Circulating Tumor and Immune Cells for Minimally Invasive Risk Stratification of Smoldering Multiple Myeloma.

PURPOSE: Early intervention in smoldering multiple myeloma (SMM) requires optimal risk stratification to avoid under- and overtreatment. We hypothesized that replacing bone marrow (BM) plasma cells (PC) for circulating tumor cells (CTC), and adding immune biomarkers in peripheral blood (PB) for the identification of patients at risk of progression due to lost immune surveillance, could improve the International Myeloma Working Group 20/2/20 model. EXPERIMENTAL DESIGN: We report the outcomes of 150 patients with SMM enrolled in the iMMunocell study, in which serial assessment of tumor and immune cells in PB was performed every 6 months for a period of 3 years since enrollment. RESULTS: Patients with >0.015% versus ≤0.015% CTCs at baseline had a median time-to-progression of 17 months versus not reached (HR, 4.9; P < 0.001). Presence of >20% BM PCs had no prognostic value in a multivariate analysis that included serum free light-chain ratio >20, >2 g/dL M-protein, and >0.015% CTCs. The 20/2/20 and 20/2/0.015 models yielded similar risk stratification (C-index of 0.76 and 0.78). The combination of the 20/2/0.015 model with an immune risk score based on the percentages of SLAN+ and SLAN- nonclassical monocytes, CD69+HLADR+ cytotoxic NK cells, and CD4+CXCR3+ stem central memory T cells, allowed patient' stratification into low, intermediate-low, intermediate-high, and high-risk disease with 0%, 20%, 39%, and 73% rates of progression at 2 years. CONCLUSIONS: This study showed that CTCs outperform BM PCs for assessing tumor burden. Additional analysis in larger series are needed to define a consensus cutoff of CTCs for minimally invasive stratification of SMM.

Genomic crossroads between non-Hodgkin's lymphoma and common variable immunodeficiency.

Common variable immunodeficiency (CVID) represents the largest group of primary immunodeficiencies that may manifest with infections, inflammation, autoimmunity, and cancer, mainly B-cell non-Hodgkin's lymphoma (NHL). Indeed, NHL may result from chronic or recurrent infections and has, therefore, been recognized as a clinical phenotype of CVID, although rare. The more one delves into the mechanisms involved in CVID and cancer, the stronger the idea that both pathologies can be a reflection of the same primer events observed from different angles. The potential effects of germline variants on specific somatic modifications in malignancies suggest that it might be possible to anticipate critical events during tumor development. In the same way, a somatic alteration in NHL could be conditioning a similar response at the transcriptional level in the shared signaling pathways with genetic germline alterations in CVID. We aimed to explore the genomic substrate shared between these entities to better characterize the CVID phenotype immunodeficiency in NHL. By means of an in-silico approach, we interrogated the large, publicly available datasets contained in cBioPortal for the presence of genes associated with genetic pathogenic variants in a panel of 50 genes recurrently altered in CVID and previously described as causative or disease-modifying. We found that 323 (25%) of the 1,309 NHL samples available for analysis harbored variants of the CVID spectrum, with the most recurrent alteration presented in NHL occurring in PIK3CD (6%) and STAT3 (4%). Pathway analysis of common gene alterations showed enrichment in inflammatory, immune surveillance, and defective DNA repair mechanisms similar to those affected in CVID, with PIK3R1 appearing as a central node in the protein interaction network. The co-occurrence of gene alterations was a frequent phenomenon. This study represents an attempt to identify common genomic grounds between CVID and NHL. Further prospective studies are required to better know the role of genetic variants associated with CVID and their reflection on the somatic pathogenic variants responsible for cancer, as well as to characterize the CVID-like phenotype in NHL, with the potential to influence early CVID detection and therapeutic management.

Unraveling the dynamics of organic micropollutants in wastewater: Online LC-MS/MS analysis at high temporal resolution.

