I have been found to decrease plasma levels of circulating vascular cell adhesion molecule-1 (cVCAM-1) in patients with congestive heart failure. As increased cVCAM-1 levels are pathognomonic for diabetics with microangiopathy, we investigated the effects of ACE-I on plasma levels of cVCAM-1, intercellular adhesion molecule (cICAM-1), and cE-selectin in microalbuminuric diabetics. In addition, the effects of ACE-I on plasma levels of plasminogen activator inhibitor (PAI-1) and of tissue plasminogen activator (TPA) were studied. Fosinopril (10 mg/day) was administered over 12 weeks to 11 microalbuminuric patients with non-insulin-dependent diabetes mellitus (NIDDM). As expected, baseline plasma concentrations of cE-selectin, cICAM-1, and cVCAM-1 were markedly higher in patients than in healthy control subjects (n = 82; P < .001). PAI-1 levels in NIDDM were similar to those in control subjects, whereas TPA levels were about 25% lower in patients than in control subjects (P = .013). Serum levels of cVCAM-1 decreased by -19% (CI: -25% to -13%) after treatment with fosinopril (P = .003) and were no longer different from those of the control group. In contrast, plasma levels of cE-selectin, cICAM-1, PAI-1, and TPA were unaffected. As expected microalbuminuria decreased by -44% (CI: -65 to -22; P = .004). In conclusion, fosinopril lowered cVCAM-1 levels along with microalbuminuria in NIDDM. This may represent a novel mechanism of action of ACE-I in diabetes-associated endothelial dysfunction. Whether decreased VCAM-1 expression is responsible for the observed reduction in microalbuminuria, deserves further investigation.

Stochastic simulation of ligand-receptor interaction

We have developed an algorithm for the stochastic simulation of ligand-receptor interactions based on 10(4)-10(5) fictitious binding sites. Reversible receptor binding was simulated by alternate random selection of sites, the first selection resulting in "occupation" if the selected site was "free," the second selection resulting in "dissociation" if the selected site was "occupied." We show that the mathematical formalism of mass action kinetics is predicted on purely statistical grounds. The model was extended by the introduction of two further selections, simulating a conformational change in the ligand-receptor complex ("receptor isomerization model"). All random selections were gauged separately by "probability barriers," taking the place of macroscopic kinetic rate constants. Simulation of gradual increases and gradual decreases of the fraction of occupied fictitious binding sites in the receptor isomerization model, using various combinations of "rate constants," resulted in biexponential time dependencies, in agreement with predictions from the integrated rate equations. Stochastic simulation of molecular processes is a powerful and versatile technique, providing the researcher with a means of studying mechanisms of increasing complexity.

Hemostasis activation in patients undergoing brain tumor surgery

Patients undergoing brain tumor surgery are at high risk for the occurrence of a thromboembolic event. To identify a laboratory marker suitable for risk estimation the authors studied the perioperative time pattern of routine coagulation parameters and the specific hemostasis activation marker D-dimer in 28 consecutive patients at high risk (11 patients with glioma and eight patients with meningioma) and low risk (nine patients with metastases) for thromboembolism, as previously reported. As is typical during major surgery, most of the routine parameters declined, probably because of hemodilution, and recovered postoperatively to values higher than baseline, probably because of an acute-phase reaction. On Days 2 and 7 after surgery no difference in the routine parameters was recorded between patients at high (meningioma and glioma) and low risk (metastasis). The level of D-dimer was elevated at baseline in patients with metastasis, indicating a hemostatic hyperactivity that is usual in cancer patients. During surgery a marked increase in D-dimer levels occurred in patients with meningioma and glioma (pre- and postoperative median 90/2000 and 100/1020 ng/ml, respectively), but the increase was less pronounced in patients with metastasis (320/660 ng/ml). Postoperatively, D-dimer declined in patients with metastases to lower than preoperative levels (Day 7, 270 ng/ml); in patients with meningioma or glioma, however, D-dimer levels remained elevated until Day 7 (450 and 200 ng/ml, respectively). These results indicate that levels of D-dimer correlate with the reported high risk for thromboembolism in patients with meningioma and glioma, and D-dimer should be evaluated for its use in estimating individual risk and the efficiency of its use in the control of prophylactic treatment.

