The Norwegian CDI-III as an assessment tool for lexical and grammatical development in preschoolers

Parental report instruments are a non-invasive way to assess children's language development and have proved to give both valid and reliable results when used with children under the age of 2;6 (and in some cases up to 3). In this study we examine the newly developed Norwegian edition of a language assessment tool for older preschoolers: MacArthur-Bates Communicative Development Inventory III (CDI-III), investigating whether this parental report tool can be used for assessing the language of monolingual Norwegian-speaking children between 2;6 and 4 years. NCDI-III results for 100 children between 2;6 and 4.0 are presented. All sections were significantly intercorrelated. All sections except Pronunciation showed growth with age. Internal consistency was measured both in terms of Cronbach's alpha and corrected item-scale correlation, and the results are discussed considering features of item difficulty distribution. Methodological considerations are discussed, as well as implications relevant both for possible later revisions and for CDI-III adaptations to new languages.

Adenosine elicits an eNOS-independent reduction in arterial blood pressure in conscious mice that involves adenosine A2A receptors

AIMS

Adenosine plays an important role in the regulation of heart rate (HR) and vascular reactivity. However, the mechanisms underlying the acute effect of adenosine on arterial blood pressure in conscious mice are unclear. Therefore, this study investigated the effect of the nucleoside on mean arterial blood pressure (MAP) and HR in conscious mice.

METHODS

Chronic indwelling catheters were placed in C57Bl/6J (WT) and endothelial nitric oxide synthase knockout (eNOS(-/-)) mice for continuous measurements of MAP and HR. Using PCR and myograph analysis, involvement of adenosine receptors was investigated in human and mouse renal blood vessels.

RESULTS

Bolus infusion of 0.5 mg kg(-1) adenosine elicited significant transient decreases in MAP (99.3 ± 2.3 to 70.4 ± 4.5 mmHg) and HR (603.2 ± 18.3 to 364.3 ± 49.2 min(-1)), which were inhibited by the A(2A) receptor antagonist ZM 241385. Activation of adenosine A(2A) receptors with CGS 21680 (0.02 mg kg(-1)) caused a significant reduction in MAP from 99.6 ± 1.2 to 73.1 ± 3.6 mmHg accompanied by tachycardia (610.5 ± 9.3 to 677.5 ± 9.5 min(-1)). The reduction in MAP observed after adenosine or CGS 21680 administrations was not significantly different in WT and eNOS(-/-) mice. In isolated human and mouse intrarenal arteries, adenosine caused a relaxation dependent on A(2A) adenosine receptor activation. A(2A) receptors were present in both human and mouse arteries whereas A(1) and A(2B) receptors were only present in mouse arteries.

CONCLUSION

In conclusion, acute adenosine administration and selective stimulation of adenosine A(2A) receptors results in an immediate, transient eNOS-independent reduction in MAP. A(2A) receptor activation causes relaxation of human and mouse arteries.

Uridine adenosine tetraphosphate affects contractility of mouse aorta and decreases blood pressure in conscious rats and mice

AIM

in the anaesthetized rat, uridine adenosine tetraphosphate (Up(4) A) is a circulating, endothelium-derived vasoconstrictor presumably operating as such in un-anaesthetized animals. The present study investigated the in vivo effects of Up(4) A in conscious mice and rats, and its direct vascular effects in the mouse aorta in vitro.

METHODS

in vivo, Up(4) A was given as step-up infusion at rates of 8-512 nmol min(-1) kg(-1) for 30 min periods in chronically catheterized rodents. In vitro, the effect of Up(4) A on rings of mouse aortae mounted in a myograph was tested.

RESULTS

high doses of Up(4) A (mice: 512 nmol min(-1) kg(-1) ; rats: 128 nmol min(-1) kg(-1) ) caused hypotension (99 (+/-)4 to 64 7(+/-) mmHg and 114 (+/-) 3 to 108 (+/-) 3 mmHg, respectively, both P < 0.01). In rats, Up(4) A significantly decreased sodium excretion by >75% and potassium excretion by approximately 60% without significant changes in urine flow. Exposure of phenylephrine-contracted rings to increasing concentrations of Up(4) A elicited contraction at 10(-7) and 10(-6) molL(-1) (18 ± 2% and 76 (+/-) 16% respectively); unexpectedly, 10(-5) molL(-1) caused a biphasic response with a contraction (19 6(+/-)2%) followed by a relaxation (-46 (+/-) 6%). No relaxation was observed when the concentration was increased further. Bolus exposure to 10(-5) molL(-1) of Up(4) A caused contraction (+80 (+/-) 2%). Added successively to untreated vessels, increasing concentrations of Up(4) A (10(-7) -10(-5) molL(-1) ) induced a biphasic response of contraction followed by relaxation.

CONCLUSION

up(4) A has direct biphasic effects on vascular smooth muscle of the mouse aorta but vasoconstriction dominates at low concentrations. In conscious rodents, step-up infusions of Up(4) A elicit hypotension and electrolyte retention.

Intracellular signalling pathways in the vasoconstrictor response of mouse afferent arterioles to adenosine

AIMS

Adenosine causes vasoconstriction of afferent arterioles of the mouse kidney through activation of adenosine A(1) receptors and Gi-mediated stimulation of phospholipase C. In the present study, we further explored the signalling pathways by which adenosine causes arteriolar vasoconstriction.

METHODS AND RESULTS

Adenosine (10(-7) M) significantly increased the intracellular calcium concentration in mouse isolated afferent arterioles measured by fura-2 fluorescence. Pre-treatment with thapsigargin (2 microM) blocked the vasoconstrictor action of adenosine (10(-7) M) indicating that release of calcium from the sarcoplasmic reticulum (SR), stimulated presumably by IP(3), is involved in the adenosine contraction mechanism of the afferent arteriole. In agreement with this notion is the observation that 2 aminoethoxydiphenyl borate (100 microM) blocked the adenosine-induced constriction whereas the protein kinase C inhibitor calphostin C had no effect. The calcium-activated chloride channel inhibitor IAA-94 (30 microM) inhibited the adenosine-mediated constriction. Patch clamp experiments showed that adenosine treatment induced a depolarizing current in preglomerular smooth muscle cells which was abolished by IAA-94. Furthermore, the vasoconstriction caused by adenosine was significantly inhibited by 5 microM nifedipine (control 8.3 +/- 0.2 microM, ado 3.6 +/- 0.6 microM, ado + nifedipine 6.8 +/- 0.2 microM) suggesting involvement of voltage-dependent calcium channels.

CONCLUSION

We conclude that adenosine mediates vasoconstriction of afferent arterioles through an increase in intracellular calcium concentration resulting from release of calcium from the SR followed by activation of Ca(2+)-activated chloride channels leading to depolarization and influx of calcium through voltage-dependent calcium channels.

Vasoconstrictor and vasodilator effects of adenosine in the mouse kidney due to preferential activation of A1 or A2 adenosine receptors

The present experiments in mice were performed to determine the steady-state effects of exogenous adenosine on the vascular resistance of the whole kidney, of superficial blood vessels, and of afferent arterioles. The steady-state effect of an intravenous infusion of adenosine (5, 10, and 20 microg/min) in wild-type mice was vasodilatation as evidenced by significant reductions of renal and superficial vascular resistance. Resistance decreases were augmented in adenosine 1 receptor (A1AR) -/- mice. Renal vasodilatation by the A2aAR agonist CGS 21680A [2-p-(2-carboxyethyl)phenethyl-amino-5'-N-ethylcarboxamido-adenosine hydrochloride] (0.25, 0.5, and 1 microg/kg/min) and inhibition of adenosine-induced relaxation by the A2aAR antagonist ZM-241385 [4-(2-[7-amino-2-(2-furyl)[1,2,4]triazolo[2,3-a][1,3,5]triazin-5-yl-amino]ethyl)phenol] (20 mg/kg) suggests that the reduction of renovascular resistance was largely mediated by A2aAR. After treatment with Nomega-nitro-L-arginine methyl ester (L-NAME) adenosine was unable to alter superficial blood flow and resistance significantly indicating that adenosine-induced dilatation is NO-dependent. Absence of a dilatory effect in endothelial nitric-oxide synthase (NOS) -/- mice suggests endothelial NOS as the source of NO. When infused into the subcapsular interstitium, adenosine reduced superficial blood flow through A1AR activation. Adenosine (10(-7) M) constricted isolated perfused afferent arterioles when added to the bath but not when added to the luminal perfusate. Luminal adenosine caused vasoconstriction in the presence of L-NAME or the A2AR antagonist 3,7-dimethyl-1-(2-propynyl)xanthine. Our data show that global elevation of renal adenosine causes steady-state vasorelaxation resulting from adenosine 2 receptor (A2AR)-mediated generation of NO. In contrast, selective augmentation of adenosine around afferent arterioles causes persistent vasoconstriction, indicating A1AR dominance. Thus, adenosine is a renal constrictor only when it can interact with afferent arteriolar A1AR without affecting the bulk of renal A2AR at the same time.

