Immunosuppression using the mammalian target of rapamycin (mTOR) inhibitor everolimus: pilot study shows significant cognitive and affective improvement.

UNLABELLED: Immunosuppression using calcineurin inhibitors (CNIs) is accompanied by neuropsychiatric side effects, which counteract longevity and quality of life benefits in 10% to 28% of patients. Following the availability of the mammalian target of rapamycin (mTOR) inhibitors, it became possible to replace CNI without increasing the risk of acute graft rejection. mTOR, a member of the phosphatidyl inositol 3' kinase family, is a downstream target of brain-derived neurotrophic factor, which has been implicated in the pathophysiology and treatment of several psychiatric disorders. Preclinical evidence has implicated the mTOR pathway in synaptic plasticity and fear memory consolidation and reconsolidation. METHODS: In the present study we prospectively evaluated the psychiatric outcomes of CNI-free immunosuppression in adult maintenance heart transplant recipients (n = 9; age: 66.1 +/- 6.1) using the Wechsler Memory Scale-Revised (WMS-R), Symptom Checklist-90-Revised (SCL-90-R), Beck Depression Inventory (BDI), Trail Making Tests A and B, Digit Span (DS), and Hamilton Depression Scale (HAMD). RESULTS: Four weeks after switching to CNI-free immunosuppression using everolimus, BDI (Z = -1.14; P = .048), Trail Making tests A and B (Z = -2.52; P = .012), WMS-R (Z = 2.37; P = .018), and SCL-90-R (Z = -2.37; P = .018) were all significantly improved while DS (Z = -1.18; P = .236) and HAMD (Z = -0.595; P = .552) remained unchanged. CONCLUSION: This report describes favorable psychiatric outcome variables using everolimus in maintenance heart transplant recipients. CNI-free immunosuppression with everolimus might provide significant improvement in memory, concentration, and overall psychiatric symptoms among heart transplant recipients.

Interferon gamma inhibits proliferation and hyaluronic acid adhesion of human malignant glioma cells in vitro.

Malignant gliomas are frequent and the prognosis is poor. The cytokine interferon gamma (IFN-gamma) enhances several immune phenomena and may be used in immunotherapy of tumours. Therefore we investigated the influence of IFN-gamma on human cell lines T98G, U87MG, 86HG39 and 85HG66, measuring cell viability (MTT-test) and proliferation (3H-thymidine uptake). IFN-gamma markedly decreased viability and proliferation of all investigated cell lines. Expression of CD44 and adhesion to hyaluronic acid (HA) are involved in glioma invasion. Influence of IFN-gamma on these two features has also been investigated. IFN-gamma markedly decreased HA-adhesion in all three investigated cell lines, whereas CD44 expression remained uninfluenced. To summarise, IFN-gamma strongly decreased cell growth and HA-adhesion of malignant glioma cell lines in vitro. We suggest further investigations to characterise better the role of IFN-gamma as a treatment opportunity for malignant gliomas.

Cellular drug resistance in acute myeloid leukemia: literature review and preliminary analysis of an ongoing collaborative study.

Cellular drug resistance is one of the main causes of the frequent ultimate failure of chemotherapy in childhood acute myeloid leukemia (AML). We here summarize the results of a literature review on in vitro drug resistance in childhood AML, focusing on studies using so-called cell culture assays. We also briefly describe some results of an ongoing collaborative study between the Research Laboratory of Pediatric Oncology in Amsterdam (University Hospital Vrije Universiteit) and the German BFM-AML Group. In general, the literature and our preliminary data on in vitro cellular drug resistance in AML are promising in terms of clinical relevance. Cell biological features and clinical response to chemotherapy are related to in vitro drug resistance. However, a large study including multivariate analysis is required to more firmly establish the clinical value of cellular drug resistance testing in childhood AML, and the collaborative study will therefore be continued. Possible applications of cell culture assays include risk-group stratification, rational improvements of current treatment protocols for subgroups of patients based on specific drug resistance profiles, individualised tailored therapy, the study of cross-resistance patterns between drugs, the study of possibilities to modulate or circumvent drug resistance, the study of drug interactions, selection of patients for clinical phase II studies and drug screening.

CD44 expression and hyaluronic acid binding of malignant glioma cells.

