Advance care planning among hematopoietic cell transplant patients and bereaved caregivers.

Younger, healthier patients contemplating high-risk (but potentially curative) hematopoietic cell transplants (HCT) may not consider advance care planning (ACP). We investigated the effect of pre transplant ACP in surviving HCT patients and bereaved caregivers using retrospective, audiotaped telephone surveys. Subjects were identified between 2001 and 2003 via databases at two high-volume HCT centers. Transcripts were coded by two investigators, with differences resolved by consensus. HCT survivors (n=18) were interviewed a median of 13 months after HCT for acute leukemia (7), lymphoma (5) or other (6); 50% had living wills, 72% had a formal proxy. Twelve (67%) had discussed mortality risk pre HCT with the medical team. Of those, 92% felt their hope and perception of the medical team's truthfulness was increased or unchanged (I/U) by the conversation, whereas all felt clinician commitment to transplant was I/U. Bereaved caregivers (n=11) were interviewed a median of 10 months post death (median 31 days post HCT, range 13-152). Nine (82%) had discussed mortality risk pre-HCT with the medical team; 7 (78%) felt hope was I/U, all felt clinician commitment to transplant and truthfulness was I/U, and most felt ACP reduced burden (67%). ACP discussions with patients and caregivers pre-HCT did not affect hope and supported confidence in medical teams.

Evaluation of the impact of HIV serostatus, tobacco smoking and CD4 counts on epidermoid anal cancer survival.

Tobacco smoking and HIV infection increase the risk of epidermoid anal cancer (EAC). No published studies have examined smoking and EAC outcomes, and the literature is discrepant regarding outcomes of HIV-positive patients with EAC. The goal of this study was to examine smoking history, HIV status and outcomes in EAC patients. We conducted a retrospective analysis of adults with invasive EAC treated in the University of Washington hospital system from 1 January 1994 to 31 December 2008. Sixty-three patients were included. Forty-seven patients (75%) had primary chemoradiation, of whom 42 (89%) completed therapy. Two patients (3%) received radiotherapy alone. Fourteen patients (22%) underwent primary surgery, of whom 11 (79%) underwent tumour excision and three (21%) abdominoperineal resection (APR). We analysed smoking history, HIV status and CD4 count (≥ 200 cells/µL/<200 cells/µL for HIV-positive patients) versus outcomes. Forty-five patients (71%) were in remission, and 44 (70%) were alive at last follow-up. Overall survival was significantly better for never-smokers than for ever-smokers. There were no differences in outcomes according to HIV status or CD4 counts. Patients with anal cancer who smoke have worse overall survival than non-smoking patients. HIV infection does not appear to affect anal cancer outcomes.

The inner life of physicians and care of the seriously ill.

Seriously ill persons are emotionally vulnerable during the typically protracted course of an illness. Physicians respond to such patients' needs and emotions with emotions of their own, which may reflect a need to rescue the patient, a sense of failure and frustration when the patient's illness progresses, feelings of powerlessness against illness and its associated losses, grief, fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings. These emotions can affect both the quality of medical care and the physician's own sense of well-being, since unexamined emotions may also lead to physician distress, disengagement, burnout, and poor judgment. In this article, which is intended for the practicing, nonpsychiatric clinician, we describe a model for increasing physician self-awareness, which includes identifying and working with emotions that may affect patient care. Our approach is based on the standard medical model of risk factors, signs and symptoms, differential diagnosis, and intervention. Although it is normal to have feelings arising from the care of patients, physicians should take an active role in identifying and controlling those emotions.

Fatal outcome due to cyclosporine neurotoxicity with associated pathological findings.

We present a case of death likely to be directly due to cyclosporine (CsA) neurotoxicity. To date, there have been no reports of deaths directly due to CsA neurotoxicity, nor has an associated histological lesion been described independent of confounding processes. A 54-year-old male received an HLA-matched-unrelated BMT for CML. He developed progressive encephalopathy and on day +79 had a generalized seizure. All CSF studies were negative for infectious causes. MRI revealed diffuse, symmetrical white matter abnormalities located in the occipital sub-cortex, thalamus, mid brain, pons, and cerebellum which were typical of CsA toxicity. The patient died of central respiratory failure within 72 h of discontinuing CsA. Autopsy revealed diffuse patchy white matter edema and astrocytic injury without evidence of axonopathy, demyelination, microvascular injury, or infectious/inflammatory process. This case demonstrates previously undescribed lethal CsA neurotoxicity and may reveal an associated primary pathological lesion.

Subcutaneous T-cell lymphoma treated with systemic chemotherapy, autologous stem cell support, and limb amputation.