Anagrelide treatment in 52 patients with chronic myeloproliferative diseases

In this retrospective multi-centre study, we report our experience with anagrelide in the treatment of thrombocytosis in patients with chronic myeloproliferative diseases. Our study included 52 patients (age 20-78 years). The initial anagrelide dose was, in general, 0.5 mg once daily and mean maintenance dosage was 1.7 mg/day. The overall response rate was 79% including 75% complete remission and 4% partial remission. Forty-two patients (81%) had adverse effects and in 29% of the study population, the adverse effects necessitated cessation of anagrelide. The most common adverse effect was moderate anaemia (50%). Two patients experienced erectile dysfunction which has been described only once previously in association with anagrelide treatment. One patient progressed to acute leukaemia. However, this patient had been pre-treated with two potentially leukaemogenic drugs and had only been in short-term treatment with anagrelide. Furthermore, a total of 13 events were recorded. More than 25% of these events occurred in patients with platelet counts between 400 and 600 x 10(9)/l and almost 40% of all events occurred in patients with platelet counts above 400 x 10(9)/l. This observation supports the hypothesis that aggressive control of thrombocytosis to a platelet count <400 x 10(9)/l might reduce the number of thrombohaemorrhagic events. Anagrelide is safe and effective in reducing the platelet counts, but a high proportion of the patients discontinue treatment because of the adverse effects of the drug.

Rapid non-genomic effects of aldosterone on rodent vascular function

The main role of aldosterone is to maintain body sodium homeostasis by promoting salt reabsorption in the collecting ducts of the kidney. In the cardiovascular system, aldosterone may be harmful in a number of disease states by inducing fibrosis and vascular dysfunction. The present review describes novel results from several laboratories, which show that aldosterone also has beneficial effects in the cardiovascular system by stimulating the production of nitric oxide (NO) from the endothelium. The effect of aldosterone is seen within minutes, and is not inhibited by blockers of gene transcription, thus pointing to a non-genomic mechanism. Furthermore, this potentially beneficial effect is observed at low physiological concentrations of aldosterone (0.1-10 pm). The effect is mediated by the classical mineralocorticoid receptor, and it involves heat shock protein 90, phosphatidylinositol (PI)-3 kinase, protein kinase B, endothelial nitric oxide synthase, and liberation of NO. It is proposed that in healthy individuals with a functioning NO system, the detrimental effects of aldosterone on cardiovascular function are balanced by activation of the potentially beneficial effect of NO. However, in situations with endothelial dysfunction, such as congestive heart failure and hypertension, the negative effects of aldosterone are unopposed and inhibition of aldosterone is warranted.

Plasma renin in mice with one or two renin genes

AIM

In the present study we have investigated whether the presence of a second renin gene exerts an overriding influence on plasma renin such that mice with two renin genes have consistently higher renin levels than mice with only one renin gene.

METHODS

Plasma renin was determined as the rate of angiotensin I generation using a radioimmunoassay (RIA) kit with (plasma renin concentration, PRC) or without (plasma renin activity, PRA) the addition of purified rat angiotensinogen as substrate.

RESULTS

In male 129SvJ, DBA/2 and Swiss Webster mice, strains possessing both Ren-1 and Ren-2, PRC (ng Ang I mL(-1) h(-1)) averaged 178 +/- 36, 563 +/- 57 and 550 +/- 43 while PRA was 2.9 +/- 0.5, 3.6 +/- 0.8 and 7.8 +/- 1.2. In male C57BL/6, C3H and BALB/c mice that express only Ren-1, PRC averaged 426 +/- 133, 917 +/- 105 and 315 +/- 72, and PRA was 3.4 +/- 1.0, 6.9 +/- 1.7 and 4.5 +/- 1.2. In the two renin gene A1AR-/- mice compared with the one renin gene A1AR+/+, PRC averaged 538 +/- 321 and 415 +/- 159 while PRA averaged 3.2 +/- 1.1 and 4.4 +/- 1.4 ng Ang I mL(-1) h(-1). Aldosterone levels showed no significant differences between one renin (C57BL/6, C3H and BALB/c) and two renin (129SvJ, DBA/2 and Swiss Webster) gene mice. Furthermore, by quantitative real-time polymerase chain reaction (RT-PCR) we found no correlation between the number of renin genes and whole kidney renin mRNA levels from one and two renin gene mice.

CONCLUSION

Our data show that baseline plasma renin is not systematically higher in mice with two renin genes than in one renin gene mice. Thus, the presence of a second renin gene does not seem to be a major determinant of differences in PRC between different mouse strains.

Rapid Inhibition of Vasoconstriction in Renal Afferent Arterioles by Aldosterone

Aldosterone has been suggested to elicit vessel contraction via a nongenomic mechanism. We tested this proposal in microdissected, perfused rabbit renal afferent arterioles. Aldosterone had no effect on internal diameter in concentrations from 10(-10) to 10(-5) mol/L, but aldosterone abolished the ability of 100 mmol/L KCl to induce vascular contraction. The inhibitory effect of aldosterone was observed from 1 pmol/L. The inhibitory effect was significant after 5 minutes and maximal after 20 minutes and was fully reversible. Actinomycin D (10(-6) mol/L) prolonged the effect of aldosterone. The effect was abolished by the mineralocorticoid receptor antagonist spironolactone (10(-7) mol/L) but not by the glucocorticoid receptor antagonist mifepristone (10(-6) mol/L). The K+-mediated increase of intracellular calcium concentration in afferent arterioles was not affected by aldosterone. Mineralocorticoid receptor was detected by reverse transcription-polymerase chain reaction and immunohistochemistry in rat renal vasculature and rabbit endothelial cells. Inhibition of phosphatidylinositol (PI)-3 kinase with LY 294002 (3x10(-6) mol/L) restored sensitivity to K+ in the presence of aldosterone, and afferent arterioles were immunopositive for PI-3 kinase subunit p110alpha. Inhibition of NO formation by L-NAME (10(-4) mol/L) or inhibition of soluble guanylyl cyclase with 1H-(1,2,4)Oxadiazolo[4,3-a]quinoxaline-1-one restored K+-induced vasoreactivity in the presence of aldosterone. Similar to aldosterone, the NO donor sodium nitroprusside inhibited K+-induced vascular contraction. Geldanamycin (10(-6) mol/L), an inhibitor of heat shock protein 90, abolished aldosterone-induced vasorelaxation. We conclude that aldosterone inhibits depolarization-induced vasoconstriction in renal afferent arterioles by a rapid nongenomic mechanism that is initiated by mineralocorticoid receptor activation and involves PI-3 kinase, protein kinase B, and heat shock protein 90-mediated stimulation of NO generation.

