A complementary role of multiparameter flow cytometry and high-throughput sequencing for minimal residual disease detection in chronic lymphocytic leukemia: an European Research Initiative on CLL study.

In chronic lymphocytic leukemia (CLL) the level of minimal residual disease (MRD) after therapy is an independent predictor of outcome. Given the increasing number of new agents being explored for CLL therapy, using MRD as a surrogate could greatly reduce the time necessary to assess their efficacy. In this European Research Initiative on CLL (ERIC) project we have identified and validated a flow-cytometric approach to reliably quantitate CLL cells to the level of 0.0010% (10(-5)). The assay comprises a core panel of six markers (i.e. CD19, CD20, CD5, CD43, CD79b and CD81) with a component specification independent of instrument and reagents, which can be locally re-validated using normal peripheral blood. This method is directly comparable to previous ERIC-designed assays and also provides a backbone for investigation of new markers. A parallel analysis of high-throughput sequencing using the ClonoSEQ assay showed good concordance with flow cytometry results at the 0.010% (10(-4)) level, the MRD threshold defined in the 2008 International Workshop on CLL guidelines, but it also provides good linearity to a detection limit of 1 in a million (10(-6)). The combination of both technologies would permit a highly sensitive approach to MRD detection while providing a reproducible and broadly accessible method to quantify residual disease and optimize treatment in CLL.

Targeting the proliferative and chemoresistant compartment in chronic lymphocytic leukemia by inhibiting survivin protein.

Chronic lymphocytic leukemia (CLL) cells located in proliferation centers are constantly stimulated by accessory cells, which provide them with survival and proliferative signals and mediate chemotherapy resistance. Herein, we designed an experimental strategy with the aim of mimicking the microenvironment found in the proliferative centers to specifically target actively proliferating CLL cells. For this, we co-cultured CLL cells and bone marrow stromal cells with concomitant CD40 and Toll-like receptor 9 stimulation. This co-culture system induced proliferation, cell-cycle entry and marked resistance to treatment with fludarabine and bendamustine. Proliferating CLL cells clustered together showed a typical morphology of activated B cells and expressed survivin protein, a member of the inhibitor of apoptosis family that is mainly expressed by CLL cells in the proliferation centers. With the aim of specifically targeting actively proliferating and chemoresistant CLL cells, we investigated the effects of treatment with YM155, a small-molecule survivin inhibitor. YM155 treatment suppressed the co-culture-induced survivin expression and that was sufficient to inhibit proliferation and effectively induce apoptosis particularly in the proliferative subset of CLL cells. Interestingly, sensitivity to YM155 was independent from common prognostic markers, including 17p13.1 deletion. Altogether, these findings provide a rationale for clinical development of YM155 in CLL.

Participación del acompañante en el cuidado del paciente hospitalizado. Instituciones de segundo nivel. Area Metropolitana. Medellín 1999-2000 / Participation of familiar attendant in the care of the hospitalized person in institutions of second level of attention in the metropolitan area of Medellin, 1999-2000