The mechanisms leading to rapid invasive growth of malignant gliomas are poorly understood. Expression of the hyaluronic acid (HA) receptor CD44 and adhesion to HA are involved in invasive properties. Our previous studies have shown that malignant glioma cells are able to adhere to extracellular HA. Here we investigated expression of the hyaluronic acid receptor CD44 protein in five human (T98G, A172, U87MG, 86HG39, 85HG66) and two rat (C6, 9L) glioma cell lines. Influence of anti-CD44 antibody and hyaluronidase-preincubation on the HA-binding was determined using HA/BSA (bovine serum albumin)-coated culture plates. While all gliomas were highly positive for CD44 with no differences in the number of positive staining cells, median fluorescence intensity decreased as follows: C6>T98G>9L>85HG66> 86HG39>A172>U87MG. Using HA/BSA coated culture plates the relative levels of specific adhesion to HA were determined as T98G>A172>9L>86HG39>U87MG> 85HG66. C6 cells failed to bind HA specifically. Incubation with anti-human-CD44 MAb significantly decreased HA-adhesion of T98G, A172, 85HG66 and U87MG human glioma cells. However the binding capacity was completely blocked only in 85HG66 cells. The three other cell lines kept a specific HA-adhesion after saturation of the receptor. Hyaluronidase pretreatment markedly enhanced HA-adhesion of C6 and 9L rat glioma cells. These results suggest that (i) HA-adhesion of malignant glioma cells is mainly, but not only, mediated by CD44, (ii) expression of CD44 does not correspond with adhesion capacity and (iii) cell-bound glycosaminoglycans may influence glioma cell adhesion to extracellular HA.

[Clinical aspects and epidemiology of hepatitis C in immunosuppressed children with mostly oncologic diseases]. / Zur Klinik und Epidemiologie der Hepatitis C bei immunsupprimierten Kindern mit vorwiegend onkologischen Erkrankungen.

Between July and October 1996 hepatitis C virus infection was diagnosed in 21 children who underwent immunosuppressive therapy mainly for malignant diseases. We report on the clinical signs and symptoms, diagnostic procedures and the clinical course of the disease in these patients. Epidemiological, diagnostic and clinical aspects of the outbreak are discussed. Analysis of all available data led to the conclusion that these infections were of nosocomial origin. This requires consequences in the hygienic regimen. In addition to the routinely used antibody-test the HCV-PCR should be the diagnostic method of first choice concerning the HCV-diagnostics in immunocompromised patients.

Hyaluronic acid binding capacity of malignant glioma cells.

The mechanisms underlying the rapid invasive growth of malignant gliomas are poorly understood. Adhesion to extracellular hyaluronic acid (HA) has been implicated in the invasive properties of tumor cells. We investigated the HA binding capacity of human (T98G, A172, U87MG, 86HG39, 85HG66) and rat (C6, 9L) glioma cell lines by means of HA coated, bovine serum albumin (BSA)-blocked (HA/BSA) and only BSA-blocked culture plates. Results were compared with adhesion to native wells (100% adhesion). Adhesion to HA/BSA was high for T98G (84.4%), medium for 86HG39 (36%), 9L (33.1%), A172 (35.5%) and low for 85HG66 (21.3%) and U87MG (26.8%). Adhesion to only BSA-coated wells was significantly lower in all these cell lines, suggesting a specific HA-adhesion. Only C6 showed similar adhesion to HA/BSA and BSA alone, therefore, C6 failed to bind HA specifically. These results suggest that adhesion to extracellular HA might be involved in the invasion of some gliomas.

Interferon-gamma inhibits proliferation and adhesion of T98G human malignant glioma cells in vitro.

BACKGROUND: The prognosis of children with malignant gliomas is poor. A new therapeutic strategy using interferon-gamma (IFN-g) as an immunostimulator substance will start in Germany in 1997. One of the therapeutic problems in malignant gliomas is the high invasiveness of the tumor cells. Adhesion to the extracellular matrix molecule hyaluronic acid (HA) is involved in invasion. We addressed the question of whether IFN-g (i) influences the proliferation and (ii) changes the HA-binding capacity of malignant glioma cells. METHOD: T98G glioblastoma cells were incubated up to 4 days with IFN-g (30 and 300 IE/ml). Proliferation was measured by a colorimetric assay (MTT) and compared with untreated controls. Expression of the HA-receptor CD44 was determined by FACS-analysis using the mouse monoclonal antibody J-173. HA-adhesion was investigated using HA-coated (3 mg/ml), bovine serum albumin blocked 24-well-plates and compared with uncoated wells. RESULTS: FN-g (300 IE/ml) inhibited proliferation to 76.3% (p < 0.0001) after 48 hours compared with untreated controls. This effect was mediated not only by inhibition of proliferation, but also by induction of cell-death, first seen 72 h after IFN-g incubation. 24 hours later only 24% of treated cells survived. 93.1% of T98G cells expressed CD44 (FACS-analysis). A specific HA-adhesion of glioma cells was shown: 85.5% of the cells adhered to HA, 13.3% to BSA compared with controls. 300 IE/ml IFN-g decreased HA-adhesion significantly (p < 0.001) to 17%, whereas BSA-adhesion remained unchanged. CONCLUSION: IFN-g inhibits tumor cell proliferation and diminishes the invasive properties of glioma cells via reduction of HA binding capacity. Our results support the use of IFN-g in the therapy of malignant gliomas.