Differential expression of T- and L-type voltage-dependent calcium channels in renal resistance vessels

The distribution of voltage-dependent calcium channels in kidney pre- and postglomerular resistance vessels was determined at the molecular and functional levels. Reverse transcription-polymerase chain reaction analysis of microdissected rat preglomerular vessels and cultured smooth muscle cells showed coexpression of mRNAs for T-type subunits (Ca(V)3.1, Ca(V)3.2) and for an L-type subunit (Ca(V)1.2). The same expression pattern was observed in juxtamedullary efferent arterioles and outer medullary vasa recta. No calcium channel messages were detected in cortical efferent arterioles. Ca(V)1.2 protein was demonstrated by immunochemical labeling of rat preglomerular vasculature and juxtamedullary efferent arterioles and vasa recta. Cortical efferent arterioles were not immunopositive. Recordings of intracellular calcium concentration with digital fluorescence imaging microscopy showed a significant increase of calcium in response to K(+) (100 mmol/L) in isolated afferent arterioles (140+/-25%) and in juxtamedullary efferent arterioles (118+/-21%). These calcium responses were attenuated by the L-type antagonist calciseptine and by the T-type antagonist mibefradil. Intracellular calcium increased in response to K(+) in cortical efferent arterioles (21+/-9%). Mibefradil and nickel concentration dependently blocked K(+)-induced contraction of perfused rabbit afferent arterioles. Calciseptine blocked the contraction mediated by K(+) (EC(50) 8x10(-14)). S-(-)-Bay K 8644 had no effect on vascular diameter in the afferent arteriole. We conclude that voltage-dependent L- and T-type calcium channels are expressed and of functional significance in renal cortical preglomerular vessels, in juxtamedullary efferent arterioles, and in outer medullary vasa recta, but not in cortical efferent arterioles.

Localization of prostaglandin E(2) EP2 and EP4 receptors in the rat kidney

We investigated the localization of cAMP-coupled prostaglandin E(2) EP2 and EP4 receptor expression in the rat kidney. EP2 mRNA was restricted to the outer and inner medulla in rat kidney, as determined by RNase protection assay. RT-PCR analysis of microdissected resistance vessels and nephron segments showed EP2 expression in descending thin limb of Henle's loop (DTL) and in vasa recta of the outer medulla. The EP4 receptor was expressed in distal convoluted tubule (DCT) and cortical collecting duct (CCD) in preglomerular vessels, and in outer medullary vasa recta. Butaprost, an EP2 receptor-selective agonist, dose dependently raised cAMP levels in microdissected DTL and outer medullary vasa recta specimens but had no effect in EP2-negative outer medullary collecting duct segments. Dietary salt intake did not alter EP2 expression in the kidney medulla. These results suggest that PGE(2) may act in the resistance vessels and in the DTL and DCT-CCD segments as a paracrine, cAMP-dependent regulator of vascular resistance and tubular transport, respectively.

[Clinical use of recombinant human thrombopoietin. Status and perspectives]

Thrombopoietin (TPO) is primarily produced by hepatocytes and regulates the production and differentiation of megakaryocytes and platelets in the bone marrow. The endogenous TPO level is increased when the megakaryocyte count is low, and high in aplastic anaemia and after myeloablative chemotherapy. TPO is cloned and manufactured by a recombinant technique for clinical use. Treatment with recombinant human TPO (rhTPO) after intensive chemotherapy may reduce the need for platelet transfusions. Administration of granulocyte colony-stimulating factor in combination with rhTPO has enhanced the mobilisation and harvest product of haematopoietic stem cells. Whether rhTPO is effective in the treatment of the myelodysplastic syndrome, aplastic anaemia, and other conditions with bone marrow insufficiency (including AIDS) is not yet known. In liver cirrhosis, the endogenous TPO level rapidly increases after liver transplantation. Accordingly, substitution of rhTPO may be indicated in advanced liver failure complicated by thrombocytopenia and bleeding.

The alpha(1G)-subunit of a voltage-dependent Ca(2+) channel is localized in rat distal nephron and collecting duct

The molecular type and localization of calcium channels along the nephron are not well understood. In the present study, we assessed the distribution of the recently identified alpha(1G)-subunit encoding a voltage-dependent calcium channel with T-type characteristics. Using a RNase protection assay, alpha(1G)-mRNA levels in kidney regions were determined as inner medulla >> outer medulla congruent with cortex. RT-PCR analysis of microdissected rat nephron segments revealed alpha(1G) expression in the distal convoluted tubule (DCT), in the connecting tubule and cortical collecting duct (CT+CCD), and inner medullary collecting duct (IMCD). alpha(1G) mRNA was expressed in the IMCD cell line mIMCD-3. Single- and double-labeling immunohistochemistry and confocal laser microscopy on semithin paraffin sections of rat kidneys by using an anti-alpha(1G) antibody demonstrated a distinct labeling at the apical plasma membrane domains of DCT cells, CT principal cells, and IMCD principal cells.

Vascular smooth muscle cells express the alpha(1A) subunit of a P-/Q-type voltage-dependent Ca(2+)Channel, and It is functionally important in renal afferent arterioles

In the present study, we tested whether the alpha(1A) subunit, which encodes a neuronal isoform of voltage-dependent Ca(2+) channels (VDCCs) (P-/Q-type), was present and functional in vascular smooth muscle and renal resistance vessels. By reverse transcription-polymerase chain reaction and Southern blotting analysis, mRNA encoding the alpha(1A) subunit was detected in microdissected rat preglomerular vessels and vasa recta, in cultures of rat preglomerular vascular smooth muscle cells (VSMCs), and in cultured rat mesangial cells. With immunoblots, alpha(1A) subunit protein was demonstrated in rat aorta, brain, aortic smooth muscle cells (A7r5), VSMCs, and mesangial cells. Immunolabeling with an anti-alpha(1A) antibody was positive in acid-macerated, microdissected preglomerular vessels and in A7r5 cells. Patch-clamp experiments on aortic A7r5 cells showed 22+/-4% (n=6) inhibition of inward Ca(2+) current by omega-Agatoxin IVA (10(-8) mol/L), which in this concentration is a specific inhibitor of P-type VDCCs. Measurements of intracellular Ca(2+) in afferent arterioles with fluorescence-imaging microscopy showed 32+/-9% (n=10) inhibition of the K(+)-induced rise in Ca(2+) in the presence of 10(-8) mol/L omega-Agatoxin IVA. In microperfused rabbit afferent arterioles, omega-Agatoxin IVA inhibited depolarization-mediated contraction with an EC(50) of 10(-17) mol/L and complete blockade at 10(-14) mol/L. We conclude that the alpha(1A) subunit is expressed in VSMCs from renal preglomerular resistance vessels and aorta, as well as mesangial cells, and that P-type VDCCs contribute to Ca(2+) influx in aortic and renal VSMCs and are involved in depolarization-mediated contraction in renal afferent arterioles.

[Circulatory support with the mechanical heart, "HeartMate"]

Treatment with the mechanical heart, HeartMate, has been introduced in Denmark. Short-term circulatory support can be obtained by intraaortic balloon counterpulsation, an external centrifugal pump and the total artificial heart. Long-term circulatory support can be established by treatment with the HeartMate. The principle of the mechanical heart is simple--a pump is implanted in parallel to the existing heart and connected to external, portable batteries. The patient quickly improves and is brought in an optimal state for transplantation. A few patients have been able to omit the subsequent heart transplantation. The patient's own heart improved during the treatment and the native heart functioned again after the system was explanted. The main complications during treatment are bleeding, infection, thromboembolic events and systemic failure. Permanent, fully implantable mechanical circulatory pumps are under development--which may herald the beginning of a whole new era for treatment of cardiac failure.

[Economic aspects of implementation of the mechanical heart, "HeartMate"]

This economic evaluation was performed to assess the economic consequences for society and for the Danish health care sector of replacing the traditional treatment with Biomedicus assist device with The Mechanical Heart, HeartMate, as a bridge to transplantation for patients with severe cardiac failure. A cost-effectiveness analysis showed that the use of HeartMate is more cost-effective than the use of Biomedicus assist device. Using HeartMate one life-year gained costs DKK 225,000. Using Biomedicus one life-year gained costs DKK 270,000. The use of HeartMate results in an additional expenditure of DKK 615,000 per patient. By this additional expenditure the patients gain 3.6 extra life-years on average. The marginal expenditure by replacing the Biomedicus treatment with HeartMate is DKK 170,000 per extra life-year gained.