Subcutaneous T-cell lymphoma is an unusual variant of peripheral T-cell lymphoma in which the malignant infiltrate preferentially involves the subcutis. The disease is often initially misdiagnosed as a benign inflammatory panniculitis or a granulomatous disease. We describe subcutaneous T-cell lymphoma in a 39-year-old man who was treated with systemic chemotherapy, autologous stem cell support, and amputation of the limb primarily involved with the lymphomatous infiltrate. This is the first report of amputation being included in the treatment regimen of subcutaneous T-cell lymphoma. Because preferential involvement of the extremities often occurs in patients with subcutaneous T-cell lymphoma, surgical debulking of refractory disease by partial or complete limb amputation may be a useful therapeutic adjunct.

Provoking nonepileptic seizures: the ethics of deceptive diagnostic testing.

The use of deception in medical care is highly suspect in this country. Yet there is one condition for which deception is often used as a diagnostic tool. Nonepileptic seizures, a psychiatric condition in which emotional or psychological conflicts manifest themselves unconsciously through bodily symptoms, are currently diagnosed by a procedure called "provocative saline infusion." The test is fundamentally deceptive, requiring the physician to intentionally and directly lie to the patient, causing the patient to believe that the administered solution caused his seizures. Without such deception, the test might be useless.

Physician-assisted suicide. Finding common ground.

In Washington state, practicing physicians have been forced to confront the emotional, complex issue of physician-assisted suicide sooner than physicians elsewhere in the US. The Washington State Medical Association has struggled at length with the issue and ultimately delineated a policy on safeguards for physician-assisted suicide. The Washington experience may prove instructive to other professional physician organizations even before the US Supreme Court rules on the issue.

Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses.

OBJECTIVES: To estimate how often physicians receive requests for physician-assisted suicide and euthanasia and to describe a case series of patient requests for physician-assisted suicide and euthanasia, including physician responses to these requests. DESIGN: A mailed, anonymous two-part questionnaire. PARTICIPANTS: A total of 828 physicians returned questionnaires sent to 1453 potential respondents, for a response rate of 57%. Questionnaires were mailed to random sample (25%) of primary care physicians and all physicians in selected medical subspecialties in Washington State. MAIN OUTCOME MEASURES: The frequency of explicit patient requests for physician-assisted suicide and euthanasia reported by physicians and individual case descriptions of patient characteristics, physician perceptions of patient concerns, and physician responses to patient requests. RESULTS: In the past year, 12% of responding physicians received one or more explicit requests for physician-assisted suicide, and 4% received one or more requests for euthanasia. These physicians provided 207 cases descriptions. The diagnoses most often associated with requests were cancer, neurological disease, and the acquired immunodeficiency syndrome (AIDS). The patient concerns most often perceived by physicians were worries about loss of control, being a burden, being dependent on others for personal care, and loss of dignity. Physicians provided assistance more often to patients with physical symptoms. Physicians infrequently sought advice from colleagues. Of 156 patients who requested physician-assisted suicide, 38 (24%) received prescriptions, and 21 of these died as a result. Of 58 patients who requested euthanasia, 14 (24%) received parenteral medication and died. CONCLUSIONS: Patient request for physician-assisted suicide and euthanasia are not rare. As perceived by physicians, the most common patient concerns at the time these requests are made are nonphysical. Physicians occasionally provide these practices, even though they are currently illegal in Washington State. Physicians do not consult colleagues often about these requests. These findings raise the question of how to ensure quality in the evaluation of patient requests for physician-assisted death.

Transfected leukocyte integrin CD11b/CD18 (Mac-1) mediates phorbol ester-activated, homotypic cell:cell adherence in the K562 cell line.

The CD11b/CD18 leukocyte integrin molecule mediates diverse neutrophil adherence-related functions, including cell:cell and cell:extracellular matrix attachments. To study the individual role of this leukocyte integrin in cell adherence in hematopoietic cells, we expressed the CD11b/CD18 complex on the surface of K562 cells, a cell line derived from an individual with chronic myelogenous leukemia in blast crisis. We used an amphotrophic retroviral vector designated LCD18SN, harboring the complete coding sequence for the CD18 subunit, to transfer the CD18 cDNA into K562 cells and select stable cell lines. The CD11b subunit in the expression plasmid pREP4 was transfected into these K562/CD18 cells by electroporation and stable cell clones were selected. These K562 cells possessed RNA and intracellular protein for each subunit, and they expressed the CD11b/CD18 heterodimer on the cell surface. When CD11b/CD18 expressing K562 cells were stimulated with phorbol myristate acetate (50 ng/mL) for 24 to 48 hours, these K562 cells formed dense cell:cell aggregates. This homotypic aggregation required both activation of the CD11b/CD18 complex and the induction of the counter-receptor for CD11b/CD18 on the conjugate cell. This cell line will (1) enable the structure-function relationships between cell activation and homotypic adherence to be assessed, (2) provide the opportunity to identify accessory molecules required for activation of the CD11b/CD18 complex, and (3) facilitate the identification of novel ligands for the CD11b/CD18 complex.