Hemostasis activation in patients undergoing brain tumor surgery

Patients undergoing brain tumor surgery are at high risk for the occurrence of a thromboembolic event. To identify a laboratory marker suitable for risk estimation the authors studied the perioperative time pattern of routine coagulation parameters and the specific hemostasis activation marker D-dimer in 28 consecutive patients at high risk (11 patients with glioma and eight patients with menigioma) and low risk (9 patients with metastases) for thromboembolism, as previously reported. As is typical during major surgery, most of the routine parameters declined, probably because of hemodilution, and recovered postoperatively to values higher than baseline, probably because of an acute-phase reaction. On Days 2 and 7 after surgery no difference in the routine parameters was recorded between patients at high (meningioma and glioma) and low risk (metastases). The level of D-dimer was elevated at baseline in patients with metastases, indicating a hemostatic hyperactivity that is usual in cancer patients. During surgery a marked increase in D-dimer levels occurred in patients with meningioma and glioma (pre- and postoperative median 90/2000 and 100/1020 ng/ml, respectively), but the increase was less pronounced in patients with metastases (320/660 ng/ml). Postoperatively, D-dimer declined in patients with metastases to lower levels than preoperatively (Day 7, 270 ng/ml); in patients with meningioma or glioma, however, D-dimer levels remained elevated until Day 7 (450 and 200 ng/ml). These results indicate that levels of D-dimer correlate with the reported high risk for thromboembolism in patients with meningioma and glioma, and D-dimer should be evaluated for its use in estimating individual risk and the efficiency of its use in the control of prophylactic treatment.

Elevated concentrations of circulating adhesion molecules and their association with microvascular complications in insulin-dependent diabetes mellitus

To better understand potential associations of circulating adhesion molecules (cAMs) with diabetic microangiopathy, circulating serum concentrations of intercellular adhesion molecule-1 (cICAM-1), vascular cell adhesion molecule-1 (cVCAM-1), and endothelial leukocyte adhesion molecule-1 (cELAM-1) were determined in patients with insulin-dependent diabetes mellitus (IDDM) (n = 70) presenting with varying degree of metabolic control and status of diabetic late complications, and were compared with age-matched healthy subjects (n = 70) in a cross-sectional study. Concentrations of cICAM-1 and cVCAM-1 were elevated in IDDM vs. age-matched controls (cICAM-1: 276 +/- 71 vs. 212 +/- 57 ng/mL; P < 0.0001; cVCAM-1: 781 +/- 245 vs. 615 +/- 151 ng/mL; P < 0.0001), whereas cELAM-1 did not differ between the groups (cELAM-1: 50 +/- 25 vs. 46 +/- 23 ng/mL, P = 0.31). The levels of cVCAM-1 were more markedly elevated in IDDM patients with diabetic retinopathy (n = 32) than in those without (n = 38) (cVCAM-1: 848 +/- 281 vs. 724 +/- 197 ng/mL, P < 0.05), as well as in patients with micro- or macroalbuminuria (n = 10) vs. those without (n = 60) (cVCAM-1: 947 +/- 256 ng/mL vs. 753 +/- 234 ng/mL, P < 0.05), whereas no difference in cICAM-1 and cELAM-1 was apparent regarding the clinical status of diabetic microangiopathy. No correlations were found between hemoglobin A1e and cAMs in the individual subgroups of patients and healthy subjects. Interestingly, however, low density lipoprotein cholesterol correlated with cVCAM-1 (r = 0.38, P = 0.03) in IDDM patients with diabetic microangiopathy (n = 33), but not in healthy controls or patients without microangiopathy (n = 37). Analyzing the pooled data of diabetic patients and healthy subjects (n = 140), concentrations of cICAM-1 were markedly related to cVCAM-1 (r = 0.45, P < 0.0001) and cELAM-1 (r = 0.31, P < 0.0002), whereas cVCAM-1 was related less to cELAM-1 (r = 0.19, P = 0.03), respectively. We conclude that, irrespective of actual metabolic control, serum concentrations of cICAM-1 and cVCAM-1 but not cELAM-1 are elevated in patients with IDDM, reflecting ongoing endothelial cell stimulation and leukocyte activation. More specifically, more marked elevation of cVCAM-1 may even hint at clinically manifest diabetic microangiopathy.