Human immunodeficiency virus-associated malignant lymphoma in eastern Denmark diagnosed from 1990-1996: clinical features, histopathology, and association with Epstein-Barr virus and human herpesvirus-8

The clinicopathological features of human immunodeficiency virus (HIV)-associated lymphoma were investigated in a retrospective study of 85 adult patients in eastern Denmark diagnosed during the period 1990-1996. The possible pathogenetic role of Epstein-Barr virus (EBV) and human herpesvirus 8 (HHV-8) in these tumours was also studied. Seventy patients (82%) presented with extranodal disease and 26 (31%) had CNS involvement at diagnosis. Diffuse large cell B-cell lymphoma was the most frequent histological subtype, comprising 65 of 79 cases available for microscopic re-evaluation (82%) and including 20 of 23 evaluable patients with CNS lymphoma (87%). EBV RNA was demonstrated by in situ hybridization in 51 of 65 evaluable tumours (79%) and in 14 of 16 cases (88%) with CNS-lymphoma. Three cases showed a T-cell phenotype. The presence of HHV-8 DNA was analysed by PCR in 32 cases. A strong band consistent with tumour cell infection was detected in only one case, weaker bands being seen in 4 cases. None of these patients had primary effusion lymphomas. In conclusion, Danish AIDS-related lymphomas are of predominantly high-grade B-cell type with extranodal localization and atypical presentation. Our results provide further evidence that EBV plays a major role in the pathogenesis of large cell AIDS-related lymphoma, whereas HHV-8 does not appear to contribute significantly to the development of solid lymphomas in this group of patients.

Exocytosis and endocytosis in juxtaglomerular cells

The cellular events related to secretion of renin are not well understood. Here we review some of the evidence that has led to the current understanding of renin secretion as a process that involves exocytosis as the predominant mode of secretion. This is based on the observation of occasional fusion events between secretory granules and cell membrane and measurement of intermittent secretion of renin from single afferent arterioles, with a renin content of each secretion episode that corresponds to the renin content of one secretory granule. More recently it has been demonstrated that the afferent arterioles lose a large number of renin granules after acute stimulation without changing the average granular volume. Current electrophysiological techniques have now permitted direct measurements of cell membrane capacitance in juxtaglomerular (JG) cells as a measure of net addition (exocytosis) or removal (endocytosis) of membrane material. With this technique we have shown that cAMP, which is a vasodilator and stimulates renin secretion, enhances net exocytosis at low concentrations, while at higher concentrations membrane retrieval processes are also stimulated. We suggest that both exocytosis and endocytosis are regulated processes in the JG-cells and both may be important for the long-term control of renin secretion at the single cell level.

Fatal virus-associated hemophagocytic syndrome associated with coexistent chronic active hepatitis B and acute hepatitis C virus infection

A 28-year-old man was admitted to our department with intermittent fever, hepatosplenomegaly and pancytopenia. Liver parameters and serum ferritin were markedly elevated. Bone marrow biopsy showed hypocellularity, histiocytic hyperplasia, and hemophagocytosis consistent with a virus-associated hemophagocytic syndrome (VAHS). There was serological evidence of chronic active hepatitis B and acute hepatitis C virus infection. The patient died despite aggressive immunosuppressive and supportive treatment. Autopsy revealed signs of acute viral hepatitis with cholestasis. Histiocytes engaged in hemophagocytosis were observed in bone marrow and spleen. The condition was interpreted as VAHS associated with chronic active hepatitis B and acute hepatitis C virus infection. To our knowledge this is the first report of a hemophagocytic syndrome in that setting.

Do blood levels of neuron-specific enolase and S-100 protein reflect cognitive dysfunction after coronary artery bypass?

BACKGROUND

Neuron-specific enolase (NSE) and S-100 protein have been used as markers for major brain damage. Cognitive dysfunction after cardiac surgery represents subtle brain damage that is detected by neuropsychological testing. We hypothesised that blood levels of NSE and S-100 protein would increase after coronary artery bypass surgery and that the change in blood level would correlate with the change in cognitive function.

METHODS

We included 35 elderly patients undergoing coronary artery bypass surgery. Neuropsychological testing was performed before surgery and postoperatively at discharge from hospital and after 3 months using a neuropsychological test battery. Serum levels of NSE and S-100 protein were measured before surgery and postoperatively after 24 h and 48 h.

RESULTS

Serum level of both NSE and S-100 protein increased significantly 24 and 48 h after coronary artery bypass. Only the increase in NSE after 24 h was found to correlate with the degree of cognitive dysfunction at discharge from hospital. The increase in S-100 protein after 24 h correlated significantly with the duration of cardiopulmonary bypass.

CONCLUSION

NSE seems to be a useful blood marker for early cognitive dysfunction after coronary artery bypass surgery.

Chloride regulates afferent arteriolar contraction in response to depolarization

-Renal vascular reactivity is influenced by the level of dietary salt intake. Recent in vitro data suggest that afferent arteriolar contractility is modulated by extracellular chloride. In the present study, we assessed the influence of chloride on K+-induced contraction in isolated perfused rabbit afferent arterioles. In 70% of vessels examined, K+-induced contraction was abolished by acute substitution of bath chloride. Consecutive addition of Cl- (30, 60, 80, 100, 110, and 117 mmol/L) restored the sensitivity to K+, and half-maximal response was observed at 82 mmol/L chloride. The calcium channel antagonist diltiazem (10(-6) mol/L) abolished K+-induced contractions. Bicarbonate did not modify the sensitivity to chloride. Norepinephrine (10(-6) mol/L) induced full contraction in depolarized vessels even in the absence of chloride. Iodide and nitrate were substituted for chloride with no inhibitory effect on K+-induced contraction. Approximately 30% of the vessels constricted in response to K+ in the absence of chloride. This response was reversibly blocked by the alpha1-blocker phentolamine (PA) (10(-5) mol/L) and, with PA present, the dependence on chloride was similar to the above series. The results show that K+-induced contraction of smooth muscle cells in the afferent arteriole is highly sensitive to chloride, whereas neurotransmitter release and ensuing contraction is not dependent on chloride. Thus, there are different activation pathways for depolarizing vasoconstrictors and for the sympathetic nervous system in renal afferent arterioles. This could be of physiological relevance for the resetting of afferent arteriolar sensitivity during changes in salt intake.

Photon statistics of amplified spontaneous emission noise in a 10-Gbit/s optically preamplified direct-detection receiver

We verify experimentally, over a dynamic range of 55 dB in the probability distribution, that the amplified spontaneous emission noise of the 0's from an optically preamplified receiver is degenerate Bose-Einstein distributed. Using the noise parameters extracted from the experiment, we are able to predict the sensitivity of a 10-Gbit/s direct-detection receiver.

Drug-specific characteristics of thrombocytopenia caused by non-cytotoxic drugs

OBJECTIVE

To analyse drug-specific clinical characteristics and to investigate the possible influence of epidemiological and other factors on thrombocytopenia induced by selected non-cytotoxic drugs.

METHODS

A retrospective analysis of drug-induced thrombocytopenia reported to the Danish Committee on Adverse Drug Reactions. One-hundred and ninety-two cases induced by the most frequently reported drugs were included and analysed from data extracted from report forms and discharge summaries.

RESULTS

Pronounced drug-specific differences in the clinical appearance of thrombocytopenia were registered. Severe thrombocytopenia with haemorrhagic manifestations was reported following exposure to gold salts, non-steroid anti-inflammatory drugs, sulfonamide antibiotics, cinchona alkaloids and vaccines. Valproic acid-induced thrombocytopenia was dose-dependent. The differences were primarily determined by the drug itself and also by its usage pattern. No specific patient-related factor responsible for the heterogeneity of the clinical appearance of the adverse reaction was identified. Factors related to the physician, such as monitoring recommendations or level of attention towards the adverse reaction, seemed to be of little significance.

