Rituximab using a thrice weekly dosing schedule in B-cell chronic lymphocytic leukemia and small lymphocytic lymphoma demonstrates clinical activity and acceptable toxicity

PURPOSE

Rituximab has been reported to have little activity in small lymphocytic lymphoma (SLL)/chronic lymphocytic leukemia (CLL) and to be associated with significant infusion-related toxicity. This study sought to decrease the initial toxicity and optimize the pharmacokinetics with an alternative treatment schedule.

PATIENTS AND METHODS

Thirty three patients with SLL/CLL received dose 1 of rituximab (100 mg) over 4 hours. In cohort I (n = 3; 250 mg/m(2)) and cohort II (n = 7; 375 mg/m(2)) rituximab was administered on day 3 and thereafter three times weekly for 4 weeks using a standard administration schedule. Cohort III (n = 23; 375 mg/m(2)) administered rituximab similar to cohort II for the first two treatments and then over 1 hour thereafter.

RESULTS

A total of 33 CLL/SLL patients were enrolled; only one patient discontinued therapy because of infusion-related toxicity. Thirteen patients developed transient hypoxemia, hypotension, or dyspnea that were associated with significant changes in baseline interleukin-6, interleukin-8, tumor necrosis factor alpha, and interferon gamma compared with those not experiencing such reactions. Infusion-related toxicity occurred more commonly in older (median age 73 v 62 years; P =.02) patients with no other pretreatment clinical or laboratory features predicting occurrence of these events. The overall response rate was 45% (3% CR, 42% PR; 95% CI 28% to 64%). Median response duration for these 15 patients was 10 months (95% CI, 6.8-13.2; range, 3 to 17+).

CONCLUSION

Rituximab administered thrice weekly for 4 weeks demonstrates clinical efficacy and acceptable toxicity. Initial infusion-related events seem to be cytokine mediated and resolve by the third infusion making rapid administration possible. Future combination studies of rituximab with other therapies in CLL seem warranted.

A radio counterpart to a neutron star merger

Gravitational waves have been detected from a binary neutron star merger event, GW170817. The detection of electromagnetic radiation from the same source has shown that the merger occurred in the outskirts of the galaxy NGC 4993, at a distance of 40 megaparsecs from Earth. We report the detection of a counterpart radio source that appears 16 days after the event, allowing us to diagnose the energetics and environment of the merger. The observed radio emission can be explained by either a collimated ultrarelativistic jet, viewed off-axis, or a cocoon of mildly relativistic ejecta. Within 100 days of the merger, the radio light curves will enable observers to distinguish between these models, and the angular velocity and geometry of the debris will be directly measurable by very long baseline interferometry.

Nitric oxide activates skeletal and cardiac ryanodine receptors

The endothelial-derived relaxing factor, nitric oxide (NO.) has been shown to depress force in smooth and cardiac muscles through the activation of guanylyl cyclase and an increase in cGMP. In fast skeletal muscle, NO (i.e. NO-related compounds) elicits a modest decrease in developed force, but in contracting muscles NO increases force by a mechanism independent of cGMP. We now demonstrate an alternative mechanism whereby NO triggers Ca2+ release from skeletal and cardiac sarcoplasmic reticulum (SR). NO delivered in the form of NO gas, NONOates (a class of sulfur-free compounds capable of releasing NO), or S-nitrosothiols (R-SNO) oxidized or transnitrosylated regulatory thiols on the release channel (or ryanodine receptor, RyR), resulting in channel opening and Ca2+ release from skeletal and cardiac SR. The process was reversed by sulfhydryl reducing agents which promoted channel closure and Ca2+ reuptake by ATP-driven Ca2+ pumps. NO did not directly alter Ca(2+)-ATPase activity but increased the open probability of RyRs reconstituted in planar bilayers and inhibited [3H]-ryanodine binding to RyRs. The formation of peroxynitrite or thiyl radicals did not account for the reversible R-SNO-dependent activation of RyRs. Ca2+ release induced by nitric oxide free radicals (NO.) was potentiated by cysteine providing compelling evidence that NO. in the presence of O2 formed nitrosylated cysteine followed by the transnitrosation of regulatory thiols on the RyR to activate the channel. These findings demonstrate direct interactions of NO derivatives with RyRs and a new fundamental mechanism to regulate force in striated muscle.

Rituximab therapy in hematologic malignancy patients with circulating blood tumor cells: association with increased infusion-related side effects and rapid blood tumor clearance

PURPOSE

Rituximab was recently approved for use in relapsed, low-grade non-Hodgkin's lymphoma; however, few data exist regarding the safety of this agent in patients with a high number of tumor cells in the blood.

