Home administration of bortezomib in multiple myeloma is cost-effective and is preferred by patients compared with hospital administration: results of a prospective single-center study.

BACKGROUND: Subcutaneous (s.c.) administration of bortezomib is the most widely used route of administration for the treatment of patients with multiple myeloma. No study has as yet prospectively evaluated home versus hospital administration of s.c. bortezomib with respect to patient preference and cost. PATIENTS AND METHODS: In this prospective trial, myeloma patients received the first administration of s.c. bortezomib of each cycle in the outpatient unit of the Department of Hematology. When possible, all subsequent doses of bortezomib within each cycle were provided at home. A cost analysis was carried out to compare the average cost of an injection of bortezomib in the outpatient unit and at home. In order to compare hospital and home administration of bortezomib for preference and satisfaction, patients had to complete 2 simple questionnaires analyzing 16 criteria, such as quality of life, well-being, social life, satisfaction, safety, quality of care, the reduction in personal transportation time, and personal anxiety. Each item was analyzed using a Likert scale. RESULTS: Fifty patients were studied. Overall, a total of 1043 s.c. injections of bortezomib were carried out, 655 (62.8%) at home, and 388 (35.2%) in the outpatient unit. The cost analysis showed that the total cost of one s.c. injection of bortezomib in the outpatient unit was €1510.09 versus €1224.57 for the home administration, which represents a reduction of €285.52, i.e. 20% of the cost of the hospital administration. The evaluation of patient preference and satisfaction showed that home administration improved the quality of life in 84% of the patients, increased well-being in 78%, and improved the activities of daily living in 72% of the cases. Overall, 98% of the patients noted their preference for home administration over the hospital administration of bortezomib. CONCLUSION: Home administration of s.c. bortezomib is cost-effective and is preferred by myeloma patients compared with hospital administration.

Upfront allogeneic stem-cell transplantation for patients with nonlocalized untreated peripheral T-cell lymphoma: an intention-to-treat analysis from a single center.

BACKGROUND: Peripheral T-cell lymphomas (PTCLs) are rare and heterogeneous diseases with dismal outcome when treated with chemotherapy alone. Because allogeneic stem-cell transplantation (allo-SCT) can cure relapse/refractory patients, we hypothesized that upfront allo-SCT may provide a better outcome. Therefore, all patients that presented with advanced PTCL in our institution at diagnosis were scheduled to undergo upfront allo-SCT after induction chemotherapy. PATIENTS AND METHODS: The aim of the present work was to assess the feasibility and toxicity of upfront allo-SCT. From 2004 to 2012, 49 newly diagnosed PTCL patients were scheduled to receive upfront allo-SCT. A human leukocyte antigen-matched donor was found for 42 patients: related to the patient in 15 cases, unrelated in 20 cases, and suitable cord blood units were used in 7 cases. RESULTS: After induction chemotherapy, 17 patients reached complete remission and 29 (60%) proceeded to upfront allo-SCT. For all patients, the 1 and 2-year overall survival (OS) rates were 59% [95% confidence interval (CI) 47-75] and 55% (95% CI 43-71), respectively. The most frequent reason we did not proceed to allo-SCT was disease progression or insufficient response after induction. For transplanted patients, the 1- and 2-year OS were 76% (95% CI 62-93) and 72.5% (95% CI 58-91), respectively. Toxicity-related mortality (TRM) 1 year after allo-SCT was only 8.2% (95% CI 0-18.5). The 2-year progression-free survival (PFS) rate of patients who did not proceed to allo-SCT (n = 20) was below 30%. The disease status at the time of transplantation was a strong predictive marker for both PFS and OS in transplant patients. CONCLUSIONS: Upfront allo-SCT in PTCLs is feasible with low TRM, and it provides long-term disease control. However, one-third of patients remain chemo-refractory and, thus, new therapeutic approaches are warranted. The role of upfront allo-SCT compared with other therapeutic approaches in PTCLs requires investigation in randomized studies.

Verneuil's disease, innate immunity and vitamin D: a pilot study.

