RESUMO
The interplay between tumor heterogeneity and microenvironmental factors is a critical mechanism for clonal selection in leukemia. Evidence of unique clonal capacities to engraft within patient-derived xenograft (PDX) models suggests that intrapatient genetic architecture may be defined by functional differences at the clonal level. However, methods to detect functional differences assigned to genetically defined clones remain limited. Here, we describe a scalable method to directly measure the functional properties of clones within the same leukemia patient by coupling intracellular flow cytometry and next-generation sequencing (NGS). We provide proof of concept utilizing primary chronic myelmonocytic leukemia (CMML) samples and granulocyte-macrophage colony stimulating factor (GM-CSF) to elucidate the interaction between tumor heterogeneity and microenvironmental factors. Mixtures of human leukemia cell lines, with known response to GM-CSF, were used to validate the accuracy of our methodology. Using this approach, we confirm that our method is capable of discriminating GM-CSF sensitive cell lines, identifies somatic variants in primary leukemia samples, and resolves functional clonal architecture in an illustrative patient. Taken together, our data describes a novel method to determine intrapatient functional clonal heterogeneity and provides proof-of-concept for future investigation aimed at elucidating the clinical relevance of functional clonal differences.
Assuntos
Citometria de Fluxo/métodos , Sequenciamento de Nucleotídeos em Larga Escala/métodos , Leucemia/genética , Leucemia/patologia , Fator Estimulador de Colônias de Granulócitos e Macrófagos/genética , Humanos , Células K562 , Células Tumorais CultivadasRESUMO
OBJECTIVES: Patients with fibromyalgia have diminished levels of physical fitness, which may lead to functional disability and exacerbating complaints. Multidisciplinary treatment comprising cognitive-behavioural therapy (CBT) and exercise training has been shown to be effective in improving physical fitness. However, due to the high drop-out rates and large variability in patients' functioning, it was proposed that a tailored treatment approach might yield more promising treatment outcomes. METHODS: High-risk fibromyalgia patients were randomly assigned to a waiting list control group (WLC) or a treatment condition (TC), with the treatment consisting of 16 twice-weekly sessions of CBT and exercise training tailored to the patient's cognitive-behavioural pattern. Physical fitness was assessed with two physical tests before and 3 months after treatment and at corresponding intervals in the WLC. Treatment effects were evaluated using linear mixed models. RESULTS: The level of physical fitness had improved significantly in the TC compared with the WLC. Attrition rates were low, effect sizes large and reliable change indices indicated a clinically relevant improvement among the TC. CONCLUSIONS: A tailored multidisciplinary treatment approach for fibromyalgia consisting of CBT and exercise training is well tolerated, yields clinically relevant changes, and appears a promising approach to improve patients' physical fitness. ClinicalTrials.gov ID NCT00268606.
Assuntos
Terapia Cognitivo-Comportamental/métodos , Terapia por Exercício/métodos , Fibromialgia/reabilitação , Adulto , Terapia Combinada , Teste de Esforço/métodos , Feminino , Fibromialgia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Aptidão Física , Resultado do TratamentoRESUMO
OBJECTIVE: The heterogeneity of cognitive-behavioral patterns in patients with fibromyalgia (FM) has been proposed to underlie the variability in treatment outcomes. It has previously been shown that pain-avoidance and pain-persistence treatments tailored to the patient's pattern are effective in improving physical and psychological functioning and overall impact in high-risk patients with heightened psychological distress. In the present study, the cognitive-behavioral effects of these treatments were evaluated to provide insight into the main proposed mechanisms, specifically pain-avoidance behaviors and activity pacing in the pain-avoidance and pain-persistence treatments, respectively. METHODS: High-risk FM patients were classified into 2 groups, pain avoidance and pain persistence, and randomized in groups to the relevant treatment or waiting-list control condition. The pain-avoidance and pain-persistence treatments both comprised 16 twice-weekly sessions of cognitive-behavioral therapy and exercise training. Cognitive--behavioral factors assessed at pre- and posttreatment and 6 months of followup were evaluated using linear mixed models. RESULTS: A significant treatment effect was found for pain-avoidance behavior in the pain-avoidance treatment and for activity pacing in the pain-persistence treatment, showing improvements in the treatment condition relative to the controls. Furthermore, the effect on functioning was mediated by changes in pain-avoidance behavior in the pain-avoidance treatment and by changes in activity pacing in the pain-persistence treatment. Both treatments also showed significant improvements in other relevant cognitive-behavioral factors. CONCLUSION: Both the pain-avoidance and pain-persistence treatments are effective in improving cognitive-behavioral factors in high-risk FM patients. Pain-avoidance behavior and activity pacing might be important mediating mechanisms for beneficial outcomes in pain-avoidance and pain-persistence treatments, respectively.
