A novel approach for BCR-ABL1 standardization to improve International Scale estimation.

INTRODUCTION: Standardization of BCR-ABL1 messenger RNA quantification by real-time PCR on the International Scale (IS) is critical for monitoring therapy response in chronic myelogenous leukaemia. Since 2006, BCR-ABL1 IS standardization is propagated along reference laboratories by calculating a laboratory-specific conversion factor (CF), co-ordinated in Europe through the European Treatment and Outcome Study project. Although this process has proven successful to some extent, it has not been achievable for all laboratories due to the complexity of the process and the stringent requirements in terms of numbers of samples to be exchanged. In addition, several BCR-ABL1 IS quantification methods and secondary reference materials became commercially available. However, it was observed that different IS methods generate consistently different results. METHODS: To overcome these difficulties, we have developed an alternative and simple approach of CF calculation, based on the retrospective analysis of existing external quality assessment (EQA) data. Our approach does not depend on the exchange of samples and is solely based on the mathematical CF calculation using EQA results. RESULTS AND CONCLUSION: We have demonstrated by thorough statistical validation that this approach performs well in converting BCR-ABL1 measurements to improve IS estimation. In expectation of a true golden standard method for BCR-ABL1 IS quantification, the proposed method is a valuable alternative.

Performance evaluation of the Sysmex(®) XP-300 in an oncology setting: evaluation and comparison of hematological parameters with the Sysmex(®) XN-3000.

INTRODUCTION: The Sysmex XP-300(®) (XP-300) is a new, fully automated hematology analyzer, designed to generate complete blood counts (CBC) with 3-part differential. In our study, the XP-300 was evaluated as a point-of-care (POC) analyzer in an oncology setting. In which blood samples from patients with different pathologies and treatments, affecting hematopoiesis, were analyzed. METHODS: Performance was evaluated according to the International Council for Standardization in Haematology (ICSH) guidelines and CLSI protocol H20-A2 . Beside precision, linearity and carry-over, a comparison study with the Sysmex(®) XN-3000 (XN-3000) and a manual reference leukocyte differential was performed. Flagging performance was also evaluated. RESULTS: XP-300 showed excellent precision and linearity results. For within- and between-run precision, the criteria, according to Ricos et al. , were met for all parameters tested, except for platelets in the low level. Less than or equal to 0.5% carry-over was seen for all parameters tested. Comparison studies showed an acceptable correlation with both XN-3000 and the manual reference leukocyte count. A suboptimal flagging performance was demonstrated. CONCLUSION: In the context of diagnosing cytopenia due to myelosuppressing agents or leukocytosis due to infection, the XP-300 showed good analytical performance. However, in the thrombocytopenic range, precision was suboptimal. In follow-up of hematological malignancies with the occurrence of abnormal cells, we advise verification with a more advanced analyzer or with microscopic review, although further studies with a higher prevalence of abnormal cells are needed.

Prolonged hyperlipasemia attributable to a novel type of macrolipase.

BACKGROUND: We present the case of an 80-year-old woman who was admitted to hospital with an intermittent volvulus of the right colon. A total colectomy was performed. Initially, serum amylase and lipase increased concordantly, but after a few weeks amylase normalized (85 U/L), whereas lipase increased to 3764 U/L. This discrepancy and persistence of hyperlipasemia suggested a macromolecular form of lipase. METHODS: The nature of the macromolecular complex was studied using high-pressure liquid gel-permeation chromatography, affinity chromatography, (immuno)electrophoresis, and immunodiffusion. RESULTS: Gel-permeation chromatography revealed a macrolipase, with a molecular mass >900 kDa, that contributed up to 56% of total serum lipase activity. Butanol extraction of the specimen did not alter the elution profile. The thermostabilities of pancreatic lipase and the macroform were similar, whereas activation energy (E:(a)) was lower in the macromolecular lipase (28 +/- 4 kJ. mol(-1). K(-1) vs 48 +/- 7 kJ. mol(-1). K(-1) (P: = 0.02). Agarose electrophoresis showed a broad band of lipase activity at the application site. Protein A-Sepharose affinity gel chromatography excluded IgG-linked lipase. Agarose electrophoresis and immunofixation excluded linkage to other immunoglobulins. Radial immunodiffusion did not show lipase activity in the immunoglobulin precipitation bands. Radial immunodiffusion with alpha(2)-macroglobulin (alpha(2)-MG) antibodies showed a diffuse spot of lipase activity within the precipitation band, suggesting a macromolecular association between lipase and alpha(2)-MG. Affinity gel chromatography against alpha(2)-MG showed lipase activity in the alpha(2)-MG-bound fractions. CONCLUSION: This is the first report of a macrolipase in which an association between alpha(2)-MG and lipase is described.

