Current opinion and consensus statement regarding the diagnosis, prognosis, and treatment of patients with essential thrombocythemia: a survey of the Spanish Group of Ph-negative Myeloproliferative Neoplasms (GEMFIN) using the Delphi method.

The current consensus on the diagnosis, prognosis, and treatment of essential thrombocythemia (ET) is based on experts' recommendations. However, several aspects of the diagnosis of, prognosis of, and therapy for ET are still controversial. The Delphi method was employed with an expert panel of members of the Spanish Group of Ph-negative Myeloproliferative Neoplasms in order to identify the degree of agreement on the diagnosis, prognosis, and treatment of ET. Nine leading experts selected a total of 41 clinical hematologists with well-known expertise in ET. An electronic questionnaire was used to collect the questions rated in a four-step scale. The questions were grouped into four blocks: diagnosis, risk stratification, goals of therapy, and treatment strategy. After the first round consisting of 80 questions, a second round including 14 additional questions focused on the recommendations advocated by experts of the European LeukemiaNet in 2011 was analyzed. The median and mean values for the first and second rounds were calculated. A summary of the conclusions considered as the most representative of each block of questions is presented. The Delphi method is a powerful instrument to address the current approaches and controversies surrounding ET.

Epidemiology and outcome of Rhodotorula infection in haematological patients.

Rhodotorula spp. are emergent opportunistic pathogens, particularly in haematological patients. However, no systematic review of this infection has been undertaken in this high-risk patient group. The aim of this study was to review all reported cases of Rhodotorula infection to determine the epidemiology and outcome of this infection in this high-risk population. The 29 reported cases were fungaemias. The most common underlying haematological disorder was the presence of acute leukaemia (65.5%). Rhodotorula mucilaginosa was the species found more frequently (79.3%). Most cases (58.6%) had several risk factors (≥ 3) simultaneously. The most common predisposing factors were the presence of central venous catheter (CVC, 100%) and neutropenia (62.1%). A substantial number of patients (81.5%) received antifungal treatment with amphotericin B. The overall mortality was higher (13.8%) than that described in non-haematological patients (5.8% in solid-organ neoplasms and 9% in AIDS or other chronic diseases). Patients with acute leukaemia had a higher mortality rate (15.7%) than patients with non-Hodgkin's lymphoma (0%). Our data suggest that patients with acute leukaemia might be managed as high-risk patients and intensive measures might be taken. In addition, it appears that the subgroup of patients without acute leukaemia have a good outcome and might be managed as low-risk patients with a less intensive approach.

Rhodotorula mucilaginosa catheter-related fungaemia in a patient with multiple myeloma.

To date, there have been several case reports of Rhodotorula infection in haematological patients, but none affecting patients with multiple myeloma (MM). We describe a 54-year-old man with MM receiving prophylaxis with fluconazole who was using a subclavian Port-A-Cath and presented two episodes of fungaemia caused by Rhodotorula mucilaginosa. The first episode was resolved with oral itraconazole and neutropenia recovery. During the second episode, caspofungin was administered without success; however, liposomal amphotericin B and catheter withdrawal resolved the fungaemia. As far as we know, this is the first case reported of R. mucilaginosa fungaemia in a patient with MM.

Essential thrombocythemia in young individuals: frequency and risk factors for vascular events and evolution to myelofibrosis in 126 patients.

The frequency of vascular events and evolution to myelofibrosis (MF) in young individuals with essential thrombocythemia (ET) is not well known. The incidence and predisposing factors to such complications was studied in 126 subjects diagnosed with ET at a median age of 31 years (range: 5-40). Overall survival and probability of survival free of thrombosis, bleeding and MF were analyzed by the Kaplan-Meier method and the presence of the Janus Kinase 2 (JAK2) V617F mutation correlated with the appearance of such complications. The JAK2 mutation (present in 43% of patients) was associated with higher hemoglobin (Hb) (P<0.001) and lower platelets at diagnosis. With a median follow-up of 10 years (range: 4-25), 31 thrombotic events were registered (incidence rate: 2.2 thromboses/100 patients/year). When compared with the general population, young ET patients showed a significant increase in stroke (odds ratio 50, 95% CI: 21.5-115) and venous thromboses (odds ratio 5.3, 95% CI: 3.9-10.6). Thrombosis-free survival was 84% at 10 years, with tobacco use being associated with higher risk of thrombosis. Actuarial freedom from evolution to MF was 97% at 10 years. In conclusion, young ET patients have thrombotic events, especially stroke and venous thrombosis, more frequently than generally considered, whereas they rarely transform to MF.

Effect of glucan on granulopoiesis and macrophage genesis in mice.