Assuntos
Aprendizagem da Esquiva/fisiologia , Terapia Cognitivo-Comportamental/métodos , Fibromialgia/terapia , Manejo da Dor , Adulto , Feminino , Fibromialgia/psicologia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Dor/psicologia , Medição da Dor/métodos , Resultado do TratamentoRESUMO
BACKGROUND: The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms, such as pain-avoidance and pain-persistence patterns, has been proposed to underlie varying treatment outcomes in patients with fibromyalgia (FM). PURPOSE: To investigate the validity of a screening instrument to discriminate between pain-persistence and pain-avoidance patterns in FM. METHOD: In a three-part study, a self-reported screening instrument that assesses pain-avoidance behavior was used to distinguish patients with pain-persistence and pain-avoidance patterns. The resultant groups were compared with regard to several pain-related cognitive-behavioral factors, performance on a physical fitness test, and with regard to the judgments of trained therapists based on a semi-structured interview. RESULTS: The validity of the screening instrument to distinguish between pain-avoidance and pain-persistence patterns was supported by other validated self-report questionnaires for pain-related cognitive-behavioral factors, physical exercise tests, as well as by a high correspondence with blinded therapist judgment after intake assessments. CONCLUSION: These findings suggest that a short self-report screening instrument can be used to distinguish between pain-avoidance and pain-persistence patterns within the heterogeneous population of FM patients, which offers promising possibilities to improve treatment efficacy by tailoring treatment to specific patient patterns.
Assuntos
Fibromialgia/psicologia , Medição da Dor/instrumentação , Medição da Dor/métodos , Dor/diagnóstico , Dor/psicologia , Adulto , Aprendizagem da Esquiva , Comportamento , Teste de Esforço , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Países Baixos , Medição da Dor/normas , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
OBJECTIVE: To illustrate a multidisciplinary group treatment for patients with fibromyalgia (FM) tailored to the patient's cognitive-behavioral pattern. METHOD: In a case-study design the tailored treatment approaches of two FM patients were described. One patient characterized by avoidance behavior (pain-avoidance pattern) participated in a group treatment aimed at changing pain-avoidance mechanisms and one patient characterized by continuing with activities in spite of pain (pain-persistence pattern) participated in a group treatment aimed at changing pain-persistence mechanisms. Assessments were made at baseline, post-treatment and at 6-months follow-up. RESULTS: Comparison of the pretest, post-test and follow-up scores on pain, functional disability, fatigue and psychological distress showed clinically significant improvements for both patients. CONCLUSION: The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms has been proposed to underlie varying treatment outcomes in FM patients. These results demonstrate that a group treatment tailored to pain-avoidance and pain-persistence patterns is feasible and can result in clinically significant changes for FM patients. PRACTICE IMPLICATIONS: FM offers a great challenge for clinicians due to the lack of effective treatment options. These case studies suggests that tailored CBT and exercise training directed at specific patient patterns can contribute to the improvement of the care of FM patients.
Assuntos
Terapia Cognitivo-Comportamental/organização & administração , Fibromialgia/prevenção & controle , Fibromialgia/psicologia , Planejamento de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Autocuidado , Atividades Cotidianas , Adaptação Psicológica , Adulto , Atitude Frente a Saúde , Aprendizagem da Esquiva , Fadiga/etiologia , Medo , Estudos de Viabilidade , Feminino , Fibromialgia/complicações , Fibromialgia/diagnóstico , Seguimentos , Comportamentos Relacionados com a Saúde , Humanos , Pessoa de Meia-Idade , Avaliação das Necessidades , Medição da Dor , Autocuidado/métodos , Autocuidado/psicologia , Estresse Psicológico/etiologia , Resultado do TratamentoRESUMO
Fabry disease, or alpha-galactosidase A (alpha-Gal A) deficiency, is a lysosomal storage disorder in which accumulation of globotriaosylceramide (Gb(3)) is thought to be responsible for the development of renal, cardiac and cerebral complications. The availability of enzyme replacement therapy has led to an increased awareness and the screening of patients suffering from complications that may be associated with Fabry disease. An association between alpha-Gal A deficiency and atherosclerosis has been suggested, although there is controversy. We therefore studied the prevalence of Fabry disease in a Dutch cohort of prematurely atherosclerotic males. Measurement of alpha-Gal A activity was performed in plasma of 440 Dutch male patients with premature atherosclerosis. Patients were included if they were under the age of 50 years and had proven coronary and/or peripheral artery disease. Analysis revealed a mean alpha-Gal A activity of 7.75 +/- 3.48 nmol/h per ml (range 0.55-34.36). In 425 patients (96.5%) alpha-Gal A activity was within the reference range (3.2-14.3 nmol/h per ml, based on historical controls); 13 patients (3%) had values above and 2 patients (0.5%) below the reference range. Additional analysis of alpha-Gal A activity in leukocytes and fresh plasma in these two patients revealed normal values (53 and 47 nmol/h per mg (reference range: 32-60 nmol/h per mg) and 31.1 and 14.2 nmol/h per ml, respectively). Thus Fabry disease was not detected, leading to an overall prevalence of 0% (95 CI 0-0.68). In conclusion, screening for Fabry disease in prematurely atherosclerotic patients seems not to be very useful, although a slightly increased prevalence is not excluded.
