Validation of WHO classification-based Prognostic Scoring System (WPSS) for myelodysplastic syndromes and comparison with the revised International Prognostic Scoring System (IPSS-R). A study of the International Working Group for Prognosis in Myelodysplasia (IWG-PM)

A risk-adapted treatment strategy is mandatory for myelodysplastic syndromes (MDS). We refined the World Health Organization (WHO)-classification-based Prognostic Scoring System (WPSS) by determining the impact of the newer clinical and cytogenetic features, and we compared its prognostic power to that of the revised International Prognostic Scoring System (IPSS-R). A population of 5326 untreated MDS was considered. We analyzed single WPSS parameters and confirmed that the WHO classification and severe anemia provide important prognostic information in MDS. A strong correlation was found between the WPSS including the new cytogenetic risk stratification and WPSS adopting original criteria. We then compared WPSS with the IPSS-R prognostic system. A highly significant correlation was found between the WPSS and IPSS-R risk classifications. Discrepancies did occur among lower-risk patients in whom the number of dysplastic hematopoietic lineages as assessed by morphology did not reflect the severity of peripheral blood cytopenias and/or increased marrow blast count. Moreover, severe anemia has higher prognostic weight in the WPSS versus IPSS-R model. Overall, both systems well represent the prognostic risk of MDS patients defined by WHO morphologic criteria. This study provides relevant in formation for the implementation of risk-adapted strategies in MDS.

Naive T-cells in myelodysplastic syndrome display intrinsic human telomerase reverse transcriptase (hTERT) deficiency

Telomeres are specialized structures providing chromosome integrity during cellular division along with protection against premature senescence and apoptosis. Accelerated telomere attrition in patients with myelodysplastic syndrome (MDS) occurs by an undefined mechanism. Although the MDS clone originates within the myeloid compartment, T-lymphocytes display repertoire contraction and loss of naive T-cells. The replicative lifespan of T-cells is stringently regulated by telomerase activity. In MDS cases, we show that purified CD3+ T-cells have significantly shorter telomere length and reduced proliferative capacity upon stimulation compared with controls. To understand the mechanism, telomerase enzymatic activity and telomerase reverse transcriptase (hTERT), gene expression were compared in MDS cases (n=35) and healthy controls (n=42) within different T-cell compartments. Telomerase activity is greatest in naive T-cells illustrating the importance of telomere repair in homeostatic repertoire regulation. Compared with healthy controls, MDS cases had lower telomerase induction (P<0.0001) that correlated with significantly lower hTERT mRNA (P<0.0001), independent of age and disease stratification. hTERT mRNA deficiency affected naive but not memory T-cells, and telomere erosion in MDS occurred without evidence of an hTERT-promoter mutation, copy number variation or deletion. Telomerase insufficiency may undermine homeostatic control within the hematopoietic compartment and promote a change in the T-cell repertoire in MDS.

CpG methylation patterns and decitabine treatment response in acute myeloid leukemia cells and normal hematopoietic precursors

The DNA hypomethylating drug decitabine maintains normal hematopoietic stem cell (HSC) self-renewal but induces terminal differentiation in acute myeloid leukemia (AML) cells. The basis for these contrasting cell-fates, and for selective CpG hypomethylation by decitabine, is poorly understood. Promoter CpGs, with methylation measured by microarray, were classified by the direction of methylation change with normal myeloid maturation. In AML cells, the methylation pattern at maturation-responsive CpG suggested at least partial maturation. Consistent with partial maturation, in gene expression analyses, AML cells expressed high levels of the key lineage-specifying factor CEBPA, but relatively low levels of the key late-differentiation driver CEBPE. In methylation analysis by mass-spectrometry, CEBPE promoter CpG that are usually hypomethylated during granulocyte maturation were significantly hypermethylated in AML cells. Decitabine treatment induced cellular differentiation of AML cells, and the largest methylation decreases were at CpG that are hypomethylated with myeloid maturation, including CEBPE promoter CpG. In contrast, decitabine-treated normal HSC retained immature morphology, and methylation significantly decreased at CpG that are less methylated in immature cells. High expression of lineage-specifying factor and aberrant epigenetic repression of some key late-differentiation genes distinguishes AML cells from normal HSC and could explain the contrasting differentiation and methylation responses to decitabine.