BACKGROUND: Verneuil's disease is a chronic inflammatory skin disease of the follicles in apocrine glands rich area of the skin (axillary, inguinal, anogenital) and is associated with a deficient skin innate immunity. It is characterized by the occurrence of nodules, abscesses, fistulas, scars. Recently, vitamin D has been shown to stimulate skin innate immunity. OBJECTIVE: The primary objective of the study was to assess whether Verneuil's disease was associated with vitamin D deficiency. The secondary objective was to determine whether vitamin D supplementation could improve inflammatory lesions. METHODS: First, 25(OH) vitamin D3 serum levels in patients with Verneuil's disease followed at Nantes University Hospital were compared to those of healthy donors from the French Blood Bank. Then, a pilot study was conducted in 14 patients supplemented with vitamin D according to their vitamin D level at baseline at months 3 and 6. The endpoints at 6 months were decreased by at least 20% in the number of nodules and in the frequency of flare-ups. RESULTS: Twenty-two patients (100%) had vitamin D deficiency (level <30 ng/mL) of whom 36% were severely deficient (level <10 ng/mL), having correlation with the disease severity (P = 0.03268) vs. 20 controls with vitamin D deficiency (91%) of whom 14% were severely deficient. In 14 patients, the supplementation significantly decreased the number of nodules at 6 months (P = 0.01133), and the endpoints were achieved in 79% of these patients. A correlation between the therapeutic success and the importance of the increase in vitamin D level after supplementation was observed (P = 0.01099). CONCLUSION: Our study shows that Verneuil's disease is associated with a major vitamin D deficiency, correlated with the disease severity. It suggests that vitamin D could significantly improve the inflammatory nodules, probably by stimulating the skin innate immunity. A larger randomized study is needed to confirm these findings.

A new approach for endoscopic neurolysis of the suprascapular nerve at the spinoglenoid notch: A preliminary cadaver study.

The suprascapular nerve (SSN) can become compressed at its 2 scapular attachments: the suprascapular and the spinoglenoid notch. The objective of this study was to describe a new arthroscopic approach for SSN neurolysis at the spinoglenoid notch. Ten cadaver shoulders were used. Two were dissected to simulate the "classical" arthroscopic approach and to help in the creation of a new "direct medial retrospinal" approach. Eight other shoulders were used to validate this new approach, with control of the whole juxta-glenoid course of the SSN as criterion of success. The retrospinal posterior approach allowed the entire juxta-glenoid segment of the SSN to be explored in 6 cases out of 8. One exploration was incomplete, another not feasible. SSN neurolysis at the spinoglenoid notch was feasible in cadavers on a retrospinal approach.

Severe mitochondrial anomaly in dystrophic mouse skeletal muscle.

Mitochondrial fractions were isolated from skeletal muscle of control (C57 BL 6J dy/+) and dystrophic (C57 BL 6J dy/dy) mice, and enzymatic activities (cytochrome c oxidase, rotenone-insensitive NADH cytochrome c reductase) were determined. After electrophoretic separation, calcium-binding proteins were identified. An important anomaly was observed in the mitochondria of dystrophic muscle, i.e., a considerable reduction of a specific calcium-binding protein (61,000 Da mol. wt.).

Calcium binding protein changes of sarcoplasmic reticulum from rat denervated skeletal muscle.

Two Ca2+ sequestering proteins were studied in fast-twitch (EDL) and slow-twitch (soleus) muscle sarcoplasmic reticulum (SR) as a function of denervation time. Ca2+-ATPase activity measured in SR fractions of normal soleus represented 5% of that measure in SR fractions of normal EDL. Denervation caused a severe decrease in activity only in fast-twitch muscle. Ca2+-ATPase and calsequestrin contents were affected differently by denervation. In EDL SR, Ca2+-ATPase content decreased progressively, whereas in soleus SR, no variation was observed. Calsequestrin showed a slight increase in both muscles as a function of denervation time correlated with increased 45Ca-binding. These results indicate first that Ca2+-ATPase activity in EDL was under neural control, and that because of low Ca2+-ATPase activity and content in slow-twitch muscle no variation could be detected, and secondly that greater calsequestrin content might represent a relative increasing of heavy vesicles or decreasing of light vesicles as a function of denervation time in the whole SR fraction isolated in both types of muscles.

