945 Are Extended Criteria Donor Kidneys from 70 years-old and above Good Enough to Accept? A Single Centre Experience

Aim

As a result of increasing demand in recent years in organ donation and transplantation, the transplant community has been utilizing organs previously considered unsuitable for transplantation, including organs from extended criteria donors (ECD) and donors after circulatory arrest (DCD). This has led to higher rates of non-functioning and poorer outcomes, increasing the uncertainty when to accept or decline a donor organ. Our objective is to measure patient and graft outcomes of kidney transplants from ECDs aged 70 years and older.

Method

A retrospective study of 104 renal transplanted patients from ECDs between April 2010 and March 2014. Recipients referred to other centres were excluded from the study. Follow-up period was 7 years.

Results

At 7 years follow up, graft survival among recipients from ECDs older were 42.5%(n=17/40) while from ECDs younger were 58% (n=37/64) (P = 0.1594). Death censored graft survival (patient died with functioning graft). ECDs older death censored graft survival was 80% (n=32/40) and 82.8% (n=53/64) for ECDs younger (P = 0.7963).

Patient survival

70.3% of recipients from ECDs younger and 60% of recipients from ECDs older were alive at seven years post-transplant. (P = 0.2945).

Conclusions

There was no significant difference between the two cohorts in graft and patient survival. The use of kidneys from donors aged ≥70 years has yielded generally satisfactory results when compared to younger ECDs 50–69 years old donors.

Minimally invasive, video-assisted thyroidectomy: first experience from the United Kingdom

INTRODUCTION

Minimally-invasive, video-assisted thyroidectomy (MIVAT) was developed to reduce scarring/trauma associated with cervical incisions used in open thyroidectomy. Results from various centres have been published internationally but none from the UK. This study reports the first results from the UK and compares them with other centres. We also aim to compare the results of a single-surgeon experience in a small/moderately-sized hospital to those of larger tertiary centres.

PATIENTS AND METHODS

Retrospective analysis of a single surgeon experience in a district general hospital

RESULTS

The cohort was 55 patients (52 female, 3 male), mean age 48 years (range, 21-77 years) who had 64 MIVAT procedures. There were 49 hemithyroidectomies (HTs), 2 isthmusectomy, 4 total thyroidectomies (TTs) and 9 completion thyroidectomies (CTs) with median operating time of 86 min (IQR 66-110 min). Individual operating times were HT 85 min (IQR 60-110 min); TT 130 min (IQR 100-140 min) and CT 77 min (IQR 70-98 min). Median operating time was shorter in the second half of this series (76 min vs 92 min; P < 0.001). Length of stay was < 1 day in 92%. Conversions occurred in 6.3% with no haematoma or re-operation. Transient voice change was present in 7 (11%), permanent unilateral recurrent laryngeal nerve palsy in 2 (3%), and transient hypocalcaemia in 2 (3%).

CONCLUSIONS

The first results from the UK are similar to those of other international centres. A single-surgeon practice can obtain results comparable to larger tertiary centres provided there is sufficient case-load. MIVAT is safe and effective, but has a steep learning curve with rapid improvement observed within first 30 cases. Future studies should focus on objective assessment of scar/cosmesis and cost-effectiveness. MIVAT is an acceptable alternative to open surgery in highly selected patients.

Primary endoluminal stenting of transplant renal artery stenosis from cadaver and non-heart-beating donor kidneys

This study evaluated the efficacy of primary endovascular stenting in cases of transplant renal artery stenosis (TRAS) from cadaver and non-heart-beating donor kidneys. Patients with TRAS (n = 13) from a single-centre transplant population (n = 476) were treated by primary percutaneous angioplasty and endovascular stenting. The short-term efficacy of this intervention is demonstrated in terms of serum creatinine, glomerular filtration rate (GFR) biochemical, anti-hypertensive medications and mean arterial blood pressure control. Stenting for TRAS was performed in male (n = 10) and female (n = 3) recipients. The median age at transplantation was 55 yr (range 10-67 yr). Stenting occurred at a median duration of 410 d post-transplantation (range 84-5799 d). Mean serum creatinine (pre, 247 micromol/L; post, 214 micromol/L; p = 0.002), GFR (pre, 82.6 mL/min; post, 100.9 mL/min; p < 0.001), arterial blood pressure (pre, 104 mmHg; post, 97 mmHg; p = 0.036) and the number of anti-hypertensive medications required (pre, 3.4; post, 3.0; p = 0.002) showed significant improvement after post-endovascular therapy. There were no serious complications encountered. Primary endovascular stenting of TRAS produces a significant improvement in biochemical parameters of renal graft function and in blood pressure stability, with the benefit of low patient morbidity and single arterial puncture. Primary endoluminal stenting of TRAS is a safe and effective procedure for the treatment of TRAS.