Estudio descriptivo transversal para identificar las oportunidades de participación en el cuidado que el equipo de enfermería propicia a los acompañantes del paciente hospitalizado. Nace como respuesta a los interrogantes continuos desde la practica académica y por vivencias personales con familiares hospitalizados. Se realiza una entrevista estructurada a 265 acompañantes de instituciones de salud del segundo nivel de complejidad, en las cuales se indagó por aspectos socio-demográficos de los usuarios y acompañantes, las acciones de cuidado que ejecuta el acompañante y cuáles son indicados, explicados y apoyados por el equipo de enfermería. La educación que éste proporciona al acompañante es otro asunto que se cuestionó en la muestra. De los usuarios con acompañante el 54 por ciento son de sexo femenino, los de mayor tiempo de compañía están en el grupo etáreo de 64 a 77 años y se caracterizan por un nivel bajo de escolaridad. Como primera causa de morbilidad está los problemas gasasculares. trointestinales; seguidos de los problemas cardiovLas personas que más acomp edad de 45 años.añan son los hijos ás realizan los acompañantes son los relcionados con la subsistencia, como el baño y la alimentación, accioade sexo femenino, con promedio de Los cuidados que nes como la lectura, el juego y la música son realmizados sólo en el 10 por ciento en contraste con la conversación que es una de las acciones que más se realizan. La interacción del equipo de enfermería con el acompañante es mínima para casi todos los cuidados explorados en el estudio, se presentó la mayor interacción en la indicación, explicación y apoyo del baño. La auxiliar de enfermería es quien más interactúa con el acompañante en estas categorías; sobresale la poca interacción del profesional en enfermería. La educación, es impartida por el profesional de enfermería en mayor proporción; sin embargo, sólo se brinda al 11 por ciento del total de usuarios hospitalizados. Solo sí se penetra en el misterio del cuidado y se aborda profundamente el carácter humano y cultural de éste podemos trascender la relación con el usuario en términos de confianza, respeto y pertinencia con su familia y con el entorno social.

Flow cytometry in the bone marrow evaluation of follicular and diffuse large B-cell lymphomas.

BACKGROUND AND OBJECTIVES: Bone marrow biopsies are routinely performed in the staging of patients with lymphoma. Despite the lack of evidence for its usefulness, many institutions include flow cytometry (FC) of bone-marrow aspirates in an attempt to increase sensitivity and specificity. The aim of this study is to evaluate the usefulness of FC for the assessment of bone-marrow involvement by lymphoma in follicular (FL) and diffuse large B-cell lymphomas (DLBCL). DESIGN AND METHODS: Seventy-nine bone marrow biopsies from 65 patients diagnosed with FL or DLBCL were examined to compare histology and FC for the assessment of bone-marrow involvement by lymphoma. RESULTS: Bone marrow histology showed involvement (BM+) in 16 cases (20.3%), lack of infiltration (BM(-)) in 52 cases (65.8%) and undetermined or undiagnosed for involvement (BMu) in 11 cases (13.9%). FC was positive for involvement in 28 cases (35.4%) and negative in 51 cases (64.6%). 65 cases (95%) showed concordance between the results of morphology and FC (BM(+)/FC(+) or BM(-)/FC(-)). No BM(+)/FC(-) cases were observed. 3 cases showed discrepant results (BM(-)/FC(+)). In these 3 cases the molecular studies (PCR) demonstrated clonal rearrangement of the heavy immunoglobulin chain (IgH) and/or bcl2-IgH in agreement with the flow results. Among the 11 cases with BMu, all but 2 were FC(+) and concordance with the PCR results was seen in 9 cases (81.9%). INTERPRETATION AND CONCLUSIONS: We conclude that FC is just as sensitive or perhaps slightly more sensitive than histology in the detection of bone marrow involvement in FL and DLBCL. FC studies may be warranted in those cases in which the morphology is not diagnosed. The clinical relevance of the small clonal B-cell population in patients without histologic bone marrow involvement (BM(-)/FC(+) cases) remains an open question.

Loci geneticos asociados al trastorno bipolar: estudios en poblacion colombiana / Genetic loci associated to bipolar disorder: studies in colombian population

Objetivos: Caracterizar una muestra de familias y tríos de una población colombiana aislada para mapear loci involucrados en la vulnerabilidad al Trastorno Afectivo Bipolar tipo I (TAB- I). Métodos: Se recolectan tríos y genealogías utilizando las entrevistas FIGS-DIGS en miembros de las familias y posibles afectados. El poder para detectar ligamiento (PDL) se estima por simulación. El modelo utilizado asume una frecuencia para el alelo afectado de 0.003, penetrancias de 0.01,0.81 y 0.9 y un marcador de cuatro alelos a 5cM del locus. Resultados: Se identificaron 28 familias con TAB-I, con 3.603 individuos y 160 afectados, y 246 tríos. Asumiendo homogeneidad genética y teniendo en cuenta la evidencia genética del mestizaje, las simulaciones mostraron PDL significativos de 100 por ciento para un LOD-score>3. Estamos examinando el desequilibrio promedio en tríos y tamizando en familias los cromosomas 12,18 y 21. Conclusión: Tenemos un grupo significativo de familias y trios pertenecientes a una población aislada con un poder para detectar ligamiento al Trastorno Afectivo Bipolar. Esto permite realizar estudios de ligamiento buscando genes involucrados en la vulnerabilidad al TAB-I en población Colombiana