Influence of the size of the polar head of non-ionic detergents on membrane proteins immunoaffinity purification.

Nonionic polyoxyethylene type detergents (CxEy) are widely used to solubilize and purify membrane proteins. The detergent hydrophobic moiety (Cx) replaces phospholipids at exposed hydrophobic regions of the membrane proteins. During chromatography on an immobilized anti-Kell antibody to purify Kell protein (an integral erythrocyte protein), it was observed that the size of the polar head of an non ionic detergent added to the mobile phase appeared to influence the interaction of the detergent-protein complex with the immobilized antibody. Further studies were performed using another erythrocyte membrane protein, Glycophorin C and three anti-GPC monoclonal antibodies directed against three epitopes of the extracytoplasmic domain of the protein. The interaction of GPC with the three Protein A-coupled monoclonal antibodies was studied in the presence of three detergents C12E<9>, C13E<15> and C12E<23>. It was observed in batch mode and in column chromatography experiments that the adsorption of GPC to the immunoaffinity supports decreased as the size of the detergent polar head increased. Thus, the polyoxyethylene chain of a detergent might prevent the interaction of the detergent-protein complex with the immobilized antibody.

Flow cytometry and immunoblotting analysis of monoclonal antibodies directed to CD-related antigens.

Thirteen monoclonal antibodies directed to red cell and white cell differentiation antigens have been analysed by flow cytometry and immunoblotting. Nine were identified as CD44 (2D3-1, -2, -3, -4), CD 47 (2D3-5 and -6), CD 58 (2D7 and -8), CD99 (2D3-9), whereas four (2D3-11, -12, -13, and 14) could not be characterised.

Immunochemical characterisation of monoclonal antibodies directed to glycophorins A and/or B.

Among sixty-nine monoclonal antibodies submitted to the workshop, 28 antibodies directed to glycophorins A and/or B but without blood group specificity were investigated by a series of methods involving agglutination, flow cytometry with CHO transfected cells expressing glycophorin A, ELISA with a carbohydrate-free peptide (residues 1-72) of glycophorin A, and immunoblotting. These MAbs were subdivided in several groups according to their specificity: N-terminal portion of GPA and GPB; N-terminal trypsin-sensitive portion of GPA; extracellular ficin-sensitive portion of GPA; intracellular domain of GPA; undetermined. Both flow cytometry with transfectant cells and ELISA with the synthetic peptide prove to be of value in order to determine subspecificities within these groups.

Flow cytometry and immunoblotting analysis of monoclonal antibodies directed to complement regulatory proteins.

A series of 18 monoclonal antibodies directed to complement regulatory proteins were investigated by flow cytometry and immunoblotting. Seventeen antibodies are directed against a phosphatidyl inositol-linked glycoprotein since they show a dual population of erythrocytes from a paroxysmal nocturnal haemoglobinuria (PNH) patient. From this group, 6 antibodies revealed a 65-70 kDa band on immunoblots allowing their identification as anti-DAF (Decay Accelerating Factor; CD55 antigen), and 11 bound to a 20 kDa molecule corresponding to MIRL (Membrane Inhibitor of Reactive lysis, CD59 antigen). One antibody revealed an homogeneous population from the PNH patient and bound to a 200 kDa band on immunoblot that might corresponds to the CR1 (Complement Receptor type 1; CD35).

Production and properties of monoclonal antibodies against human IgG isotypes.