Reassessing models of hepatic extraction

The aim of this investigation is to compare different mathematical models of the liver in the context of in vitro-in vivo correlation. We reanalyze drugs from the Houston reviews [1, 2], and compare the mathematical models. For the well-stirred model, a particular form of the distributed tubes model, and the dispersion model, fits are done to in vitro and in vivo intrinsic clearance data from microsomal and hepatocyte experiments. The distributed and dispersion models have decreased residuals as compared to the well-stirred model, but neither is to be clearly preferred over theother. It seems likely that drug-specific factors have a major impact on the quality of IVIVC correlations. While new experiments are needed to validate IVIVC models, our results indicate that improved correlation of in vitroand in vivo data is possible for high clearance drugs by using either a dispersion or distributed tube model rather than a well-stirred model.

Increased heterologous protein production in Aspergillus niger fermentation through extracellular proteases inhibition by pelleted growth

The dependence of filamentous fungal protease secretion on morphology was investigated by employing the recombinant Aspergillus niger strain AB4.1[pgpdAGLAGFP] which contains a gene for the glucoamylase-GFP (green fluorescence protein) fusion protein. Different inoculum levels were used to obtain different sizes of pellet or free mycelia. The extracellular protease activity of the cultures varied with the pellet size and decreased dramatically when the morphology was changed from free mycelia to pellets. The culture with an optimal pellet size of 1.6 mm was obtained from an inoculum of 4 x 10(6) spores/mL. It resulted in a specific protease activity of 158 units/L, only one-third of that in free mycelial growth, and a maximum specific GFP yield of 0.98 mg/g (cell mass) compared to 0. 29 mg/g for free mycelial growth with an inoculum of 10(7) spores/mL. The results indicate that this bioprocessing strategy can be effectively used to inhibit protease activity in filamentous fungal fermentation and thereby to enhance heterologous protein production.

The logic of causation and the risk of paralytic poliomyelitis for an American child

Beginning in January 1997, American immunization policy allowed parents and physicians to elect one of three approved infant vaccination strategies for preventing poliomyelitis. Although the three strategies likely have different outcomes with respect to prevention of paralytic poliomyelitis, the extreme rarity of the disease in the USA prevents any controlled comparison. In this paper, a formal inferential logic, originally described by Donald Rubin, is applied to the vaccination problem. Assumptions and indirect evidence are used to overcome the inability to observe the same subjects under varying conditions to allow the inference of causality from non-randomized observations. Using available epidemiologic information and explicit assumptions, it is possible to project the risk of paralytic polio for infants immunized with oral polio vaccine (1.3 cases per million vaccinees), inactivated polio vaccine (0.54 cases per million vaccinees), or a sequential schedule (0.54-0.92 cases per million vaccinees).

Stable production of a human growth hormone antagonist from CHO cells adapted to serum-free suspension culture