A point mutation associated with leukocyte adhesion deficiency type 1 of moderate severity.

Leukocyte adhesion deficiency (LAD) is a genetic disease characterized clinically by severe bacterial infections, and biochemically by a deficiency in the surface expression of the CD11/CD18 leukocyte integrins. We studied a teenage girl with the moderate deficiency phenotype of LAD. B-lymphoblastoid cells from this patient displayed approximately 5% of normal levels of CD11/CD18 on the cell surface. Although a normal sized CD18 mRNA was detectable on Northern blotting, a small CD18 protein was present on Western blotting. Sequencing of the RNA revealed a single base pair substitution resulting in a glycine to serine amino acid substitution at amino acid 284. This amino acid substitution occurs within a highly conserved region of the extracellular domain of CD18 in which several other mutations have been identified in LAD.

Identification of the promoter of the myelomonocytic leukocyte integrin CD11b.

The CD11b (or macrophage-1 antigen; MAC-1) subunit of the leukocyte integrin family forms a noncovalently associated heterodimeric structure with the CD18 (beta) subunit on the surface of human granulocytes and monocyte/macrophages, where it enables these myeloid cells to participate in a variety of adherence-related activities. Expression of the CD11b subunit is restricted to cells of the myelomonocytic lineage and depends upon the stage of differentiation with the most mature myeloid cells expressing the highest levels of CD11b. To study the regulation of CD11b expression, a genomic clone corresponding to the 5' region of the CD11b gene was isolated from a human chromosome 16 library. Primer extension and RNase protection assays identified two major transcriptional start sites, located 90 base pairs and 54 base pairs upstream from the initiation methionine. DNA sequence analysis of 1.7 kilobases of the 5' flanking sequence of the CD11b gene indicated the absence of a "CAAT" or "TATA" box; however, potential binding sites for the transcription activators Sp1, PU.1, ets, and AP-2 are present, as well as retinoic acid response elements. The 1.7-kilobase CD11b promoter sequence displayed functional activity in transient transfection assays in the monocytic cell line THP-1 and the myeloid cell line HL-60. In contrast, this 1.7-kilobase promoter sequence did not display functional activity in the Jurkat T-lymphoid cell line. Detailed characterization of the CD11b promoter sequence should provide insight into the molecular events regulating the tissue-specific and developmental stage-specific expression of the CD11b molecule in myelomonocytic cells.

Identification of two molecular defects in a child with leukocyte adherence deficiency.

Children with leukocyte adherence deficiency (LAD), or leukocyte cell adhesion molecule deficiency, experience recurrent, life-threatening bacterial infections related to severe deficiency in surface expression of the leukocyte integrin molecules. The leukocyte integrins consist of a common CD18 (beta) subunit and individual, noncovalently associated alpha subunits designated CD11a, CD11b, and CD11c. Defects in the CD18 subunit prevent surface expression of the CD11/CD18 complexes in children with this disease. We investigated the molecular basis of the disease in a child with the severe deficiency form of LAD and identified two molecular defects in the CD18 subunit. The first defect is a single-base pair C----T transposition resulting in an amino acid substitution of a leucine for a proline at amino acid 178. This amino acid substitution is located in a region that is highly conserved among the integrin beta subunits and where two previous defects have been located in LAD. The second mutation involves a deletion of 220 base pairs in the cDNA coding for a portion of the extracellular domain and results in a frameshift into a premature stop codon. The deleted region corresponds to a single exon in the CD18 gene. Identification of these two molecular defects in a single child with this disease indicates the compound heterozygous nature of the disorder in this child and identifies regions of the CD18 subunit that may be important for CD11/CD18 heterodimer formation and surface expression.

Regulation of expression of the leukocyte integrin CD11a (LFA-1) molecule during differentiation of HL-60 cells along the monocyte/macrophage pathway.

