The lymphoproliferative disease of granular lymphocytes. A heterogeneous disorder ranging from indolent to aggressive conditions

A multiparameter analysis, which included the evaluation of clinical features, cell morphology, karyotype, phenotypic and functional immunologic findings, and T-cell receptor beta-chain configuration was performed on 34 patients with lymphoproliferative disease of granular lymphocytes (LDGL). The two-fold aim of the study was to identify the most useful tools that would more accurately characterize these patients and to deal with the problem of classifying these lymphoproliferative disorders. The data presented in this article suggest that a single parameter may not be sufficient to define the nature of the proliferating cells or to predict the clinical course of the disease and prognosis for the patient. The use of a multiparameter approach, however, may reach this goal, thus providing important prognostic and therapeutic information. Our study supports the concept that lymphoproliferative disease of granular lymphocytes is a heterogeneous disorder that ranges from indolent and possibly reactive conditions to the manifestation of aggressive malignancies.

Hairy cell leukemia: a clinical review based on 725 cases of the Italian Cooperative Group (ICGHCL). Italian Cooperative Group for Hairy Cell Leukemia

The Italian Registry for hairy cell leukemia (HCL) has recorded 725 patients with HCL diagnosed over 25 years. We analysed this large series of patients with the aim of providing an evaluation of changes in clinical presentation, impact of initial therapy and modifications in prognostic factors over the period of two decades. Over time, a progressive down-staging of the disease at the onset, along with a reduction of patients with severe anemia and marked splenomegaly, has been observed. A second malignancy was found in 3.7% of patients, mostly detected several years after the onset of HCL. A striking improvement of survival rates has been observed, from 58.9% survival at five years for patients diagnosed before 1985 to 87.5% at five years for patients diagnosed after 1985 (p < 0.0001). Before 1985 hemoglobin alone provided prognostic information, whereas after 1985, clinical stage and the number of leukocytes correlated better with patient outcome. Survivals at 5 and 10 years were 34.4% and 29.6% respectively for untreated patients, 58.8% and 44.1% for patients receiving chemotherapy, steroids or other drugs, 64.1% and 56.1% for splenectomized patients and 88.9% (at 5 years) for alpha interferon (IFN)-treated patients (p < 0.0001). Our findings suggest that IFN has improved the prognosis of HCL, and that it must be considered a good initial treatment for patients with HCL.

Thrombohaemorrhagic complications in 101 cases of myeloproliferative disorders: relationship to platelet number and function

A series of 101 consecutive patients with chronic myeloproliferative disorders including polycythaemia vera, chronic myelogenous leukaemia, idiopathic myelofibrosis and essential thrombocythaemia have been studied. The aim was to establish the incidence of thrombotic and haemorrhagic complications and the possible role played by platelet number and function. The total incidence of haemostatic complications was 21% and the platelet functional tests investigated (platelet aggregation, generation of malondialdehyde, endogenous serotonin, beta-thromboglobulin and platelet coagulant activity) were of little help for predicting these clinical complications.

Successful pregnancy in a woman with congenital factor XIII deficiency treated with substitutive therapy. Report of a second case

A syndrome of marked fetal wastage is associated with congenital factor XIII deficiency in adult women. A previously unreported case of a woman with factor XIII deficiency is described, in which substitutive treatment with normal plasma or placental factor XIII concentrate permitted two normal pregnancies. Factor XIII activity was maintained above 1-2% with intermittent infusion of 300 ml to 450 ml of plasma every 14 days or of 500 units of concentrate every 21 days. This case confirms the only other case so far reported in which factor XIII substitutive therapy was able to permit a normal pregnancy in a woman with factor XIII deficiency and seems to suggest factor XIII to be involved in the process of annidation.

Changes in clinic vaccination coverage after institution of measurement and feedback in 4 states and 2 cities

BACKGROUND

Since 1995, states and jurisdictions receiving federal immunization funds have been required to perform annual measurements of vaccination coverage in their public clinics, based on data from Georgia where clinic coverage increased after the institution of a measurement and feedback intervention.

OBJECTIVE

To determine if clinic vaccination coverage improved in localities that used the Georgia intervention model.

DESIGN

Retrospective examination of clinic vaccination coverage data.

PARTICIPANTS

Children aged 19 to 35 months enrolled in clinics in localities that had applied the intervention for 4 years or longer.

INTERVENTION

The Georgia intervention model: assessment of clinic vaccination coverage, feedback of the information to the clinic, incentives to clinics, and promotion of exchange of information among clinics (AFIX).

MAIN OUTCOME MEASURE

Change in median clinic coverage rates, based on the primary (4-3-1) vaccine series, with comparison to results of the National Immunization Survey.