Human growth hormone (hGH) is a polypeptide with 191 amino acids and a molecular mass of 22 kDa. An hGH analogue was created with a single amino acid substitution (glycine[G] 120 to arginine[R]) in the third alpha-helix of the hGH molecule. This hGH analogue, named hGHG120R, was found to be an hGH antagonist. It is a parenteral drug candidate for treating conditions in which hGH levels are abnormally high, as found in type I diabetics. Previously, a genetically engineered anchorage-dependent mouse L cell line was created that produced and secreted hGHG120R in culture media (Dulbecco's modified Eagle's medium, DMEM) supplemented with 5% NuSerum IV. A multistep downstream process was developed to purify hGHG120R. The process consisted of cell clarification, salt precipitation, membrane ultrafiltration, size exclusion chromatography, reversed phase high-performance liquid chromatography, phase separation, and lyophilization. Here, we present the development of a superior eukaryotic system using a proper combination of genetic elements, cell line, and media formulation. This system is suitable for the large-scale production of the recombinant protein and is superior to the previously developed system in that it increases the specific production rate and at the same time eases the burden of the purification process, in both time and efficiency. Dihydrofolate reductase mutant (DHFR-) Chinese hamster ovary (CHO) cells were used that were stably transfected with an expression vector in which the hGHG120R gene is driven by the relatively strong human cytomegalovirus-early gene regulatory region. The hGHG120R tested to be biologically active. These cells were then adapted to grow in suspension in CHO-S-SFM (serum-free media). High cell densities, typically 2.0 x 10(6) cells/mL were obtained from spinner flask cultures. Partial purification of hGHG120R from CHO cell cultured media revealed that the level of impurities in SFM was significantly lower than the serum-supplemented DMEM. This suggests that the salt precipitation and the SEC step need not be employed in the purification of hGHG120R from SFM. This would result in a reduction of the operating time by 50 h and boost the recovery yield of hGHG120R to 75%.

No-fault vaccine insurance: lessons from the National Vaccine Injury Compensation Program

During the first eight years of the National Vaccine Injury Compensation Program (NVICP), 786 contested claims were resolved through published judicial opinions. The likelihood of compensation dependent in part on the closeness of the match between the described injury and a specified list of acknowledged untoward vaccine side effects. In addition, the chances of applicant success were influenced by the applicant's choice of attorney and expert witnesses, by the assignment of the Special Master to decide the case, and increasingly over time, by the applicant's ability to comply with procedural requirements. The majority of contested claims arose from pertussis immunizations. For pertussis claims, the goal of insulating manufacturers from product liability suits has been achieved by granting compensation to applicants whose injuries are not scientifically recognized effects of the vaccine. In spite of (or because of) this jarring contradiction between the legal and medical understanding of causation, vaccine availability and childhood immunization rates improved during the early years of the plan. The apparent success of the program may encourage the substitution of no-fault compensation plans for tort-based consumer protection for other products, both medical and nonmedical.

Disputed claims for pertussis vaccine injuries under the National Vaccine Injury Compensation Program

BACKGROUND

The National Vaccine Injury Compensation Program (NVICP) provides no-fault compensation to victims of serious untoward vaccine reactions under the supervision of the Department of Health and Human Services (HHS). Special Masters of the Court of Federal Claims settle compensation disputes that arise between applicants and program administrators. The majority of published NVICP claim decisions concern disputes over the cause of neurologic illness or unexpected infant death following pertussis vaccination.

METHODS

Information was collected from the published decisions to determine the medical characteristics of cases in which injuries were legally attributed to pertussis vaccination. Because of practical and statutory restrictions on the application process and the evolving nature of HHS claim denials, vaccinees in the disputed cases are not representative of all vaccine casualties, or of all NVICP applicants.

RESULTS

Injuries were blamed on pertussis vaccine in 542 claims disputed by HHS. Claims asserted that pertussis vaccine caused seizure disorders (333 claims, 189 were awarded compensation), anaphylaxis (7 claims, 6 awards), hypotonic/hyporesponsive episodes or other injuries leading to early death (107 claims, 73 awards), and long-term neurologic disease (51 claims, 18 awards).

CONCLUSIONS

Assertions that pertussis vaccine caused unexpected infant death (other than anaphylaxis), seizure disorders, and long-term neurologic damage are inconsistent with epidemiological research. Findings of legal causation may contribute to popular perceptions that pertussis vaccine is a dangerous biological product. By providing compensation for these claimants, however, the NVICP may reduce the number of successful civil suits and thus protect the nation's vaccine supply.

