How to Simplify the Evaluation of Newly Introduced Chemotherapeutic Interventions in Myeloma.

When the bortezomib [PS341], adriamycin and dexamethasone (PAD) regimen was first evaluated, the response rate in untreated patients was much superior to that elicited by conventional chemotherapeutic agents. We demonstrated the efficacy of PAD in relapsed or refractory patients by comparing the response rate obtained in 53 patients who received vincristine, adriamycin and dexamethasone (VAD) or equivalent regimen as induction therapy, using a comparative design in which each patient acted as their own control. Whereas 25 patients had a positive response to VAD, 37 patients had a response to PAD ≤ partial remission (PR) (p = 0.023). Using the more stringent response level of very good PR (VGPR) the results favored the PAD regimen very significantly (p = 0.006) (McNemars test). Similar results were seen using paired M-protein levels from individual patient comparisons. As the PAD regimen was subsequently adopted as the re-induction therapy in the British Society for Blood and Marrow Transplantation/United Kingdom Myeloma Forum Myeloma X (Intensive) trial, now concluded, we have retrospectively analyzed the findings from both studies. Comparison of response rates and adverse effects of patients having had previous autologous transplantation (Cohort 1) with the corresponding data from Myeloma X showed close correlation. These findings provide evidence that rapid results may be obtained in the evaluation of newly introduced, and potentially highly effective, anti-tumour agents by direct comparison to the response to the immediately preceding standard regimen, particularly in relatively resistant tumours.

A Novel Synthetic Simulation Platform for Validation of Breathing Rate Measurement.

Validation of biosensor algorithms is paramount for regulated medical devices applied to patient monitoring. We present validation of breathing rate (BR) measurement using a patch medical device via a novel synthetic simulation platform, in-hospital data collection and controlled laboratory study. Single-lead ECG and triaxial body acceleration signals with variability and noise are synthetically generated and quantized for a constellation according to the input parameters of heart rate (HR) as a fundamental frequency $( f_{c})$ of ECG and reference BR as a modulating frequency $( f_{r})$. Synthetic signals are input to the BR algorithms and the performance of output BRs are evaluated for a region-of-interest of the constellation $( f_{c}/ f_{r}\,\ge 3$ & $f_{c}/ f_{r}\,\le 8)$ accounting the Nyquist and physiological varability. The performances of patch sensor's BR are also evaluated in 13 post-operative patients with reference to a clinical bedside monitor and in 57 subjects carrying out a controlled laboratory protocol with reference to capnography. The synthetic simulations revealed mean absolute error (MAE) of 0.8±0.6 brpm and standard deviation of absolute error of 0.3±0.2 brpm for the BR algorithms of patch sensor. The controlled laboratory testing revealed MAE of 1.7±0.7 brpm (n=57) for stationary conditions. The proposed simulation platform can be useful for developmental refinement or validation of BR measurement prior to testing in humans at clinical or laboratory conditions and applicable for testing other patient monitoring devices with modular modifications.

Central line-related bacteremia due to Roseomonas mucosa in a patient with diffuse large B-cell non-Hodgkin's lymphoma.

A 42-year-old male patient with a history of diffuse large B-cell non-Hodgkin's lymphoma (DLBCL) developed a central line-related bacteremia due to the presence of a Gram-negative bacillus, which was difficult to identify conventionally. Sequencing of a partial region of the 16S rRNA gene identified the organism as Roseomonas mucosa with a homology score of 100% with 1003 bases called. Due to difficulties with the phenotypic identification of this genus, coupled with its emergence in line-related bacteremia in hematology patients with malignancy, Roseomonas spp. should be considered in cases of line-related infection in such patients with atypical Gram-negative organisms. Although several cases have been reported in the literature of line-related sepsis due to Roseomonas gilardii, only a few cases have been reported of Roseomonas mucosa infection in patients with hematological malignancy. This report highlights the benefits of the integration of a sequence-based typing approach in the identification of difficult-to-identify bacterial isolates employing partial regions of the 16S rRNA gene. Continued routine adoption of such techniques by clinical diagnostic laboratories may prove beneficial for the correct identification of blood-borne infections, as well as for the correct epidemiological characterization of unusual causal agents of bacteremia in immunocompromised individuals.

Tetrasomy 13 as the sole cytogenetic abnormality in acute myeloid leukemia M1 without maturation.

We report a case of acute myeloid leukemia (AML) M1 showing a 48,XY,+13,+13 karyotype. Treatment was according to the Medical Research Council AML14 trial protocol with two courses of DAT chemotherapy. Postchemotherapy bone marrow examination failed to show complete remission or cytogenetic normalization. Despite having resistant disease, the patient initially remained clinically well although requiring regular blood transfusions for anemia. However his leukocyte count gradually increased and he became symptomatic. He was treated subsequently with FLAG but died approximately 2 weeks later, 6 months after first presenting. Tetrasomy 13 as the sole cytogenetic abnormality has not been reported previously in M1 AML and has only been reported in three other AML cases, all with an immature phenotype and poor outcome.

Neither P-gp SNP variants, P-gp expression nor functional P-gp activity predicts MDR in a preliminary study of plasma cell myeloma.