Prevalence of latent tuberculosis infection in health care workers in Poland assessed by interferon-gamma whole blood and tuberculin skin tests

Health care workers (HCWs) are at risk for developing active tuberculosis (TB). The prevalence of latent tuberculosis infection (LTBI) in this group is unknown in Poland, due largely to the problems associated with the interpretation of the tuberculin skin test (TST) in BCG immunized population. The goal of the present study was to assess the prevalence of LTBI in both clinical and non-clinical 155 HCWs (120 females and 35 males) and to compare the groups at different levels of risk. All participants were interviewed using a questionnaire and underwent interferon-gamma whole blood assay (Quantiferon-Tb-Gold) (QTF) and TST. The questionnaire provided information on possible risk factors for LTBI, including demographic and socioeconomic details, the presence of BCG scars, and the degree of occupational exposure. We found that the prevalence of LTBI among HCWs was, on average, 27.1%. A higher risk of acquiring LTBI was associated with certain work locations (TB lab workers--prevalence 50%, TB ward clinicians--34%, nurses--30%). The prevalence in analytical lab technicians was 20%, in administration staff was 15%. The HCWs with positive QTF test results were older and worked longer than those who had negative results. There was a significant correlation between the level of IFN-gamma and both age (P<0.001) and length of employment (P<0.01). The correlation between the diameter of skin test induration and the magnitude of the INF-gamma response also was significant (P<0.001). We conclude that HCWs are at increased risk of infection, suggesting that appropriate preventive strategies should be undertaken. IFN-gamma test is a useful tool in detecting LTBI cases in a country where BCG vaccination is a national policy.

Prevalence, severity and underdiagnosis of COPD in the primary care setting

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common disease with a steadily increasing prevalence and mortality. However, recent epidemiological estimates differ depending on the population studied and methods used.

AIM

To investigate the prevalence, severity and burden of COPD in a primary care setting.

METHODS

From 4730 patients registered in a single primary care practice, all 2250 patients aged 40 years or more were invited to participate. Participants completed a questionnaire on smoking, respiratory symptoms, education and social status. A physical examination was followed by pre- and post-bronchodilator (BD) spirometry.

RESULTS

Of the eligible patients, 1960 (87%) participated. 92% of spirometric tests met the ATS criteria. Airflow limitation was demonstrated in 299 (15%) of the participants pre-BD and in 211 (11%) post-BD. COPD was diagnosed in 183 patients (9.3%). Of these patients, the degree of post-BD airflow limitation was mild in 30.6%, moderate in 51.4%, severe in 15.3% and very severe in 2.7%. Only 18.6% of these patients had previously been diagnosed with COPD; almost all of these had severe or very severe airflow limitation. As a result of the study, a diagnosis of asthma was made in 122 patients.

CONCLUSIONS

The prevalence and underdiagnosis of COPD in adult patients in this primary care setting made case finding worthwhile. Large numbers of newly detected patients were symptomatic and needed treatment. Limiting investigations to smokers would have reduced the number of COPD diagnoses by 26%.

Dendritic cells in autologous hematopoietic stem cell transplantation for diffuse large B-cell lymphoma: graft content and post transplant recovery predict survival

Allograft dendritic cell (DC) content has been identified as a predictor of relapse and event-free survival after allogeneic bone marrow transplantation. However, the prognostic importance of DCs has not been evaluated in the setting of autologous hematopoietic stem cell transplantation (HSCT). We prospectively determined pre-transplant and post transplant DC levels, including DC1 and DC2 subset levels, in 53 patients with diffuse large B-cell non-Hodgkin's lymphoma (DLBC NHL) undergoing autologous HSCT. Pre-transplant DCs were measured in the collected stem cell products and were therefore indicative of cell numbers infused directly into patients; post transplant analysis of DCs was performed on the peripheral blood of patients 6 weeks after the infusion of autologous stem cells. Higher pre-transplant levels of DC1 cells and total DCs were significantly associated with improved survival. Similarly, greater post transplant levels of total DCs and both subsets were significantly associated with survival. These findings suggest a relationship between DC reconstitution and survival following autologous HSCT for DLBC NHL. Strategies to increase autograft DC content or accelerate DC recovery after autologous HSCT might improve outcomes in this setting.