CONCLUSION

The primary determinant of the clinical characteristics of thrombocytopenia induced by noncytotoxic drugs is the offending drug.

[Virus-associated hemophagocytic syndrome. Diagnosis and treatment]

Virus-associated haemophagocytic syndrome (VAHS) is a rare disease characterized by fever, splenomegaly, cytopenia and histiocytic proliferation with haemophagocytosis in the reticuloendothelial system. The clinical course of VAHS can be dramatic and the prognosis is often poor. The pathogenesis of VAHS is not well understood. Many believe that viral infection provokes an abnormal immune response in predisposed individuals leading to hyperactivation of Th1 helper cells, macrophage proliferation and secretion of large amounts of cytokines. The resultant hypercytokinaemia may be responsible for the clinical and biochemical manifestations of VAHS. In this article the clinical features, presumed pathogenesis, diagnostic criteria and treatment of VAHS are discussed.

Primary gastrointestinal non-Hodgkin's lymphoma in adults: a population-based clinical and histopathologic study

OBJECTIVES

To analyse the clinical course and the histopathology of primary gastrointestinal non-Hodgkin's lymphoma (GI-NHL) in adult patients and to investigate a possible impact of Helicobacter pylori.

DESIGN/SETTING

Retrospective study of all adult patients in Copenhagen county diagnosed during a 6-year period with NHL.

SUBJECTS

A total of 55 patients with GI-NHL diagnosed during the period from 1985 to the end of 1990.

RESULTS

Twenty-eight patients had primary lymphoma in the stomach, 14 in the small intestine, 11 in the large intestine and two patients had multifocal involvement. The dominant presenting symptoms were abdominal pain, weight loss, diarrhoea, constipation and fatigue. Acute emergency problems such as severe haemorrhage or perforation at initial presentation were unusual. According to the revised European-American lymphoma (REAL) classification, diffuse large B-cell lymphoma was the most frequent histologic subtype comprising 53% of the cases. Helicobacter pylori infection was documented in 15 of 25 evaluable patients (60%) with gastric lymphomas and was not associated with any specific histological subtype. Endoscopic procedures and barium X-rays were the diagnostic approaches with highest sensitivity. In total, 30 patients (58%) achieved complete remission, 10 (19%) achieved partial remission, and 12 (23%) did not respond to treatment. The overall 5 year survival rate was 0.36 without statistically significant difference between the histological subtypes. Likewise the presence of Helicobacter pylori did not affect survival.

CONCLUSION

Primary GI-NHL is a heterogeneous disease entity with considerable therapeutic controversies. No specific clinical or histological phenotype was associated with the presence of Helicobacter pylori.

[Multiorgan failure and peripheral gangrene following a superficial dog bite]

One case of life-threatening disease caused by the gram-negative rod Capnocytophaga canimorsus and a similar case without verification are presented. The severe diseases developed two to three days after a superficial dog bite and were characterized by acute development of septicaemia and fulminant disseminated intravascular coagulation syndrome. Moreover, the cases were complicated by renal failure, respiratory insufficiency and peripheral gangrene.

[Bacterial infections as complications of dog bites]

Dog bites may result in serious bacterial infections with e.g. the gram-negative rods Capnocytophaga canimorsus and Pasteurella multocida. Human disease caused by these microorganisms can be complicated by acute development of septicaemia and/or meningitis followed by disseminated intravascular coagulation syndrome, peripheral gangrene and renal failure. The mortality of C. canimorsus septicaemia is about 23-31%. These severe infections are most often reported in immunocompromised patients and occur a few days after the bite. By reviewing the literature it is concluded that the broadest prophylactic coverage is obtained by amoxicillin/clavulanic acid and that antibiotic prophylaxis should be given to all immunocompromised patients experiencing a dog bite. Moreover, prophylactic treatment should be initiated for all patients with greater penetrating wounds and those involving the hands.

Primary gastrointestinal non-Hodgkin's lymphoma in adults: a population-based clinical and histopathologic study

OBJECTIVES

To analyse the clinical course and the histopathology of primary gastrointestinal non-Hodgkin's lymphoma (GI-NHL) in adult patients and to investigate a possible impact of Helicobacter pylori.

DESIGN/SETTING

Retrospective study of all adult patients in Copenhagen county diagnosed during a 6-year period with NHL.

SUBJECTS

A total of 55 patients with GI-NHL diagnosed during the period from 1985 to the end of 1990.

RESULTS

Twenty-eight patients had primary lymphoma in the stomach, 14 in the small intestine, 11 in the large intestine and two patients had multifocal involvement. The dominant presenting symptoms were abdominal pain, weight loss, diarrhoea, constipation and fatigue. Acute emergency problems such as severe haemorrhage or perforation at initial presentation were unusual. According to the revised European-American lymphoma (REAL) classification, diffuse large B-cell lymphoma was the most frequent histologic subtype comprising 53% of the cases. Helicobacter pylori infection was documented in 15 of 25 evaluable patients (60%) with gastric lymphomas and was not associated with any specific histological subtype. Endoscopic procedures and barium X-rays were the diagnostic approaches with highest sensitivity. In total, 30 patients (58%) achieved complete remission, 10 (19%) achieved partial remission, and 12 (23%) did not respond to treatment. The overall 5 year survival rate was 0.36 without statistically significant difference between the histological subtypes. Likewise the presence of Helicobacter pylori did not affect survival.

CONCLUSION

Primary GI-NHL is a heterogeneous disease entity with considerable therapeutic controversies. No specific clinical or histological phenotype was associated with the presence of Helicobacter pylori.

[AIDS-related non-Hodgkin lymphomas. Clinical picture and prognosis]

Patients infected with HIV are at high risk for developing non-Hodgkin's lymphomas (NHL). HIV-associated NHLs seem to be increasing in number. They consist of two major histopathological subtypes originating from B-lymphocytes: Burkitt-like lymphomas and diffuse large cell lymphomas. There seems to be a clear association between Epstein-Barr virus (EBV) and immunoblastic lymphomas (a subtype of large cell lymphomas) in AIDS patients. Patients with AIDS often have widespread disease at presentation and frequent involvement of extranodal sites (CNS, liver, bone marrow, the digestive tract and skin). The treatment of NHL in AIDS patients is controversial due to their poor response to chemotherapy as well as a tendency to develop severe hematological toxicity. Factors with a negative influence on the prognosis are: Extranodal localisation of NHL including CNS, CD4 count below 200 x 10(6)/l, platelet count below 130 x 10(9)/l, widespread symptoms of disease, presence of EBV in the lymphoma and immunoblastic histology.

[A lump in the breast. A rare first symptom of ovarian cancer]

The breast is an uncommon site for metastasis from extramammary primaries. A 43-year-old woman presented with a lump in the left breast. A tumour with atypical microcalcifications was seen on the mammogram. Needle aspiration cytology revealed adenocarcinoma cells. The final histological diagnosis was papillary adenocarcinoma with psammoma bodies, probably secondary to an ovarian carcinoma. A bilateral carcinoma of the ovaries was subsequently diagnosed and treated. A mammary tumour with an atypical growth pattern and the absence of in situ carcinoma should always prompt the pathologist to considering the possibility of a metastatic tumour even though this is a rare occurrence. Earlier recognition of metastatic tumours to the breast may result in initiation of appropriate therapy and will preclude unnecessary surgical procedures.

The treatment of fractures of the ring and little metacarpal necks. A prospective randomized study of three different types of treatment

A total of 105 patients with fracture of the neck of the ring or little metacarpal bone were randomized to receive three different types of treatment: dorso-ulnar plaster-of-Paris from the proximal interphalangeal joint to elbow; functional brace around the wrist; or elastic bandage. Twenty patients (19%) had to be excluded for different reasons leaving 85 patients in the study. The remaining patients were examined after 4 weeks and 3 months. There was no difference in patient satisfaction between the three different types of treatment. The functional brace was in our opinion superior to the two other types of treatment: the patients had as little pain as the patients treated with plaster-of-Paris and less pain than patients treated with elastic bandage. Patients treated with a functional brace mobilized as fast as patients treated with elastic bandage and faster than patients treated with plaster-of-Paris. Based on these findings, we recommend the functional brace for treatment of fractures of the neck of the ring and little metacarpals.

