Effectiveness of etoposide chemomobilization in lymphoma patients undergoing auto-SCT.

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 µg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.

Recombinant human factor VIIa (rFVIIa) can activate factor FIX on activated platelets.

The studies reported here show that factor (F)VIIa can activate factor (F)IX on activated platelets in the absence of tissue factor. Both FIX and FIXa bind to the activated platelet surface with a K(d) of 8 nM and 2 nM, respectively. With factor (F)VIIIa, FIXa binds more tightly to platelets (K(d) 0.6 nM). At rFVIIa concentrations < 100 nm, no direct binding to the activated platelet surface can be detected with electrophoretic light scattering. However, in the presence of FIX, rFVIIa binding to platelets at concentrations as low as 10 nm rFVIIa can be detected. This is reflected by a decrease in the FIX K(d) from 8 to 1.6 nM. When rFVIIa is added to activated platelets in the presence of both FIX and FVIIIa, the K(d) for FIX decreases to 0.6, suggesting that rFVIIa activates FIX on the surface of activated platelets in the absence of tissue factor. The activation of FIX by FVIIa on activated platelets can also be demonstrated by a functional assay for FIXa. These data show that pharmacological doses of rFVIIa result in the direct activation of FIX by rFVIIa to form additional tenase complexes ultimately resulting in improved thrombin generation. These results may explain, at least in part, the mechanism of action of rFVIIa in hemorrhagic conditions seen in otherwise normal patients who develop an acquired coagulopathy due to trauma, surgery or a variety of other events in which rFVIIa has been found to be effective.

Comparison of granulocyte colony-stimulating factor (G-CSF)--mobilized peripheral blood progenitor cells and G-CSF--stimulated bone marrow as a source of stem cells in HLA-matched sibling transplantation.

HLA-identical bone marrow or stem cell transplantation from a sibling is the preferred treatment for patients with chronic myelogenous leukemia, bone marrow failure syndromes, relapsed acute leukemia, and specific inborn errors of metabolism. Several groups have shown that granulocyte colony-stimulating factor (G-CSF)--mobilized peripheral blood progenitor cells (PBPCs) obtained from HLA-matched siblings are effective in reconstitution of marrow function after marrow ablative conditioning therapy. To evaluate whether G-CSF treatment before bone marrow harvest leads to enhanced recovery of PBPC counts and recovery from limited graft-versus-host disease (GVHD), we assessed the outcome of a sequential cohort of patients treated identically and then given either G-CSF--mobilized PBPCs or G-CSF--stimulated bone marrow from HLA-identical siblings. We show that the time to neutrophil engraftment is identical in the 2 cohorts, whereas platelet engraftment is earlier with the use of PBPCs. The incidence of acute GVHD was decreased, and that of chronic GVHD significantly decreased, in the group receiving bone marrow. Overall survival was not different between the 2 groups. Thus, G-CSF--stimulated bone marrow offers a source of stem cells that allows for early neutrophil engraftment with a decreased risk of GVHD.

CD34+ selection of hematopoietic blood cell collections and autotransplantation in lymphoma: overnight storage of cells at 4 degrees C does not affect outcome.

The purpose of this study was to investigate whether storing mobilized peripheral blood progenitor cell (PBPC) collections overnight before CD34+ selection may delay platelet count recovery after high-dose chemotherapy and CD34+-enriched PBPC re-infusion. Lymphoma patients underwent PBPC mobilization with cyclophosphamide 4 g/m2 i.v. and G-CSF 10 microg/kg/day subcutaneously. Patients were prospectively randomized to have each PBPC collection enriched for CD34+ cells with the CellPro CEPRATE SC System either immediately or after overnight storage at 4 degrees C. Thirty-four patients were randomized to overnight storage and 34 to immediate processing of PBPC; 15 were excluded from analysis due to tumor progression or inadequate CD34+ cell mobilization. PBPC from 23 patients were stored overnight, while 30 subjects underwent immediate CD34+ selection and cryopreservation. Median yield of CD34+ enrichment was 43.6% in the immediate processing group compared to 39.1% in the overnight storage group (P = 0.339). Neutrophil recovery >500 x 10(9)/l occurred a median of 11 days (range 9-16 days) in the overnight storage group compared to 10.5 days (range 9-21 days) in the immediate processing group (P = 0.421). Median day to platelet transfusion independence was 13 (range 7-43) days in the overnight storage group vs 13.5 (range 8-35) days in those assigned to immediate processing (P = 0.933). We conclude that storage of PBPC overnight at 4 degrees C allows pooling of consecutive-day collections resulting in decreased costs and processing time without compromising neutrophil and platelet engraftment after infusion of CD34+-selected progenitor cells. Bone Marrow Transplantation(2000) 25, 559-566.

