Terminal complement inhibitor eculizumab in atypical hemolytic-uremic syndrome.

BACKGROUND: Atypical hemolytic-uremic syndrome is a genetic, life-threatening, chronic disease of complement-mediated thrombotic microangiopathy. Plasma exchange or infusion may transiently maintain normal levels of hematologic measures but does not treat the underlying systemic disease. METHODS: We conducted two prospective phase 2 trials in which patients with atypical hemolytic-uremic syndrome who were 12 years of age or older received eculizumab for 26 weeks and during long-term extension phases. Patients with low platelet counts and renal damage (in trial 1) and those with renal damage but no decrease in the platelet count of more than 25% for at least 8 weeks during plasma exchange or infusion (in trial 2) were recruited. The primary end points included a change in the platelet count (in trial 1) and thrombotic microangiopathy event-free status (no decrease in the platelet count of >25%, no plasma exchange or infusion, and no initiation of dialysis) (in trial 2). RESULTS: A total of 37 patients (17 in trial 1 and 20 in trial 2) received eculizumab for a median of 64 and 62 weeks, respectively. Eculizumab resulted in increases in the platelet count; in trial 1, the mean increase in the count from baseline to week 26 was 73×10(9) per liter (P<0.001). In trial 2, 80% of the patients had thrombotic microangiopathy event-free status. Eculizumab was associated with significant improvement in all secondary end points, with continuous, time-dependent increases in the estimated glomerular filtration rate (GFR). In trial 1, dialysis was discontinued in 4 of 5 patients. Earlier intervention with eculizumab was associated with significantly greater improvement in the estimated GFR. Eculizumab was also associated with improvement in health-related quality of life. No cumulative toxicity of therapy or serious infection-related adverse events, including meningococcal infections, were observed through the extension period. CONCLUSIONS: Eculizumab inhibited complement-mediated thrombotic microangiopathy and was associated with significant time-dependent improvement in renal function in patients with atypical hemolytic-uremic syndrome. (Funded by Alexion Pharmaceuticals; C08-002 ClinicalTrials.gov numbers, NCT00844545 [adults] and NCT00844844 [adolescents]; C08-003 ClinicalTrials.gov numbers, NCT00838513 [adults] and NCT00844428 [adolescents]).

Surveillance CT scans are a source of anxiety and fear of recurrence in long-term lymphoma survivors.

BACKGROUND: We aimed to assess anxiety and the psychological impact of routine surveillance scans in long-term survivors of adult aggressive lymphoma. PATIENTS AND METHODS: In this cross-sectional observational study of 70 survivors of curable adult aggressive lymphoma, we measured anxiety and the doctor-patient relationship and performed a qualitative interview (n = 30) focused on patient perception of routine follow-up imaging studies. RESULTS: Participants were diagnosed with aggressive lymphoma a median of 4.9 years (2.4-38.0 years) before enrollment. Thirty-seven percent of patients were found to meet criteria for clinically significant anxiety, which was not associated with years since diagnosis. In multivariate analysis, history of relapse and a worse doctor-patient relationship were independently associated with higher anxiety levels. Despite representing a largely cured population, in qualitative interviews patients reported fear of recurrence as a major concern and considerable anxiety around the time of a follow-up imaging scan. CONCLUSIONS: Routine surveillance scans exacerbate underlying anxiety symptoms and fear of recurrence in survivors of aggressive lymphoma. Strategies to minimize follow-up imaging and to improve doctor-patient communication should be prospectively evaluated to address these clinically significant issues.

Intensive treatment strategies may not provide superior outcomes in mantle cell lymphoma: overall survival exceeding 7 years with standard therapies.