Online monitoring of organic micropollutants (OMPs) in the aquatic environment at high temporal resolution is an upcoming technique that provides insights into their dynamics and has the potential to bring water research and management to a new level. An online monitoring setup was developed to quantify OMPs in wastewater treatment plant (WWTP) influent and effluent using automated and continuous sampling, sample preparation, online solid-phase extraction-liquid chromatography-tandem mass spectrometry analysis and data evaluation. This online monitoring setup provided high selectivity and sensitivity (limit of quantification down to 1 ng/L) as well as a stable performance during one week of constant operation whilst using a high sampling frequency of 10 min (>1000 samples). Custom automated data evaluation enabled quantification within seconds after each measurement and results were comparable to those from a commercial software. Additionally, an alarm tool was included in the evaluation application, which automatically notified the user in case a substance exceeded a predefined threshold. The online monitoring setup was applied to WWTP influent and effluent, where 57 substances were monitored over a period of one week and two days, respectively. High temporal resolution enabled the observation of periodic patterns of pharmaceuticals as well as pollution by OMPs originating from point and diffuse sources, while dynamics of OMPs in WWTP effluent were less pronounced. These new insights into the dynamics of OMPs in WWTP influent, which would not be observable using 24 h composite samples, will be a starting point for new stormwater and wastewater research and management strategies.

Monocyte Subsets and Serum Inflammatory and Bone-Associated Markers in Monoclonal Gammopathy of Undetermined Significance and Multiple Myeloma.

BACKGROUND: Monocyte/macrophages have been shown to be altered in monoclonal gammopathy of undetermined significance (MGUS), smoldering (SMM) and active multiple myeloma (MM), with an impact on the disruption of the homeostasis of the normal bone marrow (BM) microenvironment. METHODS: We investigated the distribution of different subsets of monocytes (Mo) in blood and BM of newly-diagnosed untreated MGUS (n = 23), SMM (n = 14) and MM (n = 99) patients vs. healthy donors (HD; n = 107), in parallel to a large panel of cytokines and bone-associated serum biomarkers. RESULTS: Our results showed normal production of monocyte precursors and classical Mo (cMo) in MGUS, while decreased in SMM and MM (p ≤ 0.02), in association with lower blood counts of recently-produced CD62L+ cMo in SMM (p = 0.004) and of all subsets of (CD62L+, CD62L- and FcεRI+) cMo in MM (p ≤ 0.02). In contrast, intermediate and end-stage non-classical Mo were increased in BM of MGUS (p ≤ 0.03), SMM (p ≤ 0.03) and MM (p ≤ 0.002), while normal (MGUS and SMM) or decreased (MM; p = 0.01) in blood. In parallel, increased serum levels of interleukin (IL)1ß were observed in MGUS (p = 0.007) and SMM (p = 0.01), higher concentrations of serum IL8 were found in SMM (p = 0.01) and MM (p = 0.002), and higher serum IL6 (p = 0.002), RANKL (p = 0.01) and bone alkaline phosphatase (BALP) levels (p = 0.01) with decreased counts of FcεRI+ cMo, were restricted to MM presenting with osteolytic lesions. This translated into three distinct immune/bone profiles: (1) normal (typical of HD and most MGUS cases); (2) senescent-like (increased IL1ß and/or IL8, found in a minority of MGUS, most SMM and few MM cases with no bone lesions); and (3) pro-inflammatory-high serum IL6, RANKL and BALP with significantly (p = 0.01) decreased blood counts of immunomodulatory FcεRI+ cMo-, typical of MM presenting with bone lesions. CONCLUSIONS: These results provide new insight into the pathogenesis of plasma cell neoplasms and the potential role of FcεRI+ cMo in normal bone homeostasis.

Pollution Source Localization in Wastewater Networks.

In December 2016, the wastewater treatment plant of Baarle-Nassau, Netherlands, failed. The failure was caused by the illegal disposal of high volumes of acidic waste into the sewer network. Repairs cost between 80,000 and 100,000 EUR. A continuous monitoring system of a utility network such as this one would help to determine the causes of such pollution and could mitigate or reduce the impact of these kinds of events in the future. We have designed and tested a data fusion system that transforms the time-series of sensor measurements into an array of source-localized discharge events. The data fusion system performs this transformation as follows. First, the time-series of sensor measurements are resampled and converted to sensor observations in a unified discrete time domain. Second, sensor observations are mapped to pollutant detections that indicate the amount of specific pollutants according to a priori knowledge. Third, pollutant detections are used for inferring the propagation of the discharged pollutant downstream of the sewage network to account for missing sensor observations. Fourth, pollutant detections and inferred sensor observations are clustered to form tracks. Finally, tracks are processed and propagated upstream to form the final list of probable events. A set of experiments was performed using a modified variant of the EPANET Example Network 2. Results of our experiments show that the proposed system can narrow down the source of pollution to seven or fewer nodes, depending on the number of sensors, while processing approximately 100 sensor observations per second. Having considered the results, such a system could provide meaningful information about pollution events in utility networks.