Hematopoietic growth factors for the treatment of myelodysplastic syndromes

Administration of recombinant human granulocyte colony-stimulating factor (rhG-CSF), rh granulocyte-macrophage colony-stimulating factor (rhGM-CSF) or rh interleukin-3 (rhIL-3) effectively stimulate and expand marrow myelopoiesis resulting in a dose-dependent increment of peripheral blood neutrophils in most patients with myelodysplasias (MDS). Clinical outcome with fewer infections have been reported in a few studies using rhG-CSF or rhGM-CSF, including a large randomized, controlled trial with rhGM-CSF. Clinical effective stimulation of megakaryopoiesis and erythropoiesis are however infrequent. Recently, rh erythropoietin (rhEpo) has been used to overcome the ineffective erythropoiesis in MDS to reduce transfusions needed. However, the efficiency has been low in most studies with marked differences in response rates. The most impressive clinical results were obtained in patients with milder forms of MDS combined with low prestudy endogenous S-Epo levels. The possible synergistic effect of combining rhEpo with rhG-CSF or rhGM-CSF has been studied with erythropoietic response rates of about 40%. The safety of the cytokine administration seems acceptable with no significant stimulation of leukemic myelopoiesis and subsequent progression into overt acute myeloid leukemia. In conclusion, combinations of hematopoietic growth factors may be of clinical benefit in some patients with MDS. However, due to the cost and unpredictable clinical outcome there is a need for extended laboratory research to understand the functional defects of MDS stem cells and progenitors.

CD34+ megakaryoblastic leukaemic cells are CD38-, but CD61+ and glycophorin A+: improved criteria for diagnosis of AML-M7?

The aim of this flow cytometry study in acute megakaryoblastic leukaemia (AML-M7) was to describe the membrane phenotype of CD34+ progenitor subsets and compare these with the phenotypes expressed by other AML FAB types. Following conventional histopathological diagnosis mononuclear cells from bone marrow and blood were examined in seven patients with AML-M7 and compared with results from 26 sequential patients with AML-M0 to AML-M6. The CD34+ subsets in AML-M7 patients differed from that of patients with AML-M0 to AML-M6 as the CD34+ CD61+ and the CD34+ Glycophorin A+ subsets were median 31% and 20%, respectively, compared to 4% and 2% in the AML-M0 to AML-M6 (P = 0.0005). Only 1% of the CD34+ progenitors were CD34+ CD38+ in AML-M7 compared to 72% in other AML subtypes (P < 0.000). These findings suggest that the CD34+ cell compartment in AML-M7 consists of early lineage-specific progenitors. In conclusion, flow cytometry analysis of CD34+ subsets may improve the diagnostic safety in AML-M7 and consequently the prognostic significance of immunophenotyping in acute leukaemia.

Early experience with the Norwood procedure

The improved results of the Norwood procedure have recently stimulated its widespread adoption in many centres. Since 1993, 19 infants with hypoplastic left heart syndrome or similar conditions underwent a first-stage Norwood procedure. Circulatory arrest time was significantly reduced by using a modified repair of the aortic arch. The early mortality rate was 31.5% (n = 6). The addition of CO2 to the inspired gas mixture resulted in less early postoperative instability. Nine patients have subsequently undergone bidirectional cavopulmonary shunt and one fenestrated total cavopulmonary connection. Overall there have been five late deaths, two as result of failure of cavopulmonary operations. All the eight survivors are presently in good condition. One is awaiting bidirectional cavopulmonary shunt and the other seven total cavopulmonary connection. This early experience encourages the continued offering of the Norwood procedure to patients with hypoplastic left heart syndrome or its variants. Increasing experience with the perioperative care and a more careful evaluation before cavopulmonary operations may determine further improvement in the outcome.

Is the arterial switch operation still a challenge in small centers?

OBJECTIVE

In the last years, major changes as regards timing for operation, surgical technique, and perioperative care determined a great improvement in the arterial switch operation (ASO) allowing excellent mid-term results in a few leading centers. This stimulated the widespread adoption of ASO as procedure of choice for transposition of the great arteries (TGA), even in small institutions. We reviewed our early experience with ASO in an attempt to evaluate its safety in a small center.

METHODS

Since April 1992, 39 consecutive patients underwent TGA repair by ASO in our department. There were 27 patients with simple TGA, 8 with TGA and VSD and 4 with Taussig-Bing heart and aortic coarctation. Median age and weight at operation were 7 days and 3.5 kg, respectively. Neonatal repair was performed in 34 patients. In accordance with the Planché coronary classification, type I was encountered in 21 patients, type II in 4 and type III in 14. Several modifications of the original technique were used, mainly regarding coronary relocation, pulmonary artery reconstruction and approaches for associated VSD closure and aortic arch repair.

RESULTS

Early mortality was 2.6% (n = 1), the only operative death being related to unsatisfactory coronary relocation. Since modified ultrafiltration was adopted, mean ICU stay decreased from 5 +/- 4 days (n = 21) to 2 +/- 1 days (n = 17) (P < 0.05). Three patients required reoperation for residual ASD and/or VSD closure. There were no late deaths. After a mean follow-up of 26 +/- 15 months all survivors are thriving and are currently asymptomatic.

CONCLUSIONS

Although this series is rather small, most of the major coronary anomalies and complex anatomic associations were encountered. This experience suggests that neonatal repair of TGA by ASO can be safely accomplished even in small centers. Modified ultrafiltration appears to improve the early outcome of neonates undergoing ASO.

Drug-induced thrombocytopenia: clinical data on 309 cases and the effect of corticosteroid therapy

OBJECTIVE

To analyse the clinical picture and the course of thrombocytopenia induced by non-cytotoxic drugs, and to evaluate a possible therapeutic effect of corticosteroids.

METHODS

A retrospective analysis of 309 well-documented cases of drug-induced thrombocytopenia was performed. Data sources were reports from the files of the Danish Committee on Adverse Drug Reactions and discharge summaries.

RESULTS

The median length of exposure to the offending drug, before development of thrombocytopenia, was 21 days. The median nadir platelet count was 11 x 10(9).l-1, and 74% of the patients had clinical haemorrhage. Bone marrow examination generally showed hyperplastic reactive changes and a variable number of megakaryocytes. Slight leucopenia was present in 6% of the patients and 16% were anaemic. Complete recovery was seen in 87% of cases, with a median recovery rate of 8 days. The standard treatment was corticosteroids, which were administered in 53% of the cases. No difference in recovery between corticosteroid-treated and untreated patients was observed. No other clinical parameter affected the recovery rate. The mortality rate due to haemorrhage was 3.6%.

CONCLUSION

Thrombocytopenia induced by non-cytotoxic drugs is characterised by heterogeneous clinical picture and recovery is generally rapid. Although corticosteroids seem inefficient, we still recommend that severe symptomatic cases of drug-induced thrombocytopenia are treated as idiopathic thrombocytopenic purpura due to the difficult initial differentiation between the two conditions.

Thrombocytopenia induced by noncytotoxic drugs in Denmark 1968-91

OBJECTIVES

To analyse the distribution of noncytotoxic drugs reported as cause of thrombocytopenia during a 24-year period, and to draw attention to the most commonly involved drugs in modern clinical practice.

DESIGN/SETTING

Retrospective study of spontaneous case reports from the Danish reporting system on adverse drug reactions.

SUBJECTS

A total of 309 critically reviewed cases of drug-induced thrombocytopenia reported during the period from 1968 to the end of 1991.