Several monoclonal antibodies (MAbs) against human IgG isotypes were obtained by the fusion of myeloma cells with splenocytes from mice immunized with IgG fractions extracted from human plasma. Four MAbs (F7H7, D4F8, B12A8, and E7E10) were selected by an ELISA technique on the basis of their ability to detect one of the four IgG subclasses. Their specificity was checked using a panel of pure myeloma proteins representative of the main allotypes present on IgG isotypes. In addition, two other MAbs (F3E12 and E6D6) were found able to detect specifically kappa or lambda light chains. The immunochemical properties of these MAbs were analyzed mainly in respect to their capacity to detect and to purify the different human IgG isotypes. The following data were obtained: (1) The ability of the MAbs F7H7, D4F8, B12A8, and E7E10 to measure the concentration of each IgG subclass in serum was estimated by an immunocapture ELISA. Results obtained with the new antibodies were compared with several other MAbs recommended by the IUIS/WHO human Immunoglobulins subcommittee. Similar or better results were obtained with the new anti-IgG1, anti-IgG3, and anti-IgG4, MAbs. (2) The same MAbs were tested for their ability to purify a single IgG subclass from IgG preparations and from normal and pathological sera. Fractions containing about 80% of purified IgG1, IgG3, and IgG4 were obtained after one-step immunoaffinity purification. Consequently, these MAbs proved to be useful to detect, to measure and to purify IgG subclasses.

Azacitidine salvage therapy for relapse of myeloid malignancies following allogeneic hematopoietic SCT.

Patients with hematopoietic malignancies relapsing after allogeneic hematopoietic SCT (allo-HSCT) have a poor prognosis. We retrospectively analyzed the patients who received azacitidine in our center in the course of treatment of their post-transplant relapse. We identified 31 patients. Relapse occurred at a median of 3.7 (1.7-37.6) months following allo-HSCT. Patients received a median number of three cycles (1-12) of azacitidine (7 days, 75 mg/m(2) daily). Thirty-nine percent of patients had either a monosomal karyotype or a complex karyotype. Eleven patients (35%) received at least one DLI. Eleven patients responded to azacitidine, with four patients achieving a CR (13%). Median time to best response was 92 (35-247) days, with a median duration of 209 (64-751) days. One-year estimated survival rate was 14%. In conclusion, azacitidine may reinduce durable remissions in very few patients with AML or myelodysplastic syndrome. The toxicity related to azacitidine was high, although it may be difficult to distinguish between treatment-related side effects, namely due to cytopenia and toxicity due to the relapse or disease progression itself. Early administration of azacitidine after transplant followed by DLI should be considered as a pre-emptive therapy for potential relapse in patients with minimal residual disease or high-risk myeloid malignancies.

[Reperfusion delays in acute coronary syndromes with ST segment elevation (STEMI) depending on prehospital care]. / Évaluation départementale des délais de reperfusion des syndromes coronariens aigus avec élévation du segment ST en fonction de la filière de recours aux soins.

INTRODUCTION: Acute coronary syndrome with ST segment elevation (STEMI) remains a major cause of morbidity and mortality in France, directly correlated with the time management of the patient to achieve reperfusion of the artery as early as possible. But the delay of reperfusion is related to the course that will take the patient to the revascularization. METHODS: To make an observation of departmental practices, we conducted a retrospective monocentric study on the STEMI supported on 4years in the Departmental Hospital of La Roche-sur-Yon by comparing the time of reperfusion in two groups: patients who used the recommended chain=diRect chain (Call the emergency number-specialist mobile emergency unit-Cardiac intensive care unit or cardiac catheterization laboratory), and patients who used another chain=Long chain. RESULTS: On 838 patients with STEMI, 356 (42.5%) used the Direct chain. The average time of reperfusion in the Direct chain group is 4.26hours (±3.12), 6.17hours (±4.82) in the Long chain group. There is a significant difference between the two groups of 1.9hours (P<0.001). Of 186 patients who consulted a general practitioner, 40.3% of patients were not supported by the mobile emergency unit. CONCLUSION: These results should lead to improved practices, to carry on continuing medical education with all actors in the chain and patient information to shorten up the time of reperfusion.

Effect of graft source on mismatched unrelated donor hemopoietic stem cell transplantation after reduced intensity conditioning.