Effects of growth hormone antagonists on 3T3-F442A preadipocyte differentiation

We have previously shown that a bovine (b) GH antagonist, bGH-M8, which possesses three amino acid substitutions in its third alpha-helix, inhibits mouse 3T3-F442A preadipocyte differentiation. In the current studies, we used the bGH and human (h) GH analogs with single amino acid substitution, bGH-G119R and hGH-G120R, for determining their biological activity using the preadipocyte differentiation assay. Short-term and long-term GH-inducible events were studied during adipose differentiation, including late marker gene expression (adipocyte protein 2), immediate early gene induction (c-fos), and tyrosine phosphorylation of intracellular proteins. The results demonstrated that these GH analogs not only failed to induce these three events, but also antagonized GH induction of c-fos expression and phosphorylation of proteins of apparent molecular mass of 95 kDa. Our present study agrees with the notion that GH must bind to the GH receptor via site one and with a second GH receptor molecule (or with some yet unidentified 'second target') through GH binding site two. This interaction is important for subsequent GH-dependent biological events.

Active immunization of children with leukemia and other malignancies

Active immunization against measles, Haemophilus influenza B, tetanus, diphtheria, hepatitis B, influenza, poliomyelitis, and, when indicated varicella and pneumococcus induces long-lasting immunologic protection in most healthy pediatric vaccine recipients. Among children receiving immunosuppressive therapy for cancer, possible early loss of specific immunity acquired from prior vaccination or disease, and likely diminished responsiveness to initial or booster vaccination must be considered. In addition, the safety of vaccine administration requires separate study in this population. Published evidence demonstrates preservation of vaccine-induced antibody titers against tetanus, diphtheria, poliomyelitis and (in children treated for lymphoma) pneumococcus. In contrast, prior immunity to varicella, influenza, and hepatitis B (when naturally acquired), and measles (acquired by vaccination) is compromised during and/or after antineoplastic therapy. Studies of immunologic protection acquired by prior vaccination against hepatitis B, varicella, and H influenza have not been published. The safety of administering toxoids and inactivated vaccines in this population is well documented. In contrast, morbidity must be expected if live attenuated vaccines (oral polio vaccine, attenuated measles vaccine or attenuated varicella vaccine) are administered to children receiving anti-cancer therapy. The risks of using live vaccines should be measured against demonstrable benefits in any vaccine program. The response to initial or booster immunizations against tetanus and diphtheria are similar to those in healthy children. For all other immunizations reviewed, responsiveness is diminished during periods of chemotherapy, more strikingly in children treated for leukemia than for solid tumors. Antibody responses to these vaccines range from slightly blunted (in the case of H influenza B) to marginal (influenza) or completely useless (pneumococcus and hepatitis B in children treated for leukemia).

Defective production of granulocyte-macrophage colony-stimulating factor and interleukin-1 by mononuclear cells from children treated for acute lymphoblastic leukemia

The production of colony-stimulating activity (CSA) by phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PBMC) from patients receiving maintenance chemotherapy for acute lymphoblastic leukemia (ALL) was examined. Supernatants from only 14 of 22 patient PBMC cultures (64%), but all supernatants from normal PBMC cultures, supported myeloid colony growth. When present, colony-stimulating activity always included granulocyte-macrophage colony-stimulating factor (GM-CSF). In addition, in nine of ten patient studies and in all control studies, stimulated PBMC produced interleukin-1 (IL-1). These results show that the chemotherapy administered to children with ALL can damage the cytokine production mechanisms in PBMC; the diminished ability to produce GM-CSF and IL-1 may contribute to the increased risk of overwhelming infection in these patients.

Cloning and characterization of a phospholipase gene from Erwinia chrysanthemi EC16

A single gene (plcA) was cloned from a cosmid library of Erwinia chrysanthemi EC16 DNA that encoded an extracellular phospholipase. The gene was subcloned and DNA sequence data showed the presence of a single open reading frame encoding a protein with a predicted size of 39 kDa. The coding region was G+C-rich and the protein had a predicted basic isoelectric point. The protein showed no significant homology with others in the PIR library, including other phospholipases. When overexpressed in Escherichia coli cells, the plcA gene directed production of a c. 39 kDa protein that was largely localized in the periplasm, but its N-terminal amino acid sequence was that of the native protein predicted from DNA sequence data. Unlike the wild-type bacterium, an E. chrysanthemi EC16 marker exchange mutant of the plcA gene did not secrete extracellular phospholipase activity in the medium. However, no detectable change was observed in terms of the virulence of the mutant strain on potato tubers or chrysanthemum stems.