Activity of matrix metalloproteinase 2 and 9 isoforms in sputum samples from individuals infected with M. tuberculosis.

M. tuberculosis stimulates matrix metalloproteinases secretion in the host; however, the patterns of matrix metalloproteinase 9 (MMP-9) and 2 (MMP-2) isoforms are unknown. Therefore, the aim of this study was to evaluate the activities of these isoforms in sputum samples of patients with varying degrees of mycobacterial load. Sputum samples were recovered from individuals with positive and negative diagnosis of tuberculosis. Bacillary load was determined by bacilloscopy, and presence and activity of MMP-2 and MMP-9 isoforms determined by gelatin zymography. Of the recovered samples; 39 were from individuals without tuberculosis and 48 with tuberculosis; 12 had low bacillary and 36 high bacillary load. Participation of MMP-2 isoforms were not observed, but in MMP-9, there was a decrease in the latent, associated with lipocalin and homodimeric isoforms. In contrast, there was a rise in the active isoform, all with statistical significance. In conclusion our results show that MMP-2 isoforms do not seems to be directly involved with tuberculosis evolution of infection. However, variations in MMP-9 isoforms were observed, which coincided with the progression of tuberculosis infection. These results raise questions regarding how MMP-9 isoforms might influence the formation and progression of granuloma, and their use as markers of progression of tuberculosis infection.

Reference values for serum folate and vitamin B12 in a Spanish population using an electrochemiluminiscent method / Valores de referencia de ácido fólico y vitamina B12 séricos en una población española, utilizando un método de electroquimioluminiscencia

Background: Despite being the most widely used medical decision-making tool, reference intervals are not usually determined by clinical laboratories, due to the highly demanding activities and costly process it involves. However, scientific societies encourage individual clinical laboratories to establish their own reference values. This is especially important in the cases of folate and vitamin B12, due to strong differences in vitamin status among different populations. Objective: Our aim is to establish reference intervals for folate and vitamin B12 levels in a healthy blood donor population using an electrochemiluminiscent method (ROCHE DIAGNOSTICS). Method: Folate and vitamin B12 levels were measured in 141 healthy blood donors aged between 18 and 65 years. Biochemical analyses were performed using a Modular E170 analyzer (ROCHE DIAGNOSTICS) and an electrochemiluminiscent method. Reference intervals were calculated with a non-parametric percentile method following the CLSI guidelines. Results: There were not significant differences in folate or cobalamin levels between age or sex subgroups. The limits of the reference interval for folate were 2.2 and 18ng/mL (5-40.7nmol/L), and 213.8 and 763.3pg/mL (158.2-564.8pmol/L) for vitamin B12. These intervals differed from those claimed by the manufacturer. Conclusions: Our results emphasize the convenience of building reference values based on the population served by the laboratory, in order to unequivocally rule out deficiencies of folate or vitamin B12