METHODS AND RESULTS

After the observation at our institution of a rapid reduction of peripheral-blood tumor cells with associated severe pulmonary infusion-related toxicity in two patients with refractory hematologic malignancies, data on three additional cases were collected from physician-submitted reports of adverse events related to rituximab treatment. Five patients with hematologic malignancies possessing a high number of blood tumor cells were treated with rituximab and developed rapid tumor clearance. The median age was 68 years (range, 26 to 78 years). Patients were diagnosed with B-cell prolymphocytic leukemia (n = 2), chronic lymphocytic leukemia (n = 2), or transformed non-Hodgkin's lymphoma (n = 1). All of these patients had bulky adenopathy or organomegaly. All five patients developed a unique syndrome of severe infusion-related reactions, thrombocytopenia, rapid decrement in circulating tumor cell load, and mild electrolyte evidence of tumor lysis, and all required hospitalization. In addition, one patient developed ascites. These events resolved, and four patients were subsequently treated with rituximab without significant complications.

CONCLUSION

Rituximab administration in patients who have a high number of tumor cells in the blood may have an increased likelihood of severe initial infusion-related reactions. These data also suggest that rituximab may have activity in a variety of other lymphoid neoplasms, such as chronic lymphocytic leukemia and B-cell prolymphocytic leukemia.

The experience of caregiving for severe mental illness: a comparison between anorexia nervosa and psychosis

BACKGROUND

The aim of this study was to examine the experience of care giving for people with anorexia nervosa and to compare it with the experiences of those people who care for a person with a psychotic illness.

METHOD

Carers (parents, siblings and husbands) of people with eating disorders who had experienced an episode of inpatient care for anorexia nervosa (n=71) were given the General Health Questionnaire and the Experience of Caregiving Inventory. A sample of carers (N=68) of people with a psychotic illness from the community were used as a comparison group. A subgroup of the carers (n=20) of people with anorexia nervosa were asked to write about their experiences.

RESULTS

The clinical samples had a similar duration of illness, but the patients with anorexia nervosa were significantly younger and a larger proportion were living at home. The general health scores were significantly higher in the carers of anorexia nervosa and they experienced higher levels of difficulties in most areas of caregiving. A variety of variables from the Caregiving Inventory contributed to the level of psychological distress, accounting for 36% of the variance. The themes of guilt and shame were additional dimensions that were addressed in the letters.

CONCLUSIONS

Carers of people with anorexia nervosa are challenged by the difficulties their role produces.

Localization of centromere function in a Drosophila minichromosome

The DNA elements responsible for centromere activity in a metazoan have been localized using the Drosophila minichromosome Dp1187. Deleted minichromosomes were generated by irradiation mutagenesis, and their molecular structures were determined by pulsed-field Southern blot analysis. Analyses of the transmission behavior of Dp1187 derivatives localized sequences necessary for chromosome inheritance within the centric heterochromatin. The essential core of the centromere is contained within a 220 kb region that includes significant amounts of complex DNA. Completely normal inheritance also requires approximately 200 kb on either side of the essential core. This flanking DNA predominantly contains highly repeated sequences, and the amount required for normal transmission differs among division types and between the sexes. We propose that the essential core is the site of kinetochore formation and that flanking DNA provides two functions: sister chromatid cohesion and indirect assistance in kinetochore formation or function.

Neocentromere activity of structurally acentric mini-chromosomes in Drosophila

Chromosome fragments that lack centromeric DNA (structurally acentric chromosomes) are usually not inherited in mitosis and meiosis. We previously described the isolation, after irradiation of a Drosophila melanogaster mini-chromosome, of structurally acentric mini-chromosomes that display efficient mitotic and meiotic transmission despite their small size (under 300 kb) and lack of centromeric DNA. Here we report that these acentric mini-chromosomes bind the centromere-specific protein ZW10 and associate with the spindle poles in anaphase. The sequences in these acentric mini-chromosomes were derived from the tip of the X chromosome, which does not display centromere activity or localize ZW10, even when separated from the rest of the X. We conclude that the normally non-centromeric DNAs present in these acentric mini-chromosomes have acquired centromere function, and suggest that this example of 'neocentromere' formation involves appropriation of a self-propagating centromeric chromatin structure. The potential relevance of these observations to the identity, propagation and function of normal centromeres is discussed.