RESULTS

Four states and 2 cities that had applied the AFIX intervention for 4 years or longer were identified. The number of clinic records reviewed annually was 4639 to 18000 in 73 to 116 clinics for states, and 714 to 5276 in 8 to 25 clinics for cities. Median clinic coverage rose in all localities: Missouri, 44% (1992) to 93% (1997); Louisiana, 61% (1992) to 83% (1997); Colorado, 55% (1993) to 75% (1997); Iowa, 71% (1994) to 89% (1997); Boston, Mass, 41% (1994) to 79% (1997); and Houston, Tex, 28% (1994) to 84% (1997). The increase in clinic coverage exceeded that of the general population in 5 localities and was identical in the sixth. The average annual coverage rise attributable to the intervention was +5 percentage points per year (Georgia, +6 per year). The average crude direct program cost was $49533 per locality per year.

CONCLUSION

The Georgia intervention model (AFIX) can be reproduced elsewhere and is associated with improvements in clinic vaccination coverage.

CINCH: an urban coalition for empowerment and action. Consortium for the Immunization of Norfolk's Children

CINCH (Consortium for the Immunization of Norfolk's Children) is an urban coalition that was developed in 1993 to improve childhood immunization rates in Norfolk, Virginia. CINCH involves diverse citizens and institutions in effective community-based assessment, planning, and action. A needs assessment from 1993 found that only 49% of Norfolk 2-year-olds were adequately immunized. Using this data, CINCH developed a plan focused on education and communication, support for at-risk families, increased access to immunizations, and improved immunization delivery. After federal funding ended in 1995, members voted to expand the scope of the coalition to address additional child health needs and to broaden the membership. CINCH is a model for a sustainable city-citizen learning environment that intervenes to "help families help themselves to better health." The coalition is presented as an organization that focuses on community empowerment and development. The stages of coalition development and implications for coalition implementation in other sites are discussed.

Fatal pulmonary embolism and antithrombin III deficiency in adult lymphoblastic leukaemia during L-asparaginase therapy

We describe 2 adult patients with acute lymphoblastic leukaemia (ALL) who died from pulmonary embolism following L-asparaginase treatment. Since this drug is known to cause a decrease in antithrombin III, the most important protein physiologically involved in the neutralization of thrombin, we studied the behaviour of this inhibitor in 14 ALL patients treated with a protocol including a 14-day course of L-asparaginase. A significant but transient fall of biological and immunological antithrombin III and a concomitant reduction of fibrinogen were documented.

Assessing immunization performance of private practitioners in Maine: impact of the assessment, feedback, incentives, and exchange strategy

INTRODUCTION

A provider-based vaccination strategy that has strong supportive evidence of efficacy at raising immunization coverage level is known as Assessment, Feedback, Incentives, and Exchange. The Maine Immunization Program, and the Maine Chapter of the American Academy of Pediatrics collaborated on the implementation and evaluation of this strategy among private providers.

METHODS

Between November 1994 and June 1996, the Maine Immunization Program conducted baseline immunization assessments of all private practices administering childhood vaccines to children 24 to 35 months of age. Coverage level assessments were conducted using the Clinic Assessment Software Application. Follow-up assessments were among the largest practices, delivering 80% of all vaccines.

RESULTS

Of the 231 practices, 58 were pediatric and 149 were family practices. The median up-to-date vaccination coverages among all providers for 3 doses of diphtheria-tetanus-pertussis vaccine and 2 doses of oral polio vaccine, and 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at age 12 and 24 months were 90% and 78%, respectively, and did not vary by number of providers in a practice or by specialty. Urban practices had higher coverage than rural practices at 12 months (92% vs 88%). The median up-to-date coverage for 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at 24 months of age improved significantly among those practices assessed 1 year later (from 78% at baseline to 87% at the second assessment). On average, the assessments required 21/2 person-days of effort.

CONCLUSIONS

We document the feasibility and impact of a public/private partnership to improve immunization delivery on a statewide basis.

IMPLICATIONS

Other states should consider using public/private partnerships to conduct private practice assessments. More cost-effective methods of assessing immunization coverage levels in private practices are needed.

Subunits A and S inheritance in four families with congenital factor XIII deficiency

Previous studies of the inheritance of the two molecular subunits of fibrin stablizing factor (factor XIII) refer to isolated cases. The present work investigates the hereditary mode of transmission of subunits A and S, measured by the Laurell technique, in seven homozygotes and in 29 heterozygotes belonging to four families with factor XIII deficiency. The results indicate that the homozygotes were devoid of immunologically identifiable A subunit, whereas the heterozygotes could be identified by measuring this protein. The subunit S has been found to be decreased both in homozygous and in heterozygous patients, so that it seems that the two subunits, even if their synthesis is controlled by different genes, are genetically related. The mode of transmission of this disorder, supported by quantitative determinations of plasma subunit A, is autosomal recessive.