The CD11a/CD18 (LFA-1) leukocyte integrin receptor mediates homotypic and heterotypic leukocyte adhesion by binding to one of two defined ligands, ICAM-1 or 2, on the conjugate cell. In this study we investigated the molecular regulation of expression of the CD11a subunit during myeloid differentiation of HL-60 cells. Induction of monocyte/macrophage differentiation of HL-60 promyelocytic leukemia cells with PMA results in an increase in CD11a surface Ag expression and the acquisition of CD11a/CD18-mediated homotypic adherence. These changes are accompanied by a 40-fold increase in CD11a mRNA levels. Nuclear run-on transcription assays indicate that the increase in CD11a mRNA in PMA-induced HL-60 cells is not caused by an increase in CD11a RNA transcription. We assessed the posttranscriptional regulation of CD11a using two methods. By using actinomycin D to block RNA transcription, we demonstrate that the CD11a mRNA half-life in HL-60 cells is prolonged after PMA treatment. Inhibition of protein synthesis with cycloheximide also results in enhanced expression of CD11a mRNA in HL-60 cells without increasing CD11a transcription. These findings indicate that, in HL-60 cells induced with PMA to differentiate along the monocyte/macrophage pathway, CD11a expression is regulated primarily at the posttranscriptional level by a labile protein. Identification of the specific CD11a RNA sequences, and the proteins that bind to these sequences may provide insight into lineage commitment during human monocyte/macrophage differentiation.

Retroviral-mediated gene transfer of the leukocyte integrin CD18 subunit.

Children with leukocyte adherence deficiency (LAD) exhibit heterogeneous defects in the leukocyte integrin CD18 subunit that prevent surface expression of functional CD11/CD18 leukocyte integrin adherence complexes. We used a retroviral vector, designated LCD18SN, to transfer the CD18 cDNA into K562 human myeloid leukemia cells and into EBV B-cells from a child with LAD. Transfer of the LCD18SN retroviral construct, which expresses the CD18 cDNA from the Moloney Murine leukemia virus (MoMLV) long terminal repeat (LTR), into K562 cells resulted in relatively high levels of CD18 mRNA and intracellular protein. Retroviral-mediated gene transfer of CD18 into LAD EBV B-cells resulted in low, but readily measurable, levels of surface expression of the CD11a/CD18 complex in these previously deficient lymphocytes. The reconstitution of surface expression of the CD11a/CD18 complex by gene transfer of the CD18 cDNA into LAD EBV B-cells indicates that this syndrome represents a candidate disorder for gene therapy.

Regulation of expression of the CD11b and CD18 subunits of the neutrophil adherence receptor during human myeloid differentiation.

The receptor on human myeloid cells that mediates cellular adherence consists of a heterodimer complex (designated CD11b/CD18). This receptor complex plays a critical role in leukocyte chemotaxis, adherence to vascular endothelium, and phagocytosis. We investigated expression of the CD11b subunit of this adherence receptor complex in various leukocyte populations. As previously described for the CD18 subunit, enhanced CD11b surface antigen and mRNA expression are present in peripheral blood granulocytes, as well as in chemically induced, differentiating HL-60 cells. However, in contrast to CD18 mRNA expression, which is transcriptionally regulated in differentiating HL-60 cells, the steady state levels of CD11b mRNA appear to be post-transcriptionally regulated in these cells. Thus, although the steady state levels of mRNA for the individual subunits of the CD11b/CD18 adherence receptor complex generally parallel each other during human myeloid differentiation, the mechanisms responsible for regulating these levels are distinctly different.

cDNA sequence for the alpha M subunit of the human neutrophil adherence receptor indicates homology to integrin alpha subunits.

The receptor on human neutrophils (polymorphonuclear leukocytes) that mediates cellular adherence consists of two noncovalently associated subunits, designated alpha M (Mac-1 alpha, Mol alpha, or CD11b; Mr, 170,000) and beta (Mac-1 beta, Mol beta, or CD18; Mr, 100,000). We isolated a cDNA clone for the human neutrophil alpha M subunit by screening a lambda gt 11 cDNA library made from chronic myelogenous leukemia neutrophils by using an affinity-purified rabbit polyclonal antibody directed against the alpha M subunit. We used this cDNA clone to obtain additional clones from cDNA libraries made from differentiated HL-60 promyelocytic leukemia cells. Together these cDNAs constitute the complete 1137-amino acid sequence for the mature human alpha M subunit protein. The deduced amino acid sequence indicates the presence of an extensive extracellular domain with three putative metal-binding regions, (i) an amino acid region that is homologous to the A domain of von Willebrand factor, (ii) a 26-amino acid hydrophobic sequence that is a potential transmembrane domain, and (iii) a 19-amino acid cytoplasmic region. The amino acid sequence for the human neutrophil alpha M subunit contains regions that are closely related to amino acid sequences of adhesion receptors belonging to the integrin family.