RESULTS

Sodiumaurothiomalate and the combination sulfamethoxazole with trimethoprim were the most commonly reported single drugs, and nonsteroid anti-inflammatory drugs were the most frequently reported category of drugs. A pronounced shift in the spectrum of causal drugs was observed due to the introduction of new drugs and alterations in drug consumption. At present, valproic acid and measlesmumps-rubella vaccine are most numerously reported. The still-growing list of thrombocytopenia-inducing agents contained 110 different drugs. At present, 20% of reported cases concern drugs not previously registered as causing thrombocytopenia in Denmark. Twenty-five per cent of all cases were caused by drugs which appeared only sporadically in the material.

CONCLUSIONS

The spectrum of drugs reported as causing drug-induced thrombocytopenia is broadening and changing progressively, reflecting changes in drug consumption. The most frequently reported drugs at present are valproic acid and measlesmumps-rubella vaccine.

Short-term rhG-CSF priming before chemotherapy does mobilize blood progenitors but does not prevent chemotherapy induced myelotoxicity: a randomized study of patients with non-Hodgkin's lymphomas

The aim of this study was to evaluate the efficacy, safety and toxicity of short-term priming with recombinant human granulocyte colony-stimulating factor (rhG-CSF) immediately after diagnosis but before combination chemotherapy (CHOP) for non-Hodgkin's lymphomas. Of fourteen patients entering the study, seven received five days subcutaneous injection of rhG-CSF (5 micrograms/kg/day) before CHOP (CSF-group), and seven were treated with CHOP alone (control group). Blood samples were studied before and on days 1-5 during rhG-CSF priming as well as twice weekly after treatment. The number of blood and bone marrow progenitors was identified by clonogenic growth day 7, 14 and 21 of GM-CFU in semisolid medium. Blood absolute neutrophil counts increased in all rhG-CSF primed patients. The expansion of marrow myelopoiesis resulted in increased myeloid:erythroid ratios, increased bone marrow cellularity and increased numbers of myeloid progenitors both in the blood as well as the marrow. Chemotherapy induced neutropenia developed on day 9-12 in all patients independent of myeloid growth factor priming. However, neutropenia appeared earlier in the cytokine primed group (P = .0038). Five patients in the CSF-group and three patients in the control group were hospitalized with neutropenic fever, and septicemia was documented in three patients in the CSF-group. RhG-CSF induced expansion of myelopoiesis immediately before combination chemotherapy mobilized sufficient number of blood progenitors for apheresis but did not result in reduction of duration and degree of neutropenia in patients with newly diagnosed non-Hodgkin's lymphoma. Although the small number of patients prevents drawing definite conclusions, this time schedule for priming should be used with caution in the future due to an increased risk of hematologic toxicity.

Short-term in vivo priming of bone marrow haematopoiesis with rhG-CSF, rhGM-CSF or rhIL-3 before marrow harvest expands myelopoiesis but does not improve engraftment capability

In an attempt to optimize bone marrow grafts for autologous transplantation 37 sequential patients suffering from various haematological diseases were treated with either recombinant human granulocyte colony-stimulating factor (rhG-CSF) (n = 23) or granulocyte-macrophage CSF (rhGM-CSF) (n = 8) for 5 days or interleukin 3 (rhIL-3) (n = 6) for 10 days before marrow harvest. All patients were in marrow remission at study entry. In contrast to rhIL-3, the administration of rhG-CSF or rhGM-CSF caused a significant (P < 0.01) increase in blood absolute neutrophil count. An increased marrow cellularity and a rise in the myeloid:-erythroid ratio was seen in the majority of patients during therapy, and in the rhIL-3 treated group a rise in the number of megakaryocytes and increased marrow fibrosis was seen in most patients. Moreover, a median of 2-, 5- and 10-fold increase in myeloid progenitors was the result of short-term administration of rhIL-3, rhGM-CSF and rhG-CSF, respectively. However, transplantation performed with primed expanded marrow grafts did not significantly reduce the time to myeloid regeneration when compared to historical controls. In conclusion, the results demonstrate that short-term priming with haematopoietic cytokines before autologous bone marrow stem cell harvest is a safe procedure which effectively expands marrow haematopoisis without enhanced engraftment capability.

Priming and treatment with molgramostim (rhGM-CSF) in adult high-risk acute myeloid leukemia during induction chemotherapy: a prospective, randomized pilot study

In a randomized study of 18 adult patients with high-risk or advanced acute myeloid leukemia (AML) we investigated the effect of supplementing conventional induction chemotherapy with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF). For comparison, a historical control group of 90 patients treated for de novo AML with conventional chemotherapy during the previous period, 1984-1990, was also analyzed. Before induction chemotherapy, 10 patients were randomized to receiving rhGM-CSF, starting on day 1 to 3 before chemotherapy and continued for a maximum of 21 days after the start of induction treatment. Fatal complications and treatment outcome did not differ between the study groups and historical controls. Nor were there any differences between the groups in terms of hematological toxicity, e.g. time to three-lineage regeneration and need for supportive therapy. However, sequential weekly bone marrow examinations revealed a prolonged reduction of the relative number of myeloid (CD33-positive) marrow cells in the rhGM-CSF treated group. Although the small number of patients studied may not permit a definite conclusion, this randomized study did not demonstrate major beneficial effects of combining rhGM-CSF with standard induction chemotherapy in high-risk patients with AML.

Stimulation tests for the bone marrow neutrophil pool in malignancies

It has been known for decades that blood neutrophilia occurs after the administration of etiocholanolone, adrenocortical steroids, and endotoxins. Neutrophil leukocytosis in general may be due to several mechanisms such as increased stimulation of the myelopoiesis, increased release from the marrow, a shift from the marginated to the circulating pool (demargination), prolongation in the peripheral half-life, and decreased migration of neutrophils from the blood to the tissue. However, the principal cause of the neutrocytosis for each of the above mentioned agents is increased release of neutrophils from the bone marrow reserves. Since a sufficient reserve capacity is a prerequisite for optimal defenses against infections, the marrow response has been used to estimate the dose of chemotherapy expected to be tolerated without life-threatening neutropenia. However, none of the above "test substances" have gained widespread use due to adverse reactions or undesirable effects on neutrophil function. Recent progress in biotechnology has developed recombinant human (rh) hematopoietic growth factors ready for clinical use. Marrow myelopoiesis is stimulated by granulocyte colony-stimulating factor (rhG-CSF) and granulocyte-macrophage CSF (rhGM-CSF). The immediate effect, however, is mobilization of mature neutrophil granulocytes to the blood. Bone marrow cellularity seems to influence the neutrophil number mobilized during 24 hours by one subcutaneous injection of either rhG-CSF or rhGM-CSF. A recent pilot study has suggested such a "24 hour stimulation test" to predict severe neutropenia following cyclic chemotherapy. This concept is illustrated by two case reports. The "stimulation test" suggests that we may devise strategies to define patient subsets which may benefit from prophylactic growth factor administration during cyclic chemotherapy.

Unexpected hepatotoxicity after priming and treatment with molgramostim (rhGM-CSF) in acute myeloid leukemia during induction chemotherapy

The effect of supplementing induction chemotherapy with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) was studied in a randomized trial of 18 patients with acute myeloid leukemia (AML). Ten patients received rhGM-CSF, starting on day one to three before chemotherapy and continued for a maximum of 21 days after the start of induction treatment. Unexpected adverse effects of rhGM-CSF and chemotherapy combination included a transient decline in plasma coagulation factors II, VII, and X (5 of 5 patients) and an increased transcapillary escape rate of albumin (in 3 of 3 patients tested). The decline in coagulation factors was prevented in subsequent patients by prophylactic treatment with vitamin K. Although the small number of patients studied may not allow a definite conclusion, caution with regard to liver function should be shown in combining rhGM-CSF with intensive chemotherapy.

