Increasing dose intensity of anthracycline antibiotics improves outcome in patients with acute myelogenous leukemia.

To understand the effect of dose concentration in the overall survival of AML, we conducted a study on the efficacy and toxicity of a drug combination where the dose of daunorubicin was intensified. For this analysis, the outcome of patients entered into two consecutive prospective trials was compared. Inclusion criteria in both arms were identical and consisted of primary AML in adults. Treatment protocol for Cape Town Regimen 4 (CTR-IV) comprised of cytarabine infusion (100 mg/m(2)) and etoposide (100 mg/m(2)), injection daily for 7 days in combination with daunorubicin (45 mg/m(2)) on days 1, 2, and 3. Patients achieving remission were given two further courses of the same chemotherapy and received allogeneic or autologous transplantation. CTR-V was a similar treatment program, except that daunorubicin was escalated on days 1, 2, and 3 to 75 mg/m(2) during induction and to 60 mg/m(2) during a single consolidation. Patients were also offered stem cell transplantation. Between 1990 and 1997, 78 patients (median age 33; range 13-67 years) fulfilled entry criteria and received CTR-IV. From 1998 onwards, 35 patients (median age 36; range 15-66 years) were prospectively enlisted into the CTR-V trial. The patient population in CTR-V had fewer Caucasian individuals (P = 0.02) and had significantly lower presentation hemoglobin (P = 0.0002). Following initiation of induction chemotherapy, 40 patients failed to respond. Among these, 10 patients demised before day 28. Another 30 (25/69 CTR-IV and 5/32 in CTR-V groups; P = 0.01) had leukemia that was resistant to chemotherapy, and all died. Remission was achieved in 59% of patients treated with CTR-IV and 77% of those receiving CTR-V (P = 0.03). CR occurred with a single course in 64% versus 88% (P = 0.02), respectively. There were no differences in the toxicity profile between these two combinations. Disease recurred in 50% and 28% (P = 0.07) of patients. For the 113 individuals, median follow up is 254 (range 19-4,451) and 304 (12-1,702; P = 0.03) days. Survival is 23% and 40%, respectively, favoring patients treated with CTR-V (log rank; P = 0.03). Cox regression analysis showed that treatment group (P < 0.001), FAB type, hemoglobin level, and platelet count were independent factors for response to chemotherapy. Older age and not undergoing myeloablative therapy were the only adverse factors for survival. We conclude that increase in the treatment dose of daunorubicin in patients with AML led to a higher remission rate, particularly with a single course of chemotherapy and had an equivalent toxicity profile. This therapeutic modification is also likely to result in substantial reduction in patient stay in hospital and in the overall expenditure.

CD52 antibodies for prevention of graft-versus-host disease and graft rejection following transplantation of allogeneic peripheral blood stem cells.

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity after allogeneic bone marrow transplantation, but can be avoided by removing T lymphocytes from the donor bone marrow. However, T cell depletion increases the risk of graft rejection. In this study, two strategies are used to overcome rejection: (1) use of high doses of stem cells obtained from peripheral blood (PBSC), (2) admixture with a CD52 monoclonal antibody in order to deplete both donor and residual recipient lymphocytes. Two antibodies are compared: CAMPATH-1G (rat IgG2b) and its humanized equivalent CAMPATH-1H (human IgG1). A total of 187 consecutive patients at six centers received PBSC transplants from HLA-matched siblings between 1997 and 1999. A wide spectrum of diseases, both malignant and non-malignant, was included. The recovery of CD34+ cells after antibody treatment was close to 100%. The risk of acute GVHD (grade 2 to 4) was 11% in the CAMPATH-1G group and 4% in the CAMPATH-1H group (P = NS). The risk of chronic GVHD (any grade) was 11% in the CAMPATH-1G group and 24% in the CAMPATH-1H group (P = 0.03) but the risk of extensive chronic GVHD was only 2%. The overall risk of graft failure/rejection was 2%, not significantly different between the two antibodies. Antibody treatment was equally effective at concentrations between 10 microg/ml and 120 microg/ml and it made no significant difference to the outcome whether the patients received post-transplant immunosuppression or not (87% did not). Transplant-related mortality in this heterogenous group of patients (including high-risk and advanced disease) was 22% at 12 months. It is proposed that treatment of peripheral blood stem cells with CAMPATH-1H is a simple and effective method for depleting T cells which may be applicable to both autologous and allogeneic transplants from related or unrelated donors. Special advantages of this approach are the simultaneous depletion of donor B cells (which reduces the risk of EBV-associated lymphoproliferative disease) and the concomitant infusion of CAMPATH-1H to deplete residual recipient T cells and thus prevent graft rejection.