Biological and clinical consequences of NPM1 mutations in AML

Acute myeloid leukemia (AML) is characterized by accumulation of myeloid cells in the bone marrow because of impaired differentiation and proliferation, resulting in hematopoietic insufficiency. NPM1 is one of the most commonly mutated genes in AML, present in 20-30% of cases. Mutations in NPM1 represent a distinct entity in the World Health Organization (WHO) classification and commonly indicate a better risk prognosis. In this review, we discuss the many functions of NPM1, the consequence of mutations in NPM1 and possible mechanisms through which mutations lead to leukemogenesis. We also discuss clinical consequences of mutations, associated gene expression patterns and the role of NPM1 mutations in informing prognosis and therapeutic decisions and predicting relapse in AML.

A dynamic posturography study of balance in healthy elderly

Using dynamic posturography, we studied the balance of 234 community-dwelling elderly subjects (mean age, 76 +/- 5 years) as well as 34 young controls (mean age, 34 +/- 12 years). Almost all measures of balance were worse in elderly subjects compared with young controls. The decrements in older persons indicate a diminished capacity to process conflicting sensory input as well as a possible narrowing of the limit of stability (or, alternatively, an increase in sway). We propose that this occurs most likely as a result of biomechanical or central processing changes as opposed to diminished sensory or vestibular input. Furthermore, with difficult tasks sequentially presented, the performance of the older subjects improved, suggesting that balance, at least in the short term, adapts to stressful conditions. In these elderly subjects screened for age-related diseases affecting balance, only small decrements of balance occurred between the ages of 70 and 85 years. This nominal decrease over a 15-year span suggests that clinically significant balance impairment is the result of age-related disease rather than an inevitable consequence of aging and is therefore potentially treatable.

Depsipeptide (FR 901228) promotes histone acetylation, gene transcription, apoptosis and its activity is enhanced by DNA methyltransferase inhibitors in AML1/ETO-positive leukemic cells

In t(8;21) acute myeloid leukemia (AML), the AML1/ETO fusion protein promotes leukemogenesis by recruiting histone deacetylase (HDAC) and silencing AML1target genes important for hematopoietic differentiation. We hypothesized that depsipeptide (FR901228), a novel HDAC inhibitor evaluated in ongoing clinical trials, restores gene transcription and cell differentiation in AML1/ETO-positive cells. A dose-dependent increase in H3 and H4 histone acetylation was noted in depsipeptide-treated AML1/ETO-positive Kasumi-1 cells and blasts from a patient with t(8;21) AML. Consistent with this biological effect, we also showed a dose-dependent increase in cytotoxicity, expression of IL-3, here used as read-out for silenced AML1-target genes, upregulation of CD11b with other morphologic changes suggestive of partial cell differentiation in Kasumi-1 cells. Some of these biologic effects were also attained in other myeloid leukemia cell lines, suggesting that depsipeptide has differentiation and cytotoxic activity in AML cells, regardless of the underlying genomic abnormality. Notably, the activity of depsipeptide was enhanced by 5-aza-2'-deoxycytidine, a DNA methyltransferase inhibitor (DNMT). These two agents in combination resulted in enhanced histone acetylation, IL-3 expression, and cytotoxicity, suggesting HDAC and DNMT activities as a potential dual target in future therapeutic strategies for AML1/ETO and other molecular subgroups of AML.

A multicentre longitudinal observational study of changes in self reported health status in people with Parkinson's disease left untreated at diagnosis

BACKGROUND

The issue of when to start treatment in Parkinson's disease (PD) remains controversial. Some favour treatment at diagnosis while others opt for a "wait and watch" policy. The effect of the latter policy on the self reported health status of people with PD is unknown.

AIMS

To record self reported health status through longitudinal use of a validated PD specific questionnaire (PDQ-39) in untreated PD patients in multiple centres in the UK. To compare patients who were left untreated with those who were offered treatment during follow-up.

METHODS

A multicentre, prospective, "real life" observational audit based study addressing patient reported outcomes in relation to self reported health status and other sociodemographic details.

RESULTS

198 untreated PD were assessed over a mean period of 18 months. During two follow-up assessments, the self reported health status scores in all eight domains of the PDQ-39 and the overall PDQ-39 summary index worsened significantly (p<0.01) in patients left untreated. In a comparative group in whom treatment was initiated at or soon after diagnosis, there was a trend towards improvement in self reported health status scores after treatment was started.

CONCLUSIONS

This study addresses for the first time self reported health status, an indicator of health related quality of life, in untreated PD. The findings may strengthen the call for re-evaluation of the policy to delay treatment in newly diagnosed patients with PD.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 2: dentofacial outcomes and patient satisfaction

OBJECTIVE

To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom.

DESIGN

Cross-sectional outcome study.

SETTING

Fifty National Health Service cleft centers.