Differences between contrast media in the inhibition of platelet activation by specific platelet agonists.

RATIONALE AND OBJECTIVES: The authors evaluated the ability of three x-ray contrast agents--a nonionic monomeric agent (iohexol), a nonionic dimeric agent (iodixanol), and an ionic dimeric agent (ioxaglate)--to either directly activate platelets or inhibit a platelet agonist from activating platelets. METHODS: Fluorescence spectroscopy was used to detect the effect of contrast media on platelet activation. In this method, the platelet is first exposed to a fluorescent probe, which is de-esterified and trapped to Fluo-3 within the platelet. In the presence of calcium, the fluorescence emission from Fluo-3 is increased 80-fold. Thus, the increase in the free platelet calcium associated with platelet activation can be used to indicate platelet activation. RESULTS: None of the agents were shown to directly activate platelets. However, wide differences in the ability of contrast media to inhibit platelet activation by a specific agonist were observed. Activation of platelets by epinephrine or arachidonic acid was not affected by any of the three contrast media studied. All three agents partially inhibited collagen activation of platelets, with ioxaglate the more potent inhibitor. Ioxaglate was the only agent to inhibit thrombin activation of platelets. Inhibition of adenosine diphosphate platelet activation was more extensive with ioxaglate than with iodixanol; iohexol produced no inhibition at all. CONCLUSION: Direct activation of platelets by contrast media was not observed. Of greater importance is the finding that ionic contrast media, but not nonionic contrast media, inhibit thrombin activation of platelets by binding to the anion-binding exosite I, thus preventing thrombin from binding to and activating the platelet.

Effect of homo poly(L-amino acids) on fibrin assembly: role of charge and molecular weight.

Positively charged molecules such as protamine, leukocyte cationic protein, and the carboxyl terminus of platelet factor 4 have been shown to increase fibrin fiber thickness. Synthetic homo poly(L-amino acids) were used to explore the role of charge and molecular weight of cationic molecules on fibrin assembly. The effects of poly(L-lysine) (PLL), poly(L-glutamic acid) (PLG), poly(L-aspartic acid) (PLA), poly(L-histidine) (PLH), and poly(L-arginine) (PLArg) on the assembly and structure of fibrin gels were studied by using light-scattering techniques. At a PLG (Mr 60,000) concentration of 80 micrograms/mL and a PLA (Mr 20,000) concentration of 64 microgram/mL, neither of these negatively charged polymers produced a detectable change in either fibrin assembly kinetics or final structure. Positively charged PLArg (16 micrograms/mL) caused a 30% increase in fibrin fiber mass/length ratio without calcium. In contrast, PLH (16 micrograms/mL), also positively charged, had no effect in the absence of CaCl2 but produced a 40% increase in fiber mass/length ratio with 5 mM CaCl2. At concentrations as low as 1 microgram/mL, positively charged PLL increased the initial fibrin assembly kinetics and led to larger fiber mass/length ratio. The impact on fibrin mass/length ratio was equivalent for three different molecular weight preparations of PLL (Mr 25,000, 90,000, and 240,000). The lack of a molecular weight effect on fiber thickness and the low polymer concentrations required to produce the perturbation argue against an excluded volume effect as the mechanism by which lateral fiber growth is augmented. Mechanisms by which poly(L-amino acids) may perturb fibrin assembly are discussed.

Nonsecretory multiple myeloma.

A diagnosis of nonsecretory multiple myeloma, based on multiple bony lytic lesions seen on roentgenographic studies and sheets of plasma cells seen in the bone marrow, was established in two patients with severe back pain. No paraprotein was detected in the serum or concentrated urine of the patients. Immunofluorescent staining of the bone marrow demonstrated the presence of intracytoplasmic J chains in the patients' plasma cells.

The use of high-dose intravenous gamma-globulin in acquired von Willebrand syndrome.

Acquired von Willebrand syndrome has been reported in patients with a variety of primary diseases, many immunologic in nature. Usually, an autoantibody to von Willebrand factor can be identified. These patients often experience severe hemorrhages requiring large doses of cryoprecipitate or factor VIII concentrates, thus exposing them to viral and allergic complications. The success of intravenous gamma-globulin in the treatment of other autoimmune diseases prompted us to treat two patients with acquired von Willebrand syndrome with high-dose intravenous gamma-globulin. Two days after initiation of therapy, von Willebrand factor and factor VIII rose to normal levels in both patients. Patient 1 underwent dental surgery, and patient 2 underwent a splenectomy without increased bleeding and without additional factor coverage or desmopressin acetate therapy. Thus, intravenous gamma-globulin is efficacious for acquired von Willebrand syndrome and obviates the need for replacement therapy with its attendant complications.