Immune reconstitution after allogeneic bone marrow transplantation depleted of T cells.

BACKGROUND: Immune reconstitution following transplantation in individuals who had received T-cell-depleted marrow from HLA identical siblings was serially documented and correlated with the clinical recovery. METHODS: Patients were preconditioned with radiation containing programs. GvHD prophylaxis was by T-cell depletion with CAMPATH 1G (ex vivo; median dose 20 mg). After transplantation lymphoid development was studied by flow cytometry and serum Ig concentrations were determined. Charts were reviewed to determine the effects of the immune reconstitution on the clinical performance. RESULTS: The mean donor mononuclear cell number infused was 0.89x10(8)/kg. Within 6 months all the patients recovered their blood parameters and only one required therapy for GvHD. However, despite normal blood counts, 15 suffered life-threatening opportunistic infections, developing at a median of 24 weeks post grafting, but occurring even after 11 months. At 8 weeks from marrow infusion when leukocyte values had normalized in 15/20, compared to normal, immunophenotyping of blood cells from BMT revealed a significantly reduced mean lymphocyte count (1.06, SD 0.83x10(9)/l; P = 0.01), cells expressing CD3 (0.7x10(9)/l, SD 0.68; P = 0.05), CD4 (0.13x10(9)/l, SD 0.21; P = 0.0001) and CD19 (0.04x10(9)/l, SD 0.05; P = 0.001). Populations expressing CD8 and CD56 remained within normal range throughout the study. Normalization of cell numbers displaying CD2, CD3 and CD19 was delayed until 52, 52 and 24 weeks respectively, while CD4 counts persisted subnormal even at 72 weeks. Serum IgA levels were significantly decreased for the entire study period. CONCLUSIONS: T-cell depletion with CAMPATH 1G while effectively preventing GvHD, also causes clinically significant and prolonged immunosuppression with apparently important clinical implications.

Cyclic AMP regulates the expression of neurokinin1 receptors by neonatal rat spinal neurons in culture.

Neurokinin1 (NK1) receptors are up-regulated in the spinal cord during peripheral inflammation, but the biochemical mediators regulating this change have not been resolved. The promoter region of the gene encoding the NK1 receptor contains a cyclic AMP (cAMP)-responsive element. Therefore, we used primary cultures of neonatal rat spinal cord to test whether increasing intracellular cAMP can increase expression of NK1 receptors. Treatment with dibutyryl-cAMP (dbcAMP) resulted in a time-dependent increase in 125I-Bolton-Hunter-substance P (BHSP) binding in the cultures; treatment with dibutyryl-cyclic GMP did not. Treatment with forskolin plus 3-isobutyl-1-methylxanthine mimicked the increase in binding, providing further evidence for the involvement of cAMP in this effect. Scatchard analyses indicated that the increase in BHSP binding was due to an increase in binding capacity. The cAMP-induced increase in BHSP binding was preceded by an increase in levels of mRNA for NK1 receptor and was attenuated by pretreatment with cycloheximide. These data indicate that the cAMP-induced increase in binding was due to increased synthesis of NK1 receptors. Comparison of substance P (SP)-induced production of inositol phosphates between cultures pretreated with dbcAMP and controls suggested that increased expression of NK1 receptors did not result in increased generation of second messenger by NK1 receptor activation. Together, these data indicate that a persistent increase in intracellular cAMP increases expression of NK1 receptors. Because NK1 receptor activation contributes to increased excitability of spinal neurons, the increased expression of NK1 receptors may be important in maintaining responsiveness of spinal neurons to SP in central mechanisms underlying hyperalgesia.