Changes in peripheral blood lymphocyte subsets in patients undergoing radiotherapy.

PURPOSE: To investigate the changes in peripheral blood lymphocyte subpopulations in patients undergoing radiotherapy. MATERIALS AND METHODS: In 8 patients undergoing external beam radiotherapy to the pelvis, the different lymphocyte subpopulations were followed during treatment. The lymphocyte populations were determined using two-colour flow cytometry. The study comprises the T-helper, T-suppressor/cytotoxic cells, the B-lymphocytes and natural killer (NK) cells. RESULTS: The B-cells were characterized by a steep decrease at the beginning of the radiotherapy. They reached their lowest level at an equivalent total body dose of approximately 1.5 Gy and remained constant during the rest of the therapy (10% of the initial level). In T-cells (both T-helper and T-suppressor subsets) the steep decrease was less pronounced. T-lymphocytes reached a base level at 2.5 Gy equivalent total body dose (20% of the initial level). No significant differences between the T-helper and the T-suppressor/cytotoxic cells were observed. NK cells were characterized by a weak decline during the first weeks of therapy, being less pronounced than in the other populations. Near the end of therapy, the NK cells reached the level of the T-lymphocytes. CONCLUSION: In vivo, NK cells were the most radioresistant and B-cells the most radiosensitive lymphocytes. No significant differences between T-helper and T-suppressor/cytotoxic cells were observed. These data are in agreement with the differences in apoptosis induction in peripheral blood lymphocyte subpopulations after in vitro gamma-irradiation of whole blood lymphocytes.

Apoptosis induced by gamma irradiation in peripheral blood mononuclear cells is not mediated by cytochrome-c release and only partially involves caspase-3-like proteases.

Caspase 3 has been shown to be actively involved in the apoptotic process in thymocytes after gamma-irradiation. We examined caspase 3 activation in mature peripheral blood lymphocytes (PBL) after gamma irradiation. Since the activation of caspase 3 is generally prceded by a decrease in mitochondrial membrane potential (delta psi m) and cytochrome c release, these two parameters were also examined. Apoptosis in PBL after a 5-Gy gamma irradiation, is characterized by a decrease in delta psi m, but surprisingly no release of cytochrome-c and only a weak caspase 3 activation was noticed. In contrast, staurosporin treated PBL showed a decrease in delta psi m with cytochrome-c release and a clear caspase 3 activation. We were unable to block the decrease in delta psi m with the caspase-inhibitors zVAD-fmk or zDEVD-fmk after gamma irradiation, but DNA fragmentation as measured by the TUNEL assay was partially inhibited. Therefore, in gamma irradiated mature PBL, caspase-dependent and -independent pathways, but not cytochrome c, seem to be involved in the apoptotic process.

Micronucleus frequencies in cytokinesis-blocked human B lymphocytes after low dose gamma-irradiation.

PURPOSE: To investigate (1) the radiosensitivity of B versus T lymphocytes with respect to micronucleus (MN) induction and (2) the possible application of the B cell MN assay for biological dosimetry of individuals after acute exposure to low doses of ionizing radiation. MATERIALS AND METHODS: MN analysis was performed in T and B lymphocytes of six healthy volunteers exposed in vitro to gamma-ray doses ranging from 0.05 Gy to 1 Gy. For the MN assay on B cells, peripheral blood mononuclear cells were cultured and stimulated with pokeweed mitogen (PWM). Afterwards the B lymphocytes (characterized by the CD20+ phenotype) were separated with the FACSort flow cytometer and the number of MN in the sorted binucleate cells was scored. For T lymphocytes the standard MN protocol was applied. RESULTS: The number of spontaneous and radiation induced MN were significantly higher in B lymphocytes compared to T lymphocytes in the low dose range up to 1 Gy. An analysis of the present data showed that when the spontaneous MN frequencies are not known, doses from 0.08 Gy could be detected with the B cell MN assay while the conventional MN assay only allowed detection of doses > 0.25 Gy. However, in contradiction to the linear-quadratic dose-response for T cells, for B cells the initial steep increase of the MN yield with the very low dose was followed by a flattening of the curve towards higher doses. CONCLUSION: This study shows that B lymphocytes express a high number of MN for doses up to 1 Gy gamma-rays reflecting the highly radiosensitive behaviour of B cells. The results also point to the possible application of the B-cell MN assay for individual dose assessment. When blood samples can be taken within 24 h after acute accidental overexposure, the B-cell MN assay can be performed but only as a supplementary test to the conventional MN assay.