Glucan, a potent reticuloendothelial stimulant, is a glucopyranose polysaccharide derived from zymosan. Because of glucan's potential as an immunotherapeutic agent, we performed studies in order to determine its effect on granulopoiesis and macrophage production in mice. One week after the i.p. injection of 4 mg of glucan, there was a tenfold increase in colony-forming cells in the spleen and approximately a twofold increment of cells in the bone marrow and the peritoneal cavity capable of colony formation in vitro. There was a relative and absolute increase in the number of pure macrophage colonies from bone marrow and spleen. The total macrophage content in spleen, peritoneal cavity, and bone marrow as also increased in the treated mice. Serum from glucan-injected mice had high colony-stimulating activity levels, and the peritoneal macrophages elaborated increased colony-stimulating activity in vitro as compared to controls. Peripheral white blood cell counts were two times greater than those of control in the glucan-treated mice. These studies indicate that glucan administration results in increased granulocyte and macrophage production. The enhanced leukopoiesis is probably mediated in part by augmented release of colony-stimulating activity from macrophages. These observations suggest that the use of glucan as an immunotherapeutic agent can result in an increased number of available effector cells.

Effect of glucan, a macrophage activator, on murine hemopoietic cell proliferation in diffusion chambers in mice.

Pretreatment of mice with glucan, a potent macrophage activator, resulted in enhanced myeloid cluster and colony formation by bone marrow cells in diffusion chambers implanted into the peritoneal cavity. Simultaneously, erythroid colony formation was also augmented. In some experiments the plasma clots formed inside the chambers were dissolved, and the number of hematopoietic cells was determined. An increased yield of early proliferative cells, granulocytes, and macrophages was found in glucan-treated hosts. Concomitantly, higher leukocyte counts were noted in the peripheral blood of treated animals. These results suggest that glucan has a strong stimulatory effect on hematopoiesis. This stimulation is probably mediated by humoral factors of host animal origin rather than by direct interaction with proliferating hematopoietic precursors enclosed within the chambers.

Atypical IgM multiple myeloma with deletion of c-MAF.

IgM multiple myeloma (MM) is a rare subtype of myeloma that shares clinical and pathological features with Waldenström's macroglobulinaemia. These are two separate entities that differ both in therapy and prognosis. We report a 57-year-old male, who presented with anaemia, hypercalcaemia, acute renal failure and several vertebral fractures that clinically suggested a multiple myeloma. Further investigations revealed a serum monoclonal component of IgM lambda type and a bone marrow infiltrated by small, lymphoplasmocytic cells. IgM MM was finally diagnosed by means of both inmunophenotypic and immunohistochemistry techniques, stressing the importance of inmunophenotypic evaluation when clinical and morphological features are discordant. Fluorescence in situ hybridization (FISH) studies disclosed a particular combination of deletion 13q14, t(11;14) and monoallelic deletion C-MAF without t(14;16). The clinical evolution after a Bortezomib-containing polychemotherapy and autologous stem cell transplantation (ASCT) conditioned with busulphan and melphalan is also presented. This very uncommon case highlights the impact of immunophenotyping on the differential diagnosis between IgM MM and WM, to choose the best treatment and establish an appropriate outcome.

Toxic-oil syndrome. Gallium-67 scanning and bronchoalveolar lavage studies in patients with abnormal lung function.

The toxic-oil syndrome (TOS) is a multisystem disorder whose etiology and pathogenesis are as yet unknown. Lung alterations persist in a significant number of TOS patients due to the underlying vascular lesion. Computer-assisted 67Ga scanning and bronchoalveolar lavage (BAL) studies were performed in 14 TOS patients with sustained abnormal diffusing capacity for carbon monoxide (Dco). No significant difference was observed between the 67Ga uptake index of the TOS and control populations. Likewise, there was no significant difference in the number of effector cells recovered from the lungs of TOS patients and controls by bronchoalveolar lavage. However, a rise in IgA and IgG concentrations (p less than 0.002) and a fall in alpha 1-antitrypsin (p less than 0.05) and transferrin (p less than 0.01) were observed in the TOS group. Phospholipid and lecithin concentrations in the lavage fluid were similar for patients and controls. The alveolar macrophage function assayed in three TOS patients was normal. These observations raise new questions about the outcome of lung pathology in TOS and warrant further follow-up studies of the lung abnormalities observed.

Effect of beta-lactams and aminoglycosides on human polymorphonuclear leucocytes.

The effects of four beta-lactams (cefotaxime, cefoxitin, ceftazidime and latamoxef) and three aminoglycosides (amikacin, sisomicin and tobramycin) on human polymorphonuclear (PMN) leucocytes were examined. Chemotaxis was studied by agarose migration and in a Boyden chamber. Agarose migration of PMN leucocytes was not affected significantly by ceftazidime and latamoxef (25-200 mg/l). However cefoxitin (50-200 mg/l) decreased agarose migration to 52-65% of the control values, and cefotaxime (25-200 mg/l) reduced migration to 29-67% of control values. The Boyden chamber method showed no significant inhibition of chemotaxis by any of the antibiotics tested. None of these antibiotics affected phagocytosis or killing of Candida albicans by human PMNs.