BACKGROUND: Reported median overall survival (OS) in patients with mantle cell lymphoma (MCL) has been reported to be just 3-4 years. As a consequence, first-line treatment has become more aggressive. Single-center studies with R-Hyper-CVAD and/or autologous stem-cell transplant (ASCT) have produced 3-year OS rates >80%, prompting many to adopt their use. We evaluated outcomes from a single-center cohort managed in a more traditional fashion. METHODS: We identified patients with MCL evaluated at Weill Cornell Medical Center since 1997, and included those with known date of diagnosis. An online social security database was used to verify survival. RESULTS: We identified 181 patients with MCL, and date of diagnosis could be determined in 111. Three-year OS from diagnosis was 86% [95% confidence interval (CI) 78% to 92%]. Median OS was 7.1 years (95% CI 63-98 months). Adequate information on therapy was available for 75 patients. Only five were treated upfront with (R)-Hyper-CVAD or ASCT while an additional four patients received one of these regimens subsequently. Treatment type had no significant effect on OS. CONCLUSION: Outcomes with standard approaches can yield similar survival to that achieved with more intensive approaches. Biases may account for the perceived superiority of aggressive strategies.

Extended follow-up and impact of high-risk prognostic factors from the phase 3 RESONATE study in patients with previously treated CLL/SLL.

In the phase 3 RESONATE study, ibrutinib demonstrated superior progression-free survival (PFS), overall survival (OS) and overall response rate (ORR) compared with ofatumumab in relapsed/refractory CLL patients with high-risk prognostic factors. We report updated results from RESONATE in these traditionally chemotherapy resistant high-risk genomic subgroups at a median follow-up of 19 months. Mutations were detected by Foundation One Heme Panel. Baseline mutations in the ibrutinib arm included TP53 (51%), SF3B1 (31%), NOTCH1 (28%), ATM (19%) and BIRC3 (14%). Median PFS was not reached, with 74% of patients randomized to ibrutinib alive and progression-free at 24 months. The improved efficacy of ibrutinib vs ofatumumab continues in all prognostic subgroups including del17p and del11q. No significant difference within the ibrutinib arm was observed for PFS across most genomic subtypes, although a subset carrying both TP53 mutation and del17p had reduced PFS compared with patients with neither abnormality. Reduced PFS or OS was not evident in patients with only del17p. PFS was significantly better for ibrutinib-treated patients in second-line vs later lines of therapy. The robust clinical activity of ibrutinib continues to show ongoing efficacy and acceptable safety consistent with prior reports, independent of various known high-risk mutations.

A lipoprotein characterizing obstructive jaundice. I. Method for quantitative separation and identification of lipoproteins in jaundiced subjects.

Three immunochemically and electrophoretically distinct lipoproteins, LP-A, LP-B, and LP-X,(1) were isolated from the low density lipoprotein fraction (1.006-1.063 g/ml) in plasma from patients with biliary obstruction by a separation procedure which combines ultracentrifugation, heparin precipitation, and ethanol fractionation. This method, here described, permits the quantitative determination of individual plasma lipoprotein families on the basis of their protein moieties, rather than on the basis of their lipid moieties or density. The chemical composition of the unique lipoprotein, LP-X, was similar to that of an abnormal lipoprotein, OLP, isolated by Russ et al. (29) and by Switzer (30). In obstructive jaundice plasma, the combined LP-X and LP-B accounted for 98% and the LP-A for only 2% of the total protein content of the LDL fraction. This study indicates that the plasma lipoprotein pattern in obstructive jaundice is characterized by (a) a decreased concentration of HDL, (b) an increased concentration of LDL, and (c) the presence in the LDL fraction of varying amounts of a specific lipoprotein, LP-X, immunochemically and chemically distinct from LP-A and LP-B. LP-X, with its characteristically high content of unesterified cholesterol and phospholipids, is primarily responsible for the unusual protein and lipid content of the LDL fraction. Screening tests in 61 patients with various forms of jaundice indicated that a characteristic immunoelectrophoretic precipitin are between plasma samples and purified antibodies to LP-X was observed only in patients with obstructive jaundice. This simple immunochemical test may represent a valuable new tool in the differential diagnosis of obstructive and nonobstructive jaundice.