Apoptosis induced by fast neutrons versus 60Co gamma-rays in human peripheral blood lymphocytes.

PURPOSE: To investigate the effectiveness of high LET fast neutrons compared with low LET 60Co gamma-rays to induce apoptosis in resting lymphocytes. MATERIALS AND METHODS: Apoptosis induction was quantified by light microscopic analysis of irradiated lymphocyte samples from healthy donors after 24 h culture. For the dose-response analyses doses ranging from 0.05 to 5 Gy were applied at 1.5 Gy/min (gamma-rays) or 0.2 Gy/min (fast neutrons). To investigate the role of DNA repair in apoptosis induction a dose of 2 Gy was also given at low dose-rate (0.006 Gy/min). RESULTS: Dose-response curves obtained with both radiation qualities were characterized by an initial steep increase in the number of apoptotic cells below 1 Gy, with a flattening of the curves at higher doses towards 5 Gy. The calculated relative biological effectiveness (RBE) values for fast neutrons were close to unity. When a 2 Gy dose was administered at low rather than high dose-rate no decrease in apoptotic cell yield was observed. CONCLUSION: The dose-response data confirm the high radiosensitivity of lymphocytes and demonstrate that their response to undergo early interphase cell death by apoptosis is largely independent of LET. The observations that apoptosis induction is independent of LET and dose-rate may suggest that initial DNA damage, as opposed to DNA repair, dominate the induction of apoptosis in resting lymphocytes.

Induction of micronuclei and apoptosis in natural killer cells compared to T lymphocytes after gamma-irradiation.

PURPOSE: To investigate the chromosomal damage caused by gamma-irradiation in T lymphocytes and natural killer (NK) cells and compare this with apoptosis induction in both lymphocyte subsets. MATERIALS AND METHODS: Apoptosis induction by gamma-irradiation in T lymphocytes and NK cells was quantified using the annexin V flow cytometric assay. The cytokinesis-block micronucleus (MN) assay was used to evaluate the induced cytogenetic damage. For the MN assays on NK cells, gamma-irradiated peripheral blood mononuclear cells were cultured and stimulated with interleukin 15 (IL-15). Afterwards the NK cells (characterized by the CD3-/CD56+ phenotype) were separated with the FACSort flow cytometer and the number of MN in the sorted binuclear cells was scored. Doses of 1 and 2 Gy gamma-irradiation were applied. RESULTS: Higher numbers of MN in NK cells were found compared with the MN yield in T lymphocytes. In contrast, NK cells were less than T lymphocytes prone to apoptosis after gamma-irradiation. CONCLUSION: The results support the view that cytogenetic damage and apoptosis after gamma-irradiation are not necessarily correlated.

Flow cytometric scoring of apoptosis compared to electron microscopy in gamma irradiated lymphocytes.