This retrospective report compared the results of graft source on outcome after allogeneic stem cell transplantation (allo-SCT) in patients with hematologic malignancies receiving a reduced intensity conditioning (RIC) regimen. A total of 152 patients received either a RIC allo-SCT using a 9/10 mismatched unrelated donor (MisMUD, n=42) or a double unrelated umbilical cord blood (dUCB, n=110) graft. With a median follow-up of 30.3 months, the cumulative incidence of non-relapse mortality was 26% in the dUCB group versus 24% in the MisMUD group (P=0.95). Grade 3-4 acute graft-versus-host disease (GVHD) incidence was 19.7% in the dUCB group versus 21.4% in the MisMUD group (P=0.83). The cumulative incidence of extensive chronic GVHD at 2 years was 6.4% in the dUCB group versus 21.4% in the MisMUD group (P=0.02). The Kaplan-Meier estimate of overall survival at 2 years was comparable between both groups (52.3% (95% confidence interval (CI), 42.1-61.5%) in the dUCB group versus 47.9% (95% CI, 31.6-62.4%) in the MisMUD group, P=0.55). Progression-free survival at 2 years was 43.3% (95% CI, 33.7-52.5%) in the dUCB group versus 38.3% (95% CI, 23.2-53.3%) in the MisMUD group (P=0.55). These data suggest that dUCB is a valid alternative graft source with significantly less chronic GVHD compared with MisMUD in the setting of RIC allo-SCT.

Comparative biochemical study of sarcolemma and sarcoplasmic reticulum fractions isolated from mouse skeletal and cardiac muscles.

1. Ca-ATPase activity, calcium-binding proteins and Concanavalin-A-bound glycoproteins of sarcolemma and sarcoplasmic reticulum were compared in mouse cardiac and skeletal muscles. 2. Ca-ATPase activity and calsequestrin were quite reduced in cardiac muscle, and the quantity of calcium bound to these two proteins was practically negligible, contrary to what was observed with skeletal muscle. In addition, the quantity of lipid bound calcium was not greater in cardiac muscle than in skeletal muscle. 3. Certain proteins seemed exclusively specific for skeletal muscle, including a 30,000 mol. wt glycoprotein which was totally absent in cardiac muscle sarcolemma.

The murine monoclonal antibody NaM26-4C6 identifies a common structure on band 3 and glycophorin C.

The murine monoclonal antibody NaM26-4C6 (IgM class), obtained from the splenocytes of a BALB/c mouse immunized with human umbilical cord red blood cells, was characterized by agglutination test and immunoblotting analysis. The structure of the NaM26-4C6 epitope was further elucidated by using a series of peptides synthesized on pins. The antibody agglutinated untreated and chymotrypsin-treated but not trypsin- or neuraminidase-treated human erythrocytes. Agglutination-inhibition test demonstrated that the antibody recognizes an epitope located on the N-terminal trypsin-sensitive portion of glycophorin C. The antibody bound on immunoblots to glycophorin C, and also to the band 3 protein and its 69-kDa N-terminal fragment but did not bind to desialylated and de-O-glycosylated glycophorin C. Peptide mapping allowed localization of the binding site on the 23-kDa N-terminal intracellular peptide of band 3. The antibody binds to the amino-acid sequences 22EDPDIP27 of band 3 protein and 15SLEPDPGM22 of glycophorin C, and residues D and P were found to be essential. The new epitope identified by NaM26-4C6 corresponds to a linear amino acid sequence located on the N-terminal intracellular portion of band 3 and to a more complex structure involving oligosaccharide chains on the N-terminal extracellular domain of GPC.

A murine monoclonal antibody directed against the Gerbich 3 blood group antigen.