Indomethacin-sensitive monocyte killing defect in a child with disseminated atypical mycobacterial disease

A child with disseminated disease due to Mycobacterium avium had progressive disease in spite of 4.5 years of therapy with multiple antimicrobial agents selected on the basis of in vitro sensitivity testing of her organism. A defect in monocyte bactericidal activity was detected which was corrected in vitro by exposure of the patient's monocytes to indomethacin and normal serum. Indomethacin therapy resulted in normalization of monocyte bactericidal activity and striking, albeit temporary, clinical improvement.

Immunization response varies with intensity of acute lymphoblastic leukemia therapy

Twenty-four children receiving maintenance chemotherapy for acute lymphoblastic leukemia were given booster doses of tetanus-diphtheria combined toxoids. One month later, 19 of the 24 children were given Haemophilus influenzae B oligosaccharide-cross-reacting material conjugate vaccine. Following immunization, all patients had protective antibody titers against tetanus, 92% had protective antidiphtheria titers, and 84% had protective titers against H influenzae. Preimmunization titers, postimmunization titers, and response to immunization varied according to the intensity of therapy. There was no correlation with duration of therapy or quantitative hematologic values in the peripheral blood. These observations support the recommendation that children treated for acute lymphoblastic leukemia should be immunized against H influenzae B.

Childhood cancer among the Polynesian population

From June 1981 through June 1989, 95 Polynesian children were seen for initial care of malignancy at the Princess Mary Hospital for Children (PMHC). The incidence of malignancy in the Polynesian populations served, the histology of the malignancies, and the outcome of therapy were reviewed and compared with 185 non-Polynesian (non-P) patients seen during the same period. Incidence figures for Polynesians and non-P were similar, but histologic patterns differed, showing an increased occurrence of leukemia, particularly nonlymphoblastic leukemia, an increased occurrence of bone tumors, and a decreased incidence of central nervous system tumors for Polynesians. Survival for Polynesian children with acute lymphoblastic leukemia was worse than for non-P. Survival in all other disease categories was similar.

Restriction fragment length polymorphisms associated with the factor VIII and factor IX genes in Polynesians

New Zealand Maoris (72 X chromosomes) have been compared with Pacific Island Polynesians (121 X chromosomes) and Caucasian New Zealanders (51 X chromosomes) as a control group to determine the allelic frequency of six RFLPs associated with the genes for two X linked diseases (haemophilia A and haemophilia B). RFLPs examined were BclI, XbaI, and BglI within the factor VIII gene, the factor VIII extragenic TaqI system, and the factor IX intragenic TaqI and XmnI sites. The information obtained facilitates the design of strategies for both carrier detection and prenatal diagnosis of haemophilia A within these groups. Strong linkage disequilibrium was observed between the factor VIII BclI and XbaI sites in Polynesians. Genetic counselling for Polynesians with haemophilia B continues, however, to rely on phenotypic diagnosis. The RFLP data from the two separate loci on the X chromosome in Polynesians show similarities with Chinese and Japanese populations, reinforcing theories of an early Polynesian ancestry originating in east Asia.

Transient myeloproliferative disorder of the Down type in the normal newborn

Two infants with congenital nonlymphoblastic leukemia were discovered to have mosaicism for trisomy 21. Both infants achieved durable spontaneous remissions. Trisomy was apparently restricted to the leukemic clone and could be detected in neither phytohemagglutinin-stimulated peripheral blood cells or bone marrow in either patient nor in myeloid progenitor cells from the second patient after resolution of the transient myeloproliferative disorder. We conclude that spontaneous remission of congenital leukemia is not confined to infants with partial or complete systemic trisomy 21 but can occur in genetically normal newborns whose leukemic cells contain a third chromosome 21.