Comparison of four rapid D-Dimer tests for diagnosis of pulmonary embolism

Aim of this study was to evaluate rapid D-Dimer tests for their utility in diagnosis of acute pulmonary embolism (PE). Tests were performed in 183 consecutive pats referred for lung scanning because of clinically suspected PE. According to lung scans and the clinical course of disease 19 pats were classified to have PE with high probability and 164 with low probability. An ELISA (Agen) was used as the D-Dimer reference, and results compared with those of a turbidimetric (Behring), an immunofiltration (Nycomed), latex plasma and whole blood agglutination test (both Agen). There was a poor correlation between the turbidimetric test and either the ELISA (R = 0.38) and immunofiltration test (R = 0.49). The correlation between the ELISA and immunofiltration test was better (R = 0.73). The qualitative latex and whole blood agglutination tests were better fitted to ELISA since positive and negative samples were overlapped only in their 1st and 9th percentiles of ELISA values. The whole blood agglutination test was positive at lower ELISA values than the latex test. The highest sensitivity test for PE was the immunofiltration test (95%) (500ng/mL cut-off), followed by the turbidimetric method (89%) (66ng/mL), the ELISA (89%) (300ng/mL), the whole blood test (88%) and the latex test (68%). Specificity was lowest for the immunofiltration test (33%), intermediate (57-65%) for the turbidimetric and whole blood agglutination tests, and highest for the ELISA and the most insensitive latex test (76/77%). The whole blood assay was found to be the fastest and most suitable for bed site testing but weak positives were difficult to read. The immunofiltration test required plasma preparation but allowed objective semiquantitation of results. The less rapid turbidimetric assay was fully quantitative and objective.

Evaluation of a total hematology analysis system (Sysmex HS-430). Benefits for large laboratories by reducing manual work load and optimizing screening efficacy for pathologic samples

In this study, the authors evaluated a closed tube total hematology analysis system, Sysmex HS-430 (HS), which consists of two automated hematology analyzers, Sysmex NE-8000, the reticulocyte analyzer, Sysmex R-3000, and a slide preparation unit integrated in an automated sample transport system (TOA Medical Electronics, Kobe, Japan). The suitability of the system was compared with a conventional hematology system (CS) consisting of two single standing Coulter STKS analyzers (Hialeah, FL), one automated reticulocyte counter Sysmex R-1000, and the manual blood smear preparation. Evaluation was performed following the concept suggested by the Austrian-German societies for Clinical Chemistry and Laboratory Medicine that includes the evaluation of personnel supply. Eight consecutive series with a total of 4,896 samples were analyzed on both systems. Evaluation revealed that the analysis time per series was 238 minutes on the HS-430 and 359 minutes on the CS. The mean analyzer down times because of technical reasons were 36 minutes on the HS and 32 minutes on the CS. The down time because of "nontechnical" reasons was 31 minutes on the HS-430, but 173 minutes on the CS, which was mainly because of discontinuous sample loading of analyzers of the CS. The average direct technical time effort for complete blood cell count (CBC) analyses, reticulocyte counts, and blood smear preparations per series was 23 minutes on the HS and 245 minutes on the CS. In summary, these data show that an automated system like the HS-430 saves 222 minutes of manual activities arising in a large routine hematology laboratory with a mean throughout of 612 samples per day. Furthermore, the system improves intralaboratory turnaround times, avoids human errors by automated sample identification, and guarantees more safety for laboratory staff by minimizing the contact with potential biohazards.