Introducción: A pesar de ser una de las herramientas más usadas en la toma de decisiones médicas, los intervalos de referencia son raramente determinados en los laboratorios, debido a que es una labor compleja en términos de tiempo, esfuerzo y coste. Sin embargo las sociedades científicas recomiendan que los laboratorios establezcan sus propios valores de referencia. Esto es especialmente importante para el folato y la vitamina B12, debido a las grandes diferencias entre poblaciones. Objetivo: Nuestro propósito es establecer los valores de referencia en una población de donantes sanos, mediante un método electroquimioluminiscente (Roche Diagnostics). Método: Los niveles de folato y vitamina B12 se midieron en una muestra integrada por 141 donantes sanos de una edad comprendida entre 18 y 65 años. Los análisis bioquímicos se realizaron en un analizador Modular E170 (Roche Diagnostics). Los intervalos de referencia se calcularon siguiendo el método no paramétrico propuesto por las guías del CLSI. Resultados: No hubo diferencias en los niveles de folato ni vitamina B12 entre sexos ni grupos de edad. Los límites de referencia para el folato fueron 2,2 y 18ng/ml (5-40,7nmol/l), y 213,8 y 763,3pg/ml (158,2-564,8 pmol/l) para la vitamina B12. Estos intervalos difirieron de los propuestos por el fabricante. Conclusiones: Nuestros resultados subrayan la importancia de obtener valores de referencia en la población a la que da servicio el laboratorio para excluir inequívocamente las deficiencias de folato y vitamina B12

Choice of the best equation for plasma osmolality calculation: Comparison of fourteen formulae.

BACKGROUND: Many different equations have been previously described to estimate plasma osmolality. The aim of this study is to compare 14 of these equations, in order to determine which results agree best with measured osmolality. OBJECTIVES: Our aim is to elucidate which is the most accurate equation for osmolality calculation among the fourteen that were previously described. METHODS: We measured osmolality by the freezing point depression method, and glucose, urea, sodium, potassium, calcium and magnesium concentrations with Unicell DXC 800 analyzer. Goodness-of-fit rates were calculated using the Passing-Bablok regression model and the t-paired sample test. In addition, we used survival curves in order to find the percentage of cases in which the difference between measured and calculated osmolality was under 10 mOsm/kg. Data were plotted using the Bland-Altman graphical approach. RESULTS: The equation that provides the best fit between measured and calculated osmolality is 1.86(Na+K)+1.15(Glu/18)+(Urea/6)+14, followed by 2Na+1.15(Glu/18)+(Urea/6). CONCLUSIONS: According to our results, the Dorwart-Chalmer's equation should not be used for osmolality calculations. The equation 1.86(Na+K)+1.15(Glu/18)+(Urea/6)+14 is the most accurate. The widespread use of the equation 2(Na+K)+(Glu/18)+(Urea/6) is also acceptable.

Clinical characteristics and management of iron overload in 631 patients with chronic transfusion dependency: results from a multicentre, observational study.

BACKGROUND: Long-term red blood cell transfusion therapy results in iron overload. Consensus documents have been developed for several transfusion-dependent groups of patients to provide clinicians with guidance on the monitoring and treatment of this transfusion complication. The objective of this study was to describe the clinical characteristics and current standard of care for patients with transfusion dependency in Spain. MATERIAL AND METHODS: This observational, multicentre study was conducted from November 2008 to December 2009 in 41 Spanish hospitals and day-care centres. Patients who received their first transfusion after January 2007, and who had received at least 10 units of packed red blood cells at the time of inclusion were eligible for the study. RESULTS: We collected data from 631 patients with a mean age of 65±17 years. Haematological disease (84% of patients) was the most frequent underlying disorder. Patients had received a mean of 30±26 red blood cell units from diagnosis until inclusion in the study, and a mean of 18±18 red blood cell units in the previous year. Ferritin levels were available before and after starting the study for 116 (18%) and 412 (65%) patients, respectively. Mean ferritin level at study inclusion was 1,570 ng/mL, and 58% of patients had a ferritin level of at least 1,000 ng/mL. In spite of this, only 89 (14%) patients were receiving chelation therapy. DISCUSSION: The management of patients with transfusion dependency could be improved by using ferritin levels to diagnose iron overload and guide the timely start of chelation therapy.

On measuring incapacity.

PURPOSE OF REVIEW: We review the relevant literature published in the last year on assessing the capacity of mental patients to make decisions in different areas of their lives. We have analyzed the research relating to the development of capacity assessment instruments. RECENT FINDINGS: We examine recent studies focusing on the capacity of mental patients with mild to moderate dementia. Also we investigate how brief interventions affect patients' understanding of the implications of being enrolled in a particular research project. A new area of research has emerged in the field trying to elucidate which neuropsychological and clinical factors can help to predict present or future incapacity. There is still debate on the construct validity of capacity since different theoretical approaches can be used. SUMMARY: Unfortunately there is controversy regarding the utility of neuropsychological and clinical data as predictors of incapacity. It is still necessary, therefore, to use different capacity instruments to ascertain whether patients have sufficient capacity for a specific task or decision.