Successful bone marrow transplantation with split lymphoid chimerism in DiGeorge syndrome

A female infant with DiGeorge syndrome associated with severe T-cell immunodeficiency underwent a successful bone marrow transplantation from her HLA-identical, mixed leukocyte culture-nonreactive brother at 5 months of age. Mature circulating T cells and mitogen-induced proliferative responses were detectable at 10 days posttransplant, and by 8 months post-transplant functional T- and B-cell reconstitution was documented by normal responses to mitogens and normal levels of serum immunoglobulins as well as in vitro and in vivo T-cell reactivity to specific antigens and production of specific antibody to T cell-dependent antigens in vivo. Phytohemagglutinin-induced interleukin-2 production and cell surface interleukin-2 receptor expression improved posttransplant, with normal production values observed by 8 months posttransplant. Histologic examination of appendix and thoracic lymph node obtained 9 and 17 months posttransplant, respectively, revealed near-normal lymphoid architecture, with germinal center formation providing morphologic confirmation of reconstitution. Stable split lymphoid chimerism with T cells of donor origin and B cells remaining recipient in origin was documented by sex chromosome analysis. Two years posttransplant the subject remains free of serious infections. In conclusion, this case indicates that bone marrow transplantation can produce peripheral immunoreconstitution without need for significant thymic influence, most likely by providing a source of postthymic T cells, and that bone marrow transplantation should be considered a therapeutic option in patients with DiGeorge syndrome associated with severe T-cell deficiency.

Prolonged defects of interleukin-2 production, responsiveness, and receptor expression in patients with acute lymphoblastic leukemia

The proliferative responsiveness to, production of, and the expression of cell-surface receptors for interleukin-2 (IL-2) were examined in 14 children with acute lymphoblastic leukemia (ALL) in remission and receiving maintenance chemotherapy for 6 to 35 months; in 19 children with ALL in remission and off all therapy for 2 to 138 months; and 15 control subjects. Short-term concanavalin A (Con A)-activated, purified T lymphocytes from patients on, as well as patients off, therapy had a significantly decreased proliferative responsiveness to a saturating amount of exogenous, recombinant IL-2 as compared to control subjects (P less than 0.005 and less than 0.05, respectively). Phytohemagglutinin (PHA)-stimulated IL-2 production by peripheral blood mononuclear cells (PBMC) was also substantially decreased in both patient groups with the median values of IL-2 produced being 2.2, 2.1, and 8.1 U/mL in the on therapy, off therapy, and control groups, respectively. In addition, PHA-induced expression of cell-surface receptors for IL-2 on PBMC was significantly decreased in both patient groups as compared to control subjects (P less than 0.01). Lymphocyte proliferation to mitogens (PHA, Con A, and pokeweed mitogen) was similar in all three groups studied. These results demonstrate that substantial quantitative and qualitative abnormalities of the IL-2-T lymphocyte system are present in the majority of treated patients with ALL, not only during maintenance therapy, but also for a prolonged period after the cessation of all chemotherapy. These long-lasting defects of the IL-2 system are most likely a late effect of chemotherapy and may result in increased complications in some long-term survivors of ALL.

Elevated production of interleukin-2 by lymphocytes from children with acute leukemia

Abnormalities of the production of interleukin-2 (IL-2) may play an important role in the immunologic dysfunction observed in pediatric leukemia patients. For an evaluation of the ability of lymphocytes from leukemic children to produce this cytokine, the production of IL-2 by mitogen-stimulated peripheral blood mononuclear cells was determined in children with acute leukemia at the time of diagnosis, during clinical remission, and at the time of relapse. Of 16 patients, 11 (69%) with either acute lymphoblastic leukemia or acute nonlymphoblastic leukemia at the time of diagnosis had IL-2 production levels above the highest level observed in control subjects, and all but one had values above the control mean. Three of five treated patients had elevated IL-2 production at the time of bone marrow relapse. In addition, of 37 patients examined during clinical remission (both during chemotherapy and after the completion of maintenance chemotherapy), five had IL-2 production values above the control range and four of these five patients subsequently had relapses, compared with only one relapse in the remaining 32 patients with normal or below-normal levels of IL-2 production. These results demonstrate an increased ability to produce IL-2 by many patients with acute leukemia, both at the time of diagnosis and at relapse. Elevated IL-2 production may represent an immunologic response to leukemic cells and in some patients may provide a marker for persistent leukemia.