Short-term myeloid growth factor mediated expansion of bone marrow haemopoiesis studied by localized magnetic resonance proton spectroscopy

Previously we have shown that short-term myeloid growth factor priming of haemopoiesis prior to bone marrow harvest increased the yield of myeloid progenitors in the graft. The present study is intended to investigate the expansion of haemopoiesis by volume selective proton magnetic resonance spectroscopy (MRS). Six patients were treated with daily subcutaneous injections of recombinant human granulocyte colony-stimulating factor (rhG-CSF, n = 2) or granulocyte-macrophage colony-stimulating factor (rhGM-CSF, n = 4) for 5d before marrow harvest. MRS investigations were performed prior to treatment (day 0), day 5 and day 12. Spectroscopic examinations were performed with the stimulated echo acquisition mode (STEAM) method on a 1.5 T clinical whole-body imaging unit. A cubic volume of interest (VOI) was selected in the bone marrow of the left iliac bone. The patients responded with a rise in blood absolute neutrophil count from median 3.3 x 10(9)/l (range 1.3-7.3 x 10(9)/l) before to 15.6 x 10(9)/l (range 6.8-22.0 x 10(9)/l) after treatment. Concomitantly an increase in bone marrow cellularity and myeloid:erythroid ratios documented the stimulation of myelopoiesis. During priming, the light-density cell proliferation rate in marrow samples increased from median 21.9 (range 4.5-31) x 10(3) cpm to 54.7 (range 13.9-94) x 10(3) cpm and the total number of myeloid progenitors enumerated as day 7/14 GM-CFUs per volume aspirated marrow increased from median 11/8 x 10(3) (range 4.0-87.5/2.2-103.0) to 64/76 x 10(3) (range 28.4-1180.6/23.2-2850.0). MRS detected a significant increase in bone marrow 'relative water content' day 12, 1 week after myeloid growth factor treatment was stopped, from median 30.5% (range 16-45) to 79% (range 56-93). In parallel, haemopoiesis was detected in new areas of femur. In conclusion, the non-invasive MRS method may be a useful and reliable in vivo examination for expansion of haemopoiesis and a correspondent reduction of fat tissue in bone marrow after priming with recombinant human haemopoietic growth factors.

Effects of eltanolone on cerebral blood flow and metabolism in healthy volunteers

BACKGROUND

Eltanolone is a new steroid anesthetic agent that may prove to be useful in clinical practice. The aim of the present study was to evaluate the effects of eltanolone on cerebral blood flow (CBF) and metabolism in healthy volunteers.

METHODS

In a randomized cross-over study, eight subjects received intravenous eltanolone 0.6 mg/kg or its vehicle. CBF was measured with the intravenous xenon 133 technique before and 2 and 30 min after administration of eltanolone or vehicle. Cerebral metabolic rate for oxygen (CMRO2) was calculated as the product of the measured cerebral arteriovenous oxygen content difference and the blood flow.

RESULTS

CBF decreased from a baseline value of 64 +/- 4 (mean +/- SD) to 42 +/- 6 ml.100 g-1.min-1 at 2 min after administration of eltanolone and only 4% after vehicle. Cerebral oxygen consumption was 4.1 +/- 0.4 ml.100 g-1.min-1 at baseline and decreased to 2.7 +/- 0.6 at 2 min after eltanolone, whereas metabolism did not change significantly after administration of vehicle. At 30 min CBF and Cerebral metabolic rate for oxygen were 16 and 10% less than baseline values, respectively. Coupling between CBF and Cerebral metabolic rate for oxygen was preserved at all measurements. After administration of eltanolone a significant decrease in mean arterial blood pressure of 6 mmHg and a period of hypoventilation were observed. This did not occur after injection of vehicle.

CONCLUSIONS

Eltanolone was shown to reduce cerebral oxygen consumption and blood flow in healthy volunteers. Coupling between metabolism and flow was preserved.

[rhG-CSF treatment in cyclic neutropenia. Continuous versus intermittent rhG-CSF treatment in cyclic neutropenia]

Cyclic neutropenia is a stem-cell disorder characterized by regular 21-day cyclic fluctuations in the number of neutrophils in the blood and bone marrow. The neutropenic periods may be complicated by fever, stomatitis and severe infections. In this case report only daily continuous and later intermittent treatment with recombinant human granulocyte colony-stimulating factor (two micrograms/kg) administered subcutaneously effectively prevented recurrent infections.

Priming with recombinant human hematopoietic cytokines before bone marrow harvest expands in vivo and enhances ex vivo recovery of myeloid progenitors in short-term liquid cultures

BACKGROUND AND AIM

Short-term liquid marrow cultures (STLMC) are a potential source for autografting. We have previously shown that the quality of such grafts from transplantation candidates may be improved by hematopoietic cytokine support, especially if purified CD34-positive progenitors are cultured. The aim of this preclinical work was to quantitate ex vivo recovery of myeloid progenitors (colony-forming units-granulocyte/macrophage [CFU-GM]) in STLMC before and after short-term, in vivo treatment with recombinant human granulocyte colony-stimulating factor (rhG-CSF), granulocyte-macrophage colony-stimulating factor (rhGM-CSF), or interleukin-3 (rhIL-3).

EXPERIMENTAL SETUP

Twenty-two sequential patients in marrow remission for hematological malignancies and eligible for autologous marrow transplantation received rhG-CSF or rhGM-CSF for 5 days or rhIL-3 for 10 days before marrow harvest. Marrow samples before and after in vivo priming were studied for CFU-GM in pre- and post-STLMC.

RESULTS

After priming with rhG-CSF, rhGM-CSF, or rhIL-3, the number of isolated light-density cells increased nine-, six-, and two-fold, respectively. The total number of sampled (18 mL marrow) myeloid progenitors preculture (day 7/14 CFU-GM x 10(4) increased significantly from median 0.7/1.1 before to 37.3/26.7 after priming with rhG-CSF (n = 8) and from 5.6/3.4 before to 46.6/44.9 after priming with rhGM-CSF (n = 8) but remained unchanged (3.7/1.5 to 3.6/5.7) after priming with rhIL-3 (n = 6). The number of myeloid progenitors postculture (day 7/14 CFU-GM x 10(4) per 18 mL marrow) in cytokine-supported STLMC significantly increased from median 0.3/0.6 before to 7.0/5.3 after priming with rhG-CSF and from 1.9/1.6 before to 24.4/14.4 after priming with rhGM-CSF but remained unchanged (0.4/0.6 to 0.4/0.2) after priming with rhIL-3. Cytokine-primed and purified CD34+ marrow cells may be expanded in STLMC by a cytokine-driven differentiation into late myeloid progenitors and endstage cells.

CONCLUSION

In vivo priming of bone marrow cells by hematopoietic cytokines significantly increases the recovery of harvested pre- and postculture myeloid progenitors. During cytokine-supported STLMC, early myeloid progenitors may differentiate into a "very late" progenitor pool with a potential for fast marrow regeneration. The number of such progenitors in cytokine-supported short-term liquid cultures may be sufficient for fast myeloid engraftment and complete peripheral blood or marrow stem-cell support after high-dose chemotherapy.

Recombinant human granulocyte-macrophage colony-stimulating factor plus recombinant human erythropoietin may improve anemia in selected patients with myelodysplastic syndromes

The purpose of this study was to improve erythropoiesis in patients with anemia due to myelodysplastic syndromes (MDS). We treated 13 patients first with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) for 6 weeks, then with recombinant human erythropoietin (rhEpo) and rhGM-CSF for the next 12 weeks. Five patients had refractory anemia (RA), 3 refractory anemia with ringed sideroblasts (RAS), and 5 refractory anemia with excess of blasts (RAEB). Ten patients were transfusion-dependent at the time of inclusion. Eleven patients completed this phase II study. Five responded with an increase in hemoglobin level (3 patients) or a reduction in transfusion requirement (2 patients). We registered no response in the remaining 6 patients during treatment. Patients responding to combined treatment had relatively low concentrations of plasma Epo and plasma ferritin before treatment with rhEpo and a normal karyotype throughout the study. Long-term bone marrow cultures did not predict the response. Still, responders seemed to have a higher number of colony-forming progenitors than nonresponders. In conclusion, combined therapy with rhGM-CSF and rhEpo may stimulate hematopoiesis and correct or improve anemia in some patients with MDS.