PARTICIPANTS

Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received.

MAIN OUTCOME MEASURES

Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction.

RESULTS

Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds had not received an alveolar bone graft, and only 58% of bone grafts that had been undertaken were successful. Twenty percent of 12-year-olds and 40% of 5-year-olds had untreated dental caries. Less than one-third of subjects had a good facial appearance as judged by a panel of experts. Levels of patient and parent satisfaction were generally high.

CONCLUSION

A rigorous evaluation of cleft care in the United Kingdom reveals disappointing outcomes.

Mechanical strain inhibits expression of osteoclast differentiation factor by murine stromal cells

Normal dynamic loading prevents bone resorption; however, the means whereby biophysical factors reduce osteoclast activity are not understood. We show here that mechanical strain (2% at 10 cycles per minute) applied to murine marrow cultures reduced 1, 25(OH)(2)D(3)-stimulated osteoclast formation by 50%. This was preceded by decreased expression of osteoclast differentiation factor (ODF/TRANCE). RT-PCR for ODF/TRANCE revealed that ODF/TRANCE mRNA in strained cultures was 59 +/- 3% of that seen in control cultures. No significant effects on total cell count, thymidine uptake, or alkaline phosphatase activity were induced by strain. To isolate the cell targeted by strain, primary stromal cells were cultured from marrow. Mechanical strain also reduced mRNA for ODF/TRANCE to 60% that of control in these cells. In contrast, mRNA for membrane-bound macrophage colony-stimulating factor was not significantly affected. Soluble ODF ( approximately 2 ng/ml) was able to reverse the effect of strain, returning osteoclast numbers to control. Because osteoclast formation is dependent upon ODF/TRANCE expression, strain-induced reductions in this factor may contribute to the accompanying reduction in osteoclastogenesis.

The quality of life of young people with Tourette syndrome

BACKGROUND

The study examined a UK sample of 57 young people with Tourette syndrome (TS).

AIMS

The purpose of this study was to consider the impact of TS on young people's Quality of Life (QoL).

METHODS

The study used a mixed methods design, combining focus groups and questionnaire data. Child report questionnaires measured QoL and TS symptom severity.

RESULTS

The results showed that the QoL of children with TS was significantly worse than that of children in a UK normative sample. Analysis of transcripts from the groups identified four main themes; 'TS can be distressing and disabling', 'struggling to fit into society's expectations of normal behaviour', 'needing to control tics' and 'TS is one part of who I am'.

CONCLUSIONS

Poorer QoL was associated with increased symptom severity in terms of tics, Attention Deficit Hyperactivity Disorder diagnosis and obsessive compulsive behaviours.

Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder

BACKGROUND

We test the hypotheses that (a) cognitive therapy is of comparable efficacy to psychodynamic psychotherapy, (b) 8-10 sessions of therapy is as effective as 16-20 sessions, and (c) brief therapist training is as effective as intensive training.

METHOD

Of 178 out-patients referred to a clinical trial of psychological treatment for generalised anxiety, 110 patients met DSM-III-R criteria for generalised anxiety disorder and were randomly assigned to three different forms of psychotherapy. The main comparison was between cognitive therapy and analytic psychotherapy, delivered by experienced therapists at weekly or fortnightly intervals over six months. A third treatment, anxiety management training, was delivered at fortnightly intervals by registrars in psychiatry after a brief period of training. Eighty patients completed treatment and were assessed before treatment, after treatment, and at six-month follow-up.

RESULTS

Cognitive therapy was significantly more effective than analytic psychotherapy, with about 50% of patients considerably better at follow-up. Analytic psychotherapy gave significant improvement but to a lesser degree than cognitive therapy. There was no significant effect for level of contact. Patients receiving anxiety management training showed similar improvements to cognitive therapy after treatment, with rather lower proportions showing clinically significant change.

CONCLUSIONS

Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients. Significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management. However, the superiority of cognitive therapy at follow-up suggests that the greater investment of resources required for this approach is likely to pay off in terms of more sustained improvement. There is no evidence that 16-20 sessions of treatment is more effective, on average, than 8-10 sessions.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 4: outcome comparisons, training, and conclusions

OBJECTIVE

A critical appraisal of cleft care in the United Kingdom.

DESIGN

Retrospective comparative study.

SETTING

All National Health Service cleft centers in the United Kingdom.

PATIENTS/PARTICIPANTS

Children born with unilateral complete clefts of the lip and palate between April 1, 1982, and March 31, 1984 (12-year-olds), and April 1, 1989, and March 31, 1991 (5-year-olds). Newly appointed and senior cleft clinicians.