Fibrinopeptide A changes during remission induction treatment with L-asparaginase in acute lymphoblastic leukemia: evidence for activation of blood coagulation

L-Asparaginase, a widely used antileukemic agent, inhibits liver protein synthesis leading to hypofibrinogenemia and hypoprothrombinemia together with a severe reduction of antithrombin III and protein C. An increased risk of thrombosis has been reported in leukemic patients treated with this agent. We measured fibrinopeptide A (FPA) changes in 14 patients with acute lymphoblastic leukemia during induction remission treatment with a protocol including L-Asparaginase (10,000 U/m2/daily intravenous for 14 days). At diagnosis, 9/14 patients had FPA level above upper limit of normal range (mean = 4.1 ng/ml). After two days of therapy, FPA rose to 5.2 ng/ml and thereafter showed a slight increase throughout. Antithrombin III, protein C and fibrinogen dropped to its nadir on day 6 and 9. However, the ratio FPA/fibrinogen on a molar basis showed a three-fold increase during this days, demonstrating that the thrombin-dependent consumption of fibrinogen was also increased. In conclusion, our data show that activation of blood coagulation occurs in concomitance with the hemostatic derangement caused by L-Asparaginase. Replacement therapy with the recently available antithrombin III concentrates may be worthy of a clinical trial to test its effectiveness in preventing the thrombotic phenomena reported in these patients.

A phase II study of idarubicin (4-demethoxydaunorubicin) in advanced myeloma

Idarubicin (IDA) is an anthracycline analog which differs from the parent compound by the substitution of a C4 methoxyl group with an hydrogen atom in the aglycone moiety. This drug has shown greater potency and activity in experimental and human leukemias and lymphomas by intravenous and oral routes of administration together with less cardiotoxicity than doxorubicin (DX) and daunorubicin (DNR). We have treated 15 patients with advanced multiple myeloma (MM) refractory or relapsed to standard chemotherapy regimens. The treatment schedule consisted of idarubicin 40 mg/m2 orally on day 1 every 3 weeks for 6-8 months. We obtained 8/14 partial response, 4/14 minor response and 2 progressions. One patient was not evaluable for the response because of liver toxicity not related to IDA administration. The median duration of response was 8 months with a minimum of 2 and a maximum of 12 months. Hematologic toxicity occurred in about 20% of patients and no treatment was delayed. Cardiotoxicity, defined as impairement of left ventricular ejection fraction (LVEF), was observed in one case. The major systemic toxicity observed was nausea in 80% of patients and vomiting in 40%. Hair loss resulting was socially acceptable. These results indicate that IDA is useful as a single agent, easy to administer, not cross resistant with DX and recommended for a combination regimen.

The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland

OBJECTIVE

To determine whether financial sanctions to Aid to Families With Dependent Children (AFDC) recipients can be used to improve vaccination coverage of young children.

DESIGN

Randomized controlled trial.

SETTING

Six AFDC jurisdictions in Maryland.

INTERVENTION

Recipients of AFDC were randomized to the experimental or control group of the Primary Prevention Initiative. Families in the experimental group were penalized financially for failing to verify that their children received preventive health care, including vaccinations; control families were not.

PARTICIPANTS

Children aged 3 to 24 months from assigned families were randomly selected for the evaluation (911 in the experimental, 864 in the control, and 471 in the baseline groups).

MAIN OUTCOME MEASURES

Up-to-date for age for diphtheria and tetanus toxoids and pertussis (DTP), polio, and measles-mumps-rubella (MMR) vaccines; missed opportunities to vaccinate; and number of visits per year.

ANALYSIS

Comparisons among baseline and postimplementation years 1 and 2.

RESULTS

Vaccination coverage of children was low. Less than 70% of children were up-to-date for age for polio and MMR vaccines; slightly more than 50% were up-to-date for DTP vaccine. Up-to-date rates differed little among baseline, experimental, and control groups. Over time, there was a decrease in missed opportunities, and more children made at least 1 well-child visit; however, neither improvement resulted in a change in vaccination status.

CONCLUSIONS

The Primary Prevention Initiative did not contribute to an increase in vaccination coverage among these children. Minimal economic sanctions alone levied against parents should not be expected substantially to affect vaccination rates.