A lipoprotein characterizing obstructive jaundice. II. Isolation and partial characterization of the protein moieties of low density lipoproteins.

The plasma low density lipoproteins (LDL) in biliary obstruction are characterized almost exclusively by the presence of the immunochemically distinct lipoprotein families, lipoprotein B (LP-B) and lipoprotein X (LP-X). It is suggested that LP-X, with its uniquely high content of unesterified cholesterol and phospholipid, is primarily responsible for the unusual lipid composition of LDL and the abnormal plasma lipid composition in obstructive jaundice. To show their protein moieties, we isolated LP-X and LP-B from the LDL in plasma obtained from patients with obstructive jaundice. A separation procedure was employed which combines ultracentrifugation, heparin precipitation, and ethanol fractionation. Whereas LP-B was characterized by the presence of apolipoprotein B (ApoB), intact LP-X contained a protein moiety of unique composition consisting of a mixture of albumin (approximately 40%) and the specific apolipoprotein, ApoX (60%). These two protein moieties were separated by preparative ultracentrifugation at d 1.21 g/ml of a solution of partially delipidized LP-X. LP-X thus comprises an albumin-lipoprotein complex in which the masked antigenic site of albumin can be revealed by partial or total delipidization. Apolipoprotein X, the characteristic nonalbumin protein moiety of intact or partially delipidized LP-X, was immunochemically different from ApoA, ApoB, albumin, gamma-globulins, and other serum proteins. The results of analytical ultracentrifugation and the immunochemical and electrophoretic properties of ApoX indicated it to be a complex protein consisting possibly of several nonidentical polypeptides. ApoX was characterized by its amino acid composition, and by serine and threonine as the major N-terminal and alanine as the major C-terminal amino acids. It has been suggested that ApoX is similar to, if not identical with, apolipoprotein C.

Mutations in NOTCH1 PEST domain orchestrate CCL19-driven homing of chronic lymphocytic leukemia cells by modulating the tumor suppressor gene DUSP22.

Even if NOTCH1 is commonly mutated in chronic lymphocytic leukemia (CLL), its functional impact in the disease remains unclear. Using CRISPR/Cas9-generated Mec-1 cell line models, we show that NOTCH1 regulates growth and homing of CLL cells by dictating expression levels of the tumor suppressor gene DUSP22. Specifically, NOTCH1 affects the methylation of DUSP22 promoter by modulating a nuclear complex, which tunes the activity of DNA methyltransferase 3A (DNMT3A). These effects are enhanced by PEST-domain mutations, which stabilize the molecule and prolong signaling. CLL patients with a NOTCH1-mutated clone showed low levels of DUSP22 and active chemotaxis to CCL19. Lastly, in xenograft models, NOTCH1-mutated cells displayed a unique homing behavior, localizing preferentially to the spleen and brain. These findings connect NOTCH1, DUSP22, and CCL19-driven chemotaxis within a single functional network, suggesting that modulation of the homing process may provide a relevant contribution to the unfavorable prognosis associated with NOTCH1 mutations in CLL.

Monovalent selectivity of the cyclic guanosine monophosphate-activated ion channel.

Monovalent cation selectivity has been characterized for the 3',5'-cyclic guanosine monophosphate (cGMP)-activated channel in vertebrate photoreceptor outer segment plasma membranes without divalent cations. Macroscopic currents in excised, inside-out patches were activated with saturating concentrations of cGMP (200 microM). Using a bi-ionic protocol with symmetrical 120 mM ion concentrations across the membrane, alkali metal ions and certain organic cations were substituted for sodium on the cytoplasmic face. The relative permeabilities, determined from shifts in the reversal potential (Erev), were NH4 much greater than Na greater than guanidinium greater than K greater than Li greater than Rb greater than Cs (3.34: 1.0: 0.97: 0.93: 0.92: 0.74: 0.50, respectively). Erev's were also measured as a function of [Na], [NH4], and [Cs], and the slope of the relation was -59.8, -52.1, and -49.1 mV/decade, respectively. The slopes for NH4 and Cs differ significantly from the Nernst-Planck prediction of -58.2 mV/decade expected for a single ion channel. Relative permeabilities were also determined for the alkali metal series of ions with 20 mM ionic concentrations on both sides of the membrane. The permeability sequence at 20 mM was unchanged, but the relative permeability for NH4 and Cs deviated significantly from the measurements at 120 mM with 1.46 and 0.75 ratios, respectively. The dependence of Erev on absolute concentrations and the deviation from Nernst-Planck predictions are best explained by multi-ion occupancy of the cGMP-activated channel. Selectivity was also examined by comparing the conductance ratios as a function of potential.(ABSTRACT TRUNCATED AT 250 WORDS)