One of the early events occurring at the cell membrane during apoptosis is the translocation of phosphatidylserine from the inner side of the plasma membrane to the outer layer. These phosphatidylserine groups can be bound by fluorescein isothiocyanate (FITC)-labelled annexin V. The aim of this study was to evaluate the power of the annexin V flow cytometric assay in detecting apoptosis in gamma irradiated peripheral blood lymphocytes and in differentiating between apoptosis and primary necrosis in these cells. Therefore, 5 Gy and 20 Gy gamma irradiated peripheral blood mononuclear cells (PBMCs) were examined after a 24-h culture period. The terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) technique was performed as well. A comparison with an electron microscopic (EM) evaluation was made. EM is based on established morphological criteria allowing the classification of cells into four groups: viable, early apoptotic, secondary necrotic and primary necrotic cells. EM performed on annexin V positive sorted cells proved that a 5 Gy gamma irradiation of PBMCs mainly causes apoptosis, whereas a 20 Gy gamma irradiation mainly induces primary necrosis. Neither the annexin V flow cytometric assay nor the TUNEL assay were able to distinguish between primary and secondary necrotic cells. These results illustrate that if quantification of apoptosis is required, one should be careful in interpreting flow cytometric results obtained by annexin V or TUNEL staining in peripheral blood lymphocytes. Although in general primary necrotic cells show an increased forward scatter due to cellullar swelling, both early apoptotic and necrotic (primary or secondary) lymphocytes show a decreased forward scatter signal. Moreover, both primary and secondary necrotic lymphocytes are annexin V and propidium iodide (PI) positive and therefore indistinguishable. We conclude that if a new experiment focusing on apoptosis is set up, an initial EM evaluation is mandatory. If EM shows that the apoptosis inducing agent used in the design of the experiments is not causing primary necrosis, than the annexin V flow cytometric assay can provide rapid and quantitative information about apoptosis.

Quantification of apoptosis in lymphocyte subsets and effect of apoptosis on apparent expression of membrane antigens.

Annexin V binding to phosphatidylserine was evaluated by flow cytometry to examine apoptosis in different lymphocyte subsets of peripheral blood mononuclear cells after a 24 h in vitro culture period. We also applied a 2 Gy dose gamma-irradiation prior to incubation to evaluate the additional apoptogenic effect of radiation on the lymphocyte subsets. Overall, B lymphocytes showed the highest number of apoptotic cells, followed by T lymphocytes. Within the T lymphocytes, CD4-positive and CD45RA-negative cells were more prone to apoptosis than the CD8-positive and CD45RA-positive cells. Natural killer cells turned out to be most apoptosis-resistant. In the irradiated samples about twice as many apoptotic cells were found and the differences between lymphocyte subpopulations remained. Backgating of the annexin V-positive cells showed that these cells had a clearly decreased forward scatter signal. The antibody binding capacity (ABC) of lymphocyte membrane antigens was determined with CD3-fluorescein isothiocyanate (FITC), CD45RA-FITC, CD4-phycoerythrin (PE), CD8-PE, CD56-PE, and CD20-PE in viable and apoptotic cells. In the apoptotic cells a decrease of ABC was found for all antigens, except for CD20. There was no significant cell loss in the cultures. We conclude that the change in scatter and in ABC must be considered in immunophenotyping experiments on cells kept in culture for 24 h. If these changes are taken into account, percentages of subpopulations or the numbers of cells that stain positive for the studied markers do not significantly change.

A sudden awakening from a near coma after combined intake of gamma-hydroxybutyric acid (GHB) and ethanol.

OBJECTIVE: A case of a sudden awakening from a near coma after combined intake or gamma-hydroxybutyric acid (GHB) (125 micrograms/mL), ethanol (134 mg/dL), and cannabinoids is described. METHODS: GHB was determined by gas chromatography-mass spectrometry after acetonitrile precipitation and derivation with N-methyl-N-trimethylsilyltrifluoroacetamide, using valproic acid as the internal standard. CONCLUSION: The described case illustrates the consequences of GHB overdose. GHB overdose should be considered in every case of unexplained sudden coma, i.e., without any evidence of head injury, intake of coma-inducing drugs, or increasing intracranial pressure. GHB overdose will be missed by routine toxicological screening.

Haptoglobin polymorphism and chronic hepatitis C.