Bradykinin increases the proportion of neonatal rat dorsal root ganglion neurons that respond to capsaicin and protons.

A number of studies have examined bradykinin-induced sensitization of primary afferent neurons to mechanical or thermal stimuli. However, bradykinin-induced sensitization to other chemical stimuli has not been systematically addressed. We used primary cultures of dorsal root ganglion neurons from neonatal rats to determine whether bradykinin alters the responsiveness of individual neurons to capsaicin and protons. An increase in the concentration of free intracellular Ca2+ was used as a measure of a response to capsaicin or low pH. Pretreatment with bradykinin (30 nM) increased the proportion of "intermediate-size" (240-320 microm2) dorsal root ganglion neurons that responded to capsaicin (100 nM) or low pH (6.1). However, among "small-size" (160-239 microm2) neurons, bradykinin increased the proportion of neurons that responded to low pH (6.1) but not to capsaicin (10 or 100 nM). Because treatment with arachidonic acid (10 microM) did not mimic the effect of bradykinin and inhibition of cyclo-oxygenase and lipoxygenase with 5,8,11,14-eicosatetraynoic acid (10 microM) did not inhibit the effect of bradykinin on the response to capsaicin, it is not likely that the bradykinin-induced enhancement of neuronal responsiveness is mediated by arachidonic acid or its metabolites in this model. These results support the hypothesis that bradykinin sensitizes primary afferent neurons to other chemicals such as protons that are present in inflamed tissue, particularly by recruiting additional sensory neurons to respond to a given chemical stimulus. An increase in the number of responsive nociceptors that innervate inflamed tissue would contribute to hyperalgesia via spatial summation on spinal neurons in the pathway for pain. Furthermore, since bradykinin enhanced the responsiveness of small-size neurons that responded to protons but not to capsaicin, these data suggest that bradykinin-induced sensitization to protons and capsaicin occur by different mechanisms.

Characterization and regulation of neurokinin1 receptors in primary cultures of rat neonatal spinal neurons.

Neurokinin1 receptors are the primary target of substance P released from neurons during neural transmission, yet little is known regarding the regulation of neurokinin1 receptors on neurons. 125I-Bolton-Hunter-substance P was used in the present studies to determine whether primary cultures of rat neonatal spinal cord express neurokinin1 receptors and, therefore, can be used as a model to explore regulation of neuronal neurokinin1 receptors. 125I-Bolton-Hunter-substance P bound to a single site in neuron-enriched cultures with an affinity of 256 nM, which is comparable to its high affinity binding on adult rat spinal cord. Treatment of neuron-enriched cultures with 10 nM substance P resulted in a 47% decrease in 125I-Bolton-Hunter-substance P binding at 24 h which was due to a decrease in affinity of the receptor. However, at 48 h after treatment with substance P, 125I-Bolton-Hunter-substance P binding increased by 44%. The increase in binding was due to a two-fold increase in receptor density. These changes occurred in the presence of 0.5 microM tetrodotoxin, decreasing the likelihood that the changes in binding were secondary to the release of transmitters by substance P. Furthermore, substance P1-7, a metabolite of substance P that has putative physiological effects, did not alter 125I-Bolton-Hunter-substance P binding. These data provide evidence that neuronal neurokinin1 receptors are under homologous regulation in primary cultures of neonatal rat spinal cord and suggest that a similar mechanism occurs in vivo. Furthermore, the data suggest that a decrease in affinity of the neurokinin1 receptor may contribute, in part, to tachyphylaxis to substance P.

Laser angioplasty: an atherosclerotic swine model.