A murine monoclonal antibody (NaM19-3C4, IgG1, Kappa) was produced from splenocytes of mice immunized with red blood cells. The antibody agglutinated untreated Ge:2,3,4 and Ge:-2,3,4 erythrocytes in indirect antiglobulin test but failed to agglutinate trypsin-treated cells. Gerbich-negative erythrocyte of the Leach- (Ge:-2,-3,-4) and of the Gerbich- (Ge:-2,-3,4) types were not recognized by the antibody. Immunoblotting experiments showed that the antibody bound to glycophorins C and D from control erythrocytes and to the abnormal glycophorin C identified in the Gerbich-negative cells of the Yussef type (Ge:-2,3,4). No binding to the altered glycophorin C from Ge:-2,-3,4 erythrocytes was observed, indicating that the antibody specifically recognized the Ge:3 epitope localized within residues 40-50 of glycophorin C.

Calcium-related defects in cardiac and skeletal muscles of dystrophic mice.

Ca2+ ATPase and calcium binding proteins were studied in cardiac and skeletal muscles of normal and dystrophic mice. In normal and dystrophic mice, Ca2+ ATPase was quite reduced in cardiac muscle compared to skeletal muscle and was, unlike skeletal muscle, insensitive to orthovanadate. Ca2+ ATPase in skeletal muscle of dystrophic mice was reduced as compared to normal mice. In both cases (normal and dystrophic), calcium binding proteins were the same (identical molecular weight). The effect of 2 drugs (Polymixine B and Bepridil) which decrease protein bound calcium was studied: the muscle proteins of dystrophic mice did not present the same sensitivity to Bepridil as controls. These findings suggest the existence of a calcium-related defect in skeletal and cardiac muscle of dystrophic mice.

Characterization of murine monoclonal antibodies directed against the Kell blood group glycoprotein.

Murine monoclonal antibodies (MoAbs) were produced against the blood group KEL1 glycoprotein (93 kD component) immunopurified from human erythrocytes. One monoclonal antibody, 5A11 (IgGa, kappa), detects by immunoblotting a 93 and 184 kD component from KEL: 1,-2 or KEL: -1,2 red cell membrane preparations, separated by SDS polyacrylamide gel electrophoresis (PAGE) under non-reducing conditions. The 184 kD component was not detected under reducing conditions, suggesting that it represented a dimer of the 93 kD KEL glycoprotein. Neither the 93 nor the 184 kD could be detected from K0 or McLeod erythrocyte membrane preparations, indicating that the monoclonal antibody reacts with the KEL glycoprotein previously identified as a 93 kD species. Since this antibody does not agglutinate native or protease-treated erythrocytes, it is likely that it reacts with the cytoplasmic domain of the KEL glycoprotein. This was also substantiated by showing that 5A11 could immunoprecipitate the 93 kD component from intact membranes and inside-out vesicles but not from right-side-out vesicles. Immunostaining of membrane proteins prepared from human blood cells (platelets, lymphocytes, monocytes and granulocytes) and non-human erythrocytes revealed that the 93 kD molecule was only present on human red cells. Several other murine monoclonal antibodies obtained from the same fusion experiment gave identical results, but competition analyses on immunoblots indicated that these antibodies reacted with distinct epitopes on the KEL glycoprotein.

[Characterization of murine monoclonal antibodies against fetal erythrocytes]. / Caractérisation d'anticorps monoclonaux murins dirigés contre les érythrocytes foetaux.

Balb/c mice were immunized against papain-treated fetal erythrocytes and splenocytes were fused with Sp2/0-Ag-14 myeloma cells. Several hybrids secreting antibodies directed against antigenic determinants predominantly exposed on fetal and cord cells were selected and cloned twice. Antibodies NaM61-1A2 and NaM61-768 (IgM class) were shown to be specific for an endo-beta-galactosidase-sensitive oligosaccharide chain. The antigen, strongly expressed on fetal and cord cells, was identified as the i blood group antigen. The antibodies represent powerful blood group reagents to be use in conventional agglutination techniques as well as in the gel typing system and in indirect flow cytometry. The antibody NaM46-4A8 (IgG class) is specific for an antigenic structure expressed on fetal cells and accessible only after papain, ficin, bromelin and endo-beta galactosidase treatment. The antigen was not identified.