BACKGROUND/AIMS: Haptoglobin (Hp) is a hemoglobin-binding acute phase protein characterized by a genetic polymorphism due to the existence of two different alleles encoding for the alpha chain of the protein. Three phenotypes have been described: Hp 1-1, Hp 2-1 and Hp 2-2. The latter two forms are known to possess immunoglobulin-like properties and play a role in the immune response. Recently, it has been shown that in subjects suffering from hepatitis C, serum Hp concentrations were lower than in the reference population. In the present study we examined whether the haptoglobin phenotype distribution in chronic HCV patients was different from the reference population. We also looked for possible relationships between Hp phenotypes and hepatitis C virus types and response to interferon alpha therapy. Moreover, Hp concentrations were determined. METHODS: The study population consisted of 239 Caucasian patients with proven hepatitis C. Hp phenotypes were determined using starch gel electrophoresis of hemoglobin-supplemented serum, followed by peroxidase staining. Serum Hp concentrations were assayed with an immunonephelometric method. Hepatitis C virus was genotyped and classified according to an internationally accepted system. Two hundred and twenty healthy Caucasian blood-donors served as the reference population. RESULTS: In the reference population, 35 individuals (15.9%) had Hp 1-1, 106 persons (48.2%) had Hp 2-1 and 79 had Hp 2-2 (35.9%), resulting in an Hp 1 allele frequency of 0.400, which is in agreement with the Hardy-Weinberg equilibrium. Hp phenotype distributions and Hp allele frequencies in the chronic hepatitis C virus patient group differed significantly from those obtained in the reference population. In the patient population, 59 individuals (24.7%) had Hp 1-1, 112 persons (46.9%) had Hp 2-1 and 68 had Hp 2-2 (28.5%). This resulted in an Hp 1 allele frequency of 0.481, which is in agreement with the Hardy-Weinberg equilibrium. No statistically significant differences were found between Hp phenotype distribution and hepatitis C virus types or response to interferon alpha therapy. CONCLUSIONS: The observed shift in Hp phenotype distribution in chronic hepatitis C may point to a role of Hp in the natural evolution of hepatitis C.

Comparison of arbitrarily primed polymerase chain reaction and cell envelope protein electrophoresis for analysis of Acinetobacter baumannii and A. junii outbreaks.

Two successive Acinetobacter outbreaks in a neonatal intensive care unit were studied with arbitrarily primed polymerase chain reaction (AP-PCR), cell envelope protein electrophoresis (protein fingerprinting) and antibiotic susceptibility testing. AP-PCR fingerprinting and protein fingerprinting yielded identical clustering of the isolates studied. Susceptibility test results were useful for rapid recognition of the outbreaks, but clustering of several isolates was different from the clustering obtained with AP-PCR fingerprinting and protein fingerprinting. Typing results indicated that the two outbreaks, which occurred at a three-month interval, were each caused by a single strain, and that both strains differed from the strains prevailing in the hospital. The strain of one outbreak was identified as A. junii, a species commonly not involved in outbreaks. A. baumannii isolates collected from different departments of this hospital during a period of four years clustered into only five different types. Moreover, strains from different departments of a second hospital belonged to the type prevailing in the first hospital, although there were no apparent connections between the two institutions. This may indicate that only a limited number of strains of the A. calcoaceticus-baumannii complex are involved in nosocomial outbreaks.

Glomerular filtration rate and creatinine production in adult icteric patients.

Various methods for serum creatinine determination were compared and validity of the Cockroft-Gault algorithm for calculating creatinine clearance was tested in adult icteric patients. Using conventional Jaffé assays, negative interference is proportional to the serum bilirubin content. Pretreatment of the serum with bilirubin oxidase was more efficient in eliminating bilirubin than pretreatment with potassium ferricyanide. Due to a continued creatine-poor diet and liver dysfunction, erythrocyte creatine levels and creatinine output rate were decreased. Median effect (creatinine equivalent) of non-specific chromogens in the unmodified Jaffé assay was 21 mumol/l (range: 1-108 mumol/l), vs. 19 mumol/l (range: 16-26 mumol/l) for the reference population. In the absence of multi-organ failure, the Cockroft-Gault algorithm could be used for estimating glomerular filtration rate. In patients with multiple organ failure however, we recommend correction for both bilirubin and non-specific chromogens for measuring the serum creatinine concentration.

Haptoglobin polymorphism and the immune response after hepatitis B vaccination.

One hundred healthy Caucasian medical students (age 22 +/- 1 years) were vaccinated with a recombinant hepatitis B vaccine and their haptoglobin types were determined. A relationship between haptoglobin type and immune response to the vaccine was observed. Subjects with a 2-2 haptoglobin phenotype produced significantly lower hepatitis B antibody titres than those having a 1-1 or 2-1 haptoglobin phenotype. The haptoglobin phenotypes not only influenced the magnitude but also the kinetics of the anti-HBs response. For all haptoglobin types, haptoglobin concentration and immune response to the vaccine behaved independently.