[Results and experiences with a modified BFM protocol for treatment of recurrences in children with acute lymphoblastic leukemia in East German areas]. / Ergebnisse und Erfahrungen mit einem modifizierten BFM-Protokoll zur Rezidivbehandlung von Kindern mit akuten lymphoblastischen Leukämien (ALL) in den ostdeutschen Ländern.

Between 1988 and 1990, 55 patients with first relapses of acute lymphoblastic leukemia (ALL) were treated with a modified BFM-protocol (ALL REZ I/88). The patients were divided according to time and site of relapse: relapses with bone marrow involvement up to 6 months after stopping front line therapy (group A), relapses with bone marrow involvement beyond 6 month after therapy (group B) and isolated extramedullary relapses at any time (group C). During therapy the patients received alternating courses of polychemotherapy including infusions of intermediate dose methotrexate (1 g/m2 in 36 hours). The maintenance treatment consisted of daily oral thioguanine and biweekly intravenous (IV) MTX. The overall second remission rate was 89% (group A: 90%, group B: 86%, group C: 93%) and the probability of event free survival (EFS) at 4 years is 0.28 +/- 0.13 (group A: 0.22 +/- 0.12, group B: 0.24 +/- 0.18, group C: 0.57 +/- 0.15). We conclude, that with the treatment regimen applied, long lasting second remission can be achieved in about one third of patients even after intensive front line therapy. The most unfavourable prognoses were seen in patients with early bone marrow relapses (group A).

[Experiences with modified BFM protocols in the treatment of children with acute lymphoblastic leukemia (ALL) in East Germany 1981-1991]. / Erfahrungen mit modifizierten BFM-Protokollen bei der Behandlung von Kindern mit akuten lymphoblastischen Leukämien (ALL) in den ostdeutschen Ländern von 1981 bis 1991.

Between September and August 1991 818 previously untreated children and adolescents up to 18 years of age with acute lymphoblastic leukemia were entered into two modified BFM-protocols. Patients with B-ALL were excluded. From 1981 to 1987 524 patients were entered into the randomized multicenter study ALL VII/81 (modified ALL-BFM 81 protocol). Patients were divided into three risk groups standard (SR), medium (MR), high risk (HR) using the BFM risk factor. In a connecting study from 1988 to 1991 294 patients were registered on the stratified and randomized multicentric trial ALL VIII/87 (modified ALL-BFM 86 study). The main modification in study ALL VII/81 concerned the duration of treatment. Patients were randomized into two groups. The first group received as a late reinduction protocol III and then therapy was stopped. The second group received 6-MP and MTX for another six months. The other whole treatment strategy of ALL-BFM 81 was adopted. In protocol ALL VIII/87 the only modification was the reduction of the MTX dosage from 5 g/m2 to 1 g/m2 with an infusion time of 24 hours (leucovorin rescue 15 mg/m2 after 48 and 54 hours). The probability of the event-free-survival (EFS) for study ALL VII/81 was 59%. CNS events were significantly more frequent in standard risk patients with intermediate dose MTX (4 x 0.5 g/m2) compared with the irradiation group (18 Gy). The EFS for SR patients amounts to 61%, for MR patients to 59% and for HR patients to 36%. There was no significant difference of EFS for the two groups with different duration of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Therapy of acute myeloid leukemia in children--results of the AML II/87 multicenter study]. / Therapie der akuten myeloischen Leukämie bei Kindern--Ergebnisse der multizentrischen Therapiestudie AML II/87.

Fifty seven patients entered the cooperative study AML II/87 of the working group "Pediatric Hematology and Oncology" of East Germany. Two patients with initial hyperleukocytosis died prior therapy. 13 patients died within the first 4 weeks of therapy, 3 patients did not respond to therapy, and one patient is not yet in remission. 38 patients (70%) attained a complete remission. 15 patients get a bone marrow transplantation in first CR (10 autologous BMT without purging, 5 allogenous BMT). 12 of them are living and well 3 to 34 months after BMT. 9 of the 23 patients under chemotherapy relapsed, one patient is lost to follow up. 13 patients are living in continuous complete remission. The life table probabilities 48 months after the start of the protocol are 0.43 for disease free survival (DFS) and 0.60 for event free interval (EFI). The respective results of the former protocol AML I/82 were 0.34 for DFS and 0.47 for EFI.