MAIN OUTCOME MEASURES

Skeletal pattern, dental arch relationship, success of alveolar bone grafting, dental health, facial appearance, oral health status, patient/parent satisfaction.

CONCLUSIONS

This paper highlights the poor outcomes for the fragmented cleft care in the United Kingdom, compared with European centers. There is an urgent need for a review of structure, organization, and training.

The ACE gene and Alzheimer's disease susceptibility

A recent study suggested that the insertion (I) allele in intron 16 of the angiotensin converting enzyme gene (ACE) is associated with Alzheimer's disease (AD) risk. In our series of 239 necropsy confirmed late onset AD cases and 342 elderly non-demented controls aged >73 years, we found significantly different ACE genotype distributions in the case and control groups (p=0.007). Homozygotes for both the I and D alleles were associated with a higher risk compared to DI heterozygotes. While the APOE epsilon4 allele was strongly associated with AD risk in our series, we found no evidence for an interaction between the APOE and ACE loci. In addition, no interactions were observed between ACE and gender or age at death of the AD cases. A meta-analysis of all published reports (12 case-control series in total) suggested that both the II and ID ACE genotypes are associated with increased AD risk (odds ratio (OR) for II v DD 1.36, 95% confidence interval (CI)=1.13-1.63, OR for DI v DD 1.33, 95% CI=1.14-1.53, p=0.0002).

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 3: speech outcomes

OBJECTIVE

To summarize speech outcomes in children born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom.

DESIGN

Prospective descriptive study on a cross-sectional sample of children.

PATIENTS/PARTICIPANTS

Data were collected for 238 5-year-olds (born between April 1, 1989, and March 31, 1991) and 218 12-year-olds (born between April 1, 1982, and March 31, 1984) with complete UCLP.

MAIN OUTCOMES

Ratings of intelligibility, nasality, "speech cleft type characteristics" and speech therapy intervention.

CONCLUSIONS

Nineteen percent of 5-year-olds and 4% of 12-year-olds were judged to be impossible to understand or just intelligible to strangers. Thirty-four percent of 5-year-olds and 17% of 12-year-olds had at least one serious error of consonant production. Eighteen percent of 5-year-olds and 12-year-olds had consistent hypernasality of mild, moderate, or severe degree. Approximately two-thirds of both age groups had undergone speech therapy.

Antibody binding to neuronal surface in Sydenham chorea, but not in PANDAS or Tourette syndrome

OBJECTIVE

To test the hypothesis that Sydenham chorea (SC) immunoglobulin G (IgG) autoantibodies bind to specific neuronal surface proteins, whereas IgG from patients with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) or Tourette syndrome (TS) do not bind to neuronal surface proteins.

METHODS

We used live differentiated SH-SY5Y cells, which have neuronal and dopaminergic characteristics. Using flow cytometry, we measured serum IgG cell surface binding in patients with SC (n = 11), PANDAS (n = 12), and TS (n = 11), and compared the findings to healthy controls (n = 11) and other neurologic controls (n = 11). In order to determine the specificity of binding to neuronal antigens, we also used a non-neuronal cell line, HEK 293.

RESULTS

The mean IgG cell surface binding was significantly higher in the SC group compared to all other groups (p < 0.001). By contrast, there was no difference between the PANDAS or TS groups and the controls. Using the non-neuronal HEK-293 cells, there was no significant difference in IgG cell surface binding between any groups.

CONCLUSIONS

Serum autoantibodies that bind to neuronal cell surface antigens are present in SC, but not in PANDAS or TS. These findings strengthen the hypothesis that SC is due to a pathogenic autoantibody, but weaken the autoantibody hypothesis in PANDAS and TS.

A novel vasoactive peptide, adrenomedullin, inhibits pituitary adrenocorticotropin release

The potent hypotensive peptide, adrenomedullin (AdM), originally isolated from a human pheochromocytoma is present in a variety of rat and human tissues. We examined its potential effects in anterior pituitary gland, reasoning that it may be a feedback regulator of adrenocorticotropin (ACTH) secretion. Rat AdM11-50 inhibited basal ACTH secretion from dispersed, rat anterior pituitary cells in a significant, dose-related fashion (maximum inhibition at 10(-9) M). Rat AdM11-50 also inhibited, in a dose-related fashion, corticotropin releasing hormone (CRH)-stimulated ACTH secretion, but did not block the ability of CRH to stimulate cAMP accumulation in these cells. These findings suggest that in addition to peripheral actions in the vasculature and kidney, adrenomedullin may act within the anterior pituitary gland to control fluid and electrolyte homeostasis.