Assuntos
Aterosclerose/complicações , Aterosclerose/diagnóstico , Doença de Fabry/complicações , Doença de Fabry/diagnóstico , Adulto , Idade de Início , Aterosclerose/sangue , Estudos de Coortes , Terapia Enzimática , Doença de Fabry/sangue , Humanos , Leucócitos/metabolismo , Masculino , Pessoa de Meia-Idade , Países Baixos , Valores de Referência , alfa-Galactosidase/metabolismoRESUMO
BACKGROUND: Fabry disease (OMIM 301500) is an X-linked lysosomal storage disorder with characteristic vascular, renal, cardiac and cerebral complications. Globotriaosylceramide (Gb(3)) accumulates in Fabry patients as a result of alpha-galactosidase A deficiency. The phenotypic variability is high, but the relationship between clinical symptoms in individual Fabry patients has not been uniformly documented. Also, the relation between the most prominent biochemical abnormalities, elevated Gb(3) levels in plasma and urine, and clinical symptoms is not firmly established. METHODS: Clinical and biochemical characteristics of 96 (25 deceased) Dutch Fabry patients were collected retrospectively and before the initiation of enzyme therapy. RESULTS: Clinical assessment revealed that median life expectancy was 57 years for male and 72 years for female patients. Cerebral complications, acroparaesthesias and gastrointestinal complications, but not cardiac and auditory complications, were all seen more frequently in male than female patients. Glomerular filtration rate (GFR) was highly variable in male patients, including 2 patients with GFR < 30 ml/min, but median GFR did not differ between males and females (103 and 101 ml/min, respectively). Hyperfiltration was more frequently observed in the female patient group. Microalbuminuria was present in 60% of males and 45% of females. No specific pattern of combined symptoms existed except for a relationship between left ventricular hypertrophy (LVH) and cerebral complications (males 36%, females 32%), or proteinuria (males 35%, females 31%). Gb(3) was found to be more elevated in plasma samples from male (n = 26; median 6.27 micromol/L (1.39-9.74)) than female Fabry patients (n = 37; median 2.16 (0.77-4.18)). This was also observed for urinary Gb(3): males (n = 22) median 1851 nmol/24 h (40-3724); females (n = 29) median 672 (86-2052). Plasma and urinary Gb(3) levels correlated with each other in both males (r = 0.4, p = 0.05) and females (r = 0.4, p = 0.03), but no correlation between elevated Gb(3) levels and clinical symptoms could be detected. CONCLUSION: Analysis of the characteristics of the Dutch Fabry cohort has revealed that a limited relationship between various disease manifestations exists and that individual symptoms do not correlate with elevated urinary or plasma Gb(3) levels, limiting their value as surrogate disease markers.
Assuntos
Doença de Fabry/diagnóstico , Doença de Fabry/genética , Triexosilceramidas/sangue , Triexosilceramidas/urina , Adolescente , Idoso , Estudos de Coortes , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico , Masculino , Pessoa de Meia-Idade , Países Baixos , Fenótipo , Qualidade de Vida , Estudos Retrospectivos , Fatores Sexuais , Inquéritos e QuestionáriosRESUMO
Increased plasma chitotriosidase is a well established surrogate marker for the occurrence of lipid-laden macrophages in the glycosphingolipidosis Gaucher disease. The complete lack of surrogate markers for Fabry disease, X-linked globotriaosylceramidosis stemming from deficiency in the lysosomal alpha-galactosidase A (AGA), prompted us to study chitotriosidase in this disorder. In male Fabry patients plasma chitotriosidase is significantly elevated, consistent with the presence of lipid-laden macrophages in several tissues. Increased levels are detectable at very young age and precede clinical manifestations. No strict correlation exists with severity of disease manifestations. Upon therapy with either of the two available recombinant AGA preparations, plasma chitotriosidase levels are nicely normalized in male Fabry patients. However, in patients developing neutralizing antibodies towards AGA, reduction in plasma chitotriosidase is hampered. In sharp contrast to the situation in male patients, females heterozygous for AGA deficiency show no significantly elevated plasma chitotriosidase. This suggests that circulating endogenous AGA in heterozygotes is sufficient to supplement enzyme-deficient macrophages. In conclusion, for the first time a biological marker for lipid-laden cells in Fabry patients is demonstrated; elevated plasma chitotriosidase levels reflecting lipid-laden macrophages. Corrections in this marker illustrate the efficacy of enzyme replacement therapy in clearing the lipid accumulation in this particular cell type.