Oophoropexy and the management of Hodgkin's disease. A reevaluation of the risks and benefits.

Female patients with Hodgkin's disease who undergo staging laparotomy frequently have oophoropexy performed to preserve both fertility and hormone production. Because of recent changes in therapy favoring systemic chemotherapy rather than total nodal irradiation for patients with stage III Hodgkin's disease, the need for oophoropexy may be less than previously described. Thirty-nine women of childbearing age underwent laparotomy at the University of North Carolina, Chapel Hill, from 1970 to 1984. Twenty-seven patients underwent oophoropexy. Only three of these patients would have needed this procedure based on their subsequent therapy. Two patients required additional gynecologic surgery because of complications related to the oophoropexy. The success rate in preservation of menstrual function and fertility is also discussed. We review the previous experience with oophoropexy and suggest an alternative approach to the routine use of this procedure.

Hyperfibrinogenemia as a cause of prolonged thrombin clotting time.

Recognized causes of a prolonged thrombin clotting time (TCT) include a decreased plasma fibrinogen level, dysfibrinogenemia, paraproteinemia, heparin contamination, elevated levels of fibrin degradation products, and liver failure. We have frequently seen patients with an isolated prolonged TCT in the absence of any of these conditions and without obvious clinical impact. During a previous evaluation of hyperfibrinogenemia, we noted a surprisingly high incidence of prolonged TCT, prompting this evaluation of hyperfibrinogenemia as a possible cause. In our prospective study nine patients had a TCT more than 3 seconds longer than a matched control subject's TCT, with simultaneously normal prothrombin and activated partial thromboplastin times. Eight patients had fibrinogen levels more than 100 mg/dl above the control level (range 383 to 1,223 mg/dl). Only one patient's prolonged TCT could be explained on the basis of elevated levels of fibrin degradation products. In vitro studies in both a purified fibrinogen system and in plasma confirmed a delay in TCT with increasing initial fibrinogen concentrations. Kinetic measurements demonstrated a slowing of the normal initial increase in turbidity seen upon the addition of thrombin. Possible explanations include binding of thrombin to fibrin, or interference with fibrin assembly by excess fibrinogen. Regardless of the kinetic explanation, isolated prolongations of TCT due to hyperfibrinogenemia appear to be of minimal clinical significance.

Viscous factors in peripheral tissue perfusion.

To ascertain the relative importance of the factors that influence blood viscosity (VIS), we measured hematocrit (HCT), filterability index, fibrinogen level (FIB), and Ektacytometer indices at osmolarities of both 290 (EI 290) and 200 (EI 200) in 21 diabetic patients with peripheral vascular disease (DPVDs) and 11 healthy volunteers (HVs). Stepwise multiple regression analyses generated a formula based on three of the independent variables (FIB, HCT, EI 200) that accurately predicted VIS (r = 0.79, p less than 0.01). Based on the beta coefficients and F statistics, HCT and FIB were the most important elements in the linear regression equation. Compared with HVs the total group of DPVDs had lower HCT (36.5% vs. 42.4%) and higher FIB (661 vs. 276 mg/dl, p less than 0.01) values. When all HVs were compared with a subgroup of DPVDs with similar HCT (n = 10), both FIB and VIS were higher (p less than 0.001) in the DPVD than in the HV group. We conclude that the most important of the multiple factors that influence VIS are HCT and FIB. The finding of increased FIB in DPVDs could have important implications for drug and surgical therapy in this group of patients.

The physical characterization of an aggregating IgG heteropolymer containing rheumatoid factor.

An IgG heteropolymer containing rheumatoid factor activity was isolated from the serum of a patient with the polyclonal hyperviscosity syndrome. This aggregating system was characterized using ultracentrifugation, classical light scattering, and rheological methods. The degree of polymerization is shown to be reversible and dependent on both pH and concentration. Light-scattering studies show a minimum stable intermediate consisting of four IgG monomers to exist at pH 7.4. The theoretical intrinsic viscosity and radius of gyration for the feasible configurations of such a tetramer were calculated. These models were compared to the experimental values. A cyclic structure is shown to be most compatible with the experimental data. Immunochemical analysis suggests that each tetramer contains two IgG1 rheumatoid factors binding to determinants on IgG3 Fc regions.