INTRODUCTION: Multidrug resistance (MDR) mediated by P-glycoprotein (P-gp) can compromise the successful treatment of many malignancies including plasma cell myeloma (PCM). However, methods do not yet exist that can accurately determine P-gp activity in PCM patient samples. METHODS: In this study, we have utilized new advances in flow cytometric methods to determine the activity of P-gp in PCM tumor cells. Furthermore, we have used several PCR-based approaches to perform a pilot study determining the functional impact of ABCB1 SNPs in patients with PCM. RESULTS: No associations were seen between P-gp activity or expression and subgroups of PCM. Similarly, no association was seen between P-gp expression and SNPs within ABCB1 although a nonsignificant reduction in activity was demonstrated for rs1045642 (P = 0.121). CONCLUSIONS: We have described a new method for the determination of P-gp and MRP activity suitable for use in clinical studies and have optimized this method to include a gating strategy, allowing routine use on PCM bone marrow aspirate samples. This is the first patient study to consider the full impact of SNPs within ABCB1 all the way from the genome to the proteome in PCM. The methods described here could also be utilized for future studies of "stem cell like" side populations in PCM that are considered to be drug resistant. Furthermore, minor amendments to these methods will facilitate studies of P-gp, MRP, and BCRP activity in other haematological malignancies.

Multidrug resistance gene expression and ABCB1 SNPs in plasma cell myeloma.

Multi-drug resistance (MDR) leads to impaired treatment efficacy in all forms of malignancy. The main forms of MDR are thought to be mediated by the substrate transporting actions of certain adenosine triphosphate binding cassette (ABC) transport proteins. The genes ABCB1, ABCB4, ABCC1, ABCG2 and LRP1 have been identified as the most prominent contributors to clinically significant MDR. To date, no study has investigated the expression of these genes in plasma cell myeloma (PCM), or attempted to relate their expression to the incidence of relapse and/or stage at presentation. Here, we show that ABCB4 may be a prominent mediator of tumour cell MDR within PCM. Additionally, there are three SNPs (rs1045642, rs2032582 and rs1128503) within the most widely studied of these genes, ABCB1, which have been suggested to have a potential impact on OS in PCM and which may form a haplotype in ABCB1. rs1045642 in ABCB1 appears to be the only SNP affecting OS within the PCM patients studied, with minimal linkage disequilibrium demonstrated between it and rs2032582 and rs1128503.

Bronchial associated lymphoid tissue (BALT) lymphoma presenting as chronic lung sepsis.

A 58-year-old woman was referred from her general practitioner to the respiratory clinic with a 2 year history of recurrent pulmonary infections, mucus hypersecretion and right lobe consolidation following a severe pneumonic illness in 2006. She had no significant risk factors for respiratory disease. Chest computed tomography showed an air bronchogram and right lower lobe consolidation. On initial routine investigation IgA and IgG were normal; however, a discrete IgM paraprotein band in the mid gamma region was seen on serum electrophoresis. She was referred for haematological investigations. Bone marrow biopsy was positive for monoclonal lymphoplasmocytoid B cells and the patient was diagnosed with Waldenström's macroglobulinaemia. Due to recurrent infections and an unclear diagnosis of the lung process, a right lower lobectomy and wedge resection of the middle lobe was performed. This showed bronchial associated lymphoid tissue lymphoma arising in the marginal zone. She has been well since surgery with no further respiratory infections.

ABCB1 (MDR1) rs1045642 is associated with increased overall survival in plasma cell myeloma.

Multi-drug resistance (MDR) may compromise the successful management of haematological malignancies, impairing the effectiveness of chemotherapy. The P-glycoprotein (P-gp) drug efflux pump, encoded by the gene ABCB1 (MDR1), is the most widely studied component in MDR. A single nucleotide polymorphism (SNP) has been identified within ABCB1, rs1045642 (C3435T), which may alter P-gp substrate specificity and have an impact on the effectiveness of treatment, and hence overall survival (OS). We estimated the frequency of this SNP in the Northern Irish population and investigated its impact on the OS of patients with plasma cell myeloma (PCM). There was no significant difference in the frequency of rs1045642 between the PCM cohort and an age- and gender-matched control population. Findings within the PCM cohort suggest that rs1045642 genotype influences OS (p = 2 x 10(-2)). If confirmed in larger studies, these results suggest that genotyping rs1045642 may be a useful predictor of outcome in PCM and could indicate modified treatment modalities in certain individuals.

Serum TK levels in CLL identify Binet stage A patients within biologically defined prognostic subgroups most likely to undergo disease progression.

OBJECTIVE: Serum thymidine kinase (TK) levels have been shown to be correlated with survival in many malignancies, including chronic lymphocytic leukaemia (CLL). This study was designed to investigate associations between TK levels and other prognostic markers, in newly and previously diagnosed Binet stage A patients. Furthermore, the use of serum TK measurement to identify subcategories of disease within those defined by IgV(H) mutational status, gene usage and chromosomal aberrations was investigated. METHODS: Ninety-one CLL patients were enrolled. Serum TK levels were measured using a radioenzyme assay. IgV(H) mutational status and V(H) gene usage were determined using BIOMED-2 primers and protocol. Recurring chromosomal abnormalities were detected by interphase fluorescent in situ hybridisation (FISH). Flow cytometry and reverse transcriptase polymerase chain reaction (RT-PCR) determined CD38 and Zap-70 expression, respectively. RESULTS: Significantly higher serum TK levels were found in IgV(H) unmutated, compared with IgV(H) mutated, patients (P < 0.001). Elevated TK levels were also found in patients with CD38 and Zap-70 positivity (P = 0.004, P < 0.001, respectively), short lymphocyte doubling time (LDT) (P = 0.044) and poor or intermediate prognosis chromosomal aberrations (P < 0.001). CONCLUSION: A TK level of >8.5 U/L best identified patients with progressive disease. Elevated TK levels could identify patients categorised, at diagnosis, into good prognosis subgroups by the various biological markers (mutated IgV(H), good prognosis chromosomal aberrations, Zap-70(-) and CD38(-)) who subsequently showed disease progression. Additionally, patients with V(H)3-21 gene usage showed high TK levels, irrespective of mutational status, and serum TK measurement retained predictive power as disease progressed in all subcategories studied.