[MR-pool: the "Vienna blend". An interactive computer-assisted teaching system for MRI]

Advances in the field of computer technology have facilitated the development of computer-assisted instruction. In this paper we present an interactive computer-based MR teaching system for education in radiology. Our program contains 120 teaching files. Various MR sequences can be displayed and compared to conventional X-ray images, CT, angiography and scintigraphy. Using a text field, additional clinical and diagnostic hints are offered. This teaching file can be easily upgraded and distributed on CD-ROM. Furthermore, we compare computer-assisted teaching in general to other conventional instruction media.

Quantitative measurement of HbA1c by an immunoturbidimetric assay compared to a standard HPLC method

Determination of hemoglobin A1c (HbA1c) is one of the most important monitoring procedures for long-term control of diabetes mellitus. Several analytical methods have been developed for the measurement of glycohemoglobin (GHb). Those most frequently used are ion-exchange chromatography for HbA1c and affinity chromatography for total GHb. In this study, a new turbidimetric immunoassay for HbA1c (Boehringer Mannheim, Germany) was evaluated that was performed on a Hitachi 911 clinical chemistry analyzer (Boehringer Mannheim). Good linearity in the range of 5% to 15% HbA1c, within-run and between-run coefficients of variation ranging from 2.4% to 5.9% were obtained. Results of 179 diabetic and nondiabetic patients showed good correlation to those of a routine HPLC method (r = 0.96). In addition, HbA2, HbS, and HbF in samples from nondiabetic patients were not detected by the immunoturbimetric assay and the "labile" HbA1c fraction (Schiff base) did not interfere with the new test.

Effects of 17 beta-estradiol on circulating adhesion molecules

The effects of 17 beta-estradiol (E2) on the serum levels of the circulating endothelial-leukocyte, intercellular, and vascular adhesion molecules [ELAM-1, ICAM-1 (CD54), and VCAM-1] were evaluated in healthy male volunteers after single im injection of 10 mg E2 valerate. In addition, a time course of the effects of E2 on circulating adhesion molecules (AMs), cortisol serum levels, differential blood counts, and surface expression of the lymphocyte function-associated antigen-1 (CD11a/CD18), CD3, CD4, CD19, and CD25 on leukocytes was studied in another group of volunteers. A 5% decrease in circulating ICAM-1 (P = 0.045 vs. placebo) was found when a single time point (96 h after E2 injection) was studied. However, this decrease was smaller than the intrasubject (day to day) variability observed, and there was no consistent and time-dependent effect of E2 on circulating AMs. Circulating neutrophils increased 2.3-fold over baseline after E2 treatment (P = 0.0008 vs. placebo). The mean coefficients of variation for the intrasubject (day to day) and intersubject variability of circulating AMs were between 5.4-7.5% and 20-29%, respectively. Our findings indicate that the effect of E2 on circulating AMs is not distinguishable from the intrasubject variability observed after placebo treatment. Thus, an effect of E2 on adhesion molecules is unlikely to contribute to the antiatherogenic-cardioprotective effect of E2. The pronounced E2-mediated increase in neutrophils deserves further studies to elucidate its (patho-)physiological implications.

Cholinergic markers in ALS spinal cord

We analyzed binding sites for quinuclidinyl benzilate (QNB) and hemicholinium-3 (HC-3) by quantitative slice autoradiography and the activities of choline acetyltransferase (ChAT) and acetylcholinesterase (AChE) in spinal cord of 5-7 patients with amyotrophic lateral sclerosis (ALS). In the ventral horn, QNB binding sites were markedly reduced (38% of controls; P less than 0.001), whereas HC-3 binding sites were only moderately affected (76%, P less than 0.01). Losses in cholinergic marker enzymes were inconsistent. The loss of muscarinic binding sites in the ventral horn was the most reliable cholinergic disease marker in ALS.