Influenza and pneumococcal vaccination among Native American elders in a primary care practice.

BACKGROUND: More than 2 million Native Americans (ie, Native Americans and Native Alaskans) live in the United States; 60% reside in cities. This population, especially its elders, is especially susceptible to respiratory diseases; yet, adherence to guidelines for influenza and pneumococcal immunizations is unknown. OBJECTIVES: To evaluate how frequently older and high-risk adults received vaccinations for influenza and pneumococcal infection and to identify patient characteristics associated with adherence to published recommendations. METHODS: Retrospective medical record review of 550 Native American elders seen in an urban primary care practice defined using a culturally appropriate age threshold (> or =50 years) and standard criteria (> or =65 years). Univariate analyses examined demographic and clinical information by vaccination status. Logistic regressions identified factors associated with adherence to immunization guidelines. RESULTS: Among patients aged 50 years and older with any indication according to published recommendations, rates were low for influenza (31%) and pneumococcal (21%) immunizations. Likewise, few subjects at least 65 years of age had been immunized appropriately against influenza (38%) or pneumococcus (32%). Younger age and alcohol use were significantly associated with less frequent immunization; Medicare insurance, depression, and more health problems and taking more medications predicted significantly higher immunization rates. Aged 65 years or older and having cardiovascular disease or diabetes mellitus were specific indications significantly correlated with receipt of influenza and pneumococcal vaccine. CONCLUSIONS: Regardless of age or risk, inadequate vaccination rates were observed in elderly Native Americans. Our findings suggest the need to identify obstacles to immunization and to conduct prospective and elderly intervention studies in Native American populations.

The use of balloon-expandable metallic stents in the treatment of pediatric tracheomalacia and bronchomalacia.

OBJECTIVE: To evaluate the use of balloon-expandable metallic stents in the treatment of children with tracheomalacia and bronchomalacia in whom conventional therapy has failed. DESIGN: Retrospective case series. SETTING: Tertiary pediatric otolaryngology and cardiothoracic surgery referral center. PATIENTS: Six patients were identified as having undergone bronchoscopic placement of metallic balloon-expandable stents between 1994 and 1997. The age at stent placement, prior surgical interventions, and indications for and sites of stent placement were noted. Also, the complications related to stent placement and the current airway status of the patients were reviewed. INTERVENTIONS: Twelve balloon-expandable metallic angioplasty stents (Palmaz; Johnson & Johnson Interventional Systems Co, Warren, NJ) were placed bronchoscopically in 6 patients. Six stents were placed in the lower trachea, and 6 were placed in the main bronchi. The stents were balloon expanded under fluoroscopic guidance. MAIN OUTCOME MEASURE: Discontinuation of mechanical ventilation. RESULTS: The age at stent placement ranged from 1.5 to 38 months (mean age at placement, 10 months). The indications for stent placement were (1) tracheomalacia or bronchomalacia, (2) pericardial patch or slide tracheoplasty failure, and (3) bronchomalacia caused by tetralogy of Fallot and large pulmonary arteries. The primary complication of stent placement was postoperative granulation tissue formation. One patient required the removal of 2 tracheal stents because of granulation tissue formation. There were 2 deaths in the series, 1 possibly related to stent placement. Four of the 6 patients were weaned from mechanical ventilation, and 3 experienced prolonged relief of airway obstruction. CONCLUSIONS: Metallic balloon-expandable stents are effective in relieving lower tracheomalacia and bronchomalacia in select patients. Only patients in whom conventional therapy has failed should be considered for stent placement.