Rapid production of occlusive, atherosclerotic iliac artery lesions was achieved in 25 of 27 (93%) Yucatan miniature swine, using a combination of high cholesterol diet and mechanical endothelial denudation. Animals were fed a diet with 2% of their calories as raw cholesterol 2 weeks prior to balloon denudation of iliac arteries, which resulted in atherosclerotic lesions within 8 weeks. Early after denudation we have demonstrated total occlusion of arteries by fibrin thrombi, which in time organize and ultimately result in fibrotic occlusive disease. The arterial walls and intima show varying degrees of foam cell infiltration with destruction of the internal elastic lamina and calcification. Totally occluded lesions show fibrointimal proliferation, fibrosis, and multiluminal channels, which are probably secondary to organized thrombus. Our model of occlusive iliac artery disease involving vessels of 1 to 3 mm in diameter allows the development of catheter systems suitable for use in human peripheral and coronary arteries. This model is useful for the study of angioplasty, whether mechanical, balloon, or laser-mediated.

Objective benefit of nifedipine in the treatment of Raynaud's phenomenon. Double-blind controlled study.

To compare the effects of the calcium channel antagonist, nifedipine, with that of placebo, a randomized double-blind crossover study was performed in 11 patients with moderate to severe Raynaud's phenomenon. Digital skin temperature recovery time was measured after immersing the patient's hand in ice water for 20 seconds. Patients were randomly assigned to receiving either nifedipine or placebo for one week, followed by the crossover phase. Skin temperature recovery time was also measured in 21 normal volunteers. The mean time to recovery for patients taking nifedipine was 28.5 +/- 20.8 minutes versus 44.9 +/- 18.9 minutes for patients receiving placebo (p less than 0.05 by analysis of variance with repeated measures). The mean time to recovery for the normal volunteers was 11.3 +/- 7.2 minutes versus 40.2 +/- 19.9 minutes for the patients (p less than 0.01 by the Student t test). Nine of the 11 patients noted improvement of symptoms during treatment with nifedipine. It is concluded that nifedipine is an effective, well-tolerated treatment for Raynaud's phenomenon.

Multicenter double-blind comparison of nomifensine and imipramine for efficacy and safety in depressed outpatients.

Nomifensine, a tetrahydroisoquinoline antidepressant, was compared with imipramine in a 4-week multicenter double-blind study of depressed outpatients (100 on nomifensine, 56 on imipramine). Nomifensine was at least as effective as imipramine in reducing depressive symptoms at average doses of 150 mg/day. When significant differences did occur on Hamilton Depression Rating Scale scores, they favored nomifensine for improvement in cognitive symptoms and interest in work and activities. Early in treatment, nomifensine patients also showed a better relationship between clinical response and side effects. The proportions of patients experiencing at least one side effect or dropping out due to side effects were almost twice as high in the imipramine group. Dry mouth and sedating effects were 2-3 times more frequent among imipramine patients. Thus, nomifensine demonstrated clinical efficacy at least comparable with imipramine but with indications of a more favorable side effects profile.

Novel topical fluoride delivery system II: remineralization of human teeth.

A recently conceived calcium fluoride-containing remineralization system was tested using human teeth in vitro. The influence of several variables (surface pretreatment, demineralization time, and remineralization time) was studied. Appreciable levels of fluoride taken up by pumiced human teeth were found at depths up to 50 micrometers when remineralization was carried out in either the remineralizing solution or saliva. The successful performance of the delivery device in these laboratory studies is encouraging and indicates that the logical evolution of the crude devices studied thus far could lead to clinically practical fluoride delivery devices.

In vivo remineralization using a sustained topical fluoride delivery system.

The efficacy of a new remineralization system was determined in vivo by maintaining a low concentration of approximately 1 ppm fluoride for 48 hrs against a demineralized human tooth. Human subjects were selected who wore removable partial dentures containing two or more of the demineralized teeth with film system. The findings indicate levels of fluoride uptake to 500 ppm at 50 micron depths in experimental sites.