Attenuation of asparaginase-induced hyperglycemia after substitution of the Erwinia carotovora for the Escherichia coli enzyme preparation

L-asparaginase, an enzyme with established antileukemic activity, increases the induction rate and duration of remission of acute lymphoblastic leukemia when added to vincristine and prednisone for induction therapy. Enzymes derived from two different bacterial sources (Escherichia coli and Erwinia carotovora) are in common use. These enzymes may be associated with toxic reactions of differing frequency and severity. Specifically, the complication of enzyme-induced hyperglycemia may be seen more frequently after exposure to the E. coli product. The authors present two patients in whom it was necessary to substitute the Erwinia enzyme for the E. coli enzyme because of the occurrence of severe allergic reactions to the E. coli enzyme. Hyperglycemia induced by the first product improved after the substitution, suggesting that the Erwinia enzyme may be less diabetogenic than the E. coli enzyme.

Granulocyte macrophage colony-stimulating activity production by cultured human thymic nonlymphoid cells is regulated by endogenous interleukin-1

Supernatants of cultured human thymic nonlymphoid cells were assayed for granulopoietic factors using cultures of low density bone marrow mononuclear cells (LD-BMMC). Thymic nonlymphoid cell-conditioned medium (TNLC-CM) supported vigorous myeloid colony growth of LD-BMMC, and of LD-BMMC depleted of T lymphocytes and/or monocytes. Colony stimulating activity (CSA) in TNLC-CM was abrogated by a highly specific neutralizing antiserum against recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF). TNLC-CM also enhanced colony growth in LD-BMMC stimulated by colony stimulating activity from a giant cell tumor culture (GCT). The enhancing activity of TNLC-CM, unlike its CSA activity, required the presence of adherent cells in the marrow cell culture. The addition of anti-interleukin-1 (anti-IL-1) antibody to TNLC-CM inhibited the GCT-enhancing activity, but not the CSA. When the anti-IL-1 immunoglobulin was added directly to cultures of thymic nonlymphoid cells, GM-CSF production was completely inhibited, and the GCT enhancing activity was neutralized. We conclude that an intercellular regulatory network exists in cultured thymic explants in which GM-CSF expression is induced by IL-1. In this system, the granulopoietic effect of IL-1 derives not from a direct effect on myeloid progenitors, but from its ability to recruit CSA production by other cells.

Interleukin 1-dependent paracrine granulopoiesis in chronic granulocytic leukemia of the juvenile type

Marrow and peripheral blood cells from nine children with juvenile chronic granulocytic leukemia (JCGL) demonstrated intense (94 +/- 16% maximum) spontaneous granulocyte/macrophage colony growth but cells from five children with the adult variety of CGL did not. This unusual pattern of colony growth depended upon a stimulatory protein(s) produced by mononuclear phagocytes. No GM-CSA activity was found in any chromatofocused fraction of JCGL monocyte-conditioned media but an activity that induced GM-CSA in umbilical vein endothelial cells was detected at pI 6.9-7.2. Moreover, the CSA-inducing monokine was neutralized by an anti-IL-1 antibody in vitro and, in the one case so tested, the same antibody also inhibited "spontaneous" colony growth. Therefore granulocyte/macrophage colony growth in JCGL is characteristically abnormal and distinguishes JCGL from the adult form of the disease. This abnormality depends upon the production, by mononuclear phagocytes, of IL-1 which, in turn, stimulates the release of high levels of colony stimulating activity by other cells. The high proliferative activity of CFU-GM we found in JCGL patients, and the high levels of GM-CSA found in their serum are compatible with the view that the in vitro abnormality reflects a similar abnormality in vivo.

Unsuspected non-Hodgkin's lymphoma of the tonsils and adenoids in children

Six children with lymphoreticular malignancy arising in the pharyngeal tonsils or adenoids are presented. Early clues to the possible malignant nature of the enlargement of tonsils and adenoids in this series include: asymmetric and persistent enlargement, the absence of such manifestations of infection as fever or pain, and the association of atypical adenopathy. Lack of clinical suspicion brings with it the risk of delayed diagnosis and possible compromise of optimal therapy.

Expression of normal myeloid-associated antigens by acute leukemia cells

Monoclonal antibodies that react with hematopoietic cells and their precursors in a stage and lineage restricted fashion were used in indirect immunofluorescence assays to examine leukemic cells from 105 pediatric age patients. The differentiative states of blasts from 42 patients with acute nonlymphocytic leukemia (ANLL) were defined by these antibodies. When these were compared to their morphologic and histochemical levels of differentiation as defined by the French-American-British (FAB) classification, no direct relationship was found. The reactivity of these antibodies with leukemic cells from 63 patients with acute lymphocytic leukemiA (ALL) was also investigated, and the usefulness of these antibodies in distinguishing leukemias of myeloid from those of lymphoid origin was demonstrated.