Characterization of an antisense transcript spanning the UL81-82 locus of human cytomegalovirus

In this study we present the characterization of a novel transcript, UL81-82ast, UL81-82 antisense transcript, and its protein product. The transcript was initially found in a cDNA library of monocytes from a seropositive donor. mRNA was obtained from monocytes isolated from a healthy donor with a high antibody titer against human cytomegalovirus (HCMV). The mRNAs were cloned into a lambda phage-derived vector to create the cDNA library. Using PCR, UL81-82ast was amplified from the library. The library was tested for the presence of numerous HCMV genes. Neither structural genes nor immediate-early genes were found. UL81-82ast was detected in five bone marrow samples from healthy antibody-positive donors. This same transcript was also found in in vitro-infected human fibroblasts early after infection but disappears at the same time that UL82 transcription begins. Not only was the transcript amplified using reverse transcription-PCR and sequenced but its protein product (UL82as protein) was detected by both Western blot and immunofluorescence. Phylogenetic studies using UL82as protein were conducted, showing a high degree of conservation in clinical isolates, laboratory strains of HCMV, and even in chimpanzee CMV. The transcript could be involved in the posttranscriptional regulation of the UL82 gene, affecting its mRNA stability or translation. Since the UL82 product, pp71, functions as an immediate-early transactivator, its posttranscriptional control could have some effect over latency reactivation and lytic replication.

Intracellular cytokines of peripheral blood lymphocytes in nephrotic syndrome

Idiopathic nephrotic syndrome (NS) is probably caused by abnormalities in T-lymphocyte function. The presence of several immunological abnormalities in these patients supports this hypothesis, but to date there is no agreement about immunological status and its influence on the course of NS. Thirty-six children with NS [19 with first episode (group I) and 17 in remission (>6 months) of NS (group II), aged 4-17 years, mean 7.1 years] were included in the study. Nineteen age-matched healthy children constituted the control group. Anti-cytokine antibodies were used in conjunction with antibodies against cell surface antigens to study cytokine synthesis in different lymphocyte populations. In the present study the intracellular synthesis of interleukin-2 (IL-2), interferon-gamma (IFN-gamma), IL-4, and IL-6 was measured. The intracellular synthesis of IL-2 was higher in group I compared with the controls, both in the whole population of T-lymphocytes (12.1+/-6.2% vs. 7.6+/-6.7%, P=0.0281) and in the subpopulation of CD8- lymphocytes (17.3+/-8.5% vs. 7.2+/-4.8%, P=0.0001). No significant differences in IFN-gamma intracellular expression were found. The intracellular synthesis of IL-4 was lower in group I compared with the controls, both in the whole population of T-lymphocytes (1.98+/-1.92% vs. 3.6+/-3.3%, P=0.012) and in the subpopulation of CD8- lymphocytes (2.4+/-2.3% vs. 6.5+/-6.4%, P=0.0002). Similarly, the intracellular expression of IL-6 was lower in group I compared with the control group, in the whole population of T-lymphocytes (0.85+/-0.6% vs. 2.2+/-3.1%, P=0.004), in the CD8- subpopulation (1.1+/-1.1% vs. 2.2+/-2.0%, P=0.006), and in the CD8+ subpopulation (1.1+/-0.9% vs. 2.8+/-3.4%, P=0.0008). The results of this study indicate that the acute episode of NS is associated with increased intracellular synthesis of IL-2 and decreased intracellular synthesis of IL-4 and IL-6.