Immunoelectrophoretic evidence of a thrombin-induced abnormality in a new variant of hereditary dysfunctional antithrombin III (AT III 'Vicenza')

An Italian family with thrombosis and hereditary dysfunctional AT III, i.e. reduced biological activity and normal levels of the immunoreactive protein is presented. The abnormal molecule, called AT III 'Vicenza', was characterized by two-dimensional crossed immunoelectrophoresis either in the absence or presence of heparin. In the presence of heparin, a normal pattern was found in plasma, but abnormality was evident in serum. A similar abnormality was found in plasma artificially clotted with thrombin. The role of thrombin in inducing the immunoelectrophoretic abnormality of AT III 'Vicenza' is discussed.

Long-term results of the HEAVD protocol for adult acute lymphoblastic leukaemia

Between 1979 and 1987, 82 adults (age 14-71 years) with acute lymphoblastic leukaemia (ALL) were treated with a 6-course protocol called HEAVD, the main feature of which was the early postremission administration of escalating doses of doxorubicin (total 405 mg/m2) and cyclophosphamide (total 2.5 g/m2). A complete remission (CR) was attained in 66 patients (80%, 95% confidence intervals, [CI] 71%-89%). Factors affecting favourable CR achievement were age less than 60 years and absence of lymphadenopathy-hepatosplenomegaly at presentation (P less than 0.05). Median duration of CR was 27 months. 26 patients remain in first continuous and unmaintained CR, 18 of whom between 5.9 and 11.1 years, for an estimated 39% prolonged disease-free survival (95% CI 27%-51%). CR duration correlated significantly with absolute blast cell count (15 x 10(9)/l or less compared to more) and age (30 years or under compared to over). Overall, 29 patients are alive with a median follow-up of 6.7 years, the projected long term survival being 35% at 11 years (95% CI 24%-46%). Treatment-related toxicity included 1 lethal case of L-asparaginase-related thromboembolism and 3 toxic deaths among 66 CR patients. Late-onset toxicity was not observed in long-term survivors. The relatively late occurrence of endpoint events (relapse and death) in adult ALL confirms that long-term updating is necessary to determine the curative potential of modern chemotherapy programs for the disease.

Synthesis and characterization of cross-linked chitosan microspheres for drug delivery applications

The present study deals with the synthesis and characterization of cross-linked chitosan microspheres containing an hydrophilic drug, hydroquinone. The microspheres were prepared by the suspension cross-linking method using glutaraldehyde as the cross-linking agent of the polymer matrix. Perfectly spherical cross-linked hydrogel microspheres loaded with hydroquinone were obtained in the size range of 20-100 microm. The effect of the degree of polymer cross-linking, chitosan molecular weight, chitosan concentration and amount of the encapsulated drug on the hydroquinone release kinetics was extensively investigated. It was found that slower drug release rates were obtained from microspheres prepared by using a higher initial concentration of chitosan, a higher molecular weight of chitosan or/and a lower drug concentration. Most importantly, it was shown that the release rate of hydroquinone was mainly controlled by the polymer cross-linking density and, thus, by the degree of swelling of the hydrogel matrix.

Reinforced HEAV'D therapy for adult acute lymphoblastic leukemia: improved results and revised prognostic criteria

Thirty-six adults with acute lymphoblastic leukemia (ALL) were treated with adriamycin, vincristine, prednisolone, and asparaginase for remission induction, followed by vincristine-adriamycin-cyclophosphamide consolidation courses, cranial irradiation, a short ara-C plus VM-26 pulse, and vincristine plus cyclophosphamide rotating weekly with ara-C plus VM-26 for three months (reinforced HEAV'D). Thirty-one patients achieved a complete remission (86 per cent). Compared with historical results from a prior study, age > 30 years, absolute blast count > 15 x 10(9)/l, and CD10-negative immunophenotype were not associated with higher relapse rate and shorter survival, suggesting a positive effect from intensification therapy with ara-C and VM-26 in these poor prognostic categories. However, patients with an abnormal karyotypic pattern or a positive molecular study for BCR-ABL rearrangement detecting t(9;22) had a far greater likelihood of treatment failure (probability of remission at 3 years 0.10) than those with normal karyotype or negative molecular study (probability 0.70), and those not studied or with insufficient methaphases (probability 0.50) (p < 0.05 by log-rank test). These results underline the prognostic importance of chromosomal abnormalities and the usefulness of ara-C and VM-26 in the management of adult ALL.

Treatment of acute lymphoblastic leukemia in adults

Thirty-seven adult patients with acute lymphoblastic leukemia were treated with a protocol called HEAV'D including Adriamycin, Vincristine, L-Asparaginase, Cyclophosphamide and Dexamethasone. The complete remission rate was 70 per cent. The median duration of remission was more than 30 months. Patients with initial leukocyte count below 20 000/mmc experienced a longer remission (median not reached) than patients with a leukocyte count above 20 000/mmc (median 10 months).