Enhanced lymphocyte response to PHA among leukemia patients taking oral lithium carbonate

Seven children receiving maintenance therapy for acute lymphoblastic leukemia (in remission) were given oral lithium carbonate for 12 weeks. Hematologic values, serum immunoglobulin levels, and responsiveness of peripheral blood mononuclear cells to mitogen stimulation were studied during the lithium treatment period, and compared to measurements made during a 12-week period when no lithium was administered (children served as their own controls). Changes attributable to treatment with lithium carbonate included increases in total white blood cell count, circulating neutrophil count, and response to phytohemagglutinin-P. No important toxicity to lithium carbonate was observed.

The effects of thymic epithelial monolayer-conditioned medium on suppressor cell function following chemotherapy in pediatric patients

Human thymic epithelial monolayer-conditioned medium (TEM-CM) enhanced concanavalin A (ConA)-induced suppressor T-lymphocyte activity in 15 of 17 studies of fractionated light-density bone marrow mononuclear cells (LD-BMMC) obtained from pediatric cancer patients within 7 days of chemotherapy (P less than 0.001). However, TEM-CM depressed ConA-induced suppressor T-lymphocyte activity in 14 of 18 studies of LD-BMMC obtained from patients who had received their chemotherapy 14-21 days previously (P less than 0.05). In studies of LD-BMMC from normal subjects, TEM-CM did not show any significant effect on suppressor cell activity, nor did TEM-CM significantly affect spontaneous suppressor cell activity in patients or normals. The effect of direct culture on thymic epithelial monolayers was equivalent to the effect of TEM-CM in both ConA-induced and spontaneous suppressor cell assays. These data demonstrate thymic factor-mediated changes in suppressor T-cell activity of pediatric cancer patients and suggest a postchemotherapy alteration in the bone marrow population of inducible prethymic T cells.

Immunodiagnosis of childhood ALL with monoclonal antibodies to myeloid and lymphoid associated antigens

Sixty-five cryopreserved leukemic samples from children diagnosed and treated as having acute lymphocytic leukemia (ALL) were retrospectively examined for the presence of lymphoid and myeloid associated antigens by indirect immunofluorescence using monoclonal antibodies. Expectedly, the majority of these specimens expressed antigens known to be expressed on lymphoid, and not myeloid malignancies. These included the common acute lymphoblastic leukemia antigen (CALLA), the p32 B-cell associated antigen, and T-cell associated antigens. Leukemic cells from the 8 remaining patients expressed antigens known to be present on both myeloid and lymphoid leukemias. These included HLA/DR, and the antigens identified by BA-1 and BA-2. Cells from 2 of these 8 patients reacted with antibodies that define antigens present on normal and malignant myeloid cells. Both specimens reacted with 1G10, an anti-granulocyte antibody, and one reacted with 5F1 which reacts with monocytes, nucleated red blood cells, megakaryocytes and platelets. One of these patients relapsed while receiving ALL therapy, and the morphology of her leukemic cells became characteristic of acute monocytic leukemia (AMoL). The second patient failed ALL therapy but responded to standard acute nonlymphocytic leukemia (ANLL) therapy, clearing her peripheral blasts. Thus these studies confirm that cell surface phenotyping with monoclonal antibodies can recognize ALL cells that express myeloid rather than lymphoid associated antigens and demonstrate that the malignant cells display a clinical behavior consistent with the diagnosis of ANLL.

Vincristine in the etiology of toxicity of high-dose methotrexate therapy

A 14-year-old received a six-hour infusion of methotrexate (71/2 g/M2) with vincristine (2 mg) and citrovorum rescue according to a standard protocol for adjunctive chemotherapy of osteogenic sarcoma. Signs of mild vincristine toxicity occurred from 2-5 days following the infusion; these including jaw pain, decreases in deep tendon reflexes, and a transient ileus. Clearance of serum methotrexate was delayed during the period of ileus and severe methotrexate toxicity was observed.