Stimulatory effects of carbenicillin and ticarcillin on the adhesion and spreading of human polymorphonuclear leukocytes.

The in-vitro effects of ticarcillin and carbenicillin on adhesiveness, spreading, chemotaxis, phagocytosis and Candida-killing of human leukocytes have been comparatively studied. Adhesion and spreading of cells was increased by incubation with ticarcillin and carbenicillin. We found significant enlargement of surface and length measurements by optical and scanning electron microscopic examination. (P less than 0.0005). The number of cells was only significantly increased after exposure to ticarcillin (P less than 0.05). There were no modifications of chemotaxis, phagocytosis and Candida-killing capacity with respect to control values.

Defective activity of monocytes from patients with non-Hodgkin lymphoma. The modulatory effect of granulocyte-macrophage-colony stimulating factor.

BACKGROUND: Mononuclear phagocytic function is not well defined in non-Hodgkin lymphoma patients although, defective function of those cells has been reported in patients with Hodgkin disease and other solid tumors. The potential application of granulocyte-macrophage-colony stimulating factor (GM-CSF) in the prevention and treatment of infections in those patients is being studied. METHODS: Phagocytosis and microbiocidal activity of monocytes in peripheral blood from 10 newly diagnosed patients and 14 healthy donors were tested cytologically against a strain of Candida albicans, and chemotaxis was evaluated in a Boyden chamber using zymosan-activated serum as a chemotactic agent. Cells were assayed under basal conditions and after incubation with GM-CSF (12 ng/mL). RESULTS: The phagocytosis and chemotactic activity of monocytes from non-Hodgkin lymphoma patients was lower than results obtained with cells from healthy donors (P < 0.05), and microbiocidal activity against Candida albicanswas similar in both groups. After exposure to GM-CSF, the functional activity of monocytes from control donors was only slightly modified (P > 0.05); by contrast, the percentage of mononuclear phagocytic cells in non-Hodgkin lymphoma (NHL) patients increased from 41 +/- 3% to 53 +/- 3%, the phagocytic index from 0.6 +/- 0.1 to 0.87 +/- 0.1 (P < 0.05), microbiocidal activity against Candida from 54 +/- 5% to 66 +/- 6% (P > 0.05), and chemotaxis from 43 +/- 8 cells per field to 48 +/- 9 cells per field (P > 0.05). CONCLUSIONS: The results of this study indicate that there is defective phagocytic and chemotactic activity in monocytes from NHL patients at diagnosis. "In vitro" improvement of phagocytic activity was observed after exposure to GM-CSF.

Effect of granulocyte-macrophage colony-stimulating factor on leukocyte function in cirrhosis.

BACKGROUND: Cirrhotic patients have been reported to have leukocyte impaired function as well as a high incidence of infectious diseases. Granulocyte-macrophage colony-stimulating factor (GM-CSF) increases the number and function of phagocytic cells, and clinical applications are under study. We tested in vitro effects of GM-CSF on phagocytosis, phagocytic index, and chemotaxis in polymorphonuclear leukocytes from 21 cirrhotic patients (12 with compensated cirrhosis and 9 with spontaneous bacterial peritonitis). METHODS: Polymorphonuclear leukocyte functions were tested under basal conditions and after incubation with GM-CSF (10 ng/mL). Phagocytosis was tested against a clinical strain of Candida albicans, and chemotaxis was evaluated using a Boyden chamber. Results were compared with those obtained from 14 healthy donors. RESULTS: Leukocytes from cirrhotics displayed lower basal functional activity than control cells in phagocytosis (P < 0.01) and chemotaxis (P < 0.01). After GM-CSF stimulation, the percentage of phagocytic polymorphonuclear leukocytes in noninfected patients increased from 60% +/- 2.5% to 69.9% +/- 2.42% (P < 0.01), phagocytic index from 0.79 +/- 0.07 to 1.02 +/- 0.07 (P < 0.001), and chemotaxis from 61.2 +/- 12.6 to 82.3 +/- 10.2 cells/high power field (P < 0.05). In patients with peritonitis, the phagocytic index increased from 0.87 +/- 0.08 to 1.08 +/- 0.05 (P < 0.01), phagocytosis from 57.8 +/- 3.57 to 64.7 +/- 2.34 and chemotaxis from 83.3 +/- 17.8 to 110.2 +/- 24.1. CONCLUSIONS: Our results indicate that a defective leukocyte function is present both in compensated and infected cirrhotic patients. An in vitro improvement was observed after GM-CSF stimulation.