Assuntos
Doença de Fabry/enzimologia , Doença de Fabry/terapia , Hexosaminidases/sangue , Metabolismo dos Lipídeos , Macrófagos/metabolismo , Adolescente , Adulto , Distribuição por Idade , Anticorpos/imunologia , Biomarcadores , Criança , Doença de Fabry/sangue , Doença de Fabry/patologia , Feminino , Fibroblastos/imunologia , Heterozigoto , Humanos , Células de Kupffer/ultraestrutura , Macrófagos/patologia , Masculino , Pessoa de Meia-Idade , Testes de Neutralização , alfa-Galactosidase/imunologiaRESUMO
Fabry disease is an X-linked lysosomal storage disorder caused by deficiency of the lysosomal enzyme alpha-galactosidase A. Manifestations of the disease in placental tissue have been reported only twice. We report for the first time on the biochemical, histological and genetic features of two cases: placenta A derived from a mother heterozygous for Fabry disease who gave birth to a hemizygous son, and placenta B obtained from a healthy mother who carried a heterozygous daughter. Biopsies of placentae A, B and of four healthy controls were taken directly after birth. Assessment of alpha-galactosidase A (alpha-Gal) activity was performed both in fetal leukocytes (derived from umbilical cord blood) and in the biopsy specimens. The tissue was further examined by electron microscopy, immunohistochemistry and biochemical analysis for the presence of storage material (ceramide trihexoside (CTH)). In placenta A, characteristic zebra bodies reflecting accumulated storage material were seen in all biopsies evaluated. CTH values were markedly elevated as compared to the controls and alpha-Gal activity in both fetal leukocytes and placental tissue was very low. Placenta B showed no storage material at all. CTH values were within the control range. alpha-Gal activity ranged from intermediate to near normal; enzyme activity in fetal leukocytes was significantly decreased. As placental tissue is mainly derived from fetal cells, we may conclude that, in a boy suffering from Fabry disease, extensive storage of CTH is already present at birth. As complications develop only around the age of 10 years, it may be not the CTH itself but secondary processes that cause cellular and organ damage.
Assuntos
Doença de Fabry/diagnóstico , Doença de Fabry/metabolismo , Placenta/metabolismo , Adulto , Feminino , Heterozigoto , Humanos , Imuno-Histoquímica , Recém-Nascido , Lipídeos/química , Masculino , Microscopia Eletrônica , Placenta/ultraestrutura , alfa-Galactosidase/metabolismoRESUMO
In this article we present the path that led to current concepts regarding antimicrobial treatment of endocarditis caused by viridans streptococci highly susceptible to penicillin. Early treatment trials indicate that some patients with subacute endocarditis can be cured with shorter treatment duration than currently advised by international guidelines. Also, high-dose antibiotics, as recommended today, have a predominantly pharmacokinetic and pharmacodynamic rationale that is based mostly on experimental animal studies. Shortening antimicrobial treatment in select patients with endocarditis would be of great benefit. As yet there are no predictors of cure that can be used to individualize treatment duration in patients with bacterial endocarditis.
Assuntos
Antibacterianos/uso terapêutico , Endocardite Bacteriana Subaguda/tratamento farmacológico , Penicilinas/uso terapêutico , Infecções Estreptocócicas/tratamento farmacológico , Estreptococos Viridans/efeitos dos fármacos , Antibacterianos/administração & dosagem , Endocardite Bacteriana Subaguda/microbiologia , Humanos , Penicilinas/administração & dosagem , Infecções Estreptocócicas/microbiologia , Resultado do Tratamento , Estreptococos Viridans/isolamento & purificaçãoRESUMO
Lysosomal storage disorders are a group of disorders characterised by the deficiency of a specific lysosomal hydrolase. These diseases are rare, with only a few hundred patients in the Netherlands. Fabry's disease, an X-linked lysosomal storage disorder, is caused by a deficiency of the lysosomal enzyme α-galactosidase A which results in, among other things, left ventricular hypertrophy, renal failure and cerebrovascular events. Patients with Fabry's disease, especially males, have a decreased life expectancy. Recent studies have shown that Fabry's disease may be much more common among patients with left ventricular hypertrophy (LVH) than previously thought. Up to 7% of male patients with left ventricular hypertrophy and up to 12% of female patients with unexplained LVH were found to suffer from Fabry's disease. Thus, Fabry's disease should be considered in patients with unexplained LVH. This case report summarises the main features of the disease. In addition recent developments concerning prevalence, diagnosis and the current available treatments are discussed and an algorithm on who and how to screen for Fabry's disease is presented.