One hundred consecutive laparoscopic cholecystectomies performed in a rural hospital.

Laparoscopic cholecystectomy has quickly become the treatment of choice by most surgeons for the treatment of gallstone disease. The authors reviewed their first 100 consecutive patients undergoing laparoscopic cholecystectomy at a rural hospital. Twenty-three patients had previous abdominal procedures. The open insufflation technique was used on all patients with previous abdominal operations, with the exception of those who had an appendectomy only. Operative cholangiography was performed routinely and successfully on all patients, with the exception of the first seven because of nonavailability of a cholangiocath. In 54 percent of the first two-thirds of these patients, the operation was completed in less than 1.5 hours. In contrast, 88 percent of the last one-third of the patients were operated on within the same time period. All but 9 of the 100 patients were discharged within 24 hours of their surgery. Laparoscopic cholecystectomy can be performed safely and routinely in the rural hospital setting with results similar to those expected in larger metropolitan centers.

Recurrent coumadin-induced soft tissue necrosis resulting in mastectomy.

A 58-year-old woman developed Coumadin-induced necrosis of the left breast, resulting in a mastectomy. This patient had experienced an earlier episode of coumadin-induced necrosis that resolved spontaneously. The etiology of this rare complication is unknown. The literature has suggested that patients can be restarted on Coumadin without difficulty. This case and others in the literature suggest that this may not be true. Patients requiring long-term anticoagulation should be considered for other treatment modalities if they develop Coumadin-induced skin necrosis.

Intermittent decathexis--a type of parental dysfunction.

This paper describes a type of parental dysfunction--intermittent decathexis--which apparently has not previously been reported although it occurs frequently, to varied extent. The dysfunction is introduced by some of the clinical material that originally brought it to the author's attention, is contrasted with the more usual parental investment in their children. Its relationship to depression and then to aggression is next clarified. Examples of the manifestations of having been intermittently decathected are offered from both child and adult analyses as well as the impediments it provides for a child's progressive emotional development. Finally, the evidence is presented which led the authors to conclude that metapyschologically intermittent decathexis is a primitive defensive manoeuvre.

BTK inhibition targets in vivo CLL proliferation through its effects on B-cell receptor signaling activity.

Bruton agammaglobulinemia tyrosine kinase (BTK), a cytoplasmic protein tyrosine kinase, is a component of the B-cell receptor signaling pathway. Ibrutinib, a BTK inhibitor, has demonstrated a significant clinical activity against chronic lymphocytic leukemia (CLL) in early clinical trials. Understanding the molecular mechanisms of action would shed light on CLL pathophysiology and provide additional opportunities for the development of new therapies. In this study, we have chosen an in vivo approach by employing an ongoing phase 1b trial of ibrutinib. We prospectively collected and analyzed serial samples from the CLL patients before and after the initiation of ibrutinib. We found that the blockage of cell proliferation was one of the primary effects of ibrutinib against leukemic CLL cells in vivo. Using a co-culture system that induces CLL proliferation in vitro, analysis of several parameters, including Ki-67 expression and bromodeoxyuridine (BrdU) incorporation, revealed that the proliferation of CLL cells was directly inhibited by ibrutinib. Furthermore, activities of BTK and phospholipase Cγ2 as well as downstream signaling molecules, AKT and ERK, were all coordinately downregulated over time in ibrutinib-treated patients. Our findings suggest that the cell proliferation is one of the essential properties of CLL. Blocking cell proliferation via inhibition of BTK-mediated signaling may contribute to clinical responses in ibrutinib-treated patients.