Do psychiatric patients improve their competency to consent to hospitalization after admission? A prospective study in an acute inpatient ward.

OBJECTIVES: Competency to consent to hospitalization has important clinical and ethical implications. However, there are no follow-up studies that evaluate improvement in competency during psychiatric hospitalization. The authors sought to determine whether patients admitted to a psychiatric ward as incompetent to consent to hospitalization improve their competency during hospitalization. METHOD: A total of 160 consecutively admitted patients were administered the Competency Questionnaire (CQ), a structured scale designed to assess competency to consent to psychiatric hospitalization. The CQ was administered both upon admission and at discharge. Severity and acuity of the psychiatric disorder were assessed with the Severity of Psychiatric Illness Scale and the Acuity of Psychiatric Illness Scale. RESULTS: Of the 160 assessed patients, 70 (43.8%) were rated incompetent. Forty-five of these 70 incompetent patients completed the admission-to-discharge follow-up. Twenty-one of these 45 patients (46.6%) remained incompetent at discharge. Participation in the treatment process was the only variable that predicted improvement on competency during hospitalization. Severity of psychiatric illness at admission did not predict improvement on competency. CONCLUSIONS: Nearly half of the patients who upon admission were incompetent remained incompetent at discharge.

Comparison of apical leakage between immediate versus delayed post space preparation using AH Plus sealer.

The purpose of this study was to compare the effect of immediate versus delayed post space preparation on the apical seal using AH Plus sealer. Forty-six single rooted anterior extracted teeth were instrumented and divided into four groups. Twenty teeth in groups 1 and 2 and three teeth in groups 3 and 4. In groups 1 and 2, each canal was obturated using warm vertical compaction and AH Plus sealer. In group 1 the post space was made immediately at the time of obturation and in group 2 the post space was made after placing the teeth in saline at 37 degrees C for 1 wk. Group 3 and 4 represented positive and negative control groups, respectively. The teeth were placed in India ink for 72 h. The teeth were sectioned and the amount of apical dye migration was measured. Significant differences were found between teeth whose post spaces are prepared at the time of obturation versus 1 wk later using warm vertical condensation and AH Plus sealer.

Variability in the degree of expression of phosphorylated IkappaBalpha in chronic lymphocytic leukemia cases with nodal involvement.

PURPOSE: Based on previous preliminary observations, we hypothesize that the molecular and clinical variability of chronic lymphocytic leukemia (CLL) reflects differences in the degree of nuclear factor (NF)-kappaB activation, as determined by the expression of phosphorylated IkappaBalpha (p-IkappaBalpha). EXPERIMENTAL DESIGN: The expression profile (mRNA and protein expression) was analyzed with the Centro Nacional de Investigaciones Oncologicas Oncochip, a cDNA microarray containing 6386 cancer-related genes, and a tissue microarray (TMA). The results were correlated with the IgV(H) mutational status, ZAP-70 expression, cytogenetic alterations, and clinical outcome. RESULTS: We found correlations between the presence of p-IkappaBalpha, a surrogate marker of NF-kappaB activation, and changes in the expression profile (mRNA and protein expression) and clinical outcome in a series of CLL cases with lymph node involvement. Activation of NF-kappaB, as determined by the expression of p-IkappaBalpha, was associated with the expression of a set of genes comprising key genes involved in the control of B-cell receptor signaling, signal transduction, and apoptosis, including SYK, LYN, BCL2, CCR7, BTK, PIK3CD, and others. Cases with increased expression of p-IkappaBalpha showed longer overall survival than cases with lower expression. A Cox regression model was derived to estimate some parameters of prognostic interest: IgV(H) mutational status, ZAP-70, and p-IkappaBalpha expression. The multivariate analysis disclosed p-IkappaBalpha and ZAP-70 expression as independent prognostic factors of survival. CONCLUSIONS: A variable degree of activation of NF-kappaB, as determined by the expression of p-IkappaBalpha, is an identifiable event in CLL, and is correlated with changes in the expression profile and overall survival.