[Thrombocytopenic thrombotic purpura. Retrospective study of 22 consecutive occurrences in 16 patients]. / Púrpura trombótica trombocitopénica. Estudio retrospectivo de 22 episodios consecutivos en 16 pacientes.

BACKGROUND: Thrombotic Thrombocytopenic Purpura (TTP) is an uncommon clinical syndrome with high mortality rate in the absence of treatment. Despite the therapeutic efficacy of plasma exchange, patients often relapse even after long periods of time in remission. Over the last few years, late relapses in previously diagnosed patients have been seen in our hospital. PATIENTS AND METHODS: We analyzed retrospectively 22 episodes of TTP in 16 patients diagnosed during a four-year period. We reviewed the clinical features at diagnosis as well as the therapeutic results. In all but one, the treatment included daily plasma exchange. Other treatments, including vincristine, were also used in addition to plasma exchange, in 18 of 21 episodes. RESULTS: A complete remission was obtained in eighty-two percent of the episodes treated by plasma exchange. The median number of plasma exchange to achieve a complete remission was 6. In 4 episodes, 20 or more plasma exchange were required before achieving a satisfactory response. A complete remission was obtained in 78% of episodes where vincristine was used, versus 84% response rate in episodes where vincristine was not used. In four patients the cause death was directly related to TTP, while a fifth patients died of progressive lymphoma without evidence of TTP. Five of the eleven surviving patients relapsed with a median time to relapse of 24.6 months. Relapsing episodes presented with a less severe clinical picture including less clear signs of microangiopathic hemolytic anemia (MAHA), when compared with the initial ones. All patients in relapse responded promptly to treatment. The variables analyzed failed to predict either the response to treatment or the probability of relapse. CONCLUSIONS: The therapeutic efficacy of plasma exchange in the treatment of TTP has been demonstrated in our series as previously observed by many other groups. We have observed some slow responders where the prolongation of treatment by plasma exchange succeeded in achieving a complete remission. The use of vincristine did not show any therapeutical advantage in our experience.

[Remission of invasive sinusal and pulmonary aspergillosis with liposomal amphotericin B in a patient with chronic lymphatic leukemia following failure with conventional amphotericin]. / Resolución de una aspergilosis invasiva sinusal y pulmonar con anfotericina B liposómica en un paciente con leucemia linfática crónica tras fracaso de la anfotericina convencional.

Invasive aspergillosis is a severe complication in the immunocompromised patient. Despite antifungal treatment the mortality rate is higher than 90% if the immunity deficiency is not corrected. The use and dosage of conventional amphotericin B (deoxycholate-suspended formulation) is limited by its toxicity, especially nephrotoxicity. To reduce these untoward effects, amphotericin B has been formulated in liposomes. Better tolerance and lower nephrotoxicity in the liposomal formulations allow higher doses to be given safely, even in the presence of renal failure. Liposomal encapsulated amphotericin B (LAmB) is a safe and effective alternative to conventional formulations for antifungal therapy. We present a case of a 60-year-old man affected by chronic lymphocytic leukaemia. In the course of his disease and after chemotherapy treatment, he presented an invasive aspergillosis of the lung and paransal sinuses. The rhino-sinusal lesion had progressed despite surgical debridement and treatment with amphotericin B in a dosage of 50 mg per day. Moreover, renal impairment caused by conventional amphotericin was detected. Then, LAmB was started at a dose of 150 mg per day. Treatment with LAmB has resulted in clinical recovery and radiologic ressolution.