[Bacterial bone and joint infections in childhood--a review. 4. Subacute and primary-chronic osteomyelitis, rare forms of osteomyelitis]. / Bakterielle Knochen- und Gelenkinfektionen im Kindesalter--eine Ubersicht. 4. Subakute und primär-chronische Osteomyelitis, seltene Osteomyelitisformen.

This is an overview of the most important aspects of pathogenesis, etiology, diagnostics, therapy and differential diagnostics of the subacute and primary chronic osteomyelitis in children. This group of disease includes Brodie's abscess, plasma cellular osteomyelitis, sclerosing osteomyelitis (Garré) and the chronic recurrent multifocal osteomyelitis. The treatment of children with these not completely understood diseases requires a close cooperation between pediatricians, pediatric surgeons and radiologists.

[The significance of various hematological parameters for the early diagnosis of bacterial infection in premature and full-term neonates. 1. Patients and study methods, normal values for the blood picture of newborn infants]. / Untersuchungen zur Bedeutung einiger hämatologischer Parameter für die Früherkennung bakterieller Infektionen bei Früh- und reifen Neugeborenen. 1. Patienten und Untersuchungsmethoden, Normwerte für das Blutbild bei Neugeborenen.

We examined the white blood count in 101 premature infants and full-term neonates on their first day of life (before or within the 12th hour), on 2nd, 3rd, 4th, 5th, 10th, 15th and 20th day of life. Infection was suspected in the course in 31 infants (without demonstration of pathogenic organisms). In 73 infants without infections we were therefore able to establish normal values. We could establish reference limits corresponding to the standard deviation for all kinds of white blood cells, except the whole leucocyte count. Because of considerable individual differences of the whole white blood cell count in newborns without infections we fixed for this reference limits from 5 to 20 Gpt/l. The means of leucocyte and neutrophil counts reached their maximum in the 12th hour after birth, decreased until the 5th day of life and leveled off then. The segmented neutrophils and the lymphocyte counts crossed over after the 5th day of life resulting in a relative lymphocytosis. The physiologic left shift decreased in the first days of life. These described changes after birth were significant.

[The significance of various hematological parameters for the early diagnosis of bacterial infections in premature and full-term neonates. 3. Discussion of the study results]. / Untersuchungen zur Bedeutung einiger hämatologischer Parameter für die Früherkennung bakterieller Infektionen bei Früh- und Neugeborenen. 3. Diskussion der Untersuchungsergebnisse.

Haematological examinations may contribute, especially by repeated investigations of parameters changing dynamically, to a greater safety of decisions concerning the beginning or termination of chemotherapy in neonates with suspected infections. We recommend to check the blood count every 6-12 h in such cases. A normal blood count does not exclude a sepsis but haematological changes may precede clinical symptoms for hours. We can confirm the good experiences of some authors with "screening-scores" to detect early infants with sepsis. Such a score should include I/T-Quotient, thrombocyte count, CRP and micro-ESR. This contributes to a greater predictive probability of an infection.

[The significance of various hematological parameters for the early diagnosis of bacterial infections in premature and full-term neonates. 2. The blood picture in premature and full-term neonates with suspicion of existing infection or with confirmed infection]. / Untersuchung zur Bedeutung einiger hämatologischer Parameter für die Früherkennung bakterieller Infektionen bei Früh- und Neugeborenen. 2. Das Blutbild bei Früh- und reifen Neugeborenen mit Verdacht auf Vorliegen einer Infektion bzw. mit gesicherten Infektionen.

We compared the normal values of white blood counts in premature infants and full-term neonates, as described in part one of this paper, with blood counts of 31 infants with suspected infections and 81 infants with sepsis and/or meningitis. The half of these infected infants had leucocyte and neutrophil counts beyond the reference limits. The values tended to leucopenia in diseases beginning within the first five days of life and to leucocytosis later on. More than 80% of the patients had a left shift. One is able to predict a sepsis with a probability of 16.3%, according to our experiences, with leucocyte counts below 5 or above 20 Gpt/l. In the case of left shift the probability is about 25%. Combining these parameters the predictive value is even mounting to 56.1%. We were able to make a prognosis too referring to the blood count of infants with sepsis.

[Pneumococcal infections in children: hemolytic-uremic syndrome]. / Pneumokokkeninfektionen im Kindesalter: Hämolytisch-urämisches Syndrom.

By the example of a case-report diagnostic and therapeutic features of the haemolytic-uraemic syndrome are discussed within the frame of infections by pneumococci. In case of infections by pneumococci but also of those ones caused by other bacteria or viruses neuraminidase may be set free, that on its part may lead to an enzyme-induced haemolysis and in some cases also to a damage of other cell systems. In case of an active share of the kidney a haemolytic-uraemic syndrome may be the consequence.