The molecular signature of mantle cell lymphoma reveals multiple signals favoring cell survival.

Mantle cell lymphoma (MCL) is a prototypical neoplastic disease in which a common cytogenetic alteration, t11;14, leading to cyclin D1 overexpression, is associated with other changes that need to be considered in an explanation of the clinical, morphological, and molecular variability of this disease. Using a cDNA microarray (Oncochip-CNIO) containing clones for 6386 cancer-related genes, we have analyzed the expression profiles of a series of 38 cases. After normalization with the expression profiling of sorted mantle zone lymphocytes, we have related the findings to conventional clinical and molecular variables, including immunoglobulin variable heavy chain somatic mutation, blastoid cytology, increased proliferation, and long-term survival. MCL signature (446 genes) includes genes involved in apoptosis, cell cycle, signal transduction, and cell structure. Especially striking was the presence of multiple concurrent alterations in the tumor necrosis factor and nuclear factor kappaB pathway, and the overexpression of IL10R and SPARC genes. We also identified a molecular signature for the presence of immunoglobulin variable heavy chain somatic mutation, which includes a number of genes potentially relevant in cancer (CDC14A, ras, and others). Signatures for proliferation and blastoid cytology were also found. An integrated analysis of these data yields a gene-expression based survival predictor (26 genes grouped into two clusters), which distinguishes half of the patients with a survival probability of 52% at 5 years. The predictive model has been confirmed by cross-validation. In conclusion, MCL seems to combine a disease-specific signature and different sets of genes of which the expression is associated with key clinical, molecular, and immunophenotypical events.

Tandem transplants with different high-dose regimens improve the complete remission rates in multiple myeloma. Results of a Grupo Español de Síndromes Linfoproliferativos/Trasplante Autólogo de Médula Osea phase II trial.

Between 1994 and 1999, 88 multiple myeloma (MM) patients were included in a phase II study to evaluate a tandem autologous stem cell transplantation (ASCT) programme. The first was conditioned with melphalan 200 mg/m2 (MEL200-ASCT1), and the second with cyclophosphamide, etoposide and BCNU (CBV-ASCT2). All patients were in response after MEL200-ASCT1. A control group of MM patients with response to a single ASCT was selected to compare outcomes. After MEL200-ASCT1, 26 patients (30%) achieved complete remission (CR). Of the remaining 48 evaluable patients, 16 (33%) achieved CR with CBV-ASCT2. The final CR rate was 48%. The 5-year survival (OS) was 55%[95% confidence interval (CI) 43-67%] while the event-free survival (EFS) was 28% (95% CI 15-39%). CR status after CBV-ASCT2 was the most important prognostic factor for OS and EFS (P = 0.00001), although no differences in outcomes were detected when the patients in CR after MEL200-ASCT1 were compared with those who obtained CR after CBV-ASCT2. Univariate and multivariate analyses showed improved OS and EFS for the tandem series as compared with the control series treated with a single MEL200-ASCT. However, in a stratified comparison by response, there were no prognostic differences between tandem patients and control patients treated with a single ASCT. In summary, our study suggests that the benefit of a second high-dose therapy course depends on its capacity to result in CR for MM patients who have not attained CR after ASCT1.

Estudio farmacológico e histopatológico de la acción anestésica local de la imipramina en ratas / Pharmacologic and histopathologic study of the local anesthetic action of imipramine in rats

Se plantea en este trabajo que durante mucho tiempo se han empleado diferentes sustancias, con acción estabilizante de la membrana, por su acción anestésica local en distintas maniobras quirúrgicas. Sin embargo, existen pocos datos referidos en la literatura médica acerca de la acción anestésica local de psicofármacos tal como lo es la imipramina. Es nuestro objetivo buscar una concentración de dicha sustancia que a la vez de resultar inocua a los tejidos, mantenga una adecuada potencia anestésica local. En la experiencia fueron utilizados dos grupos de ratas blancas adultas y conejos blancos. El primer grupo de ratas a su vez fue dividido en dos subgrupos: A y B(AU)